Knot Your Average Problem: How do Tongue Ties Impact Oral Myofunctional Health?
Hadia Hussain
Knot Your Average Problem: How do Tongue Ties Impact Oral Myofunctional Health?
Sitting in the nursery of the dental office where I worked, I reviewed Baby V’s medical history and reports from the Emergency Department at Jersey City Medical Center. I found it odd that, despite multiple visits and clear signs of malnutrition, no physician had been able to diagnose the cause. Baby V, at a low weight of 12 pounds was struggling with difficulty nursing and bottle feeding, excessive gassiness, colic, clicking sounds when feeding, milk dribbling out of the mouth, and mouth breathing—but doctors had dismissed these signs, labeling him as "healthy." It didn’t make sense as his low weight raised serious concerns.
According to Pediatric specialists Jenny Olson, DNP, and Sarha DeVrieze, ARNP, at the UnityPoint Clinic, a 9-month-old baby boy should weigh anywhere in between the range of 17 to 25 pounds. Baby V's situation was clearly a cause for serious concern. As I assisted the dentist in evaluating Baby V, we quickly suspected that his symptoms were likely linked to a restricted tongue. The string of tissue underneath his tongue was preventing him from latching properly and causing his lip to curl, which made him swallow more air, and led to gassiness. We explained to the family that a simple procedure—a frenectomy to release the tongue tie—could potentially resolve his feeding issues and help him gain the weight he needed. The family, overwhelmed, needed time to decide. As the dentist and I stepped out of the nursery, I realized just how important it is to recognize the impact of tongue ties on a baby’s ability to feed properly—an issue that can affect much more than just nutrition.
A tongue tie, also known as Ankyloglossia, is a condition where the frenulum — a piece of tissue connecting the tongue to the floor of the mouth — is shorter, thicker, or tighter than normal. This seemingly minor anatomical feature can significantly impact oral myofunctional health (OMH), which refers to the proper functioning of the muscles in the mouth and face that are essential for activities like sleeping, breathing, eating, and speaking. OMH plays a vital role in developing healthy oral habits and overall well-being. Yet, restricted tongue mobility can lead to a range of complications from difficulty nursing in infants to speech and dental issues in children and adults.
In the article, “Rethinking Tongue Tie Anatomy: Anterior versus Posterior is irrelevant,” by Bobby Ghaheri, MD, an Ear, Nose, and Throat (ENT) surgeon, emphasized that “most practitioners use a classification where the tongue tie is given a grade of 1, 2, 3, or 4. Classically, class 1 and 2 are thought of as anterior, whereas class 3 and 4 are posterior.” Unlike medical conditions such as cancer, where higher stages indicate greater severity, these classifications do not reflect severity. Instead, these classes describe where the frenulum is attached to the tongue. Class 1 involves a restriction near the tip of the tongue, whereas the restriction of Class 2 is just behind the tip of the tongue. Despite their different locations, both anterior tongue ties can lead to noticeable challenges with breastfeeding and speech development, emphasizing the importance of accurate diagnosis and treatment.
In contrast, Class 3 and 4 tongue ties are classified as posterior ties. Class 3 ties involve restrictions in the middle of the tongue, where the frenulum is thicker and shorter. Class 4 ties located near the very back of the tongue, are often hidden under mucosal tissue—the smooth, flat layer covering the floor of the mouth—which makes them more difficult to diagnose. Although less visible, posterior tongue ties can severely impact oral function, leading to muscle compensation and long-term issues such as poor swallowing patterns, speech delays, and dental misalignment or crowding. Understanding these classifications helps healthcare providers accurately assess and address tongue-tie-related challenges based on the frenulum's location rather than perceived severity.
Similar to Baby V’s case, infants with tongue ties frequently experience difficulty breastfeeding or bottle feeding due to a poor latch. This improper latch prevents the baby from effectively drawing milk, leading to inadequate nutrition, poor weight gain, and issues like colic. Additionally, an infant may experience gassiness due to excessive swallowing of air causing discomfort and feeding frustration. These early feeding difficulties are not just frustrating but can have long-term consequences on a child's development.
According to Dr. Soroush Zaghi, MD, an ENT specializing in pediatric cases, limited tongue mobility caused by tongue ties can lead to speech delays. This is because the tongue has difficulty making precise movements to produce sounds such as "t," "d," "n," "s," "r," and "z." For clear speech development, these sounds are critical, and not being able to make these sounds can lead to speech impediments like lisps or unclear pronunciation. Understanding these classifications helps physicians, dentists, and ENTs accurately diagnose and assess the difficulties a patient is experiencing.
Another significant consequence of a restricted tongue is the impact on dental and orthodontic development. Dr. Mrunali Deshkar, a pediatric dentist at Sharad Pawar Dental College and Hospital, highlights the importance of proper tongue posture throughout her article, “The Influence of the Tongue on the Development of Dental Malocclusion”. She highlights that when an individual has good OMH, the tongue rests against the roof of the mouth or at the upper dental arch and encourages a broad, U-shaped arch development. On the other hand, poor posture - when the tongue sits flat at the bottom of the mouth, it promotes a V-shaped narrow plate leading to crowded teeth and a tongue thrust during swallowing or speaking. Many children with tongue ties later require palatal expanders to correct this issue because the palate doesn’t develop fully without the tongue's natural pressure. Many children with tongue ties later require palatal expanders to correct this issue because the palate doesn’t develop fully without the tongue's natural pressure.
Figure 3: The image showcases a narrow, V-shaped palate before and after
orthodontic expansion
Treatment options for tongue ties have greatly advanced since the traditional scissor method was used as early as the 1600s, yet each method has its own advantages and disadvantages. Although scissors are often used in the present day to perform frenectomies, this technique can cause more trauma and it often involves a local anesthetic and cutting through more blood vessels. This results in increased bleeding and a higher risk of scarring. Additionally, the procedure requires stitches, leading to a longer and uncomfortable recovery process. In contrast, modern advancements such as diode and CO2 based lasers offer a less invasive alternative treatment (Baxter, 2020). In the dental office where I work, a CO2 based surgical laser called the Light Scalpel has minimized tissue damage, reduced bleeding by cauterizing blood vessels as it cuts, and had a lower risk of infection and scarring. In fact, the Light Scalpel can be used to perform a frenectomy on patients as young as a few days old with minimal discomfort and healing times as fast as a couple of months. However, laser treatments are more expensive, typically costing about $25,000 to $100,00 dollars, and require specialized training for practitioners, which may not be accessible in many healthcare settings.
Figure 4: The image showcases the Light Scalpel a CO2-based surgical laser
To address the difficulties associated with tongue ties, it is necessary to raise awareness about the importance of correct tongue posture and OMH. Understanding the link between tongue ties and oral function is not only vital for infants facing problems breastfeeding and bottle feeding but these issues will lead to long-term health issues. Improper tongue posture can interfere with the correct development of the jaw, leading to misaligned teeth, crowding, narrow palates, poor swallowing patterns, and chronic pain such as Temporomandibular disorder or TMD — pain in your jaw joint and in the muscles that control jaw movement.
As awareness of tongue ties grows, this topic has become a rising trend in the healthcare field. Taking advantage of this increased attention, some practitioners may take advantage of this trend for financial gain, recommending procedures even when there are no clear functional issues. This can place an emotional and financial burden on families, who may feel pressured into treatments that their child does not genuinely need. Overdiagnosis can lead to unnecessary medical interventions and undermine trust in healthcare providers. However, in our dental office, we only recommend tongue tie treatments when there are clear functional issues, such as those observed in Baby V’s case.
Our evaluations focus on each patient's specific symptoms—difficulty with feeding, speech delays, or other myofunctional challenges such as mouth breathing, snoring, sleep apnea, or narrow palate—rather than relying solely on visual assessments. This careful approach ensures that families receive proper guidance, and procedures are performed only when they will truly benefit the patient’s health and well-being. Additionally, promoting oral myofunctional therapy after the release can significantly improve long-term outcomes for individuals. This therapy helps retrain tongue muscles to function properly, fostering better oral posture, breathing, and swallowing patterns. Providing education on tongue ties, their impact on oral health, and available treatment options empowers families and healthcare providers to make informed decisions, ultimately contributing to better health outcomes.
Baby V’s journey to recovery post-procedure showcases that the impact of proper diagnosis and treatment is nothing short of life-changing. Prior to his frenectomy, Baby V was just 12 pounds — having difficulty breastfeeding, was gassy and fussy. Yet, two weeks post-procedure, his transformation was extraordinary. At his follow-up appointment, he weighed a healthy 15 pounds and 8 ounces, happily breastfeeding, free of discomfort, and full of life. Baby V’s story is more than a success; it’s a wake-up call. How many more infants will silently suffer as their struggles are dismissed or misdiagnosed? How many families will be left feeling helpless, working with a healthcare system that overlooks the obvious? Raising awareness about tongue ties isn’t just important—it’s critical because every baby deserves the chance to thrive, not just survive.
Resources:
Chong, L. (2024, July 12). Benefits of adult tongue tie release: Comprehensive care at sydney holistic dental centre. Pain Free Dentist Sydney. https://painfreedentistsydney.com.au/blog/2024/6/21/understanding-adult-tongue-tie-release-benefits-and-procedures
Coles, T. (2022, March 9). Your appearance-genetics vs. Breathing Total Care Dental and wellness. Total Care Dental | Holistic Dentistry. https://www.totalcaredental.com/your-appearance-genetics-vs-breathing/
Deshkar, M., Thosar, N. R., Kabra, S. P., Yeluri, R., & Rathi, N. V. (2024, May 29). The influence of the tongue on the development of Dental Malocclusion. Cureus. https://pmc.ncbi.nlm.nih.gov/articles/PMC11211712/
Ghaheri, B. (2014, March 24). Rethinking tongue tie anatomy: Anterior vs posterior is irrelevant. DrGhaheri.com. https://www.drghaheri.com/blog/2014/3/22/rethinking-tongue-tie-anatomy-anterior-vs-posterior-is-irrelevant
Ghaheri, B. (2014b, April 4). How to choose your provider: Does laser vs scissors matter?. DrGhaheri.com. https://www.drghaheri.com/blog/2014/4/3/laser-vs-scissors-how-to-choose-your-provider
How much should my baby weigh? Baby Growth Chart and developmental milestones by Month. How Much Should My Baby Weigh? Baby Growth Chart and Developmental Milestones by Month. (n.d.). https://www.unitypoint.org/news-and-articles/a-review-of-milestones-and-your-babys-growth-chart
Kee, C. (2018, May 23). Mom shares photo of her baby after dramatic weight loss due to breastfeeding problem. BuzzFeed News. https://www.buzzfeednews.com/article/carolinekee/photo-of-underweight-baby-breastfeeding-tongue-tie
Mayo Foundation for Medical Education and Research. (2024, August 2). Tongue-tie (ankyloglossia). Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/tongue-tie/symptoms-causes/syc-20378452
“Surgical CO2 Lasers - Dental Lasers - Soft Tissue Lasers.” LightScalpel, 8 Sept. 2023, www.lightscalpel.com/.
Symptoms of tongue-tie in adults. BKS Dental. (2024, March 13). https://bksdental.com/blog/symptoms-of-tongue-tie-in-adults/
What’s the best tool to use to treat a tongue-tie? - Alabama tongue-tie center: Dr. Baxter & dr. Trego: Birmingham, AL. Alabama Tongue-Tie Center | Dr. Baxter & Dr. Trego | Birmingham, AL. (n.d.-b). https://tonguetieal.com/whats-the-best-tool-to-use-to-treat-a-tongue-tie/
Zaghi , S. (2019, July 9). Https://onlinelibrary.wiley.com/doi/full-xml/10.1002/ece3.3216. Lingual frenuloplasty with myofunctional therapy: Exploring safety and efficacy in 348 cases. https://onlinelibrary.wiley.com/doi/full-xml/10.1002/ece3.3216
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