Many mothers who start on a breastfeeding journey are met with confusion or difficulty in those early days, myself included. When these mothers reach out to friends or professionals, more and more often they’re informed that their baby likely has a “tie,” whether it be tongue (lingual), lip (labial), cheek (buccal), or all three. I’d like to offer my unique perspective as a board certified pediatric dentist, a mother of three, and a person who personally underwent a tongue-tie release as an adult and whose two eldest children underwent tongue-tie and lip-tie releases in infancy. All release procedures were performed using a CO2 laser in a dental office setting.
First, let’s define some terms.
Some of these terms are used interchangeably, but they mean different things:
- Frenum or frenulum – the connective tissue membrane that connects two tissues in the mouth, such as the lip to the gum, the gum to the cheek, or the tongue to the floor of the mouth or gums. There is a maxillary labial (top lip) frenum, a mandibular labial (bottom lip) frenum, a lingual (under-the-tongue) frenum, and several buccal (cheek) frena.
- Tie or tethered oral tissue (TOT) – a tissue that is restricted in movement and function (tongue, cheek, lip) associated with a frenum that is too short, thick, or fibrotic.
- Please note: It is incorrect to refer to an anatomical structure (the frenum) as a “tie”. A frenum is an anatomical structure; a tie is a diagnosis or description of a problem with or defect of that anatomical structure and its associated tissue. A frenum can be short, thick, and/or fibrotic and result in decreased mobility and function of an associated tissue. The associated tissue can then be described as a TOT or as being tied, but a well-informed provider will make the distinction between the anatomical structure (frenum) and the diagnosis (tie) of the associated tissue.
- Also be aware that across professions, the recognized types of TOTs vary widely, as does the belief that treatment is necessary for all of them, or if indicated, what treatment is appropriate. More on this later in Part 2 with a discussion of the recent Academy of Otolaryngology (AO) and Academy of Breastfeeding Medicine (ABM) position statements on TOTs.
- Frenectomy – complete removal of the frenum
- Frenotomy – partial removal of the frenum
- Other terms sometimes used interchangeably are frenulotomy (partial removal like frenotomy) and frenuloplasty (incison of the frenum with rearrangement of the points of attachment).
All four of the surgical terms indicate that the provider is cutting frenal tissue, using tools such as scissors, scalpel, or laser.
What's all the buzz about “ties”?
With the rise worldwide in breastfeeding rates due to its long list of benefits for both mother and baby, more and more nursing dyads are presenting to medical providers with difficulty breastfeeding. Commonly reported issues for mom associated with difficulty nursing include a painful latch, cracked or bleeding nipples, poor milk supply, clogged ducts, and mastitis. For the infant, such reported issues associated with difficulty nursing include failure to thrive or gain weight, gassiness, fussiness, and reflux.
Providers across a broad spectrum of professions and the general public have grown increasingly aware of a potential association between tethered oral tissues and breastfeeding difficulty. Given the desire of more and more mothers to exclusively breastfeed, treatment (or “release”) of these tethered oral tissues has risen in popularity over the past decade. These releases can be performed relatively quickly and easily in-office on newborns and many mothers report improvement with breastfeeding upon release of their infant's tethered oral tissues.
Why the recent increase in diagnosis and treatment of tethered oral tissues?
It could be that evolutionary factors are at play, resulting in a higher rate of occurrence of tethered oral tissues. It could also be that providers and the public are simply more aware of the potential problem and are more thoroughly evaluating for tethered tissues when a mother reports difficulty with nursing.
I personally suspect the rise in both diagnosis and treatment are related to a general increase in breastfeeding rates overall, coupled with a rise in cultural factors (public awareness of the existence of tethered oral tissues and their potential impact on breastfeeding, broad acceptance of this type of surgery for a newborn or infant, and belief that breastfeeding is important and worth pursuing despite initial challenges) and clinical factors (high demand from the general public, cash-pay patients, more conditions being linked to tethered oral tissues, and more providers evaluating for, referring for, and performing TOT release procedures across various specialties). Dentistry is rapidly picking up on the trend and more and more dental providers are moving to serve an eager public in search of in-office general-anesthesia-free TOT release procedures.
As I mentioned above in clinical factors, I believe the number of frenectomies performed is also on the rise because some providers are linking tethered oral tissues with other conditions in addition to breastfeeding difficulty and they're treating them via TOT releases as well. Some of the additional TOT-associated conditions being treated include speech disorders, sleep disorders like obstructive sleep apnea, jaw growth abnormalities, and feeding issues beyond breastfeeding. It is my hope that providers performing these releases based upon any diagnosis or condition, whether breastfeeding difficulty or any of the myriad of others, are working alongside and consulting with other professionals whose specific area of expertise includes that diagnosis or condition (e.g. lactation consultants with nursing difficulties, pediatricians with failure to thrive, dentists with jaw growth abnormalities, ENTs/neurologists/sleep medicine physicians with OSA, and SLPs with feeding issues or speech disorders).
Be aware that all of these diagnoses and conditions being linked to tethered oral tissues, including breastfeeding difficulty, are complex and often multifactorial in nature. The methods of best treatment and management for these conditions are still contentiously debated amongst professionals. Many professionals and their organizations are still awaiting rigorous scientific evidence before establishing best-practice guidelines and formalized broadly applicable diagnosis and treatment recommendations, which means in some ways it's the wild west out there. You will find some providers who deny the existence of tethered oral tissues and their associated conditions and you will find other providers on the opposite end of the spectrum who rarely meet a condition that couldn't be improved upon by a frenum release (or three).
Who can diagnose TOTs and perform a TOT release?
A surgical release of tethered oral tissues (TOTs) can be performed by any practitioner with the appropriate training and who is licensed to perform surgeries involving oral tissues. Diagnosis of TOTs, however, has become a bit of a contentious topic. It is believed that some providers step beyond their medicolegal scope of practice if they attempt to formally diagnose a TOT (which is a medical condition or defect) when they are not technically licensed by their respective boards to do so. A list of the most common professions diagnosing and/or treating tethered oral tissues are:
- Nurses and International Board Certified Lactation Consultants (IBCLCs) (I’ve encountered many caregivers who received a TOT diagnosis from a labor and delivery nurse or an IBCLC, but medicolegally speaking, many boards indicate that doing so is outside their scope of practice given that they cannot formally diagnose a medical condition or defect. Just be aware that this “scope of practice” discussion related to the diagnosis of TOTs is in debate across many professional circles (physicians, nurses, dentists, lactation consultants, attorneys, and licensure boards to name a few).
- Nurse practitioners (NPs) and nurse midwifes (diagnosis and referral, not treatment)
- Speech language pathologists (SLPs) (diagnosis and referral, not treatment)
- Pediatricians (diagnosis and treatment)
- Dentists (diagnosis and treatment, primarily by pediatric dentists, periodontists, or oral and maxillofacial surgeons (OMFS))
- Otolaryngologists AKA ear nose throat physicians (ENTs) (diagnosis and treatment)
How are these surgical providers trained to treat TOTs?
In truth, most medical and dental training programs include little instruction specific to the diagnosis and treatment of tethered oral tissues. Pediatric, ENT, pediatric dental, periodontal, and oral and maxillofacial surgery residencies may include some discussion of tethered oral tissues, but the breadth and depth vary widely across programs. My pediatric dentistry residency program (graduated in 2014) included little discussion of this topic at the time.
Pediatricians and ENTs complete medical school and residency training and hold MD degrees. Oral surgeons are dual trained as physicians and dentists, holding both an MD and DMD or DDS degree. Dentists complete dental school and hold a DDS or DMD degree, and if they are pediatric dental specialists they completed an additional 2-3 year residency program where they received either a certificate or Master’s degree. Periodontists are dentists who complete an additional 2-3 year residency program focused on the treatment of the periodontium (the gums, mucosa, and supporting bone around the teeth).
The surgical experience of dentists varies widely as it relates to the treatment of tethered oral tissues. Specific in-depth experience and training in this area are often received after graduation through continuing education courses of varying lengths. Many of these education programs offer certificates of completion in order to distinguish the providers who have gone through this additional training.
It is my belief that all of these providers are capable of performing releases of tethered oral tissues in a safe and effective manner, but as a mother, I recommend inquiring about the provider’s experience level and training. A quick litmus test might be to evaluate the terminology the provider uses: is he or she referring to the anatomical structure of the frenum as a tie? Sometimes providers try to speak more colloquially to help a patient understand what we mean, but probe further and ask what particular criteria the provider is using to determine that your child’s frenum and its associated tissue is in fact tethered or tied. Also have the provider clarify what condition(s) should be improved with the release of the tethered oral tissue(s). The diagnosis of a tie should always be based on function and not appearance alone. If any provider is diagnosing a tie based on a picture and no other information – look elsewhere!
Another important factor I would consider when selecting a provider to diagnose and treat tethered oral tissues would be the depth of the provider's discussion of the associated risks and complications that could arise from a release as well as that provider's plan to address these complications should any arise. Many providers describe TOT releases as virtually risk-free and painless, but based on my own experience with a tongue-tie release and from performing the recommended stretches on my two eldest children after their procedures, the wound is in fact quite painful. The procedure itself is also far from risk-free, as with any surgery, and there have been reported instances of surrounding tissue damage, infant hospitalization due to bleeding and consequent hypovolemic shock post frenotomy, as well as breathing problems, pain, weight loss, poor feeding, and oral aversion following tongue-tie surgeries in babies. Make sure that your provider is acknowledging these risks and has procedures in place should any of these complications arise post-operatively.
This post is growing so long that I need to break it into one (maybe two) more pieces, so stay tuned!
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