Infant Tongue Ties and Lip Tie Release by Laser Dentist

 Dr. Geisler is passionate about helping families with young children who are having difficulty feeding.  Her story in this field started like many dentists who treat infants.  When her newborn was first handed to her, it was evident to her immediately that there was a tongue tie.  The tip of her tongue was heart-shaped, tied to the lower ridge and the tip of the tongue could barely pass over the ridge. After a lactation consultant recommended "wait and see" it became very clear after a few weeks that the tethered oral tissue was negatively influencing their breastfeeding experience.   Her only regret was waiting and not doing it immediately.  Pain-free, successful nursing was the result for her and her daughter.   Even though that was her experience, we very strongly recommend seeing a lactation consultant, a feeding consultant or myofunctional therapist, and a cranial sacral therapist for the best outcome.   All children are different, so what one family experiences after a release may not the same for another family. Helping child and mother successfully bond and nurse is more rewarding than completing the most beautiful veneer case .  

Dr. Geisler is a dentist in Minnesota who treats infants and children with tongue-ties and lip-ties

Dr. Geisler is a dentist in Minnesota who treats infants and children with tongue-ties and lip-ties

 

What is a frenum?

A frenum, or another term, frenulum, is a small fold of connective tissue that holds and restricts our lips and cheeks with relation to our jaw.   Some people describe it also as midline fascia. We have seven frenums in our mouths, but the most commonly problematic ones are the lingual frenums (under the tongue) and the maxillary labial frenum (upper lip).  Less frequently, the upper side frenulums (buccal ties) can contribute to a problem.  However, frenums are not always a problem, or every person God created would need a release!  Dr. Geisler will discuss with you if the frenum release is medically necessary.  The definition of medically necessary treatment is "health-care services needed to prevent, diagnose, or treat an illness, injury, condition, disease or it’s symptoms."  During the assessment we discuss symptoms in the baby and the symptoms of the mother (if nursing). We also evaluate the babies function, the appearance and feel of the anatomy of the oral cavity, and do suck testing, to determine if a tongue or lip tie release is recommended. 

The following are symptoms that may point to anklyoglossia, also known as a tongue-tie, as a problem:

In the child:

  • difficulty achieving a good latch

  • falls asleep attempting to nurse

  • slides or pops off breast when attempting to nurse

  • clicking, swallowing air or inflated tummy

  • short sleep episodes (needing to feed frequently)

  • strongly pursed lips

  • child appears to have a small mouth

  • child will not open their mouth wide to feed

  • child appears to have a short tongue

  • heavy or noisy breathing

  • snoring (even a little)

  • witnessed events of breathing stopping (apnea)

  • unable to keep pacifier in

  • waking up congested

  • sleeping only in upright position

  • unhappy when laying on back

  • torticollis

  • arches back when put to breast

  • discomfort when upper lip is raised by adult

  • gagging once solid food introduces

  • needing to supplement after a nursing session

  • picky and messy eater once solid food is introduced

  • colic

  • milk leaking out sides of mouth or nose during feedings

  • failure to thrive, not gaining weight

  • falling off the babies growth curve for weight

  • long nursing sessions, baby not satisfied with session

  • swallowing air

  • uncoordinated suck-swallow-breathe pattern

  • excessive gas

  • gulping or just “drinking” a heavier let down

  • clicking sound while nursing

  • cannot keep nipple of a bottle in mouth

  • biting or chomping on bottle nipple instead of sucking

  • blisters on lip(s) and or tongue

  • difficulty swallowing

  • choking on milk

  • unable to move tongue side to side and lift up

  • heart shaped tongue or cleft or notch in tip of tongue

  • can extend tip of tongue over lower ridge only or not even to lower ridge

  • cannot raise tongue

  • high and narrow palate

  • retracted lower jaw

  • plagiocephephy, brachycephaly, or scaphocephaly head shape

  • a scissors "snip" at birth that did not resolve problem

  • a health professional suggesting a tie may be a problem

In the mother:

  • cracked, creased, misshapen or blanched nipples

  • painful nursing

  • painful latching

  • bleeding, abraded or cut nipples

  • poor or incomplete draining

  • feeling of baby chomping

  • infected nipples or breasts

  • plugged ducts

  • mastitis

  • lipstick shaped nipples

  • breast, areola, or nipple thrush

  • feelings of depression

  • over or under supply of milk

  • knowing "something isn't right" compared to a previous breastfeeding experience

  • nursing for long periods of time

  • unable to breastfeed so switched to bottles

LIP TIE CONSEQUENCES

  • unable to make proper seal on breast or bottle

  • leaking air

  • leaking milk

  • lip blisters

  • tense jaw from compensating

  • a shallow latch

  • coming off the breast when lip flipped up by mother

  • a space greater than 1.5 mm between upper teeth (some space is normal between baby teeth)

  • a milk trap, making cleaning difficult which may contribute to dental decay

  • an altered smile

  • a high or low upper lip

BUCCAL TIE CONSEQUENCES

  • not as commonly problematic

  • may contribute to poor seal

  • can impede a good latch

  • baby may have preference to nurse only on one side

  • can cause asymmetric smile

  • contributes to muscle tension and jaw tightness

  • can contribute to a pull on cranial bones

  • can contribute to recession

Consequences of Tongue tie

The following are possible short and long term consequences of restricted tongue and to some degree, the upper lip:

  • poor breastfeeding experience, therefore higher chance of switching to formula

  • reduction in milk production

  • speech problems

  • gulping air leading to gassiness

  • sleep apnea

  • snoring

  • narrow dental arches which means crowded and crooked teeth

  • swallowing problems

  • high vaulted palate (roof of mouth)

  • difficulty chewing and swallowing food (creating a slow and picky eater)

  • dental decay on front upper incisors (lip tie)

  • central incisors that are rotated in (tongue tie)

  • malocclusion (poor alignment of teeth)

  • symptoms of gastric reflux

  • breathing through mouth instead of nose (leading to lifetime poor oxygenation)

  • inability to move tongue for licking ice cream cones and other foods

  • affect sexual activity as adult

  • contribute to TMJ or TMD

  • space between front two teeth

  • gum recession

  • head and neck postural problems which leads to pain in neck and back and headaches

  • anxiety

A simple revision, done early in life, can prevent a lot of health problems. A frenulectomy for a newborn infant is much easier than when a child is a toddler or preschooler.  A frenulotomy (different term but same as a tongue tie release) can be done at those ages, but it is a difficult procedure for the child, difficult to treat safely, and is also difficult to do the necessary exercises in the weeks that follow to prevent reattachment and to train proper function.   An oral facial mycologist should be the first stop for a parent with a toddler to age 4 child with a suspected tongue tie to assess oral function, tongue posture, head posture, speech development and breathing.   We are currently seeing newborns through age 18 months for examinations focused on ties and airway and also at age four and above.   Dr. Geisler routinely releases adolescents and adults. Our general dentistry practice sees toddlers and preschoolers everyday for exams and cleanings.  If you are curious if your child has a restricted frenum in the age range of 18 months to 4 years, we can see the child for a full exam and cleaning.  If a restriction is diagnosed at the comprehensive exam for your child, Dr. Geisler will not release them in that age range.   Dr. Geisler will discuss with you the recommended course of action and best options for the child who has restricted oral tissues.

Why hasn't this been diagnosed yet?

More research needs to happen to validate the suggestion, as mostly animal studies have been used to research developing brain negative effects from general anesthesia. Many parents we see are beyond frustrated with the amount of appointments and time it took them to find someone who would diagnose the tethered oral tissues as a problem and could offer the solution.   They have brought their child to multiple providers who tell them there is no tie, there is a tie but it's not the problem, or that release would be dangerous and require hospital sedation.  It takes a trained practitioner to diagnose the tie, especially if the tip of the tongue is not severely tied to the lower arch.  Dr. Ghaheri, a leading expert in Oregon, uses the analogy of a sailboat to explain that every anterior tie has a posterior tongue tie component.  When a tongue tie is "clipped" just at the front, an incomplete release is done.  Imagine a sailboat with the sail up trying to get under a low bridge.  The sail is "lowered" with a (quick scissor clip) but the mast that is still upright will prevent the boat from moving under that bridge.  The mid to back (posterior) portion of a frenum also needs to be released to allow the tongue to move correctly.  Our mouths are designed to have the central part of our tongue raised up against the palate.  Tongue-up posture is what is called the correct oral rest posture. A lip tie that prevents lips from coming together at rest can also negatively impact normal rest posture and swallowing. When a person is swallowing, the front of the tongue moves forward and up, then almost in a wave-like motion, the mid to back of the tongue elevates to the palate. A negative pressure, or a vacuum is created by this motion and is necessary for normal breastfeeding. This vacuum is what expresses milk and not compression on the nipple.  Recent research ultrasound videos of a baby swallowing show the healthy way a tongue should move.  A restriction makes the body compensate and doesn't allow the shape of the mouth and face to develop correctly.  Many parents discover a tongue-tie when the child is a toddler, preschooler or older.  The procedure can be done for older children, and for adults for that matter, and we will the discuss the when and how questions at your consultation.  Our goal is to offer treatment without having a surgical intervention by an ENT the operating room which requires general anesthesia. If at all possible, putting babies to sleep is advised to wait as research may be telling us there is long term consequences to exposure to those medications. Some people have a bad reaction or adverse health outcome during anesthesia in an operating room. Because of safety of doing the procedure in the office compared the risks and costs of general anesthesia, we feel we can help more families stay out of the OR.

The entire subject of tethered oral tissues, or ties, is controversial. The controversy stems from the lack of education and the need for more studies.   Traditional training for physicians, dentists and lactation consultants often downplays or opposes entirely, the impact a tie can have.  Breastfeeding is not taught in most professional schools. Even in dental schools, dentists are not educated on tongue and lip ties.  Recent pushes in training of professionals has increased the number of providers, but only for those who are eager and open to learn about it.  The scientific studies are being published more and more, but it is difficult to do a double-blind study, when delaying treatment for a child who is failing to thrive is unethical.   The amount of research published on the subject has exponentially increased in the past two decades. As the word is spreading, lactation consultants, pediatricians, mid-wives, speech therapists, dentists and other are being educated about oral restrictions.  Frenums are significantly more prevalent and problematic than believed in the past.  The increase in breast feeding in this country in the past twenty years has increased the number of children that present with a tie. It is suspected that a dominant gene could be part of the increase in tethered oral tissues, it is not a fad to do a frenectomy.   For a child's best health, nursing is recommended exclusively for the first six months of life.  The World Health Organization promotes feeding to age two for best health of children.  We are not here to judge your goals with feeding your child, but want to help.  We also do see children that are bottle fed (with breast milk or formula) who are having difficulty feeding from a bottle due to inability to use the tongue correctly or flange the upper lip.  Children starting on solid foods often gag, have swallowing difficulty, prefer soft (unhealthy) foods and take a long time to eat.  The influence of a lip tie is more debated among professionals, where some say "where's the harm in a lip release" and others say "wait and see."  The wait and see approach may be risky in that fact that part of "Medically necessary" care involves preventative treatment services.  An infant who is not getting a good seal from a turned under upper lip will still be swallowing air, leading to gassiness, fussiness and sometimes screaming after a feeling.  A study found that after 1000 babies were treated (when medically necessary) with a upper lip and tongue frenectomy, and they were on reflux meds, over half were able to wean off the medication. The American Academy of Pediatrics set recommendations in 2018 that recommend not medicating babies with reflux meds, such as omeprazole and ranitidine, due to the lack of benefit and harmful effects. Some of the potential negative side effects are an increase in food allergies and bone fractures in children who were given these medications while babies. Aerophagia, or swallowing air while feeding, should be first on the list of the possible causes (health professionals call this the differential diagnosis) of reflux. Similarly, if parents believe there is a cause to colic, and not just accept that their baby screams all day long because of their personality, then their questioning will likely bring to light a health problem. Remember to ask “why” is a symptom happening, and treat the etiology, instead of trusting that pharmaceuticals are the solution.

Did you know that an infants brain grows by 1% every single day in the first three months?  If the child doesn't get enough oxygen due to breathing poorly (snoring and mouth breathing are very common in tongue-tied babies), or isn't getting the nutrition he needs, the brain is effected negatively.  Sleep disordered breathing (SDB) is on the rise and the long term consequences are honestly terrifying. An immensely important study on over 11,000 child showed that the younger the age a child is snoring, the higher the incidence of behavioral problems at age 4 and 7. This study was published in the April 2012 Journal of Pediatrics, written by Karen Bonuck et al. The results read “In this large, population-based, longitudinal study, early-life SDB symptoms had strong, persistent statistical effects on subsequent behavior in childhood. Findings suggest that SDB symptoms may require attention as early as the first year of life.” The procedure to release oral tethered tissues is simple and has very low risks with very high benefits. Often, babies who snore have a tongue tie. The tongue cannot raise up to rest against the roof of the mouth, causing a soft tissue obstruction against the throat and decreasing the air flow to their lungs. More research needs to be done to prove what I have experienced anecdotally with my patients, that releasing a tongue tie can alleviate snoring and improve sleep quality. A literature review regarding sleep disordered breathing and cognitive development can be found here.

So how do you know if your child has tethered oral tissues that should be released?  A consultation is the first step.  Having seen a lactation consultant to work out any other contributing factors in nursing is very helpful.  For older children and adults, a visit with an orofacial myologist is recommended prior to a frenectomy.  At the consult, we discuss health issues, maternal symptoms, infant symptoms, and other health professionals opinions.  A simple exam is done with Dr. Geisler standing at the 12 O'clock position.  We take photos and discuss the findings.  Parents have the choice of whether to do a laser frenectomy, and no judgement is made if they decide to hold off.   Most are ready for treatment and only want to know what is involved in the procedure. At Life Smiles, we swaddle the child and have them laying on a flat but soft surface.  Laser goggles are worn by the baby.  Numbing is based on the age and weight of the patient and length of time the frenectomy will take. Sweet Ease is a sucrose liquid that can be dropping on their cheek prior to treatment.  It doesn't alleviate pain but distracts their brain, and is frequently used in NICUs prior to procedures.  Sweat Ease is optional, some choose to forgo.  We use both a CO2 laser by LightScalpel.  We also use low level light therapy (which looks like a flashlight) to improve healing.   Laser releases heal faster and are less uncomfortable that scissors or a scalpel, and causes no bleeding.  The laser is much more precise than an electrocautery (which burns and cauterizes) and the collateral damage is very small.  A dental laser seals lymph nodes and promotes healing. It may take ten seconds for a thin upper lip tie, or up to thirty seconds for a thick, posterior tongue-tie release.  The LightScalpel laser has a very short distance it works, so a laser beam is not cutting deeply into the tissues.  The work is done without touching the laser tip to the tissue as the laser energy itself is doing the work. As soon as your child is finished, we bring him or her directly to you so you can nurse in private or give a bottle.  We work with lactation professionals and body workers (for cranial sacral therapy) to treat any problems with a team approach.  For older children, a referral is given to an oral facial myologist to help train the muscles involved in breathing, swallowing and speaking.   Tongues don't automatically know how to function well without some training and exercises.  Please schedule a consultation, and if the procedures are recommended, we often offer to perform the them the same day.  We will educate you on what to expect afterwards, and give information of how to care for the site(s).   Some parents have used a combination of essential oils or arnica to help healing and reduce discomfort and others choose Infants Tylenol. There is not research to prove that using Tylenol (acetaminophen) and arnica at the same time is safe. Some parents don't use pain relievers at all and find the baby is only fussy during the stretches.  We offer follow-up visits for all who have a frenectomy, typically at one week and as needed after.  Please feel free to ask questions about fees, billing and insurance of our two patient coordinators, Leslie and Bobbie.  Find the questionnaire form for the first appointment in the "Download Forms" section under our menu.  Find the after-care instructions here.