Tongue Ties Part 2: It’s Not Just About Licking an Ice Cream Cone!

First, a story. A mom and her son visit the pediatrician for his annual check-up.

Dr: “Do you have any concerns?”

Mom: “Yes, he doesn’t seem to sleep very well, he still wets the bed and has started having nightmares. He’s tired when he wakes up, but is hyperactive during the day, and his teacher says he’s having trouble paying attention in school. “

Dr: “He’s a boy, he’s going to be active. And he’s still young, he’ll grow out of the bed wetting. We can evaluate for ADHD and treat that with medication if it really becomes an issue.”

Mom: “He also has trouble eating - certain textures make him gag, he only wants to eat chicken nuggets and French fries.”

Dr: “His weight is fine, I’m not concerned.”

Mom: “He breathes through his mouth a lot and has had 3 ear infections this year.”

Dr: “Ear infections are a common childhood illness, he probably mouth breathes when he’s congested, that’s normal.”

Mom: “I’ve heard a tongue tie can cause some of these issues, can you check him for that?”

Dr: “Hmm, a tongue tie? Well, OK, stick out your tongue.”

The boy sticks his tongue out just past his front teeth.

Dr: To the boy “Can you lick an ice cream cone?” The boy nods. “He’s not tongue tied, he’s fine. I’ll see you for his next well-check and immunizations.”

Ankyloglossia (tongue tie) was defined by A.F. Wallace in 1963 as “a condition in which the tip of the tongue cannot be protruded beyond the lower incisor teeth because of a short frenulum linguae.” This definition supported the simple, yet not completely effective, test to diagnose a tongue tie by having the patient stick out their tongue. If they could reach the tongue past the lower front teeth then they were determined to not have a tie. Many people can remember their doctor asking them if they can lick an ice cream cone - if the answer was “yes”; then you’re fine. The problem with this definition from the 60’s, and the resulting assessment, is they fail to take into account the more complex functions required of the tongue. Some examples are the tongue needing to move in a peristaltic (wave-like) motion and for the back of the tongue to be able to reach the soft palate. These actions are needed in order to efficiently breastfeed, to develop a more mature swallowing pattern after infancy, and to make sounds such as “Ka” and “Ga”. When the tongue can’t effectively swallow, the Eustachian tubes may not clear completely, this leads to a higher risk for ear infections. Children who have trouble managing food with their tongue and who do not develop a mature swallow may have difficulty with certain textures and may become picky eaters or avoid certain foods altogether due to the difficulty in eating them. 

The tongue plays an important role in the growth and development of the jaw and face. The position of the tongue at rest should be lightly suctioned in the palate; this consistent pressure acts as a natural palatal expander, and encourages a healthy nasal breathing habit. When the tongue rests low in the mouth, such as when there is a tongue tie, there is no consistent pressure in the roof of the mouth to encourage growth, and the person is more likely to breathe through their mouth. Continually breathing through the mouth can contribute to the development of adenoid facies (a long facial growth pattern) identified by a narrow upper jaw, high vaulted palate, teeth crowding, open mouth resting posture, a short upper lip, flaccid lower lip, narrow or crooked nose, dark under eye circle, and low facial tone. Instead of the jaw developing in a wide, forward pattern it develops a narrow, downward growth that does not allow for a large airway space above and behind it, this can lead to disordered breathing and sleep disorders such as snoring, upper airway resistance, and obstructive sleep apnea. 

Signs of sleep-disordered breathing (SDB) in children are mouth breathing, snoring, restless sleep, night terrors, bed wetting, and ADHD-type symptoms (inattention, impulsivity, and hyperactivity). Children suffering from sleep-disordered breathing are often identified as “wired, but tired”. 

Tongue ties go far beyond just the ability to breastfeed or speech issues in childhood. Tongue posture and function are a critical component to proper growth, healthy breathing, and restorative sleep. An untreated tongue tie can cause long lasting physical, mental and emotional effects. If you suspect your child has a tongue tie, consult with a provider experienced in tethered oral tissues and insist on a thorough examination to determine the proper course of treatment. 

It’s not just about licking an ice cream cone. 

For more information on tongue ties, I recommend the book “Tongue Tied” by Richard Baxter, DMD.

If your child has sleep concerns, the book “Sleep Wrecked Kids” by Sharon Moore is a great resource.

Are you an adult with a tongue tie? Stay tuned for part 3 of our series…