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A Slip of the Tongue

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Releasing lip and tongue ties resolves serious childhood health problems

A mother brought her 7-month-old baby in to see me recently because he was experiencing a number of serious, but unexplained problems. The biggest concern was that he wasn’t gaining weight. Much of that had to do with the fact that he’d lost interest in breastfeeding. When he did feed, his sessions were long and labored until he became exhausted and finally gave up. In addition, he was experiencing constant reflux and irregular bowel movements. Naturally, the alternating hunger and constipation left him irritable, and his mother overwhelmed much of the time. 

Unfortunately, it’s relatively common that I see parents who are experiencing these mysterious symptoms with their young children. These parents have often seen more than ten or fifteen doctors before coming to me. The most incredible part is that many of the doctors they’ve seen have told them these problems are normal and that they’ll eventually iron themselves out, but they don’t.

As complex as the situation appeared, I was confident there was a simple solution. When I reached up to pull the baby’s upper lip away from his gums, it showed very little forward movement. Turning the lip over, I could clearly see that the baby had a very short and rigid frenulum, the band of tissue that attaches the lips to the gums, that was preventing him from having full mobility of his mouth. In fact, the frenulum was so short that it pulled on the upper lip in an unnatural way and prevented the baby from smiling properly, leaving him with a slightly frowning appearance. 

I noticed that he had a short frenulum behind his lower lip, as well, which in most cases contributes more heavily to the symptoms of reflux and spitting up. Through a total body examination, I could tell the child had suffered from a very traumatic birth and the aftereffects of such an experience. After consulting an osteopathic physician, I knew that the solution to these complex problems would be much easier than anything this poor child and his frustrated mother had been through thus far.   

Releasing the upper and lower frenulae in two separate procedures (known as a frenectomy), done one week apart, would free up the baby’s mouth and allow for a proper mouth seal around the nipple and effortless feeding. This would also eliminate the air that got into the baby’s stomach as a result of its gulping and gasping, and solve the reflux, gas, and irritability issues. At the same time, his new rhythmic suckling pattern would coordinate his intestinal peristalsis, allowing him to have regular bowel movements. Because he would be eating more and keeping down every ounce of milk he consumed, he would return to a normal weight very quickly.

Naturally, the mother was thrilled at this news. The sad part is that most parents, and even pediatric dentists, don’t understand how something as simple as a short lip or tongue frenulum can cause so many problems in childhood and how this issue, if not identified early, can lead to serious and permanent complications in adulthood.

Incomplete Separation  

It’s important to note that while frenulum is a formal medical description, other physicians may use the terms lip tie, tongue tie, tethered tongue, tethered lip, frenulae (plural) or frenum (an informal abbreviation), to describe the same condition. There are actually seven frenulae in the mouth, with the most prominent being inside the upper and lower lips, and beneath the tongue. Around the 7th week of gestation, a baby’s lips and gum tissue begin to separate from each other and become distinct structures. Small interruptions in this process result in remnants of tissue being formed that tack the lips and tongue to the substructure of the mouth, providing stability without undue restriction. 

Sometimes, the separation process between the lips and gums doesn’t quite reach completion, leaving too much tissue behind as an anchor. This leaves a child with a tongue and lips that are tethered too tightly to the substructures of the mouth, resulting in severely limited mobility. As a result, the baby is unable to properly latch on to the breast, leading to the inability to feed, as well as digestive and irritability issues. Because the baby will try any method to get its mouth around the nipple to feed, sessions can often be quite painful for the mother.

When babies are unable to breastfeed, an unfortunate but quick fix, suggested by some doctors, is bottle feeding. Depending on the design, bottles don’t often require babies to open their mouths as wide as they normally would during breastfeeding. As a result, many babies with short tongue and lip ties can feed from a bottle, while their frenulum issues go undetected for years leading to serious complications later in life.

Naturally, frustrated mothers tend to opt for bottle feeding because it seems to solve (at least temporarily) their baby’s problems, but without the proper intervention and myofunctional treatment, the compensating habits of the child’s mouth, tongue, head, and neck only get progressively worse. In fact, by the time the re-education effort about the overwhelming benefits of breastfeeding began in the 1980s, several generations of bottle-fed babies had grown up with their frenulum issues undetected, leaving them to suffer with many chronic, unexplained problems in adulthood.

While a baby’s inability to breast feed is one of the hallmarks of a frenulum problem, it shouldn’t be viewed as the definitive symptom. In cases where the mother happens to produce an abundance of milk, a child with an undetected short frenulum may still be able to breast feed and thrive, even with a shallow breast latch. In such cases, babies will still experience symptoms such as regurgitation, reflux and bowel problems because they’re feeding from the mother in the same way they would from a bottle and engaging 45 or more unnecessary muscles to compensate during the process. So, it’s always wise to consider a baby’s whole experience rather than simply looking for one or two signs of a frenulum problem.       

Quick Fix Consequences

Everything in the human body is connected. Like the interconnected parts of a synchronized machine, one element cannot be moved or altered without also creating a chain reaction of secondary changes throughout the rest of the mechanism. If the tongue is tethered too tightly, it’s restricted to the bottom of the mouth. When the tongue can move freely, its natural resting place is on the roof of the mouth behind the front teeth, with the lips closed. As the oral cavity grows, it uses the tongue at the roof of the mouth as a template around which all the upper teeth will erupt in order and perfectly straight. The lower jaw responds by following the teeth alignment of the upper jaw, creating a beautiful matching bite. 

If the tongue cannot reach its normal resting place at the roof of the mouth because of a tight frenulum, the skull will develop a narrow upper palate as it grows, around which there won’t be enough room to accommodate all the child’s teeth. As a result, the teeth will end up crooked and overlapping as they randomly erupt and fight for space. With no proper template to follow from the upper jaw, the teeth in the lower jaw will emerge in an equally erratic fashion leading to a recessed jaw or “weak chin” and misaligned bite or malocclusion. 

In the case of crooked teeth, braces are the most common solution offered by orthodontists that never seem to question that teeth don’t grow crookedly for no reason. The body is programmed for beautifully straight teeth. When they grow in crooked, that’s the effect of a deeper cause, which most often turns out to be a tight frenulum. To force a child’s teeth into an unnatural position with braces, while the rest of the oral cavity and skull have developed in a completely opposite direction, is to create unnecessary tension within the cranium that can lead to migraines, TMJ disorder and other problems later in life. In adulthood, most people who grew up with undetected frenulae problems find that their earlier orthodontics interventions fail, resulting in continuous dental work and life-long use of a retainer.

As the child’s upper palate collapses inward, the central and mid-facial development follows suit, as the cheekbones sag in and downward, creating an unnaturally elongated face that will permanently change the child’s appearance, if not detected. Under normal circumstances, a child’s oral cavity, jaws and facial structure develop in a forward fashion. If the cranium experiences resistance from rigid frenulae as it attempts to grow forward, it will compensate by shifting that growth in a backward and downward direction. Instead of creating expansion in the child’s face, jaws, oral cavity, throat, and airway, it does the exact opposite.

Children with tight frenulae suffer from smaller sinus cavities and narrower airways, which leave them with chronic sinus problems and breathing difficulties. In a completely unconscious reflex to get more breath into their bodies, these children often jut their heads forward in an attempt to create a wider airway, nearly always breathing through their mouths.  This is because their nasal passages have developed too narrowly, as well. Tongue thrust is often a telltale sign of a narrow airway and a tight frenulum. Naturally, the inability to breath properly results in subtle anxiety in the child, which affects his or her behavior in ways that are often misdiagnosed as ADHD and treated with unnecessary medication. Not getting enough air, even to a slight degree, triggers the autonomic nervous system and the fight-or-flight mechanism that further affects breathing, emotions, and even gut health. Darick Nordstrom, DDS, osteopathic oral appliance developer, explains how this phenomenon happens.    

“We all know the feeling of butterflies in our stomach, but for those with tethered oral tissues, that feeling can be generated mechanically by tongue movement, and can lead to confusing social cues, and out-of-context self-doubt, as the brain attempts to process the additional sensory input. Fortunately, research into lower primate social interactions has expanded our understanding of the extensive influence of this additional proprioceptive sensory input.”

Because the tongue does not have full mobility, the child isn’t able to exercise it fully and so experiences atrophy in the tongue muscles. This results in a loss of coordination that leads to swallowing problems, and even sleep apnea.   

These mouth breathers, as they’re called, always have their mouths open, even when they’re not eating or speaking. For children without frenulae issues, breathing is done through the nose alone with lips sealed and the tongue at the roof of the mouth. Of course, when the head is thrust forward in an unnatural position to breathe through the mouth, it throws the rest of the body out of alignment, creating additional problems for the head, neck, spine, posture, hips, and even gait.

Essential Early Intervention   

All babies should have their first dentist visit by or before 6 months. Although there are no teeth to examine at that age, a knowledgeable pediatric dentist or orthodontist can check for rigid or short frenulae, tongue mobility and mouth flexibility. If a baby shows any signs of consistent difficulty in breastfeeding or swallowing, inability to gain weight, reflux, vomiting or spitting up, gas, irritability or colic, bowel irregularity or tongue thrust, he should be examined by a professional as soon as possible. 

Research has shown that what’s known as the MTHFR gene has been associated with short frenulae, so it’s important to check a baby as close to birth as possible, and certainly if either parent has a history of lip or tongue tie problems. The earlier an intervention is made, the less compensation a baby will make in the use of its body, and the faster its recovery will be. Dr. Nordstrom emphasizes that missing frenulae problems was far less common in decades past, when oral examinations were part of the standard birthing process.   

“For millennia, experienced midwives and doctors have routinely inspected the newborn for these restrictions, and quickly released them to facilitate a natural, productive, comfortable, and satisfying breast-feeding experience. There was a lapse in this knowledge and practice when western civilization experimented with bottle feeding.”   

It should be noted that family doctors and pediatricians often miss frenulae problems altogether or underplay the seriousness of the issue. I had one patient who told me that while her child’s pediatrician did diagnose a tight upper lip frenulum, he suggested no treatment. Brushing it off he said, “Don’t worry about it. He’s going to fall, hit his mouth on something and rupture it anyway.” It’s also very common for regular pediatricians to miss problems with the secondary or posterior frenulum beneath the tongue at the base, which is much more difficult to isolate and examine than the anterior frenulum at the front that’s immediately visible when the tongue is lifted. Although equally important to mouth mobility, Dr. Nordstrom believes that the term posterior tongue tie or posterior tongue frenulum is a mislabel that can cause confusion for both doctors and parents. 

“This restriction, although not a frenulum or rope-like tether, can also have similar debilitating effects, and is deserving of proper diagnosis and treatment. It appears to be a form of connective tissue error (similar to laxity, Ehlers Danlos, etc.), and arises from inadequately differentiated or matured fascia that, instead of acting as a thin, sliding and integrating muscle sheath, behaves sluggishly, and proprioceptively creates negative feedback to the musculature… One cause of this growing problem is the reduction in outdoor activity and natural sunlight, as vitamin D3 has a very substantial influence on the methylation pathways so important in the maturation of connective tissue (including fascia), and healthy activity facilitates connective tissue formation and orientation (even in the developing fetus).”

A child’s oral cavity and mid-facial skeletal structure stop growing and reach their permanent formation around age 11. This is why it’s extremely important to identify a frenulum problem as early as possible. When we can take advantage of the child’s rapid growth rate while still very young, his or her craniofacial growth pattern can be completely reversed back to normal. In many cases, this means that braces for crooked teeth aren’t even necessary, as teeth naturally realign as the face expands forward and outward, sometimes with the help of temporary oral appliances. 

Frenectomy Fundamentals

If a frenectomy is necessary, the frenulae in question are numbed while a laser (sometimes a scalpel) quickly severs the tissue, vaporizing it on contact. Nanoparticle silver, ozonated water or olive oil is then applied to minimize inflammation and prevent infection. Although there is very little blood involved in a frenectomy, a laser simultaneously cauterizes the site, rendering the procedure virtually bloodless. When releasing the frenulae, Dr. Nordstrom recommends a surgical approach that patterns itself after the body’s natural processes to minimize tissue trauma and prevent scarring. 

“It is desirable for a healthy release to mimic the natural biological process that failed to complete. For example, nature dictates that the surgeon absolutely avoids attempting to release by cutting across a frenulum… In the case of dense fascial tethering, the release is conducted on the fascia (as a dissection) through a smaller opening in the mucosa to avoid the rapid bridging, scarring potential of the denser connective tissue.”

Immediately after the procedure, most babies are able to breastfeed properly. The difference is often dramatic, as their natural instincts kicks in. Some babies, however, do require 2-3 weeks to fully coordinate the new freedom they experience in their tongue and lips. During this time, it’s extremely important to work together with a certified lactation consultant, osteopathic physician, and your pediatric dentist/orthodontist to support the baby and ensure the best possible results.

Others, however may require more extensive intervention, particularly if they’ve exhibited a significant lack of tone in the tongue and mouth (hypertonia) prior to the surgery. These children often can’t even accept bottles or pacifiers. For babies with this advanced condition, standard treatment may not be adequate, with more ongoing care required, as well as intra-oral manipulation to maintain the release during healing. Interaction with the osteopath and lactation consultant before and during the release should be mandatory in cases like torticollis, CP, asymmetrical function, or perinatal or childhood trauma. In the case where more than one frenulum needs to be released, Katherine Gill MD, recommends performing them in separate procedures. 

“In my experience, it is better for the patient to have a delay between lip and tongue frenectomy, at least one week for infants and possibly longer for adults… This gives the body time to reorganize structural elements throughout the entire system that were reacting to the fulcrum provided by the excessive tethering.”

Parents are also given specific oral stretching exercises to do with their baby or child several times per day for 3-4 weeks after the surgery. This is to ensure that the frenulae do not re-attach, creating the same problem again. Both before and after the procedure, I conduct an osteopathic, comprehensive, whole body examination with an emphasis on the head, neck, back, and hips to provide additional interventions that ensure a return to balance for all body systems that might have been affected.    

Osteopathic Advantage  

Although the solution seems like a simple one (and in some ways it is), the compensating habits, swallowing difficulties, body misalignments, speech issues, and other problems acquired as a result of a rigid frenulum will take time to reverse. This is why an osteopathic approach is essential for a truly successful outcome. It’s not just a matter of snipping a frenulum and then sending a child home until his next checkup. When new patients tell me their child’s frenectomy didn’t solve their related issues, I know before I even ask them, that either there wasn’t enough release in the frenulum, or they did not take an osteopathic approach toward healing. Dr. Gill naturally agrees. 

“In the case of a frenectomy, the whole patient is treated because the whole body is affected… After treating hundreds of newborns with these issues, it has become clearer how to diagnose the whole body effects of tight frenulae in adults. The most important benefit of osteopathic treatment before and after frenectomy is that a disorganized human system becomes coordinated and then receptive to the interventions of myofunctional therapy and dental orthopedics. In this case, there is much better success in developing tongue function, positioning, and control. If the tongue functions normally, most of these other problems will not occur.”  

I can’t express the joy I feel when I see a child thriving and off as many as five medications just weeks after a frenectomy and osteopathic intervention. Watching these children come alive is one of the most dramatic experiences I’ve had the blessing to witness. Equally rewarding is seeing how the relationships between these children and their mothers improve because they can finally bond in the way that nature intended. In this way, a frenectomy is a small procedure that provides great gifts for both mother and child for years to come.

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