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Tongue-tie in adults

29/1/2016

This post is a follow-on from the previous blog article on tongue-tie in children. It's worth reading as an adjunct to this article for adults ...

Because a tongue-tie in children is rarely treated, I see a lot of ankyloglossia in adults. By the time I see this in adult patients, years and decades of adaption have occurred. Therapists will very often and repeatedly treat the symptoms of a tongue-tie, for example, a degenerative neck, without addressing the causative circumstances.

Some of these secondary adaptions include:

An immobile sternum. Because of the fascial, muscular and neural connections from the mouth and jaw down to the sternal area, stiffness can result. This may lead to circumstances like altered breathing patterns, rib problems, lung and cardiac restrictions (due to sternopericadial and sternopleural attachments) and thoracic pain.

Tightness around the base of the skull and upper neck, which may contribute to neck pain, headaches, swallowing issues …
Tension in the front of the neck or the muscles along the side of the neck. One side may be more tender than the other, which can link to a tighter frenulum on the same side.
Tension in the bone and cartilage at the top of the throat. This should be fairly mobile to allow for correct speech and swallowing. It should easily move side to side and a restriction to one side may again correlate to a tighter frenulum on the side it has trouble moving away from.
Tightness here may also pull the bone and cartilage upward which can translate tension all the way down to the stomach via the oesophagus. This is where reflux, heartburn and hiatial hernias can be apparent.
Tightness in the muscles under the jaw. This can manifest as a straight line between the point of the chin and the throat, under the jaw. This can pull the jaw downwards and backwards, leading to TMJ issues.
Tightness in the floor of the mouth. Any of my patients who’ve had mouth work done can tell you how tight these muscles can get. The tongue should be able to elevate towards the roof of the mouth without the floor of the mouth coming upwards.

At the same time, with a tight frenulum, often only the tip of the tongue will rest on the palate (behind the upper teeth). On the picture below left, the solid blue bar represents the frenulum; the red arrow represents the pull of the frenulum; the yellow vectors represent the resultant pull of the frenulum in the horizontal and vertical planes; the blue arrow is one of the eventual effects where the posterior tongue sits low and back, which produces an array of sucking, breathing, speech and TMJ problems. At rest, the middle and back parts of the tongue should nestle up against the back of the hard palate (picture on the right).

Tightness in the jaw muscles of the cheek. Ropey, sore muscles here may indicate that they are working too hard. A tight frenulum will cause the jaw to move backwards, disrupting the mechanics at the TMJ. This can also be a problem at night, as the same backwards movement can constrict the airways and contribute to an obstructive sleep apnoea.
Tightness in other associated areas in the hands, arms, neck, back, sacrum, and pelvis.
Speech and breathing issues. For example, mumbling and talking quietly or developing a sore throat or gravelly voice towards the end of the day. Also, it lends itself towards becoming a mouth breather, which leads to hyperventilation and poor diaphragm mechanics.

Good manual therapy can go a long way towards minimising or eliminating some or most of these issues. It will usually include a raft of home exercises, as well.

Some patients will opt for a frenectomy, which is a relatively quick procedure to release the membrane under the tongue, done in a dental practice experienced with this surgery. It is usually performed with a laser and doesn’t require anaesthetic. To prevent re-scarring, a month long regime of exercises is necessary. All surgery has potential complications, but should be minimal in this case and in the hands of a dentist who has some experience. Be careful of damage to the salivary glands under the tongue.

Post surgery, you might expect to feel or see:

Better tongue movement
More tongue relaxation
A wider tongue
The tongue sitting more on the roof of the mouth
Better facial symmetry in the cheeks, nose, mouth or eyes
Less grinding of the teeth
Better sleep
More relaxation and openness in the throat area
Less chest tension
Better neck and back posture
Changes to a Dowager’s hump
Less tension around the base of the skull
Changes to ease of swallow
Less back pain

This is a basic overview of some of the issues and possibilities surrounding a tight frenulum and therapy or surgery. Despite such a small restriction, the repercussions are manifest.

Tongue-Tie in children

24/1/2016

In practice I sometimes come across adults and children who suffer from a tongue tie. This relatively common affliction refers to the membranous structure underneath the tongue, called the frenulum linguae.

There is some suggestion that this structure shouldn’t be apparent at all. Embryologically the right and left sides of the tongue come together, fuse and then the tongue extends outwards during development. At this stage it is suggested the frenulum should recede completely. If it doesn’t, and it retains a degree of tension, this small structure has the capacity to effect an enormous number of issues in our lifetime.

A tongue tie is a poorly diagnosed and treated affliction. Mostly, it is never picked up and if so, reluctance to treat it is common. For the purposes of this article, it may be better to break down the issues in relation to what I find in a paediatric population compared to adults. Although the anatomy is similar, I commonly treat either group for entirely different symptomology.

The Anatomy

The tongue is a group of muscles (technically, it’s an organ) that have significant attachments and substantial fascial (also known as ‘connective tissue’, it supports and connects structures throughout the body, often forming networks that traverse large distances) planes. It attaches to bones in the throat (hyoid), the jaw (mandible) and the skull (temporal bone). The tongue has as much ability to affect any of these structures, as they have to affect the tongue.
The tongue is innervated by no less than 5 cranial (brain) nerves.
The tongue is involved in functions of speaking, swallowing, posture and alignment.

Children

Here I will outline some of the more common reasons that parents will bring their children to see me. Not all of these cases are related to tongue tie in that there are other potential causes, but tongue can can produce the following issues. When the mobility and therefore function of the tongue are affected, it won't be able to extend for long periods of time and may recoil (a possible cause of clicking when feeding) when the baby lowers the jaw during sucking. This results in breaking the seal and poor suction.

Sometimes there are problems breastfeeding. Some of the factors to consider include:

Not latching on properly
The latch cannot be sustained for long
Sliding off the nipple
Prolonged feeds
Restlessness after prolonged feeds
Falling asleep on the breast
Gumming and chewing on the breast
Not gaining weight
Unable to utilise a dummy

Given the problems above, potential results that may ensue include:

Nutritional deficits
Colic
Reflux
Spilling from the side of the mouth
Stimulation of the gag reflex
Sleep apnoea
Altered sleep patterns
Speech problems
Impairment of facial and jaw development
Dental decay
Teeth gapping
The teeth either growing away from the tongue or inwards towards it

To breastfeed well and without pain requires a good and correct latch. This means:

That the chin should rest on the breast, below the nipple
The lips should roll outwards
The lower lip (if not both) should be hinged outward
The jaw is open wide (130-160 degrees)
The top lip should be just above the nipple (not the areola)

Some of the more common issues from an improper latch include clicking noises from tongue recoil, colic and reflux.

If excessive amounts of air reach the stomach (Aerophagia) because of an improper swallow, the results can include:

Abdominal distension
Burping
Flatulence

Colic (pain in the stomach or small intestine) usually produces crying and screaming and manifests within the first couple of weeks. It may last for several months. The exhaustion that comes from it can also be a reason why breastfeeding fails. Mothers are sometimes advised to wean but similar problems can also occur during bottle feeding.

Reflux can have colic type symptoms but usually involves regurgitation of milk or food. The pain and symptoms are usually worse on laying down flat, after feeding or when sleeping. It may result in the baby arching the back or neck to relieve the pain, coughing, gagging, drooling, problems swallowing and hiccoughing. The baby may refuse to feed (or conversely, constantly feed).

Unfortunately, treatment is often delayed to see if they symptoms will resolve themselves over
a few months. In a percentage of cases, infants may be placed on medications like Mylanta to reduce the reflux.

Is your child tongue tied?

If you were to sweep your finger across the floor of your child’s mouth, under the tongue, the floor should be smooth, which is great and indicates no problem. A small speed bump under the tongue may indicate a potential problem and a large speed bump will likely develop into issues. If you encounter a membrane under the tongue, problems are manifest.

The membrane itself may be very strong and feel like a piece of wire. If you push on it, look for a tongue tip indentation and bending of the tongue tip downwards.

The tongue tie will not correct of its own accord and will likely go on to affect breast feeding, breathing and speech - most likely the “l” and “th” sounds.

Treatment

If the problem is diagnosed and treated early enough, there should be minimal repercussions for the infant. Up until approximately 12 years of age, the bones of the face and cranium as still quite malleable. If the tensions created by the frenulum are allowed to exist over this period, the craniofacial development can be altered remarkably. There are many, many times I wish I had the chance to correct some adult issues when they were in childhood. In fact, the consequences in adulthood are so rampant that you could build a career out of treating them. I have written an article on adult tongue tie, which I would encourage you to read them as it provides different and more detailed information than I have written here.

Rather than treating the consequences, the most effective manual treatment will be no substitute for a frenectomy, This relatively simple procedure can be done in a dental practice with instruments or a laser. It doesn’t require a general anaesthetic (you can choose to have a local or nothing at all) or stitches. You will, however, have to adhere to an exercise program with your child for a couple of weeks so that the frenulum is prevented from scarring up.

PHIlosophy(a blog)

Tongue-tie in adults

Tongue-Tie in children

david macdonald

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