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Jun 10

Effects of Oral Restrictions (Tongue and Lip Ties)

Friday, June 10, 2016

Oral restrictions can effect far more than the mouth. Effects can be far reaching due to bodily compensations, and the fact that the tongue and lips are not muscles that act in isolation. Furthermore, at different stages of an individual’s life, different effects may take place.

Here I will explore the journey from infancy to adulthood.

However, in a later blog, I will cover their effects on the following anatomical regions and physiological systems:

  • The mouth
  • The head and neck region, and the musculoskeletal system
  • The respiratory system
  • The digestive system
  • Other body systems

The journey from infancy to adulthood 

Infants

As an infant, the tongue’s function becomes important within the first 20 minutes of life. Research (1)shows that infants need to establish functional breast feeding immediately after birth if they are to go on to develop normal feeding, swallowing and breathing habits. Under normal circumstances such as a normal atraumatic birth, and a mother-baby dyad who are both healthy and functioning normally, the natural instinct for the baby to make it’s way onto the mother’s breast is strong. Much like a newborn lamb, the baby will make movements towards the breast without any coercing. The baby knows what to do.

It is evident that a restricted tongue can play a significant role in the ability to function normally (2). Moreover, effective release of such restrictions by a trained professional has been shown to be of benefit (3).

During delivery ward routines, once the baby is through in the initial danger of child birth, the next thing that should happen is successful feeding. This is imperative, not only for bonding with the mother, but for delivery of nutrition, and learning of normal swallowing and breathing patterns. It is normal for babies to lose some of their initial birth weight. However, functional and successful feeding enables survival beyond the initial stages of life outside the nurturing environment of the womb.

In modern times, we have the apparent luxury of options including bottle feeding (either with expressed breast milk, or with infant formula, or mixtures of the two), as well as use of nipple shields to protect the mother from the painful effects of dysfunctional feeding patterns. However, it is well documented that exclusive breast milk is the ideal nutrition for an infant (4-7). Furthermore, it is not only the nutritional content of the breast milk which plays a part in development of the infant. The specific act of breast feeding appears to have clear benefits for development of the dental arches, and for prevention of dental malocclusion (8). It is functional feeding which sets up the neuromuscular pathways which become the individual’s default, habitual swallowing patterns. Any treatment to enable functional feeding is likely to have an effect on re-establishing normal neuromuscular reflexes, setting the baby up for better function throughout life.

There may be a more sinister reason to consider treating tongue ties in the infant. There are suspicions that Sudden Infant Death Syndrome (SIDS), which may be an infant form of sleep apnoea, may be related to mouth breathing (9). It is evident from clinical experience that tongue tied babies are more often mouth breathing than non tied babies, and mouth breathing is related to breathing dysfunction.

Children

The direction and growth of the dental arches is affected by aberrant swallowing patterns such as tongue thrusting, reverse swallowing and excessive use of the buccinator (cheek) muscles; as well as open mouth posture (mouth breathing) which leads to lowered tongue posture (10-14)

Since functional breast feeding establishes normal feeding, breathing and swallowing patterns, it can easily be extrapolated that tongue restrictions will play a significant role in dental malocclusion.

Breast feeding difficulties do not just directly cause malocclusion. It is often the case that bottle feeding will be substituted for breast feeding when breast feeding is difficult for either the mother, or the child. In addition, a pacifier may be used in order to help calm the struggling infant. Research shows that non nutritive suckling habits (pacifier use) further add to the tendency towards childhood malocclusion. The main issue being that a foreign object in the mouth during feeding and swallowing (such as a bottle teat, a pacifier, or a digit) leads to aberrant swallowing patterns since they get in the way of the tongue (15-16), and activate muscles of facial expression such as the buccinators and lips. These muscles should not be so intensely activated during swallowing

As the child continues to grow, speech and language difficulties may arise. Difficulties in touching the roof of the mouth, to pronounce sounds such as ‘t, d, n, l, s, z’; or difficulties pronouncing sounds such as ‘r’ may become apparent. Correction of the restriction has been shown to have positive benefits (17).

By childhood, habitual dysfunctional oral posture and swallowing patterns (neuromuscular pathways) can be firmly ingrained in the brain, since these functions are largely habitual. As the child continues to display such dysfunction, other “indirect”symptoms may arise. These are symptoms related to restricted jaw growth, mouth breathing and malocclusion.

Indirect symptoms of oral restrictions in children can include: 

  • mouth breathing and subsequent breathing dysfunction
  • symptoms related to breathing dysfunction (see section on this)
  • enlarged adenoids and tonsils
  • snoring and sleep apnoea
  • Bruxism
  • TMJ dysfunction and associated symptoms
  • inability to sleep well and difficulty concentrating
  • postural effects on the head and neck
  • difficulty eating solid foods
  • pronounced gag reflex

Adults

Long term compensations for dysfunction can lead to many symptoms as below.

The body will always compensate to enable survival. Therefore, given that feeding and breathing are high up on the list of the brain’s priorities, other parts of the body which are less related to survival may be affected. Chronic poor posture and back pain is one such example.

Symptoms may include: 

-chronic head and neck pain from chronic subluxation of the head and neck

-severe sleep apnoea from severely underdeveloped jaws and airway

-chronic states of stress from chronic poor sleep and chronic pain

Seemingly unrelated symptoms may prove to be related to the oral restriction.

 

References: (The Journey From Infancy to Adulthood - written by Dr Dan Hanson)

1. Lancet 1990; 336: 1105-07. Effect of delivery room routines on success of first breast-feed

2. Breastfeed Rev. 2011 Mar;19(1):19-26. Tongue-tie and breastfeeding: a review of the literature. Edmunds J1, Miles SC, Fulbrook P. Effects of Tongue Ties on the Mouth Throughout Life

3. Arch Dis Child. 2015 May;100(5):489-94. doi: 10.1136/archdischild-2014-306211. Epub 2014 Nov 7.

Tongue-tie and frenotomy in infants with breastfeeding difficulties: achieving a balance.

Power RF1, Murphy JF1.

4. Goldman AS. The immune system of human milk: antimicrobial, antiinflammatory and immunomodulating properties. Pediatr Infect Dis J 1993 Aug;12(8):664-71.

5. Slade HB, Schwartz SA. Mucosal immunity: the immunology of breast milk.

J Allergy Clin Immunol 1987 Sep;80(3 Pt 1):348-58.

6. Immunology of Milk and the Neonate. Edited by J. Mestecky et al. Plenum Press, 1991.

7. JAMA Pediatr.2015;169(6):e151025. doi:10.1001/jamapediatrics.2015.1025. Breastfeeding and Childhood Leukemia Incidence. A Meta-analysis and Systematic Review

8. Exclusive Breastfeeding and Risk of Dental Malocclusion. Australian Research Centre for Population Oral Health, School of Dentistry, University of Adelaide, Adelaide, Australia.

9. Eur J Pediatr, 1999 Nov;158 (11):896-901. Conclusion: Mouth breathing appears to be associated with an increased risk for cot death.

10. H. Brown Otopalik DDS American Journal of Orthodontics - Dentofacial Orthopedics Vol. 113 No. 6 June 1998.

11. Soft Tissue Dysfunction: a missing clue when treating malocclusions. German O. Ramirez-Yanez, Chris Farrell. International Journal of Functional Orthopedics (2005).

12. Prevalence of malocclusion among mouth breathing children: do expectations meet reality? Souki BQ, Pimenta GB, Souki MQ, Franco LP, Becker HM, Pinto JA, Federal University of Minas Gerais, Outpatient Clinic for Mouth-Breathers, Belo Horizonte, Brazil. Int J Pediatr Otorhinolaryngol. 2009 May; 73(5): p.767-773.

13. Etiology, clinical manifestations and concurrent findings in mouth-breathing children. Abreu RR, Rocha RL, Lamounier JA, Guerra AF. J Pediatr (Rio J). 2008 Nov-Dec; 84(6): p.529-535.

14. Radiological evaluation of facial types in mouth breathing children: a retrospective study. Costa JR, Pereira SR, Weckx LL, Pignatari SN, Uema SF. Int J Orthod Milwaukee. 2008 Winter; 19(4): p. 13-16.

15. Karjaleinen et al. Association between early weaning, non-nutritive sucking habits and occlusal anomalies in 3 year old Finnish children. Int J Paediatr Dent. 1999-9: 169-73

16. Page DC. “Real”early orthodontic treatment From birth to age 8. Funct Orthod. Spring-Summer; (1-2):,56-8 2003; 20:48-54.

17. Otolaryngol Head Neck Surg. 2002 Dec;127(6):539-45. The effect of ankyloglossia on speech in children.