Tongue Tie Clinic FAQs
There are common questions which are asked by our guests in relation to tongue and lip ties. Having treated hundreds of infants and children for tongue and lip tie, Dr Dan has complied this list in conjunction with his colleagues at Enhance Dentistry (where he also performs infant procedures) and The Tongue Tie Institute (which he is co-founder of).
1. Is there a difference between “tongue tie”, “tongue tether”, “oral restriction”, or “ankyloglossia”?
All of the above are interchangeable terms which related to the lingual frenum causing restriction of movement in the tongue. Traditionally, these terms are thought of as relating to the entire tongue being fixed, or tied to the floor of the mouth. However, most cases are be less obvious to see. The tongue needs to be able to elevate, more than it needs to protrude and so thorough history taking, and careful observation during function are the only way to diagnose “tongue tie”or whatever term you choose to use.
Tongue and lip ties are the result of a failure of cell death (apoptosis) along the midline of the head and neck at 12 weeks in-utero. The exact reason for this failure of apoptosis is the subject of debate at present with various hypotheses currently being explored. Whatever the reason, this failure of apoptosis almost always affects both the lip and tongue. This does not mean that both will always need treatment. It is our experience that for breastfeeding infants, the lip usually contributes to the presenting symptoms. For older children, due to the descending of the bone with the eruption of the upper teeth and the mouth no longer needing to function for breastfeeding, an upper lip will be assessed based on other clinical signs and symptoms.
In infancy: breastfeeding difficulties are common, as well as colic and reflux. In childhood: speech difficulties, poor jaw growth /dental crowding and fussy eating are common. In adulthood: head and neck tension, snoring and sleep apnoea may be related
A tongue tie, especially a posterior tie, can be difficult to identify without undertaking a full oral examination utilising the correct palpation technique. In other cases, a health professional may hold the belief that a tongue tie is only an issue if it presents on the anterior (front) underside of the tongue.
In fact, all tongue ties have a posterior element, whether or not there is an anterior component. Another way to explain this is that every tongue restriction has an anchor under the oral tissue (submucosal). In many cases posterior tongue ties do not prevent the protrusion (sticking out) of the tongue and so cannot be readily identified visually. The accurate identification of a posterior tongue tie, especially a sub-mucosal tie, requires manual palpation by a health professional experienced in the correct examination technique. In addition a good functional history is required. Symptoms which are experienced by the child and mother are an indication that there might be a tie.
In certain rare cases a health professional may express an opinion that posterior ties do not exist, however there are numerous articles in reputable scientific journals as to the presentation and effect of posterior tongue ties and the effective treatment of them with laser. Please feel free to contact us if you would like access to these articles.
To make a proper diagnosis, a proper functional history (discussion of the story so far and knowing what symptoms you have had) is essential. Furthermore, a functional assessment (observing the tongue during function), as well as palpatory assessment (feeling under the tongue) is necessary.
Many health professionals are not aware of the implications of not treating a tie. Often, the thought process is that providing the baby can put weight on (with difficult breast feeding, bottle feeding, or otherwise) then there is no point in treating. The problem is that the tongue is imprortant throughout life, and particularly during growth. The tongue drives the growth of the mid face and jaws so a tied tongue will usually result in a narrow and small jaw with dental crowding later on. Furthermore, the tongue affects overall body posture, in particular the head and neck. It’s important in speech, swallowing and talking as well. So if it’s tied, ideally it would be treated as soon as possible in order to attempt to limit the chances of severe dental crowding, lack of jaw growth and other future problems.
The most important factor in the success of any surgery is always going to be the operator. Without this, there are more risks involved. The operator must have done the necessary training to ensure competence and must have had plenty of experience to give a better chance of success. Dr Dan (founder of Gold Coast Tongue Tie Clinic) has treated hundreds of babies. He is also co-founder of The Tongue Tie Institute, and one of Australia’s most experienced tongue and lip tie surgeons.
In relation to laser Vs scissors:
Firstly, there are many types of laser. Some are dry (diodes) and create a heating of the tissues, while others like ours use water to keep tissues cool during surgery.
A laser “ablates”(vaporises) the tissue. It does not cut, or crush the tissue like scissors. It also seals nerve endings to reduce immediate post-op pain, and helps to coagulate to reduce bleeding. A laser is extremely accurate. In the hands of an experienced user it is almost impossible to ablate the wring area, or cause unwanted injury.
Not all lasers are the same. We use different lasers in different circumstances. However, for infants we believe that the procedure needs to be as quick as possible so we can get the baby back to it’s mother for feeding after treatment. Furthermore, minimal penetration of tissues and less heat is desirable. This is why we always use a Waterlase iPlus 2.0 (Er,Cr:YSGG laser) for infants.
There are many possible reasons but here are a few:
- Lasers are highly regulated (especially in Queensland) and so require special training, as well as several different licenses to use and to possess them. The premises within which the laser is used must also comply with regulations, so considerable remodelling of premises may be required.
- Lasers are very expensive to buy. In our case, the Waterlase is an investment of around $100,000. We used to use a diode laser (only $7000). However, as soon as we saw the Waterlase being used on infants with less trauma, and greater speed, we decided we could not continue in that way, and decided to take the step towards what we believe is a better way for our patients.
- Preparation for your consultation
We will send you some important documents with lots of information to prepare you for your consultation. Depending on what is needed, several appointments may be necessary before we see you. Eg: with a lactation consultant, and / or with a body worker (chiropractor / osteopath / physiotherapist)
- The consultation
A through consultation is essential for effective diagnosis and for educating our guests in how to best care for the infants in the post-operative period. Usually this consultation will be a joint consultation with our dentist and lactation consultant or mid-wife
- The procedure
Laser tongue and lip tie surgery is quick and effective. Throughout the procedure our dedicated nurse will be there to sooth and talk to our little guest. We move Immediately post-operatively our lactation consultant or mid-wife who will be there to assist with the feeding and after-care. Skin-skin contact is provided for as much of the process as possible. You will have as much time as you like to feed and soothe your baby. We have a dedicated relaxation zone called “The Chill Out Space”which we can use in the event that you wish to stay longer than your normal appointment time.
- The care call
We will make an appointment with you to call you 1-2 days later so we can assist you in whatever way is necessary
- The 1 week review
Our protocol involves you returning to our clinic 1 week later for a free review appointment with our lactation consultant, or mid-wife. This helps to ensure that everything is going according to plan
- Continued phone checks
Followed by a 2 month review via email. If all is going well, we don’t need to see you again
Consistent with the approach endorsed by the Australian Dental Association, the application of anaesthetic will depend on the age of the patient and nature of the procedure. Due to potential complications associated with injectable anaesthetic, these are not used in very young children. In addition, the effect of anaesthetic prevents effective breastfeeding immediately after the procedure which is important for healing, for settling and comforting the child post-surgery, and to enable our team to observe the breastfeeding latch. The laser we use has an analgesic effect following application, however this does not usually remove all discomfort and infants may experience some pain during the brief period of surgery. In slightly older, non-breastfeeding children, a strong topical anaesthetic gel may be applied. For some children, the taste of the anaesthetic is more disconcerting than the feeling of the laser release. Parents who wish to may also give an age appropriate analgesic to their child about an hour before surgery, although preparations containing ibuprofen (like Nurofen or Advil) and aspirin should not be used.
The vast majority of our little guests settle within a minute or two after the procedure during the post-op feed. The anaesthetising quality of the laser seals the nerve endings and so there is less pain than there would be otherwise. Most babies leave the clinic either asleep, or very calm after having been fed. The babies do not appear to be in any pain at this time. Later on, normal inflammation happen as a part of healing and so we will advise you of your options for pain relief.
These can include:
- Baby Panadol providing the baby is over 4 weeks old and is the correct weight (for the dose)
- Homeopathic remedies such as “tongue tie drops”which contain Arnica and other herbs
- Frozen breast milk, grated into icicles and applied to the mouth
- Skin-to-skin contact
We would never stop you being there is that is your choice. However, for the following reasons we prefer that you remain in the consultation room:
- We like to focus on the baby and not be concerned for your emotional or physical wellbeing during surgery
- We like you to be as relaxed as possible after the procedure as you will be required to soothe and feed the baby
- We like to keep the number of people in the surgery to a minimum. This assists with sterility as well as safety
- The consultation is just over 30 minutes
- We will be with your baby in surgery for around 7 minutes
- Preparation (not surgery) takes approximately 4 minutes
- The surgery itself is approximately 3 minutes
- The post-op feed and recovery takes around 20 minutes
- This is a total of approximately 1 hour
Regardless of age, we recommend patients receive manual therapy (chiropractic/osteopathy) in the 24-48 hours prior to treatment and in the 24-48 hours subsequent to treatment.
Manual therapy from an experienced and appropriately qualified practitioner (one who has worked with infant tongue ties on a regular basis) reduces tension in the muscles of the mouth, head and neck, significantly increasing accessibility in the mouth for surgery. In addition, manual therapy is valuable in teaching new muscle habits and establishing new neural pathways, leading to better function.
The following research papers show the evidence to support this approach in infants.
Regardless of the feeding method, an LC who is experienced in working with infant tongue and lip ties is an essential part of the team. The LC is a “feeding expert”for infants and toddlers. Therefore, they can advise on how to feed most effectively with the breast, and the bottle alike. Furthermore, they can give you tips and tricks to limit of avoid the need for using the bottle (such as finger or syringe feeding). Moreover, they can assist with issues associated with eating solids.
Patients who do not keep in close contact with their “tongue tie LC”often do not get the best outcomes. They are there to guide you through the healing process and beyond.
At Gold Coast Tongue Tie Clinic, the consultation and procedure are both considered “dental treatment”, so they are not covered under Medicare. However, for private health insurance, the following item numbers are used:
- 015 (consultation)
- 391 (per frenectomy)
There are minimal restrictions on travel or other activity after surgery. However, carers should bear in mind that our active wound management protocol requires stretches to be performed 6 hours after surgery and every 4 hours for 3 weeks post-treatment, then every 8 hours in the 4th week. So travel plans will need to be considered carefully to ensure this regime can be maintained. In general it is best to take things easy in the first couple of days post-surgery and we advise against swimming or other medical procedures (such as immunisations) for seven days after the procedure.
We routinely do the following 4 things in order to follow up and check things are going well.
In the event that you need further support, we encourage you to call our clinic so we can advise of the best course of action. Usually, the best person to assess function is the LC which is why we encourage you to team up with an LC both before and after treatment.
- The care call – We will call you 1-2 days later so we can assist you in whatever way is necessary
- The 1 week review – our protocol involves you returning to our clinic 1 week later for a free review appointment with our lactation consultant, or mid-wife. This helps to ensure that everything is going according to plan
- Continued phone checks – we encourage you to call your lactation consultant, or call our clinic whenever you need to
- Two month review via email. If all is going well, we don’t need to see you again