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Tongue Ties and Other "Tethered Oral Tissues"

Updated: Apr 2

An estimated 2-10% of babies have tight lingual (tongue) frenula. (A frenulum or frenum is a band of tissue, in this case, under the tongue.) Experts estimate that about 20% of these may need to be treated by a doctor or dentist to help with maternal nipple pain or difficulty transferring milk.

Tongue tie (ankyloglossia) diagnoses have increased over 800% in the past decade, and now lip (labial) and cheek (buccal) ties are suddenly being diagnosed. The group of oral tissues is referred to as “tethered oral tissues” if the clinician believes they are restricting movement of the structures needed for optimal breastfeeding. The Academy of Breastfeeding Medicine (ABM) has raised concerns about this, and they encourage lactation consultants and other professionals to rely on evidence, not theory or opinion. The New York Times recently investigated the "booming business" of tongue tie surgeries and produced a guide for parents.

In 2020, the Australian Dental Association (ADA) published a statement written by a multidisciplinary panel of experts in the field of pediatric dentistry, oral maxillofacial surgery, lactation, neonatology, midwifery, speech-language pathology, and others to review the scientific evidence on the diagnosis and management of tongue tie and other oral frenula.

They found that:

  • “Breastfeeding issues can be associated with ankyloglossia.

  • A minority of children may develop speech problems as a result of ankyloglossia

  • No available evidence demonstrates causative association between ankyloglossia and speech articulation problems

  • There is no evidence to suggest that buccal or labial frena can lead to problems with feeding or speech

  • Oral problems, such as malocclusion, may arise in a minority of individuals with a prominent lingual or labial frenum”

Before the considering surgery, the ADA recommends management by a qualified IBCLC, midwife, speech language pathologist, or child health nurse, including “advice on positioning, latch optimisation, feed frequency, supporting mothers to maintain milk supply, and the use of external tools such as nipple shields or supplementary nursing systems.”

Once those nonsurgical methods have been exhausted, a qualified physician (pediatric dentist, ENT doctor, oral surgeon, pediatric surgeon, or oral maxillofacial surgeon) can assess the need for frenotomy (cutting or lasering the tie).

When is a Visible Frenulum a “Tie”?

Let’s look at the picture above. First of all, clearly that baby has a visible frenulum, but is it a “tie”? You can see that the tongue may be able to move around well, in that it doesn’t appear totally glued to the floor of baby’s mouth. It also looks likely that they have had a few milliliters of their frenulum cut already. We don’t know how well the baby can extend their tongue, but not much extension is involved in breastfeeding. We don’t know if the mother is experiencing pain or if there are milk transfer issues. 

Tongue tie is a functional, not a visual, diagnosis; this means that it’s impossible to diagnose it from a picture—the clinician needs to see how the tongue moves. Some lingual frenula may be “stretchier” than others, and many babies with visible frenula breastfeed very well with proper positioning and latch.

The picture is concerning though, and I would suspect there still may be some restriction. The baby needs to have a breastfeeding assessment including weighted feedings and possibly be referred for further examination to a qualified physician. If this baby does indeed have a tight lingual frenulum that restricts normal movement, the mother’s milk supply can drop over time due to ineffective breastfeeding.​

Surgery of anterior ties (attachment to the tip of the tongue, or close to it) is usually low risk, with minimal pain to the baby (but still should not be done without good cause, because low risk does not mean no risk). Surgery for a “posterior tie” (the existence of which is controversial), however, cuts more deeply into the tissue and is more painful. The risks of cutting into this highly sensitive and vascular area are considerable (potential nerve or muscle damage, excessive bleeding, injury to salivary glands, infection, and more).

Cold steel is recommended for frenotomies in babies <28 days; either cold steel or laser can be used for older babies (but has higher risks, such as eye exposure and inhalation of coolant spray).

Post-operative instructions to stretch or manipulate the wound have no evidence supporting them, are extremely painful to the baby, and can cause scar tissue formation. The ABM and ADA advise against them. Pain in a baby’s mouth can create oral aversion, meaning refusal to let anything into the mouth, including their mother’s nipple.

Other Tethered Oral Tissues

Labial frenulum in breastfed baby
Source: public Facebook lip tie support page

There is no evidence that a tight labial frenulum (lip tie) affects breastfeeding. As long as the lips can form a seal to allow suction, the lip is functioning as intended with regard to breastfeeding. In fact contrary to what we thought, new MRI research shows the upper lip does not even need to be everted (flipped out) while latching! In the picture above, you can see a normal labial frenulum (not a tie, despite the many comments on the page from laypeople diagnosing it as such). Cheek (buccal) ties are quite simply not a thing. They are part of the normal anatomy of the mouth.

The picture below is an example of what people are finding online about reasons to have oral tissues assessed.

tethered oral tissues unsupported claims
There is absolutely zero evidence that “ties” cause—I’m not even joking—things like anxiety, having a double chin, ADHD, bed-wetting, pelvic floor dysfunction, and toe walking.

There is absolutely zero evidence that “ties” cause—I’m not even joking—things like anxiety, having a double chin, ADHD, bed-wetting, pelvic floor dysfunction, and toe walking. There is also no evidence to support surgically altering the mouth “just in case,” to prevent potential future issues (real or imagined). (About 5–9% of people will eventually get appendicitis, which can be life-threatening, but it is still not recommended to remove everyone’s appendix. Yes, I know that’s an extreme example, but just saying.)

(Source) Red X’s and NOPES indicate that these are theories with not enough evidence to make any kind of conclusion about and/or are ludicrous. The green checkmark has higher quality evidence (but breastfeeding management should still be optimized before considering surgery). The yellow question mark indicates there is some research showing an association between tongue tie and speech articulation disorders, but there is not enough evidence to conclude that tongue tie treatment in infancy leads to better speech articulation outcomes. This 2021 systematic review found no association between tongue tie and speech disorders.

What Does “Trained in Ties” Mean?

It means “proceed with caution.” Practitioners referred to as “tie savvy,” “trained (or specializing) in ties,” or “TOTS Specialty Trained” tend to diagnose ties for conditions that have (a) not been studied, or (b) have been studied and found to be not associated. Courses that teach and certify individuals as tethered oral tissue experts are not regulated by any independent agency. The ADA’s expert review panel concluded that “no training courses exist that allows any member of a health profession to register as a specialist or ‘expert’ in the treatment of ankyloglossia.”

Although tongue tie “experts” may believe strongly that they’re doing the right thing for their patients, belief is not evidence. One also has to consider the fact that after after investing significant amounts of effort and money in courses and certifications, there may be an unconscious emotional incentive to believe that ties are everywhere and affect everything in the body. This is why it’s important to practice in accordance with the scientific evidence, and not personal belief, despite how experienced a person might be—especially when cutting or lasering a baby’s mouth is being considered. Babies cannot report numbness or movement difficulty, and it can be hard to know how much pain or discomfort they’re feeling.

Unproven post-frenotomy treatment plans, such as craniosacral therapy or “bodywork,” while gentle and risk-free (except for chiropractic), they are expensive, time consuming, and there is no evidence that they work any better than just letting your baby grow and develop more.

Proceed with caution, and discuss your thoughts on this subject with your pediatrician. For more in-depth information, see this 2020 review of the scientific evidence by the ADA’s panel, and this 2017 Cochrane Review.

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