Tongue-Ties

Being tongue tied isn’t just a figure of speech. For people with a tongue tie, speaking, eating, and dentition may be affected by a small piece tissue sitting under the tongue.  A tongue tie, or “ankyloglossia,” is a condition where there is a thick, tight, and/or shortened band of tissue called the lingual frenum that attaches the tongue to the floor of the lower jaw and restricts tongue movement. While everyone has a lingual frenum, infants, children, and adults with tongue ties can’t move their tongue freely in and around their mouth which can result in difficulties with breast or bottle feeding, eating, swallowing, breathing, dentition, postural control, and/or speaking.

As an occupational therapist, I often see the impact of tongue ties with children who have difficulty transitioning to solid foods or are considered “picky eaters.” Take Eli, a 4-year-old boy who came to occupational therapy to expand his food repertoire for improved nutrition. When reviewing Eli’s history, his mother reported that she had a difficult time breastfeeding Eli, unlike her older child, and that he had trouble transitioning to solid foods around 6 months old. “It was as if he didn’t know what to do with food in his mouth,” she said.

Currently, Eli eats a very limited diet consisting of most carbohydrates, chicken nuggets, cooked carrots, and some softer fruits. Mealtimes usually take over 45 minutes to complete. Eli is also a “messy” eater, typically ending his meal with food on his teeth, around his mouth and on his shirt. While feeding himself with his fingers, Eli often puts his fingers in his mouth along with the food. After talking more to Eli and his mother, I observed that Eli also had trouble accurately producing certain speech sounds.

When approaching this situation, my first step was to do an oral exam to look at Eli’s mouth, given that his tongue wasn’t functioning as it should. When he placed a piece of food in his mouth, it appeared as though he had to work extra hard to move around the food based on the amount of movement in his facial muscles. Even so, food still seemed to get stuck in his cheeks and teeth. Typical eating should first start in the middle of the tongue and then move to the molars for chewing and then back to the tongue in order to swallow. Without being able to comfortably move the tongue around the mouth, the simple task of chewing and safely swallowing can become extremely challenging and tedious. Individuals with tongue ties often take a long time to eat meals, use extra muscles in their face for support, and prefer softer or “pre-chewed” foods, like those that Eli eats. These foods require less work of the tongue and more safe, comfortable eating.

Messy eating and placing fingers in the mouth when finger feeding are also signs of limited tongue function. Without having adequate tongue strength and range of motion in the mouth, children, like Eli, often use their fingers to strategically place the food where they’ll have the most control for safe chewing and swallowing. As a result, food will frequently wind up in places they never intended, such as their cheeks, teeth, and lips. Children that are bothered by this “messy” feeling, may be seen using their fingers to clean out their mouth in-between bites or after a meal is complete.

Perhaps you can relate. Imagine eating a piece of popcorn. You put it on your lips, your lips push it to your tongue, and your tongue pushes it to your molars to chew. You chew a few times before your cheek and your tongue work together to position that chewed up popcorn into the center of your tongue. Your tongue rolls it all backwards, then you swallow. A second later, you feel a tiny kernel lodged between two back teeth. You try to ignore it, but now it’s all you can think about. What do you do? First you try to get that kernel out with your tongue. You twist your tongue all the way back, using all the strength your tongue has, to try and pop that kernel out of your teeth. If that doesn’t work, you try to get it out with your fingers or a toothbrush, or some floss.

Now, think about this situation for a child who has a tongue tie. Not only is chewing and swallowing challenging, but the uncomfortable feeling of having something stuck in the teeth may just not be worth it. After the first time a child with a tongue tie tries a chewy, tough, or sticky food, s/he may have that same unpleasant feeling. S/he may be thinking that eating that food was too much work or too difficult to safely and confidently control. Initial negative associations are powerful and oftentimes long-lasting.

Why does Eli like these foods? Soft, single texture (rather than different foods mixed together), and/or “pre-chewed” foods, such as chicken nuggets, soft fruit, and most simple carbohydrates are easy to eat. They require little chewing and are easy to maneuver around the mouth with limited tongue strength and mobility.

Results of Eli’s oral exam indicated limited tongue range of motion and strength. He was not able to use his tongue to successfully lick his lips or teeth and was unable to hold his tongue up to the top of his mouth. While occupational therapists do not formally diagnose a tongue tie, the results of the oral exam, coupled with parental reports and observations of difficulty feeding and production of specific speech sounds, demonstrate good evidence of a tongue restriction. As a result, I would refer Eli to a knowledgeable provider, such as a pediatric dentist or ENT for a tongue tie diagnosis and possible tongue tie revision (a procedure called a frenectomy or frenuloplasty).

Regardless of the diagnosis, Eli still demonstrates significant difficulty with feeding and potential limitations with speech. Therefore, I would recommend occupational therapy services to address feeding skills and a speech therapy evaluation to assess for difficulties with articulation. Together, the occupational therapist and speech therapist will work together to improve Eli’s oral motor skills for improved function.

For more information about tongue ties, please click here. 

Author – Julia Marvil, OTD-OTR/L