Jj is for Jottings 140.  Tongue Tie.

After discussing /s/ speech sound problems in the previous post, in a way the topic of this post is the opposite: tongue tie.  Why is it the opposite?  Some /s/ problems involve tongue protrusion or sideways movement. But tongue tie anchors the tongue which limits movement to varying degrees.

WHAT IS TONGUE TIE?

The “real” name for tongue tie is ankyloglossia.  (“Gloss” is Greek for “tongue”; “ankylo” means “crooked” or “bent”.)  Tongue tie is when the frenulum which attaches the tongue to the floor of the mouth is too long or too tight.  This anchors the tongue to the floor of the mouth and restricts movement.  Before we answer the question of what is tongue tie, we’d better ask…

What is a Frenulum?

A frenulum (interchangeable with “frenum”) is a piece of soft tissue that helps to anchor a semi-mobile body part.  The term “frenulum” comes from the Latin term meaning “little bridle.” As the name suggests, frenula help to “rein in” organs and structures that are not completely connected to each other.  There are two types of frenula (or frenulums) in the mouth:

• Labial frenula: There are two – one between the top lip and gum (superior labial frenulum) and one between the lower lip and gum (inferior labial frenulum). If there is an issue with a labial frenulum, it can change the way your teeth grow and influence your dental health. It can even pull your gums away from a tooth, revealing the root.  I have to admit that I wasn’t aware of that possibility until now.
• Lingual frenulum: Extends along the bottom of the tongue and connects to the bottom of the mouth just behind the teeth. This is the one involved in tongue tie.  Frenula can vary in length and thickness.

You can easily both feel and see (in a mirror) all three frenula in your mouth.

A Little Frenulum Story.

When my elder son (co-administrator of this page) was a toddler, he tripped over and hit his face on the edge of a cardboard box.  He started to bleed from his mouth.  And bleed.  And bleed.  His bathwater turned pink.  And we didn’t realise quite how much he was bleeding until his father checked him a while after putting him to bed and found his pillow soaked with blood.  After a rush to the local doctor (out of hours, naturally) it transpired that he had torn his top labial frenulum.  The doctor actually said he had torn his frenular artery, and that’s why he was bleeding so much, and that made sense.  Anyway, I had to hold him down while the doctor stitched his frenulum, and I will never forget the look in his eyes locked onto mine as I was holding him down.  The doctor didn’t enjoy the experience, either.

And That Wasn’t The End.

You wouldn’t believe it – or perhaps you would – a few days later we had to repeat the whole process because he fiddled with his stitches and pulled them out.  The doctor was horrified at being called upon to stitch him again, and he even begged us to take him elsewhere.  This was ludicrous, since he was far closer than the next medical practice.  I think he was responding to the look in Kieran’s eyes, too.

Interestingly, I can’t find any evidence of there being a frenular artery in the mouth.  The frenula there seem to be just mucous membranes.  There may be, and I just haven’t managed to find the information.  However, that turns out to be quite significant, since years later we discovered that my son has a blood clotting disorder.  If there was no such thing as a frenular artery in the mouth and we had known that, we might have been alerted to the blood disorder much sooner.

Back to Tongue Tie.

Now we know what a frenulum is and the fact that it is involved in tongue tie, we need to go a little further into its involvement.  Tongue tie varies in degree of severity. There are mild cases in which the frenulum is a little long or tight and tongue movement is a little restricted.  Then there is a thickened white, non-elastic tissue which anchors the tongue further.

The extreme end of the scale can even have the frenulum extending along the floor of the mouth in a fan shape, reaching towards the lower front teeth and completely tethering the tongue to the floor of the mouth.  In this extreme case there can be discomfort or pain when the tongue’s owner attempts to move it.  An infant with this degree of tongue tie would not be able to feed. So the problem would be detected quickly and the tongue tie snipped or lasered.

 

What Does a Tongue Tie Look Like?

This depends on the severity of the tongue tie, and I have seen a number of slightly tongue-tied children who have no obvious visual signs until you ask them to poke out their tongue.  The tongue is indented in the middle, resulting in a heart shape because the tight frenulum is pulling back the middle of the tongue.

With a more severe tongue tie, a baby’s tongue may look small, rounded and permanently heart-shaped.  As the child grows older the appearance changes, and the tongue may look square and even more “split” in two.  Or it may look thickened and too large for the mouth, so that it curls up at the sides.  The appearance becomes more conspicuous as the child grows older.

DIAGNOSIS.

In milder cases, diagnosis may be difficult; it is not always apparent by looking at the underside of the tongue.  In this case diagnosis is often dependent on the range of muscle movement.  For infants, passively elevating the tongue tip with a tongue depressor may reveal the problem. And tongue tie is always worth considering for infants who have feeding difficulties.

For older children, making the tongue move to its maximum range will demonstrate the tongue tip restriction.  This includes poking out the tongue; trying to touch the nose and chin with the tongue (not simultaneously!); opening the mouth wide and touching upper teeth with the tongue.  (Or not, if there is a tongue tie!)  An oral examination involving these types of activities is an important part of assessing any speech problem.

Speech Sound Problems.

Older children with tongue tie will often present with speech sound difficulties, and this may also lead to a diagnosis of tongue tie.  Obviously the more severe the tongue tie, the more severe are the articulation difficulties. Disquietingly, I read in a journal article that many children can have speech therapy for years with little improvement.   Tongue tie was not even considered as a possible cause.  By doing an oral exam, together with noting which sounds are involved, a speech pathologist should uncover a tongue tie early on.  (It wasn’t an actual study with statistics involved, so I’m hoping that “many” children was an exaggeration.)

As with any speech sound problem, the more words you put together, the more complex the movements become.  The more complex the movements, the more likely it is that speech will be unclear.  And that leads to the question of whether or not you should correct your child’s speech.  (The last part about feeding in correct sounds is the relevant part here.)

 

TREATMENT.

II mentioned treatment of the actual tongue tie above: if it is causing problems, appropriate health professionals can laser or snip it.  This is a quick and simple process.  However, sometimes tongue tie also involves a shortened muscle in the tongue, and so sometimes snipping the frenulum isn’t enough to produce tongue movement in all directions.

Surgery can occur from weeks old right through to adults who decide to have their tongue tie released in an attempt to improve issues, including dental, sleep, and tension in the neck.

SIDE EFFECTS OF TONGUE TIE.

There are several side effects of tongue tie which can interfere with quality of life in various different ways.  These include: cosmetic appearance; oral and dental hygiene; feeding difficulties; oral kinaesthesia; tongue mobility; and emotional factors.  And of course there is the more direct effects requiring speech therapy.  Since this article is quite long enough, we will discuss these side effects in the next article.

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