​Tethered Oral Tissues: challenging for babies, parents, and healthcare providers.

Introduction

Tethered Oral Tissues (TOTs) is a term describing one or more restrictions in the range of motion within the lips, cheeks, or tongue of an individual. This restricted range of motion may be due to an overly short or taught frenum—a membranous fold of tissue which supports or restricts the mobility of one body part to another less mobile body part, or it may be due to fascia tension elsewhere within the body. The end result of tethered tissue regardless of the root cause is that the muscles of the lips, cheeks, and/or tongue are unable to move with sufficient range of motion to support normal and healthy development of the orofacial complex, impacting the ability of an infant to suck, swallow, and breathe functionally. Dysfunction in the orofacial complex may lead to a host of other ailments as the infant physiologically matures, resulting in diagnoses later in life that might have been prevented with swift treatment in infancy.

Exactly what the difference between normal and tethered oral frena and what movement ability constitutes a normal range of motion, or what impact this has on activities of daily living has yet to be widely accepted. As such, optimal treatment protocol has yet to be accepted and standardized.

Incidence and Prevalence

Tethered Oral Tissues

No data exists to explore the incidence of tethered oral tissues (TOTs) as a whole. Some data exists for tethered frena in the tongue; however, this data looks only at the attachment point of the frenum and not at other factors (like fascia restrictions) which may inhibit range of motion of the orofacial complex.

Tied Lips and Cheeks

Labial (lip) and buccal (cheek) tethers are contentiously debated in the literature. The human mouth contains 7 frena: one in each quadrant of the maxilla and mandible which attaches the gums to the cheeks, one connecting the upper and one connecting the lower lips to the gums, and one underneath the tongue. Variations in the insertation points of those frena, their thickness in size and their contribution to trapping liquid and food can adversely impact oral and dental development when they restrict functional range of motion within the orofacial complex (D’Onofrio, 2019).

Maxilllary labial (upper lip) ties can result in painful breast/chest feeding for the nursing parent when the upper lip is pursed or tense in order to achieve a proper seal on the areola and in doing so, prevents the infant from latching deeply (D’Onofrio, 2019; Kotlow, 2013; Benoiton, Morgan & Baguley, 2016). An overly taught labial frenum can become problematic later in life as well, when it can pull the gingival margin from the tooth or prevent the closure of a diastema (space between the teeth) during orthodontic treatment and can foster the accumulation of plaque along the gingeva and increase the rate of periodontal recession (Priyanka, et al., 2013; Stylianou, et al., 2020). Lip ties may cause central incisors (the front teeth) to rotate, separate or flare (D’Onofrio, 2019).
​
Pronounced buccal frena can limit the movement of the buccinator muscles in cheeks and impact oral cavity function (Iwanaga, et al., 2017), and may contribute to the pocketing of food in oral vestibules (D’Onofrio, 2019; Rathee & Jain, 2021). The buccinator muscle benefits chewing and swallowing with its maximum range of motion and is one of the first muscles activated when an infant begins suckling. Restrictions in functional range of motion impact the infant’s ability to create a seal on the breast tissue by pulling the corners of the mouth laterally and as it can aid in the comfortable closing of the mouth (Rathee & Jain, 2021), its restriction may impact the ability to keep the lips closed at rest. When these muscles are restricted, excessive pressure may result that impacts the underlying hard tissues, thus resulting in high, narrow palatial arches and malocclusion (Rathee & Jain, 2021).

Tied Tongue

What once seemed self-evident, that the muscles in the tongue need to have optimal range of motion to function correctly is now in question by many as squabbles about where the frena should be attached, what constitutes a “normal” range of motion, or assertions that feeding is successful if the parents perceive it as such. We do know that the upper and lower insertion points of the lingual frenum, as well as the thickness and flexibility of the free tongue muscles impact the tongue’s range of motion and general oral function (D’Onofrio, 2019), and that its ability for vertical lift to the hard palate is a better measure for normal lingual function rather than the ability to extend the tongue horizontally past the incisors, as is commonly cited (Yoon, et al., 2017).
​
Numerous studies in recent decades have claimed a wide variety of prevalence of ankyloglossia and other tethered oral tissues. One of the most widely cited, and therefore most commonly accepted, studies by Messner and colleagues (2000) for ankyloglossia throughout the scholarly literature cites prevalence establishes an incidence of 4.8%. This study is not definitive, however, as diagnosis was subjective and conducted without the use of a validated diagnostic protocol with proven interrater reliability; this study also involved just 36 breastfed study participants and 36 breastfed control infants (Messner, et al., 2000). It is unclear how this incidence rate can be used ethically in research when the diagnostic screening utilized by its authors was admittedly subjective in nature when standardized diagnostic protocols were available at the time, though to be fair they had not yet been deemed to be as valid and reliable at that time as they are today more than 20 years later.

TOTs Impacts

Tethered oral tissues are linked in the literature with causing a variety of problems. They adversely impact breast/chest feeding, eating, and swallowing in the baby (Cho, et al., 2010; do Rêgo Barros de Andrade, et al., 2020; Ferrés-Amat, et al., 2017; Fernando, 1998; Flavel, & Nordstrom, 2004; Forlenza, et al., 2010; Geddes, et al., 2008; Hong, et al., 2010; Hand et al., 2020; Le Réverénd, et al., 2014; McClellan, et al., 2015; Moss, 1997; Miles, et al., 2013; Parr, 2018; Pransky, et al., 2015; Rasteniene, et al., 2021; Rike, et al., 2004; & Srinivasan, et al., 2019). Many of these children also have gastrointestinal impacts, including receive reflux diagnoses and subsequent avoidable pharmaceutical treatment (Baird, et al., 2015; Bredenoord & Smout, 2007; Collins, et al. 2019; Fishbein, et al., 2013; Gonzalez Ayerbe, et al., 2019; Granderath, et al. 2007; Hand, et al., 2020; Hibbs & Lorch, 2006; Kotlow 2011; Kotlow 2016; Kotlow 2018; Lightdale, et al., 2013; Shepherd, et al., 2013; Siegel 2017; & Watson & Mystkowski, 2008).

Nursing parents experience nipple pain and feelings of helplessness (Riordan & Wambach, 2010) as well as sleep deprivation (Fernando, 1998). There is also an increased risk of postpartum depression in parents who wished to nurse their children but struggled or failed (Sá Vieira, et al., 2016; Wedad Saad, et al., 2018).
Tethered oral tissues can cause malocclusion and adversely impact orofacial growth and development (Boyd, 2011; D’Onofrio, 2019; Le Réverénd, et al., 2014; Pirilä-Parkkinen,  et al., 2009; Sari & Auerkari, 2018; & Upledger & Vredevoogd, 1983). They often lead to disordered breathing such as sleep apnea and its subsequent tonsil and adenoid inflammation (Boyd & Kelly, 2019; D’Onofrio, 2019;  Guilleminault, et al., 2016; Huang, et al., 2015; Lee, et al., 2007; Olivi, et al., 2013). Disordered sleep breathing is linked with an increased risk for ADHD diagnoses (Blesch & Breese McCoy, 2016),  a 40% increased risk for needing special education services (Besson, 2015) and suboptimal orofacial development with subsequent risk of an increased body mass index (Ozbek, et al., 1998)., poor gut microbiota and subsequent physical challenges (Sekirov,  et al., 2010), as well as postural deficits subsequent to airway protection and muscular strain (Ozbek, et al., 1998; Olivi, et al., 2015). Children born with TOTs also may have challenges with speech articulation (Baxter & Hughes, 2018; Bruderer et al., 2015;  D’Onofrio, 2019;  Daggumati, et al., 2019; Ito, et al., 2015; Kent, 2021; Lalakea & Messner, 2003; Le Réverénd, et al., 2014;Messner & Lalakea, 2002, Ostapiuk, 2006; & Walls, et al., 2014).

Assuming the frequency of ankyloglossia is the generally accepted 4.8% of the population, that would be a staggering proportion of our population impacted by that alone, even without considering other forms of tethered oral tissues. Of course, more accurate estimates of prevalence based upon reliable evidence-based diagnostic criteria are likely to be much higher than 4.8%. Diagnostic tools are widely considered to be poor (for a variety of reasons) and inconsistent. Treatment methodology and disciplinary paradigm varies tremendously and there is little discussion about how a healthcare professional can ascertain whether treatment was successful given the poor quality of diagnostic criteria available and disagreement about TOTs’ physiological ramifications.
​
Research into the parental experience of trying to feed a child with TOTs is extremely limited in number and scope, focusing only on their nursing experience and related challenges. But what of babies who are bottle-fed? And what of babies who didn’t have any apparent feeding issues? Surely they are impacted by TOTs as well, and while there is literature supporting the impacts on various physiological systems, the decision of whether to perform a surgical revision of tethered oral tissues is limited by industry guidance to challenges nursing parents face. This is a subject area sorely in need of an interdisciplinary perspective that can tie together (pun intended) the research from a variety of fields in order to present a holistic view of what TOTs entail and how they impact families.

Conclusion

Clearly, this is a complex issue that cannot be resolved by seeking empirical data utilizing typical scientific methods to find direct causality. Quality randomized controlled trial studies about TOTs are incredibly difficult to produce due to the inherent binary “this causes that” quantifiable nature of that methodology, when it is clear from both historical and current data that TOTs result from a complex set of symptomologies through the body that is seldom explained as simply as a short lingual frenum.

But what about accounting for the experiences of families with regard to their symptom presentations? Can this data not be objectively ascertained from families that have received diagnoses according to various diagnostic criteria? What of those families who did not realize that the tonsiladenoidectomy their child had may have been prevented by an evidence-based release of their tongue-tie and adequate habilitation of their oral function? The ability for parents to locate multidisciplinary provider teams that have sufficient education to address all of the areas in which their families are impacted by their tethers would be a wonderful beginning. The first step in that process is to allow these parents to have a voice in the literature with the hopes that the scientific community can put their egos aside and remember that families are needlessly struggling all around the world. To date, the efficacy of typical treatment methods and the lived experiences of the families impacted by TOTs have not had representation within the literature. This is problematic, and is why my dissertation research project, The Case for Establishing Evidence-Based TOTs Management Standards: Implications for Public Health Policy has been submitted to the Union Institute & University's Institutional Review Board (IRB) for approval of my mixed-methods research project. Expected completion date is 12/20/2022.

References

  1. Academy of Breastfeeding Medicine. (2004). ABM Protocol # 11: Guidelines for the evaluation and management of neonatal ankyloglossia and its complications in the breastfeeding dyad. Retrieved from https://abm.memberclicks.net/assets/DOCUMENTS/PROTOCOLS/11-neonatal-ankyloglossia-protocol-english.pdf
  2. Agência Brasil. (2019). Pediatricians call for end of mandatory tongue test. Retrieved from: http://agenciabrasil.ebc.com.br/saude/noticia/2019-04/pediatras-pedem-fim-da-obrigatoriedade-do-teste-da-linguinha?fbclid=IwAR3OdLGxh58JLpgthtFZnVJ3QLJTbAJjMpWORf4Np6PiHNGmYjla4Pt5IIA 
  3. Agência Brasil.(2014). Linguinha test in newborns is now mandatory across the country. Retrieved from https://www.jurisway.org.br/en/article.asp?id_dh=14221#:~:text=The%20determination%20was%20created%20by,generate%20the%20popular%20tongue%2Dtied.
  4. American Academy of Pediatrics (AAP). (2017). Infants prescribed antacids for reflux have increased risk of bone fractures. Retrieved from https://publications.aap.org/aapnews/news/11547
  5. American Osteopathic Association (AOA). (2017). Newborn OMT module: First year. Retrieved from https://certification.osteopathic.org/pediatrics/wp-content/uploads/sites/14/2017/09/pomt-newborn-omt-module-v2.pdf
  6. American Speech-Language-Hearing Association. (n.d.). Orofacial Myofunctional Disorders. Retrieved from https://www.asha.org/Practice-Portal/Clinical-Topics/Orofacial-Myofunctional-Disorders/
  7. Auychai, P., Neff, A., Pitak-Arnnop, P. (2021). Tongue-tie children with a severe Hazelbaker score or difficult breastfeeding greatly benefit from frenotomy or frenuloplasty with/without anaesthesia − First do or do no harm? Journal of Stomatology oral and Maxillofacial Surgery. 8(23).  https://doi-org.10.1016/j.jormas.2021.09.007
  8. BabyLase. (2018). Provider Resources: Form. Function. Physiology. Retrieved from https://babylase.com/provider-resources
  9. Baird, D.C., Harker, D.J. and Karmes, A.S. (2015).  Diagnosis and treatment of gastroesophageal reflux in infants and children. American Family Physician. 92(8). 705-717.
  10. Basic Medical Key. (2016). The deep front line. Retrieved from https://basicmedicalkey.com/the-deep-front-line/
  11. Baxter, R., Hughes, L. (2018). Speech and feeding improvements in children after posterior tongue-tie release: A case series. International Journal of Clinical Pediatrics. 7(3). 29-35. https://doi-org.10.14740/ijcp295w
  12. Benoiton, L., Morgan, M., & Baguley, K. (2016). Management of posterior ankyloglossia and upper lip ties in a tertiary otolaryngology outpatient clinic. International Journal of Pediatric Otorhinolaryngology. 88. 13-16.
  13. Berg-Drazin, P. (2016). IBCLCs and Craniosacral Therapists: Strange bedfellows or a perfect match? Clinical Lactation. 7(3). pp.92-99. https://doi.org/10.1891/2158-0782.7.3.92
  14. Berger, K. M., Wood, J. L., Jenkins, B., Olsen, J., Morse, S. S., Gresham, L., Root, J., Rush, M., Pigott, D., Winkleman, T., Moore, M., Gillespie, T. R., Nuzzo, J. B., Han, B. A., Olinger, P., Karesh, W. B., Mills, J. N., Annelli, J. F., Barnabei, J., Daniel, L., & Hayman, D. T. (2019). Policy and science for global health security: Shaping the course of international health. Tropical Medicine and Infectious Disease, 4(2), 1–15. https://doi-org.proxy.myunion.edu/10.3316/informit.521263075764731
  15. Besson, N. A. (2015). The tongue was involved, but what was the trouble? The search for the cause of a preschooler's difficult behavior leads to a surprising discovery. ASHA Leader, 20(9). http://link.galegroup.com.proxy.myunion.edu/apps/doc/A428356819/AONE?u=vol_m761j&sid=AONE&xid=277220e7 
  16. Blesch, L., Breese McCoy, S.J. (2016). Obstructive sleep apnea mimics attention deficit disorder. Journal of Attention Disorders. 20(1), 40-42. https://doi-org.10.1177/1087054713479664 
  17. Boyd, K. & Kelly, J.J. (2019). Prevention and correction of pediatric SDB/OSA and post-T&A relapse: A non-surgical orthodontic/dentofacial orthopedic approach. Sleep Apnea and Snoring: Surgical and Non-Surgical Therapy. Retrieved from https://ancestralhealth.org/wp-content/uploads/2019/08/AHS-Sleep-Apnea-and-Snoring-Dr.-Boyd-Chapter-74.pdf
  18. Boyd, K.L. (2011) Darwinian dentistry part I: An evolutionary perspective on the etiology of malocclusion. Journal of the American Orthodontic Society. 11(6). 34-39. https://www.mydigitalpublication.com/publication/?m=4034&i=88622&p=34&ver=html5
  19. Bredenoord, A. J., & Smout, A. J. P. M. (2007). Physiologic and pathologic belching. Clinical Gastroenterology and Hepatology, 5(7), 772.
  20. Brooks, E. (2017). IBCLC scope of practice for tongue-tie assessment. Clinical Lactation. 8(3). 121-125. http://dx.doi.org/10.1891/2158-0782.8.3.121
  21. Bruderer, A.G., Danielson, D.K., Kandhadai, P., & Werker, J.F. (2015). Sensorimotor influences on speech perception in infancy. Proceedings of the National Academy of Sciences of the United States of America. 112(44). https://doi.org/10.1073/pnas.1508631112
  22. Buddy D. Ratner, Allan S. Hoffman, Frederick J. Schoen, Jack E. Lemons. (2013). Biomaterials Science : An introduction to materials in medicine. Vol. 3rd ed. Burlington: Academic Press; 2013 Retrieved from: https://search-ebscohost-com.proxy.myunion.edu/login.aspx?direct=true&db=nlebk&AN=485462&site=eds-live&scope=site
  23. Canadian Paediatric Society. (2021). Position statement: Ankyloglossia and breastfeeding. Retrieved from https://cps.ca/en/documents/position/ankyloglossia-breastfeeding#ref16
  24. Catherine Watson Genna. (2017). Supporting sucking skills in breastfeeding infants: Vol. Third edition. Jones & Bartlett Learning.
  25. Centers for Disease Control (CDC). (2021a). Cesarean deliveries by state. Retrieved from https://www.cdc.gov/nchs/pressroom/sosmap/cesarean_births/cesareans.htm
  26. Centers for Disease Control (CDC). (2021b). Births- method of delivery. Retrieved from https://www.cdc.gov/nchs/fastats/delivery.htm
  27. Centers for Disease Control (CDC). (2021c). Results: Breastfeeding Rates. Retrieved from https://www.cdc.gov/breastfeeding/data/nis_data/results.html
  28. Choi, K.W. & Sikkema, K.J. (2016). Childhood Maltreatment and Perinatal Mood and Anxiety Disorders: A Systematic Review. Trauma Violence Abuse. 17(5). DOI: 10.1177/1524838015584369
  29. Clunie, A. (2021). Surgery… A violent profession. Hartford Sage. https://www.hartfordstage.org/stagenotes/ether-dome/history-of-surgery
  30. Collins, C. R., Hasenstab, K. A., Nawaz, S., & Jadcherla, S. R. (2019). Mechanisms of aerodigestive symptoms in infants with varying acid reflux index setermined by esophageal manometry. The Journal of Pediatrics. 206. 240–247. https://doi-org.proxy.myunion.edu/10.1016/j.jpeds.2018.10.051002-9416(61)90221-4
  31. D’Onofrio, L.D. (2019). Oral dysfunction as a cause of malocclusion. Orthodontics and Craniofacial Research. 22(Suppl 1): 43–48. https://doi-org.10.1111/ocr.12277
  32. Daggumati1, S., E. Cohn, J.E.,  Brennan, M.J., Evarts, M., McKinnon, B.J. & Terk, A.R. (2019). Speech and language outcomes in patients with ankyloglossia undergoing frenulectomy: A retrospective pilot study. OTO Open. 3. https://doi-org.proxy.myunion.edu/10.1177/2473974X19826943
  33. do Rêgo Barros de Andrade, F. M., Azoubel Barreto, K., Barbosa Lira, T. C., & Aparecida de Menezes, V. (2020). Is the occurrence of ankyloglossia in newborns associated with breastfeeding difficulties? Breastfeeding Medicine : The Official Journal of the Academy of Breastfeeding Medicine, 15(2), 96–102. https://doi-org.proxy.myunion.edu/10.1089/bfm.2019.0199
  34. Douglas, P. (2017). Making sense of studies that claim benefits of frenotomy in the absence of classic tongue-tie. Journal of Human Lactation. 33(3). 519-523. DOI: https://doi-org.10.1177/0890334417706694/
  35. Durgan, D. J., Ganesh, B. P., Cope, J. L., Ajami, N. J., Phillips, S. C., Petrosino, J. F., Hollister, E.B., Bryan, R. M. (2016). Role of the Gut Microbiome in Obstructive Sleep Apnea-Induced Hypertension. Hypertension, 67(2), 469–474.
  36. Eastwood, J.G., Phung, H. & Barnett, B. (2011). Postnatal depression and socio-demographic risk: factors associated with Edinburgh Depression Scale scores in a metropolitan area of New South Wales, Australia. Australian and New Zealand Journal of Psychiatry. 45(12). https://doi-org.proxy.myunion.edu/10.3316/mais.52385
  37. Edmunds, J. E., Fulbrook, P., & Miles, S. (2013). Understanding the experiences of mothers who are breastfeeding an infant with tongue-tie: a phenomenological study. Journal of human lactation, 29(2), 190–195. https://doi-org.proxy.myunion.edu/10.1177/0890334413479174
  38. Ferrés-Amat  E., Pastor-Vera, T., Rodriguez-Alessi, P., Ferrés-Amat, E., Mareque-Bueno, J. & Ferrés-Padró, E. (2017). The prevalence of ankyloglossia in 302 newborns with breastfeeding problems and sucking difficulties in Barcelona: a descriptive study. European Journal of Paediatric Dentistry. 18(4). pp. 319-325. doi: 10.23804/ejpd.2017.18.04.10.
  39. Fishbein, M., Branham, C., Fraker, C., Walbert, L., Cox, S.,&  Scarboirough, D. (2013). The incidence of orpharyngeal dysphagia in infants with GERD-like symptoms. Journal of Parenteral and Enteral Nutrition. 37(5). 667-673. https://doi-org.10.1177/0148607112460683
  40. Forlenza, G. P., Black, N. M. P., McNamara, E. G., & Sullivan, S. E. (2010). Ankyloglossia, exclusive breastfeeding, and failure to thrive. Pediatrics. 125(6), e1500–e1504. https://doi-org.10.1542/peds.2009-2101 
  41. Geddes DT, Langton DB, Gollow I, Jacobs LA, Hartmann PE, Simmer K. (2008). Frenulotomy for breastfeeding infants with ankyloglossia: Effect on milk removal and sucking mechanism as imaged by ultrasound. Pediatrics, 122(1), 167. https://doi-org.proxy.myunion.edu/10.1542/peds.2007-2553
  42. Genna C. W. (2015). Breastfeeding infants with congenital torticollis. Journal of human lactation, 31(2), 216–220. https://doi-org.proxy.myunion.edu/10.1177/0890334414568315
  43. George T, De Jesus O. (2021). Physiology, fascia. StatPearls. Retrieved from: https://www-ncbi-nlm-nih-gov.proxy.myunion.edu/books/NBK568725/
  44. Grady, P.A. &Hinshaw, A.S. (2017). Using nursing research to shape health policy. Springer Publishing Company. Retrieved from: https://search-ebscohost-com.proxy.myunion.edu/login.aspx?direct=true&db=nlebk&AN=1471605&site=eds-live&scope=site
  45. Granderath, F. A., Kamolz, T., Granderath, U. M., & Pointner, R. (2007). Gas-related symptoms after laparoscopic 360° Nissen or 270° Toupet fundoplication in gastrooesophageal reflux disease patients with aerophagia as comorbidity. Digestive and Liver Disease, 39(4), 312–318. https://doi-org.proxy.myunion.edu/10.1016/j.dld.2006.11.011
  46. Guilleminault, C., Huseni, S., & Lo, L. (2016). A frequent  phenotype for paediatric sleep sleep apnoea: short lingual frenulum. European Respiratory Society Open Research Journal, 2(3), 00043–2016. https://doi-org.10.1183/23120541.00043-2016 
  47. Haller, L.A. & Brown, T. (2016). Upper-Lip Frenum as a Predictive Marker for Unexpected and Unexplained Asphyxia in Infants. Journal of Rare Disorders: Diagnosis & Therapy. 2(38).
  48. Hand, P., Olivi, G., Lajolo, Gioco, G., Marigo, L., Castagnola, R., Cordaro, M. (2020). Short lingual frenum in infants, children and adolescents. Part 1: Breastfeeding and gastroesophageal reflux disease improvement after tethered oral tissues release. European Journal of Paediatric Dentistry. 21(4). 309-317.
  49. Hauser, B. Salvatore, S. & Vandenplas, Y. (2019). Diagnosis and management of gastroesophageal reflux disease in infants and children: From guidelines to clinical practice. Pedatric Gastroenterology, Hepatology and Nutrition. 22(2). 107-121.  https://doi.org/10.5223/pghn.2019.22.2.107
  50. Hazelbaker, A.K. (2005). Newborn tongue-tie and breast-feeding. Journal of the American Board of Family Practice. 18(4). https://doi-org.10.3122/jabfm.18.4.326
  51. Herman M. J. (2006). Torticollis in infants and children: common and unusual causes. Instructional course lectures. 55. 647–653. https://pubmed-ncbi-nlm-nih-gov.proxy.myunion.edu/16958498/
  52. Herzhaft-Le Roy J, Xhignesse, M., Gaboury, I. (2016).  Efficacy of an osteopathic treatment coupled With lactation consultations for infants' biomechanical sucking difficulties. Retrieved from http://journals.sagepub.com/doi/abs/10.1177/0890334416679620?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dpubmed&#
  53. Hibbs, A. & Lorch, S.A. (2006). Metclopramide for the treatment of gastroesophageal reflux disease in infants: A systematic review. Pediatrics. 118(2). 746-752. https://doi-org.10.1542/peds.2005-2664
  54. Hogan, M., Westcott, C., & Griffiths, M. (2005). Randomized, controlled trial of division of tongue-tie in infants with feeding problems. Journal of Paediatrics and Child Health, 41(5-6), 246–250. https://doi-org.proxy.myunion.edu/10.1111/j.1440-1754.2005.00604.x
  55. Hong, P., Lago, D., Seargeant, J., Pellman, L., Magit, A. E., & Pransky, S. M. (2010). Defining ankyloglossia: a case series of anterior and posterior tongue ties. International Journal of Pediatric Otorhinolaryngology, 74(9), 1003-1006.
  56. Huang, Quo, Berkowski & Guilleminault. (2015). Short Lingual Frenulum and Obstructive Sleep Apnea in Children. International Journal of Pediatric Research. 1(1). https://www.kidstownapp.com/wp-content/uploads/short-ling-frenum-and-sleep-apnea-1.pdf 
  57. International Association of Pediatric Dentistry (IAPD). (2021). IAPD Foundational articles and consensus recommendations: Management of ankyloglossia. https://iapdworld.org/wp-content/uploads/2020/12/08_Management-of-Ankyloglossia.pdf
  58. International Board of Lactation Consultant Examiners (IBLCE). (2017). Advisory opinion: Assessment, diagnosis, and referral. Retrieved from https://iblce.org/wp-content/uploads/2017/05/advisory-opinion-assessment-diagnosis-referral-english.pdf
  59. International Board of Lactation Consultant Examiners. (2021). Current statistics on worldwide IBCLCs. Retrieved from https://iblce.org/about-iblce/current-statistics-on-worldwide-ibclcs/
  60. Ito, Y., Shimizu, T., Nakamura, T., & Takatama, C. (2015). Effectiveness of tongue-tie division for speech disorder in children. Pediatrics International, 57(2), 222. https://doi-org.proxy.myunion.edu/10.1111/ped.12474
  61. Iwanaga, J., Takeuchi, N., Oskouian, R. J., & Tubbs, R. S. (2017). Clinical Anatomy of the Frenulum of the Oral Vestibule. Cureus, 9(6), e1410. https://doi-org.proxy.myunion.edu/10.7759/cureus.1410
  62. Kapoor, V., Douglas, P.S., Hill, P.S., Walsh, L.J., & Tennant, M. (2018). Frenotomy for tongue-tie in Australia from 2006-2016: an increasing problem. The Medical Journal of Australia. 208(2). 88-89. https://doi-org.10.5694/mja17.00438/
  63. Kim EJ, Choi JH, Kim KW, Kim, T.H., Lee, S.H., Shin, C., Lee, K.Y. & Lee, S.H. (2011). The impacts of open-mouth breathing on upper airway space in obstructive sleep apnea: 3-D MDCT analysis. European Archives of Otorhinolaryngoly. 268(4). 533‐539. https://link-springer-com.proxy.myunion.edu/article/10.1007%2Fs00405-010-1397-6
  64. Knickman, J.R., Kovner, A.R. (2015). Jonas and kovner’s health care delivery in the United States, 11th Edition: Vol. 11th edition. Springer Publishing Company.
  65. Kotlow, L. (2011). Infant Reflux and Aerophagia Associated with the Maxillary Lip-tie and Ankyloglossia (Tongue-tie). Clinical Lactation. 2(4). 25-29. https://www.kiddsteeth.com/assets/pdfs/articles/aerophagia_2011.pdf
  66. Kotlow, L.A. (2011). Infant Reflux and Aerophagia Associated with the Maxillary Lip-tie and Ankyloglossia (Tongue-tie). Clinical Lactation, 2(4). 25-29. https://www.kiddsteeth.com/assets/pdfs/articles/aerophagia_2011.pdf
  67. Kotlow, L.A. (2013). Diagnosing and understanding the maxillary lip-tie (superior labial, the maxillary labial frenum) as it relates to breastfeeding. Journal of Human Lactation. 29(4). 458‐464.
  68. Kotlow, L.A. (2016). Infant Gastroesophageal Reflux (GER): Benign Infant Acid Reflux or just Plain Aerophagia? International Journal of Child Health and Nutrition. 5(1). 10-16. https://www.kiddsteeth.com/assets/pdfs/articles/finalrefluxpaper3162016.pdf
  69. Krol, D.M. & Keels, M.A. (2007). Oral Conditions. Pediatrics in Review. 28. 15-22. https://doi-org.10.1542/pir.28-1-15
  70. Kumar M, Kalke E.(2012).  Tongue-tie, breastfeeding difficulties and the role of frenotomy. Acta Paediatrica. 101(7). 687-9. [PMID:22404175]
  71. Lalakea M.L., Messner A.H. (2003). Ankyloglossia: the adolescent and adult perspective. Otolaryngology, Head & Neck Surgery. 128(5). 746-752. https://doi.10.1016/s0194-5998(03)00258-4
  72. Le Réverénd, B.J.D., Edelson, L.R., & Loret, C. (2014). Anatomical, functional, physiological and behavioural aspects of the development of mastication in early childhood. British Journal of Nutrition. 111. 403-414. https://doi-org.10.1017/8007114513002699 
  73. Lee SH, Choi JH, Shin C, Lee, H.M., Kwon, Y., & Lee, S.H. .(2007). How does open-mouth breathing influence upper airway anatomy? Laryngoscope.117(6). 1102‐1106. https://onlinelibrary-wiley-com.proxy.myunion.edu/doi/full/10.1097/MLG.0b013e318042aef7
  74. Legiscan. (n.d.). New Jersey Senate Bill 1230 (Prior Session Legislation). Retrieved from https://legiscan.com/NJ/bill/S1230/2016 
  75. Li, L., Lin, C., Peña, M. and Challa, C. (2020), Trigeminocardiac reflex in pediatric adenotonsillectomy: A report of two cases with literature review. The Laryngoscope. 130. 803-805. https://doi-org.proxy.myunion.edu/10.1002/lary.28016
  76. Lightdale, J.R., Gremse, D.A., Heitlinger, L.A., Cabana, M., Gilger, M.A., Gugig, R., Hill, I. (2013). Gastroesophageal reflux: Management guidance for the pediatrician. American Academy of Pediatrics Clinical Report. 131(5). 1684-1695. https://doi.org/10.1542/peds.2013-0421
  77. May, H. & Chun, L.T. (1948). Congenital ankyloglossia (tongue-tie) associated with glossoptisis (retruded mandible) and palatum fissum (cleft palate). Pediatrics, 2(6), 685–687.
  78. McClellan, H.L., Kent, J.C., Hepworth, A.R., Hartmann, P.E. & Geddes, D.T. (2015). Persistent Nipple Pain in Breastfeeding Mothers Associated with Abnormal Infant Tongue Movement. International Journal of Environmental Research and Public Health. 12(9). 10833–10845. https://doi-org.proxy.myunion.edu/10.3390/ijerph120910833
  79. Melink, S., Vagner, M. V., Hocevar-Boltezar, I., & Ovsenik, M. (2010). Posterior crossbite in the deciduous dentition period, its relation with sucking habits, irregular orofacial functions, and otolaryngological findings. American Journal of Orthodontics and Dentofacial Orthopedics. 138(1), 32–40. https://doi-org.proxy.myunion.edu/10.1016/j.ajodo.2008.09.029
  80. Messina, G. (2917). The tongue, mandible, hyoid system. European Journal of Translational Myology. 27(1). 74-76
  81. Messner A.H., Lalakea M.L. (2002). The effect of ankyloglossia on speech in children. Otolaryngology,  Head & Neck Surgery. 127(6). 539-545. https://doi-org.10.1067/mhn.2002.129731
  82. Messner, A. H., Walsh, J., Rosenfeld, R. M., Schwartz, S. R., Ishman, S. L., Baldassari, C., Brietzke, S. E., Darrow, D. H., Goldstein, N., Levi, J., Meyer, A. K., Parikh, S., Simons, J. P., Wohl, D. L., Lambie, E., & Satterfield, L. (2020). Clinical consensus statement: Ankyloglossia in children. Otolaryngology-Head & Neck Surgery, 162(5), 597–611.
  83. Messner, A.H., Lalakea, M.K., Aby, J., Macmahon, J., & Bair, E. (2000). Ankyloglossia: incidence and associated feeding difficulties. Archives of Otolaryngology Head and Neck Surgery. 126. 36-39.
  84. Michas, F. (2021). Births delivered by forceps or vacuum extraction in the U.S. 1990-2019. Retrieved from https://www.statista.com/statistics/276067/us-births-delivered-by-forceps-or-vacuum-extraction/
  85. Miles TS, Flavel SC, Nordstrom MA.(2004). Stretch reflexes in the human masticatory muscles: a brief review and a new functional role. Human Movement Science. 23(3–4).337‐349. https://doi-org. 10.1016/j.humov.2004.08.010. PMID: 15541521.
  86. Miller, J.E., Miller, L., Sulesund, A.K., Yevtushenko, A. (2009). Contribution of chiropractic therapy to resolving suboptimal breastfeeding: A case series of 114 infants. Journal of Manipulative & Physiological Therapeutics. 32(8). pp. 670-674.
  87. Miller, M. (2018). The truth about TOTs: Unpacking the controversies of diagnostics, treatment, and impact of tethered oral tissues [master’s thesis]. Union Institute & University. Retrieved from https://www.researchgate.net/publication/354866889_Title_The_Truth_about_TOTs_Unpacking_the_controversies_of_diagnostics_treatment_and_impact_of_tethered_oral_tissues
  88. Mills, N., Keough, N., Geddes, D. T., Pransky, S. M., & Mirjalili, S. A. (2019). Defining the anatomy of the neonatal lingual frenulum. Clinical Anatomy, 32(6), 824. https://doi-org.proxy.myunion.edu/10.1002/ca.23410
  89. Montgomery-Downs HE, Crabtree VM, Sans Capdevila O, Gozal D. (2007). Infant feeding methods and childhood sleep-disordered breathing. Pediatrics. 120(5). 1030-1035.
  90. Moss ML. (1997). The functional matrix hypothesis revisted.1.The role of mechanotransduction. American Journal of Orthodontics & Dentofacial Orthopedics.112. 8‐11.
  91. Muzik, M., Morelen, D., Hruschak, J., Rosenblum, K. L., Bocknek, E., & Beeghly, M. (2016). Psychopathology and parenting: An examination of perceived and observed parenting in mothers with depression and PTSD. Journal of affective disorders, 207, 242–250. doi:10.1016/j.jad.2016.08.035
  92. National Highway Traffic Safety Administration (NHTSA). (2001). Final report: Legislative history of .08 per se laws. Retrieved from https://one.nhtsa.gov/people/injury/research/pub/alcohol-laws/08history/index.htm#CONTENTS
  93. National Institute of Child Health and Human Development (NICHHD). (2017). What are the recommendations for breastfeeding? Retrieved from https://www.nichd.nih.gov/health/topics/breastfeeding/conditioninfo/recommendations
  94. Neifert, M., Bunik, M. (2013). Overcoming clinical barriers to exclusive breastfeeding. Pediatric Clinics. 60. 115-145. http://dx.doi.org/10.1016/j.pcl.2012.10.001
  95. O‘Shea, J.E., Foster, J.P., O’Donnell, C.P.F., Breathnach, D., Jacobs, S.E., Todd, D.A., & Davis, P.G. (2017). Frenotomy for tongue-tie in newborn infants (Review). Cochrane Database of Systematic Reviews. 3. https://10.1002/14651858.CD011065.pub2/
  96. O’Callahan, C., Macary, S., & Clemente, S. (2013). The effects of office-based frenotomy for anterior and posterior ankyloglossia on breastfeeding. International Journal of Pediatric Otorhinolaryngology, 77(5), 827-832.
  97. Obladen, M. (2010). Much ado about nothing: two millenia of controversy on tongue-tie. Neonatology, 97(2), 83–89. https://doi-org.proxy.myunion.edu/10.1159/000235682
  98. Olivi, G., Signore, A., Olivi, M., Genovese, M. (2013). Lingual frenectomy: Functional evaluation and new therapeutic approach. European Journal of Paediatric Dentistry. 13(2). 101-106.   
  99. Ozbek, MM, Miyamoto, K, Lowe, A.A., & Fleetham, J.A. (1998). Natural head posture, upper airway morphology and obstructive sleep apnoea severity in adults. European Journal of Orthodontics. 20(2). pp. 133-43.
  100. Parr, C.L. (2018). Evaluation of oral function before and after frenectomy in breastfed infants diagnosed with tethered oral tissue [doctoral dissertation]. Louisiana State University. Retrieved from https://digitalcommons.lsu.edu/cgi/viewcontent.cgi?article=5756&context=gradschool_dissertations
  101. Pirilä-Parkkinen K, Pirttiniemi P, Nieminen P, Tolonen, U., Pelttari, U., Löppönen, H. (2009). Dental arch morphology in children with sleep-disordered breathing. European Journal of Orthodontics.31(2). 160‐167. https://academic.oup.com/ejo/article/31/2/160/467349
  102. Pransky, S. M., Lago, D., & Hong, P. (2015). Breastfeeding difficulties and oral cavity anomalies: The influence of posterior ankyloglossia and upper-lip ties. International Journal of Pediatric Otorhinolaryngology, 79(10), 1714–1717. https://doi-org.proxy.myunion.edu/10.1016/j.ijporl.2015.07.033
  103. Priyanka, M., Sruthi, R., Ramakrishnan, T., Emmadi, P., & Ambalavanan, N. (2013). An overview of frenal attachments. Journal of Indian Society of Periodontology, 17(1). 12-15. https://www.jisponline.com/article.asp?issn=0972-124X;year=2013;volume=17;issue=1;spage=12;epage=15;aulast=Priyanka
  104. Rasteniene, R., Puriene, A., & Aleksejuniene, J. (2021). Tongue function characteristics in infants experiencing breastfeeding difficulties and changes in breastfeeding after frenotomy procedures. Clinical Oral Investigations, 25(8), 4871–4877. https://doi-org.proxy.myunion.edu/10.1007/s00784-021-03793-z
  105. Rathee M., Jain P. (2021). Anatomy, Head and Neck, Buccinator Muscle. StatPearls Publishing. Retrieved from https://www-ncbi-nlm-nih-gov.proxy.myunion.edu/books/NBK546678/
  106. Rike, L.A., Baker, N.J., Madlon-Kay, D. J., & DeFor, T.A. (2005). Newborn Tongue-tie: Prevalence and Effect on Breast-Feeding. Journal of the American Bord of Family Practice. 18(1). 1-7.
  107. Sá Vieira, A.E., Torquato, C.N., Moraes Di, L.M., Maite, V., & Aparecida, S.I. (2016). Depressão pós-parto e autoeficácia materna para amamentar: prevalência e associação / Postpartum depression and maternal self-efficacy for breastfeeding: prevalence and association. Acta Paulista de Enfermagem. 6. 664. https://doi-org.proxy.myunion.edu/10.1590/1982-0194201600093
  108. Safe, M., Chan, W.H., Leach, S.T., Sutton, L., Lui, K., & Krishnan, U. (2016). Widespread use of gastric acid inhibitors in infants: Are they needed? Are they safe? World Journal of Gastrointestinal Pharmacology Therapy. 7(4). 531-539. https://doi-org.10.4292/wjgpt.v7.i4.531
  109. Sargent, B., Kaplan, S.L., Coulter, C., Cynthia Baker, C. (2019). Congenital muscular torticollis: bridging the gap between research and clinical practice. Pediatrics. 144(2).  https://doi.org/10.1542/peds.2019-0582
  110. Sari, L.N.I. & Auerkari, E.I. (2018). Molecular genetics and epigenetics of ankyloglossia. Conference: 11th International Dentistry Scientific Meeting (IDSM 2017). https://doi-org/10.2991/idsm-17.2018.14
  111. Schack-Nielsen, L., Michaelsen, K.F. (2006), Breast feeding and future health. Pediatrics. 9. 289-296.
  112. Schmidt J.E., Carlson C.R., Usery A.R., Quevedo A.S. (2009). Effects of tongue position on mandibular muscle activity and heart rate function. Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology. 108(6). 881-8. doi: 10.1016/j.tripleo.2009.06.029.
  113. Sekirov, I., Russell, S.L., Caetano, L. Antunes, M., Finlay, B.B. (2010). Gut microbiota in health and disease. Physiological Reviews. 90(3). 859-904.
  114. Shepherd, K., Hillman, D., & Eastwood, P. (2013). Symptoms of aerophagia are common in patients on continuous positive airway pressure therapy and are related to the presence of nighttime gastroesophageal reflux. Journal of clinical sleep medicine. 9(1). 13–17. https://doi-org.proxy.myunion.edu/10.5664/jcsm.2328
  115. Siegel, S. A. (2017). Aerophagia induced reflux in breastfeeding infants with ankyloglossia and shortened maxillary labial frenula (tongue and lip tie). Journal Of Clinical Pediatrics. 16(1). 1369.
  116. Silva do Nascimento, L., da Silfa Santos Soares, V., Leonel da Silva Costa, T. (2015). Tongue-tie test: situational diagnosis about the applicability of the protocol in newborns in Distrito Federal / Tongue-tie test: situational diagnosis about the applicability of the protocol in newborns in Distrito Federal. Centro de Especialização em Fonoaudiologia Clínica – CEFAC. 17(6).  https://doi.org/10.1590/1982-021620151768915 
  117. Srinivasan, A., Al Khoury, A., Puzhko, S., Dobrich, C., Stern, M., Mitnick, H., & Goldfarb, L. (2019). Frenotomy in Infants with Tongue-Tie and Breastfeeding Problems. Journal of Human Lactation. 35(4). 706–712. https://doi-org.proxy.myunion.edu/10.1177/0890334418816973
  118. Stellwagen, L., Hubbard, E., Chambers, C., Lyons Jones, K.  (2008). Torticollis, facial asymmetry and plagiocephaly in normal newborns. Archives of Disease in Childhood. 93. 827-831. http://dx.doi.org.proxy.myunion.edu/10.1136/adc.2007.124123
  119. Stuebe, A. (2009). The Risks of Not Breastfeeding for Mothers and Infants. Reviews in Obstetrics & Gynecology. 2(4). p 222-231.
  120. Stylianou, P., Soldatos, N., Edmondson, E.K., Angelov, N., & Weltman, R. (2020). Early creeping attachment noted after mandibular labial frenuloplasty. Case Reports in  Dentistry. 2020. https://doi-org.10.1155/2020/3130894
  121. T.E.C. Jr. (1982) . Bartholomäus Metlinger on the Care of the newborn infant (1473). Pediatrics, 69(1), 99.
  122. Tashakori, A., Behbahani, A. Z., & Irani, R. D. (2012). Comparison of prevalence of postpartum depression symptoms between breastfeeding mothers and non-breastfeeding mothers. Iranian journal of psychiatry. 7(2). 61–65.
  123. Thomas, K. A., & Spieker, S. (2016). Sleep, depression, and fatigue in late postpartum. The American journal of maternal child nursing, 41(2), 104–109. doi:10.1097/NMC.0000000000000213
  124. Todd, D. (2014). Tongue-tie in the newborn: what, when, who and how? Exploring tongue-tie division. Breastfeeding Review. 22(2) p 7-10.
  125. Trackbill.com. (n.d.). New Jersey S1503 Requires newborn infant screening for tongue tie. Retrieved from https://trackbill.com/bill/new-jersey-senate-bill-1503-requires-newborn-infant-screening-for-tongue-tie/1544460/ 
  126. United Nations. (1989). Convention on the Rights of the Child. Retrieved from https://legal.un.org/avl/ha/crc/crc.html
  127. Upledger Institute International. (2021). Discover craniosacral therapy. Retrieved from https://www.upledger.com/therapies/
  128. Upledger, J.E. & Vredevoogd, J.D. (1983) Craniosacral therapy. Eastland Press.
  129. Van Biervliet, S., Van Winckel, M., Vande Velde, S., De Bruyne, R., & D’Hondt, M. (2020). Primum non nocere: lingual frenotomy for breastfeeding problems, not as innocent as generally accepted. European Journal of Pediatrics, 179(8), 1191. https://doi-org.proxy.myunion.edu/10.1007/s00431-020-03705-5
  130. Wallace, AF. (1963). Tongue-tie. Lancet. 2(7304). 377-378. https://doi-org.proxy.myunion.edu/10.1016/s0140-6736(63)93057-5
  131. Watson, N. F., & Mystkowski, S. K. (2008). Aerophagia and gastroesophageal reflux disease in patients using continuous positive airway pressure: a preliminary observation. Journal of clinical sleep. 4(5). 434–438.
  132. Wedad Saad A.M., Buthainah Ali A.A., Bushra Ahmed A.G., Abdullah H A.Q., & Nourah H A.Q. (2018). Prevalence of Postpartum Depression and is Correlation with Breastfeeding: A Cross-Sectional Study. International Journal of Medical Research & Health Sciences. 7(2): 28-34.
  133. Whitman, C. L., & Rankow, R. M. (1961). Diagnosis and management of ankyloglossia. American Journal of Orthodontics, 47(6), 423–428. https://doi-org.proxy.myunion.edu/10.1016/0002-9416(61)90221-4
  134. Wong, K., Patel, P., Cohen, M.B., & Levi, J.R. (2017). Breastfeeding infants with ankyloglossia: Insight into mothers’ experiences. Breastfeeding Medicine. 12(2). https://doi-org/ 10.1089/bfm.2016.0177
  135. World Health Organization (WHO). 2015. WHO statement on caesarean section rates. Retrieved from http://apps.who.int/iris/bitstream/10665/161442/1/WHO_RHR_15.02_eng.pdf
  136.  Yoon A, Zaghi S, Weitzman R, Ha, S., Law, C.S., Guilleminault, C., Liu, S.Y.C. (2017). Toward a functional definition of ankyloglossia: validating current grading scales for lingual frenulum length and tongue mobility in 1052 subjects. Sleep Breath. 21(3):767‐775. https://doi.org/10.1007/s11325-016-1452-7
  137. Youssef, N.A., Ege, M., Angly, S.S., Strauss, J.L., Marx, C.E. (2011). Is obstructive sleep apnea associated with ADHD? Annals of Clinical Psychiatry. 23(3). 213-24.
  138. Yucesoy, C. A., Maas, H., Koopman, B. H. F. J. M., Grootenboer, H. J., & Huijing, P. A. (2006). Mechanisms causing effects of muscle position on proximo-distal muscle force differences in extra-muscular myofascial force transmission. Medical Engineering and Physics, 28(3), 214–226. https://doi-org.proxy.myunion.edu/10.1016/j.medengphy.2005.06.004
HO*LIS*TIC ~ADJECTIVE: Relating to or concerned with complete systems rather than with individual parts 
WNY Orofacial & Breastfeeding Support Center is a division of Holistic Parenting Network, LLC, located within the village of East Aurora, NY.
​121 Elm Street East Aurora, NY 14052                                        fax: (716) 508-3302                                       (716) 780-2662  [text friendly]