***(Disclaimer: this blog post is not a diagnostic tool for tethered oral tissues and should not be used as a replacement for an official screening, diagnosis, evaluation, or treatment by a trained professional. This post is intended to raise awareness and is for educational purposes only).***
In a previous blog post, we discussed some myths and facts regarding tethered oral tissues (TOTs), also known as lip, tongue, and/or cheek ties. We established that ties are defined as frena that are too tight and/or too short, and they can affect many areas of life, such as breathing, speech, sleep, feeding, and more.
What should we be looking for if we suspect a child has TOTs?
As an SLP, I look for some structural indicators (as in the physical parts of the mouth and the articulators) and functional “red flags” (or patterns that affect daily life) as part of my TOTs screening. While many parts of screening for TOTs require in depth assessment of the oral musculature, some can be easily visually observed. Let’s look at some of the physical red flags of suspected TOTs first that are easily observable with the naked eye, and why it can be a potential indicator of TOTs.
Physical Red Flags
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A potential restriction will cause the tongue to appear heart-shaped when elevated, or “scalloped.” |
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The tongue aids in the adequate expansion of the hard palate (that hard bone behind your front teeth). When the tongue rests on the bottom of the mouth instead of the roof, the palate does not expand as far, resulting in a high and narrow mouth shape. |
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Just like the placement of your tongue can affect your palate shape, it can also affect the alignment of your teeth. For example, frequent thumb sucking or frequent tongue protrusion between the teeth can push the front teeth forward, often resulting in an overbite or an open bite. |
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There could be many reasons why TOTs contribute to facial asymmetry (ex: torticollis/ tight facial muscles due to restricted tissues). |
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Depending on the size, severity and thickness of the tie, a band of tissue running between the two front teeth can be an indicator of a labial tie. |
In addition to these physical indicators, I also usually ask about and/or observe functional and behavioral patterns. Because tethered oral tissues can affect so many different areas of life, some of these red flags may not, upon first glance, look related. Let’s go through some common patterns that can be attributed to TOTs and see if we can start connecting the dots!
Feeding Red Flags
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As mentioned in our previous blog post, tethered oral tissues can cause difficulty when attempting different movements, such as sucking motions, moving the tongue up and down, side to side, etc. |
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From my personal experience, this is typically caused by decreased lateral tongue range of motion (the tongue can’t reach the back teeth when moving side to side). We chew on our back molars, so children with restricted movement often have difficulty chewing and maintaining control of chewy/ harder textures (just like–you guessed it!–meat and raw vegetables). |
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Again, this could be due to many reasons, but feeding difficulties and acid reflux/ GERD tend to go hand in hand. |
Sleeping Red Flags
| Snoring | The tongue is resting on the bottom of the mouth, which is blocking the airway. |
| Sleep apnea | This could be due to different reasons, but can indicate that the upper airway is potentially blocked. |
Other Potential Indicators of TOTs
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Placing objects or fingers/ thumb in the mouth can push the tongue down on the bottom of the mouth to push the tongue out of the way of the airway. It’s actually sometimes easier for children with TOT’s to breathe if there is something in their mouth. |
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This could be due to the development of the airway, as well as the restricted range of motion. |
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This means the child demonstrates a forward tongue position at rest, tongue thrusts “forward” against the teeth due speech and feeding). While this movement is considered normal for extremely young children, kids should move away from this pattern of motion, as it can cause dental issues and more at later stages. |
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The tongue plays a large role in swallowing and saliva control. If range of motion is restricted, it can be difficult to keep saliva in the mouth. |
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This can be due to the misaligned teeth we discussed in the “structural” portion. |
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From my personal experience, the speech sounds that children with TOTs tend to express the most difficulty with are: /t/, /d/, /l/, /n/ (aka, sounds that require tongue tip elevation to the roof of the mouth behind the teeth.)
Lisping or distortions of /s/ are also common. Rounded sounds like OO, OH, CH, J, and W can also be difficult for children with diagnosed labial ties. |
If we look at the pattern here, we can see that TOTs can affect nearly everything that involves the use of your mouth and nose, such as breathing, feeding, and speech (and even more)! If your child demonstrates these traits or you notice these red flags, I always recommend seeing a trained SLP or certified orofacial myofunctional therapist (COM) for a TOTs screening, as well as for pre-op and post-op therapy to address speech and feeding. I also frequently refer clients to a TOTs trained pediatric dentist, oral surgeon, or ENT for an evaluation and to address the structural red flags that may occur with TOTs.
What connections did you find between the red flags and tethered oral tissues? If you have any questions, be sure to call and schedule an appointment! (801) 996-7510.
-SLP Katie