By Heather Boerner, MA, CCC, SLP; Principal of Chatty Child
September 30, 2016

This is a commentary for parents and caregivers that I raise today because of questions that have been raised about a condition that may be present in infants and small children, and that medical professionals may be raising, or parents may hear in support groups.

The conversations between parents and caregivers -- pediatricians, dental surgeons, speech-language pathologists, pediatric ENTs, and others -- have recently involved the discussion of lip and tongue "frenulum," that, is soft tissue of the lip or tongue that (for example) helps to determine the movement of upper lip and tongue elevation.  (That is, frenulum linguae.)

The "lingual frenulum" stabilizes and checks undue movement of part of our tongue. The tip of the tongue, when affected, may at times be said to cause "tongue tie." 

It is important to keep in mind that the oral cavity of the child changes over the course of the first four or five years, in terms of shape and size, as the young child grows.  Teeth appear.  The tongue grows and usually narrows at the tip.  The soft tissue that is the frenulum in most cases recedes, and stretches.  So "time" and "oral growth" typically address the condition if it exists.

The pediatrician, the pediatric dentistry specialist, a surgeon, or a pediatric ENT (ear, nose, throat) specialist will diagnose and prescribe treatment where these professionals think treatment is necessary.  (Note that treatment of the frenulum is one of the specialties recognized by the American Dental Association, or ADA requiring specialized training and knowledge.)

Some of the conditions in frenulum may be described as ankloglossia, or "tongue tie," where (for example) there is an abnormally short, thick lingual frenulum which affects tongue movement -- such as adhering to the floor of the mouth.  In those cases, which appear to be less frequent according to the medical literature, the opinion of an oral and maxillofacial special surgeon may be needed.

In 2013, the "Case Reports in Dentistry" journal addressed this in "clinical guidelines and management of ankyloglossia" to expand awareness of the condition and surgical approaches.  There appears to be ongoing research on the subject in the dentistry journals.

The important thing to keep in mind as a parent or caregiver is that the "decision to clip" is a medical one, and not in the scope of the practice of the speech-language pathologist. 

The surgery is usually completed by a surgical incision, or by CO2 laser, depending on a number of factors, and again, the decision is made by the medical professional. One pediatric surgeon experienced in this noted that the focus should be on function.  Is function affected by the condition [of the tongue or lip]?  That is a discussion that the parent needs to have with the medical professional.  The speech-language pathologist could be part of this discussion; the condition may affect speech or feeding, for example.  The Speech-Language pathologist plays an important role in treatment and improving tongue and lip movement, and functions following any surgery(if needed).

As speech-language pathologists, we rely on the advice and prescription of the medical professional in these matters.

Members of my professional association, the American Speech-Language-Hearing Association (ASHA), are engaged in the conversation about frenulum, and how the therapist may be able to help detect issues that the medical professional may then discuss with parents and address (or not address).  One of the confusing factors is that it appears that not treating the small fold or ridge of tissue (the frenulum) may not affect speech as the child grows older.

There is no clear consensus among speech-language pathologists, or among many medical professionals, regarding the need for surgery or functional outcomes following surgery. 

Most of my professional peers agree that "frenulecomy" (surgery) is not usually indicated for speech corrections, unless it is very severe and there are concomitant oral-motor problems evident.

In my practice, I usually advise the parent to be patient and keep close watch on the condition as the child grows and her/his little body undergoes changes.  In my practice, I would advise a parent to consider surgery after age 3 or 4 -- not typically in younger children -- unless there are breast feeding or bottle feeding issues to address in the infant or very young child.  This may affect the child's overall nutritional or caloric intake; or, there are swallowing issues to address. I would recommend Beckman Oral Motor Protocol to stretch the tissue (a "non-invasive" approach).

Again, it is important to stress, the decision is to be made by parent and medical professional regarding the possibility of any type of surgery to address issues of this kind. 

With the increased conversation among parents and between parents and medical professionals, there is increased focus on the condition (frenulum of tongue or lips), and I am tracking the conversations and opinions shared by medical professionals and speech-language pathologists.  In some cases, the literature is quite small and so many professionals in ASHA and medical specialties agree, more research is definitely needed.

I hope that this is helpful.  If you have questions, please ask me via email, by telephone (347.491.4451), or when you are in the office.