/Please continue reading

/

Now, why do I bring up*FACT 10*? Because two interesting theories have 
emerged in the last ten years. One theory proposes that the upper lip 
frenum can cause breastfeeding problems. One case history was published 
detailing the way in which the upper lip frenum created a problem. (4) 
Recently, an article fleshing out the theory was published proposing a 
classification schema to help people determine the presence of a lip 
frenum that negatively impacts breastfeeding. (5) Unfortunately for the 
proposer, the classification system proposed did not go through the 
validation process so it really cannot yet be said that it accurately 
identifies the type of upper lip frenum that could cause a breastfeeding 
problem.

Let’s look at the assertion that a tight, prominent upper lip frenum 
causes breastfeeding problems more closely. We can use anatomy, 
physiology and development as our guide.*First:*the upper gumline 
changes with growth. A frenum that appears to be restricted in early 
infancy may substantially change as the baby 
grows.*Second:*breastfeeding does not require a lip flange, merely lip 
eversion.*Third:*the assertion that dental caries is caused by an upper 
lip tie begs to be proven. Breastmilk does not pool in the mouth. The 
position of the nipple in the mouth and the manner in which that milk is 
moved into the pharynx for the swallow won’t allow it. Both the 
peristaltic action of the tongue and the pressure differential created 
by tongue movements quickly push/pull the milk to its ultimate destination.

*Fourth:*the lips follow the tongue, if the tongue retracts, the lips 
move inward toward the gumline and when the tongue everts, the lips also 
evert. This is a developmental reflex that remains active throughout 
life. Anyone who has ever French-kissed can assert the truth of this. 
Tongue position plays such a keen role in the positioning of the lips 
that many types of*/acquired/*structural issues, like torticollis, can 
cause the tongue to retract thereby pulling in the lips. In my 
experience, this can be mistaken for what the theorists call an upper 
lip tie.

In my clinic this past year I saw such a baby. She had been misdiagnosed 
with both a tongue-tie and an Upper Lip Tie (ULT). She actually had low 
cheek tone and overactive, tight lip tone. One of my colleagues 
performed some very effective bodywork to bring down the lip tone and 
bring up the check tone. It took her 3 minutes to rectify the problem at 
no cost to the mother*/and/*the baby was saved from unnecessary surgery.

That leads me to my next point, without a valid definition of upper lip 
tie (one based on solid facts about how the labial frenum impairs lip 
mobility in the SPECIFIC manner that actually impairs breastfeeding) 
then we are hard-pressed to be able to assess it properly. The exact 
characteristics of a phenomenon must first be established before 
assessment tools can be generated to assist the clinician in proper 
diagnosis. No such work has yet been done.

We have put the proverbial cart before the horse when it comes to the 
theory of upper lip tie. How many babies have suffered the consequences 
as a result?

Does that mean Upper Lip Tie doesn’t actually exist?/Theoretically/it 
could because any connective tissue in the body might, out of tightness, 
negatively impact function. Does a tight, prominent labial frenum 
actually negatively impact breastfeeding? Only future research will 
prove or disprove this theory. Until the evidence shows us what is true, 
ethics dictate that practitioners remain conservative in their clinical 
approach.

*Let’s talk about the second theory:*that of the sub-mucosal posterior 
tie. I have been liberally accused of not believing in the posterior 
tie. Belief has nothing to do with it! Any clinician operating by belief 
is shirking his or her professional and ethical duty.

My clinical approach to the sub-mucosal tie theory is conservative. To 
my knowledge, no research has ever been done to verify that a 
restriction at the tongue-base that presents as a thick, shiny string 
under the mucosa is an actual tongue-tie. My experience as a structural 
therapist, and in the experience of many a bodyworker throughout the 
world, has shown that this type of tongue and/or mouth floor restriction 
resolves with simple bodywork; that the actual cause of this type of 
restriction is an acquired soft tissue strain pattern due to 
intrauterine or birth events.

Once again, anatomy can inform us. That tight shiny string of tissue 
underneath the mucosa at the tongue base may very well be the septum of 
the genioglossus muscle, the tough aponeurosis (a type of fascia) that 
connects the two halves of the genioglossus muscle together helping to 
stabilize the tongue in the mouth. The septum attaches to both the 
inside of the mandible at the mentis and to the hyoid bone in the upper 
throat and is confluent with the hyo-epiglottic ligament. The septum is 
easily visualized when two fingers press back against the tongue-base. 
Some practitioners claim this maneuver renders an accurate diagnosis of 
“sub-mucosal tongue-tie” but it may be revealing the septum of the 
genioglossus muscle. One has to know what one is visualizing to avoid 
making an erroneous diagnosis.

Ultimately, what seems to get lost in the argument over sub-mucosal 
tie’s existence or non-existence is that theories must be proven. We all 
share the burden of that proof (or disproof.) It is completely 
legitimate to remain skeptical until more data emerges, especially when 
the “cure” suggested involves cutting on a baby! I remain skeptical. The 
dearth of evidence for this phenomenon, which may or may not be the 
congenital anomaly we call tongue-tie, coupled with my own experience 
working with these babies as a bodyworker keeps me sitting on the fence.

*Let’s now turn to the myths:*

*Myth 1:*The incidence of tongue tie is increasing. No one, anywhere can 
make this assertion. No accurate incidence statistics existed prior to 
Todd’s 2014 study. (2) The incidence may well indeed be population-based 
but epidemiological studies must be done to assert this as fact.

*Myth 2:*All babies who have a tongue-tie have an upper lip-tie. How can 
this be true? We have no idea what a lip tie actually is and no valid, 
reliable assessment tool to even begin discerning who may have an issue 
and who does not.

*Myth 3:*Laser frenectomy is better than scissors frenotomy. No evidence 
demonstrates that this is the case. Any advantages of either are postulated.

*Myth 4:*All tongue-tied babies need a deep frenotomy. It might be true 
that some babies will achieve optimal range of motion of the tongue with 
a shallower snip. We need more evidence to make such a determination.

*Myth 5:*LASER frenectomy is completely safe. LASERs are, in fact, very 
dangerous and can do significant damage when used by an untrained 
practitioner. A definitive set of safety rules guide practioners to 
utilize LASER equipment without posing harm to themselves or their 
patients. There are several different types of LASERs; some more suited 
for soft-tissue surgery. The wrong LASER can damage collateral tissue 
and create excessive scar tissue that may cause re-attachment. 
Currently, there is no requirement for a dentist or doctor to receive 
training to use LASERs before performing surgery on babies.

*Myth 6:*The scar tissue in the wound bed must be broken down several 
times per day to prevent excessive scar tissue formation 
(re-attachment). According to new research, the frenum is a tendon, a 
type of fascia. (6) Breaking down the scar tissue in the fascial wound 
bed causes myofibroblasts to lay down a dense collagen network 
(excessive scar tissue formation). (7) Gentle is better, both 
physiologically and psychologically. It is a shame when we cause a baby 
trauma from too aggressive post-surgical management. Come to think of 
it, there is no*solid*evidence that post-surgical aftercare prevents 
re-attachment. Two studies have been performed; one was extremely flawed.

*Myth 7:*There is a posterior tie behind every anterior tie. 
Histologically this is not true. (6) This cute statement is misleading 
if the purpose is to encourage surgeons to remove enough tissue to 
adequately mobilize the tongue. It seems much clearer to say that enough 
tissue must be removed (without cutting into muscle) to restore optimal 
tongue mobility in some babies.

*Myth 8:*Posterior ties are more common than anterior ties. Oops! Todd’s 
research definitively shows this is not true. Proper assessment, proper 
assessment, proper assessment and differential diagnosis!

*Myth 9:*Classification schema serve as proper assessment. Nope, they 
don’t. An assessment tool must possess the following: validity, 
reliability, sensitivity and specificity. (8) In other words, they must 
be designed and be proven to accurately identify the phenomenon being 
assessed, be able to do so accurately from assessment to assessment and 
from assessor to assessor and must be able to do so nearly 100 percent 
of the time. A tool that falsely identifies someone as having a problem 
when they don’t or not having a problem when they do is not accurate enough.

*Myth 10:*Any lactation consultant knows how to properly assess for 
tongue-tie. As in any profession, members of that profession must be 
trained to properly assess for any given phenomenon. For that matter, 
not all physicians, dentists, speech-language pathologists, etc. have 
been trained to assess for tongue-tie. It behooves parents to ask if the 
practitioner has been trained to assess for tongue-tie using an 
evidence-based assessment tool.

*For some reason*, tongue-tie has become the poster child for dogma and 
controversy. We are at the very beginning of our understanding of this 
congenital anomaly. (Don’t let anyone tell you otherwise!) That means 
that no one knows the entire story, yet. Time and more research will 
tell us what is true and not true about this phenomenon. Until then, we 
must exercise healthy skepticism, continue to ask the hard questions, 
engage in respectful dialectic and err on the side of caution. Our 
vulnerable babies depend on us to keep them safe from harm, and that 
includes holding off on surgery if no evidence exists to put them 
through such surgery.

Our egos must learn to stand the strain of not knowing.

*References:*

1.Hazelbaker, A.K. (2010)./Tongue-tie: morphogenesis, impact, assessment 
and treatment/. Aidan and Éva Press.

2.Todd, D. (2014)./Personal communication./

3.Dollberg, S. et al. (2014)./Lingual frenotomy for breastfeeding 
difficulties: a prospective follow-up study./Breastfeeding Medicine: 
Vol.9: 6: 286-289.

4.Weissinger, D. & Miller, M. (1995)./Breastfeeding difficulties as the 
result of tight lingual and labial frena./Journal of Human Lactation: 
11: 313-316.

5.Kotlow, L. (2010)./The influence of the maxillary frenum on the 
development and pattern of dental caries on anterior teeth in 
breastfeeding infants: prevention, diagnosis, and treatment./Journal of 
Human Lactation: 26: 304-308.

6.Martinelli, R., et al. (2014)./Histological characteristics of altered 
human lingual frenulum./International Journal of Pediatrics and Child 
Health: 2: 6-9.

7.Schleip, R., et al. (2012)./Fascia: the tensional network of the human 
body/. New York: Churchill Livingston.

8.Greenhalgh, T. (2010). How to read a paper: the basics of 
evidence-based medicine (4th ed.). Hoboken: Wiley-Blackwell BMJ Books.


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