Be aware of the tie that binds: A descriptive article of ankyloglossia or tongue-tie

Ankyloglossia, or tongue-tie, has become a growing topic among dental practitioners. There is controversy over surgical revision (or frenectomy), and whether it is necessary for proper development and nutritional purposes in relation to breastfeeding.¹ Before one can properly analyze the necessity of revision, they must first understand the origins of ankyloglossia, how it can negatively affect mothers and their infants, and why it is so often overlooked.

An evidence-based review reports that tongue development begins as early as the fourth week of gestation.² As weekly development occurs, the tongue usually separates from the floor of the mouth. Ankyloglossia occurs when this separation fails, resulting in a “tissue-tie” that restricts the ventral surface of the tongue to the floor of the mouth.

Origins of ankyloglossia

In their review, Talmor and Callaway include the history of ankyloglossia, stating that Aristotle (in 350 BC) first recognized it in people exhibiting a lisp.² However, surgical revisions were not introduced until academic literature wrote about them in the 1600s. Documentation of the first “revisions” were said to have been completed by midwives using scissors or their fingernails. Today, dental professionals refer to these procedures as frenectomies, the surgical removal of the muscle attachment causing movement restriction.

Breastfeeding: Recommendations and ramifications

The World Health Organization includes a recommendation that mothers breastfeed for at least six months exclusively.³ In a policy statement from the American Academy of Pediatrics and the World Health Organization, again it is recommended that mothers exclusively breastfeed their babies for the first six months.^3,4

Despite numerous evidence of breastfeeding’s benefits and organizations that support it, Nagel et al.⁵ found that only 60% of mothers meet their own breastfeeding goals (whether that be for one month or for the recommended six months). Results indicated that mothers’ psychological distress may impair their breastfeeding goals. Reported pain exhibited by improper infant latch may cause mothers to have adverse psychological outcomes related to breastfeeding.⁵ Outcomes include stress or release of high cortisol levels, inhibiting the let-down reflex.

The let-down reflex is a natural response by the body that causes breastmilk to flow, triggered by the stimulation of nerves in the breast during feeding. This stimulation causes the release of two hormones: prolactin and oxytocin. Prolactin is responsible for milk production, while oxytocin causes the milk ducts to contract and pushes the milk toward the nipple.

Nagel reports that high levels of cortisol may cause a domino effect: the mother is stressed that milk is not being excreted, and the baby becomes stressed and begins crying as the breast tries to trigger the let-down reflex, which can trigger a pause in lactogenesis (inadequate milk production).⁵ While paused lactogenesis can occur due to inadequate suckling by the infant, it may also occur for many other reasons. Further, Nagel⁵ acknowledges that design methods of studies included in the review were not universal, and more research is needed to fully comprehend the extent to which these factors can influence feeding methods.

A meta-analysis conducted in 2023 found that ankyloglossia can adversely affect breastfeeding outcomes and the mother’s overall mental health.⁶ The review found that 49.3% of the participants experienced breastfeeding difficulties overall, and a 3.9% prevalence was associated with ankyloglossia. It was also reported that mothers of infants experiencing adverse breastfeeding outcomes exhibited long-term emotional difficulties (disappointment, resentment toward one’s partner, and skepticism of the health-care system). Consequently, it may not be unusual for dental practitioners to find some new mothers mistrusting of all health-care providers.

In Counselling for Maternal and Newborn Health Care: A Handbook for Building Skills,³ it is recognized that after birth, society tends to focus mostly on the infant and gloss over the mother’s personal concerns. Asking questions specifically about the mother can help develop trust with the parent. Suggested questions include: How are you feeling mentally, physically, emotionally? How are your night and daytime feeding routines going? Are you having any pain or discomfort while feeding? Is there anything else that concerns you?

Children are not often seen in the dental office until the first tooth erupts. After developing trust with the mother and to encourage seeing the infant earlier, a simple conversation at the first prophylaxis following birth may be effective in establishing the child’s future dental home.

Why is ankyloglossia often overlooked?

If ankyloglossia can cause such negative outcomes for mothers and their infants, why do health professionals often overlook it? Contributing factors for underdiagnoses may include the lack of a universal classification system to aid practitioners with diagnosis and the fact that ankyloglossia can be classified in several different degrees and severities.⁶ The Kotlow, Coryllos, and Hazelbaker classification systems are the most used.^6,7 However, in a systematic review and meta-analysis by Cordray, challenges identified include that each system has its own criteria and descriptive method.⁶

Further, these authors recognized that surgical revision criteria vary among dental practitioners. Authors also suggested that since dental practitioners often use ankyloglossia as an umbrella term representing different oral tie locations, they could be describing oral ties in the tongue, lip, buccal region, or all of the above.

Suggestions from a review of the literature by Brzęcka et al. include utilizing a universal system developed through further research over frenectomy outcomes in infancy.⁸ A frenectomy is a surgical revision severing the tie that anchors the oral structures and limits their mobility. The review analyzed frenectomy outcomes and its possible benefits in breastfeeding. Authors suggest that oral assessment should be within the standard of care for all newborns. Surgical intervention should also be performed soon after diagnosis.

A clinical trial found developmental disturbances from infancy may cause malocclusion and speech defects in relation to articulation, but not necessarily speech defects themselves.⁹ Additional systematic reviews and a meta-analysis evaluated the outcomes of surgical revision on speech.^10,11 They concluded that overall improvements can be made in relation to speech articulation, but as the age of the child increased, the positive outcomes decreased. Dental professionals may thus infer that proper and early diagnosis could change systemic outcomes.

Considerations for surgical intervention

It’s important to stress that surgical revision should not be taken lightly. A clinical study on laser revision in pediatric patients discussed the controversy in providing treatment too early on infants without suckling issues.¹² Researchers believed the practice may result in permanent scarring. It was suggested that the decision to provide surgical intervention should not rely on the various classification systems alone, because the different systems can vary in the degree of severity. Authors recommend incorporating severity of symptoms and concerns expressed by the parents in the treatment plan considerations.

If surgical intervention is recommended, follow-up data should also be completed. The systematic review and meta-analysis by Carnino et al. found that 5% of patients were lost due to lack of follow-up alone.¹¹ To collect thorough follow-up data, practitioners cannot simply evaluate the surgical site to assess if the tie has grown back. Rather, data such as infant feeding times and a maternal questionnaire should be collected.

Since the dental clinicians’ scope of practice already includes completing a thorough intraoral examination, assessing oral ties and incorporating questions concerning the well-being of new mothers can easily become commonplace. As health-care professionals, it is our duty to uphold the best interests of our patients and to review all related evidence-based data when considering each aspect of treatment. A multifaceted approach to managing these complicated situations can result in the best outcomes for all. 

Editor's note: This article appeared in the March 2025 print edition of RDH magazine. Dental hygienists in North America are eligible for a complimentary print subscription. Sign up here.

References

1. Rowan-Legg A. Ankyloglossia and breastfeeding. Paediatr Child Health. 2015;20(4):209-218. doi:10.1093/pch/20.4.209
2. Talmor G, Caloway CL. Ankyloglossia and tethered oral tissue: an evidence-based review. Pediatr Clin North Am. 2022;69(2):235-245. doi:10.1016/j.pcl.2021.12.007
3. Postnatal care of the mother and newborn. In: Counselling for Maternal and Newborn Health Care: A Handbook for Building Skills. World Health Organization; 2013:chap 11.
4. Meek JY, Noble L, Section on Breastfeeding. Policy statement: breastfeeding and the use of human milk. 2022;150 (1):e2022057988. doi:10.1542/peds.2022-057988
5. Nagel EM, Howland MA, Pando C, et al. Maternal psychological distress and lactation and breastfeeding outcomes: a narrative review. Clin Ther. 2022;44(2):215-227. doi:10.1016/j.clinthera.2021.11.007
6. Cordray H, Mahendran G, Tey CS, et al. Severity and prevalence of ankyloglossia-associated breastfeeding symptoms: a systematic review and meta-analysis. Acta Paediatr. 2022;112(3):347-357. doi:10.1111/apa.16609
7. Becker S, Brizuela M, Mendez MD. Ankyloglossia (Tongue-Tie). StatPearls Publishing; 2025. https://www.ncbi.nlm.nih.gov/books/NBK482295/
8. Brzęcka D, Garbacz M, Micał M, Zych B, Lewandowski B. Diagnosis, classification and management of ankyloglossia including its influence on breastfeeding. Dev Period Med. 2019;23(1):79-87. doi:10.34763/devperiodmed.20192301.7985
9. Amr-Rey O, Sánchez-Delgado P, Salvador-Palmer R, Cibrián R, Paredes-Gallardo V. Association between malocclusion and articulation of phonemes in early childhood. Angle Orthod. 2022;92(4):505-511. doi:10.2319/043021-342.1
10. Hatami A, Dreyer CW, Meade MJ, Kaur S. Effectiveness of tongue-tie assessment tools in diagnosing and fulfilling lingual frenectomy criteria: a systematic review. Aust Dent J. 2022;67(3):212-219. doi:10.1111/adj.12921
11. Carnino J, Lara FR, Chan WP, Kennedy D, Levi J. Speech outcomes of frenectomy for tongue-tie release: a systematic review and meta-analysis. Ann Otol Rhinol Laryngol. 2024;113(6):566-574. doi:10.1177/00034894241236234
12. Komori S, Matsumoto K, Matsuo K, Suzuki H, Komori T. Clinical study of laser treatment for frenectomy of pediatric patients. Int J Clin Pediatr Dent. 2017;10(3):272-277. doi:10.5005/jp-journals-10005-1449