Evaluation of a tongue-tie: The range of motion of the tongue should be assessed in all patients
By Shirley Gutkowski, RDH, BSDH, and Timbrey Lind, RDH
You're doing your cancer screening and, as you've done hundreds or thousands of times before, you try to grab the tongue. But the tongue won't come out. You can't grab it at all. You do your best; you try to examine both sides of the tongue, but you have to stand to see the opposite side. That is ankyloglossia, a condition that restricts the tongue's range of motion. But contrary to what you may think, oral cancer screening is not the only problem with tongue mobility.
Studies show that ankyloglossia occurs in 4-5% of the population, but rates as high as 10% have been recorded, according to a 2005 article in the Journal of the American Board of Family Practice. Tongue-ties are more likely to show up in males than in females. We in dentistry don't always look for the tongue-tie. We don't see children until they're three, after all. Today, we know that the freedom of the tongue is required to apply counterbalancing forces, which allow the arches to reach their fullest potential. Impaired tongue movement can cause symptoms that range from painful neck and upper back pain to speech impediments to gastric reflux, restless leg, bruxism, and indirectly, Alzheimer's.
Yes, it's a scary and diverse list of potential symptoms. It's more important than ever to get on the ball and evaluate our patients' tongues. The tongue is not just for cancer exams any longer. Let's look further into the effects of ankyloglossia, who suffers from this condition, and how to recognize it.
There are quite a few terms nowadays for being tongue-tied. Tethered oral tissue, restricted lingual frenulum, tongue-tie (this can be anterior or posterior), and ankyloglossia. Anterior ankyloglossia is much more obvious and readily managed when compared to posterior tie, which is poorly recognized. Ankyloglossia-the medical term-is how most dental hygienists learned it in school. In Esther Wilkins' Clinical Practice of the Dental Hygienist, ankyloglossia is defined as "a congenital oral anomaly that may decrease mobility of the tongue tip and is caused by an unusually short, thick lingual frenulum, a membrane connecting the underside of the tongue to the floor of the mouth." That's the classical definition of a tongue that is truly tethered to the floor of the mouth. We now consider grades of attachment, as even a little restriction can cause systemic issues we've never linked together before.
Tongue-ties in infants-We are all born with certain survival instincts. One of them is to suck so we can be fed. In order to breastfeed, babies suck the nipple to the back of their mouth and use their tongue to press the nipple to the top of their palate. Using the pressure from the suck while pressing the nipple against the palate, the baby extracts milk. When an infant has a tongue-tie, they may not be able to latch onto the nipple and extract the milk from the breast properly.
If a mother brings an infant to an appointment, simply asking how nursing is going can give you some tongue-tie insights. If the mother expresses exasperation or mentions pain, look into the infant's mouth to be sure the tongue is free. Use a gloved finger to sweep gently under the tongue and feel for resistance from the frenulum. If there is any resistance, a proper evaluation from an orofacial myofunctional therapist can help.
Tongue-ties in adults-Adults who suffer from tongue-tie could be patients who have an anterior open bite caused from a tongue thrust, orthodontic relapse, speech impediments, poor oral hygiene, acid reflux, difficulty swallowing pills or drinking, and most of all, complaints of TMJ pain. Tongue-ties can have a major impact on the health and function of the jaw joint over time. This transfers into neck and shoulder pain from forward head posture. The head follows the tongue, so when the tongue is low and forward, so is the head. The head-forward posture makes the sternocleidomastoid muscle (SCM), trapezius muscle, and surrounding muscles end up having to support the head. Head-forward posture is also an adaptation of the body to open the airway. This is something you can easily notice about your patients when they are sitting in the waiting room or while you're walking them to your operatory. Take a look at their posture! Is their head in alignment with their shoulders or is it hanging forward?
Assessment and research
There are a few different ways to assess the tongue. Let's evaluate three well-known leaders' and experts' approaches to this. We will start with Dr. Larry Kotlow's different classifications, or grades as some people refer to them. There are several methods of classifying a tongue-tie, and currently, different professions use their own means of assessment. Dr. Larry Kotlow is a well-known pediatric dentist and considered an expert in the field of evaluating and treating restricted frenum in infants. His classification descriptions for a tongue-tie are as follows:
• Class I: From the base of the tongue, halfway to the salivary duct
• Class II: Between the back to the salivary duct, halfway to the base of the tongue
• Class III: From the salivary duct, halfway to the tip of the tongue
• Class IV: At the tip of the tongue and extending halfway between the salivary duct and the tip of the tongue
Dr. Kotlow also gives instruction on assessing for a tongue-tie simply by "feeling" for any problems. You do this by sweeping your finger under the tongue and feeling for any catches. If it is a smooth sweep, more than likely, there isn't a problem. If you feel your finger catch on a thick or thin membranous tissue, you are dealing with a tongue-tie. Again, his specialty is infants.
In adult patients, you can always ask questions. Ask about their family history and if their siblings or parents have any of the issues listed above. Considering tongue-tie is hereditary, you can find out through a family member.
Quantitative evaluation of the lingual frenulum was used in research done in Sao Paulo, Brazil, by Dr. Irene Queiroz Marchesan, the leader who initiated the national tongue-tie law in Brazil. Now all newborns are checked for tongue-tie-it's that big of a deal.
Her research used a digital caliper to measure the frenum and tongue of an adult subject with tongue-tie. This is part of her "general" test she requires after taking a health and family history. Then she goes into functional tests such as sticking the tongue straight out and back, to the top of the palate while the mouth is wide-open, side-to-side touching the corners of the mouth, touching the upper and lower molars, and sucking the tongue up against the palate. After reading all of these, I had to run through the test myself to make sure I could even do them all! Phew... I passed.
Lastly, as a survivor of tongue-tie into her fourth decade of life, Dr. Alison Hazelbaker makes a point of properly and fully assessing the tongue's range of motion and function, just as Dr. Irene Marchesan does. This is very important because just visually looking at the frenulum to see if it is tied leads to an incomplete evaluation. A lot of ties are missed because of this. If you are assessing the tongue, ask yourself if the tongue moves freely in all the ways it normally should. If not, to what degree is it restricted? What impact do the restrictions have on the individual? Here are some tests you can run through with your patient for a short evaluation:
• An oral exam is very useful. An open bite, tongue thrust when swallowing, poor oral hygiene, and periodontal disease are all symptoms of a tongue-tie.
• Can they clean food off of their teeth with their tongue? This is a simple question we would never think to ask, and some people cannot do this and think that is normal.
• Consider a quick speech assessment. Ask them to pronounce words with the syllables "t," "d," "n," and "l" in them (e.g., water, dog, none, lake).
• Check range of motion. You can check the degree of extension beyond the lower lip by asking them to stick their tongue out. Also check the elevation of the tongue to the palate with the mouth wide-open, making it a point they do not close their
'The human tongue ... can roll back and dart forward in all directions; and herein too its freedom and looseness assists it. This is shown by the case of those whose tongues are slightly tied: their speech is indistinct and lisping, which is due to the fact that they cannot produce all the sounds.' -Aristotle, Parts of Animals mouth while lifting the tongue. A lot of people do this naturally because they feel their tongue being strained. And the last range of motion indicator is to ask if they can move their tongue back and forth, to each corner of the mouth while keeping their tongue straight.
These are simple things you can run through with your patient when looking for a tongue-tie. Evaluating for tongue-ties can change your patients' lives, just as it did my patient who suffered from severe TMJ, head, and neck pain. After getting her tongue released, she said she "felt like a weight was lifted off of her shoulders and her whole body relaxed." This was something she carried with her from childhood. It's amazing that something so simple and sometimes so obvious can affect us that much.
On your next patient, really look at the tongue. Can it do tricks like touching the palate without closing over 50%? Can it reach back to the last tooth? Does the patient have crowns on all their molars and they're under 45 years old? It could be a restricted tongue. The next time you see a child with early childhood caries, check to see if their tongue or lip is fully mobile. If it isn't, the decay could be from a tied tongue, or a frenum that attaches too low, allowing liquids to pool. Look around in there! RDH
Timbrey Lind, RDH, is a practicing dental hygienist with a holistic approach to care. Specializing in orofacial myofunctional therapy, her passions are working with infants and children. Her practice, The Connection, is based in Agoura Hills, California. Shirley Gutkowski, RDH, BSDH, is a practicing dental hygienist specializing in orofacial myofunctional therapy. Her practice, Primal Air, LLC, is in Sun Prairie, Wisconsin. Ms. Gutkowski is also the host of Cross Link Radio, a podcast with timely information integrating oral and systemic health.
