As I alluded to in our last post about the life of a tongue tie, today I want to cover the various treatments that are available for tongue tie. Whether you are a parent of an infant with tongue tie, or an adult who has recently discovered that you have a tongue tie yourself, you should learn about the options that are available for treatment. This post will sum up the pros and cons of the most common treatment methods, and discuss which ones we use here at Kidstown Dental (and why).
The types of treatment for tongue tie
The essential treatment for tongue tie is to create a small opening in the mucosa (skin) under the tongue which reveals the embryonic, restrictive fibers, and then to gently remove just the restrictive fibers which releases the tongue tie and allows the tongue to have a full range of motion in all directions.
- Cautery, in which a hot implement is used to sear through the skin and the fibers causing the restriction. It is impossible to keep the heat and damage off of the other structures such as the muscle fibers with this tool. This is an old-fashioned method, and is not generally recommended to be used today as it is the most painful afterward and can cause considerable scar tissue formation.
- Using scissors or a scalpel to cut the skin and fibers. This might seem old-fashioned as well, but in fact this technique can be very effective when the provider has been trained to do a full release and when it is done correctly. When other tools are not available, scissors can be effective in releasing a tongue tie. A common problem I see is that this method is often used to only release the thin, anterior portion and leave the person with restrictive fibers remaining in the more middle and posterior areas of the frenum. ENT’s are generally trained in this method and trained only to release the front portion. This method is also shown in research to cause more contraction of the skin during healing, which makes the area tighter and less mobile. There is also more bleeding and more risks for bleeding and collateral damage with this technique in a moving baby.
- A diode laser, is less heat than cautery and can be used to effectively remove the restriction with little to no bleeding. That is the main point of any laser, little to no bleeding, making it easier to get to the middle and posterior (deeper) portions of the restriction. The diode does have some heat, but if the surgeon is trained extensively on laser physics of the diode, they can keep the heat at a minimum, and use functional dissection techniques in the mid and posterior part of the restriction. There is a little bleeding combining the diode with dissection, but it will keep the area from having too much heat and provide and excellent release. This is the best way to use the diode in my opinion and we achieved years of great results in the past. If the diode is used for the entire release or if used too high of a setting, then post operatively you will have the same issues as cautery, pain, contraction and scarring.
- CO2laser is a generally non-heat laser (though all lasers can cause heat and the provider must have thorough knowledge on the laser physics and be adept in adjusting based on the patient’s tissues). With little to no heat, and no sharp instruments, a very precise release can be accomplished with the CO2 laser for the entire release. This tool, when used properly can result in a great release, great healing, and little to no post operative pain (Keep in mind, the stretches are alway uncomfortable for all ages and with all tools.) The one warning with this laser especially, is that it is so good at managing the tissues (little to no bleeding because of the laser/tissue interaction) that it is easy and possible to be too aggressive and not see it during surgery. I have even seen videos posted of a CO2 laser showing a provider going right from the mandible to the tongue, destroying the salivary glands and other important structures. The laser did it with no bleeding and it “looked” very thorough, but for anyone that knows the anatomy and how to do a release properly, the video was sickening. My personal belief is that all providers should learn with scissors or scalpel first so that they are keenly adept at the anatomy, and only then be given a powerful tool, such as a CO2 laser, to be used.
- Waterlaser can be used to provide a very accurate and painless release. The huge advantage of the Waterlaser is that the fibers can be released from the insertion point all the way down to the glands with no heat or damage to other tissues. All other lasers can only release in the center of the restriction, which can give a full release, but leave some fibers dormant on tongue tip. This means that after the release with diode or even CO2, you may see a “V” or “heart” shape still cosmetically, but the tongue will be fully released. With the Waterlaser you can remove all the fibers to the tip and have a rounded tip when complete. The downside is the Waterlaser is too big for little babies, they cannot manage the water and are at risk for aspiration. Some providers use the Waterlaser on infants but in order to manage the problem with the water they turn off the water. This creates heat and is not wise. To understand, ask the provider to put the laser on the frenectomy setting, turn off the water, and let you feel it on your hand. It is HOT!
Which type of treatment is best?
Patients and parents: it is crucial not to buy into all of the marketing hype around certain types of lasers. Laser companies are spending millions of dollars to push their lasers in the marketplace so patients and parents will demand a certain type of laser. Please know that ALL instruments and lasers can cause damage, pain, and bleeding. All lasers can create heat and therefore more contraction and more scarring and pain. All lasers can be used to provide an excellent release with minimal heat, even the diode. What is most important is how well trained the provider is in the release and how well they know the physics of the laser they are using. Sadly it is possible to purchase a laser and start using it without taking any extensive training and many providers do not realize the complexity of their new tool.
Questions to ask provider before surgery
Please ask your provider how many releases they do per day. Ask how many they have done since they started. Look for laser training certifications on their wall if they are using a laser. Ask what types of classes they have gone to for laser training, how many hours. Ask what other factors they think are important to address when considering a release. They should have a pre and post protocol for all age patients to have the most effective results. Ask what they do if a patient looks like they have a lot of tension, contraction and even scarring after a release? What is their protocol? If they say they never have that happens, be cautious. If they have no protocols, be cautious. (Please be sure to watch my Youtube video on the misconception of “reattachment” to avoid having multiple surgeries!)
During the treatment
The aim of a tongue tie treatment is to achieve what is called “functional release”, whereby the tongue is able to move more freely without cutting any more tissue than is required. In order to test this, the practitioner may ask the patient to perform some functions during the procedure. For an adult patient, they might be asked to perform tongue exercises during the surgery, so that the practitioner can assess how much tongue movement is possible. With a baby, the practitioner will look at their sucking, swallowing and lateralization functions to make sure that they achieve proper release.
Doing these tests during the treatment helps to ensure better function after the surgery, with the minimum amount of scaring and healing possible.
What factors affect healing?
A big reason that patients are concerned with the different types of treatment is that they want to promote healing after the operation. The larger the cut that is made, the more the skin will contract as it heals, leading to tightness and reduced function. However, there are a number of factors which affect healing:
- The surgery. As discussed, a larger cut will take longer to heal. The way the surgery is performed, instrument used, technique used. Heat vs non-heat. Functional release vs arbitrary “cut” all affect healing.
- Pre- and post-operative therapy. It is vital for any adult who undergoes a tongue tie operation to have myofunctional therapy (before and after surgery) in order to retrain the use of their tongue. The tongue is a muscle and, like other muscles, it needs to be trained to work correctly. The process called “neuro-muscular re-education” is vital to get the tongue functioning correctly. For infants and young children we do have some pre-operative exercises which are very helpful. The emergent need for release and the child’s ability to do the pre-work determine how much we recommend prior to the surgery. Babies for example my have none if are struggling with growth, breathing or other serious issues, or they may have a couple of weeks worth if they do not have emergent needs. Working with a skilled IBCLC or SLP prior to the visit is ideal!
- Body work. The tongue and mouth are connected to the rest of the body via a complex system of connective tissue filled with nerves, veins, and muscles. If their connective tissue has tightness in other areas this can “pull” and affect healing negatively. If there are signs of tightness or a history of trauma, definitely seek out craniosacral treatment prior to the surgery. Many patients require treatments like physical therapy, occupational therapy, or Osteopathy in order to treat tensions, torsions or restrictions elsewhere in the body that are affecting the range of motion and function of the mouth muscles.
- Systemic inflammation. Systemic inflammation will negatively impact the healing process and can lead to poor wound healing. This can cause the area to look and act like a tongue tie again. Illness, allergies to food, and vaccines during healing all create some systemic inflammation. How much that inflammation will affect healing is very individual and has to do with genetics. If you have concerns, we can recommend a developmental panel prior to surgery to evaluate systemic inflammation and healing capacity. When this happens, the answer is not doing another surgery, but rather to reduce the systemic inflammation and get remodeling of the wound.
Just so you know, in our clinic we typically use a Waterlaser or CO2 laser for older patients and a CO2 laser for infants, but there are times when we will use a diode laser during part of the surgery, depending on the particular needs of the patient. Collectively we have done thousands in our clinic since we opened in 2012. I (Dr. Amy Luedemann-Lazar) began learning frenecotmies in residency in 2005, but I learned them with scissors and cautery and not in conjunction with breastfeeding issues. My training with lasers and breastfeeding dynamics didn’t start until 2009. We have diodes, Waterlasers and CO2 lasers as well as low level laser treatments for healing in our office and we use all of these lasers all day everyday.
As you can see, there are many ways to approach treating a tongue tie, and which particular option is right for you or your child will depend on your particular needs. If you’re in the Katy, Texas area and you want to learn more about the tongue tie treatments that we offer at Kidstown Dental, then get in touch with us and we’d be happy to help.