Modern Myths about Tongue-tie - Page 2
|Modern Myths about Tongue-tie|
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 this type of tongue and/or mouth floor restriction resolves with simple bodywork; 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 hyoepiglottic 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 nonexistence 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 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. 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 t he 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 practitioners 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 reattachment. 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 (reattachment). According to new research, the frenum is a tendon, a type of fascia. Breaking down the scar tissue in the fascial wound bed causes myofibroblasts to lay down a dense collagen network (excessive scar tissue formation). 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 reattachment. 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. 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. In other words, it 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.
This article appeared in Pathways to Family Wellness magazine, Issue #48.
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