In my private practice, I often consult with other SLPs about their clients with shortened or restricted lingual frenums. The concerns that are typically voiced to me are 1) they are unsure whether ankyloglossia (tongue tie) should be treated at all, 2) if they were to treat it what should be done, and 3) ASHA’s position on this occurrence. After working with several clients with tongue tie over the past 18 months, I decide to present on this topic to the Pediatric Treatment Study Group in Portland this January. Following is a synopsis of that presentation.

First of all, ASHA does not have a lot to say on the subject. Quoting Ann Kummer in the ASHA Leader in 2005, “There is virtually no evidence in the literature to establish a definite causal relationship between ankyloglossia and speech disorders. In fact, there is very little in the literature that addresses ankyloglossia and speech at all. (emphasis mine) This is probably because a causal relationship is not what is typically seen clinically. Therefore, it can be assumed that ankyloglossia is unlikely to cause speech problems in most cases. Most experienced speech-language pathologists would conclude that frenulectomy is rarely indicated for speech reasons unless it is very severe or there are concomitant oral-motor problems. It may, however, be warranted for problems with early feeding, bolus manipulation, dentition, or aesthetics. Although frenulectomy is a minor procedure with a low risk of morbidity, the true danger is the disappointment that can result when parents are led to believe that this will correct speech problems that are actually due to other causes.”

That said, there are many children who experience this phenomenon that can benefit from our clinical eye, expertise in feeding, and/or a sound referral to another medical professional. Never judge solely on the acoustic quality of speech. As those of us who work with clients with craniofacial syndromes know, children can be quite adept at inventing compensatory techniques in an attempt to achieve typical-sounding speech. In the case of clients with tongue tie, it is often overuse of the jaw.

In deciding if a client’s tongue tie is interesting or problematic we should evaluate the structure of the frenum, the function of the tongue, and the concomitant behaviors that result in the lack of typical structure or function.

In evaluating the structure of the frenum, placement is most important. A lingual frenum attached close to the tip may be able to stretch to some degree but will continue to impede typical mobility. This is a primary diagnostic indicator for a frenectomy referral. The quality of the tendon itself can give important information about its ability to be stretched.

When examining lingual function, focus should be on tip protrusion, elevation, retraction, lateralization, and circumlocution. Stability, range of motion, and jaw involvement should be considered. Behaviors that might be observed include low forward tongue posture, tongue thrust swallow, inefficient or messy eating, oversalivation, and poor articulation of alveolar and velar sounds. It must be said that clients with poor tongue function do not necessarily have tongue tie, but poor function is often a byproduct of this experience.

When considering a referral to a doctor for a frenectomy (most often an ENT or pediatric dentist), we can defend our recommendation by noting anterior placement, rigidity of the tendon, and lack of meaningful progress in a stretching program. Physicians consider feeding, dental hygiene, and lingual function a much higher priority than poor articulation alone.

In implementing a stretching program either before and/or after a frenectomy, the goal should always be on typical lingual function. Proper stability in rest posture promotes optimum hard palate and dental development. Full mobility promotes efficient eating, the ability of the tongue to clear the molars and buccal cavities of debris, movement independent of the jaw, and ease of coarticulation. Stretching after a frenectomy is highly recommended as the tissue can reattach, especially if the tongue has habituated a low rest posture. Typical functioning is not automatic and maladaptive compensatory techniques need to be retrained.

In summary, when evaluating akyloglossia keep in mind structure of the frenum, lingual function, and resulting behaviors. Consider feeding and oral health as well as articulation when determining if a client needs treatment or referral for a frenectomy. Treatment is based on typical functioning, stability, and range of motion. Consult with your colleagues or a medical professional if you’re unsure how to proceed.

If you have questions or are interested in a consultation or  presentation, please contact me at linda@donofrioslp.com.

Linda D’Onofrio