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Tongue Tie: Understanding Anterior & Posterior Tongue Tie and Its Impact on Children and Adults

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A red cord with a tight knot, symbolizing the restricted tongue movement associated with tongue tie.

Tongue Tie: It's Deeper Than You May Think

Illustration of a woman experiencing jaw pain, a potential symptom of undiagnosed tongue tie.
My Eye-Opening Experience

I’ve dealt with chronic teeth grinding (bruxism) and jaw pain (temporomandibular joint disorder, or TMJD) for most of my life. It wasn't until I was 48 that I learned a surprising possible explanation: a mild, previously undiagnosed, tongue tie which was further back under the tongue than we traditionally think of a tongue tie.  A posterior tongue tie is not as easily seen and was thought to not have much of an impact on an individual's health.

I learned that I had been compensating for the difficulty in raising my tongue by using other parts of my mouth in ways they weren't meant to be used. For example, while I could move my tongue tip to the spot just behind my teeth, with my mouth open, when I did so my tongue was pulling all the fascia in the floor of my mouth, like the salivary glands, with it, making it much more effortful.  I could definitely feel the pull when I tried to open wide and touch my tongue tip to the top. To stick my tongue outside of my mouth, especially to the side, I was using my jaw and lips to increase the range of motion. To swallow, my tongue was thrusting forward to compensate for the difficulty of the back of my tongue to fully raise.

I share my experience to raise awareness about the complexities of tongue tie and to encourage others to explore potential connections between speech, swallowing, and other oral health issues and this often-overlooked condition. I hope this information can empower individuals to seek appropriate evaluation and treatment.

What exactly is Tongue Tie?
Ankyloglossia: A photo illustrating a severe case of anterior tongue tie, where the frenulum significantly restricts tongue movement. Photo by Klaus D. Peter
Image: frenulum linguae.jpg by Klaus D. Peter.
Licensed under CC BY 3.0 DE via Wikimedia Commons

Traditionally, we think of tongue tie (ankyloglossia) as a simple condition: a short, tight band of vertical tissue running from the bottom of the tongue to the floor of the mouth (the lingual frenulum) restricts tongue movement. You can see an example of the traditional use in the picture on the left.  

But the reality is much more nuanced. Current research recognizes that tongue tie can present in various forms, including subtle limitations and attachments further back in the tongue (posterior tongue tie), which may not be immediately apparent.

For years, the focus was on severe limitations, primarily impacting breastfeeding. When I was in graduate school (a quarter of a century ago!), tongue tie was briefly mentioned, but it was considered only impacting speech or swallowing if the tip of the tongue could not reach the top of the mouth. Basically, if the child could breastfeed and say /t/ or /th/, it was considered sufficient.  Which explains why I was identified as having a tongue tie at 48!

The recognition and understanding of tongue tie and its potential impact on overall health are continuously expanding. This is an evolving field, with ongoing research to refine assessment and classification methods. Currently, there is no single, universally accepted protocol, which can sometimes lead to varying interpretations and approaches among healthcare professionals.

However, emerging evidence suggests that even subtle restrictions can have significant, often overlooked, consequences.
Basic Oral Anatomy: An illustration depicting the tongue, teeth, jaw, and surrounding structures, relevant to understanding tongue tie and its potential impact.
Current research suggests that tongue tie assessment should include:
  • Length between tongue tip and the attachment of the frenum to the tongue (Kotlow Free Tongue Measurement)
  • Difference between maximum opening of mouth and maximum opening with tongue tip to just behind top teeth
  • Difference between maximum opening of mouth and maximum opening with tongue suctioned to roof of mouth
  • Compensations - floor of mouth, jaw, lips, neck
  • Tension - present or absent in mouth, jaw, neck, etc.
It is the presence of the compensations and tension more than the measurements that are more indicative of a problem with the tongue tie, especially in adults.  And yet, those are the most difficult to consistently "measure," especially between professionals.

How does posterior tongue tie affect feeding and swallowing?

A posterior tongue tie affects the mid and back of the tongue. It can interfere with the proper movement of the tongue and cause issues with proper feeding and swallowing.  Some experts even argue that the movement of the posterior portion of the tongue is even more important than the movement of the anterior!

Tongue Tie and Feeding: An image depicting a baby feeding from a bottle, highlighting potential challenges associated with inefficient sucking and latching.
Babies:

  • creating the seal needed for breastfeeding
  • fussy feeding
  • choking, coughing, gurgle sound
  • inefficient sucking, can lead to increased air intake during feeding causing excessive spitting up
  • Feeding fatigue
  • Cracked, bleeding, or severely bruised nipples

Children (and adults):

  • poor chewing movement and control of food bolus (clump), which can cause food spillage and/or food left in pockets of mouth
  • Poor movement of food bolus to the back of the mouth for swallowing
  • Increased risk of choking or gagging
  • may result in reluctance to try new textures

Beyond Feeding and Speech

While speech and feeding difficulties are well-known, the impact of tongue tie can extend far beyond infancy, affecting various aspects of oral health and well-being. Research on the long-term consequences of tongue tie in adults is still ongoing. Furthermore, the lack of a standardized assessment and classification system for tongue tie presents a challenge in consistently identifying and understanding its impact across different individuals.
"Underbite in a Bulldog: An example of how restricted tongue function can potentially impact jaw development and bite alignment."
  • Oral Motor Challenges: Restricted tongue movement can affect oral motor skills crucial for chewing, swallowing, and even breathing.  This can present itself as difficulty licking lips, blowing bubbles, or clicking the tongue.
  • Speech (Articulation) Difficulties:  Because posterior tongue tie is often overlooked, it may be a hidden contributor for children who have trouble with back sounds, such as /k,g,r,sh/.
  • Dental Issues: Some studies suggest that tongue tie and the resulting poor oral posture can contribute to dental problems like crowding, misalignment, and even underbite or overbite.  There has also been some suggestion that tongue positioning can affect the way the upper and lower jaws grow and develop.  This can occur because the tongue plays a crucial role in proper tooth and jaw development and alignment.
  • Jaw Pain and Dysfunction: My experience highlights a potential link between undiagnosed tongue tie and TMJ problems, such as jaw pain, clicking, locking, and limited jaw movement.
  • Bruxism (tooth grinding): May have been exacerbated, or even caused, by abnormal tongue posture and function, potentially contributing to my TMJD. A current theory is that some, if not all, bruxism arises from the jaw's attempt to find a comfortable resting position. Proper tongue posture can naturally provide this comfortable resting position for the jaw.  The exact relationship between tongue tie, tongue posture and bruxism is still under investigation.
    "Tongue Tie and Sleep: An illustration of snoring, emphasizing the potential link between restricted tongue movement and sleep-disordered breathing."
  • Breathing, Snoring, and Sleep Apnea: While tongue tie can, in some cases, contribute to sleep-disordered breathing, such as upper airway resistance syndrome (UARS), it's not a direct cause of sleep apnea. Good resting oral posture, which can be compromised by tongue tie, is important for healthy breathing.  This can contribute to mouth breathing, which has been shown to impact oxygen intake, among other things.
    • Many people with tongue tie may also have a longer velum, or soft palate (the tip can be seen as the uvula in the oral anatomy diagram above).  This soft tissue is likely stretched to help compensate for restricted posterior tongue movement. This can increase the risk of snoring.
    • Regular snoring, in both children and adults, should be evaluated by a medical professional.  Snoring can significantly disrupt sleep quality, leading to daytime fatigue, difficulty concentrating, and an increased risk of accidents due to excessive daytime sleepiness. Furthermore, chronic snoring can increase the risk of serious health problems, including high blood pressure, heart disease, stroke, and type 2 diabetes.

The Importance of Early Recognition

Early identification and intervention are crucial. For infants, addressing tongue tie can improve breastfeeding, speech development, and overall oral health. However, it's important to remember that tongue tie can still be addressed in adults.

My personal journey has been eye-opening. While I may not be able to completely reverse the effects of years of undiagnosed tongue tie, I'm exploring treatment options to improve my oral function and overall well-being. 

"Multidisciplinary Approach: Illustration of a team working together to assemble a large puzzle, highlighting the importance of collaboration in treating tongue tie."
Treatment team can include:

  • Pediatrician or General Practitioner: Often the first point of contact for concerns about tongue-tie, and can conduct initial assessments and refer to other specialists as needed.
  • Orofacial Myofunctional therapist - most often a specially certified dental tech or SLP, specializes in correcting improper function of the oral and facial muscles, including tongue posture and movement.
  • Otolaryngologist (ENT) - Specializes in disorders of the ear, nose, and throat and can diagnose and treat tongue-tie, including performing surgical procedures
  • Dentist - Can assess the impact of tongue-tie on oral health, including dental development and alignment and may perform tongue-tie release procedures (frenectomy).
  • Physical therapist (PT) -  Tongue-tie can sometimes contribute to postural imbalances. PT can help address these issues, such as forward head posture, which can impact oral function.
  • Lactation Consultant - Assists with breastfeeding challenges related to tongue-tie, providing guidance to both mother and infant.
  • Speech-Language Pathologist (SLP) - Evaluates and treats speech, language, and feeding/swallowing difficulties related to tongue-tie, and can provide oral motor exercises and therapy to improve tongue function.

A Call to Awareness

This experience has reinforced the importance of:
  • Broadening our understanding of tongue tie.
  • Early identification and intervention.
  • Considering tongue tie as a potential factor in a wider range of oral health and developmental issues.
  • More research on classifying tongue tie and how it impacts daily life.
If you have concerns about your child's speech, feeding, or oral motor skills, or if you experience any of the issues mentioned above, consult with a qualified healthcare professional, such as a pediatrician, dentist, or speech-language pathologist.

Resources:

I hope this blog post provides valuable information and encourages further discussion about this often-overlooked condition.

Mrs. Speech
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Hey there! I'm Mrs. Speech, your friendly SLP. Since 2000, I've been rocking the school scene across three different states, but in 2020, I took the leap into teletherapy, changing lives one click at a time. Oh, and digital materials? Been there, done that since 2013—always on the hunt for niche gems to make learning a blast. With two daughters—one a teen, the other adult—I've mastered the art of juggling. So whether you're a fellow SLP, a teletherapy newbie, or just love cool materials, stick around! Let's make learning fun together!

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