Thursday, March 29, 2012

It explains some things... (Calling for tongue-tie experts)

So here's the situation. Earlier this week I took the children to the dentist. She informed me that Michael has a mild-moderate tongue-tie. My mental response: Umm what? Are you sure? How on earth could I have possibly missed that!!! Did you make that determination based upon physical examination or behaviors?

I wasn't present for his examination because they accidentally scheduled the children at the same time and I was busy with Ava keeping her very overloaded sensory system calmed down just enough to get a little cleaning in through holding her in my lap, trying to simultaneously cover her ears and hold her hands, and singing soothing songs. But that's another story and I digress.

I knew Michael can't raise his tongue on command and that he can't stick it out very well. When you ask him to stick his tongue out he can get it out, but it curls down and sticks to the outside of his lower lip. He cannot stick it out forward at all. He can't raise it at all. I had always assumed that that was part of the same motor-planning spectrum that I've become so familiar with in Ava - or possibly a weakness issue. Well, look at where assumptions get you.

When we got home, I grabbed a clean cloth and pried up his tongue. Sure enough, you can't get it up very far and his lingual frenulum extends pretty far towards the tip of his tongue. On top of that, the lingual frenulum doesn't stretch at all and therefore even with some gentle manual pulling you can't get a lot of distance between the tongue and the bottom of his mouth. On top of that, he cannot get any upward curl of the tip of his tongue at all.

Let's summarize. Michael does appear to have a mild-moderate physical tongue tie. He has speech problems with /f, v, s, z, and th/. He produces all of those sounds as an interdental /s/ that is produced auditorily as a nice sharp /s/ sound. So, his /s/ sounds sound fine but are produced "incorrectly" and his /th/ sounds are produced with proper placement but sound like an /s/. He can, however, produce /t, d, and l/ just fine and those involve alveolar placement.

So here's my question for anyone out there who wants to chime in with an opinion. Given that he can produce /t, d, and l/ is it likely that the tongue-tie is the issue with the other speech errors? If there is no functional consequence of the tongue-tie I'm reluctant to have it clipped. However, if it is likely that the tongue-tie is impacting his speech errors, even in part, getting it clipped seems like an option to consider.

I already have a pediatrician appointment set up for Friday to discuss Michael's chronic mouth-breathing and nasal congestion and I intend to get her opinion about the tongue-tie issue then. However, she's not a speech-path so her opinion on whether it is effecting his speech isn't going to be an expert one. She's more the person to offer information and pros and cons on the procedure itself.

Thoughts and opinions from SLPs with some experience with tongue-tie? Please. :-) I tried to get some pictures for reference, but it was tricky. I had to try to manipulate his tongue with my left hand while taking the picture one-handed with my right. I apologize for the picture quality.

The first picture is what he does if you just instruct him to stick his tongue out.

The second picture is what he can do if you model sticking the tongue straight out without letting it curl downward.

The third is his attempt to curl his tongue up. He tilts his entire head backward and tries to push it up with his bottom lip and bottom jaw.

The fourth picture is my attempt to get an actual picture of his lingual frenulum.


  1. We did a study about tongue tie and speech production back in the 90s when I was at the University of Michigan Medical Center. Pre- and post-op artic evals revealed no difference unless the artic errors were tongue tip sounds /t, d, n, s, z, l/ and even then there was minimal difference. On the other hand, it is a very minor procedure. If you child is having another procedure (like tonsil/adenoidectomy) then it's not a big deal to clip the frenum "while you're at it". It is extremely vascular area and heals very quickly.

  2. Based on your pictures and description, I would guess that the tongue tie is not the reason for his artic issues. He appears to have enough elevation and protrusion for articulation. One thing you didn't mention is any feeding issues. With tongue tie, I like to make sure they can clean food from their lips, and from their molars, etc.

  3. Taken from Carmen Fernando web site and book.
    I trust her opinion because Tong tie is her specialty.

    This page contains links to other websites which provide more information on tongue tie. The links are listed under the following 3 headings:

    General Information on Tongue Tie

    Dr Caroline Bowen's Article
    A detailed and comprehensive description on what the tongue does and how tongue tie affects its actions. Written by a highly experienced and qualified Australian Speech-Language Pathologist, Dr Caroline Bowen, PhD.
    Dr Lawrence Kotlow's Presentation
    A presentation titled "Is Your Child Tongue-Tied?" by Dr Lawrence Kotlow, DDS. Dr Kotlow is a specialist paediatric dentist based in Albany, NY, USA, who has done much research on tongue ties and their treatment. His website contains many other articles on tongue tie.
    Dr Brian Palmer's Presentation
    Dr Brian Palmer, DDS, of Kansas, USA, has been evaluating frenums for 25+ years. His presentation on this topic is intended to help educate all who might be interested as to why it is best to do frenotomies on newborns and to do frenectomies on others who did not have frenotomies at birth.
    Mrs Maya Sanghi's Article
    General information on tongue tie written by Speech-Language Pathologist Mrs Maya Sanghi of India. It is part of the "India Parenting" website. The page on tongue tie includes a very active forum where people from all over the world (mainly those who believe they have a tongue tie) have added their comments. Access to the forum may be gained by clicking 'here'

    I ALWAYS SAY CLIP THE TONGUE because I've attended 2 conferences where they list a host of other problems, the least of which are speech...
    Such as increase in cavities secondary to inability to clear food properly with tone

    This is embarrassing but intimacy as they get older. Kissing is difficult.

    Self esteem.

    Email me if you need more info

  4. I agree with the above comments. I honestly would be more concerned with the mouth breathing. Many times remiving large tonsils and adenoids can make all the diference. But if he does have a medical procedure, to ease your worry - you can always have it clipped while the other procedures are done.

  5. I don't have any info to give you but I've been suspecting my 28 month old son with CAS also has a tongue tie. The pictures you show look just like my son. I am planning to bring it up with our ENT at his appointment next month, or the dentist which he sees for the first time in May. Please let us know what you decide to do.

  6. Judging by the dimple in the center above his top lip, I be willing to bet that he has a lip tie too. They usually (though not always) occur together. Having any degree of restriction in the tongue can impact speech, eating, digestion. They can contribute to dental decay and cause spacing issues for teeth. Did he have issues with nursing (latch, pain for you, slow growth/FTT, etc) or reflux as a baby? More often than not, those are the first symptoms that show up. A lip/tongue tie is a midline defect, and midline defects can affect motor planning. Bodywork (chiropractic, cranio-sacrel, myofacial) is highly recommended after a lip/tongue tie revision to release the tension along the midline.

    Even with the bad angle in the last picture, I can see that it's likely a stage 3 or 4 tongue tie (stage 4 is the worst) since it comes almost to the tip. Did you know that a tongue tie can cause sinus issues and mouth breathing? Since the tongue doesn't naturally rest against the palate like it should, this usually results in a high, narrow palate. And a high palate causes the nasal passages to narrow to the point that you have difficulty breathing through your nose. The structural issues can potentially be corrected through nutritional therapy.


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