Ep 350: Sleep Struggles This Season? The Surprising Role of Tethered Oral Tissues

We have seen firsthand time after time, and I have endless stories of cases I will not bore you. Endless stories of cases that when a release is indicated, it's paired with the right therapy. It can be life changing. Hello my friends and welcome to episode 350 of the Untethered Podcast. I'm your host, Hallie Balkan, and today we're going to dive into a quick episode on something that I just feel like has been popping up all over the Internet as of late, and that has to do with tongue ties and releasing tongue ties. So let's dive in. Welcome to the Untethered Podcast. I am your host, Holly Balkan.

I'm a certified myofunctional therapist, feeding specialist, podcaster, business owner and mentor. This podcast is all about getting your questions answered and collaborating with colleagues to bring you the most up to date information in the orofacial myofunctional therapy, airway, tethered oral tissue, and pediatric feeding therapy space. If you're new here, I challenge you to keep an open mind and join my mission to spread this message far and wide.

If you've been around since June 2019.

Thanks for being a loyal listener. As we jump into today's episode, remember to listen with correct oral rest. Posture, tongue up, lips closed, teeth apart.

Breathe through your nose.

Let's get started.

Okay, so lately there's been a lot of discussion about Thai releases, like whether they're necessary and when they're not. And here's the truth, not all tethered oral tissues need to be released. That's it. That's the whole episode. No, I'm kidding. But here's the thing, right? There's like a scope and collaboration conversation that needs to happen here because one, like deciding if a release is needed and the details around that release that is in the scope of the release provider, which is typically a dentist, oral and maxillofacial surgeon, or an ent. Okay. And so depending on where you're located, you may be able to diagnose a tongue, lip or buckle tie as a therapist. But in some places, like I know, for example, I believe it's in New Jersey, for example, like SLPs are supposedly not allowed to diagnose tethered oral tissues. A tongue, lipper, buckle, you know, cheek time. So you need to know what your local rules say, what your scope of practice is, and that really comes into play with your state licensure. For example, in Maryland and Florida, where I am currently licensed, at the point of me recording this episode, like, I can diagnose due to specialized Training, but not everyone can. Okay, and the other thing that I want to focus in on for a moment is like, function over appearance. Because a lot of the conversations I see online are people talking about, like, is this a tongue tie? Is that a tongue tie? And my goodness, by now I would hope that, like, this conversation was like, done and we would have moved on from here, but that's just not the case because a lot of people still post photos in Facebook groups and they're like, is this a tie? Is this as high? Is this as high? It's like, oh, hey, you can't just diagnose from an image. Right. So let's talk about why this function versus appearance conversation is necessary. Like form versus function. Right. Or function, you know, versus structure. Form versus structure. And it really ties into whether or not the release is necessary because it comes down to one thing. Is it impacting sleep? Like that tethered oral tissue? Is there tight tissue present? And is it impacting sleep, breathing, airway, feeding, speech, et cetera? Right. Because function drives everything. And the AAO HNS consensus per SAGE Journals emphasizes the same thing. Diagnosis and management is based on functional impact, not appearance alone. Okay. So that's what I really wanted to kind of like hone in on here and just remind everybody about, because the research ultimately is both for and against releases, depending on what you read and depending on the different areas. And so the evidence is very mixed as far as the published research goes. But a 2020 prospective cohort by Baxter et al found that when complete trinectomy was paired with exercises, parents reported an 89% improvement in speech and 83% improvement in solid feeding and an 83% in sleep. Okay, and you can read more about this on like tongue. Tongue tial.comal.com Is it supportive? Yes. Is it definitive? Not yet. Right. But we also know what we see in daily practice, and it very much so mirrors like, what was in this prospective cohort published. That was published. Okay. We also know that pre and post op therapy helps studies from MDPI and EJPD continue to show better outcomes when the release is paired with structured either myofunctional or oral motor therapy. Right. So either that orofacial myofunctional therapy or the oral motor therapy, the sensory oral motor therapy that we see inside of pediatric feeding, you know, for kids who are not yet appropriate for myotherapy based on like, their cognitive age and everything. So one of the quotes. Okay, this is from a SpringerLink article. When release is considered, outcomes are best with A program that addresses tongue tie space. Sorry, tongue space. Like palate constriction, tongue tone and posture through myofunctional therapy and oral habits both before and after the procedure. Wow, this is like music to my ears. I have been preaching this for a very long time. And even before a lot of this data was in support of what we were seeing clinically. Right. So what we were seeing clinically was actually ahead of the published research. And again, it is supportive but not definitive. However, we know what we see clinically, we know what results we're seeing. We know when we're able to dismiss children, when they pit their goals and they're out of therapy, they are functioning. They are not just surviving anymore, they are now thriving. Right. So it's really important to not forget that part of the evidence based triangle, if you will, like evidence based practice does include the clinical experience that many of us have. It's not just what's published. And many of us seem to forget that in the speech pathology world if we want to look further into the evidence based practice. It's very interesting because I had this whole discussion around this on my Instagram recently about how like research is often about 17 years behind clinical reality. Some people say, well, if you, you know, read the research, it's actually that, you know, the research is published and then clinical practices 17 years behind what's been published. And yes, that is the case at times, but that's not always the case. Sometimes we've actually found, depending on which journals you look in, like in the dental space, for example, there is some published research around how there's a 12 year gap and how typically what's being done in the dental field does not. It actually precedes what's being published in the research. And so we're seeing it in both directions. And honestly, at a certain point it's semantics. The point is there is a 17 year gap between research and clinical reality. And so you've got to use that evidence based practice triangle. Okay. Like I was just talking about a few moments ago. And so just to kind of reiterate, because I didn't mention all three parts of it, that includes clinical experience, as I mentioned, it also includes patient values and research evidence. Okay. Our goal is always to help our patients without harm and to do it truly benefits them, the patient. If something were published in an article that was not actually benefiting a patient, will we keep doing it just because it's published? No. No, we would not. Right. And that's going to be based on patient values in clinical experience and just having the knowledge, experience and background to know when we might need to change something, despite the fact that it's not published yet or this is maybe not supported in the research yet, we're not causing harm and in fact we're seeing progress made. Right. So how do we decide like how we, how do we decide like who might need a release consult and who might not? Because again, it's not necessarily. Aside from what I've shared with you, there isn't this like definitive protocol in the research that tells us exactly like step A, step B, step C, I can share with you what we are doing in my practice, what we've been doing for 10 years. I can share with you what others are doing. Right. Our protocol, kind of our framework, if you will. And I will also say that as an SLP, who is certified as a myofunctional therapist, a CMT and who's had other certifications in MYO that have actually dropped for other reasons that we won't dive into today, I can't definitively, definitively say, yes, this patient needs a release because that is out of scope. Right. That call actually belongs to the release provider. But I can absolutely identify functional impact and collaborate to guide that decision. Okay. And so we have seen firsthand that when a release is indicated and it's paired with the right therapy, it can be life changing. I mean, I have so many different stories. I had one kid who had maybe been in a total of eight days of school about halfway through his school year where he did not vomit at lunch and get sent home. And it was because of the impacts of him, the sensory impact. When he walked into the lunchroom, all of the sights, sounds, smells, experiences for him, it was too overwhelming to his system and he would vomit as a response. And as soon as his tongue tie was released, that went away. Now are you going to find that in the literature? No, you're not. Because there's all kinds of different scenarios where these one off instances happen. But what's very interesting and what is not so far fetched and what we see as a pattern across different kids is that tethered oral tissue, right, can impact the nervous system, which can impact what appears to be sensory responses externally and other behaviors that oftentimes shift change, you know, oftentimes again for the better following a release, because now the body's able to regulate itself, right? So there are different scenarios, stories, and like I could just keep going, right. I had a kid who came in, he'd been through seven other SLPs, he was going into high school, he was in eighth grade. Mom was like, we want him to correct his speech and sound like he is very clear with his speech by the time he goes into high school in Nepal. And I was like, that is a big lift. We have less than a year. This kid has been in speech therapy since he was 2. He scored below the age of a 2 year old on the Goldman Fristo Test of Articulation 3, which is very heavily dependent on the ability to say R, especially at his age, which we know as SLPs. R is like its own, like vocabulary, non vocabulary, its own Alphabet. Like there's so many variations of R, right? So prevocalic, post vocalic, on its own, whatever. And so it was challenging. However, I looked in this kid's mouth and I had never seen so much webbed tissue under his tongue. Such a restriction. And I was. He was like, no one's ever looked under my tongue before.7 Speech language pathologist he had been to, and no one had ever looked in his mouth under his tongue, asked him to move his tongue around. What are we doing? Like, what is happening now? Let me tell you, mom, I ended up hiring somebody to help him. Kind of just with the drill, more for like, hey, I'm assigning the work. This person's gonna help make sure you get it done on a daily basis. This kid was. Kid was prepped for a release. He had the release. We had post op therapy, right? He went through mayo. He went through. We did some speech stuff once the tongue was released and able to actually hit the correct articulatory targets. And the craziest part of it all was that he was able to graduate from speech therapy within six months of starting with me, within six months of his assessment. And this is a kid who had been in therapy since he was 2 years old, which is wild. Absolutely wild. So I share this with you because again, the evidence base is not as supportive of, you know, stories like this. And when we do post our case studies, we get torn apart by the people who are all holy and almighty, you know, research, clinical, PhD, blah, blah, blah. And I'm not pooping on PhDs, you guys. Like, if that's what you want to do, that's what you want to do. But let me tell you, there's a very big difference between what happens in a clinical setting and oftentimes what is being researched. And so when the research does get published by those who are in the clinical setting, and it might not be a type 1 RCT for whatever reason, whether it's not going to be approved by an IRB, or it's just not something that is easily studied or it just hasn't happened yet or whatever. Again, the case may be, man, they love to tear apart that research and it's sad because it's being done by individuals within my profession. Right. Anyways, I'm off on a tangent here, but I want to go back to this, right. We have seen firsthand time after time and I have endless stories of cases I will not bore you, endless stories of cases that, you know, we have seen firsthand that when a release is indicated, it's paired with the right therapy. It can be life changing. Right. And so I just want to remind you that like, appearance isn't everything. In some cases, appearance is important, but we can't just look at a photo like I was saying before and decide, yes, sometimes the tongue looks very obviously restricted, but the question is, is it impacting function? Some people compensate really, really well, but compensation often comes with long term costs. And for adults, we tend to see like tmg, TMJ pain, migraines, sleep disorder, breathing and a whole host of other symptoms. Okay. And honestly we're starting to see this in kids, which is a little bit scary because that was not always the case. But we're definitely seeing kids with sleep disorder, breathing, we're seeing kids with TMJ issues. We're seeing kids with long, narrower faces, their mouth is open, they're getting headaches, they seem tired all the time, they've got those allergic shiners where their eyes are all, you know, there's again, there's a whole host of signs and symptoms that we're seeing. So I just want to kind of tie this up with a pretty little bow and, and give you a little bit of an insight into whole sleep and area world, world. But a 2024 systematic review. Okay, this is on SpringerLink supports an association between ankleglossia tongue tie and pediatric obstructive sleep apnea osa. And so evaluations, this tells us evaluations should consider both tongue mobility. Right. And a high arched palate, or in other words, tongue space like I was talking about at the beginning of today's episode. And myofunctional therapy continues to prove its worth because a recent meta analysis and your PMC showed that myotherapy can reduce the apnea hypopnea index by about 50% in adults and often even more in children. And that, my friends, is so important. It is huge and it supports everything that we do to improve airway and tongue posture, like tongue position. Right. And so I want to give you a few guidelines, a few rules of thumb, if you will. Number one, okay, I'm going to give you, maybe give you three, three little steps here. One, start with an initial assessment. Okay. If they're under the age of four, that's going to be a sensory, oral, motor feeding evaluation. And that should be done with somebody who has taught some MYO training, kind of like what I teach in Feed the peds. Okay. In my 12 week Feed the Peds pediatric feeding course. Because we adapt myo, which is really only for children who have the cognitive ability of at least a four year old. But oftentimes the kids do better if they're five or six. So under four, sensory, oral, motor feeding, evaluate with a pediatric feeding therapist, SOP OTPT with toss and myotraining, and then for ages 4 and up, cognitively, like cognitive functioning, an orofacial myofunctional evaluation would be awesome. Right. If the child is ready for it. But you can do that all the way through adulthood. Okay, so that's number one, start with that initial assessment. And number two, I want you to consider the pallet size and any muscle tension. Sometimes the tongue appears restricted because the palate is too small, not because the tongue is too big. Right. We will hear people say, oh, the tongue's too big. No, it's too big for that mouth. That mouth is too small for that tongue. But the tongue is not actually like, it's not macroglossia, it's not too large of a tongue. It's just the tongue is a normal size and it doesn't have enough room to fit in the garage. Right. It's kind of like the car doesn't fit in the garage. The car being the tongue, the mouth being the garage. And so Dr. Liao, who has been on the podcast, he's spoken to my study club, my, my, you know, back pre2020 and then even since then, and he's written many books, he has an analogy, you know, six foot tiger, three foot cage. So it's basically like trying to put a six foot tiger in a three foot cage. It's just not going to work. And if you do cram it in there, it's going to be just that crammed. Okay? So that's, number two is to consider pallet size and muscle tension. And then number three, address airway or space first. Okay. So number one, initial assessment. Number two, consider pallet size and muscle, muscle tension. And number three, Address airway or space first. And to kind of go into that a little bit further. Number three, that airway and space first conversation. Palatal expansion may come before a release. If creating more space improves function. And it seems like the tongue is no longer restricted, a release might not even be needed. So I'm a big, big advocate for early intervention. This can be done at any age. I'm an adult in a MARPI going through expansion myself. Yes, I had all the traditional expanders, braces, invisalign younger, I had a DNA vivos as an adult. I had a nasal surgery three years ago, ENT surgery, septoplasty, et cetera. And then now I'm in Murphy. And so had I expand, I feel like I did things kind of backwards, but whatever, that's my trajectory. That's my story that, you know, I got to where I am because that's what I needed to do at the time. But with some younger kids, when we're not quite sure and we're borderline addressing that airway first by going through palatal expansion definitely will help us determine whether the release is still necessary afterwards. And again, we're not making that decision. We're part of the team. But it's ultimately up to the release provider. We're providing the data that will help them make the decision, however, because we are the ones looking at how that tongue fits into the space. If it's blocking, you know, the visual part of the airway that we can observe if it's impacting function as far as feeding, sleep, breathing, etc. Goes. So speech, etc. So there you have it. Okay, so Myo should always come first. Or that, you know, if not expansion, then Maya would be the next thing that comes first. Or the pediatric feeding intervention, the sensory, oral, motor intervention. If you start therapy, right, like breathing, posture, bodywork and function improves, that's awesome. If it doesn't, then a release consult may make sense as the next step. Okay, when we are, when we've done our due diligence, right, our evaluation, we've started therapy, we've made some referrals, and function is still not changing. Following all of those things again, that may be when it's time to proceed with a release, right. We don't want to jump in. There's no reason to rush it. If you're talking about, like, a newborn and they're not feeding and there's other things going on, then that may be a different conversation, different story. I'm not talking about that at this moment in time. I'M talking about the majority of cases that we see. Okay. Because again in practice speech improvements can be dramatic. Like that story I shared with you about that kiddo who was headed into ninth grade after a proper release and myo. And so some kids who have been in articulation therapy for years and that one case is not, unfortunately, I will say that in this one case the webbing under the tongue was a little bit atypical. We don't typically see that, but we do still have kids with posterior and anterior restrictions. And so a lot of these kids who have been in therapy, articulation therapy for years tend to make more progress in six months after combining the two. Right. The intervention of the release and MYO when it's needed, then they made in the prior six years, assuming that they're like at least six years of age. It's wild. It is absolutely wild. And it's. What's even crazier is we still have SLPs on the other side of this going like myofunctional therapy is not a real thing and there's end zones. And we're not even going to get into that because it's the most ridiculous conversation at this point. And in my professional opinion, people who are still, who still believe in end zones and want to believe those lies because one person published an article in the 80s or whenever it was, you're doing them. I'm just my psa. You're doing a major disservice to your patients. And if you cannot admit that you maybe are wrong and maybe open your eyes to what's actually working in therapy, what's most beneficial to your patients. Just going to venture to say you are causing harm whether you realize it or not because it's more money out of a parent's pocket, more time out of the parent's schedule and the kid's schedule for unnecessary ongoing therapy that could have gra. Where a child could have graduated much faster. Right. And I felt really guilty when I realized this. It was very early in my career, thank goodness. But I was like, oh my gosh. I went to a university where they preached ensomes. They were very anti oral motor therapy. And within a couple years I was like, like why can't I graduate? These kids like I get it pheno, phonological, you know, and I started questioning phono, phonology and like, like phonological processes. I was like I really don't think this is language based. Like these kids feel just can't physically make these sounds. And so yeah, of Course we see patterns because if there's a restriction or there's some kind of a oral motor issue or something is just not integrating well, it would make sense that every single time there'd be a pattern. But that doesn't mean that there's like a language race based rule behind it. And I will tell you guys, I would have gotten canceled for this three, two, three, four years ago. But there is some new research and we can talk about this a different, on a different episode. There's basically some new research out that really supports my beliefs behind this. And that phonological processes and using that as an intervention, like treating phonological processes and phonological interventions for speech sound productions is total, totally bogus. It is totally bogus. Putting it out there. I think it's fake news. Fake news. All right, come at me. Okay, so I've already shared a little bit about what we see in practice, but what we're seeing in feeding is also incredible. Right? We are also seeing about an 84% improvement. Right. Baxter shared that in that 2020 article. And so we're seeing that 84% improvement in children's feeding after the tongue tie release when paired with therapy. Right. And then for infants, the AAP in 2024 reminds us that many breastfeeding difficulties improve with skilled lactation support. I haven't really mentioned lactation. That is very important when we're talking about our babies that maybe breasts or bottle feeding. Right? And bottle feeding. If they're not breastfeeding, they're only bottle feeding, then that's when maybe it's more appropriate to work with like speech language pathologists, occasional therapists, physical therapists with the feeding side of things. But if there is breastfeeding involved, then lactation support is critical. But many breastfeeding difficulties improve with skilled lactation support. Frenatomy is preserved for cases where a restrictive frenulum is clearly causing an unresolved, unresolved latch pain or transfer issues. And that's in Pediatrics 20. And that's function first care. Right. There's obviously more things that can be happening. They're very focused on the feeding side of it there, which is fantastic. I don't want to downplay that. But in infants, just know that everything else we've talked about as far as like airway and sleep and breathing and all the things that can also be very, very impacted. So that kind of leads into the next thing I want to talk about, which is really the last thing before we kind of wrap this up for today. And that, my friends, is if your child snores, if they grind their teeth, you know, child or the patient you're working with, if they snore, grind teeth, they sleep with their mouth open, an evaluation is in order. Okay. Persistent bedwetting in school age children, that can be a red flag for sleep disorder breathing and absolutely warrants an evaluation. It is never typical to bed wet past like the toddler years. Once a child is potty trained, like the night training should be happening around the same time as the day training. Um, again, I know people are going to come at me for that, but there is no reason that a 6, 7, 8 plus year old should be wetting the bed. It's not, and they're not proud of it. Oftentimes there's a psychological component to there too, where they're very impacted by this still happening and there's embarrassment and they don't want to, you know, they don't want their friends to know, they might not want their siblings to know. So persistent bedwetting and school age children, that is not typical and that is something that absolutely warrants evaluation and oftentimes is tied to sleep disorder breathing, which can also, it may be, you know, tied to tethered oral tissues. Tongue tie, it may not, but it needs to be assessed and ruled out. And so if you see an open mouth posture, that alone is enough of a reason for an orofacial myofunctional evaluation, especially over the age of four. Because we talked about like, you know, that cognitive age of four. Right. Okay, so let's recap this. Let's, let's tie this up with a pretty bow. This is what I want you to take away today. Not every time needs to be released. Number one. Number two, function, not appearance, drives decisions. Number three, pre and post op therapy matters. Number four, collaboration is key, which is something, you know, I preach if you listen to the podcast. Number five, patient goals always come first. All right. And our myo goals relate. They remain the same. Tongue up, lips closed, teeth apart, brief your nose. And that little mantra. Now you guys. Is published in our tongue tie series books. As you can see behind me, my tongue is stuck. How to train your tongue. Let's get your tongue unstuck. Just gonna put a little plug in for those books behind me. I wrote this with my dear friend and colleague, colleague, Dr. Jennifer Tippograph, who is a biological and airway centric dentist. She's phenomenal. And so together we wrote all three books and pulled in both of our, you know, areas of expertise. We do sell. They are sold separately on Amazon. So you can just like Google them and they'll pop up or go on Amazon and look for them. They're also like Barnes and Noble. Like, all you know, you can Google it. They'll come up. But I will say my tongue is stuck is kind of the realization that the tongue is not moving the way that it should. And then how to train your tongue, you know, the child goes into the dentist, discovers that there's a tongue tie present based on function and appearance, but mostly the function concern, right? And then meets the myofunctional therapist, goes into mayo, and then let's get your tongue unstuck is basically the story of the tongue tie release. And we separated it out so that parents can choose, like, which stories they introduce. But honestly, they're all very playful and there's like a superhero theme. We wanted to keep it like less medical, more playful. Very normalize the conversation. So if your child is going through this or you think your child's going through this, or you own a clinic and you want these books in there, or you own dental practice, the ortho practice. These are great series to have, like sitting out on the table because it just again, normalizes the conversation around a lot of this. And the kids are like, hey, that's, that's what I'm doing or that's me. Right? Like, they relate to it and it seems really cool to see, like yourself in a sense, like in a character in a book. So anyways, okay, if you can achieve this consistently that tongue up, lips closed, teeth apart, brief your nose, our little mantra, you're going to change health, health outcomes, your own and others, Right? And so an evaluation is always worth it if you notice mouth breathing or open mouth posturing. Okay. Sometimes therapy alone can make all the difference. We meet our patients where they are. Not everyone wants a release that is okay. We, our role is to support optimal function and educate with compassion. All right, so if this episode helps somebody who's wondering, like, does every tide need to be released? The answer is no. And now you know why. Please share, Please let everybody else know too. Because I feel like there's a lot, a lot, a lot, a lot of information out there that is just not super accurate. And so if you are an slp, ot, pt, RDH or dds, and you want more training in the myofunctional therapy space and you want to dive into this further, learning how to manage pre op and post OP care, understanding OMDs or rotational myofunctional disorders and make confident collaborative decisions. You can join us@themyomethod.com when you join you actually will get a couple months free inside of the membership and inside the myomembership.com and there's just like a ton of support in there. Plus we have now something called Halle AI which in addition to the live mentors that you get by nature of being inside the membership for free for a couple months, you also get Hally AI which is a 247 pocket mentor and you are never going to be without answers to your mayo questions, myo tongue tie, airway etc questions like ever again. So super cool stuff is happening around here. Anyways, I cannot wait to see you guys inside the MYO method inside the MY Membership, Inside Hallie AI this is Hallie signing off. And don't forget to go to the myomethod.com@ the very least check it out and we'll see you inside.

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