Episode 184: Not All Ties Need to be Released

Hi and welcome to episode 184 of the Untethered Podcast. It's your host, Hallie Balkan, and today we're going to dive into a quick episode on the fact that not all ties, whether they're tongue lip buckle, not all ties need to be released. So let's dive in. Quick disclaimer.

All information, content and material of this podcast are the opinions of the speakers and is for the informational purpose only and not intended to serve as a substitute for the consultation, diagnosis and or medical treatment of a qualified healthcare provider. Welcome to the Untethered Podcast. I am your host, Hallie Balkan. I'm a certified orofacial myologist, feeding specialist 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, tethered oral tissue and airway space. I challenge you to keep an open mind and join my mission to get this information out to the masses.

Let's get started. All right, so welcome to this episode. I have noticed lately that quite a few conversations just seem to have been popping up about Thai releases and when it's necessary and when it's not. And so I really wanted to just take a quick episode and dive into this because no, not all tethered oral tissues need to be released now. Quick disclaimer. Okay, is that this is not in the scope of an slp, a speech language pathologist, an occupational therapist, a registered dental hygienist. Right. This is typically only in the scope in terms of determining if the release is needed and the details regarding the release is in scope for the release provider, which is typically a dentist, a orofacial maxillary surgeon, an ent. Right. So those providers typically determine whether or not a release is needed. But depending on where you're located, you may be able to diagnose a tongue tie or lip tie or buckle ties. Okay, Cheek ties. So know where you live, know what the rules are, where you live. You know, for example, where I exist and where I'm licensed currently, like in Maryland and Florida, for example, I can diagnose. I have a specialized level of training. Not everybody does. So it really depends again on where you live, what your specialty training is, and so on and so forth. As to one, whether or not you can diagnose and then you know who is the available provider in your area to determine if a release is needed. And these are typically the providers that we would be referring to for a consultation as deemed necessary. But let's talk about releases and you know, when they may not be necessary or why they may not always be necessary. First of all, we have to look at function. And if you've listened to the podcast, this is definitely something you've heard me preach in the past. Function, function, function, function drives everything. Right? Function is talking about, what do I mean by that? Function means, is it impacting sleep, breathing, airway, is it impacting feeding? Is it impacting speech? There's been a lot of interesting research, depending on what you read and how you break it all down, that sometimes is for or against a release for any one of these areas. But there's also research that's come out and that's been supportive of releases for patients, certain patients who who have speech sound disorders, who have feeding delays or disorders who have really more disordered feeding, usually who have sleep disordered breathing. There is a growing body of articles and courses and people sharing results from cases that they've worked on. And we need to remember that research is about 17 years behind. So what often gets published and used in clinical decision making if we're just solely basing this on research, that research that got published last year, Right. We're kind of like working, as they say, we work about 17 years behind. So we have to look at the entire evidence based practice triangle. We have to consider clinical experience, what is working for our patients, right. While still making sure that anything that we are doing is not causing harm, it's beneficial to the patient, and so on and so forth. Right. So how do we determine, right. Who may be good, who we need to send for a release consult, and who we don't think needs a release consult? Because again, as an slp, I, even though I'm certified in oral facial myology, I cannot say, yes, this patient needs a release. No, this patient doesn't. Now, do we have conversations behind the scenes with some of our release providers who say, hey, like, what do you think? And I'm like, hey, this is your scope. But I can share though, is, you know what? I think it's impacting function. And I think that if we did have it, it would, you know, we'd be able to do X, Y and Z in therapy and they would greatly benefit from that release. Right? So I'm not saying, yes, they need the release, but I'm saying this is what I feel is happening as a result of that tethered oral tissue. And this is what I think may, may happen if we don't have that restriction in place. Right. Of course, I don't have a magic ball. So it's not. So I never promise anything to a patient because we never actually know. And there's a lot of factors and variables that play into this. But I do know from working with patients and my team working with patients and training other therapists and I'm working with patients, we do know what we are seeing. We do know that releases can be very beneficial if done right and if the therapy before and after is supportive of that patient's needs. Not just like a cookie cutter approach, but also we have to look at various things. We're going to dive in a little bit into what some of those things are. For example, I mentioned it comes down to function, not solely appearance. We can't just take a picture and go, oh my gosh, that kid is so tongue tied. Now when you do this for a while, you can look at a tongue and be like, oh, wow, that's a heart shaped tongue. That tongue is really just stuck to the floor of the mouth. They can't elevate it at all. The sides barely elevate. The tip is completely pinned to the floor of the mouth and go, I wonder how this person, if it impacts their speech, if it impacts their sleep, if it impacts because of their ability to breathe, if it impacts their ability to chew and swallow their food. And so most likely, yes, now, yes, because obviously they can't do what they typically would need to do, which is elevate that tongue for a lot of these activities. And they just can't possibly do that if it's physically tethered to the floor and it can't elevate at all. Some people learn to compensate and some people compensate very, very well. And so it also just comes down to do you want to live a life of compensation where it can snowball over time and potentially lead to other issues? Like we see temporomandibular joint dysfunction, we see migraines, we see obstructive sleep apnea. We see a lot of things snowball into adulthood that greatly impacts our overall health. Can we say that every tongue tie is going to do that? No, we can never say anything definitively. But can we say that we see a lot of adults who have tongue ties, obviously it was there at birth who have developed into adults with these issues. Yeah, we see that every day in our practice. So again, it comes down to not just how it looks, but how is it impacting function. And sometimes this is subjective. Sometimes the patient may not recognize how much it's impacting their function because they've Never known anything else. This is their daily normal. I've had grown men cry. When they had an evaluation, they said, you are the 12th person that I have been to for my issues. I basically decided to go out and figure out who else I could see because nobody believes me. People think I make this up. And. And this individual had an orofacial myofunctional disorder, obstructive sleep apnea that was missed. You know, tethered oral tissues. Right. And so after treatment and this patient did proceed with a tongue tie release and myofunctional therapy, you know, they came back again in tears. You know, at first it was tears because it's like, wow. It's someone who finally is listening to me and not just basing it on like, what one article says online or in a research journal, but actually like listening to me as a patient, hearing what my symptoms are, kind piecing the pieces of the puzzle together to figure out how we can best proceed in this individual's case. What's needed, what may be the first line of defense versus the last, right. And. And from there, right. We proceeded. And then at the end, they were in tears again because they're like, I didn't. I knew that I couldn't function, but I never knew how much I was missing. And it gives me chills because there's so many people walking around with children and adults who have no idea what normal sleep feels like, what restorative sleep feels like. They have no idea what it feels like to nasal breathe most of the time, right outside of eating and speaking. They have no idea what it feels like to have a clear. Like Peyton Nairs, to have a clear nose, open nostrils without enlarged turbinates or a deviated septum. I even had surgery six months ago, actually six months ago tomorrow, from the date that I'm recording this. And the ability to breathe out of both sides of my nose was not something I. I paid attention because I'm in this space, but it's not something I realized how challenging breathing was for me and how much more energy I was expending until after I had my septum fixed and my. I had my turbinates reduced and nasal swell bodies reduced as well. And I tell you, like now when I sleep eight hours, I actually wake up feeling refreshed. I feel like, wow, like I could take on the day I'm ready to go versus before I would wake up, like, dragging. It was almost like, why do I even bother sleeping? I feel exhausted when I wake up because based on my sleep Study I was getting fragmented sleep. I was getting basically anytime I went into REM in the, least the first half of the night, REM sleep, my body just jolted me out of it. And so I was never getting that, that rapid eye movement sleep that's also very restor. I wasn't getting that. So it didn't matter if I slept four hours, eight hours, five hours, seven hours, whatever. It was basically all the same and it was as if I wasn't sleeping much. So I go back to function. Function is what is important. Function is all the things that I've mentioned so far. If we cannot function in our day, we can't eat, we can't focus, we can't breathe properly, we can't sleep well, we can't. Maybe it's impairing our speech and so it's impairing our communication ability. A lot of kids get bullied and made fun of because of the way they speak, especially past a certain age. Kids are mean these days. I say it, but it's true. And all it takes is one, one child making fun of another child. That sometimes just sends these, sends some of our kids into not wanting to speak at all and just kind of keeping more to themselves or their small friend groups because they're afraid of what others are going to think when they speak or they're embarrassed to say something and have somebody them past a certain age. Right. I'm talking more about like kindergarten upward. So I want to focus on a couple things. Right. One, again, how do. There's a couple rules of thumb that I use in determining if we should refer out for a release consult. Okay. So number one, obviously an initial assessment is always required under the age of four. We've talked about how that's a sensory, oral, motor feeding evaluation with somebody who has training in TOTS and myo like in the peds course. But then, you know, we're also focusing on Now4Plus. Like what about the kids who are over the age of four through adulthood? That is an orofacial myofunctional disorder. Now, they may need other evals too. They may need speech to be addressed. They may need more of a feeding eval beyond just the MYO eval. That's fine. But for all intents and purposes, let's focus on getting everybody started with a baseline eval. We need to know where you're starting. We need baseline. Okay. Pictures are great, videos are great. We need to know what that person looks like, how they're functioning, how function is impacted. If we don't know that from the get go. How, how do we create a treatment plan and what do we know? How do we know what we're working towards? Right. So that's absolutely number one with that. We also can visualize or sometimes palpate or determine if this person is carrying tension in surrounding muscles. Sometimes our tongue may appear more restricted than it is for one of two very common reasons that I find. One, the pal is too small and the tongue can actually get into the palate. And so it's a tongue space issue. We just don't have enough room for the tongue in the palate. The tongue is not too big for. The tongue is not too big, the palate is too small, the mouth is too small for the tongue. It's not that the tongue is too big. Macroglossia is rare. Okay? That is a rare occurrence. It's that the tongue is too big for its cage. Like Dr. Liao talks about, you know, six foot tiger stuck in a three foot cage. Great book, by the way. So that's, that's one part of the equation here. The other part is we often carry tension in the surrounding muscles around the frenulum and around that little string under the tongue and even throughout our face and our neck and our shoulders and our entire body, our core, on down, on down to our toes. When we carry tension in one area and we start to compensate, that impacts how other areas function. There's like this trickle down effect and, or a snowball effect or whatever you want to call it. And so over time, our compensations, we may be compensating well, but over time that may also start to break down. So we don't want to dismiss a patient because they're compensating well, but we look at, okay, if we start myofunctional therapy with them, or facial myofunctional therapy. Right, we start that and maybe they need bodywork. Refer them out to an osteopath or craniosacral therapist or Cairo or somebody who knows how to work with our patients and they can address the full body impact. Right. We work on breathing, we work on all these different things. Do we find that the tongue actually gains more function and that tether tissue doesn't appear to be impacting function as much because we've released tension and we're working on training the tongue on how to actually do its job. Like, is it possible that we can avoid a release in that case? Yeah, that does happen. And especially in cases where it's like borderline, we're like, it's kind of borderline in diagnosing this as like a tongue tie, for example. Let's do some therapy and see where we get. Right. And in a lot of these cases, especially in kids who are like over the age of like five or so, usually, and assuming also that they have intact cognitive abilities, like they're typically developing everything, you know, they can follow directions really well, they are compliant in the sessions, they do their homework. Usually we can see changes in a matter of like three to four sessions over like three to four weeks. Okay. And that can help us determine if we're headed to a release provider or not. I don't love to refer to a release provider immediately because we don't have enough information yet. Right. There may be a rare case where we do, but that's going to be a rare case and it's going to be based on specific factors regarding, you know, related to the patient. And I'm talking about older kids and adults. All right, so or even not older kids, but like traditional myo age, like 4, 4 on up. Let's just stick with that number. 4 years of age on up. So if we can see changes that quickly, typically determining if we even need that release consult and the patient's doing some bodywork if needed, and you know, their homework and they're really compliant, we may be able to avoid the release. So it doesn't make sense to send people to send patients out on a wild goose chase to go provider to provider to determine if we need a release when we don't even know yet. Like, is this tongue tie going to change in regards to how it's impacting function once therapy gets started? Right. So start therapy first is. Is the message here? Because again, as I mentioned before, we may be carrying tension. Right. Also we may not know because maybe we need some expansion. Maybe we need to expand first and see if addressing those compensations, intention and therapy and teaching the tongue how to do its job and giving it more space to exist in the palate through palatal expansion. Maybe that's the first line. Referral is to a expansion provider because we need to determine if there's enough. If giving more space for the tongue, does that help change the appearance and the impact on the function? There's all these things that have to be taken into consideration, which is why I say not all ties need to be released. But if you've done your due diligence, right, you've done your eval, you've gotten started in therapy, the referrals have been made the patient's really compliant. You know, all these things that you're checking all these boxes and you're like, yeah, that tongue is not really changing much. Like, it's not that the surrounding oral muscles are compensating in a way that we can address. You know, sometimes we have. We have to provide. Proceed with a release, if that's what the provider. The release provider agrees with. Because we are working to gain function. Right. And we have seen firsthand how. I know I'm going to get people who are like she said it. How speech drastically improves following a tongue tie release. Yes, it's true. Like those kids sometimes who are stuck in therapy for years and years on end working on their articulation. Yep. Sometimes they have a release. They do myo. We touch up a few sounds, and they're out the door in six months. Twelve months max and done with speech. No longer needing speech. Like what? Tell me it doesn't work. But they had been in 12 years of speech therapy prior to coming to us. Hmm. It's kind of hard to argue that the anatomy wasn't impairing their ability to improve their speech sounds when we see cases like this and we see it repeatedly time and time and time again. Okay, so can some individuals who have, like, a tongue tie all the way to the tip that's, like, nailed down to the floor of their mouth speak clearly and. Sure, yeah, they can. It's going to take a lot more energy. They're going to compensate. Okay. They're going to really struggle with certain sounds. And even if they compensate well, again, it snowballs over time. But that shouldn't be a determining factor one way or the other. We don't typically send a kid for a tongue tie release just because there's speech issues. That may be why they came to us initially. But we often find that feeding is impacted or sleep is impacted, and those are two big drivers, both for kids and adults. Because we see feeding issues from infancy with nursing and taking a bottle or transitioning to a bottle or transitioning to solids. Right. We see all kinds of negative responses, aversions develop, limited food repertoire, determining, you know, they realize it's hard to choose certain things and swallow certain things when they get to solid foods. And so they limit what they eat, or they only what they feel safe eating because they eat what they can manage. So it's something. And then this continues into adulthood. There's a lot of picky adults out there. I know that Baxter had done a study where they saw an 84% improvement in children with feeding issues, post tongue tie release, if it was impairing their function before and they had the therapies needed and the tongue tie release, 84% of them, their feeding issues improved. Like, that's, that's a big number. That is a big number that we should not be ignoring as far as sleep goes. Right. We know that children who grind their teeth, they snore. Really any audible noise at night, this is a sign of sleep disorder breathing. And so we need to prep them properly so that we don't want to just release a tongue or it can fall back in the airway if it's not prepped before a release. We need to do the therapy. It's really important. That's why you hear me preach pre op, post op, both are equally as important as the other. But we need to train that tongue to rest in the palate, to exist in the palate when not eating or speaking. Right. Nasal breathing, lips are closed, sleep disorder breathing. We see, and I talked about this in a recent episode, we see kids who are restless sleepers. Maybe they wet the bed, they. That we see failure to thrive in some of these kids and failure, you know, and struggle to gain weight. We see growth issues. We also see ADD, ADHD issues, and 5 year olds on ADHD meds and antidepressants at 5, like, without ever having a sleep study breaks my heart. All right, so, you know, we may see inflammation of tissues in the airway. Adenoids and tonsils are typically the ones that are, you know, discussed. All kinds of things could be going on. Right. And so we have to be looking at sleep because this, the sleep and the airway component of it, that in and of itself, even if there are no obvious feeding or. And I get this question a lot. Well, my child sleeps with their mouth open. Should I still have an evaluation? Yes. We want to determine if there's a functional impact that is, you know, that a professional might recognize that maybe you're not seeing firsthand in your child yet, but maybe things that you don't realize are related will be uncovered in the evaluation. That happens a lot. We get a lot of family who, who say to us, oh, like them needing, them needing like extra time on tests or them having a struggle to, you know, my child struggling to focus in school or, you know, needing tonsils or adenoids removed or, you know, mouth breathing. These things are all related. Yeah, bedwetting. That's a big one. A lot of like frequently waking, you know, outside of like a child who is still feeding at Night, you know, once you're beyond that age. So I hear pediatricians say all the time, like, oh, it's normal for a child to wet the bed till like 8 or 9 years of age. No, it's not. It's absolutely not. Nighttime training might be, and I'm not a potty trainer. Okay. But I've potty trained two kids of my own. Nighttime potty training might be a little bit more challenging initially, but you generally, in a child who doesn't have sleep issues, who isn't losing control of their bladder, they should typically be potty trained at night not too long after their potty trained during the day. Sometimes kids potty train, you know, at the same time for, you know, both nighttime and daytime. Again, I'm not a potty training expert, but I can tell you that it's not okay for a child to still be bedwetting at 8 or 9. This is an airway issue. We should be looking into sleep. So, yes, if you see your child with an open mouth posture, that is enough reason to have an, or an orofacial myofunctional evaluation done, especially over the age of four. If they're under the age of four, you're going to want to call an SLP or an OT trained in pediatric feeding, sensory oral, motor feeding that also has training with myofunctional therapy and tetheral tissues, tongue ties, tots, et cetera. Okay. So hopefully that helps to kind of clear this conversation up a bit because again, no, not every time needs to be released. And just because your child presents with some of these symptoms doesn't mean they have a tie. And if they do have a tie, it doesn't mean it needs to be released. Maybe they just need some, some behavioral therapy. When I say behavioral, I don't, I mean like the kind of intervention that we do where we're actually working with the anatomy, we're working with the orofacial structures, we're teaching them where they should exist in the mouth. We're teaching them how to nasal breathe. Right. Because our goals, when we are coming from a myo standpoint is it's tongue up, lips closed, nasal breathing, and our teeth should be resting slightly apart, not together. Okay. And so if we can accomplish that 100% of the time that we're not speaking or eating, that's going to drastically improve a child's overall health. An adult too. So we need to. Yes, so it's absolutely worth it to have an evaluation if mouth breathing or open mouth posture is recognized. So, yeah, hopefully that helps to clear things up. I'd love to know if you have any questions regarding this topic, but nope, not all ties need to be released. It all comes down to function and what do we need to do to get this child or adult to function optimally. Right. Without all these compensations. And then lastly, the thing that we need to consider are the patient's goals, whether that's the patient, the child's caregiver, or the adult themselves. Some adults come and say, you know what, I don't want to do this whole treatment plan thing. I just don't want it to get worse. Can you help me prevent it from getting worse or can you help teach me what to do based on my current anatomy? Right. Understanding that we can only go so far. Can we help them? Yes, we can help them. Are we going to get them to optimal function? No. But that's not their goal for themselves. Right. So we also have to meet our patients where they're at and I want to keep that in mind because not everybody wants a release, even if they understand the benefits that may come from it. So hopefully, hopefully this is helpful and hopefully you can share this with somebody who is on the fence or confused or feels like does every tongue tie need to be released? Like that is the infamous question. The answer is no. But really, there's a lot that goes into determining the answer for each individual patient. So hope this was helpful. I look forward to chatting with you all next week. This is Holly signing off real quick. If you're listening to this and you're a SLP and OT and RDH or DDS and you're thinking you want more training in the myofunctional therapy space, determining what's needed for pre op and post post op therapy, therapeutic intervention, as well as just that whole knowledge base of OMDs and what to do with tongue ties and when to release and all that fun stuff, jump into the myomethod.com with us, which will currently give you three months free access to the myomembership.com and you're going to find a world 23 hours full of information to help you on your journey to better helping your patients. So the myomethod.com is where it's at and I hope to see you in there.

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