Episode 193: Tongue Ties and Speech: Yes Virginia, there is a connection!

Hi and welcome to episode 193 of the Untethered podcast. It's your host, Hallie today and we are diving into, as promised, the impact of tongue ties on speech sound production. Because yes, tongue ties do impact speech. So let's dive right on 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 health care 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. Hello everybody. It is me, Kali. I'm back again. We're going to talk today, as promised, about tongue ties and speech. So here's the thing, right? Do we need more research? Sure. Do we know what we're seeing clinically? Yes, we do. Do we know that you can find research for and against what I'm going to talk to you about today? Yeah. So we have to look at both sides of the picture. We also have to look at and turn to evidence based practice, individuals who are actually treating these patients, the patients are actually receiving these treatments or not receiving them. We have to look at patient goals. We have to look at more than just like random controlled trial type of data. Is that important? Yeah, but so is everything else, right? We can't just put these RCT level one and two studies like above everything else that exists out there, regardless if it's for or against what we're preaching. Right. We have to look at all the data. Okay, so here's what I want to share with you. We're going to dive deep into my experience, my truth as I know it, based on the patients I have treated before I was a specialist in this space and the patients I treated after I was a specialist in this space. This space being infant toddler feeding, myofunctional therapy, tether oral tissues. Right? And I'm going to tell you there are patients. I wish I could go back and redo certain cases or try different. Try different things based on the knowledge that I have now, because I think things would have changed. They would have turned out very differently. I also think that some of those patients who had to come back later for further intervention could have potentially prevented that had we taken a different approach. So put your ego aside if you're a provider listening to this and be open to what I have to say and share with you, based on the experience of many therapists, many specialists, many patients, and the results that we're getting by taking this type of an approach. All right, so let's. Let's dive in and not waste any further time here. Now, can tongue ties impact speech? Yes. Yes, they can. When a child has a tongue tie. Okay. Or let's just say yes, the answer is yes. Okay, let's dive in. When a child has a tongue tie, they may struggle to produce specific sounds. Okay. Specific speech sounds. Some of the common sounds that we see are like, I'm going to say the letter first and then I'll go through. I'll say the sounds after. But sz, the sh, ch, zh, dj and that's like J. So. Right. I said them together, spelled out with the letter name first so that you would understand those sounds. Because I know in a podcast this could be a little bit harder to hear. Frontal lisps. Right. We might see that on the. That S or Z, that's alveolar sounds like T, D, N, L, T, D, N, L. Did that one backwards back sounds as well. The kgr, like K, G, er, and R. Right. R actually is produced. It's like its own Alphabet. It's produced many, many different ways. But the bottom line is that each of these deserve their own attention. Each of these like groups of sounds. So I'm going to talk about them separately, but I have it on. This is my unpopular opinion. I know amongst certain people in the speech language pathology profession, just because a sound sounds good doesn't mean that it's being produced correctly. Okay. Properly. And this is frequently overlooked, dismissed in the SLP community. Okay. I was taught in grad school, if it sounds fine, it is fine. This could not be the further. This could be further from the truth. And if you recently listen to my podcast with physical therapist Liana, who is also a myofunctional therapist and TMJ specialist, we talk about the muscles and the recruitment of the muscles and the compensations for these patterns. And so if you missed that episode, go back and listen because she talks to this as well, which is wonderful. As does Dr. Rebecca Baco, who was on prior to her also as an orthodontist, made a comment that these are compensations. They're not being produced correctly. Right. We are humans who have an anatomy that is supposed to operate a certain way. Right. We have form, we have function when things are not functioning as they should, unfortunately, that takes a toll in other areas. So. So just because it sounds fine does not mean it's fine. Right. If the sound is not produced in the correct place in the mouth, then there's more going on than just a speech problem. And we should be doing like a full blown orofacial myofunctional evaluation to explore the root cause of the speech sound disorder. If they're like over, if they're four years of age or older, under four, we're going to take that speech, that articulation test approach. However, we're going to also look at their oral motor skills. Yes, I said it. Okay. All right, so let's, let's dive into the lisps for a moment. A lisp is never normal. As I said on the prior episode, frontal lisps occur when the tongue pushes against or through the front teeth and makes a th sound for an S or Z. Like a for Z. Right. Like I thought, I thought a puddy cat, right? Instead of I thought I saw a puddy cat. A pudding. Listen to me. Cat, right? A cat, right? That's like one of the famous ones that just like, is stuck in my brain from having watched cartoons when I was a kid. Like, there's different types of phrases out there that when you stop and think about it, you're like, oh, that's a lisp. Right. Why does it happen? Well, a frontal lisp can occur for a number of reasons. Some may include, like, having a high and narrow palate. Tongue can't actually go where it's supposed to in the mouth. Changes the shape of the space for the tongue inside the mouth. Maybe there's an unstable lower jaw. There could be a tongue tie restricting the tongue and holding it from having full range of motion. Okay. Like any other type of lisp. And we'll talk about lateral lisps next. Frontal lisps need to be addressed and myo eval. Right. For those kids who are four plus would also, especially if done with an A speech language pathologist will include assessing for speech. Right. But a mild eval should, regardless of who it's with, whether it's a rdh, a dentist, an slp, an ot, a pt, whoever, should include assessment, you know, to rule in or out tongue and lip ties and or determine if a referral needs to be made elsewhere for that diagnosis to be Ruled in or out. But we need to conduct this to determine the front cause. Like, what is the front cost? The root cause of the frontal list. Once that root cause has been identified, then we can form an appropriate treatment plan. Right. And address that frontal list. It's one of those things that actually, like, I dreaded treating before I was in the myo and tot space, and then I really enjoyed treating after because of how easily and quickly these children and teens and some adults even, they all of a sudden, after having a tongue tie release or having, you know, with mayo or having mayo or expansion with release and myo or expansion in myo or whatever the case may be, once they had room and they had full range of motion, guess what happened? They very quickly were able to correct the lisp because we showed them how to produce a sound they physically could, and boom, gone. Matter of days, weeks, sometimes not years, not months and years. Okay, now that was a frontalist. Let's talk about a lateral lisp. Okay. A lateral lisp is also impacted by tongue ties, in order. And I'm not always saying that every lisp is, you know, the root cause of the tongue tie. Don't get me wrong. But can it be? Yes, it can. In order to produce sounds, like I was saying before that that. Right. The lateral borders or the sides of our tongue need to come up and make contact with the hard palate, which is just inside our dental arch or our teeth. If the hard palate is too narrow, it's high. You know, the lower jaw is unstable. There's a tongue tie at play. These things that I just mentioned, we were talking about frontal lisps. This is going to become challenging. And a lateral lisp may be present with the lateral list. We hear air escape sideways, like, over the side of the tongue, and instead of it being directed forward, and so it creates, like, the slushy or wet speech quality. And this is never developmentally appropriate. Never. Okay. When there is a list present, frontal or lateral, there is an orofacial myofunctional disorder at play. High root cause. Yes. Let's figure what out. What? Figure out what it is. Right. And so we need a mile assessment as step one along with that speech eval. All right, so just gonna put that out there. Now let's dive a little bit deeper into alveolar sounds, and then I want to talk about back sounds. Okay, so alveolar sounds, those are the sounds I mentioned that are like the T, D, N, O. It's where the tip of the tongue has to make Contact with your alveolar ridge. T, D, N, and L require the tip of the tongue to do that. It has to. The tongue has to move independently. The tip of the tongue specifically has to move independently of the mandible or lower jaw, which allows the tip of the tongue to make contact with that alveolar ridge, which is like that bumpy area behind our front upper teeth. And it's on the hard palate. Okay. These sounds can be challenging to produce when the tip of the tongue is restricted. Oftentimes the tongue moves with the lower jaw, and we see changes in the way that the sounds are produced. Okay. We see decreases in speech clarity. We have reports of, like, this child or person mumbles a lot, you know, amongst other things. So our goal as an SLP or myofunctional therapist here is to eliminate all the compensations by treating the root cause of the issue. Speech therapy without addressing oral structures and compensatory behaviors is just putting a band aid on a larger problem. There, I said it. Love me or hate me. That is the truth. Okay? And what really I find fascinating is there are, like, big influencer, big influencer accounts on social media who are normalizing compensations. Now, look, if. If a older child, young adult, adult wants. They choose that for themselves after having informed consent, like, they're making informed consent. They've had all the data laid out in front of them. They've had all the data, you know, not data, but maybe, like, results of their assessment explained to them. They know the different options because, look, some of my patients just want. They just want to compensate, and that's fine. That is their choice. But. And some parents decide certain things for their children and say, you know what? Like, things seem okay right now. Let's. Let's, you know, continue doing, using these strategies you've given us, and we'll call back if something kind of falls off track. Okay? But they're making an educated choice and decision for themselves or their child because we've laid it all out for them. And what I'm finding is that from an ego standpoint, there are therapists, especially speech language pathologists, who feel the need to discount the impact of tongue ties on speech breathing, sleep feeding. And unfortunately, this is at a major disservice to patients who are struggling with issues that could be resolved by taking this type of an approach that I've been talking about. Right. Myo eval airway assessment, addressing tubidural tissues if necessary, expansion if needed. Right. Why? I just ask why? It is your job, your ethical Responsibility as a practitioner or medical professional to give a patient all options and let them choose what's best for themselves. But if your ego is influencing their decision because either you pay a lot of attention or you really put up on a pedestal a certain approach over another, you've now made the decision for them. They've not necessarily made the decision for themselves because they're going to be influenced by that person. You have a role of power by being a medical professional over certain patients who really look up to and put professionals in this, you know, in the feeding, speech, medical spaces. Like, they put us up on a pedestal. You shouldn't. Right. Maybe we do know things because we went to school, but parents, I tell you, if you're listening, you are an equal part of this treatment team and conversation and follow your gut. Follow your gut and honestly work with a person who, who matches you and your goals for you or your child most. All right, so we'll leave that there. But the bottom line is I was that. That SLP who knew nothing about this was told, you know, oh, any kind of work inside the mouth for speech sounds or even feeding that doesn't involve food, you know, oh, these are end zones. Oh, this is not necessary. Oh, you know, tongue ties aren't a thing. Right. I've heard it all. This is how I was trained to a certain extent. And then, and then I actually moved out of my own way, listened to what others had to share, listen to newer research coming out, listen to the practitioners who are seeing all these patients and, oh, my gosh, these kids are getting off loads. They're graduating. They're not in there. They're not lifers in therapy. They're not coming back every two years to work on the next set of speech sounds, are struggling with, oh, my goodness. Wow. Right? And again, I'm talking about a certain subset of patients. I'm not talking about everybody. Obviously, there are many diagnoses and many patients that we treat in the, you know, as SLPs. I'm talking about these kids who truly have a tongue tie and present with some of these things that we're talking about keeping them in therapy without going in their mouth, assessing for a tongue tie, ruling that out, assessing for an orofacial malfunction disorder. Understanding whether or not you need to refer to an allergist and ENT due to enlarged, inflamed tissues, possibly obstructing the airway, which can also have an impact on where the tongue sits and how speech is produced. Without understanding if a child needs to be referred to an expansion provider because they have a palate that does not fit their tongue without understanding how to rule in and out tethered oral tissues and whether or not the tongue has full range of motion without compensation. These are things that we need to, we need to have an appreciation for because we need to move with the times. None of these things are new. There's just more of a platform to advocate for it. And so now we're getting a lot more professionals going. This is interesting. Maybe I should pay attention. Right. And I will tell you also, if you are a professional space, don't feel guilty over these band aid compensations that maybe you've used in the past. If you are stepping into this world and you're stepping into furthering your knowledge, you can better help your patients. Kudos to you. I mean, that is, that's huge. That is huge. So I digress. Let's. Let's start to wrap this up a little bit. But we're going to talk about back sounds and then we'll talk about compensations. But one thing I do want to mention is, you know, Stanford Children's, they recognize that, yeah, ankle glossy or tongue tie can impact speech, amongst other things. There's an article out there, and I'm going to get to back sounds in a second. But there's an article out there that talks about. It's a study that provided some, like, preliminary evidence that there was no difference between tongue mobility and speech outcomes in young children with or without intervention for tongue tie during infancy. And they basically, their conclusion was, you should not, like, release a tongue tie during infancy if your goal is to improve speech production later in life. Well, duh. I mean, who's doing that? That's, that's not, we don't, we're not necessarily releasing a tongue tie now because we think there may be a problem down the road. In fact, we don't define it as a tongue tie unless there is a functional impact. So if structurally we are concerned that maybe there is a tongue tie at play, but functionally everything is functioning. You know, baby's feeding well, breathing well, sleeping well, and, you know, it's not a tongue tie, or maybe it will present as one as the child grows and it will become a problem later and there will be a functional impact and we address it, then. Okay, I'm not for, and obviously it's not my decision, but I'm not for referring to or working with providers who are just going to release a tongue tie because it looks like one exists that can actually be Harmful to a child who is functioning really well and who doesn't need intervention right now. But we need to do a full workup, right? We need to really look at that baby's posture, how the baby's feeding, how they're breathing, how they're sleeping, you know, are they on track with other milestones, what are their gross motor skills look like and then as they start to develop speech, what does that look like? Right? Is the baby able? Do they lift their tongue up when they cry? Are they colicky? Do they have all these other symptoms? Right. I could list off like 20 symptoms, but we've had episodes on that. So that's not the point here we need to be looking at is if they're compensating and if they are, are they compensating well and there's no concerns between that feeding dyad and that, you know, the caregivers of the infant right now. Or are there concerns and then maybe we do need to address it. But I hesitate to refer onward a infant to prevent issues down the road when there are no issues right now. If there's issues right now, we have a conversation about, oh, well, this is what could happen down the road. That's a different. That's a different conversation. That's a different. Just know that a lot of SLPs are using studies like these to as proof that we shouldn't intervene and that tongue ties like aren't a real issue. They're misreading the outcome of these studies or the point of the study. They're basically bending it to fit their narrative. There was a article that showed that after tongue tie releases paired with exercises, most children experience functional improvements in speech, feeding and sleep. And I will link, I'll link all of these, you know, or both of these here so you can look at both of them in the show notes. But just know there is more research being being done. But it. We can't discount past. We can't discount. Sorry clinical findings and the thousands and thousands of patients across the lifespan that have been helped with tongue tie releases and you know, expansion early expansion and expansion later than the traditional age and all these other things. So anywho, going back. Back sounds. Right? So back sounds. Those are the sounds I mentioned at the beginning of the episode. Like the K G and R. Like K G. Right. That requires retraction of the back of our tongue. So we have a front right portion of our tongue. We got middle portion, the back on the body of our tongue when the tongue is tied anteriorly or posteriorly. This often prevents the back of the tongue from like, retracting from pulling backwards. Okay. To produce that. Those that k GR that. Okay. And like I said, there's lots of R or ear air variations. Okay. Kids who've been in therapy forever who have never had an interoral evaluation that includes rolling out a tongue tie need to be checked as soon as possible. This is your kid. Please seek out a provider who can help you with this. Feel free to DM me. I'm happy to see if I know anybody in your area or check with my my colleagues. Because the bottom line is, yes, tongue ties and orofacial myofunctional disorders as well do cause speech sound disorders. They can be the root cause of a speech sound disorder. We're going to wrap this up by talking about compensations. Common compensations that we see could be things like the floor of the mouth elevating when trying to achieve tongue tip up to the spot that space a couple millimeters behind your upper central teeth on your upper central incisors. Your front two teeth spot is about 2, 3 millimeters behind it on the alveolar ridge, that bumpy area we talked about earlier. In this episode, there's facial neck check, chest tension, there's muscular engagement that is trying to support the oral movements that are dysfunctional. And then we see mandibular involvement, the jaw, especially in lingual movements, or a lack of dissociation where the tongue is not working independently of the jaw and sometimes it's not working independently of the lips or even the cheeks. We should be seeing that in our children that should have all their speech sounds, especially, you know, like by ages, like 5, 6 years of age. We should not see the tongue moving with the jaw anymore. It should be working independently when it comes to speech. So simply put, teaching compensations are a temporary effects, okay? It's why many children end up back in speech therapy or they are just in ongoing years of speech therapy working on sound production. Okay? So if that's your child, please seek second opinion. Further evaluation, orofacial myofunctional evaluation with make sure they look at in the mouth, under the tongue, under the lips. Getting to the root cause and collaborating with other medical professionals when needed is key. Okay. Because it's usually structural in nature and related to something going on in the mouth, the airway or bow. So for everyone listening, I ask you because it's ultimately your choice as a parent or, you know, patient or parent of the patient or even the provider, would you rather slap a temporary band aid on the issue and keep ending up back in speech therapy or keep having those kids end up back in your, you know, on your caseload with issues that just kind of snowball into adulthood because the issues were already there in infancy and toddlerhood and early on. Or would you rather address the root cause now so that you can maximize the child's chance at optimal health now and in the future? Okay. The other thing I will say is approaching a problem, like a speech problem with like watch me and copy what I'm doing. It's not enough to correct the neuromuscular repatterning that needs to happen in so many of these cases. Okay. So that's, that could be a whole nother episode, but I'm going to throw that out there because that is often what happens. It's like, watch me look at my mouth. And while yes, maybe some kids can correct their sounds that way, it oftentimes is not enough. And that is why children, some of these, like experts on social media and influencers with large followings, share their before and afters. Like sometimes their photos, sometimes they're videos. And you look at them and you're like a child sound does. They don't sound right. Like the sounds are still not being produced correctly or it hasn't generalized. So sometimes they'll get it in therapy and then we don't see it carry over to everyday speech. Because what we do in therapy sometimes is very different than what happens in everyday speech. Right. We co articulate sounds kind of fall all over each other. Our words kind of blend together a little bit. They're not super clear. It's not super clear like I'm talking right now. Right? Things kind of blend together. It's not super clear like I'm talking right now. If you listen to that versus when I slow down and over articulated certain sounds. The way we work in therapy is like hitting all the sounds that doesn't actually happen in connected speech in the real world when we're talking. So that's where we see a lot of these kids fall apart is either in trying to carry it over into everyday speech and or it happens and then they all sit in like some growth happens. New sounds are expected because they're older that weren't addressed earlier and all of a sudden they have trouble with those sounds as well and they're back in therapy. Right. We see this a lot. So I'm just gonna kind of leave you with that. But teaching compensations is a temporary fix. It's a band aid and it's going to lead to other issues. Because if they're compensating with speech, they're compensating with other things that are arguably more impactful to a child's health, like the way they breathe, which impacts how they sleep, which impacts how their brain restores itself after every night, which impacts their behavior during the day and their ability to attend in school and their interest in certain things, which, I mean, the list goes on, right? So definitely take a good hard look at whether or not compensations are the primary method of intervention or if we're truly looking at the root cause and working to address that through the way that we are intervening. All right, I hope this is helpful. I do want to wrap this up. I said it would be a short episode. It's gone a little bit longer than some of the other ones, but a lot of jam packed information here that I think is absolutely critical for everybody to understand. All right, everybody, this is Hallie signing off. I'll be back on the next episode to dive a bit deeper into whether or not we should pause myofunctional Therapy when we're in an expansion appliance. All right, that one will be really super short and sweet. So see you. See you next week.

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