Is the Tethered Oral Tissue the Problem or Just Part of It?

Feeding function is what gives anatomy its meaning. I'm gonna say that again. Feeding function is what gives anatomy its meaning. A restriction without dysfunction is not a tongue-tie. I'm gonna say it again. A restriction without dysfunction is not a tongue-tie, and it's not gonna require the same intervention as a restriction that is clearly disrupting feeding mechanics.

Welcome to the Untethered Podcast. I am your host, Hallie Bulkin. 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. Hello everybody and welcome back to the Untethered Podcast. Today we're talking about something that's coming up in feeding evaluations more and more, and that's tethered oral tissues. Lip ties, tongue ties, diagnosed ties, suspected ties, we're told by the dentist ties. And the real question that I keep hearing from clinicians is this. How do I decide if the tethered oral tissue is actually the problem or just part of a much bigger picture? Because if you're honest, this is where things can feel a little murky, right? You're in a feeding evaluation, you see a visible restriction, or the child already has a diagnosis. The parent's looking at you. Sometimes they've already been told this is why your child's struggling, and there's a subtle pressure in the room to explain everything through that lens, right? It happens to new clinicians. It happens to seasoned clinicians. It happens across SLP, OT, PT, right? And here's the reframe I want to anchor you in from the very beginning here. Okay. Seeing a restriction tells you something exists. It does not tell you what is driving the feeding difficulty. And that distinction right there, that is everything, right? Because the most important decision in a tethered, like when it comes to tethered oral tissues, and in that case, isn't about whether to release, because that's not even in our scope, right? But it's about function. Function, right? Here's why TOTS cases, like TOTS being tethered oral tissues, here's why they feel so confusing for many. And for some of you, it's not even confusing. Some of you have told me like, this just feels hard. This feels so hard. Feeding challenges are almost always multifactorial. A child with tethered oral tissue might also have delayed oral motor skill development or sensory sensitivities. Maybe there's GI discomfort, there's airway considerations, a history of reflux, prematurity, bottle feeding challenges, postural instability, low tone. Maybe there's learned feeding aversions, right? There's a whole host of things that on. And when a restriction is present, it's very easy to assume that it's the root cause because it's visible, it feels tangible, it feels actionable, right? Here's the reality though: a restriction can exist without being the primary feeding problem. I said it. I know people are gonna be like, what? But you're so pro-tongue-tie. Yeah, I am. I do believe if they're— if it's impairing function and we can't make progress in therapy, we should do something about it. But just because it's there doesn't mean that we do something about it, right? Doesn't mean that we physically have like a release provider physically releases it necessarily. There's something we should be doing is behavioral intervention. And when I say behavioral, I don't mean like behavior behavior. That's the type of work that we do that is non-surgical, right? So this is where I see so many clinicians getting stuck because maybe we were taught how to identify a tie, but we were not taught how to systematically assess assess its functional impact on feeding. We learn what ties look like. We learn classifications. Maybe, maybe we learn the anatomy, or maybe you didn't learn any of that, right? But even if you got that, you probably weren't taught how to answer, like, is this restriction affecting bolus formation? Is it limiting lateralization? Is it impacting suction? Is it altering swallow timing? Is it changing endurance? Is it affecting coordination? Without a feeding assessment, without that lens through which to look, anatomy becomes the headliner. Right? It's kind of news story. Here's the headline. It's all about the anatomy. And sometimes it's just one paragraph in a much larger news story. It's not the whole news story. Okay? So I wanna gently name a few traps, not with blame, but to give awareness. Okay? Some, there's some common clinical traps I see. Trap number 1 is letting anatomy lead the plan, which I've already alluded to, right? You see the tie and the clinical reasoning. Stops right there. Tongue can't elevate well, must be the tie. But did we look at stability? Did we assess jaw grading? Did we assess rib cage mobility and breathing? Did we assess sensory processing? Anatomy matters. Doesn't automatically dictate function. Okay. Number one. Trap number two, assuming tie equals paws. Presence does not equal primary driver or root cause. Just because something exists does not mean it's the reason. Okay. Just putting that out there. It could be, but just cuz it's automatically there does not mean it's automatically the reason either. Trap number 3, treating the restriction instead of the feeding pattern. So sometimes therapy becomes pre-release prep or post-release stretches without ever fully analyzing what the feeding breakdown actually is. What skill is missing? What coordination is off? What compensation is happening? Which leads to trap number 4, and I'm gonna circle back on this in a moment. Trap number 3 is why I've had people come to me and say, hey, Hallie, you teach that Feed the Feeds course. Can you separate out the tots and bio modules and just teach that separate from the rest of the feeding course? Because, oh, I have some experience in feeding, or, oh, I've taken a bunch of courses. No, I can't, because there's absolutely zero course. There is no course on the market that exists like Feed the Feeds to date. Okay. And I've seen them all. There's nothing. I haven't gone through all of them, but from what I've seen in the outline and from what I spoke to people who have gone through different courses, They have, are constantly telling me, and this is even some of our certified members who have taken literally every course on the market, there is absolutely nothing out there that exists like Feed the Pete. So I guess we're not circling back, we're going right into this right now. A lot of times that pre and post-release therapy that is taught is not actually looking at the whole feeding picture. And if we don't fully analyze where the feeding breakdown is happening, that pre and post-op therapy may not even be the proper pre and post-op therapy. It's not just one set of exercises. It's not just a printout PDF that you share. It's not just what the dentist recommends. They're not the feeding therapist. We have to figure out what skill is missing, right? And what coordination is off and what compensation is happening. It's so much more than just a release and prepping them and post-oping, like pre and post-oping them. Okay, I really want to drive that down. You have to understand pediatric feeding as especially when working with birth to 5. Absolutely have to if you're dealing with these tots kiddos. And beyond that, they may be a feeding case or a MI-O case, right? Once you get to a traditional age of 5 plus chronologically, or cognitively, sorry, not chronologically, but cognitively. Okay. Hope that hit home. If not, this is a podcast. Rewind and relisten. All right. And this leads us to trap number 4, skipping a full feeding assessment because the child feels explanatory. Ding, ding. We just look under the tongue, we're like, yep, there's a tie that explains everything going on. No, it doesn't. No, it doesn't. Maybe it does, but most often there's other things going on too. When the explanation feels obvious, we sometimes stop asking deeper questions. And here's the hard one. Okay. Trap number 5, feeling pressure to answer parents quickly. Families are overwhelmed oftentimes, right? They've seen providers, they've heard opinions, they want clarity. Maybe they're coming to you because they've been to other people and you're the tie queen. You can tell them whether there's a tie or not. But you gotta figure out if function is impaired before you can tell them it's definitively a TIE or not, right? And how we approach that TIE in therapy is determined by the presentation of the child in the assessment, and then how we start probing them once we intervene, right? So we can feel that urgency from the families, from the other providers, from overwhelmed families. People just want answers, but faster answers do not equate to better clinical decisions, my friends. Clear assessment does. So this is the feeding-first shift. This is a shift I want you to make. Instead of asking, is there a tie? Ask, how is this child functioning during feeding? Because listen, I am very pro tongue-tie. I am very— in terms of meaning, we should be looking for it, we should be assessing for it, it should be part of our assessment. It's not a standalone assessment, it's also not a standalone treatment. It's part of a larger treatment protocol and approach, if you will. So I want you to be asking, How is this child functioning during feeding? Because that question changes everything. Feeding assessment shows you what skills are present, what skills are absent, what's breaking down, like when they're under demand and what compensations are happening, right? And we can ask things like, is the child using jaw, a jaw thrust to compensate for limited tongue mobility? Are they overusing their lips to stabilize? Are they fatiguing quickly? Are they losing control of the bolus? Are they gagging due to sensory input? Are they avoiding textures because of motor inefficiency, right? When you assess feeding systematically, patterns emerge, and those patterns tell you whether the tethered oral tissue is the primary driver, one contributing among several, or incidental. And so here's the anchor, like the anchor line that I want you to hold onto. I want you to grab onto this. Okay? Write this down. Feeding function is what gives anatomy its meaning. I'm gonna say that again. Feeding function is what gives anatomy its meaning. A restriction without dysfunction is not a tongue tie. I'm gonna say it again. A restriction without dysfunction is not a tongue tie, and it's not gonna require the same intervention as a restriction that is clearly disrupting feeding mechanics. Two children can thus have similar looking ties and completely different feeding presentations. Why? Because function is influenced by stability, tone, experience, sensory processing, airway, strength, coordination, developmental history, all these things. And this is why feeding assessment is not optional in Todd's cases. It's foundational. It's mandatory. So here's what it looks like when the tie is primary, right? It's a primary driver. It is the cause of what's going on. I wanna briefly differentiate this. When the tethered oral tissue is a primary driver, you're often gonna see clear mechanical limitation during feeding, reduced tongue elevation after suction— or not after, but affecting the suction, I should say— poor lateralization that's impacting bolus movement, right? They're going to have persistent anterior loss. They're going to have inefficient stripping of the spoon. They're going to have clear improvement with manual support, right? The restriction is directly interfering with skill execution at this point. And so in those cases, the tie may absolutely be a major or primary driver, but even then you still need to assess what skills need development around it because release alone does not create coordination. It does not fix all of our problems, right? So this is compared to when the tie is secondary, like what that looks like. Sometimes the restriction contributes, but maybe it's not the root cause. So for example, A child with low tone who also has a tie. A child with sensory aversion and visible restriction. A child with poor postural stability and limited oral control, right? In these cases, if you only address the tie, feeding may not improve significantly because the feeding breakdown is living elsewhere. So the tie may matter, but again, it's part of a bigger system. It's what helps you tease this apart. When the tie is incidental, this is the one that clinicians are sometimes afraid to consider, right? Yes, there's a restriction, but the feeding challenges are clearly tied to sensory defensiveness, learned aversion, feeding patterns. Maybe there's a global developmental delay. Maybe there's airway-related fatigue. Maybe there's other medical complexity at play. And the restriction may not be functioning like, or functionally limiting feeding at this time. Doesn't mean it doesn't matter and that it never matters. It just may not be the priority in our feeding plan from the beginning. This is where confidence lives, my friends. You're not choosing sides here. You're not being like pro-release or anti-release. I really hate that people have created these two, two camps. We're using our clinical reasoning, right? And that's where confidence lives in clinical reasoning where we're like, okay, you know what? I think there's some other things driving the boat here. We're gonna work on those first and we're gonna see if things improve. And if they don't improve, we're then gonna come back to this tether oral tissue and then consider moving forward, right? It's maybe not the primary driver. Something else needs to be addressed first and then we can revisit this cuz yes, it's impacting things. There is functional impact. But I don't think it's the primary thing. Or maybe it is, right? So I want you to think about a recent tether oral tissue case if you've had them. Pause for a second and ask yourself what feeding skills were actually limited? Not what anatomy was present, not what it looked like. What was the functional impact? Was there one? What skills were breaking down? Was it bolus formation? Was it a chewing pattern? Maybe coordination or endurance or sensory tolerance, right? What compensations was the child using? If you're not completely sure, that's super common. This is a skill that develops with structured guidance and practice, right? It's also why so many clinicians feel really unsettled in these cases because we were trained to see ties, but we're not always trained to interpret feeding function deeply. And feeding assessment, my friends, that is a real skill. That is why we dive into it in Feed the Peds, right? Feedthepeds.com. Doors are open. Go check it out. Many clinicians are taught what ties look like, what classification exists, what red flags to watch for, and fewer are taught like, how do we assess feeding function systematically? How do we prioritize our findings? How do we decide what matters before making recommendations? This is exactly why feeding assessment is such a critical skill, especially in our tethered oral tissue cases, right? It helps you decide, is there restriction the main driver? Is it just one contributor? Or is it the focus right now or is it not? Okay. So again, in Feed the Peeds, we spend a significant amount of time teaching clinicians how to assess feeding in a structured way. So the decisions are not based on assumptions, pressure, or incomplete analysis, right? Because when you understand feeding function, you don't have to guess. You don't have to default to anatomy. You don't have to rush forward or away from release. You can make recommendations that are grounded in what the child is actually doing during feeding. And here's the thing, to wrap this up with a pretty little bow, tethered oral tissue cases, they don't need faster answers. They need clearer assessment. You don't need to pick a side. Okay. This is your permission slip to not have to pick a side. You need to understand function. When you understand feeding function, like truly understand it, you can confidently determine what, what role a tethered oral tissue is or is not playing, right? Is it primary? Is it secondary? Is it incidental? Right? That clarity shifts everything. It changes everything. When you understand feeding, you don't have to guess what role that tetheral tissue is playing. You get to decide from skill, not from pressure. And that's where real clinical confidence lives. If this episode resonated with you and you're realizing you want stronger feeding assessment skills, that is exactly the work that we do inside Feed the Peeds. We don't just identify red flags, we teach you how to interpret them because feeding clarity doesn't come from spotting anatomy. Right? It comes from understanding function, function. And that is a skill that you can build. That is a muscle that you can flex, right? Jump into Feed the Peets with us, www.feedthepeets.com. And until we see you inside the course, I'll see you next time on the podcast.

Quick disclaimer: all information, content, and material of this podcast are the opinions of the speakers and serves as informational purposes only and not intended to serve as a substitute for the consultation diagnosis, and/or medical treatment of a qualified healthcare provider.

Thanks for listening to this podcast. If you found value in this episode and want to hear more of these myotats, airway, and feeding related episodes, be sure to leave a review on Apple Podcasts and share this episode on your social media platforms. You can access free resources and all I offer at halliebulkin.com or pop over to @halliebulkin on Instagram to get all the latest updates.