Tongue Tie Diagnosis: Why Function Matters More Than Appearance

This is kind of like a functional diagnosis framework, if you want to call it that. It's where form meets function. Right? But function leads the way. So the framework, if you will, is function, form, impact, decision. So let's break this down. Hello, friends. Hallie Balkan here. Welcome back to the Unto Other podcast. I want to talk about one of the most understood topics in our field. Okay, so let's talk about tongue tie diagnosis, because every week I hear clinicians say it looks tied, or I'll hear a doctor say it's a mild tie. The truth function is what determines a diagnosis, not appearance. So today we're going to unpack the real markers of dysfunction, what's normal variation, and how to make confident, clinically sound decisions. Let's jump 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 here's why so many clinicians feel stuck, right? We were taught maybe in some tongue tied courses or in courses where they're talking about tongue ties. Now we're taught to look at the frenulum. Now, if you're coming out of grad school undergrad, you're not taught to look at any of this. But anyone who's even taught to look at the frenulum is typically not taught taught to understand the impact on function. All right, so what I want to really dive into is this myth that if it looks short or tight, it must be a tie. That is not necessarily true. Okay, so not all short frenula restrict movement. Some might look really tight, but they might actually be functioning beautifully. So again, it comes down to function. Form plus function is what is going to lead to a diagnosis. Looking at just form or just function doesn't really give us a definitive answer. Okay, now, conversely, posterior tongue ties often look pretty normal if you're just looking in the front because visually you don't see the tie. Unless you know how to expose the tissue properly with a certain maneuver in a, like an intraoral assessment, an assessment in the mouth, under the tongue. But these posterior ties create major functional restriction. So do you see the difference here? Where sometimes a tie might look like, it might look like the tissue's tight and it's super tied, but there may not be a functional impact at play. Whereas you may not be able to see the tie, but it's there and it's creating a major functional restriction. And those are not the only two scenarios. I just want to highlight that to really dispel this myth of like, oh, if it looks short and tight and it's all the way at the front, like, yeah, it's causing a problem. Well, it might be right. But the appearance based mindset leads to over and under diagnosis of ties. Okay? And so what matters again is how the tongue moves within the oral cavity, within the mouth and how the system compensates. Now, you know, if you've been following me for a while, I do not teach compensation. I do not say, oh, you know, they're compensating well, so let's just ignore it. Here's the thing. They may be compensating. Well, they may be, but why are they in your office? Why are they coming to see you? Why are they seeking help? Maybe it's because the compensations have become too much. Maybe the compensations are breaking down. So while there are other speech pathologists and all kinds of different work, whether it's feeding or myo or articulation, phonology, whatever. While they may teach compensations and plenty of the big names in the industry do, I do not believe in that. I believe in undoing compensations, figuring out the root cause and getting down to the bottom line. Why is this happening if we can figure that out? And how do we then improve function? Everyone wants to thrive, not move. We don't want to be surviving all the time. And when you're teaching compensations, you're teaching survival mode because compensations take a lot more energy and there are certain points where compensations will break down. That's, that's just the bottom line. That, that's that. Okay, I said it. There it is. So the other thing I want to highlight here is that misdiagnosis creates two big problems. Okay, so first let's talk about over diagnosis. Children and adults, you know, will undergo an unnecessary releases with no functional limitation. And therefore what are we releasing for just because the tissue looked tight? Right. Did we want to maybe try some other Interventions first to see if that tissue releases. Not. Not that a true tongue tie will release itself, but sometimes tissue appears tight because it's compensating for something else that's not doing its job. And so there can be a change in the presentation of the tissue. So I want to get your wheels turning there a little bit now under diagnosis. On the flip side, right, there could be missed ties because it didn't look bad enough. But again, both scenarios delay functional progress and it can create distrust amongst family and families and providers. And so the goal here, okay, is to shift from does it look tied? To does this tongue do what it's supposed to do? Is this tongue functioning and not just is the tongue compensating? Well, that might be a question we ask, but can this tongue do what it needs to do? Right. Does it have the range of motion? Does it have the functional ability to do what it's supposed to be doing? And if not, can we support it to get to the desired result? Right. All right, now the third thing I want to highlight here is why function is the missing link. I've already kind of drilled this in already, but let's think of it this way. Like your tongue is like the muscular hydrostat. Okay? It's not about the criminal. It's about mobility, coordination, control. And so function is going to impact every single system, whether that's speech, feeding, swallowing, airway. Right. Which then impacts sleep, posture. Right. List goes on. So in a functional assessment is going to tell you, is this structure impacting behavior or performance? Right. Especially in these areas, these systems I just mentioned, form is static. Function, my friends, is what tells the story. Okay? So I just want you to kind of keep that in mind. All right? Okay. So let's talk about some, like, red flags versus normal variation, if you will, like what's normal, what's not. Let's break it down. So red flags for tongue tie dysfunction are especially on, like an infant, for example, Right. You're going to might maybe have poor latch, prolonged feeding times in infants, clicking, leaking, loss of suction, difficulty with elevation or lateralization. Now, this will move beyond the infant stage into toddlers and even through adults with that difficulty with elevation, lateralization, separating the tongue at a certain age from the floor of the mouth, from the lips, the tongue, the jaw. Right. Not, not the tongue from itself, but the lips, tongue and jaw should be working independently of each other by about 18 months of age. Are there compensatory floor of mouth movements because of tension? Right. Do we see any tension in the Face in the neck. You know, in older children, we may also see. And when I say older, I mean older than infancy. But drooling, speech sound challenges, you know, oral fatigue, tongue thrust. Right. In adults, we may see all of that, plus airway restriction, snoring, oral tension. Right. And so it's kind of like that snowball that just keeps building with symptoms and dysfunction, unfortunately, as you get older. And so the other thing I want to highlight is like, some normal variations. Like a normal variation that may not necessarily signify there is a tie at play. Right. A visible frenulum with full functional range. We should have a frenulum, a frenum, a frena, whatever you want to call it. That little tissue under the tongue, we should all have that. And. But we should have full range of motion. Okay? That's the key here. Number one. Number two, mild tethering, but no impact on eating, speaking, airway. Right. You know, so it appears to be a little tight, but there's really no functional impact. And we probably, you know, if we have concerns, we probably want to get in there and see is there something else that's making the tongue compensate, making the floor of the mouth compensate, that's making that tissue more tense. Maybe it's not truly tight, short tissue. Maybe it's just a little tense because of another etiology. And then the last one is like a slight midline attachment without functional limitation. Okay. Which kind of goes hand in hand with what I was. With what I was just saying. So the real question here isn't like, is there tissue? Because, hi, the tissue should be there. It's. Is the tissue impacting function? Right. That is where your clinical reasoning skills, my friends, must come into play. So let's dive into how I train SLPs, OTs, PTs, RDHs, dental colleagues. Right. How I train students and mentees in my programs to think about tongue tie assessment. Right. Cause this is kind of like a functional diagnosis framework, if you want to call it that. It's where form meets function. Right. But function leads the way. So the framework, if you will, is function, form, impact, decision. So let's break this down. Okay? Start with function. Number one, function. What the tongue can or can't do. Can it elevate, lateralize, extend without compensation? Is it coordinating with the jaw and the lips or other muscles stepping in to compensate? Are we observing during real tasks? Right. So when we observe, I want you to look and see what the tongue can do. Well, feeding, swallowing, speaking, breathing, whatever's in your scope of practice. And if function is limited, that right there is your first clue. Okay, so that's number one. That's number one in the framework. Number two is form. So first we start with function, then we move to form. So I want you to assess the anatomy here in context. Because, look, I know I've said function over form here, but it's function plus form that we really need to consider when making a diagnosis. So we do want to look at like, is there a visible restriction or tension that explains whatever functional limitation we're seeing? Where is the attachment, if it exists? Is it anterior, mid, posterior? What is the quality of that tissue? Right? Is it really tight? Is it elastic? Right. What does it look like? And just keep in mind that you're not like just checking boxes on an eval form. Right? We need to kind of combine what we're seeing with structure and then the observed function in order to make this diagnosis. All right? So that's function, form. That's followed by impact. Okay? This is the bridge from observation to diagnosis. So how does the limitation affect the person's life? Whether this is an infant, a toddler, a school age child, an adult. Right. So for infants, for example, their feeding efficiency, weight gain, I know weight gain's a big one that, that doctors like to pay attention to. It's not meant to be a sole key factor. It is one of many. So I like to mention it and not ignore it. But ma, comfort, if you're breastfeeding, that's another big one too. Right? And there's a whole list of other ones too. But this is what I want you just to start thinking about. Now, for kids who are, you know, beyond the age of infancy, chewing, swallowing, articulation, sleep quality. Right? And then adults, airway restriction, fatigue, tmj, tension, it could also be chewing, swallowing, articulation, sleep quality. The functional limitation without meaningful impact does not automatically equal diagnosis, Right? Because we need to treat what matters functionally. So there needs to be an impact on the patient. The patient can't say, oh, yeah, I can't move my tongue out of my mouth to look an ice cream cone or oh, I can, but my tongue deviates to the side. But I don't really care. Why am I here? Well, there's not going to be a meaningful impact with the intervention. So we need the functional limitation plus meaningful impact to get to diagnosis. Okay. And that, my friends, brings us to step four, which is the decision. Right? So we had function, form, impact, and now we get to decision. So once you see the functional limitation plus that structural restriction, plus the meaningful Impact, that is when you get to diagnose, assuming that it's that you can diagnose ties in, you know, under your license. Okay, so then we want to create a treatment plan addressing both structure and function. Now, function and structure. And what you can address again is going to depend on your scope of practice. As a speech pathologist. I work with soft tissue. So as long as I can impact the structure and the function of the soft tissue, that works. I don't work with hard tissue or bone. I also don't do surgical releases. So if a release of this tissue is necessary, that falls under the scope of the release provider, a dentist, ent, oral surgeon, whatever. Right. So I like to point that out so we understand what I mean when I say, like, what is in your scope when looking at structure and function. But anyhow, this decision sometimes means that therapy might come first, sometimes the release, although there should be therapy first followed by release, you know, that pre op at minimum. And then, you know, sometimes there's, there are both things going on. Sometimes we don't need a release, sometimes we do. The key here though is that clinical reasoning is going to drive the decision, not the appearance. Okay, so this framework I just gave you gives you this repeatable, defensible process for diagnosing tongue ties that is grounded in evidence, it's grounded in function, it's not simply grounded in opinion or esthetics. And I think this is really, really important because of the heat that is brought on this topic on a daily basis. And, and you know, the well meaning individuals who don't believe in tongue ties, they don't believe that we have tight tissue in our body. I'm sure what that means or why they say that, but here we are. So, all right, now that you've identified a functional restriction, right? Let's say you've identified one. Now you're like, okay, great, how do I decide what to do about it? This is where clinical reasoning becomes your superpower. All right, so I'm going to give you three things to focus on here. So we kind of already covered the first one. You want to assess function and then structure, right? We kind of talked about that. So what does this look like though? Well, always start with how the tongue moves before you look under it. Okay. And consider breaking down the compensations first so you can treat those. And look, look at like what is happening with the jaw, the cheek, cheeks, the lips. Right? Because the compensations you see there are likely masking true movement. And then we can kind of look at like, okay, how Ready are we? You know, if we're working through things, how ready are we to maybe move towards a release? If that's where we're headed. Right. Functional readiness is going to tell you if and when the body is ready for that lingual release. And that is why there are a lot of teams where they'll have the release provider say, okay, team, I want you all like, you know, feeding therapists or myofunctional therapists, slash, you know, other individuals working on the child's body, whether it's pt, craniosacral, whatever. I want you to tell me and sign off like green light, ready for release. Okay. Because if a child can't lateralize or elevate at all, well, we're going to work on that in therapy before the release. That's going to be part of the pre op protocol. If the child or if the function, sorry, not the child, but if the function improves, but we start to hit a ceiling due to structure, that's usually an indicator that we need to bring in a surgical, you know, a release provider and collaborate on this case and say, hey, I'm sending you for, sending them for a consult. We've hit a ceiling in a wall, wherever you want to call it. Like, can you please do your thing? Right. Do your assessment right. They're not releasing on the spot, they're assessing, coming back to discuss. And we're taking a collaborative approach on how to move forward. Okay, so that's number one. Number two is I want you to consider the whole system. The tongue is often talked about like itself in isolation, but it does not live in isolation. It's part of a very connected system involving our airway, our jaw, our cervical spine, our nervous system. So when we address oral tension and posture and breathing patterns before or after any release, we see better results than if we just address like the tongue on its own. Okay. Whole system is super important and collaboration is really critical. Like I was just saying when I was talking about, you know, assessing functions and structure and what that might lead to, you know, the collaboration piece of. So, you know, I've already kind of mentioned it, but a myofunctional therapist or feeding therapists for that pre post op work based on the age of the child, you know, but a body worker or craniosacral therapist, they may be helpful with release prep and integration and everything too ENT or dentist for that surgical assessment and follow up. Right. So you're going to, at minimum, probably have these individuals on the team. Sometimes there will be other individuals as well. But I want you to remember, number one was assess function and structure. Number two, consider the whole system. And number three, when it comes to, like, your clinical reasoning for treatment decisions, I want you to focus on function, not just freedom. Okay? The release itself is not an instant fix. It's not the fix. It's not the standalone fix. Right? It's what happens before that release and after the release that really drives the future results. Right. Obviously that release is super important. I'm not downplaying that, but I like to explain this so that you all can explain this to your families and families listening, you know, the release is not a magical instant fix. Okay? Functional therapy is going to ensure and ensure that the brain learns new movement patterns. Right? Or maybe there were some old movement patterns that it's relearning. But the idea is that the functional therapy teaches those new motor patterns to the brain. Okay? Neuromuscular re education. This is where your role therapist, if you're listening to your therapist, this is where your role as a therapist is super transformational. It's not transactional. It's transformational. Because our goal here is efficient, coordinated, effortless movement, not just range of motion. I know we talk a lot about like, does the tongue come off range of motion? That's all good and great, but that's kind of just like on the front end of the discussion, right? Our goal towards the end is that efficient, coordinated, effortless movement that's integrated in and is happening naturally. It's habituated. Right? And so when we treat the whole system and we prioritize function, our patients thrive and so do we as clinicians. Okay? So next time you're assessing a tongue tie, remember this structure supports function, but function determines diagnosis. Okay? Now, if you want to master the art and science, I like to say it's a dance between art and science. Functional tongue tie assessments. I want you to either join me inside Feed the peds. We do have a MYO membership if you're looking for Mayo stuff, or you can always DM me at Hellybalkin on Instagram and I can help you kind of figure out, like, which path is the best for you. But if you're working with anyone, if you're an SLP, OTP, working with kids under the age of five, feed the PEDs is definitely the route to go. So anyways, my goal for you is to help you make confident, evidence based decisions in every case. All right? So go to FeedThePedes.com and check it out. If you are one of those clinicians or like I said, you know, reach out to me at Hallie Balkan. You can also share this on Instagram. I love to see what you all are learning and applying and I love knowing when you listen to these episodes. So that's that and I will catch you all on the next episode.

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