Tongue Ties Revisited: Why Not All Ties Need Release

4 years ago, I recorded an episode called Not All Ties Need to Be Released. It was episode 184. It went on to become one of the most downloaded episodes of the Untethered Podcast, this podcast, and I still stand by the premise completely. Not every tongue tie needs to be released. But if I sat down to record that episode today, after 4 more years of teaching this, mentoring clinicians, watching the research evolve, and honestly just getting better at clinical reasoning myself, I would explain it differently. Back then, the conversation was very focused on like whether or not a release was necessary. Today, I think the most useful question is— 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. Today, I think the most useful question is, what is this tongue actually doing? How is it affecting function, which is something we looked at back then too? And what does this patient need next? And that may eventually include a release consult, but it may not. And for most clinicians listening to this, this episode, whether a surgical release actually happens isn't our decision to make anyways, right? Our role is to understand function, identify what may be limiting progress, treat what falls within our scope, and know when another provider needs to enter the conversation. That distinction is really where clinical reasoning lives. And tongue-tie has somehow become one of those topics where everybody feels like they just need to choose a side. You're either in the camp that thinks tongue-ties are responsible for everything from picky eating to poor sleep to speech issues, or you're in the camp saying tongue-ties are overdiagnosed, releases are unnecessary, and everybody needs to stop talking about them. Here's the thing. I don't really live comfortably in either one of those camps because both can lead us to the exact same problem. We stop thinking about the actual patient sitting in front of us. One side sees tissue and immediately assumes pathology. The other side sees tissue and immediately dismisses its relevance. Neither approach begins with what the person in front of us is actually able to do, like, hello, function. So a tongue tie or ankyloglossia is not simply the presence of a frenulum. We, we all have frenula. What matters clinically is whether that tissue is restricting tongue mobility in a way that has a meaningful functional impact. And that distinction sounds obvious when I say it out loud, but I still see pictures posted online with people asking like, is this a tie? And yes, it's a tie. Sometimes they're clinicians. And here's the thing, we've been over this, but the problem is that a photograph can only tell you so much, right? You can describe the tissue, you can notice where it attaches, you can recognize that something deserves a closer look, but you haven't seen how the tongue moves, right? You haven't seen how it functions. You haven't watched the patient eat or swallow. You haven't observed what happens when the jaw, lips, or tongue— when the tongue is trying to move, you don't see how they work together or separately. You don't see what's happening with the head as the tongue is moving. You don't know the whole story yet. And I think sometimes we confuse making a fast decision with being a confident clinician. And to me, confidence is, it's not flipping up a tongue, you know, or getting the tongue lifted, flipping a child over like I did with my daughter when I came home from my first myo course and immediately seeing like tethered tissue under her tongue and knowing the answer right away, right? Confidence is being able to look at something and say, I see a potential problem here. I got a concern. Now I need to figure out what that actually means for this patient. And that is a much deeper level of clinical practice. Now, I've taught the framework of function, form, impact, and decision, you know, before, and I still like that way of thinking, but rather than walking you through 4 separate boxes again today, I want to talk about how those pieces actually change the way we approach a case. Because function has to lead the conversation. That is driving the boat here. Let's say I look at somebody's tongue and the frenulum visually seems short or tight, thick, tight, short, whatever you want to call it. That observation might matter, but it isn't enough on its own. I want to know whether the tongue can elevate. Lateralize, like move side to side and move independently from the jaw, especially after like 18 months of age. I want to know what happens during chewing and swallowing. If speech is the concern, I want to understand what happens during speech. I want to know where the tongue rests and whether we're seeing efficient movement or whether the jaw lips or even, you know, the head and neck are helping the tongue to accomplish something it's not able to do on its own, because that information is much more useful to me than whether somebody labels the tissue mild, moderate, or severe based on appearance, which by the way, I hate. When they do those labels, either you have a tie or you don't have a tie. There's no mild, moderate, or severe tongue tie. Just, you know, putting that lips ties, lip ties and cheek ties, it's all the same. Now, there's another side of this conversation though, because sometimes a clinician sees compensation and says, well, they're functioning, so they're fine. Maybe they are, or maybe they developed a really effective workaround that's working for them right now, right? Because the human body is incredibly good at finding another way to accomplish a task when one movement isn't available. And compensation itself isn't automatically a problem. The more important question is whether that strategy is efficient, is it sustainable, and actually, is it meeting the actual person's needs? And if the answer is yes and the person's functioning well, that is useful information. But if the answer is no and the compensation is starting to break down or create other problems, that's really important for us to be paying attention to. Okay. Then when we look at like impact, this is where I think clinical reasoning really starts to separate, you know, separate thoughtful assessment From just looking at anatomy. Even if I identify limited tongue mobility, I still need to understand what that limitation means for the person sitting in front of me, right? Is it feeding related, or is that affected? Is bolus manipulation hard for them? Is a child avoiding certain textures because they mechanically, like motorically, cannot manage them well? Or is something completely different driving the feeding concern? Okay. If speech is the reason they were referred, Does the speech pattern actually line up with the movement limitation that I'm seeing? Is the patient reporting discomfort or difficulty with a specific functional task? Does the family have a concern that's connected to any of this, right? Finding a limitation during an assessment doesn't automatically mean you found a reason that the patient walked through your door. We need to stop and think about that. We need to be asking them what their concern is, why they are here, whether it's the parent of a child or whether An older child or an adult, they're the patient, we need to ask. 'Cause I may find restricted tongue movement in a child who was referred for selective eating, but that doesn't give me permission to decide the restriction caused the selective eating, right? Maybe it's contributing, maybe it's not. In most cases it is, but you know, we'll leave that there for now. I still need to consider other things like sensory processing, oral skill, medical history, GI factors, regulation, development, the feeding environment, like, and then just any other pieces of the puzzle that might be part of that child's story. Okay. And to me, that's what integrated care actually means. Like, it doesn't mean finding one hidden problem and using it to explain everything. It means widening our lens enough that we stop jumping to conclusions before the case has earned said conclusion. And airway is a really good example of where this matters because I think this is one area where all of us need to be very, very precise with our language. A child can have a limited tongue mobility and airway concern at the same time. They can mouth breathe, snore, sleep poorly, have a narrow palate, and also have a restricted frenulum, right? All of those things can coexist in the same patient and oftentimes do, right? We're used to that. We're used to seeing that. But coexistence does not automatically mean that one caused the other. It's not causal, right? It's not proving a causal relationship. So if a child snores, mouth breathes, they have chronic open mouth posture, or they have other signs that concern me for sleep disorder breathing, I absolutely want that investigated. But my next thought isn't just, you know, I'm not automatically going like, oh, we need to release the tongue, which by the way is not my call. Usually it's like, oh, I need to send them to a release provider because I have concerns and maybe they'll recommend a release, right? That said, my next thought is not that. It's really, hey, we need to understand the airway, like what's going on here? And that might involve an ENT, medicine, dentistry, orthodontics, you know, allergists, who knows, or more than one of those providers. The exact team depends on the child, but the principle's the same. Follow the dysfunction instead of trying to make the dysfunction fit your favorite explanation of what you think is going on, right? And the same thing applies when we're talking about speech. There are children who have tongue mobility restrictions and speech sound disorders, and there are plenty of children with speech sound disorders who do not have clinically significant tongue restrictions. So if speech is the reason we're considering a release consultation, I want to know exactly what the tongue can't do and how that limitation relates to their speech pattern, if we think it does. And what's already been addressed in therapy, and whether the anatomy actually appears to be limiting progress. That's very different from seeing a child with an R error, you know, R being like rah rah or like er er, that that R error, and a tongue tie, you know, and deciding that the tongue tie is that's got to be the cause. You know, that R is hard because they've got a tongue tie. That might be true, but one is not causal over the other. And you know me, I'm always going to look inside the mouth, and I'm always going to take a look at oral function. But looking deeper should make us more. Thoughtful, not more certain about everything. One of the most useful things we can watch clinically is where progress hits a ceiling. Imagine this for a second, okay? You've completed a thoughtful eval, you've identified the functional limitation, you're treating what you know falls in your scope, and maybe you've also made a few referrals as needed. The child's improving, jaw dissociation is getting better, feeding skills improving, movement and coordination are becoming easier. Amazing. Well, first of all, keep going. That's awesome. There's no reason though here to interrupt meaningful functional progress simply because tissue exists Under the tongue, right? We're making progress. Now imagine a different scenario. You're providing appropriate therapy, the patient is participating, the plan makes sense, and you reach a point where progress starts to stall. The patient understands the movement, they can approximate it, the compensations are decreasing, but anatomy appears to be creating a physical ceiling, right? We've got a ceiling at play here that therapy just can't get past. That's a very different clinical picture. Okay. Because now we've got compensations, Even though they might be decreasing, anatomy's still like, we're hitting a wall anatomically with what we're able to do beyond some decreasing compensations. So this gives me useful information that I can then bring to a release provider. And so if I'm sending a referral, I have helpful info. I'm not sending a referral that says, this child has a tongue tie, please release it, right? I'm saying, hey, here's this functional limitation I observed. This is what's impacting function. Here's what we've addressed in therapy. Here's what I've seen improve. Here's where progress Stopped. That's key. Where is it stopping? We've hit a wall. I would like your assessment of whether the front heel is contributing to the remaining limitation. That is collaboration. That's also more of an integrated care model because you're taking what you've observed, you're talking about it with the provider you're referring to, and you're saying, this is why I'm sending them your way, right? You're not telling them how to do their job, but you're sharing what you— what their concern is, what your concern is, what you're seeing, what you've tried. That is so helpful. Also, let me tell you, keeps us inside our scope while still giving the medical or dental provider like valuable clinical information. And it also prevents from putting families through a procedure simply because something looked abnormal anatomically, right? We don't want to just release, you know, not that I'm doing the releases, but we don't want to be releasing tissue just because it looks tight, right? There needs to be a functional impact. Because a release, while it might be simple and quick, in a lot of cases, it's still a procedure, and there's got to be a reason for doing it. Plus realistic expectations about like what it may or may not change. We need informed consent. There's got to be discussion of alternatives as well, appropriate, you know, pre-op and then post-op follow-up. You know, all these things have to be in play. And you guys have heard me talk for years about pre and post-release care. I still strongly believe in preparing function when a patient needs preparation and supporting functional retraining afterwards. Because if we're going to release tissue, we have got to have that preparation ahead of time, that pre-op prep, and we've got to have the post-op rehab. If somebody gains new mobility, that doesn't mean the nervous system immediately knows like how to use that mobility during eating and speaking and swallowing or rest, right? And so we gotta teach them releasing the tongue and just like letting it float around the mouth is not helpful for majority of people. There may be a case here or there where they just like spontaneously start using their tongue better and you're like, amazing, wow, dismissed. But that's more not common. So here's the thing too, individualized therapy and a standardized protocol are also not the same thing, okay? Every patient does not need the exact same pre-release plan. Every patient does not need the exact same post-release plan. Even the team may look different depending on the person. And that's— this is really important for all ages, but especially with our infants. If an infant is struggling with breastfeeding, that baby and parent deserve a complete feeding and lactation assessment. Okay? Pain matters. I was told it was normal. It wasn't. Milk transfer matters. Latch matters. Weight gain matters. Maternal anatomy matters. Infant anatomy matters. There's just a lot of reasons that breastfeeding can be difficult. And that doesn't mean that we never refer for an infant release. It means we don't reduce every breastfeeding problem to the frenulum. Unless we have really good evidence and reason to believe that that's contributing. Okay, which in many cases it is, right? But not in every case. Now, good clinical care also means understanding as much of the whole picture as we can before deciding what happens next. And the lens also changes as children get older. Like, you know my stance here. I'm not doing Mini Mayo with a 2-year-old. With toddlers and preschoolers, I'm looking at this through a developmentally appropriate pediatric feeding, oral function, sensory motor development, and speech When speech is relevant type of lens. Okay, we are adapting the goals of MYO to what we're doing in pediatric feeding for a lot of these kiddos, because that's literally a part of what we do as a pediatric feeding therapist. It's just looking at it through an additional goal, but the way we accomplish it is actually through pediatric feeding. I can't drill that home enough. People still seem confused about that. Anyways, mini MYO is not a thing. Okay, moving on. So when a child's developmentally and cognitively ready for a more formal myofunctional program, like at, let's say, 4 to 5 years of age cognitively, right? Not chronologically, cognitively, meaning their brain functions at the level of a 4 or 5-year-old. Then that becomes another tool that we can use. We're still treating the person in front of us. We're not simply treating the tissue, right? But we're just like talking about the tools to support them here. That is really a central point that I want you to leave with today. Somewhere in the tongue-tie conversation, the tissue became the main character. And it really shouldn't be. The child is the main character. Their function matters. Their goal matters. Their family's priorities matter. And we need to keep that in mind, right? The tissue is one piece of the story here. So when you walk into your clinic tomorrow, I want you to change, or wherever you work, right? I want you to change the way you're thinking about these cases. Instead of asking, does this look like a tongue tie? I want you to ask yourself, what isn't functioning the way you would expect? And what evidence do you actually have for that? Because when you communicate with another provider, You'll be more easily able to describe what you know, right? You can tell them that you've observed limited elevation or significant jaw compensation. You can tell them the patient can't manage a particular movement during chewing, or that you've made progress in several areas, but one specific limitation remains. This is the kind of information that's so clinically useful because it doesn't ask your assessment to prove something that it hasn't proven yet, right? It's literally what you got from your assessment that's making you go, hmm. I think this tissue is a problem because I'm seeing these functional limitations in my assessment, right? And then when you start therapy and then progress stalls, you know, we don't want to immediately assume that that means someone needs a release. I want you to kind of widen your lens there first and still ask like, what could I be missing here? Could there be an airway issue? Is there enough space for the tongue? Is another developmental, sensory, or structural factor involved? Have we truly reached an anatomical ceiling, or is there another reason that progress may have slowed, right? And after you kind of go through this exercise and you ask yourself these questions, you go through this clinical reasoning, then you have a better idea of if that referral is necessary. Okay. Again, this is clinical reasoning. And I think that's a big part of what's changed most for me since episode 184, because back then my message was simple. Not all ties need to be released. And like I said, I still believe that. But today I would add that our job isn't to become pro-release or anti-release. We're not here to win the tongue-tie debate online. Our job is to become really good at understanding function. We need to be good enough to recognize when tissue matters, good enough to recognize when it may not, good enough to treat what falls within our scope, and good enough to recognize when another provider needs to enter the conversation. That is a much harder skill than spotting a frenulum, but it's also the skill that actually changes care and moves the needle forward. I don't want clinicians known as the person who sees tongue ties everywhere, and I don't want them known as a person who never believes tongue ties matter either. I would much rather somebody in your community say, send that patient to her, she's going to look at the whole child and figure out what actually needs to happen next. Like, how cool would that be? That's the clinician I want you to become. And I hope you want that for yourself. If you want to go deeper into functional tongue-tie assessment and how I think through these cases clinically, you can check out the Tongue-Tie Boot Camp at feedthepeds.com/tongue-tie-bootcamp. And if you haven't listened to episode 184 in a while, I actually think it would be really interesting to go back, listen to it after this one because good clinicians evolve. And I know so many of you have been with me for so long. Our thinking should become more nuanced as we learn more, as we work with more patients, as we mentor more clinicians and have better information available to us. Changing the way that like you explain something doesn't always mean that what you believed before was wrong. Sometimes it just simply means you've learned to ask a better question or the way you discuss this topic has evolved, right? And for me, the better question today isn't, does the tongue tie need to be released? It's actually, what does this patient need in order to function better? And what is the most appropriate next step to help them get there? That's where I want us practicing. All right, y'all, I'll see you next time on the Untethered Podcast. Quick disclaimer, all information, content, and material of this podcast are the opinions of the speakers and serves as the 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 @holliebulkin on Instagram to get all the latest updates.