Tongue Ties: The Functional Deep Dive

It comes down to function. Form plus function is what is going to lead to a diagnosis. The release itself is not an instant fix. It's not the fix. It's not the standalone fix because our goal here is efficient, coordinated, effortless movement, not just range of motion.

It's not a true tongue tie really unless it's something that's functional that's going on, and sometimes it's not tongue. They just don't— they've never done it before.

So many of us go through life having no idea that anything is awry. And then all of a sudden someone points out, oh yeah, all these other symptoms that you were saying are related to what's going on in your mouth. You start to address that and deal with it, and it's— I can't tell you how many adults have gone in for a tongue-tie release, come out afterwards, and then, I had no idea what I was missing.

Now, can tongue ties impact speech? Yes, yes they can. When a child has a tongue tie, they may struggle to produce specific sounds, specific speech sounds. Just because a sound sounds good doesn't mean that it's being produced correctly.

Hello friends, Hallie Bulkin here. I want to talk about one of the most misunderstood 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. Okay, so here's why so many clinicians feel stuck, right? We were taught maybe in some tongue-tie courses or in courses where they're talking about tongue 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 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? 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 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 the tissue is 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 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, 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. 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 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 lick 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 4, 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 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. 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 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 aesthetics. 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 not really sure what that means or why they say that, but here we are. 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 gonna give you 3 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 like what is happening with the jaw, the 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. I want you to consider the whole system. The tongue is often talked about, 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, the collaboration piece. So I've already kind of mentioned it, but a myofunctional therapist or feeding therapist 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. And to your dentist for that surgical assessment and follow-up, right? So you're gonna at minimum probably have these individuals on the team. Sometimes there will be other individuals as well. I want you to remember number 1 was assess function and structure. Number 2, consider the whole system. And number 3, 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 that the brain learns new movement patterns, right? 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 reeducation. 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 a tongue have enough 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 is 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, that's great.

I think that's so much more of that is needed, just screening in general. We talk about this in the pediatric feeding space too, screening babies for airway and tethered oral tissue and feeding and all the things at birth, not waiting till a problem because I knew with my second, I was, well, the chance of her being tongue-tied is pretty high, but I'm just gonna ignore it for the first 24 hours and live in bliss. And the second I latched her, I was, oh no, here we go again. I don't even need to look. I can feel it.

It's there.

This is dysfunctional. And here we are. So interesting existing in this space. And it was very different with my second than my first, cuz I was not working with the infant population. I was really more so working with toddler on up with feeding and My older one threw me into, I took a myofunctional therapy course. She threw me into the tongue-tie, myo world after I took that course. So I was, oh, you're 24 months old. You already have these things going on, which then led to me teaching my feeding, my pediatric feeding course from like, guys, we gotta be talking about this at birth, not when they're 5. I know that's what traditional myo starts 4 or 5, but we got it. And yes, we're gonna address it then, but also can we talk about this earlier? Cuz hi, it's here from the get-go in a lot of these kids.

So it's.

It's just a very interesting journey.

It is. Yes. I love that. And so in childhood and babies and all that, but sometimes it's just such a habit that people have no idea that that tongue is intended to be up in the roof of their mouth. And so they're adults. And I think I learned it from you that it's not, or maybe it was a book.

I don't know.

I love books, but it's not a true tongue tie really, unless it's something that's functional that's going on. And sometimes it's not tied. They just don't, they've never done it before. They've never. Suction it up. They don't even know what that is. And it's wild for me to watch them and that tongue will curl back or that. And so then you just have to teach them, but I've been amazed at how many can go away and practice and come back and you're like, that's amazing. It's fun. It's really fun to start to, and people have no idea that neck and back pain can be related to tongue tie, that digestive issues can be related to that, sleep issues. You can't get that tongue out of the airway. There's so much that can be connected. Breathing. If you can't get that tongue up, it's going to change your breathing as well. It's, it's wild. And one time there was a functional medicine doctor that was in part of, I think I mentioned I had this wellness collaborative in Wilmington and I want to develop another one here, but I was teaching some of that stuff with breathing and do, do these, and I would have them do some myofunctional exercises. And she realized at that moment that she could not get her tongue to the roof of her mouth. And she never knew that before. And so we had this conversation after, but not common knowledge.

So, I mean, that is literally every SLP, OT, PT, RDH, dentist sitting in a myofunctional therapy course, all trying to do the exercises for the first time.

Even us, right?

So I think it's, we're all, can we not do this because it's new? Or can we not do this because we're actually tired? Or what is happening? And that begs the question of, cuz you're exactly right, there has to be a functional impact. It's not just a form and what it looks, but is there a functional impact? And sometimes we might see a functional impact, but maybe it's not a functional impact in the eyes of the patient, right?

So then there's that whole conversation.

But so many of us go through life having no idea that anything is awry. And then all of a sudden someone points out, oh yeah, all of these other symptoms that you were saying are related to what's going on in your mouth. You start to address that and deal with it. And it's, I can't tell you how many adults have gone in for a tongue tie release, come out afterwards and been like, I had no idea what I was missing.

I didn't know.

I mean, this happened to me with breathing. Here I am, a certified myofunctional therapist, and I go in for my nasal surgery 3 years ago. And I'm, huh, I had no idea I couldn't breathe well outta the left side of my nose.

I'm over here, got my mirror.

I'm going, right? Yeah.

Right.

Yep.

All the time.

Can't breathe equally outta both sides of my nose and that the left side is almost completely obstructed.

What?

My septum is all— it was mind-blowing to me. And so it was, as a specialist in this space, to even have that personal experience, it's such a good reminder that we don't know what we don't know. We don't know what we can't really feel. And also we don't realize it sometimes because we've lived with it for so long and then we're compensating so well or, or not compensating so well that that's just our normal. And until something drastic changes, sometimes we go, oh, I get it now. I understand what you're saying. I didn't realize that that was the way I was living, right?

Yeah.

So that is always so fascinating to me. But I love that you really highlighted the functional impact because yeah, we do see patients that sometimes they're carrying so much other tension, it mimics a tie. Sometimes they just don't have enough space for their tongue in their mouth. And so it's hard to know, is it really a tie or is it a space issue? Is it just, we haven't done this before, we need to learn it and we can actually do it.

We have better range of motion than we're demonstrating in the evaluation.

Who knows, right? And so that's why I'm, I'm very pro-release when they're needed, but I'm also very pro, let's do other interventions first and see if we can avoid a procedure because there's no reason to do it if we don't need it.

Right.

So I love that you've touched on that. There's so many different variables at play here.

There's so many, and I always say it's not magic, right? We can fix structure. So for you, it was magic as far as the nasal breathing and oh my goodness, I had no idea, but you also had this high awareness. So sometimes people will go in thinking it's this magic fix. I'm gonna get my nose, my nasal surgery, and then it's done. And it's the same because no one ever taught them how to breathe through their nose again. And it's nasal disuse. And so if you don't use it, you can't use it as well. If you breathe through your nose more, it becomes easier to breathe through your nose. If there's a structural reason you can't, then that needs to be fixed. But there can also be inflammation that causes all that congestion. And yeah, so it's fun to look at the non-surgical, and that's the same way I look at dentistry too. It's okay, I can do the filling, I can do the crown, I can fix things, I can place an implant, but why did that tooth break?

Why did that—

what's the reason behind so that I don't do something that's gonna have the exact same thing happen? Or let's address your caries risk. Let's see if we can figure out why this is happening instead of just fix it, which I'm a fixer. That's hard to do too.

But sometimes it feels easier if we could just fix it.

Right.

And we get parents who come to us and go, can you just fix this?

Can you fix what's going on? And we're like, let's have a conversation. I mean, but that might take 2 years. I mean, depends what does fix look to you? Because what fix looks to me might be a very different conversation. This is not going to be a One and done. I think one of the biggest struggles that a lot of therapists have that I speak with even are we see things knowing what could be the ultimate end goal for this case, right? And what that looks for us versus what that looks for a patient and their end goal and why they're here, what their chief complaint is and what they wanna work on. Sometimes you just gotta meet them where they're at and bite our tongues and just be, this is what makes them happy and feel they're living their best life. Like, we'll help you get there.

Yes. And I've started asking, what does success look for you? Because it's interesting what that answer is sometimes, because it's very different. Sometimes I have to pause, I just have to go, okay, don't, don't say anything. Let's see how this plays out for them, because what I see, and that's even if I'm doing something aesthetic or whatever, and we've got these dental eyes, so we see fractions of a millimeter or the tiniest little things that I wish I could turn that off sometimes, but I'll have to stop myself and I'll just give the mirror and be like, what do you think? And I, not that I didn't do my best that day, but I see that little tiny thing that I can improve on. But sometimes you get to doing that and then it's not as good. So it's really just trying to, like you said, meet patients where they are and figure out how you can help them get as healthy as they wanna be. Right? Because you can't want it more than they do. I've learned that over and over again.

Yeah. Yeah. I mean, I always think back to this one patient I had where it was an adult patient and she was, I don't want expansion. I know I'm very high and narrow. I know my tongue doesn't really fit up there. She's like, can you teach me enough to help me maintain where I'm at so that things don't get worse? And I was like, okay, we can definitely give that a go. Let's, let's see what we can do. And that was just so interesting because I don't think that would have ever come up. Even I'm over here, I want it all, I want it all. I want to feel healthy, I don't care what it takes. I want to open my airway and we can make straight teeth at the end of that without losing the expansion. I'm here for all of it, give me all the things, right? Whereas most people are, I don't have an endless budget or endless timeline, I really just want to feel good now. What can we do in this short term to get me back to— I don't want to be in pain.

Okay, Great.

What is that one thing that's really jumping out for that person? And I'm over here, gimme the 5-year plan, gimme the 10-year plan. I'm in it. I know that's not the average, right?

Yeah.

Yeah.

Yes, absolutely. And I think that sometimes people forget, patients, whatever, that they're human. And so we can predict a lot of things, but when it comes to this expansion and orthodontics and whatever, to create the room, sometimes you have to stop and then use a different appliance or a different approach, or what are we missing? Do we need to add in the myofunctional therapy now all along the way and there's just so many pieces to it. And you're so right that there's these expectations where they wanna know how long, how much is it gonna cost? And you're doing your best to get all the answers, but nobody necessarily has all the answers and we have to give ourselves grace. That's every profession, right? I mean, it's even in fixing your house, stuff comes up and you just never know what you're gonna find.

We won't know until we get in there and we start working with you. And I try to give people, look, On average, it takes this much time for what your goal is.

I tell people, we're all human.

We all have life things come up. We don't know.

It could be this, it could be that, it could be longer, it could be shorter.

It depends. I always laugh when I tell people it depends.

Yeah.

Yeah.

Because we're dealing with humans.

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 who 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 RCTs, these level 1 and 2 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. Here's what I want to share with you. We're going to dive deep. 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. 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 now, can tongue ties impact speech?

Yes.

Yes, they can. When a child has a tongue tie, They may struggle to produce specific sounds, specific speech sounds. Some of the common sounds that we see are S, Z, the SH, CH, ZH, DJ, and that's like /d��/, alveolar sounds like /t/, /d/, /n/, /l/, /t/, /d/, /n/, /l/, back sounds as well, the K, G, R, like /k/, /g/, /r/, 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 an un— this is my unpopular opinion— just because a sound sounds good doesn't mean that it's being produced correctly, okay, properly. And this is frequently dismissed in the SLP community. I was taught in grad school, if it sounds fine, it is fine. We are humans who have an anatomy that is supposed to operate a certain way, right? 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 a full-blown orofacial myofunctional evaluation to explore the root cause of the speech sound disorder. All right, so let's dive into the lisps for a moment. A lisp is never normal. Frontal lisps occur when the tongue pushes against or through the front teeth and makes a TH sound for an S or Z. Why does it happen? Well, a frontal lisp can occur for a number of reasons. Some may include having a high and narrow palate. Tongue can't actually go where it's supposed to in the mouth. It 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. Frontal lisps need to be addressed. Once that root cause has been identified, then we can form an appropriate treatment plan. Right. And address that frontal liss. 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 myo or having myo or expansion with release in 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 the sound they physically could and boom, gone. Matter of days, weeks, sometimes not years, not months and years. Okay, that was a frontal lisp. Let's talk about a lateral lisp. Okay, a lateral lisp, 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, a lateral lisp may be present. With the lateral, we hear it sideways over the side of the tongue instead of it being directed forward. And so it creates a slushy or wet speech quality. And this is never developmentally appropriate. Never. When there is a lisp present, frontal or lateral, there is an orofacial myofunctional disorder at play. Alveolar sounds. 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. So we see decreases in speech clarity. Our goal as an SLP or myofunctional therapist here is to eliminate all of 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. That is the truth, okay? And what really I find fascinating is there are like big influencer accounts on social media who are normalizing compensations. Back sounds, those are the sounds of K, G, and R, that requires retraction of the back of our tongue. When the tongue is tied anteriorly or posteriorly, this often prevents the back of the tongue from retracting. Kids who have been in therapy forever, who have never had an intraoral evaluation that includes pulling out a tongue tie, need to be checked as soon as possible. If this is your kid, please seek out a provider who can help you with this. Yes, tongue ties and the root cause of a speech sound disorder. Simply put, teaching compensations are 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. Getting to the root cause and collaborating with other medical professionals when needed is key because it's usually structural in nature and related to something going on in the mouth, the airway, or both. 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? All right. I hope this is helpful. All right, everybody, this is signing off. See you next week. Quick disclaimer: all information, content, and material of this podcast are the opinions of the speakers and is for informational purposes only and not intended to serve as a substitute for the consultation, diagnosis, and/or medical treatment of a qualified healthcare provider.

That wraps up today's special compilation. My goal with these episodes is to bring together the conversations and the insights that are truly moving the needle in our field right now. Next, whether you're a parent looking for answers or a clinician looking to sharpen your skills, remember that the most important tool you have is your own clinical reasoning. Don't just look at the surface-level symptoms, look at the underlying systems. If today's episode shifted your perspective or gave you a new aha moment, I would love to hear about it. Take a screenshot of you listening, post it to your stories and tag me @HallieBulkin. You can always find more resources and past episodes over at untetheredpodcast.com. Thanks for tuning in, and I'll see you back here next week on The Untethered Podcast.