Manual Therapy for Tethered Oral Tissues

DEFINITION

  • A congenital condition characterized by abnormally short, thickened, or tight frenulum, or an anterior attachment, that restricts mobility of the tongue and/or lip.
    • Variably causes reduced tongue mobility and has been associated with functional limitations in breastfeeding, swallowing, and speech.
    • Orthodontic problems including malocclusion, open bite, and separation of lower incisors,
    • Mechanical problems related to oral clearance and psychological problems.
    • It is also implicated with Aerophagia Induced Reflux.
    • AKA – Ankyloglossia/Tongue-Tie. Buccal-Tie. Lip-Tie.
  • The restriction is a functional Visual degree not considered severity.
    • In the competition between muscle and bone, muscle always wins.
  • Present in 15-25% of newborns.
    • TOT accounts for 25-60% of all breastfeeding problems in newborns. (REF?)

TYPES

  1. Attached from the very tip of the tongue to 4-5 mm from the tip with a sail
  2. Attached 4-5 to 10 mm from the tongue tip with a sail; but can be submucosal without a sail.
  3. Attached 4-5 to 10 mm from the tongue tip without any visible membrane above the mouth floor
  4. Attached >10 mm from the tongue tip with no visible membrane above the mouth floor. It is all Submucosal.

DIAGNOSIS

HISTORY INDICATORS

Breastfeeding:           Success / Postures / Pain

  • Difficulty/inability to achieve a deep latch
  • Latch pain &/or burning (50% tongue tie have pain. 50% don’t.)
  • Difficulty swallowing fast flowing milk (rapid letdown or bottle held upright). Pulls away.
  • Frequently falling off the breast, +/- a click
  • Tires while feeding (falling asleep briefly & feeding all the time or crying in frustration)
  • Milk supply does not increase in volume at the expected time (or ever)
  • Milk is not removed leading to engorgement, plugged ducts, mastitis, or abscess
  • Lip Stick Deformity – typical of anterior tongue-tie (MC deformity)

Other Hx Indicators

  • Struggles with weight gain
  • Urine and stool output are poor; stool remains a dark green >5 days; risk of jaundice
  • Choking, grunting or crying when lying on the back (diaper changes, sleep)
  • Frequent emesis or “apparent” GERD (in part due to AIR)
  • Extreme Anxiety needing bouncing every waking moment, especially during nursing
  • Inability to use a pacifier successfully due to the poor seal – often forcefully ejected

PHYSICAL EXAM FOR TOT

  • Recognize At-Risk Oral Anatomy
  • Perform a Simple Suck Assessment

The Oral Exam

  • Every newborn should be examined for:
    • Ability to open the mouth widely
    • Tongue rising above mid-mouth (when crying)
    • Tongue able to extern past the lower lip (1cm)
    • Symmetrical seating of the mandible
    • Intact hard and soft palates (note shape, pockets, symmetry)
    • Upper and lower lips intact and evert easily
    • Finger sweep under the tongue
    • (Especially a single upper tip blister.)
    • Visible midline membranes & tongue shape

The Organized Suck Pattern

  • With your 5th finger upside down in the infant’s mouth you should feel:
    • Good seal & suction (no air leak & pulling finger back moves the infant’s head)
    • A strong rolling undulation wave from the front of the infant’s tongue to the back
      • Peristaltic movement of tongue initiates that throughout whole GI tract.
    • No snap-back.

WHAT THE HECK IS A FAUX TONGUE TIE?

  • Look like tongue tie but respond to alternative Tx. Sx same (functional impairment) but no actual TOT. Usually due to birth strain.
  • Birth Trauma– Cranial deformity from in-utero pressures indicate body muscular and/or fascial tightness that make it difficult for the newborn to turn/rotate the head in all directions needed for effortless breastfeeding. This mimics many of the features of a true tongue tie though the tongue function may be entirely normal. [Faux Tongue Tie]
  • Actual & Faux Tongue Tie– After a complete release of all restrictive elements and demonstration of perfect tongue function, the infant may not improve at all when put to the breast. When a highly skilled lactation specialist cannot latch an infant who has had a complete tongue tie released, muscle/fascial restriction is almost always cause.

GERD VS AEROPHAGIA INDUCED REFLUX (AIR)

  • Over 50% of infants with GERD resolve after TOT revision
  • Swallowed air distends the stomach making emesis more likely
  • A poor seal at the breast may be due to tongue tie, upper lip tie, or both
  • Aerophagia is reduced substantially by a deeper latch and by “fish lips”
  • Avoiding Rx

Reduced acidity in infant GI árisk of infection & âcritical nutrient absorption.

Clove Essential Oil 1d/10mL coconut oil on Q tip to wound for 10 sec before EX

 

Article on Aerophagia and ULT:        Aerophagia Induced Reflux in Breastfeeding Infants With Ankyloglossia and Shortened Maxillary Labial Frenula (Tongue and Lip Tie) by Scott A. Siegel

  • http://www.ijcp.elmerpress.com/index.php/ijcp/article/view/246

 

DECIDING FACTOR:       FEEDING

  • Visual degree not considered severity. Impact on feeding & function determines Tx.
  • Rule #1: Feed the baby!

TREATMENT

  • Surgical: No difference between lazer and blade in literature
    • Likely depends primarily on practitioner expertise
  • Effectiveness?
    • True RCT not possible.
    • Cohort and case series studies look very positive in terms of breastfeeding success and long-term tongue ROM.
      • Difficult to assess speech.
    • Impact on nipple pain consistently higher if revised in 1stweek of life
  • Risks?
    • Wound care. (See Drghaheri.com – videos on wound care)
    • Oral aversion tends to occur more if paranoid about it
    • Minor bleeding is MC reported
      • Vitamin K shot at birth? Von Willebrand Disease unDx at that time
      • 1 of Dr S’s patients had excessive bleeding after blade revision by Dr B.
    • Expectations
      • Fixed vs. Dynamic Notch - Fixed notch doesn’t go away right away
      • Immediate Improvement vs Retraining Time (3-8 weeks)

WHY FOLLOW UP WITH MANUAL CARE IS RECOMMENDED

  • Connectedness of fascial and connective tissue structures
  • Immediate change in superficial ST after surgery
    • Complete the adaptive release of tethered tissues
  • Support healing with full and functional ROM
  • Treatment of “Faux Tongue Tie”

MANUAL CARE FOR TOT

  • THERE ARE THE BONES OF THE CRANIUM THAT PRIMARILY EFFECT SUCK:
    • Frontal: Shifts so one side is slightly prominent after feeding.
    • Occipital: Major impact on CN due to foramina
    • Parietal: Often rigid. Consider sagittal suture restriction. (midline tether)
    • Temporal: TMJ implications
    • Sphenoid:      Rocks sella turcia to stimulates pituitary to release GH during BF
    • Palate: Impacts suck response and latch directly
  • CRANIAL NERVES THAT EFFECT SUCK
    • Hypoglossal nerve (XII) - Hypoglossal Canal (occiput)
      • Controls tongue movement (motor only)
      • Patterns necessary for latch and suck
      • Travels through the hypoglossal canal
      • Disruption of the occipital segments can lead to nerve entrapment causing ineffective, mis-patterned, loose muscle control in tongue.
    • Glossopharyngeal (IX) - Jugular Foramen (occiput/temporal)
      • Sensory fiber post palate and tongue
      • Travels through the jugular foramen
      • Gag reflex!
    • Vagus (X)                         - Jugular Foramen (occiput/temporal)        & C1
      • Sensory fibers control the larynx, heart, lungs, trachea, liver, and GI tract, and external ear
      • Motor fibers control the larynx, heart, lungs, trachea, liver, and GI tract
      • Poor suck with a high-pitched squeal during feeding
    • CAUSES OF CRANIAL MISALIGNMENT THAT MAY AFFECT SUCK
      • Fetal position in utero
      • Birth process - too fast, too much pressure, malposition
      • Birth Interventions
        • Forceps – Direct & forceful cranial compression. Consider TMJ.
        • Vacuum – Hematoma. Usually less harmful than forceps. Depends on technique.
        • CS – Statistically less likely to BF. Consider cranial stimulus during passage, potential in-utero malposition, & excess forces/distress.
      • TOT – Soft tissue tether points impacting cranial symmetry and restriction patterns.

INDICATORS THAT CST AND CHIRO CAN HELP WITH BF

  • Asymmetry of cranium
  • Gag response
  • Favours a breast.
  • Looks toward 1 side
  • Takes a long time to nurse. Exhausting. Never satisfied.
  • Always hungry
  • TOT – tethered oral tissue
  • Excessive gas
  • Arching in frustration. (Dural tension & ANS)

TREATMENT PLAN

  • Always starts a full assessment. Treatment with intention requires understanding.

 CMT:  RULE OUT AND TREAT

  • Torticollis or lateral flexion restrictions (ST & JT)
  • Rotation restriction or malposition (C1!!)
  • Severe TMJD
    • Feeding Rhythm: Breath, suck, swallow.
    • Temporalis mm should be engaged.
    • Should not be furrowed/angry.
    • Distract jaw and lift frontal bone while feeding and see if it helps.
    • Internal & external STT
    • CMT: manual (SH/HVLA), AM, DROP
  • Sacral malposition
  • Dysautonomia

 CST: TREAT WHAT YOU FIND

  • Address global tension pattern in dural system first.
  • NSDP
    • Requires correction at C1/OCC first. Foundation.
  • Palate symmetry
  • Sutures
    • Especially sagittal. Cf Midline defect.

 HOMECARE

  • TOT stretches
  • Palate pressure
  • TMJ support (external only)
  • Tummy time (hate tummy time = red flag
    • 1 mo 15 min total a day
    • 2 mo 30 min
    • 3 mo 1 hr
  • Corrective care (torticollis, rotation restrictions, etc.)

 MOM SUPPORT

  • Support for Milk Supply.             (See blog)
  • Perinatal mood disorders (Stress, sleep, support)
  • CST together (So great!)
  • BF training or retraining (for mom & babe)
  • Nipple healing (see photos in slides
    • Consider lazer treatment (Rutland Physio)
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