ADULT TONGUE TIE: HOW TO SPOT, SYMPTOMS AND TREATMENT

Medically Reviewed by Dr. Sony Sherpa (MBBS) - February 19, 2024

The common misconception that tongue tie, or ankyloglossia, is just a childhood condition needs to be dispelled. In reality, this condition is more prevalent in adults. Ankyloglossia is not always resolved or even identified during childhood, and its persistence into adulthood can lead to a range of complications and challenges.

Ankyloglossia, commonly known as tongue tie, is a condition where the lingual frenulum, the tissue connecting the underside of the tongue to the floor of the mouth, is shorter, tighter, or thicker than usual. This can significantly restrict the tongue's range of motion. While often identified and treated in infancy or early childhood, it can go undetected and persist into adulthood, sometimes without noticeable symptoms until later in life.

The tongue plays a vital role in various activities, including speaking, swallowing, and maintaining oral health. When the lingual frenulum restricts the tongue’s movement, it can impede these functions, leading to difficulties in speech, eating, and even breathing. The effects of an untreated tongue tie in adults extend beyond mere physical discomfort, potentially affecting emotional well-being and social interactions. Therefore, recognizing and addressing this condition in adults is as important as it is in children.

Recognizing Tongue Tie In Adults

Tongue tie in adults often represents a case of an unrecognized or unaddressed issue from childhood. It is not uncommon for a tongue tie to go unnoticed during childhood, especially if the symptoms are mild or do not significantly interfere with early speech and eating habits. In some cases, children adapt to their restricted tongue mobility, developing compensatory mechanisms that mask the underlying issue.

As these people transition into adulthood, the demands and complexities of speech, eating habits, and other oral functions increase, potentially bringing to light the limitations imposed by the tongue tie. What might not have been a problem during the simpler linguistic and dietary requirements of childhood can become more pronounced and challenging in adulthood.

In some adults, the connection between symptoms and a childhood tongue tie may not be immediately apparent. It often requires a healthcare professional to identify the underlying issue. The recognition of tongue tie as a potential contributor to these diverse and seemingly unrelated symptoms is crucial for appropriate management and treatment.

Types Of Tongue Tie

Tongue tie, or ankyloglossia, can be classified into different types based on the position and severity of the lingual frenulum attachment. Correct diagnosis and therapy depend on having a thorough understanding of these types.

• Anterior Tongue Tie: This is the most easily recognizable form. The lingual frenulum attaches near the tip of the tongue to the floor of the mouth. It is visible when the tongue is lifted and often forms a noticeable "V" or "heart" shape at the tongue's tip. Anterior tongue ties can restrict the tongue's forward and upward movement.
• Posterior Tongue Tie: More challenging to diagnose, the posterior tongue tie involves a frenulum that attaches farther back on the tongue's underside. It is often hidden under the mucous membrane and can be overlooked. This type of tongue tie restricts the tongue's lift and range of motion, especially in the back.

Coryllos' Classification of Tongue-tie

Coryllos' classification of tongue-tie is a system used to categorize its extent and nature based on the location of the lingual frenulum's attachment points. This classification system was developed by Dr. Elizabeth Coryllos, a surgeon, and her colleagues, to help healthcare professionals diagnose and decide on the treatment for tongue-tie, a condition that can affect feeding, speech, and oral hygiene.

The Coryllos classification divides tongue-tie into four types, focusing on the attachment of the lingual frenulum:

• Type I: The alveolar ridge (gum ridge behind the upper front teeth), and the tip of the tongue are where the lingual frenulum is attached.This type is the most noticeable and can significantly restrict the tongue's movement.
• Type II: The frenulum attaches slightly behind the tip of the tongue and near the alveolar ridge. While there is more mobility than Type I, the tongue's movement is still notably restricted.
• Type III: The attachment is further back on the tongue and midway along the floor of the mouth. This type may not be as visually obvious but can still affect tongue mobility and function.
• Type IV: Also known as a posterior or submucosal tongue-tie, the frenulum is attached near the base of the tongue, with its presence often obscured by the mucosal covering. It is the hardest to diagnose visually because the restriction is hidden beneath the mucosal surface.

Signs and Symptoms: When to Suspect Tongue Tie

When considering the possibility of a tongue tie in adults, it is important to be aware of various signs and symptoms. These symptoms can manifest in several aspects of daily life, emphasizing the multifaceted impact a tongue tie can have. Here is a relatable list of symptoms and signs, along with examples of how they might appear in everyday situations.

• Speech Difficulties - Struggling with specific sounds, like 'r', 'l', 't', 'd', 'n', 'th', resulting in unclear or slurred speech and having a sore jaw after extended periods of talking.
• Eating and Swallowing Challenges - Longer meal times due difficulty in chewing efficiently and struggling to swallow large bites or pills.
• Dental and Oral Health Issues - Persistent dental issues despite good oral hygiene.Difficulty in reaching back teeth when brushing or flossing due to limited tongue movement.
• Physical Discomfort - Persistent tension or discomfort in the jaw, neck, or shoulders resulting in headaches or migraines.
• Regular snoring and Mouth breathing.
• Limitations in Activities such as difficulty playing wind instruments or singing, and struggling with activities requiring precise tongue movement, like licking an ice cream cone.

Potential Consequences of Undiagnosed and Untreated Tongue Ties

The potential consequences of an undiagnosed and untreated tongue tie in adults are wide-ranging and can significantly impact various aspects of health and quality of life. Here is a breakdown of these potential consequences.

Speech Difficulties

• Issues like mumbling, stuttering, and poor articulation
• Fatigue while talking due to the extra effort required
• Lisping, clarity issues, and pronunciation difficulties can affect communication
• Difficulty playing wind instruments or singing, especially with fast lyrics or notes

TMJ Dysfunction and Teeth Grinding

• The altered oral mechanics can lead to temporomandibular joint (TMJ) dysfunction, characterized by jaw pain, clicking, or locking
• Increased likelihood of bruxism (teeth grinding), leading to tooth wear and jaw discomfort

Parafunctional Habits

• Development of abnormal oral habits, such as frequent tongue thrusting, cheek biting, or nail biting

Eating and Swallowing Difficulties

• Challenges with effectively chewing food, possibly resulting in slow eating
• Difficulty swallowing large food items or pills

Muscle Tension and Pain

• Facial, neck, and shoulder muscle tension, often leading to chronic pain
• Increased risk of headaches or migraines due to continuous muscle strain

Chronic Tongue Pain and Discomfort

• Persistent discomfort or soreness in the tongue from strain or overextension

Tongue Thrust

• An abnormal swallowing pattern where the tongue presses too far forward, potentially affecting dental alignment

Oral Health Problems

• Increased risk of gingivitis and gum disease due to difficulty in maintaining oral hygiene
• Potential for dental crowding or misalignment and an increased risk of tooth loss

Sleep Difficulties

• Issues like sleep apnea, characterized by breathing pauses during sleep
• Mouth breathing and snoring, leading to poor sleep quality and daytime fatigue
• Brain fog and decreased cognitive function due to disrupted sleep

Social and Emotional Effects

• Feeling self-conscious while speaking in public or during social interactions.
• Avoidance of situations where clear speech is necessary, like meetings or presentations.

Early diagnosis and appropriate treatment can mitigate these consequences and significantly improve quality of life.

Diagnosis and Evaluation

Diagnosing tongue tie (ankyloglossia) in adults is a multifaceted process that involves a combination of physical examination, potentially imaging techniques, and functional assessments. The process aims to evaluate the structure and function of the lingual frenulum and the tongue's range of motion. Here is an overview of the diagnostic approach.

Physical Examination

• Visual Inspection: The healthcare provider will visually inspect the tongue and frenulum. They look for indications of tongue tie, such as a tight, thick, or short frenulum that tether the tongue to the floor of the mouth.
• Palpation: The provider may palpate (feel) the area under the tongue and around the floor of the mouth to assess the frenulum's structure and any associated tension or restriction.

Functional Tests

• Range of Motion Assessment: The provider will ask the patient to perform various tongue movements, such as lifting the tongue to the roof of the mouth, sticking it out, and moving it side-to-side, to evaluate mobility and any restrictions.
• Speech Assessment: Speech-language pathologists may conduct specific tests to evaluate how tongue tie impacts speech, including articulation and clarity.

Imaging Techniques

• While not always necessary, imaging techniques like ultrasound or MRI may be used in some cases to get a more detailed view of the frenulum and its attachment, especially if the tongue tie is not clearly visible or if there are concerns about underlying structures.

Healthcare professionals involved in the evaluation and treatment of tongue tie in adults include

• Dentists- They play a crucial role in the initial identification of a tongue tie, especially when it is related to oral health issues. Dentists can assess the impact of the tongue tie on dental health and may refer patients to specialists for further evaluation and treatment.
• Speech-Language Pathologists- These professionals are essential in assessing and treating the functional aspects of tongue tie, particularly its impact on speech and swallowing. They can provide a detailed evaluation of speech patterns and recommend appropriate therapy.
• ENT (Ear, Nose, and Throat) Specialists- ENT doctors may be involved in cases where the tongue tie is affecting breathing and swallowing or has other medical implications. They can provide comprehensive evaluations and are qualified to perform surgical procedures if needed.
• Oral Surgeons or Maxillofacial Surgeons- In cases where surgical intervention is considered, these specialists can perform procedures like frenectomy or frenuloplasty.

Treatment Options for Tongue Tie in Adults

Treatment options for tongue tie in adults are diverse and can be tailored to the specific needs and severity of the condition. Here is an overview of the available treatments.

Myofunctional Therapy

This therapy focuses on strengthening the tongue muscles and improving overall oral function.

Exercises are designed to enhance awareness of the tongue's position and movement and the ability to make rapid, alternating movements with the tongue. Myofunctional therapy can help retrain the tongue's movement patterns, improving speech, swallowing, and even breathing.

Speech Therapy

Speech therapists use specific exercises to improve tongue mobility and strength, which can enhance speech clarity and articulation. Therapy often involves exercises to target pronunciation, increase tongue agility, and correct compensatory speech patterns developed due to the tongue tie. Speech therapy can be effective on its own or in conjunction with other treatments and is especially beneficial for addressing the functional aspects of tongue tie.

Frenotomy

This is a minor surgical procedure in which a tight frenulum is cut to release the tongue tie. Frenotomy is often quick and can sometimes be performed without general anesthesia. The recovery is usually rapid, with minimal discomfort.

Frenectomy or Frenuloplasty

These procedures involve the removal (frenectomy) or modification (frenuloplasty) of the lingual frenulum. They can be performed using traditional surgical methods (scissors or scalpel) or with advanced techniques like laser surgery.

Combination Therapy

Often, the best outcomes are achieved by combining therapies. For instance, myofunctional therapy and speech therapy can be used alongside surgical interventions to maximize functional improvement. This approach ensures that the underlying structural issue is addressed while also improving the functional use of the tongue.

CO2 Laser

A CO2 laser is a technique used in frenectomy and frenuloplasty procedures. It offers advantages like reduced bleeding, less post-operative pain, and quicker healing compared to traditional surgery. The precision of the laser allows for more controlled and accurate treatment.

Each treatment option has its indications and potential benefits. The choice of therapy depends on the severity of the tongue tie, the specific symptoms and challenges faced by the individual, and personal preferences.

Deciding the Type Of Surgery

Deciding on surgery for tongue tie in adults involves careful consideration of various factors. Here is a decision-making framework to help weigh the benefits and risks and determine if surgery is the right choice.

The Severity of Symptoms and Tongue-Tie Restriction

Evaluate how significantly the tongue tie restricts tongue movement. Consider the severity of symptoms, such as speech difficulties, eating challenges, and physical discomfort.

Impact on Speech, Swallowing, and Oral Health

Assess how the tongue tie affects speech clarity, articulation, and other aspects of communication. Consider the impact on eating and swallowing, including any difficulties or discomfort during meals. Evaluate any oral health issues, like dental hygiene challenges or recurrent dental problems.

Response to Non-Surgical Therapies

If non-surgical treatments, such as myofunctional therapy or speech therapy have not led to significant improvement, surgery might be considered.

Personal Preference and Goals

 Align the decision with personal life goals and how the tongue tie affects achieving them.

Common Concerns About Tongue Tie Surgery

Common concerns and anxieties surrounding tongue tie surgery in adults often include

• Fear of Pain and Discomfort: Modern surgical techniques, especially laser surgery, tend to involve less pain and quicker recovery.
• Worry About Speech and Eating Post-Surgery: Discuss these concerns with healthcare providers to understand the realistic outcomes and recovery timeline.
• Anxiety About the Procedure Itself: Learning about the procedure, recovery process, and success rates can help alleviate fears.

Remember, the decision to undergo surgery should be made in collaboration with healthcare professionals, considering all individual factors and potential outcomes. For many, it can be a step towards significant improvement in function and quality of life.

Living with Tongue Tie

For people with tongue ties who choose not to undergo surgery, there are several coping strategies and modifications that can help manage the condition and improve daily functioning. These strategies focus on adapting to the tongue tie and mitigating its impact.

Compensatory Speech Techniques

• Work with a speech-language pathologist to learn techniques that can improve speech clarity and articulation, despite the tongue tie

• Practice specific exercises designed to enhance the strength and mobility of the tongue and other oral muscles

• Slow down speech and deliberately practice challenging sounds to improve pronunciation and reduce lisping or slurring

Oral Hygiene Modifications

• Adapt brushing and flossing techniques to ensure thorough cleaning, especially in hard-to-reach areas due to limited tongue movement
• Use tools like electric toothbrushes or water flossers, which can be more effective for people with restricted oral mobility
• Regular dental check-ups are important to monitor and manage any oral health issues related to the tongue tie

Dietary Adjustments

• Opt for softer, easier-to-chew foods if chewing is challenging
• Take smaller bites and chew slowly to facilitate easier swallowing
• Stay hydrated to aid in swallowing and maintain oral hygiene

Mindfulness and Relaxation Techniques

• To ease the stress in your shoulders, neck, and jaw muscles which can be made worse by tongue ties, try mindfulness or relaxation exercises
• Gentle stretching or yoga can help alleviate muscle strain related to compensatory movements

Lifestyle Modifications

• For those with speech-related professions or hobbies, consider adjustments that reduce vocal strain
• Engage in activities that do not heavily rely on precise tongue movements, reducing frustration and discomfort

Conclusion

It is important for people living with tongue tie to know that there are ways to manage the condition effectively, even without surgical intervention. Working closely with healthcare professionals like dentists and speech therapists can provide guidance and support in adapting these strategies to individual needs and lifestyles.

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