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Breast feeding is recommended by WHO for the first 12 months of a baby’s life, but it can be heart-breakingly hard work for some mum’s and babies.  Tethering of the tissues in the mouth may affect baby’s ability to create a good seal and an effective suck when feeding, potentially causing tummy pain and reflux. Tongue, lip and buccal ties may also lead to trouble with chewing, swallowing and speech.

Kristie-Lee Anning is a local dentist with a masters degree in oral tissue revision. She shares with us the in’s and out’s of what this is all about and what can be done about it.

 

Dorte Bladt: I’ve got Kristie-Lee Anning with me today from Honeysuckle Dental and she’s going to talk to us about tongue-ties, and lip-ties and things like that. I’m so pleased you could be here. Thank you for joining us.

Kristie-Lee Anning: Thank you for having me.

Dorte Bladt: I’ve given people your name. Tell us a little bit about yourself.

Kristie-Lee Anning: I’m a general dentist and I’ve done some additional training in laser dentistry, so I did a Master’s of Laser Dentistry over in Slovenia. That’s given me the opportunity to have a bit of better understanding about tongue-ties and things like that, and the release and benefit of the release. But I’ve also got a nursing background before I did dentistry. That’s also piqued my interest in that area.

Dorte Bladt: We just spoke before about you potentially being a little bit hyperactive. You have definitely been. You have confirmed my suspicions. You’re crazy. So why taking a course in Slovenia?

Kristie-Lee Anning: Yeah. The academy over in Slovenia, the Laser & Health Academy, they produce the lasers that I use in my clinic and they’re one of the best lasers in the world. So the training academy that they have there is really comprehensive so that’s why I’ve done the travel over to Slovenia to do the training on site.

Dorte Bladt: Okay. Excellent. So tell us a little bit about… I think for many parents, there’s a lot of confusion about what the tongue-tie or lip stuff, what is it that you actually look for and work with?

Kristie-Lee Anning: Often, I get a lot of mums coming in with babies that are having challenged with their feeding patterns, sleeping patterns. Babies have not been able to breastfeed effectively and have had to go onto bottle feeding. And parents that are wanting to improve the feeding experience often reporting that their children or their babies have got reflux or colic, very unsettled sleeping.

So when they come in to see me, we’re doing an evaluation to see if those feeding patterns, if there’s a contributing factor from tongue-tie release or tongue-tie that might require some release or some intervention. But also checking the other tissues within the mouth, checking lip ties as well and buccal ties and just seeing what the movement or range of movement is of all of those oral tissues.

Dorte Bladt: So what I hear you say is that you’re doing quite a comprehensive assessment both of the symptom, if you wish, but also what may be the cause.

Kristie-Lee Anning: Yes.

Dorte Bladt: It’s not enough just to come in and say, okay, I lift my child’s or my baby’s tongue up and I can see that it’s tied and I want it done.

Kristie-Lee Anning: Yes. There are quite a number of factors that we’re evaluating. Everyone has a freedom attachment or that piece of tissue that’s under the tongue or under the lip that tethers the tongue in some way. It’s whether or not that tissue is restrictive and functionally limiting in feeding, food consumption for older toddlers as well, not just babies, speech development and other factors. So there has to be some limiting factors there that contribute to it in order for us to want to treat that.

Dorte Bladt: Right. Is there a way that parents can have a look in their baby’s mouth and say, “Oh, it looks like I should possibly see someone about this”?

Kristie-Lee Anning: Yes. Some parents will come in and say, “Look, I can definitely see they’ve got tissue under their tongue that’s going all the way to the tip of the tongue and I’ve got a family history and my other kids have had a release and I think my child needs a release as well.” That’s often why they come in.

Sometimes they just don’t know what they’re looking for, which is understandable. You have to have a trained eye as to know what to check for and others just say, “I just want to get it checked”. That’s perfectly fine as well.

Dorte Bladt: So do you work with lactation consultants and people like that?

Kristie-Lee Anning: Yeah. We have a really good network where we work, liaise with lactation consultants, people like yourself as well, where we refer off for body work or myofascial work as well. So it’s not just limited to the release. There are other aspects that we need to consider in that treatment.

Dorte Bladt: As in retraining after not having function properly.

Kristie-Lee Anning: Yeah, absolutely. As you know, if the tissue is restricted there, any muscle or any other tissue in the body, if it’s not being able to be used effectively, you then have to train it how to work properly or how to do something properly. That’s the same with the tongue.

Dorte Bladt: Someone told me that the tongue, is it the strongest muscle in the body?

Kristie-Lee Anning: Yeah.

Dorte Bladt: The one that works the most.

Kristie-Lee Anning: Yeah. That’s quite a group of muscles that all work together so it’s a very strong muscle.

Dorte Bladt: It’s pretty cool. So you mentioned buccal ties. That’s not something that is spoken so much about. Do you want to explain what that is?

Kristie-Lee Anning: Yes. It’s one of the least treated tie in the mouth. It doesn’t tend to affect as many people. But when we’re doing oral assessment, we’re checking for all of the different tissue types and anatomy there and seeing whether or not there might be some restrictions in the movement of the lips as well as the tongue or the cheeks. That’s just one of the assessment areas.

We tend to find buccal ties affect more so people who are a little bit older and they’ve got the eruption of their teeth and they might have some recession to the gum as a result of really tight ties around their cheeks. So they have functioning and they’ve got good muscle strength there but then, with that, there’s actually pulling on the gums. Sometimes we might release that when they’re a little bit older if needed as well.

Dorte Bladt: Right. Does buccal tie affect breastfeeding?

Kristie-Lee Anning: It can. It’s like any tissue. If it’s restricted and it’s limiting movement, it can affect it. So wanting to get all that muscle working nice and freely, and if that’s one of the ties that’s restricting that then, yeah, definitely.

Dorte Bladt: That’s excellent. What are your thoughts on this epidemic in tongue ties as it seems like some people they’re referring to it like that? Do you feel that there are an increasing number of ties or is it more that we’re more aware of them? What’s happening?

Kristie-Lee Anning: I think there’s a change in the education about ties. Historically, ties were treated back in the 1800s as well through conventional methods of using scissors or a scalpel. As the education has changed, we’re seeing kids coming through… like everyone can compensate to a point so it’s just trying to enable everyone to function to their best ability.

And now with the development of laser technology as well, those procedures can be performed a lot safer than what they historically have been able to be performed. So they’re more prevalent in terms of treatment not necessarily in incidence.

Dorte Bladt: Right. So tell me what the difference is in… obviously, I know that what the difference is between the scalpel and a pair of scissors and a laser. That’s easy. But what sort of difference is there in outcome from the different way of approaching a tie?

Kristie-Lee Anning: With the release of a laser, I’m speaking from experience, I am finding that patients’ recovery time is a lot better because the tissue that we’re actually releasing there, it’s a very superficial layer. We’re only releasing the tissue that we need to get adequate movement. But the laser works really effectively at creating a nice little fibre layer over the top, almost like a body self-made bandaid. It’s really protective and nourishing of the tissue so you get a good clot forming over there and a good healing area as well.

And the laser in the treatment of it, you’re finding we’re not needing to use local anaesthetics to treat it, so you don’t have that downtime immediately after. There’s that reduced pain stimulation after as well. So I’m finding lasers to be a very effective tool.

Dorte Bladt: So what is it in the laser that makes that protective bandaid, for lack of a better word?

Kristie-Lee Anning: There are a couple of different types of lasers and the laser that I use is an erbium YAG laser. It’s actually a cold laser. It’s not producing a heat response, which means that you’re not getting that pain response that you would get with other lasers such as a diode. That’s why we prefer to use that one.

And in the creation of that cutting and sealing the tissue as well to a point that your body is producing that smear layer over the top as it’s called.

Dorte Bladt: I thought that was because of the heat, but it’s not.

Kristie-Lee Anning: No. This one is an ablation laser but it’s a cold laser.

Dorte Bladt: Okay. And what is the healing, recovery time after having had a procedure done? Let’s just say, in an average, six-week old.

Kristie-Lee Anning: As you said, it does vary depending on the age and the severity of the tie previous. But generally you’ll find you’ll get good closure of that wound within five days or so. You’ll see good changes in the tissue health and changes in closure within five days or so. Within two weeks we’re developing good muscle tone to the area with exercises that we prescribe as well. And then after about four weeks we’re seeing a big change to feeding patterns by movement of the tongue.

Dorte Bladt: So when you have just had it done, would you expect… let’s just stick to the six-week-old baby and let’s say they’re breastfed. Would they be able to feed straightaway?

Kristie-Lee Anning: Yes. Immediately after the procedure, I get all mothers to feed their babies whether it be breastfed, bottle-fed. Some parents will report an immediate improvement and I see that quite often. Generally, you’ll notice less clicking when they’re feeding, a better, deeper latch, less milk dribbling out, less regurgitation, reduction in reflux symptoms and a longer feed as well.

So often parents will say they’re feeding for very short periods, arching their back, uncomfortable, reattaching frequently, and then they’ll have to take them off and then try again. This is a pattern that they form. Over that time, they’re very unsettled but, often, I will witness immediately after, extended feeding and no challenges.

Dorte Bladt: So the baby is comfortable on the breast, comfortable feeding and probably not fatiguing as much.

Kristie-Lee Anning: Exactly.

Dorte Bladt: Because it’s hard work, feeding.

Kristie-Lee Anning: It’s exhausting.

Dorte Bladt: They may not think so. And what about that whole risk of reattachment that seems to be the biggest fear for parents?

Kristie-Lee Anning: Yes. With the laser, the other fantastic thing is, because we’re really cutting and sealing that tissue to a point, the reattachment rates are a lot lower than what it would be from a conventional scissor release or a scalpel release. We’re not needing to place any stitches or sutures there, so that’s fantastic as well.

But it is really important that these parents are doing exercises with their babies, and we prescribe those to get the tissue moving and to reduce the likelihood of reattachment. So it doesn’t matter what procedure you do. There is going to be some risk there, and we’re minimizing that through exercises.

Dorte Bladt: Okay. You can’t really show us what are the exercises, but what do parents have to do to make sure that the reattachment doesn’t happen?

Kristie-Lee Anning: Usually, I’ll get the parents, which I show them at the time, but we get parents to basically have their child on their lap with their head closest to them so they can get a good look at the tissues. And when lifting the tongue up towards the roof of the mouth and pushing it towards the back of the mouth as well, just getting it out…

Dorte Bladt: So stretching the whole basically.

Kristie-Lee Anning: Yes, getting the full range of movement. And running fingers along the ridge as well, getting the tongue to chase that.

Dorte Bladt: As in the bridge of the mouth or the gums?

Kristie-Lee Anning: Yes, the gums. And with the top, we’re getting that lifting all the way up again toward the nose so we can see that lip flanging all the way up. And it’s really just moving the tissue within its normal range of movement now that it’s been released.

Dorte Bladt: Yes. That one they can actually do it. So you mentioned that although you said toddlers and other children could have issues as well, what would be a symptom, maybe, that you would expect or suspect that there’s a lip tie or tongue tie within an older child?

Kristie-Lee Anning: Often I’ll see kids coming in with challenges with feeding. They might have had some choking episodes over time or trouble with clearing food from the roof of their mouth. They tend to pack food in the pockets and they have challenges with their brushing and cleaning of their teeth.

Dorte Bladt: Pockets of their mouth rather than the pockets of their clothes.

Kristie-Lee Anning: That’s exactly right.

Dorte Bladt: My son used to put food in his pockets as in on his pants.

Kristie-Lee Anning: Yes. Often you’ll find food in their cheeks and around the gums as well.

And not wanting to brush their teeth, so parents often are chasing their kids around the house. Because if they’ve got a tie there, sometimes that toothbrush can be a little bit uncomfortable to try and get in around those more difficult to reach places so kids just don’t want to do it at all.

Dorte Bladt: What about speech? What would be a speech pattern of someone with a tongue tie? If there is one, I don’t know.

Kristie-Lee Anning: Yeah. I do tend to find that kids have challenges with saying ‘L’ sounds, ‘S’ sounds if they’ve got a tether there. They do compensate extremely well. So if I think that there’s a speech challenge there, I’ll send them off to a speech pathologist and get them to have a good look and do an assessment for me. And I’ll do the examination within the mouth and just see whether there is some other restrictive movement of the tongue.

But we’re also looking at the shape of the palate as well. Often, in a kid that’s got a tongue tie, you’ll find that their palate has got a really high vault. They don’t have that flattened, broad palate that you would see in someone whose tongue rests in a normal position.

Dorte Bladt: And why is that?

Kristie-Lee Anning: When the tongue is restricted, it tends to lie on the floor of the mouth and so as we grow, we’re reliant on the tongue being such an important muscle and quite a strong muscle to actually help the movement and growth of the bones and associated structures as well.

Dorte Bladt: So basically, what you’re saying is if the tongue is not putting pressure at the roof of the mouth, you’re not getting the expansion of the top jaw to the extent, it just narrows up and gets quite…

Kristie-Lee Anning: That’s right.

Dorte Bladt: Okay. Does that affect sinus issues potentially?

Kristie-Lee Anning: It can affect sinus issues as well. The maxillary sinus sits right above that structure so that can change the pattern in which that forms. And also we can find, if the tongue is not moving and sitting in the appropriate areas when you’re feeding or drinking, you can get some of that fluid running up or regurgitation up into the sinus area, especially in babies. That can certainly give them some sinusitis or chronic infection of that area as well.

Dorte Bladt: That doesn’t sound very good. So with regards to the adult, is this something that may have gone unnoticed until they get a little bit older?

Kristie-Lee Anning: Yes, absolutely. Often, some parents will come in with a newborn they’re having trouble feeding and then they’ll say, “Oh, my parents said that I had the same problems when I was a kid.” And you might look in their mouth and see that they also have a tongue tie.

And they’ve compensated extremely well over the course of their life but they might report that they’ve got constant headaches or they tend to posture forward and they get backaches, shoulder aches. These things can all be related to a tongue tie as well.

So sometimes we’re diagnosing later in life but still getting a very good treatment outcome from working with releasing that as well as doing some body work with them.

Dorte Bladt: I guess I’m wondering if your tongue is tied, you were saying that toddlers end up with food in the pockets of their cheeks and whatever. I imagine that an adult would often have…

Kristie-Lee Anning: The same.

Dorte Bladt: Yeah, or tooth health issues because they can’t clean even if it’s just without necessarily brushing their teeth but you’re cleaning your teeth with your tongue.

Kristie-Lee Anning: Absolutely. So you can find that there’s increased rate of carries, or decays as it might be known. And the positioning of the bite patterns as well, that can also have structural implications to the joint in the jaw.

Dorte Bladt: Can you just repeat that for me? The position of the what?

Kristie-Lee Anning: Of the jaws themselves. So the teeth position can be altered by having some tethered tissues. As a result, that can impact on just the overall structures or relationship to the jaw in the mouth.

Dorte Bladt: So if you have like a lip tie, it might keep the front teeth further apart? Is that what you’re saying?

Kristie-Lee Anning: You can have a lip tie where your teeth at the top, the two front teeth, the centrals can have a gap between them and that can be associated with a lip tie. But also in terms of growth of the mandible or the lower jaw or in the maxilla, the top jaw, you can have discrepancies there. And so the relationship between the top jaw and the bottom jaw can be altered too.

Dorte Bladt: Okay. That doesn’t sound like that would be very good. So how long have you been doing this sort of work?

Kristie-Lee Anning: I’ve been a dentist for five years, but prior to that, as I was saying, I was doing my nursing.

In terms of the laser releases, I’ve been doing this since I’ve basically started working as a dentist. The last three years I’ve really done a lot more training in that area.

But prior to that when I was a nurse as well, I was fortunately getting to go around doing home visits and working with babies and things, doing lactations consultations so that’s certainly helped with this field as well.

Dorte Bladt: So you know a little bit about everything from all angles. That’s very useful. And do you have a favourite type of work that you think, oh, I have a day full of this? What’s your bliss day at work?

Kristie-Lee Anning: Oh, gosh, it varies so much. I really love to see new patients and making treatment plans with them and deciding how we’re going to go about it. But restorative work with the laser, I love doing that. So reconstructing patients’ smiles but also working with kids. I love working with the kids. They’re always good fun. They prove to be a challenge sometimes but they’re good fun.

Dorte Bladt: I could imagine that some of them might not want to sit in your chair for a long time.

Kristie-Lee Anning: Absolutely.

Dorte Bladt: So what do you do actually if you have… so probably be a one-year-old. Let’s talk about someone with teeth. How the heck do you get in there?

Kristie-Lee Anning: Sometimes we have to go back to the basics and just sitting in mom’s lap or dad’s lap, toothbrush in hand and just look at counting teeth and brushing teeth and just get a good look that way draws interest.

Sometimes on the first visit, we might not be able to have a look at anything at all. It’s just getting to know that child and that child understanding who we are and what we do, and make a bit of a game of it. And then as we continue to see them over the course of their life, they become more and more familiar with us.

Dorte Bladt: So what if they have a tie though? Can you assess it?

Kristie-Lee Anning: Often, we’ll be able to assess it and we’ll be able to get a bit of a look there. We may need a number of appointments to do a really comprehensive assessment. In terms of releasing it, if it needs to be released, then we evaluate that tie once we’ve built up some rapport.

I’ve got a little boy at the moment who I’ve been seeing since he was around about eight months or so. Didn’t want me anywhere near him at eight months. He’s now 13 months, we’ll say, and loves coming in. He gets excited, jumps in the chair. And we’ve had a chat to him about what we’re going to do. You wouldn’t think at 13 months that they would understand, really, but he’s nodding, you know.

And we’ve been able to do quite a bit of other treatment with him and he’s been fantastic. So the next step when we get to it should be interesting again, but it should be good.

Dorte Bladt: Well, I suppose one step at a time.

Kristie-Lee Anning: Yes, that’s right. And sort of throwing this at you and you may or may not be able to do this but can you think of an episode or a work person that you’ve cared for that has been particularly funny or weird?

Kristie-Lee Anning: I’ve had all sorts of wonderful people in my chair. There’s one patient in particular that I can think of that when she first came in was absolutely refusing to have any treatment. She’d go, “Are we done yet?”

“No, I haven’t even looked in your mouth yet.”

But, over time, we’ve got into a bit of a game of everything and so we might have 10 minutes where she’d go, “Okay, there’s your 10 minutes. You’re done now.”

And now she’ll come in just to have a chat.

Dorte Bladt: Okay. She’s a little one or an adult?

Kristie-Lee Anning: She’s an adult, an out-patient.

Dorte Bladt: Right. Just come in for a little chat.

Kristie-Lee Anning: So she’ll come in for a little chat. She’d go like, “Okay, I guess you can look at my teeth.” She’s always a bit of fun.

Dorte Bladt: Well, it’s better that way than the other way because usually you’ve got 16 instruments in your mouth and the dentist says, “So, how’s your holiday?”

Kristie-Lee Anning: Oh, yeah. I do that too, sometimes. I have to think.

Dorte Bladt: So do you have any advice? This is for the people that we care for at this practice, I suppose. Do you any advice for moms of young babies what to maybe look out for and be aware of?

Kristie-Lee Anning: Sure. Often, moms will come to me and they’ll say, “I’ve seen lactation consultants, I’ve seen lots of other midwives and paediatric specialists and they’ve all said to me, ‘Oh, no, no. It’s fine’.”

But they have an overwhelming sense that something is not quite right with their feeding. They’re noticing that they’ve got clicking when they’re trying to get a good latch. It’s painful for them to feed if they’re still breastfeeding, or sometimes they haven’t been able to successfully breastfeed and they’ve had to transfer to bottle feeds. And they’re spilling milk, the baby’s unsettled.

If you really feel like something is going on, don’t be afraid to go and get another opinion. There’s never any harm in getting another opinion. So go ahead and do that.

When you do see the clinician that you’re seeing, just ask them how do they do a release if one is indicated. Do they use a laser? What type of laser are they using? Is it a cold laser, like the erbium YAG laser that we use, or is it conventional scissors? And then looking at different outcomes for that patient based on what they need.

So ask lots of questions, basically.

Dorte Bladt: Okay. That’s excellent advice. I think it’s one of those things with mothers often know best.

Kristie-Lee Anning: That’s right.

Dorte Bladt: Even though we might look in there or might care for them a certain way, and say, “No, no, no. You’re fine.” But if you’re not fine, you’re not fine.

Kristie-Lee Anning: Yes. If you have an overwhelming sense of something is not right, you’re probably right.

Dorte Bladt: Yes. How can people contact you? Where can they find you?

Kristie-Lee Anning: I’m based at Honeysuckle Dental in Newcastle. So you can ring our surgery and we’re more than happy to make an appointment there and do a consult for you.

Dorte Bladt: Okay. And your name?

Kristie-Lee Anning: I’m Kristie-Lee Anning, a general dentist.

Dorte Bladt: At Honeysuckle.

Kristie-Lee Anning: At Honeysuckle Dental, yes.

Dorte Bladt: Thank you so much for your time.