In older babies, children and adults with a tongue tie, compensatory oral habits may be present. During pregnancy, a baby swallows amniotic fluid with a tongue tie, which means that hiccups may already be present. An older child and adults have exhibited compensatory behaviors for years as surrounding muscles and tissues compensate for the limited functional movement of the tongue. Think of moving food in the mouth from side to side, swallowing well without choking, wiping your teeth after eating and talking. Often the patient swallows with his tongue forward instead up and back, which is called a tongue thrust. This can affect the position of the teeth, jaws and the overall body posture.

The preparation for a treatment is therefore twofold:

1. Compensatory movements in the head and neck region can be quite “stuck” and therefore better checked and treated by a special therapist before a tongue tie release. We hear from patients that they have this done by a physiotherapist, manual therapist, orofacial therapist, chiropractor or osteopath for complaints such as incorrect posture, stiff neck, jaw clenching, grinding and headaches. Treating a tongue tie alone is not sufficient if the surrounding muscles keep the compensating behaviour and restrict functional movements.

2. Treatment also improves if the patient goes to a specialized speech therapist in OMT (oromyofunctional therapy) before and after the treatment. This can help to analyze incorrect oral habits and swallowing and train or unlearn these. If an OMT speech therapist is not available, the Kieferfreund app is an option to train and practice (see www.kieferfreund.com and https://www.tonguetieclinic.com/tongue-tie-therapy/https://www.tonguetieclinic.com/tongue-tie-therapy/)

Providers use a classification system to describe the tongue tie. This system only indicates where the tie is attached between the floor of the mouth and tongue. Providers usually use four classifications of Coryllos  or Kotlow, (see pictures below).

Type 1:

The anterior tie is easy to see when the baby cries or tries to lift up the tongue. It can also be felt with your finger under the tongue. It is attached all the way to the tip of the tongue. Very often it makes a heart-shaped tongue when the baby cries or tries to move it.

Type 2:

The anterior tie is a little further from the tip of the tongue. It is also felt like a guitar string or easily seen when the baby cries or tries to lift the tongue. The tongue stays low in the mouth when the baby cries or tries to move the tongue, very often you see a bowl- shaped tongue when crying (only the edges move up).

Type 3:

The posterior tie is further away from the tip and can be made visible by using a special tool, the groove director, or by using your two index fingers that push back the mucous in the direction of the throat and lift up the tongue simultaneously. The tongue stays low in the mouth when the baby cries, tries to move the tongue, or shows indentation or creases, very often you see a bowl shaped tongue when crying (only the edges move up). With your finger you can feel a “speedbump” or guitar string further back.

Type 4:

The posterior tie is not visible, but “hidden” behind the mucous. It can only be shown with the groove director or with two index fingers that back push the mucous in the direction of the throat and lift up the tongue simultaneously. The tongue stays low in the mouth when the baby cries or tries to move the tongue, or shows indentation or creases, very often you see a bowl shaped tongue when crying (only the edges move up). With your finger you can feel a “speedbump” or guitar string further back.

To get an optimal result after a tongue tie release you can do these exercises at the speech pathologist who is specialized in OMT or OMFT. It is best to exercise before and after the release. Older children and adults work on improving tongue movement, tongue rest posture, mouth breathing, lip seal and swallowing properly.  It is best to start one or two weeks before the release. It is also advisable to see a manual therapist beforehand to release any tension from compensating mechanisms build up over the years of living with a tongue tie.

There’s a list of speech pathologists (logopedisten) who are specialised in OMFT in The Netherlands who can help you or your child to improve your tongue function.

Here we have some videos of excellent providers from around the world.

Dr. Rishita Jaju and Smile Wonders staff in Reston, VA show you what post-Waterlaser Frenectomy exercises will work for your little ones.
Tongue Release Therapy Days 1-14 OMT of Stanley Dentistry
Tongue Release Therapy Days 15-21 OMT of Stanley Dentistry
The Four Goals of Myofunctional Therapy by Sarah Hornsby RDH, BS.
Carol Vander Stoep of Mouth Matters OMFT indications for problems and tongue tie.

With bottle feeding, the baby may have trouble drinking the bottle completely because it is not possible to make a good seal with the lips and create negative pressure with the tongue. Other symptoms may include: “playing” with the bottle, clicking sounds, consuming a lot of air, colic, spitting, burping and reflux may play a role. Drink the bottle very slowly or not completely empty. Less than average growth can also sometimes be a reason.

Often only the tongue tie is acknowledged to be important in feeding the baby and the lip tie is dismissed.

The importance of the upper lip flanging out while deeply latching on to the breast or bottle ensures a better seal of the oral cavity. Several studies with ultra sound images show a good movement of the tongue while breastfeeding. The normal tongue movement while breastfeeding is best achieved when the baby can open the mouth wide. This wide opening is best achieved when the baby is able to curl the upper lip, so that the mucous membrane portion of the lip (instead of the dry outer part) is in contact with the breast. This provides a better seal, which is the first step in generating negative pressure in the mouth while breastfeeding. This also applies to the bottle. When a lip tie is anchored to the upper jaw, the outward curling movement is impeded. This results in a smaller mouth opening and forces the baby to take a shallow latch and gives a poor seal while breastfeeding or bottle feeding.

Depending on the size and spread over the jaws, there are two options:

Pearl of Epstein:

These are small thickened inclusion cysts on the palate, but can also occur on the gums or palate. Usually seen as multiple, white, rice grain large elevations in the vestibular (lying against the cheek) mucous membrane of the upper jaw (alveolaris processus). They are small cavities filled with fluid, (cystic nodule) covered by a thin epithelium (layer of skin) and filled with keratin (a type of protein).

The Epstein pearls are completely harmless, do not hurt, do not need to be treated and disappear spontaneously. Treatment is therefore not necessary.

“Bohn’s” nodules (hard bumps):

These are white-like bumps spread over the entire upper and / or lower jaw (see photos). The exact aetiology is unknown, but it is suspected that they arise as a remnant of the dental lamina or of heterotrophic salivary glands. They can be present over the entire lower or upper jaw or on the palate (palate). These hard bumps are benign and disappear over time. Treatment is therefore not necessary.

Sometimes other normal anatomical structures are being noticed. It often concerns bulges or ridge on the floor of the mouth and they have nothing to do with the tongue tie.

There is a lot of discussion about determine and treating the types of tongue tie and / or lip ties. Sometimes there is no clear membrane visible under the tongue and parents are sent home by the doctor without treatment, while a “hidden” tongue tie is the cause of feeding problems. Therefore, the classification does not determine the severity of the feeding problem, it only determines the degree of attachment.

The classification that is generally used is Kotlow his classification of the lip tie (1 to 4) and Coryllos her classification of the tongue tie (1 to 4) (see frequently asked questions what does a liptie or a tongue tie look like).

Tongue tie:

• Heart-shaped tongue;
• Indetation in the middle
• During crying a low tongue position with sometimes a dent or a bowl shape;
• White debris from halfway the tongue to the back

Liptie:

• Suction blister upper lip in babies;
• Bloodless and red/ white line under nose when drinking babies; (see photo)
• Blanching attachment of tie on the edge of the upper jaw (see photo);
• A diastema when teeth come through

• Signs of restricted mobility of the muscles of the tongue and the upper lip:

Due to the tie the tongue can only move the front and sides a bit. The tongue cannot go up and back properly, difficulty latching on, drawing in the nipple deep. While very often at the same time the upper lip cannot flange out over the breast, because the tie pulls it inward. So the baby slides off easily. Resulting in small latch, letting go of nipple. Latching on and drinking difficult or only works with a nipple shield or bottle. Falling asleep at the breast or bottle, frustrated, doesn’t seem to want to drink, doesn’t empty the bottle.

• Signs of compensating due to restricted mobility of the tongue and lip tie:

Tries to hold on to the breast by clenching jaws together. Uses cheek muscles to draw milk. Mother experiencing pain especially at latching on. But not always painful, also just sucking really “hard” or “strong”. Chin quivers from jaw muscles tension. Sucking blisters on lips from friction. This compensating is weary for the baby and especially in compromised growth or premature babies it’s a shame it costs energy. Sometimes babies are called lazy drinkers.

Nipple should come out round, but comes out flattened, with blisters, discoloured and sore. “Raynaud” like symptoms from diminished blood flow to nipple.

• Signs of compromised ability to get sufficient milk:

Due to the baby’s restricted mobility, only suckles at the nipple and hardly at any breast tissue. There is too little milktransfer as a result. The baby draws in the nipple as if sucking in spaghetti, hangs on nipple like a “cliffhanger”, often pulling and moving the head in an attempt to pull out the milk, sometimes using hands to pull the breast in older baby’s, drinking suddenly painful when teeth come.

Baby doesn’t “empty” the breast (or bottle), drinks often to get enough milk. Plugged ducts, overproduction from drinking often, compromised production in the end.

Baby loses weight more than 7% in the first days, getting back to birth weight takes more than 10 days. Growth stagnates after weeks or months when production decreases. Babies don’t always show; they save energy by sleeping long for example. A sign could be very few poop diapers.

Baby only drinks the “easy” milk, during the milk ejection reflex.  Drinks short or very long. Only making the chin tug and drinking when MER or giving breast compression or supplementing at the breast.

• Signs of compromised possibility of making a good seal:

Due to the low tongue position, often high palate and the upper lip not flanging out completely over the nipple, bottle or breast, your baby cannot make a good seal and loses suction, you can hear clicking sounds. Also very loud drinking, gulping it down and choking. Complaints of swallowing air.
The swallowed air needs to go somewhere; it goes up or down. Burping, hiccough, spitting, windy, colic.  GER or reflux with or without spitting (hidden reflux). In hidden reflux the baby tries to keep the milk down by swallowing again, sometimes forgetting to breath momentarily. During feeding it can be very uncomfortable for the baby and can become restless.  It’s difficult to put the baby down to sleep. Parents walk with their baby until symptoms subside. The baby can experience pain from the stomach acid in the oesophagus. GERD. Sometimes medication is given which lowers stomach acid.

Thrush is often confused with tongue tie problems. Although you can see it both at the same time. The tongue may have debris in the papilla (from day of birth) due to the fact that the tongue hardly touches the palate so it doesn’t “rub clean”. Pinching and stabbing pain can be from thrush or compensating behaviour from tongue and lip tie. In tongue tie you can see white debris on the posterior part of the tongue behind the tongue tie, the front of the tongue rubs clean against the inside of the upper maxilla. Thrush is a “pearl white” shine or white plaques on the inside of the lips and on the mucous membranes of the inside of the mouth.

*Note that not all symptoms have to be present at the same time.

Providers use a classification system to describe the attachment or the lip tie. This system only indicates where the frenulum (tie) is attached between the lip and the upper jaw. Providers usually refer to four types or lip tie due to the Kotlow classification. (pictures below).
This system does not indicate the severity.
A class 1 lip tie is quite rare (no restriction in attachment).

A class 2 lip tie adheres to the gums somewhere in the middle above the gum line.

Type 3 can be a very flexible frenulum with no symptoms while a very tight frenulum (type 2) can give a whole range of symptoms.

Type 4 is therefore not any “worse” than type 2.

Although a tight type 4 obviously gives even less movement of the lip and can affect the ability of the lip to flange and hold on to the breast or bottle.
Babies and children manage to compensate really well with their jaw muscles and people can grow old with a lip tie often with hardly any symptoms.
Sometimes the upper lip tie creates a gap between the front teeth, but that is not always easy to predict exactly.
Brushing the front teeth can be difficult and painful with a tie “in the way”.
With debris stuck under a lip tie, caries may occur earlier in the upper front teeth. To determine if there is an impairment of the flange of the lip onto the breast a Lactation Consultant (IBCLC) can observe the breastfeeding. The Lactation Consultant lifts up the upper lip to see if it flanges out.
If there is blanching on the gum, there is tension. The tension may result in too little movement of the lips and ability to flange out and to open the mouth wide.

During the consultation, the dentist or doctor examines whether there is a tongue tie and / or lip tie present and whether the problems could be related to this. She then explains what this means and gives advice about a possible treatment. If desirable, a release can take place in the same appointment. The health record and the intake form will first be discussed before a release is performed. Depending on age, superficial anaesthesia is applied with a cotton swab or local anaesthesia with a syringe and needle. Depending on the age, instruction of aftercare and exercises take place before the actual release itself. After the release for baby’s, a Lactation Consultant IBCLC assists with bottle or breast feeding and helps you to get on your way home, after the wound has been checked. There is too little time for a complete consultation of the Lactation Consultant IBCLC. The focus of the actual appointment is on consulstation and/or treatment.

Even though a baby grows well, several complaints can be experienced by both the mother and the baby. See FAQ: signs and symptoms of tongue and lip tie 

Frequent plugged ducts and mastitis, pain and discomfort can be a reason for the mother. In babies it is possible that a lot of air is swallowed in, sometimes gastroesophageal reflux disease is present, cramps and colic, the high frequency of drinking and often restlessness during feeding can also a be the reason for the tongue tie and/or lip tie to be treated.

In the long run, babies and children may have difficulty with eating solids, speech and overall mouth development (for example, the shape of the jaws and how the teeth are aligned). However, it is not possible to say with certainty whether a baby or child will actually have long term consequences of the tongue tie or lip tie.

In addition to the aforementioned checklist of signs and symptoms (see FAQ checklist complaints), an assessment at the Tongue Tie Clinic of tongue tie and lip tie in breastfeeding or bottle-feeding can be useful. An assessment can rule out whether the ties are the most likely cause of the complaints. The reasons to have an assessment can be very different and not all complaints described need to be present at the same time. In case of doubt, one can contact the the Tongue Tie Clinic. A short list of complaints and a video or photo of the tongue tie and lip tie does not provide a definitive answer, but can always be mailed to the following address: info@tongriem.com. When making the video or photo, take care of a good posture of yourself and the baby (link). Good light is important. One person lifts the tongue and then the lip and the other makes photos or video. A photo / short video when the baby cries for a moment is also helpful to check the possibility of restricted tongue movement.

The midwife, lactation consultant, maternity care nurse or speech therapist, may have told you about the possible functional problems in babies and children due to a tongue tie or a lip tie. The knowledge is also shared among parents through the internet.

A tongue tie is not always easy to see, especially if it is deeper under the tongue. Not every doctor, midwife, lactation consultant IBCLC or maternity care nurse has enough experience to assess this properly. It is wise to find a practitioner with experience in this area. A lactation consultant IBCLC who has experience in assessing the tongue tie and lip tie may be able to assess it.  After doing an oral examination she may even find the tie “hidden” behind the oral mucosa. When in doubt, make an appointment with a lactation consultant or a practitioner with experience. Sending a photo is possible for review, but can never provide a definite answer.

Pediatrician Dr. James Murphy (link) came up with the following method. When the finger slides under the tongue, it should be easy and smooth. If it is difficult to move from left to right under the tongue over the floor of the mouth and a “string”, “speed bump” or “fence” is felt, this may indicate a tongue tie.

When the baby is crying, and the tongue stays down, it could be caused by a tongue tie actually pulling the tongue down. Sometimes only the sides of the tongue rise so that the tongue makes a bowl shape.

The upper lip should be able to flange relatively easily. If the lip is lifted and gently pulled, and the upper jaw turns bloodless where the lip tie is attached, that may be an indication of a lip tie. This test is also called “blanching” or anaemia test (see photo).

In the Netherlands children up to 18 years are insured for dental care. The applicable dental rates that are calculated are determined by the Dutch Healthcare Authority. Prices 2024

When you have a Dutch insurance, the consultation or treatment is directly invoiced to the health insurance. You do not have to pay in advance. If you do not have Dutch health insurance, you pay after the consultation. You receive a letter for the insurance which explains about the treatment and costs, so you may can get it reimbursed.

For the costs of a consultation or treatment of therapists other than dentists, you should contact the relevant practitioner.