- The document discusses ankyloglossia (tongue-tie) and how it can affect breastfeeding and other areas of life. Statistics are provided on breastfeeding rates from 1972 to 2009. - Common myths and misconceptions about ankyloglossia held by medical professionals are outlined, such as the beliefs that tongue-ties correct themselves or do not impact speech. - Diagnostic criteria for ankyloglossia are proposed including anatomical appearance, functional ability, and symptoms in infants and mothers. A classification system is presented. - Potential relationships between ankyloglossia and other issues like sleep apnea, dental problems, and developmental delays are explored.

1. How ankyloglossia can
affect our lives
Lawrence Kotlow DDS
Board certified specialist in
Pediatric dentistry

2. The Surgeon General’s Report:2011
Lawrence Kotlow DDS

3. Statistics
1972 - 22 percent of US mothers breastfed their infants
1972=3,258,411 total births
716,850 breastfeed infants
2009 - breastfeeding report card from the CDC found that
74 percent of women start breastfeeding, 33 percent were
still exclusively breastfeeding at three months and 14
percent were still exclusively breastfeeding at six months.
2009=4,131,019 total births
3,057,000 breastfed infants
1,363,00 after 3 months
578,000 after 6 months
Lawrence Kotlow DDS

4. Many Myth(stakes) & Fairy
Myth(stakes)
Some times, we
either fail to see
the what is before
our eyes and is
obvious or we
see it and fail to
consider it.
A Myth is a fiction
something which is untrue.Lawrence Kotlow DDS

5. Diagnostic Myth-stakes that interfere with proper care
and treatment of newborns presenting with latch problems
Comments made to parents by pediatricians, ENT
physicians and dentists
★Tongue-ties will correct themselves.A tight lingual
frenum will stretch or tear without treatment.
★Tongue-ties do not exist.
★Ankyloglossia does not cause maternal discomfort.
★Ankyloglossia does not effect developing speech.

6. Diagnostic Myth-stakes that interfere with roper care and
treatment of newborns presenting with latch problems
Comments made to parents by pediatricians, ENT
physicians and dentists
★Tongue-ties will not effect nursing.(as recently as February
2012 the Medical Director of an Insurance company with 45 years experience as a pediatrician
told me “in his 45 years as a pediatrician he never saw one case where an infant was tongue tied
and it caused any breastfeeding problems !”
★Posterior tongue-ties do not exist.
★The upper lip is not important in breastfeeding.
★If you release the upper lip ,it will effect the roots of the
baby teeth.

7. Surgical revision Myth-stakes that interfere with proper
care and treatment of newborns presenting with latch
problems
Comments made to parents by pediatricians, ENT
physicians and dentists
★Revisions of tongue-ties are dangerous due to bleeding,
cutting nerves or blood vessels.
★You need to wait until the baby is at least 4 years old.
★Surgery requires the operating room and general anesthetics.
★Lasers do not work & are not safe for children.

8. Surgical revision Myth-stakes that interfere with proper
care and treatment of newborns presenting with latch
problems
Comments made to parents by pediatricians, ENT
physicians and dentists
★If you cut the upper lip it needs to be tacked down.
★Revising the upper lip causes “floppy lips”.
★The infant will pull out the stitches and not be able to
handle the healing time.
★The post surgical exercises are too difficult and stressful for
parents.

9. “I am in cahoots with the
lactation consultants”
Comments made to parents by pediatricians, ENT
physicians and dentists
★Inconsistent,inaccurate and conflicting information
passed to parents
★All of this creates barriers to inter-professional
collaboration
★Information passed on by these health care providers
is not based upon any real research or experiences

10. 10
*Medically necessary care (MNC) is the reasonable and
appropriate diagnostic, preventive, and treatment services
and follow-up care as determined by qualified, appropriate
health care providers in treating any condition, disease, injury,
or congenital or developmental malformation. MNC
includes all supportive health care services that, in the
judgment of the attending dentist, are necessary for the
provision of optimal quality therapeutic and preventive oral
care. *Academy of Pediatric Dentistry 2010
Medically necessary care
Lawrence Kotlow DDS Introduction to Lasers and Breastfeeding course

11. Why we need to be proactive in
assisting mothers breastfeed
Ankyloglossia
Lip-ties
“Sling shot” finger habits
Non-orthodontic pacifiers
Bottle-feeding
Malocclusions
High palates
Narrow dental arches
Receded chins
Sleep apnea
Bed wetting
ADHD,etc
Noisy breathing,snoring
High Blood pressure
Heart disease
Brian Palmer December 27,. 2011
The evolution of malocclusion and sleep apnea

12. Is the tongue a muscle, an
organ or
Maybe a yet unknow or
unnamed body system ?
• organ
a structural part of a system of the body that is
composed of tissues and cells that enable it to
perform a particular function
12

13. What exactly is our tongue ?
13
• The tongue consists of a
complex group of muscles
that gives it great mobility.
• Some important functions in
which the tongue is involved
include mastication, phonetic
articulation, swallowing,
taste.
• The tongue also serves as a
natural means of cleaning one's
teeth
• Its muscles are attached to
the mandible, the palate, the
hyoid bone and the styloid
frenum
Hyoid bone

14. Our tongue is more than a muscle,
it is also an “Organ”
14
1.The four paired extrinsic
muscles protrude, retract,
depress, and elevate the
tongue.
2.The four paired intrinsic
muscles
of the tongue originate and
insert within the tongue,
running along its length. These
muscles alter the
shape of the tongue by:
lengthening and shortening it,
curling and uncurling its apex
and edges, and flattening and

15. 15
What is a tongue-tie ?
Lawrence Kotlow DDS helping nursing mothers since 1974
As defined by the International Affiliation of Tongue-tie
Professionals (www.tongue-tie.net)
The Embryologic remnant of the tissue in the midline of the
undersurface of the tongue and the floor of the mouth.
An (abnormal) attachment of the membrane that fastens the
tongue to the floor of the mouth which may interfere with
the normal mobility and function of the tongue

16. What are the best criteria we can use to
diagnose ankyloglossia ?
16
Ankyloglossia can be
defined in three ways
Anatomic & clinical
appearance
Ability to function
Infant’s &
mother’s
symptoms
Lawrence Kotlow DDS Introduction to Lasers and Breastfeeding course
The most
important
diagnostic
criteria

17. 17
Classification of newborn abnormal lingual frenums:based
upon anatomic appearance
Type **I(4*) -total tip involvement
Type III (2) Distal to the
midline.The tongue:may
appear normal
Type -II (3) Midline-area under
tongue (creating a hump or
cupping of the tongue)
Type IV (I) Posterior area which
may not be obvious and only palpable,
Some are not visible if they are
submucosally located *Numbers in parenthesis =Dr.Kotlow
** Numbers outside parenthesis= LCLawrence Kotlow DDS Introduction to Lasers and Breastfeeding course
Tight guitar string
submucosal attachment
3.5
Classificazione del neonato linguale anomala frenums:basato sull'aspetto anatomico

18. 18
or should function ?
James G. Murphy, MD, FAAP, FABM
Assistant Prof of Pediatrics
F. Edward Hébert Medical School
USUHS Bethesda, Maryland
Total tie down resulting in
No up or down function
Cupping and hump
Unable to elevate and
touch the hard palate
Heart shape, pointed tip
Diagnosis based on
function or lack of
function
unable to extend tongue past
alveolar ridge
Lawrence Kotlow DDS Introduction to Lasers and Breastfeeding course

19. NORMAL RANGE
OF MOTION
CLASS 1
12-16 mm MILD
CLASS II 8-12 mm
MODERATE
CLASS III 4-8 mm
SEVERE
Kotlow classification of tongue-ties (1999)
CLASS IV 0-4 mm
COMPLETE 19

20. Diagnosing problems related to
an infant with ankyloglossia
(tongue-tied)
20
Preliminary initial evaluation
Just by running your finger under an infants tongue from
one side of the mouth the other side will give you an
indication if the tongue attachment is a problem.
Lawrence Kotlow DDS

21. 21
Interpreting your assessment-completed in the delivery room
James G. Murphy, MD, FAAP, FABM
Assistant Prof of Pediatrics
F. Edward Hébert Medical School
USUHS Bethesda, Maryland
Use your finger moving under the tongue across the floo
of the mouth.
A smooth mouth floor = No Problem
A small speed bump = Potential Problem
A large speed bump = Most likely will be a problem
A small, medium or large membrane = Definitely will
develop into a problem.!! ! ! ! !
If the membrane feels very thin and strong like fine wire,
push on it and look for tongue tip indentation and a slight
bow of the tongue tip.
Feel for problems !
A quick assessment to determine need for further evaluation
Lawrence Kotlow DDS Introduction to Lasers and Breastfeeding course

22. Examination of infants
The key to correctly examining an infant is
proper placement on you lap. Place his
face facing the mother.
Lawrence Kotlow DDS

23. 23
Identifying the submucosal posterior tongue tie
Lawrence Kotlow DDS

24. 24
“It is not just the tongue that allows for a
good latch-on the upper lip must have
adequate mobility to all the infant to
complete the latch.”
My theory and treatment concerns

25. 25
What is a Lip-tie ?
A remnant of the tissue in the midline of the upper lip and
the gum which holds the lip attached to the gum (gingiva) and
may interfere with the normal mobility and function of the upper
lip contributing to poor latch by the infant onto the breast and in
some cases when mothers elect to at-will breastfeed during the
night, without cleaning off the teeth after nursing, may contribute
to decay formation on the front surfaces of the upper teeth.
Lawrence Kotlow DDS
Helping mothers breastfed since 1974
Latch Difficulties Caries Formation

26. Class IV: inserts
into anterior papilla
Class III: Beginning to insert
into anterior papilla
Class II: inserting just above
or in between central incisorsClass I: normal
Kotlow Classification of maxillary
Lip-Tied attachments in children

27. Classifying Infant Lip-Ties
Class IV: inserts into anterior papilla
27
a

28. Class IV
Attachment just into the hard palate or
papilla area
28
Kotlow Infant and newborn Lip-Tie classifications
!
Class II
Attachment primarily into the gingival tissue
!
Class III:
Inserts just in front of anterior
papilla
Class I: No significant attachment
Lawrence Kotlow DDS

29. A simple surgical procedure
29
!
Erbium:YAG
!
Lawrence Kotlow DDS

30. Pediatric reflux-clicking-Aerophasia
30
The tongue is held down in the center of the tongue causing the posterior tongue to
hump up. The baby can not extend the tongue to remove it from the back of the
mouth therefore causing gagging. The gagging causes the baby to regurgitate. This
appears to be reflux. Release of the tongue may lead to elimination of gagging and
and thus eliminate reflux. In infants when the frenum has not been released,
suggested medical treatment may be to put the baby on medication. After a lingual
frenectomy is completed the reflux often goes away immediately especially with the
“posterior” tongue ties. if we wait until after the frenum is revised to treat the
infant using medication, the physician may not have to place the infant on
drugs.
a
Lawrence Kotlow DDS

31. Obstructive Sleep Apnea & its relationship to
tongue-ties
Usually found in
children from age 2-6
The most common cause -enlarged tonsils and
adenoids

32. Obstructive Sleep Apnea & its relationship to
tongue-ties
Ankyloglossia may be a contributing cause
Dr.Brian Palmer :”Anyone with a high arched palate,
narrow dental arches, overjet .... Is at high risk for sleep
apnea.

33. Ankyloglossia with deviation of the epiglottis and larynx
Ann otol rhinol laryngol 100:1991 Mukai et al Ankyloglossia & Dyspnea
In China The Frenectomy has been completed since 1050-BC
In japan, Suzuki & Katagili in 1989, noticed a pattern in infants
displaying ankyloglossia of mild dyspnea as well as deviation of the
epiglottis and larynx
The paper also discusses the relationship of ankyloglossia and SIDS

34. Problems which may occur with ankyloglossia
1.Incomplete examination of the tongue will result in
missing deviation of the tongue’s movements the degree
of mobility of the tongue may not reflect the real state of
the ankyloglossia
2. Displacement of the of the epiglottis and larynx
resulted in difficulties during breastfeeding with choking
resulting in a decrease in Oxygen saturation.
3.After revision of the lingual attachment position of
the epiglottis and larynx as well as choking
disappeared.

35. 4.Dyspnea was the result of increased upper airway resistance
caised by displacement and less abduction of the larynx as well
as decrease in activities of respiration.
5.Interesting observation : after treatment and increased
oxygen saturation the infant showed thicker hair (usually over
a two week period)
6. Signs and symptoms of hypoxia :dark foreheads, rounding of
the lips, yawning, inactivity, difficulty in gazing at objects, light
sleep , underdevelopment of the mandible and temporal
muscles, choking and reflux, behavioral abnormalities (adhd).

36. Infants with ankyloglossia & sleep apnea
★High arched palates
★Bubble palate
★narrow dental arches
★Orthodontic problems
★Dental Crossbites
★Overjet of the arches, relationship of the
upper and lower dental arches
★Stuffy noses due to silent reflux
★Attempts at mouth breathing
★Swallowing problems

37. Obstructive Sleep Apnea & its relationship to
tongue-ties
★Sleep apnea is defined as cession of airflow for more than
10 seconds
★Hypopnea: A sleep disorder, a hypopnea event considered
to be clinically significant when there is a 30% (or greater)
reduction in flow lasting for 10 seconds or longer and an
associated 4% (or greater) desaturation in the person's O2
levels, or if it results in arousal or fragmentation of sleep.
★During an obstructive hypopnea, in comparison to an
obstructive apnea, the airway is only partially closed. However,
this closure is still enough to cause a physiological effect (i.e.,
an oxygen desaturation and/or an increase in breathing effort
terminating in arousal).

38. ✴Snoring — loud snoring or noisy breathing during sleep.
✴Periods of not breathing — although the chest wall is
moving, no air or oxygen is moving through the nose or
mouth into the lungs. The duration of these periods is
variable and measured in seconds.
✴Mouth breathing — the passage to the nose may be
completely blocked by enlarged tonsils and adenoids leading
to the child only being able to breathe through his/her
mouth.
✴Restlessness during sleep — the frequent arousals lead to
restless sleeping or "tossing and turning" throughout the
night.
Common symptoms of obstructive sleep apnea.
Every child is different and symptoms may vary.

39. ✴Sleeping in odd positions — the child may arch his neck
backwards (hyperextend) in order to open the airway or sleep
sitting up.
✴Behavior problems or sleepiness — may include irritability,
crankiness, frustration, hyperactivity, and difficulty paying
attention. Reduced oxygen to the brain. ADHD ADD ?????
✴School problems — children may do poorly in school, even
being labeled as "slow" or "lazy."
✴Bed wetting — also known as nocturnal enuresis, although
there are many causes for bedwetting besides sleep apnea.
✴Frequent infections — may include a history of chronic
problems with tonsils, adenoids, and/or ear infections.
Common symptoms of obstructive sleep
apnea.

40. Blocked Airway
40
The airway becomes smaller, and the tonsils and adenoids block the airway,
making the flow of air more difficult and the work of breathing harder.

41. If left untreated, OSA can cause poor growth ("failure to thrive"), high blood
pressure, and heart problems. OSA can also affect behavior and cognition.
Therefore, it is important to get it evaluated early. In infants where the airway
is compromised the result may be reduced oxygen to the brain resulting in the
behavior concerns and brain growth

42. Case History (Holly Puckering) 9 year old male
★Family history of tongue-ties
★As an infant was unable to breastfeed
★Started solid foods at age 7 months, was unable to eat
solid foods without coughing, gagging. At pureed foods only
★Speech abnormalities: mild lisp,difficulties with “R”s
(wabbit not rabbit)
★Snoring,dry mouth,bad breath
★Tonsillectomy and adenoidectomy at age 7 years
★Difficulties beginning in school due to speech and snoring
at friend homes duing sleepovers.
Medical diagnosis by Physicians and Pediatrician
Airway disorder and obstructive sleep apnea

43. Case History (Holly Puckering) 9 year old male
Medical diagnosis by Physicians and Pediatrician
Airway disorder and obstructive sleep apnea
Oral examination reveals
★Undiagnosed Upper lip-tie and posterior tongue-tie
★Functional restrictions of the tongue
★Unable tp elevate tongue adequatey
★Unable to form a bowl with the tongue
★TMJ clicking and popping during range of motion
evaluation
★Tongue thrust
★Diadochokinetic rate impairment :(DDK) refers to an
assessment tool, used by speech-language pathologists, that
measures how quickly an individual can accurately produce a
series of rapid, alternating sounds.

44. Thank you......