How ankyloglossia can affect our lives

Lawrence Kotlow DDSBoard certified specialist in

Pediatric dentistry

The Surgeon General’s Report:2011

Lawrence Kotlow DDS

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 monthsLawrence Kotlow DDS

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

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.

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.

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.

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.

“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

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*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

Why we need to be proactive in assisting mothers breastfeed

AnkyloglossiaLip-ties“Sling shot” finger habitsNon-orthodontic pacifiersBottle-feeding

Malocclusions High palates Narrow dental arches Receded chins

Sleep apneaBed wettingADHD,etcNoisy breathing,snoringHigh Blood pressureHeart disease

Brian Palmer December 27,. 2011 The evolution of malocclusion and sleep apnea

Is the tongue a muscle, an organ or

Maybe a yet unknow or unnamed body system ?

• organa structural part of a system of the body that is composed of tissues and cells that enable it to perform a particular function

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What exactly is our tongue ?

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• 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 process.

frenum

Hyoid bone

Our tongue is more than a muscle,it is also an “Organ”

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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 rounding its surface.

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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

What are the best criteria we can use to diagnose ankyloglossia ?

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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

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Classification of newborn abnormal lingual frenums:based upon anatomic appearance

Type **I(4*) -total tip involvement

Type -twoMid portion of the

tongue creating a hump orcupping of the tongue

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 whichmay 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

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or should function ?

James G. Murphy, MD, FAAP, FABMAssistant Prof of Pediatrics

F. Edward Hébert Medical SchoolUSUHS Bethesda, Maryland

Total tie down resulting inNo up or down function

Cupping and hump

Unable to elevate andtouch the hard palate

Heart shape, pointed tip

Diagnosis based onfunction or lack of

function

unable to extend tongue pastalveolar ridge

Lawrence Kotlow DDS Introduction to Lasers and Breastfeeding course

NORMAL RANGE OF MOTION

CLASS 1 12-16 mm MILD

CLASS II 8-12 mm MODERATE

CLASS III 4-8 mmSEVERE

Kotlow classification of tongue-ties (1999)

CLASS IV 0-4 mmCOMPLETE

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Diagnosing problems related to an infant with ankyloglossia

(tongue-tied)

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Preliminary initial evaluationJust 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

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Interpreting your assessment-completed in the delivery room

James G. Murphy, MD, FAAP, FABMAssistant Prof of Pediatrics

F. Edward Hébert Medical SchoolUSUHS Bethesda, Maryland

Use your finger moving under the tongue across the floor of the mouth.

A smooth mouth floor = No ProblemA small speed bump = Potential ProblemA 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

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

Identifying the submucosal posterior tongue tie

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Identifying the submucosal posterior tongue tie

Lawrence Kotlow DDS

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“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

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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

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

Classifying Infant Lip-TiesClass IV: inserts into anterior papilla

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a

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

A simple surgical procedure

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!!Erbium:YAG

!1064 Diode

Lawrence Kotlow DDS

Pediatric reflux-clicking-Aerophasia

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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

Obstructive Sleep Apnea & its relationship to tongue-ties

Usually found in children from age 2-6

The most common cause -enlarged tonsils and adenoids

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.

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

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.

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).

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

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).

✴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.

✴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.

Blocked Airway

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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.

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

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

Case History (Holly Puckering) 9 year old maleMedical diagnosis by Physicians and Pediatrician

Airway disorder and obstructive sleep apneaOral 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.

Thank you......