What is the cause of oral restrictions (tongue and lip ties)?

Oral restrictions (a relative failure of proper apoptosis of the tongue or lip frenal attachments) can effect more than just the mouth. Effects can be far reaching due to muscular, skeletal and neurological compensa-tions which occur in an attempt to enable relatively normal function.

The tongue and lips, like all other mus-cles are not structures which can act in isolation from the rest of the body. Furthermore, at different stages of an individual’s life, different effects may occur.

Some of such effects in infants and toddlers range from feeding challenges, to speech difficulties, to snoring and sleep apnoea. In children and adults, underdevel-oped jaws, and head and neck pain are often present in addition to the same challenges faced by infants and toddlers.

In fact the majority of adults who I have treated for Tongue Tie describe relief in head and neck tension after surgery. Often after years or headaches and migraines. Tongue Tie is not just a problem for infants.

The number of cases of tongue and lip ties being diagnosed in clinical practice around the world is certainly increasing. While this does not necessarily prove that oral restrictions are on the rise (as there is now more education on the subject so there is more access to knowledgable practitioners) the consensus amongst many who treat such problems is that prevalence may be increasing. Why could this be?

The truth is that nobody knows for sure why there may be an increase in prevalence. However, one of the most commonly discussed reasons is related to the use of synthetic folate during pregnancy, especially for individuals with the commonly occurring genetic polymorphism in the Methyltetrahyrofolatereducatse (MTHFR) gene. This gene encodes for the a liver enzyme which helps with metabolism of folate (vitamin B12) which is important for a number of bodily functions.

The theory is that synthetic folate may not be fully absorbed and may block some receptor sites for B12 absorption, which ultimately leads to inadequate B12 absorption. The thought process is that there is suffi-cient B12 absorbed to prevent neural tube defects such as spina bifida. However, there may not be enough absorbed to prevent other ‘midline defects’ which may include oral restrictions and hypospadias. The jury is out, and we do not have sufficient research yet to back the theory that MTHFR defects and synthetic folate use is indeed the cause. My own stance on this is that I don’t have enough information to make a well in-formed opinion. So I’m remaining on the fence at this time.

….. But there may be another cause which is less often talked about. In fact I have not heard anybody other than me talk about it. But I’m talking now and spreading the word in blogs like this because I think there’s good reason to believe it could be a major cause.

So here it is:

I was sitting in a nutritional conference a few years ago when an eminent Professor on an ‘expert panel’ be-gan to talk about the prevalence of Iodine Deficiency Disorders (IDD) and stated that it was a huge problem worldwide. Then he went on to describe a research paper (Orphanet Journal of Rare Diseases 2010, 5:17) which discussed Congenital Hypopthyroidism, which is thought to be linked to IDD .

The paper stated:

“Clinical manifestations (of CH) are often subtle or not present at birth… Common symptoms include de-creased activity and increased sleep, feeding difficulty, constipation,…Signs include myxedematous fae-ces…macroglossia…hypotonia…Thyroid dysgenesis accounts for 85% of primary permanent CH…it is asso-ciated with congenital hypopituitarism…Transient CH more commonly occurs in areas of endemic iodine defi-ciency.”

The following symptoms of the following caught my attention for the following reasons:

  1. Increased sleep – sometimes infants who are not feeding properly become lethargic, or have low energy and sleep for much of the day
  2. Feeding difficulty – for obvious reasons this is related to tongue and lip ties (as shown by many research papers and clinical practice) as the fact that the tongue is important for swallowing coordination, and the lip can help with assisting with oral seal and latching on to the breast or bottle
  3. Constipation and myxedematous faeces – when an infant is not feeding well they often only get the fore milk which does not contain all of the nutrition required for good digestion and overall health, this can po-tentially affect the consistency of the faeces as well as bowel movements. Furthermore, uncoordinated swallowing often accompanied by aerophagia (air intake) which could lead to gut problems, reflux and gen-erally poor digestive health
  4. Macroglossia – enlarged tongue is a very rare condition. In fact I’ve never actually seen it in over 20 years of looking in people’s mouths, except in some Down Syndrome cases or other syndromes. What I do see fre-quently though are normal sized tongues in mouths which are underdeveloped (small mouth with a normal tongue which makes the tongue look too big relatively – but it’s just relative). So this really grabbed my at-tention. Could the so called “macroglossia” in some of those cases just be underdeveloped jaws making the tongue look big? Which coincidentally happens when the tongue is postured low (as is the case in tongue tie). This is because the tongue normally sits high in the palate and presses on the jaw bone to stimulate it to grow, so we usually see small jaws and high palates in tongue tied infants. There is no doubt that macro-glossia is indeed related to the rare condition of CH. However, perhaps sometimes the tongue is not as big as it seems (due to the underdeveloped jaw making it appear that way)
  5. Hypotonia – poor muscle tone (inside the mouth) is often seen in infants with feeding dysfunction and tongue and lip ties

When I read this paper I immediately wondered what the link between the tongue and the thyroid gland is, because from what I could see it appeared that CH shares the same or similar symptoms with tongue (and lip) ties.

I came to the following hypothesis after going back to my embryology notes from university – something I’d forgotten all about having graduated all that time ago!

Hypothesis:

Given that the thyroid gland and the tongue are intimately related in early embriology. That is to say that they share the same structures until the thyroid gland descends. Could it be that a thyroid functional prob-lem (CH) is related to a tongue frenum problem (TT)?

Given that apoptosis (relative removal of the excess frenum) is a biochemical process, affected by meta-bolic processes, and CH is a metabolic problem, this hypothesis seems at least as plausible as the MTHFR / synthetic folate hypothesis.

Perhaps even a combination of the two hypotheses, or either or hypotheses are plausible? Only time will tell.

I hope that someone out there with a head for research might consider attempting to collate data on CH and Tongue and Lip restrictions. I wonder what the prevalence of infants with CH combined Tongue and Lip re-strictions is?

Could oral restrictions (tongue and lip ties) be related to Congenital Hypothyroidism?

One potential issue with this hypothesis is that CH appears to only be found in 0.03% of infants, while oral restrictions are found in anything between 2% and 20% of infants (depending on which research paper you read).

However, I wonder whether even a small challenge with thyroid function, given it’s importance for metabo-lism (apoptosis) might cause oral restrictions? ie: perhaps there are more than 0.03% of cases of infants with mildly sub-optimal thyroid function which is not sufficient enough to be classified as CH, but is suffi-cient enough to cause defective apoptosis.

As os often the case in birth defects, or any other illness or disease, the reality is that there is usually a mul-ti-factorial aetiological landscape.

Perhaps we can add thyroid dysfunction, and Iodine deficiency to the list of potential causes of oral re-strictions.

Written by Dr Dan Hanson
– Myofocus Co-founder

A ‘Triple-Care’ Approach To Infant Feeding Challenges

It is well known that breast feeding up to and beyond 12 months of age improves health outcomes for both infants and mothers.1 Lesser known advantages include nurturing the gut microbiome,2 cognitive benefits3, prevention of the onset of sleep apnoea4 and its sequelae cardiovascular disease; as well as positive impacts on craniofacial structures with reduction in dental cross-bites and other forms of malocclusion5. Healthcare initiatives aimed at supporting functional feeding dyads are essential for a preventive, rather than reactive model of care.

The current standard of care during feeding challenges is often a ‘watch and wait’ approach, or advice to bottle feed, despite the presence of oral ankylofrenula (including tongue tie), which often goes undiagnosed and is proven to cause feeding difficulties (references available), resulting in premature non-elective cessation of breast feeding and subsequent loss of known health benefits.

Currently, only around 21% of Australian children are breastfeeding at 12 months (references available), with an even smaller percentage feeding optimally. Three professions which offer feeding support for infants, include International Board Certified Lactation Consultants (IBCLC), paediatric manual therapists, and surgeons offering frenectomies when necessary. While studies have shown each of these therapies to improve feeding outcomes independently of each other (references available), such modalities are not routinely utilised in our current paradigm of care and rarer still, are they used in combination with each other. There are however some teams offering this approach. These include The Gold Coast Tongue and Lip Tie Clinic on the Gold Coast.

Dr Dan Hanson: http://www.drdanhanson.com/goldcoast-tongue-lip-ties

Myofocus in Melbourne : https://www.myofocus.com.au/laser-tongue-lip-tie/

Timely referral to an ‘integrative unit’ of all three types of practitioners can facilitate profound improvements in feeding function and this ‘triple-care’ approach to correction of oral anykylofrenula has been shown to be highly effective clinically. As a result, there are a growing number of clinics, within Australia and overseas which deliver this integrative ‘triple care’ approach.

We hope this will lead to an evolution in the current paradigm, with more practitioners offering a ‘combined approach’ to care, with resulting improvements in the health of the next generation.

Author: Dr D Hanson B.D.S.

References:

  1. Paediatrics 2005; 115;496. DOI: 10.1542/peds.2004-2491. Breastfeeding and the Use of Human Milk.
    http://pediatrics.aappublications.org/content/pediatrics/115/2/496.full.pdf
  2. JAMA Pediatr. 2017 Jul 1;171(7):647-654. doi: 10.1001/jamapediatrics.2017.0378.Association Between Breast Milk Bacterial Communities and Establishment and Development of the Infant Gut Microbiome.
    https://www.ncbi.nlm.nih.gov/pubmed/28492938
  3. J Korean Med Sci. 2016 Apr; 31(4): 579–584. Effect of Breastfeeding Duration on Cognitive Development in Infants: 3-Year Follow-up Study.
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4810341
  4. ERJ Open Res. 2016 Jul; 2(3): 00043-2016. A frequent phenotype for paediatric sleep apnoea: short lingual frenulum.
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5034598/pdf/00043-2016.pdf
  5. 5. Am J Orthod Dentofacial Orthop. 2010 Jan;137(1):54-8. doi: 10.1016/j.ajodo.2007.12.033. Relationship between breastfeeding duration and prevalence of posterior crossbite in the deciduous dentition.
    https://www.ncbi.nlm.nih.gov/pubmed/20122431

Malocclusion Causes

What are the Causes of Malocclusion?

It is widely accepted that the teeth and jaws are at the mercy of the muscles of the lips, cheeks and tongue, and that “soft tissue dysfunction”, or aberrant swallowing (and breathing) patterns are the major cause of malocclusion. (Soft Tissue Dysfunction: a missing clue when treating malocclusions. German O. Ramirez-Yanez, Chris Farrell. International Journal of Functional Orthopedics. 2005)

Any factor that leads to either soft tissue dysfunction, or breathing dysfunction, may therefore lead to malocclusion.

Why is it that malocclusion is on the rise?

There is no doubt that malocclusion has risen since more primitive times.

It appears that malocclusion appears to be related to environmental factors. The fact that wild animals and more isolated populations of human beings do not exhibit much (if any) malocclusion (Weston A Price- Nutrition and Physical Degeneration) indicates that it is likely to be linked to our modern way of life.

It appears that it is a multifactorial syndrome which has come about due to one or more of the following factors (plus other factors that have not been listed) which are all related to our modern ways of living and cultural tendencies. Essentially, the introduction of anything that leads to aberrant swallowing patterns, poor posture, or dysfunctional breathing will exert some effect on the incidence of malocclusion.

Below are 10 factors that happen more in modern times, than in more primitive times which might explain why malocclusion may be on the rise:

1. Use of sedatives such as pethidine during labour

Maternal use of any sedative during labour causes effects on the newborn infant. Pethidine half life is much greater in a neonate than a mother (13 hours compared to 30 minutes). Thus, the infant spends some their first day under the influence of sedation. It has been shown that this has an effect on the infant’s ability to learn to suckle properly and so establishment of proper swallowing (and breathing) patterns becomes difficult. The first 20 minutes post-partum has been shown to be the most important time to establish proper suckling. Correct or incorrect early suckling patterns were shown to be of prognostic value for the duration and success of breast feeding. Proper breast feeding helps to establish proper swallowing patterns. (Lancet 1990; 336: 1105-07. Effect of delivery ward routines on success of first breast feed)

2. Separation from the mother’s skin immediately after birth

The Lancet study named above also showed that separation from the mother’s skin prior to the onset of the first feed negatively affected the infant’s ability to suckle correctly. In fact the combination of pethidine with separation from the skin had the most deleterious effect.

3. Use of pacifiers during early childhood

Pacifiers (dummies) cause the infant to learn to swallow in a dysfunctional manner and therefore, increased use of pacifiers would lead to increased malocclusion (see causes of malocclusion).

4. Use of bottles during feeding

Bottles have a similar effect to pacifiers, in that they have the potential to alter normal swallowing patterns.

5. Mothers being too tired to feed infants easily

It is not uncommon in our modern world for our mother’s to be managing multiple commitments. Modern mothers often take on more than just mothering and have to run the home as well as a business, or full time job. Mothers are likely to be more tired than they used to be and many tell stories of having to breast feed while they are half asleep and feeling incredibly stressed.

At times tiredness from modern pressures makes them get sick or have difficulties with lactation.

6. Soft, sloppy and refined diets

When vets tell us to give bones to our puppies so they can develop proper masticatory muscles and grow strong jaws they are giving us sound advice. Compare this to the common foods eaten by young babies, and it’s clear to see that we typically feed our young soft foods, that are more sucked than chewed. Primitive populations had a harder diet compared to the sloppy nutritionally devoid foods that we often feed our modern babies and this allowed more primitive populations to develop proper swallowing patterns and stronger masticatory muscles, which in turn led to well formed jaws. (Weston A Price – Nutrition and Physical Degeneration)

7. Poor nutritional content of modern foods

Prior to refrigeration, and preservatives, foods were mostly fresh, seasonal and diverse. Nowadays, foods can be months, or even years old by the time we eat them. Furthermore, the food industry has altered our food sources to enable longer shelf life and higher yield. Whilst this has it’s advantages, it certainly comes with a health warning. One example of such a modification is in cow’s milk. There is a substantial body of evidence to support theories that proteins such as casein in milk may be major causes of allergy and congestion. Consumption of high volumes of cow’s milk products is a modern phenomenon. Propaganda relating to it’s benefits is supported by the huge marketing budgets of the dairy industry, and it is worth considering that we are the only species that drinks milk after infancy, and certainly the only species that drinks the milk of another species. (Hill et al Clinical Manifestation of cows milk allergy in childhood the diagnostic value of skin tests and RAST Clinical allergy 1988; 18; 481-490.) (Stricker T et al Constipation and intolerance to cows milk J Paed Gastroenterology and nutrition 2000;30;224)

The fact is that a food that has been refined in any way, has a greater chance of having poor nutritional content, than a completely fresh, seasonal, chemical free version. Moreover, the lack of diversity in our diet puts us at further risk of being over-fed but undernourished. This malnourishment is linked to an increased frequency of illnesses. In 10 years from 2001 to 2011, there was a five fold increase in anaphylaxis from food allergy. (J Allergy Clin Immunol 2011 127:688-76)

However, illnesses may range from the common cold, to ADHD, to congestion and diabetes. Since illness often leads to a blocked nose and open mouth posture, it goes without saying that it may lead to malocclusion. A child who is often sick with a blocked nose, and open mouth posture will be more likely to exhibit a vertical growth pattern. The tongue is supposed to be free to sit up high in the palate and stimulate proper growth of the maxilla. Mouth breathing due to sickness, or congestion leads to low tongue posture.

8. Poor nutritional content of modern foods

Modern children are future chiropractic time bombs. Poor posture is a major symptom of a comfortable and sedentary lifestyle. Watching TV, or playing on computer games whilst sitting on a beautiful soft leather sofa might be fun. However, it is a recipe for poor core strength, a subluxation of the neck and resultant poor posture. Since posture affects breathing patterns and growth direction, it is likely to affect malocclusion formation.

9. Increased stimulation leading to illness

Modern humans are over stimulated compared to their more primitive counterparts. Exposure to screen technology past the hours of darkness, such as TVs and I-pads may lead to poor sleep due to suppression of the sleep hormone melatonin. (Lighting Research Center at Rensselaer Polytechnic Institute)

Good quality sleep is linked to better health. Better health is linked to less congestion and nose breathing and therefore less malocclusion.

10. Increased sympathetic nervous system activity and increased respiratory drive (mouth breathing)

All of the above have the potential to excite the “fight or flight” sympathetic autonomic nervous system. Prolonged and frequent excitation of this is likely to lead to increases in breathing dysfunction since increased respiration occurs during such events. This increased respiratory drive on a frequent basis may lock the child into a pattern of “over-breathing” or “habitual hyperventilation.” When this happens the Minute Volume (volume of air breathed per minute) at rest increases. Once this becomes the norm, an open mouth posture and habitual mouth breathing occurs to allow the bigger volume of air to be breathed. Open mouth posture and low tongue posture effects craniofacial growth and jaw development.

Prevalence of malocclusion among mouth breathing children: do expectations meet reality? Souki BQ, Pimenta GB, Souki MQ, Franco LP, Becker HM, Pinto JA, Federal University of Minas Gerais, Outpatient Clinic for Mouth-Breathers, Belo Horizonte, Brazil. Int J Pediatr Otorhinolaryngol. 2009 May; 73(5): p.767-773.

Etiology, clinical manifestations and concurrent findings in mouth-breathing children. Abreu RR, Rocha RL, Lamounier JA, Guerra AF. J Pediatr (Rio J). 2008 Nov-Dec; 84(6): p.529-535.

Radiological evaluation of facial types in mouth breathing children: a retrospective study. Costa JR, Pereira SR, Weckx LL, Pignatari SN, Uema SF. Int J Orthod Milwaukee. 2008 Winter; 19(4): p. 13-16.

Why is there a need for an effective early interventional approach?

Malocclusion is not just about the teeth. The teeth are simply a symptom of an overall “syndrome”, and are merely the tip of a very large ice-berg. Jaw growth occurs throughout childhood with the majority of growth being completed before the permanent dentition is fully erupted.

Achieving close to the maximum genetic potential for growth of the maxilla and mandible are not just important for straight teeth. These bones make up parts of the face, and are gateways to the airway.

Waiting for all the teeth to erupt until age 12 or 13 is condemning the child to a face that is potentially less symmetrical, and an airway that is potentially smaller than it might otherwise have been. For these reasons alone, it makes no sense to isolate the problem to the teeth, and only act in the best interests of straight teeth.

Previously, “phase 1 pre-orthodontics” has been rejected by some due to the potential for relapse while waiting for the final eruption of the permanent dentition. However, many of the systems used for phase 1 have not focused on changing the myofunctional patterns at the same time as expanding the jaws and aligning the teeth. A better system would involve both correction of myofunctional causes, and active expansion and alignment where necessary. Or better still, in the case of an oral restriction such as a tongue tie, early correction using an inter-disciplinary approach as recommended by the Tongue Tie Institute.

The fact that malocclusion is more than just crooked teeth, suggests that a system which works on all aetiological factors and co-morbidities of malocclusion is preferential. Therefore, involvement of a team of professionals working to establish proper function is a better approach. This team may involve the following professions:

  • Dentist or orthodontist to diagnose the condition and expand the jaws to make space
  • Dentist or orthodontist to monitor treatment progress and to prescribe the treatment plan
  • Oral Myofunctional therapist to help train the muscles (lips, cheeks and tongue) to function normally
  • Bodyworker to assist with musculoskeletal compensatory co-morbidities such as altered neck posture
  • Breathing educator to assist with correction of habitual hyperventilation and establish proper breathing patterns

So what should be done if malocclusion is suspected?

Early diagnosis and intervention is essential for complete treatment, so refer to a dentist or orthodontist who focusses on “Pre-Orthodontics”. Not all practitioners are the same and often have different training with exposure to different philosophies and modalities. Given that malocclusion is linked to dysfunctional swallowing and breathing patterns, and given that it is not just a problem for the teeth – it’s a growth disorder – referral to a dentist or orthodontist who focusses on establishing proper growth as early as possible is essential.Do not accept a treatment plan which involves monitoring every 6 months until all the teeth have erupted. These plans are only given out by practitioners who only see the problem as a problem for the teeth. The jaws need growing now and the dysfunction needs correcting immediately.

How can malocclusion be reduced or prevented?

  • Do everything possible to establish functional breast feeding from day 1 of life. If there is a tongue or lip tie get it diagnosed immediately and treated as early as possible. It is functional breast feeding which leads to functional swallowing and breathing patterns. See a qualified IBCLC to help with this, and if tongue tie surgery is needed be sure to use a multi-disciplinary approach to care (dentist / oral surgeon, IBCLC and bodyworker). Ensure a thorough surgery is carried out by an experienced laser surgeon. The laser is the only way to achieve a complete release of all components of the restriction unless several incisions are made with scissors or scalpel (which would require a GA and sutures).
  • Avoid non-nutritive sucking habits such as pacifiers at all costs. These create dysfunctional swallowing patterns.
  • Avoid use of bottle feeding if possible. Bottles also create dysfunctional swallowing patterns leading to malocclusion. In our modern society where mums often have to go to work this can be very difficult. However, when it is an option, avoid bottle feeding.
  • Introduce healthy, fresh, seasonal non-refined solid foods to your infant when the baby teeth emerge. These foods encourage proper chewing patterns. Avoid the sloppy refined foods.
  • Promote proper core strength. Ensure plenty of ‘tummy-time’ – aim for 30 minutes a day by 4 months of age.
  • Encourage healthy play outdoors and do not allow your child to use tablets excessively, or sit in car seats for long periods of time as unhealthy posture will result.
  • No screens after dark. This is to assist with proper sleeping patterns.
  • Get the jaw growth and tooth eruption checked by a Pre-Orthodontic practitioner by age 5 years of age.

Call our clinic on (03) 9329 2929 for a consultation today.

New Online Presence for mYofocUs

The team at mYofocUs is excited to announce the launch of our new online presence. Through our new website, we hope to assist with an evolution in the health journey of the families we connect with. We do our level best to ensure that our guests feel empowered and educated to make sound health choices.

At mYofocUs we ensure that we do everything in our power to create functional oral health from birth to beyond.