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Who's Manning the Ship?

One of the key tenets of the E3 Model of Care is consistent coordination and support for the patient/family. So often a patient gets a frenectomy and gets sub-optimal results for likely one of the following reasons: 1) Did not have a functional assessment 2) Did not undergo other interventions that may influence 3) Did not have pre-procedure therapy 4) Did not get a full release 5) Did not have post-procedure therapy 6) Did not do active wound management techniques (When sutures are not utilized)

Read on. I'll go over the importance and rationale for each one of these reasons for sub-optimal results or pitfalls.

1) A functional assessment should be completed prior to a procedure. A patient needs to be evaluated based on what the tongue can or cannot do, while taking the physical structure into consideration. This provides a baseline and is much easier for all parties involved to track progress and indications for a procedure. This additionally aids in insurance reimbursement and provides more data leading to a correct diagnosis. The professional providing a functional assessment needs specific training in ties. Please note that no one profession has universal standardized training in ties. A great question to ask is what training has the professional attended specific to tethered oral tissues. Ask prior to having an evaluation with them. 2) Many times other interventions or diagnostics/consults are needed prior to a frenectomy procedure. For example, if the tongue does not have room, due to narrow/underdeveloped palate/arch, then expansion may be indicated prior to frenectomy. Another example, may be airway concerns/sleep disordered breathing. Our body's main priority is breathing. We will never get the tongue resting in the palate if the patient cannot breathe. This indicates a need for ENT/Sleep Medicine consult. Deciding if other specialties, interventions, imaging, or diagnostics are needed is individual on a case-by-case basis. 3) Pre-procedure therapy accomplishes many objectives. It continues to demonstrate the need for release, but may help improve symptoms and other functions in the meantime. It allows the professional to assist in preparation for the procedure (what to expect, common troubleshooting issues, red flags, etc). If you think about knee replacement surgery, we want a strong calf and a strong hip to support that new structure. Same with tongue tie release. We want to work on the jaw, lips, cheeks, etc. Think about who heals better. An olympic athlete or someone who does no physical activity? We want to work to tone, strengthen, coordinate, and sequence patterns while inhibiting compensations prior to a procedure. Bodywork such as chiropractic, craniosacral therapy, myofascial release has an impact on tension patterns and discomfort. Patients with oral aversion or sensory defensiveness need densensitization work prior to a procedure. 4) Sometimes not all the mucosal and fascial restrictions are released with a procedure. This can be due to many factors, but typically related to the training, experience, and how a provider conceptualizes tongue tie. 5) Post-procedure therapy is indicated to undo compensations and habits, while training optimal oral function. Functional movement and support after the procedure helps guide healing, reduce symptoms, and establish proper function. A trained therapist can alert the release provider to anything needing attention as well. Think of it as having webbed fingers. The doctor releases the webbing and the anatomy/structure is normalized and not restricted anymore. This action gains passive range of motion. In the case of webbed fingers, the patient will still need to gain strength, coordination, endurance, etc to be able to hold a pencil to write, button their shirt, or snap their fingers. This is why post-procedure therapy is crucial. 6) Due to wound healing principles, any wound left open post-procedure will try to contract and stabilize by reattaching. It is highly important to for patients/parents to be instructed on active wound management techniques. The time to learn this is prior to the procedure for the best success. (I have a whole lecture under resources on my website that I presented at the IAOM 2018 called "Active Wound Management: The Young and the Restless.")

Please don't send your patients on a life boat! Take the wheel and help them prepare and navigate the choppy waters surrounding tongue tie comprehensive care. Set them up for success! The oral function professional needs to "man the ship" to create cohesive and coordinated care.

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