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Tethered Oral Tissues: An Overview

What are TOTs?

Tethered Oral Tissues (TOTs) is a term used to describe tight, restrictive connective tissue between oral structures. This connective tissue is called frena. Everyone has frena but when this tissue is thick, tight, and restrictive of typical movement we say that that there is a “tie.” Lip ties, tongue ties and cheek ties fall under the TOTs umbrella. Identification of TOTs is important as these ties have the ability to negatively impact a child’s feeding skills, proper facial structure development, breathing, sleeping, and speech/language development.

Signs and Symptoms of TOTs

How can you tell if your child may have TOTs? Here are some signs and symptoms:

In babies (0-12 months):

  • difficulty latching to nipple (breast or bottle)
  • difficulty gaining weight/slow weight gain
  • losing milk/formula out of corners of mouth when eating
  • audible “clicking” sound while eating/sucking
  • difficulty holding a pacifier in mouth
  • congestion
  • reflux
  • open mouth posture
  • high, narrow hard palate
  • difficulty transitioning to solid foods

In toddlers and older children (12 months +):

  • history of symptoms reviewed above
  • drooling
  • messy eating
  • picking eating
  • snoring/sleep issues
  • delayed talking
  • speech that is difficult to understand
  • persistent speech sound errors

If you suspect TOTs, what are the next steps?

If your child is demonstrating any or all of the above deficits, I would always encourage you to discuss the issues with your child’s pediatrician. Your pediatrician may be able to point you in the right direction of the professional which may be the best fit to help treat your child. For example, if breastfeeding, seeking the help of an International Board Certified Lactation Consultant (IBCLC) may be the most beneficial professional to work with. The IBCLC may be able to offer different positioning options and give the most specialized advice for the mother/infant feeding relationship. If feeding or speech and language is involved, another professional you may come in contact with would be a Speech-Language Pathologist (SLP). SLPs are knowledgeable regarding feeding across the lifespan and specialize in speech/language development. Myofunctional Therapists may be an appropriate professional to treat your older toddler or child. You may also be referred to a pediatric dentist, ENT, or oral surgeon who specializes in the assessment and revision (surgical intervention to “release” the tight tissue) of TOTs; however, surgical intervention is not always warranted. TOTs are treated based on the functional deficits that are being demonstrated and not always how the tissues appear in the oral cavity.

From feeding to speech and language development, Tethered Oral Tissues (TOTs) can impact many areas of your child’s development. If your child is demonstrating any deficits reviewed in this post, please reach out to a qualified professional for an evaluation! At APT, our goal is to Advance our Patients to their next Therapeutic level. If we can help you and your child, please call us today! We would love to hear from you.

Megan C. Robbins, MS, CCC-SLP