The tongue
The most important articulator for speech production is undoubtedly the tongue. During speech, the amazing range of movements the tongue can make include tip-elevation, grooving, and protrusion.

Relatively short at birth, the tongue grows longer, and thinner at the tip, as we get older.

As well as having a speech function, the tongue is needed for sucking, chewing, swallowing, eating, drinking, tooth and gum health, kissing, sweeping the mouth for food debris and other particles (such as hairs), warming the air during mouth-breathing, and oral play (for instance, poking the tongue out and waggling it about for fun).

The terms 'ankyloglossia', 'short fraenum', 'short fraenulum', or 'tongue tie', refer to a restricted lingual fraenum due to a consolidation of tissue, usually leading to reduced mobility of the tongue.

It is commonly observed that a person with tongue tie cannot protrude the tongue tip beyond the edges of the lower incisors, or to the maxillary alveolar ridge (behind the upper incisors). Sometimes when a person with tongue tie attempts to protrude the tongue it forms a characteristic 'W' shape.

Parents of infants and toddlers with tongue tie are sometimes advised that the tie will "stretch", or "break" permitting a free range of movement, as the child grows. These stretching and breaking phenomena have not been formally studied or documented in the medical or speech-language pathology literature.

Potential effects of tongue tie
1. Speech development
It is important to note that tongue tie does not necessarily impair speech, in fact, it rarely appears to do so. Many individuals compensate well and have normal sounding speech, even those with the fraenum attached very close to the tongue tip under the tongue. Some individuals with tongue tie may have imprecise articulation, especially at speed. 

"Most experienced speech-language pathologists would conclude that frenulectomy is rarely indicated for speech reasons unless it is very severe or there are concomitant oral-motor problems." Ann W. Kummer

2. Dental health
Cavities ('dental caries') can occur due to food debris not being removed by the tongue’s action of sweeping the teeth and spreading saliva.
3. Periodontic health
Gingivitis (gum disease) can develop, for the reason stated above.
4. Oral hygiene
Halitosis (bad breath) may be present, due to caries and food debris.
5. Eating and digestion
Some children with tongue tie are messy eaters due to a restricted ability to tidy up inside and outside of their mouths while they are having a meal. Some are unable to circle their lips with their tongues in order to fully lick their lips. In extreme cases poor oral hygiene can lead to digestive complaints.
6. Sexual function
Restricted tongue movements may affect sexual expression.
7. Appearance
The tongue can be unduly obvious or unusual looking in some individuals, particularly when they are close up, or appear on video, film or TV.
8. Oral play
Children in particular may not be able to participate in play routines involving tongue movements and gestures.
9. Self esteem
It has been noted clinically that occasionally an older child or adult will be self-conscious, embarrassed or resentful about their tongue tie.

Assessment
When asked by parents or dental or medical colleagues to assess the need for tongue tie surgery (frenectomy), a speech-language pathologist takes into account the above factors. They look at the range of tongue movements, the two points of attachment of the fraenum, and speech development. As Purcell (2000) cautions,  not every tongue-tie requires surgery:

"Tongue tie or ankyloglossia may impact on accurate speech production, early feeding and the ability to clean the teeth with the tongue after meals or snacks. However, these problems are usually observed in only the more severe instances of ankyloglossia. Thus, it is important to note that each individual with ankyloglossia requires a thorough individual assessment and evaluation in order for the most appropriate management strategies to be selected."

Primary concerns for the speech-language pathologist are the effects of the ankyloglossia on the particular child’s speech, dental and periodontic health and oral hygiene. Subjective factors, such as concerns about self-esteem, cosmetic appearance, sexual function and oral play tend to be the domain of the child’s parents, with the speech-language pathologist fulfilling an information-sharing role, if required.

Examining for tongue tie
In a typical initial consultation the speech-language pathologist conducts a case history interview and assessment, recording the following information:
Date
Name
Date of Birth
Age
Parents
Address
Telephone
History including family history and language development
Presentation
Early feeding
Feeding now
Teeth
Tongue Movements
Appearance
Oral Hygiene
Saliva control (swallowing)
Phonological development (organisation of the speech-sound-system),
Speech sound (phonetic) development
Speech clarity

Lingual frenectomy and lingual frenotomy are different procedures. Lingual frenotomy is often performed on newborns and neonates with tongue-tie to enable them to latch and suckle. Lingual frenotomy is sometimes referred to as "tongue clipping". It is done with a local anaesthetic. This is about frenotomy.

The decision for toddler or child to proceed with frenectomy is arrived at through consultation between the client (if he or she is old enough), his or her parents, the SLP and the surgeon (and the family's GP in some instances).

Some parents/caregivers like to seek two speech-language pathology opinions to help them make their decision whether to not to proceed with tongue tie surgery.

The potential for complications and discomfort need to be discussed by parents with the surgeon and anaesthetist.

Children should be assessed by a speech-language pathologist prior to tongue tie surgery. Some require pre-operative exercises, and most require post-operative exercises under a speech-language pathologist's supervision.

1. Develop new muscle movements, particularly those involving tongue-tip elevation and protrusion, inside and outside of the mouth.
2. Increase kinaesthetic awareness of the full range of movements the tongue and lips can perform. In this context, kinaesthetic awareness refers to knowing where a part of the mouth is, what it is doing, and what it feels like. 
3. Encourage tongue movements related to cleaning the oral cavity, including sweeping the insides of the cheeks, fronts and backs of the teeth, and licking right around both lips.

Exercises
Discuss these suggested exercises with YOUR child's speech-language pathologist before commencing them. The SLP will modify them according to your child's age and requirements. Encourage oral play generally, and do a selection of the following exercises, in any order, in 3 to 5 minute bursts, once or twice daily for 3 or 4 weeks post-operatively. Have a torch and hand-mirror handy. Make it fun. 

1. Stretch your tongue up towards your nose, then down towards your chin. Repeat. 
2. You can vary the exercise above and make it more interesting by putting a dab of food in various positions above the top lip, to be retrieved with the tongue tip (You could call this game "Elephant Tongue" and read books about elephants (e.g. "Babar") to stimulate your child's interest in playing the "tongue games" spontaneously at other times - not just when you are there. 
3. Open your mouth widely. Touch your big front teeth with your tongue with your mouth still open. Can you FEEL how tough your teeth are?
4. Look in the mirror. Still with your mouth open wide, say dar-dar-dar, now say nar-nar-nar, now say tar-tar. Look in the mirror to see what your tongue is doing. Can you FEEL where it is? 
5. Lick your whole top lip from one side to the other. 
6. Now go back the other way. 
7. Lick your whole bottom lip from one side to the other. 
8. Go back the other way. 
9. See how many times you can lick your lips right around. 
10. Poke your tongue out as far as it will go. 
11. Shut your mouth and poke it into your left cheek to make a lump. 
12. Do the same on the other side. 
13. Now see if you can make your top lip fat without opening your mouth.
14. Can you go in-out-in-out-in-out with your tongue? (demonstrate) 
15. Put your tongue behind your teeth and shut your mouth. Can you find your big top teeth with your tongue while your mouth is still shut? FEEL how tough your teeth are. 
16. Play your own version of copy cats, Simon Says or Follow the Leader incorporating the preceding movements. 
    
    PLEASE - discuss these suggested exercises with your child's speech-language pathologist before implementing them. They may not be necessary or appropriate for your child.

Since all speech-language pathology intervention is based on face-to face assessment  it would be impossible, as well as unethical, for me to offer individual advice (see DISCLAIMER). My suggestion to these correspondents is for them to start by seeking an opinion from a speech-language pathologist. 

SLPs as well as members of the community and medical practitioners vary in their views on the advisability of, and the necessity for, tongue-tie surgery for adults and children. 

When frenectomy is performed, the operation is likely to be done by a general surgeon, an ENT surgeon, a cosmetic ("plastic") surgeon, or an oral surgeon. 

The decision for an adolescent or adult  to proceed with frenectomy is arrived at through consultation between the client, the SLP and, of course, the surgeon. 

Many people report that they have found it difficult to access a surgical remedy when they ask for a referral from their own doctor, or approach a surgeon directly (without an SLP opinion). 

Page updated 29 April 2009

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