By Timbrey Lind, RDH, and Shirley Gutkowski, RDH, BSDH
A rudder is something that guides and holds a course. It is the piece that matters most when steering something in the direction you want, and even more so, need it to go. The tongue is the rudder for the human body when it comes to posture, airway, and facial development.
The tongue is made up of eight different muscles; it's not just one. Think of all that the tongue does throughout the day without getting fatigued-talking, eating, swallowing, and maintaining the size of the maxilla (just to name a few). We don't come home after our day and say, "Man, my tongue is so sore after exercising it all day. I need to rest." However, people actually do experience this, even if they do not realize it. They are in our chairs every day.
We have all seen patients who complain of constant migraine headaches, temporomandibular joint (TMJ) disorders, jaw pain, head and neck pain, shoulder pain, and even back pain. Is it possible the tongue could be contributing to these? If so, how can hygienists help provide them with relief? The answer is in assessment of tongue posture and frenulum attachment.
If our hamstring is tight, does it allow us to bend over and touch our toes? Not without some discomfort. Well, the same goes for the frenulum we have under our tongue. If there is restriction (e.g., ankyloglossia or a tongue-tie), then it is not just restraining the tongue, but also every muscle attached to the tongue, and as a consequence, every muscle those muscles are attached to-hence head, neck, and back pain. We learned about ankyloglossia, but we never went into depth about all that it affects.
To give you a better idea, let's revisit anatomy class and walk you through all the muscles the tongue affects. As mentioned earlier, the tongue has eight muscles just within itself. It has four intrinsic and four extrinsic muscles.
The extrinsic muscles are the most affected, so we will focus on them. They are the genioglossus, hyoglossus, styloglossus, and palatoglossus. (You may remember that the names of muscles always have their insertion and origin within the name. This is the only way I passed my tests.)
The hyoglossus connects to intrinsic muscles of the neck, which connect to the major muscle of the neck, the sternocleidomastoid muscle (SCM). The SCM then connects to the pectoralis major, which connects to the trapezius and so on. You get the idea. This is also a major reason why dental hygienists are encouraged to wear loupes to maintain healthy posture by keeping these muscles balanced. They are such large muscles that it takes time to rehabilitate once they are out of balance.
Patient Obtains Relief
One new patient came in with complaints of headaches and TMJ pain. She started her treatment of orthotropic orthodontics with a well-known orthodontist, William Hang, DDS, MSD, and myofunctional therapy with Joy Moeller, BS, RDH, to help solve her grinding patterns and TMJ pain. When I saw her for her cleaning appointments, I noticed her ankyloglossia and asked if anyone ever suggested getting it released.
Once she had the procedure, a lingual frenectomy, she told me she "noticed an immediate sense of release" throughout all the muscles in her head and neck, as if she "had taken the strongest muscle relaxer in the world." You can see for yourself in a video interview at Dr. Hang's office (Consider viewing related YouTube video. Search for "William Hang, DDS" and select title of "Tongue Tie Release.). There are other first-hand testimonials on YouTube too. A tied tongue is nothing to be toyed with.
The effect the release had on her was so immense that talking about it brought her to tears. It was life changing. The video points out how the tongue really affects many muscles throughout the body and how ankyloglossia can negatively affect them. For over four decades she compensated for that tongue-tie. When her TMJ disorders and other symptoms finally brought her to the right specialists, she had reached compensation burnout. Imagine the inflammatory profile of this person-so many muscles were involved in contributing to her overall inflammatory load.
Types of ties, according to expert Dr. Irene Marchesan
1. Short frenulum: holds the tongue low into the floor or the mouth
2. Anterior: the attachment approaches the tip of the tongue creating a very short tongue blade. If severe the tongue tip will have a heart shaped appearance.
3. Short and anterior: tongue is low and cannot protrude, very small blade
4. Ankyloglossia: severe, no movement.
Source: Dr. Marchesan is on the executive board for the Academy of Applied Myofunctional Sciences.
The following are two fun functional tests to try with your patients:
1. When a patient is seated in your chair, ask them to open their mouth and count each tooth using the tip of their tongue. This is especially fun for kids to do and it gives you a great visual of the frenulum. You can assess if it is short, strained (you'll be able to tell by blanching), or normal. If they struggle with this, you may want to recommend a referral.
2. Another functional test you can do is have them open wide and stick their tongue straight out, side to side, and up to the roof. When you do this, you want to make sure their tongue is not resting on their teeth or lips and that it stays pointed the entire time. If the tongue takes on a different shape, gets tired, or cannot extend fully, these are things to note and include in the referral.
Putting your knowledge to work
For your own enjoyment, watch your patients walk into your treatment room. If they have a head that is not in alignment over their shoulders, take a look at their lingual frenulum. Is it tied or short? Ask patients if they have a lot of headaches, migraines, or if they are seeking chiropractic care for issues with their neck. To get a quick idea of what you're dealing with, simply ask the patient to open wide and touch the tip of their tongue to the roof of their mouth. If they need to bring their mandible up, closing more than 50% in order for their tongue to reach the palate, that's a red flag.
A patient with a high-arched, narrow palate is also likely to have ankyloglossia. The tongue determines the size of the palate. If the tongue cannot reach it, the forces of the cheeks will keep the palate narrow. A narrow arch equates to narrow sinuses and resistance in breathing. The restricted airway causes forward head posture, a smaller airway, and mouth breathing that stresses the TMJ, which over time causes pain.
Then, look at their children. Ask if the child is chewing food or resists foods that need any chewing. In the book Tongue Tie by Alison Hazelbaker, PhD, she talks about her experiences with ankyloglossia, which ranged from hiding behind her father during meals so her mother wouldn't chide her about chewing with her mouth open, to learning how to accommodate articulating common words (e.g., "like") with a tongue tied to the floor of her mouth. She had her frenulum released when she was in her fourth decade of life; Dr. Hazelbaker also expressed relief in the muscles of her head and neck.
Consequences when ankyloglossia is not treated can begin in infancy. Problems in feeding, breastfeeding, oral hygiene, dental health, dental occlusion, tongue mobility, chewing, swallowing, voice, speech, and even self-esteem are possible. Self-esteem and conﬁdence issues surface when a tied tongue causes speech problems. And the list of problems can go on-including ADHD-all because the tongue wasn't engaged at a young age.
When it comes to the airway, we want the maximum size, and the tongue is in charge of the whole thing, even during prenatal development! The tongue must be free to express milk from the mother's breast, pressing the breast against the palate; when not feeding, the baby's tongue must be free to press against his or her own palate. Midwives and lactation consultants are becoming more aware of this problem and are making referrals to an array of specialists to have the frenulum released. Pediatric dentists, oral surgeons, ear, nose, and throat specialists, and pediatricians are all on board with this usually simple procedure (see relating article).
Most health professionals do not know how to diagnose ankyloglossia. The important thing to know and start with is to observe the tongue in action. We cannot evaluate the frenulum only by what we see with a simple tongue lift or heart shape. Therefore, it is always best to refer to an orofacial myofunctional therapist for a full evaluation.
Once you start looking for ankyloglossia, you'll be amazed. Take a few minutes to create a code in your practice management software to track all the tongue-ties you find in your practice. What's your number after a few months? That number will likely be higher than you think. RDH
Timbrey Lind, RDH, OMT, is a practicing dental hygienist with a holistic approach to care. Specializing in orofacial myofunctional therapy, her passions are working with infants and children. Her practice, The Connection, is based in Agoura Hills, California.
Shirley Gutkowski, RDH, BSDH, is a practicing dental hygienist specializing in orofacial myofunctional therapy. Her practice, Primal Air, LLC, is in Sun Prairie, Wisconsin. Ms. Gutkowski is also the host of Cross Link Radio, a podcast with timely information integrating oral and systemic health.