by Felix Liao
Here, moderate tongue-tie results in mild crossbite in the molars and severe fatigue from sleep apnea.
According to a 2015 Taiwan study, “Children with untreated short frenulum [frenum] developed abnormal tongue function early in life with secondary impact on orofacial growth and SDB [sleep-disordered breathing].”(7) The authors concluded that tongue-tie may “lead to abnormal orofacial growth early in life, a risk factor for development of SDB [sleep-disordered breathing]. Careful surveillance for abnormal breathing during sleep should occur in the presence of short lingual frenulum.”
Dental offices trained to provide Holistic Mouth checkups are a good place to monitor tongue-tie and orofacial development.
Treatment for Tongue-Tie
Tongue-tie is treated with a combination of surgical release and myofunctional therapy to free the tongue and oral-appliance therapy to make room for it.
Release of a tongue-tie does not mean cutting or clipping. “To cut” means to detach, while “to release” means to liberate. The tongue is freed with a surgical release called lingual frenectomy, after which the tongue will suddenly have a much wider reach while still being attached.
Releasing tongue-tie is a simple procedure that can be done at birth in a hospital without anesthesia. In older children, frenectomy is done in a dental office using laser and topical numbing gel only. There is little or no pain, and recovery takes less than a day or two. In cases of very narrow jaws, it may be necessary to use a palatal expander before myofunctional therapy and tongue-tie release.
Equally important as the surgical release is the orofacial myofunctional therapy, starting that same day. Properly practiced until correct swallowing is automatic, it can develop or redevelop the tongue’s tone and posture. According to the Academy of Orofacial Myofunctional Therapy, a wide variety of other benefits have been reported, including:
Airway development
Normalizing oral functions and mitigating sleep disorders (8)
Correcting oral dysfunction in chewing, swallowing, and speaking
Stretching tethered oral tissues (tongue- and lip-ties)
Remedying TMJ disorder
Guiding healthy craniofacial development
Relieving orofacial pain
Helping orthodontic results hold, minimizing relapse
Providing early intervention to avoid developmental consequences
Improving brain function and neuroplasticity
Healing chronic pain with myofunctional connections(9)
The two cases below show just how powerful orofacial myofunctional therapy can be. Orthodontics was stopped and an oral face mask was used in the first case while the second simply closed her lips during the day and slept with her oral face mask attached to her maxillary appliance.
In short, orofacial myofunctional therapy trains the tongue and swallowing muscles to complement oral appliances’ work on redeveloping the maxilla, the mandible, and the associated hard tissues. When tongue-tie is properly diagnosed, orofacial myofunctional therapy as a part of Holistic Mouth Solutions can keep your face looking younger despite gravity and time.
The key with the diagnosis of a tongue-tie: the owner-operator of the tongue, lips, and swallowing muscles needs to work diligently and conscientiously to replace the old dysfunctional pattern with a healthier functional pattern. This takes a lot more than watching myofunctional exercise videos online. Seeing a myofunctional therapist can be most helpful.
Holistic Mouth Bites
The tongue is a major architect of your face and smile, but conditions such as tongue-tie and habitual mouth breathing can ruin their naturally beautiful design and initiate Impaired Mouth Syndrome.
Laser release of tongue-tie followed by oral-facial myofunctional therapy has been shown to improve a long list of health problems and dental complications.
Soft tissues shape the bones. If genes are not fully expressed, jaw structures do not reach their full potential, triggering a cascade of health problems.
Orofacial myofunctional therapy is invaluable for correcting orofacial habits caused by tongue-tie—a condition with serious long-term consequences if left untreated.
Chapter Fourteen
Tongue-Tie’s Treachery on Immune Health: Case Study
Oral diseases and conditions are related to other health problems.
– Oral Health in America:
A Report of the Surgeon General(1)
Tongue molding happens when a normal tongue is free to reach the roof of the mouth to serve as a natural palatal expander. This tongue molding results in a wider U-shaped palate. When I see a narrower V-shaped maxilla, I suspect tongue-tie, habitual mouth breathing, or both.
C.K.’s tongue-tie (lower left), deficient maxilla (upper right), and lingual tori (green arrows) indicating chronic jaw clenching and teeth grinding.
While serious cases like Lucy’s are starting to get the deserved attention early, milder cases of tongue-tie often go undetected, which can start a domino of medical-dental problems.
C.K. was born with a tongue-tie but did not find that out until he was forty-three and recovering from cancer. This is not to say that tongue-tie caused his cancer. There is no evidence for that yet. However, there is plenty of evidence linking airway obstruction to America’s leading causes of death, including cancer.
Tongue-tie in a 9 year-old leads to narrow palate and crowded lower front teeth.
“About 28 million Americans have some form of sleep apnea,” reported The New York Times in 2012, “though many cases go undiagnosed…. In one of the new studies, researchers in Spain followed thousands of patients at sleep clinics and found that those with the most severe forms of sleep apnea had a 65 percent greater risk of developing cancer of any kind.”(2)
Moderate OSA patients (AHI 15 to 30) had twice the risk of dying (mortality) compared to those with the same cancer but without OSA, while severe OSA patients (AHI above 30) had 4.8 times the risk, reported a twenty-two-year follow-up to the Wisconsin Sleep Cohort Study: “Baseline SDB [sleep-disordered breathing] is associated with increased cancer mortality in a community-based sample.”(3)
Left unrecognized, tongue-tie is an oral condition that casts a very long shadow on health and life quality.
Tongue-Tie’s Domino Effects: The Case of C.K.
C.K. had just finished chemotherapy for testicular cancer when he first came to see me. “My doctor-wife says she can’t fix me by herself and that I need to see you.”
“Your doctor-wife is a real integrative doctor. So tell me, if Fairy Godmother could wave away your top three symptoms you’re living with now, which ones would you ask of her?”
“First, get rid of my cancer, of course,” he said. “Then tiredness on waking up, sleepiness during the day, major brain fog, feeling winded, and leg edema and neuropathy.”
“That helps me understand you better. Some of these are chemo-related, of course, but not all. When was the last time you had a good week’s sleep?”
“About four years ago—before our daughter was born.”
“That’s understandable. Let’s take a look at your mouth.”
Holistic Mouth checkup revealed:
C.K.’s oral airway’s narrowest diameter was only 30 percent of low normal.
His nasal passage was mostly blocked. (“Yes, I have constant stuffy nose,” he said.)
He had crowded teeth with matching wear facets indicative of teeth grinding.
His lower jaw had bony outgrowths on the tongue side called lingual tori, which are suggestive of jaw clenching and teeth grinding.
He had tongue-tie.
He had clicking jaw joints and jaw deviations on opening and closing his mouth (TMJD).
His Epworth sleepiness score was 14 out of a possible 24, well above the low-risk range of 3 to 8.
A sleep test confirmed teeth grinding, leg movement, and restless sleep of 17.8 sleep arousals per hour, but not the medical diagnosis of OSA.
Shortage of oxygen is a condition for c
ancer, according to Nobel Prize winner Otto Warburg, even if C.K.’s sleep test did not rule in OSA.
A “Lemon” Mouth’s Systemic Effects
“Mr. K, if I may use a car analogy, you have a ‘lemon’ for a mouth. Were you breast-fed?”
“My mom tried, but she said I could not latch on.”
“That’s a red flag in my book. You have a pretty severe case of tongue-tie. Did you have lots of antibiotics in your early childhood?”
“Yes, I had lots of ear and sinus infections growing up. How can you tell?”
“I’ve seen this pattern many times: tongue-tie understandably leads to bottle-feeding, which in turn creates malocclusion—bad bite with crowded and crooked teeth from narrow and misaligned jaws.”
“Oh? How?”
“Bottle-feeding and tongue-tie combine to create an abnormal swallowing pattern—picture a kid’s mouth as they suck up a milkshake through a straw—which can lead to narrow jaws, crowded teeth, long faces, and very frequently a weak chin and clicking jaw joints.”
“That’s me alright. I also have frequent ear and sinus infections. Can they be connected to my mouth?”
Impaired Mouth’s Role in Gut Inflammation and Allergies
“This is a common pattern I see, starting when an exhausted mom resorts to bottle-feeding to soothe the miserable baby with tongue-tie. This blocks full development, resulting in an impaired mouth, which is the structural start of snoring, sleep apnea, and teeth grinding later. Retruded jaws block the airway and disrupt sleep, and a narrow upper jaw makes you prone to sinus infections.”
“That’s why I had a lot of antibiotics and ear tubes as a kid and all my problems as a grownup?” C.K. asked.
“Yes. Now we know antibiotics can also kill good bacteria in the gut and create dysbiosis, in which bad bacteria dominate. German doctors know that life or death lies in the intestines. Improper weaning and premature introduction of adult foods then result in baby’s gut inflammation.” I continued, “This inflammatory bowel syndrome (often called ‘leaky gut’) can lead to food sensitivities, earaches, sinus infections, swollen tonsils, and a runny-stuffy nose that results in habitual mouth breathing, which then leads to oxygen deficiency, which leads to yet another way that an impaired mouth perpetuates gut problems.”
“What’s that?”
“Oxygen deficiency from an impaired mouth can aggravate dysbiosis, allergies, and fatigue in our adult years, all as a result of airway obstruction by the tongue.”
“Yup, I’ve got major fatigue and gluten sensitivity and was finally diagnosed with celiac disease two years ago. I’m sure exposure to lots of fumes, chemicals, and vaccines in my military career didn’t help.”
“Health is the sum of many factors. Your tongue-tie didn’t cause your cancer, but your mouth did put your health behind the proverbial eight ball long before you joined the military. It’s fair to say your mouth is a big cause in your health’s downhill slide.”
“So what’s your solution to my problem, doc?”
“Do you want to treat the symptoms or the causes?”
“My doctor-wife has said my cancer is a symptom. I want to get to the root causes because I sure don’t want it back.”
“I don’t treat cancer, of course, but I can say this: opening up your oral and nasal airway can only help you.”
“Let’s fix my mouth then because I have a four-year-old daughter.”
C.K.’s Holistic Mouth Solutions Treatment Plan
C.K. was treated with a biomimetic oral appliance on both jaws. He was instructed to wear them fourteen to sixteen hours each day, including during sleep, and to continue his cancer recovery under a doctor’s supervision.
C.K.’s Progress Report
After three months of wearing oral appliances to sleep and taking supplements from his doctor-wife, he reported being able to sleep through the night and having more energy during the day. “My attention and focus are getting better,” he added.
C.K. is alive and well 5 years later, when I saw him at his doctor-wife’s office party. While we don’t know the conclusion to C.K.’s story, I believe his case does highlight two important points:
Tongue-tie can contribute to an impaired mouth, pinched airway, and eventually sleep apnea.
Tongue-tie is worthy of attention—and the earlier, the better.
Holistic Mouth Bites
Tongue-tie can contribute to an impaired mouth, pinched airway, interrupted sleep, and a host of related health troubles. Research has shown that apnea and other sleep-disordered breathing appear to raise cancer risk.
Breast-feeding is a crucial part of healthy orofacial development, letting the tongue do its work as a natural palatal expander.
Unrecognized tongue-tie is all too often the first step in health’s downward spiral. Releasing tongue-tie early is good proactive care.
Chapter Fifteen
Enjoying Freedom from CPAP: Case Study
Oftentimes, I recommend a referral to a dentist to treat obstructive sleep apnea. Most patients will ask me, “How is a dentist going to help me?” My answer is that since obstructive sleep apnea is mainly a problem from small jaws and crooked teeth, they have a variety of different ways of helping you to breathe better and sleep better.
– Steven Y. Park, MD,
Author of Sleep Interrupted(1)
“I can’t get comfortable sleeping with a CPAP mask,” said Robert, a fifty-eight-year-old gentleman at his first visit, “yet I know the importance of the airway and oxygen. Can I try an oral appliance instead?” He had been on a CPAP device for two years after a sleep test had diagnosed OSA.
At our initial consultation, Robert said his issues were daytime fatigue, needing a nap every day, annoying low back pain, and high blood pressure (140/90 where normal is less than 120/80). His Holistic Mouth checkup revealed good dental health with no cavities, nor gum disease, and:
Medically diagnosed OSA with an AHI of 9.9 during REM sleep
Low sleep efficiency at 79 percent, meaning he was not asleep 21 percent of the time he was in bed; his REM sleep was half of healthy normal at 16 percent.
Mild forward head posture and posterior head rotation suggestive of airway deficiency
Signs of teeth grinding, including generalized abfractions, gingival recession, and matching wear facets
Mild to moderate crowding of his lower front teeth, suggesting a deficient maxilla
A grade 4 Friedman tongue position (uvula not visible) suggests a high risk for OSA(2)
An airway width of 5.57 mm at its narrowest on his 3D-CT scan, or less than half of low normal; his oral airway volume was 15.5 cc, about 40 percent less than comfortable.
I find this a very useful clinical pearl: “In adults, it is likely that palatal and mandibular tori are manifestations of undiagnosed sleep-disordered breathing, and may represent a valuable diagnostic sign in the triad of TMD, sleep-disordered breathing, and malocclusions.”(3)
Cephalometrics showed a low ceiling for his “three-foot cage” and a Class III skeletal malocclusion—Robert’s maxilla was retruded by 13 mm. The net effect was cramped quarters, forcing his tongue into his throat. This is how a retruded maxilla contributes to sleep apnea.
Narrow Maxilla and OSA
If your paycheck is cut by 7 percent, do you feel it? The jaw width of OSA patients in Malaysia was found to be 7 to 11 percent narrower near the front of the upper dental arch, and 10-11 percent narrower in the molars region than non-OSA patients. “Supporting their role as etiological factors, size and shape differences in dental arch morphology are found in patients with OSA.”(4)
Robert’s Holistic Mouth Solutions Treatment Plan
At Robert’s request to “keep it simple,” we tried a mandibular oral appliance (OAm) first, but it failed to help his symptoms because his airway issue was rooted in his retruded maxilla.
He then opted for biomimetic (OAb) oral appliances. I used a type called an mRNA appliance, which combines maxilla treatment with mandibu
lar advancement. We would redevelop his airway by epigenetically regrowing his maxilla in width, length, and height.
Robert was instructed to wear the appliance fourteen to sixteen hours a day, including during sleep, and turn the expander screw once a week. He was to see his own doctor and chiropractor as needed. I also provided sleep hygiene instructions: eat a small dinner at least four hours before bedtime; use blackout blinds in the bedroom; have no TV, cell phone, tablet, or computer there; and be in bed by 10:30 p.m. and asleep by 11 pm.
He would return once a month so that I could monitor his progress and adjust his bite as needed.
Results: CPAP Freedom
After a week of wearing the appliance, Robert said in a video for patients coming after him:
My name is Robert from Stafford, Virginia. I have had a week’s time with the DNA appliance, both the upper and the lower. I had been using CPAP in the past and did not care for it at all. I did get some relief from my sleep apnea, but I do prefer the DNA device: less care with hoses and cleaning, and I am feeling quite refreshed. Don’t need a nap in the afternoon like I did in the past. So if you are thinking of trying it, so far it’s been a very positive experience for me.
Over the course of two years, Robert made excellent progress. He gained 72 percent in his minimal airway width (9.56 vs. 5.57 mm) and 40 percent in airway volume (21.7 vs. 15.5 cc), and his jaw opening between the front teeth widened by 5 mm, indicating more relaxed jaw muscles. His Epworth sleepiness scale score dropped 47 percent, from 15 to 8, compared with the range of 0-10 in adults without a chronic sleep disorder.(5)
Robert then took a break from therapy for one year before resuming oral-appliance therapy. He made a second video two years from the start: