ASHA 2018 Presentation Handout

TOTs: A Hot Topic!

1-hour Seminar
Session #1609
Friday, November 16, 2018 at 5-6 PM
CC/254B (Level 2)
Authors: Robyn Merkel-Walsh, MA, CCC-SLP & Lori Overland, MS, CCC-SLP, C/NDT, CLC


Presentation explores:
  1. What is TOTs?
  2. Why is TOTs a hot topic?
  3. Surgical controversies and
  4. Therapeutic controversies


TOTs! This acronym for Tethered Oral Tissues is appearing in blogs, social media and speech pathology workshops. Three terms are being used synonymously to identify this condition:
  1. Ankyloglossia
  2. Tongue-Tie and
  3. Tethering of Oral Tissues (TOTS)
Tethering of Oral Tissues (TOTs) is a fairly new term that was coined by Kevin Boyd, DDS at the International Association of Tongue-tie Professionals at their annual conference in Quebec, Montreal Canada in October of 2014. TOTS as a term is more inclusive of tissue restriction of the tongue, lips and buccal frena (Boyd, 2014).

TOTs has been called a “fad” by some (Ghaheri, 2014), and well known clinicians such as Kummer, have presented articles and blogs about unnecessary surgical intervention (Kummer, 2016). Ghaheri (2014) stated that TOTs is not a fad, and increased awareness is based on recently discovered genetic factors and the increased rate of breastfeeding. TOTs has also been brought into the limelight due to the Brazil’s Teste da Linguinha/Frenulum Inspection Law which now requires all infants to have their frenulum inspected at birth, and revised, if warranted (Martinelli, Marchesan & Berretin-Felix, 2012).
The ASHA Leader Blog had an ongoing debate about Evidenced Based Practices (EBP) regarding TOTs and the question of the SLP’s role in this controversy (Potock, 2015; Potock, 2017; Merkel-Walsh, 2017). Clinical symposiums have included: Connecting the Dots for TOTs (Siegel, Calasuma, Emanuel, Fabbie, Watson-Genna, Merkel-Walsh & Overland, 2017) and manuals and texts have been published such as: The Functional Assessment and Remediation of TOTs (Merkel-Walsh & Overland, 2018), Please Release Me - The Tethered Oral Tissue Puzzle (Pine, 2018) and Demystifying the Tongue Tie (Boshart, 2015). In the past few years, ASHA Conventions have also featured sessions and poster sessions regarding TOTs (Meaux, Savage & Gonsoulin, 2016; Kummer, 2016; Merkel-Walsh & Overland, 2017) with disagreements among the presenters regarding the need for surgical and therapeutic interventions.
Organizations such as the International Association of Orofacial Myology (IAOM) and the Academy of Orofacial Myofunctional Therapy (AOMT) have been highlighting this diagnosis and implications for therapy and surgery. As SLPs we do not learn a great deal about TOTs in our collegiate education, but can learn more about the condition on a post-graduate level. Linda D’Onofrio presented at the ASHA Convention in 2017 about the importance of teaching students orofacial myofunctional therapy in their graduate programs (D’Onofrio, 2017a). To date, SLP’s who want specific TOTs education have relied on interprofessional workshops held by the IAOM or AOMT, or TOTs organizations such as the International Affiliation of Tongue-Tie Professionals (IATP) and the International Consortium of oral Ankylofrenula Professionals (ICAP). Training can be intensive but also expensive and the quest for certification level programs is raising interprofessional tensions. SLPs as consumers must be cautious regarding the credentialing agency and what their certification actually means in regards to state licensure and national certification, such as the Certificate of Clinical Competence from ASHA.
The areas of research that are most prevalent regarding TOTs include: the impact of TOTs on breastfeeding (Merdad & Mascarenhas, 2013) and the possible relationship of TOTs and aerophagia (Siegel, 2017). Other researchers have linked TOTs to Obstructive Sleep Apnea (OSA) (Huang, Quo, Berkowski & Guilleminault, 2015). There is emerging evidence that orofacial myofunctional therapy is an effective treatment method in OSA (Camacho, Certal, Abdullatif, Zaghi, Ruoff, Capasso & Kushida, 2015), and this once again leads to the question of what professional scope encompasses this treatment. Certainly with upper aerodigestive tract and respiration written into the SLP’s Scope of Practice (ASHA, 2016) this may be an evolution in the therapeutic practices of SLPs.


So why is TOTs such a hot topic? Over the past few years, TOTs has been more frequently discussed in the fields of lactation, speech pathology, oral surgery, orofacial myology and otolaryngology. Not only is it discussed, there seems to be an ongoing social media war regarding diagnosing and treating TOTs. This presentation explores the following debates:
HOT TOPIC #1: Best Practices for surgical revision (scissor versus laser)
TOTs surgery known as: frenectomy or frenotomy, can be performed by several surgeons, but is usually performed by dentists, oral and maxillofacial surgeons, or otolaryngologists. There are two procedures that are often performed: scalpel/scissor or laser. Generally, the revision of TOTs is a low risk procedure. Common complications include mild pain, bleeding, reattachment, scarring and incomplete release (Raghevendra-Reddy, Marudhappan, Devi & Narange, 2014; Siegel, 2017; Ghaheri, 2015 Chabey, Arora, Thakur & Narula, 2011).

Several isolated incidents were reported in the literature. For example:
  • Yang, Woo, Won, Kim, Hu, & Kim (2009) reported possible tongue tip numbness with frenectomy.
  • Schuster (2014) chronicled her neuropathy pain from an errant stitch post-frenectomy that caused complex medical complications with pain management through pharmaceuticals. 
  • Genther, Skinner, Bailey, Capone, & Byrne, (2015) looked at airway obstruction after lingual frenulectomy in two infants with Pierre-Robin Sequence. 
  • Walsh & Kelly (1995) reported an upper airway collapse. 
These are unique cases, as most patients have an uneventful procedure, but it is important to note that no surgery goes without risks.

Both scissor/scalpel and laser procedures have evidence base in the literature. In the text by Merkel-Walsh & Overland (2018), Dr. Anthony Jahn presented the positive outcomes of scissor /scalpel frenectomy which included: controlled surgical release with time to assess the patient while under a brief period of anesthesia, decreased pain, decreased anxiety and primary healing. Dr. Scott Siegel presented detailed information on the use of a CO2 laser, and the advantages were listed as: the ability to cut and cauterize simultaneously and the avoidance of general anesthesia. Dr. Jahn concurred that the laser procedure can have advantages especially in the cases of anterior lingual restriction.
HOT TOPIC #2: Who Leads a TOTs Team?
When treating individuals with a diagnosis of TOTs, there is a team of professionals that may be involved. Based on extensive literature review on an international level, this includes but in not limited to: the surgeon (dentist, oral maxillofacial surgeon, ENT), speech-language pathologist (SLP), registered dental hygienists (RDH), bodyworker (occupational therapist, licensed massage therapist, physical therapist, CranioSacral provider, chiropractor etc.) and/or a lactation consultant (IBCLC). There are often debates as to who the team leader should be, but ideally, if the proper cycle of patient care occurs, TOTs care is a team model. The patient will first be seen by the team member who does the initial evaluation. This will vary based on the presenting symptoms. The initial consultation may not be for TOTs specifically, but rather a symptom itself such as: a self-limited diet (Potock, 2017), or breastfeeding difficulties (Merkel-Walsh & Overland, 2018). If TOTs is observed, the initial evaluator should refer to the other team members based on both structure and function, and make the proper referrals to lead the patient to pre-and post-operative care. With all the professionals involved it can become confusing to the patient, so it is important to determine how TOTs is impacting functional skills to pair the patient with the proper specialists.

HOT TOPIC #3: What is the need for a specific certification (Certified Orofacial Myologist®)?

Currently, the Certified Orofacial Myologist (COM®) is the only trademarked, board regulated certification that has been widely accepted for many years. This certification is available to professions that have orofacial myofunctional therapy written in their scope of practice. To date, this has been limited to speech-language pathologists, registered dental hygienists and dentists/physicians (IAOM, 2018). According to a personal communication with Mary Billings, past president of the IAOM, the IAOM protects the public by: maintaining professional eligibility; completing the educational curriculum and requirements in a timely manner; requiring passing a written and clinical skill assessment; maintaining membership within the certifying organization; adhering to organization policies, procedures and ethical standards of care; and meeting continuing education requirements in a timely manner to ensure ongoing competency. It is important to note that according The American Speech-Language-Hearing Association, orofacial myofunctional disorders and structural anomalies fall under the SLP’s scope of practice; therefore SLP’s may deliver orofacial myofunctional therapy without the COM™ certification (ASHA, 2016). Additional training for professionals regarding TOTs care can be obtained via TalkTools®, Chrysalis Feeding, ITAP, ICAP, AOMT, Lactation Education resources and other profit and non-profit organizations.

HOT TOPIC #4: Scope of Practice

There are other professions that encompass breastfeeding, feeding and active wound management into scope such as: occupational therapy, lactation consulting and physical therapy. In some cases these professionals are calling themselves “Orofacial Myofunctional Therapists” after various post-graduate training courses and this adds to the ongoing controversy, since there are currently no U.S. states that have licensure or certification for the professional title Orofacial Myofunctional Therapist. Many SLPs on social media are expressing concerns regarding professional encroachment. Since ASHA cannot enforce the professional scope of other professionals this leads to frustration within our field.

Pediatric feeding therapy should not be confused with OMT (Holtzman, 2018). Merkel-Walsh (2018) points out that it is essential to recognize the variation between pediatric feeding therapy and orofacial myofunctional therapy and determine by age which is more appropriate. D’Onofrio (2017b) outlined the similarities and differences in her recent ASHA presentation. When working with infants and toddlers with TOTs, there may be many members of the team who help assist with posture and alignment, feeding, oral rest posture, and speech (Merkel-Walsh & Overland, 2018); however it is important to remember that there is no such license for an orofacial myofunctional therapist nor was OMT meant to be done with infants or children below the age of four (Holtzman, 2018). An SLP is unique to have both pediatric feeding and OMT within scope and is a likely provider for TOTs patients. Professionals are encouraged to stay in their lane, as quoted from social media from Emanuel (2018), while working collaboratively for TOTs patients.

HOT TOPIC #5: The Role of the Bodyworker

As aforementioned, TOTs is a team approach. A bodyworker is a relatively new term in relation to TOTs in infants. The Ankyloglossia Bodyworkers is an organization encompassing many of the professionals who have specific training in the remediation of TOTs. According to the website:  A bodyworker is a professional who has a hands-on license to touch and extensive continuing education hours in CranioSacral therapy, Myofascial release, etc. A licensed professional may be an occupational, physical or speech therapist, chiropractor, osteopath, nurse, massage therapist, among others. Bodywork helps a baby with body awareness and maximizes baby’s access to postural reflexes and natural movement inclinations through the nervous system (Price-Emanuel, 2017).

HOT TOPIC #6: Pre- and Post-Operative Care:

Pre-operative care is important when considering a frenectomy. Not only is it beneficial for establishing baseline skills, it can be critical for those patients who do not readily accept intraoral stimulation. Neuromuscular re-education can start prior to surgery to maximize the success of the therapy after a surgical revision (Merkel-Walsh & Overland, 2018).

Post-operative therapy is important for three main purposes:

  1. Decreasing the risk of scarring;
  2. Decreasing the risk of reattachment and
  3. Improving functional skills for feeding and speech.

Generally there are two phases of post-operative therapy. The first stage is stretching exercises that are scripted from the surgeon/physician’s office. This is more common in laser revisions with a dentist or oral surgeon. According to Dr. Scott Siegel (Merkel-Walsh & Overland, 2018), these stretching exercises for the active wound management are not in substitution for the functional exercises that are prescribed by the feeding/speech/myofunctional therapist, they are in addition to these other exercises.

The second stage of treatment is what Merkel-Walsh & Overland (2018) describe as neuromuscular re-education. The authors stress the importance of task analyzing the oral sensory-motor skills needed for feeding and speech and how TOTs may impact those skills. Strategies are then outlined for remediating the functional impact of TOTs. There are several additional therapeutic manuals such as: Please Release Me: The Tethered Oral Tissue (TOT) Puzzle (Pine, 2018) and Demystifying Tongue Tie, Methods to Confidently Analyze and Treat a Tethered Tongue (Boshart, 2015).

Both stages of treatment are equally as important. This is why patients should be encouraged to have post-surgical sessions scheduled with the appropriate therapist(s) after the revision. Therapy can start several days after the procedure with medical clearance. There must be a diamond-shaped wound in order to have a full release of a tongue- tie (Ghaheri, 2015). Patients are instructed to keep the diamond open (Merkel-Walsh & Overland, 2018). Scissor or scalpel procedures may or may not discuss a diamond depending on the type of procedure completed. There has been debate on working on or off the wound. In reviewing multiple physicians’ aftercare websites, the majority of physician’s suggest working off the wound(s). Abrasive agitation of the wound is contraindicated. Passive and active stretches maintain the integrity of the wound and prevent scarring and reattachment (Ghaheri, 2015).


In summary, it is important for SLPs to learn the latest research regarding the hot topic of TOTs. Numerous professionals are involved in the diagnosis and remediation of TOTs including: lactation consultants, OTs, PTs, chiropractors, dental hygienists, oral surgeons, dentists and otolaryngologists. Without proper academic education, the SLP’s role is slowly diminishing out of this multidisciplinary team. Since orofacial myofunctional therapy, feeding and articulation therapy for TOTs is often a post-graduate specialty for a small number of practicing clinicians; other practitioners within reasonable scope of practice are treating TOTs which may risk leaving SLPs out of the team. We must elevate our professional knowledge to move forward and maintain our important role as experts in orofacial myofunctional therapy, feeding and speech to include aerodigestion and respiration in our diagnostic and treatment protocols for TOTs patients.


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