TOTs: A Hot Topic!
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
- What is TOTs?
- Why is TOTs a hot topic?
- Surgical controversies and
- Therapeutic controversies
- Tongue-Tie and
- Tethering of Oral Tissues (TOTS)
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).
PRESENTATION OF THE PROBLEM
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.
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 #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:
- Decreasing the risk of scarring;
- Decreasing the risk of reattachment and
- 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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