TOTs (Tethered Oral Tissues)

What is TOTs?

TOTs (Tethered Oral Tissues) has become a common acronym used by speech, feeding and dental professionals, and those who practice orofacial myofunctional therapy. TOTs includes lingual restriction -- also known as ankyloglossia -- but can also be a restriction of the frena of the lips and cheeks, by a band of tissue. There are seven frena in the oral cavity that can be impacted by TOTs. The Mayo Clinic has indicated that tongue tie can affect the way an individual eats, speaks, swallows and can interfere with breastfeeding. With the topic of TOTs comes some controversy, and speech-language pathologists are often left confused in their own role of diagnosing and treating TOTs.

For more information on TOTs, check out this in-depth TOTs Newsletter

TOTs Surgical Team Cheat Sheet

The Workshop

NEW WORKSHOP OPTIONS -- now virtual!

So many speech and feeding professionals told us they needed more information and training on this essential topic -- so we've expanded our original course! Have a look at the options (Note: courses can be taken as a single-day option or as a combo)

    • OPTION 1 -- The Functional ASSESSMENT of TOTs:
      This course provides participants with a “Task Analysis” of TOTs, walking through breast, bottle, cup, spoon, solid and straw feeding in addition to the oral placements required for speech clarity. Numerous demonstrations, practicums and video slides will teach participants to execute both a structural and functional assessment with child and adult protocols. Participants will also learn how to use a TOTs 5-Step Screening Tool. This course is rich with evidence based practices and will address many of the controversies that make TOTs a “hot topic”.
    • OPTION 2 -- The Functional REMEDIATION of TOTs:
      This course provides participants with specific neuromuscular re-education tasks that will assist with the functional impact of TOTs on pre-feeding, feeding and speech. Robyn and Lori will teach participants specific passive and active exercises for breast, bottle, cup, spoon, solid and straw feeding in addition to the oral placements required for speech clarity. This course is rich with evidence based practices and will address many of the controversies that make TOTs a “hot topic” (e.g., who is the team leader?).
    • NEW! OPTION 3 -- WORKSHOP COMBO: The Functional ASSESSMENT & REMEDIATION of TOTs (combination of Workshop 1 and Workshop 2):
    • TOTs is now offered as a 2 day course! You now have the option to take this course from anywhere in the world. TOTs experts Robyn Merkel-Walsh, MA, CCC-SLP, COM®️ and Lori L. Overland MS CCC-SLP, C/NDT, CLC, FOM. will lead this two-day course that will bring you both the Assessment AND Remediation of Tethered Oral Tissues (TOTs).

Get a peek at what you'll learn!

"Tongue on a Shelf" exercise from the book, Functional Assessment and Remediation of TOTs

The Book

TOTs experts Robyn Merkel-Walsh, MA, CCC-SLP, COM®️ and Lori Overland, MS, CCC-SLP, C/NDT, CLC have created a comprehensive, evidence-based program to assist in the identification and functional implications of TOTs. The Merkel-Walsh and Overland TOTs Protocol is explained in the new co-authored book, Functional Assessment and Remediation of TOTs (Tethered Oral Tissues). This practical speech and feeding program includes a pre- and post-surgical treatment plan to avoid long-term issues, such as scarring and reattachment.

The Experts

Robyn Merkel-Walsh, MA, CCC-SLP, COM®️ 

Robyn Merkel-Walsh, MA, CCC-SLP, has specialized for over 24 years in OPT, myofunctional disorders and feeding disorders. She is employed by the Ridgefield Board of Education, runs a private practice in Ridgefield, NJ, is the board chair of the Oral Motor Institute, and is a member of the TalkTools® speakers bureau. She teaches TOTs, Autism and Tongue Thrust courses in addition to multiple webinars on topics including but not limited to lisps, oral structure, Orofacial Myofunctional Disorder, feeding and clinical parameters for Autism Spectrum Disorder. Robyn has been invited to speak on Oral Placement disorders by Conversations in Speech Pathology, Bergen County Region V, the IAOM, The Apraxia Network, AAPPSPA and the MOSAIC Foundation. Robyn has received specialized training in Oral Placement Disorders, feeding, apraxia, Applied Behavioral Analysis, autism, cranio-facial anomalies, Beckman Techniques and PROMPT and is on track to become an IAOM Certified Orofacial Myologist.

WHY I BECAME AN SLP... I went to Montclair State College (now University) as a dance major. My first semester wasn't going well as I caught a bad cold that turned into bronchitis and sinusitis. The intense demands of performance classes didn't allow for absences. As an honors student, I never received a bad grade and I was afraid of failing. My aunt Janine was working as an SLP clinical supervisor on campus. I went to meet her to get a care package. I saw her working through the clinical two-way mirror doing speech therapy with a baby. It just hit me that I wanted to help people in that same way. I changed my major that month to Communication Sciences and Disorders and I was on my way!

MY OPT STORY... Once again, it was my Aunt Janine who taught me about Sara Rosenfeld-Johnson and what was then "Innovative Therapists International" (now TalkTools). I saw Sara teach at the NJSHA convention and I was hooked, even when when my professor told me that blowing horns couldn't help articulation. I already knew it isn't just about the horn, because it is about the hierarchy and the feel of speech. I continued my training with Sara and Lori as well as the great masters including: Bahr, Beckman, Marshalla and the IAOM. I reached out to Sara directly in 1998 because I had been developing a Myofunctional program (SMILE) in my school system because traditional methods weren't working. Sara insisted we meet, and she and her husband Phil agreed to publish my program as long as I agreed to teach it. The rest is history. I've dedicated my entire career to the TalkTools family and our extended family - the people we are able to help through our methods and programs. My role is not only author and lecturer, but most importantly an advocate for evidence based practices that support the work we do.

Lori Overland, MS, CCC-SLP, C/NDT, CLC, FOM

 Lori Overland, MS, CCC-SLP, N/NDT, CLC is a speech and language pathologist with more than 36 years of professional experience. Lori specializes in dealing with the unique needs of infants, toddlers, pre-schoolers and school-aged children with oral sensory-motor, feeding and oral placement/speech disorders. She has received an award from the Connecticut Down Syndrome Association for her work within this population. Lori consults with children from all over the world, providing evaluations, re-evaluations, program plans and week-long therapy programs. Lori also provides consults to local school districts and Birth-to-Three organizations. Her goal in addressing feeding and speech challenges is to improve the quality of life for both the children she serves and their families. In addition to her private practice, Alphabet Soup, Lori is a member of the TalkTools® speakers bureau. Lori has lectured on sensory-motor feeding disorders across the United States and internationally. She teaches TOTs, Feeding and Down Syndrome courses in addition to her pre-feeding webinar. Lori holds degrees from Hofstra University and Adelphi University and has her neurodevelopmental certification and is a certified lactation counselor.

WHY I BECAME AN SLP... It’s crazy… but I was a pre-law major undergrad. After two semesters of required classes (still not sure how biology is related to pre law) and introduction to justice research, writing and reasoning, I was closed out of an introduction to judicial process course (that I am sure would have been equally boring and just as much writing!). One of my friends was registered for an introduction to speech and hearing sciences class that fulfilled an elective requirement. Needing to fill my schedule, I reluctantly signed up for the course. The professor was the most entertaining and interesting speakers I had thus far in college. One class led to another and before I knew it I had a dual major, and the unintended major was much more appealing. When my “future” sister in-law, who was coincidentally an SLP, invited me to spend the day observing her practice, I was hooked. It was easy to give up reading law briefs to work with children!

MY OPT STORY... The phone rang and a woman introduced herself as Sara Rosenfeld-Johnson. Sara said, “I never get reports from Speech Pathologists that talk about feeding, do you want a job?” 'Who is this crazy lady,' I thought. I thanked her and graciously declined the offered, wondering who would offer a job to someone they had not met. Sara was persistent and talked me in to a co-treat session with this child we were sharing.

My journey as an SLP, at that time, was filled with more questions than answers. Some of my frustrations included how I should work with children who did not have the underlying motor skills to support intelligible speech (and could not look, listen and imitate the sound) and WHY I was asked to write language goals to increase the length of utterance in a child who was unintelligible to the uncued listener. Sara was the first therapist I met who was looking at underlying motor skills. Many years before she defined OPT, she was asking the question "Where does your mouth have to be to make the sound?" and looking at the underlying motor skills to support intelligible speech. I DID take the job the “crazy” lady (who became my good friend and mentor!) offered me, and it changed the way I evaluate and treat my clients. It opened the door for me to apply similar task analysis to the motor skills used for safe, nutritive feeding and allowed me to figure out why so many of my clients were picky or problem eaters. This career has always been more of a marathon than a sprint, and the day I hit the finish line I will retire!

Convention Presentations


2022 IAOM CONVENTION | Kansas City | OCT 2022










EBP (Evidenced-Based Practice)

  • Go to TalkTools References for a complete list of references

TOTs Newsletters

  • TOTs 101, Do you need help explaining pre- and post-op therapy to parents? Look no further than this exploratory newsletter, written by TalkTools instructor, Robyn Merkel-Walsh.
  • TOTs, What you need to know: This article focuses on what parents and physicians need to know about tongue tie.

For more information on TOTs, check out this in-depth TOTs Newsletter



TOTs Blog

The OMI worked in collaboration with ASHA to update the Orofacial Myofunctional Disorders portal on the SLP's role in the assessment of ankylogossia. The new portal reads as follows:

Ankyloglossia, also referred to as tongue-tie or tethered oral tissue(s) (TOTs), is a medical diagnosis. The decision to perform a frenectomy, frenotomy or frenuloplasty is a medical decision made on a case-by-case basis by dentists, oral surgeons, and otolaryngologists. As members of an interdisciplinary team, SLPs may be asked to provide input on the functional implications caused by a tongue-tie or help support medical necessity for surgery. If concerns regarding the frenulum's structure or function arise during an examination of the orofacial complex, a referral to a surgeon who has experience with frenectomies should be made. There is evidence that releasing a tongue-tie may improve breastfeeding function (Ghaheri et al., 2021; Buryk et al., 2011), and preliminary evidence continues to evolve regarding speech and feeding beyond the breast (Baxter et al., 2020; Ghayoumi-Anaraki et al., 2022). See ASHA's Practice Portal pages on Pediatric Feeding and Swallowing, Adult Dysphagia and Speech Sound Disorders."

Thanks to the American Speech -Language and Hearing Association for recognizing the evolving evidence based practices that are so important for SLPs and the patients and students they service, by acknowledging our critical roles in the diagnosis and treatment of Tethered Oral Tissue(s).

Reference: American Speech-Language-Hearing Association. (n.d.). Orofacial Myofunctional Disorders. (Practice Portal). Retrieved 05/08/23, from

Link Here

Robyn Merkel -Walsh MA CCC -SLP COM®️
Licensed Speech Pathologist
OPT/Feeding/Myofunctional Therapy
Board Certified Orofacial Myologist®️
Ridgefield , NJ

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