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 these resources:
The Workshop
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.)
The Functional Assessment of TOTs
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. Demonstrations, practicums and video slides teach participants to execute both a structural and functional assessment with child and adult protocols, including the TOTs 5-Step Screening Tool.
The Functional Remediation of TOTs
Specific neuromuscular re-education tasks that assist with the functional impact of TOTs on pre-feeding, feeding and speech — specific passive and active exercises for breast, bottle, cup, spoon, solid and straw feeding, plus the oral placements required for speech clarity.
Workshop Combo: Assessment & Remediation
TOTs is now offered as a 2-day course, available 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 lead this two-day course covering both Assessment and Remediation of Tethered Oral Tissues.
Get a peek at what you'll learn!
"Tongue on a Shelf" exercise from 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.
Buy Your Book Today!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 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, and is on track to become an IAOM Certified Orofacial Myologist.
I went to Montclair State College as a dance major. A bad cold that turned into bronchitis kept me from performance classes, and I was afraid of failing. My aunt Janine was an SLP clinical supervisor on campus — I watched her doing speech therapy with a baby through the clinical two-way mirror, and it hit me that I wanted to help people in that same way. I changed my major to Communication Sciences and Disorders and I was on my way.
My Aunt Janine introduced me to Sara Rosenfeld-Johnson and what was then Innovative Therapists International (now TalkTools). I saw Sara teach and I was hooked — even when a professor told me blowing horns couldn't help articulation. I already knew it isn't just about the horn, because it's about the hierarchy and the feel of speech. I later developed a Myofunctional program (SMILE) in my school system, and Sara and her husband Phil agreed to publish it as long as I agreed to teach it. I've dedicated my career to the TalkTools family ever since.
Lori Overland, MS, CCC-SLP, C/NDT, CLC, FOM
Lori Overland, MS, CCC-SLP, C/NDT, CLC is a speech and language pathologist with more than 36 years of professional experience, specializing in 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, consults with children from around the world, and is a member of the TalkTools® speakers bureau. She teaches TOTs, Feeding and Down Syndrome courses, holds degrees from Hofstra and Adelphi University, and has her neurodevelopmental certification and lactation counselor certification.
I was a pre-law major undergrad, but after being closed out of a course I needed, a friend's elective — Introduction to Speech and Hearing Sciences — filled my schedule instead. The professor was the most entertaining speaker I'd had in college. One class led to another, and before I knew it my "unintended" major was far more appealing than pre-law. Observing my future sister-in-law's SLP practice for a day sealed it — I was hooked, and happy to trade law briefs for working with children.
Sara Rosenfeld-Johnson called me out of the blue and said, "I never get reports from Speech Pathologists that talk about feeding, do you want a job?" I declined at first, wondering who offers a job to someone they haven't met — but Sara was persistent. Taking that job changed the way I evaluate and treat my clients. Sara was the first therapist I met who looked at underlying motor skills, asking "Where does your mouth have to be to make the sound?" That question has shaped my entire career.
Convention Presentations
1-hour seminar: TOTs: A Hot Topic! — Presenting Authors: Lori Overland, MS, CCC-SLP, C/NDT, CLC; Robyn Merkel-Walsh, MA, CCC-SLP, COM®
Poster: SLP's Role in Post-Frenectomy Care for Children Who Present With Feeding Challenges — Authors: Lori Overland (presenting); Robyn Merkel-Walsh
EBP & Newsletters
EBP (Evidence-Based Practice)
TOTs Newsletters
Explore the TalkTools blog for more articles on TOTs, feeding, and myofunctional therapy.
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 ankyloglossia. 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 asha.org.
OPT/Feeding/Myofunctional Therapy
Board Certified Orofacial Myologist®
Ridgefield, NJ
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