Is the incidence of tongue-tie increasing? Why are health professionals identifying ties more often? What risk is there from this simple operation?
Large temporal increases and substantial spatial variations in ankyloglossia and frenotomy rates have been observed that may indicate a diagnostic suspicion bias and increasing use of a potentially unnecessary surgical procedure among infants (Joseph, Kinniburgh, Metcalfe, Razaz, Sabr, & Lisonkova, 2016).
Increase in the number of faulty babies?
The figures suggest that currently there exists an epidemic of over diagnosis and over treatment of tongue and lip-ties.
- In Australia, between 2006 and 2016, there was a 420% increase in the rate of frenotomies per 1,000 children aged 0 to 4 years (Kapoor, Douglas, Hill, Tennant, & Walsh, 2017).
- Similarly, in the U.S.A. there has been an 834% increase between 1997 and 2012 (Walsh, Links, Boss, & Tunkel, 2017).
- Canada has seen an 89% increase from 2004 to 2013 (Joseph et al., 2016).
There are no data to indicate any underlying changes in recent years in the prevalence of tongue-tie, says Australian Dental Association Queensland (ADAQ) President Gary Smith and goes on to express concern over those practising ‘at the fringe of dentistry’ who ‘have linked in their minds the release of lip and tongue ties to all manner of long term health issues’ in, for instance, orthodontics, speech, posture, and sleep.
Following these and other concerns relating to this widespread therapeutic illusion, the ADAQ Council has approved a submission to the Dental Board of Australia requesting guidance for dental practitioners on tongue and lip-tie surgery. It refers to bias and self-promotion by practitioners who have made a considerable income and built their professional reputations from surgically treating tongue-tie and promoting others to do likewise [one popular U.S. practitioner is named as an example].
“Not surprisingly, there are many half-truths and fallacies pushed by those who promote tongue tie surgery for financial gain.” ADAQ News (December 2017) 643, 5-6.
Risk to the community
In June this year, a dentist performed upper lip-tie surgery on a baby. When the baby was back home and eight hours away, the dentist reported on social media that the patient had developed a delayed bleeding episode. Having no idea what to do, the dentist was asking for help in a Facebook group alongside a disturbing photo of the baby wearing a blood covered bib and bleeding from the corner of its mouth. The child was clearly in considerable distress and a second close-up photo of the crying baby’s mouth revealed an inflamed wound.
The dentist was communicating via Skype with the baby’s parents and had recommended a tea bag compress and keeping the child in an elevated position. Wondering whether the parents might see a local dentist had caused this dentist to fear that the new dentist might ‘freak out’ making ‘matters worse’. Participants in the Facebook group offered various suggestions but it was some time into the conversation before any one recommended taking the baby to hospital. This baby might easily have died. The dentist is popular and well known, a so-called ‘preferred provider’ and is still practising as a prominent speaker in tongue-tie education.
Researchers at the University of North Carolina, Department of Otolaryngology, recently published a study describing two cases of hypovolemic shock following outpatient labial and lingual frenulectomy. (Hypovolemic shock is an emergency condition in which severe blood or fluid loss makes the heart unable to pump enough blood to the body. This type of shock can cause many organs to stop working.) The patients required emergency interventions of cardiopulmonary resuscitation and blood transfusion. These rare, but life-threatening outcomes warrant recognition as potential complications illustrate the real harm that can follow this presumed benign and low-risk procedure (Tracy, Gomez, Overton, & McClain, 2017).
Those examples are extreme. However, you can read, daily, on Facebook posts from mothers reporting the anguish their babies go through following these surgeries; here are just two examples:
- A dentist told parents of an 11-week-old that it would take a maximum of ten minutes to laser his tongue and lip-ties, and whisked him off, only to return him forty minutes later, ‘shaking and screaming like crazy’. Rather than handing the baby to his mother, the parents were first shown how to do stretches on his wounds. (There is no evidence to support the efficacy of post surgical stretches that further traumatise a wound.) The baby was difficult to calm and the parents were informed that the tie had been ‘severe’, ‘all the way down to the muscle’. The baby, who had been quite settled prior to the surgery, remained unhappy and crying in between bouts of sleep and refused to breast or bottle-feed. The parents visited the cranial sacral therapist and chiropractor recommended by the dentist and when nothing they did helped, they went to the paediatrician four days later, who found the wound in the baby’s mouth to be deep and aggressive.
- We had an upper lip-tie and posterior tongue-tie lasered on Friday. The dentist and lactation consultant said his tongue was connected right up to his lower gum line, which I assume means it was a more severe restriction. Immediately after the procedure, he was fine. However, by evening he was inconsolable and wouldn’t feed. We started using pain relief medication and without it he refused to feed at all. It’s now Wednesday evening and I stopped giving pain meds earlier today and he is inconsolable. I am worried he is in pain. Is this normal? How long do more severe tongue-ties take to heal up and stop hurting?
What is a ‘severe’ tie? How long is the pain following surgery expected to last? How many parents report the practitioner when the surgery did not go well? How many practitioners would report another practitioner for carrying out a surgery they believed was unnecessary or bungled? Whose job is it to identify a tongue-tie and how? There are a lot of questions.
Not infrequently tie surgeries do not facilitate easier breastfeeding, which is often the purpose for carrying them out. Some parents subject babies with no feeding problems to tie surgery in fear of future ramifications. You can find memes on Facebook listing supposed problems that will transpire in the coming years if you don’t laser or cut restrictive oral tissues, yet there is no evidence to support any claims of these supposed future consequences.
Let’s start calling these severing procedures ‘surgeries’ rather than trying to soften the nature of the invasive intervention. After all, even when skilfully and painlessly performed, these are body modifications. And sometimes they are mutilations.
Joseph, K. S., Kinniburgh, B., Metcalfe, A., Razaz, N., Sabr, Y., & Lisonkova, S. (2016). Temporal trends in ankyloglossia and frenotomy in British Columbia, Canada, 2004–2013: A population-based study. CMAJ Open, 4(1), E33–E40. doi:10.9778/cmajo.20150063
Kapoor, V., Douglas P. V., Hill, P. Tennant, M., Walsh, L.J. (2017). Australian national and state trends in paediatric frenotomy rates for tongue-tie, 2006–2016: Early evidence of an apparent epidemic? Med J Aust. in press.
Smith, G., Australian Dental Association Queensland President (December 2017) ADA News Bulletin, 643, 5–6.
Tracy, L. F., Gomez, G., Overton, L. J., & McClain, W. G. (2017). Hypovolemic shock after labial and lingual frenulectomy: A report of two cases. International Journal of Pediatric Otorhinolaryngology, 100, 223–224. doi:10.1016/j.ijporl.2017.07.013
Walsh, J., Links, A., Boss, E., & Tunkel, D. (2017). Ankyloglossia and lingual frenotomy: National trends in inpatient diagnosis and management in the United States, 1997–2012. Otolaryngology-Head and Neck Surgery, 156(4), 735–740. doi:10.1177/0194599817690135
AND good to see this online now:
Douglas, P., & Geddes, D. (2017). Practice-based interpretation of ultrasound studies leads the way to more effective clinical support and less pharmaceutical and surgical intervention for breastfeeding infants. Midwifery. doi:10.1016/j.midw.2017.12.007
Read my other blog posts on ties here.