What Are Tethered Oral Ties (TOTs)?

How the tongue functions can tell us a lot about their reflux

Tethered oral ties, also known as TOTs, are a collective term used for tongue ties, lip ties & buccal (cheek) ties.

These ties are when natural connectives tissues in the mouth, known as frena, are tight, thick & short, usually restricting normal movement. The result? A tongue that is unable to function properly which can impact a whole host of associated things for an infant, & can make breastfeeding harder for both mum & baby.

The most common TOT is a tongue tie, known as ankyloglossia, & is said to affect 3-4% of infants. The degree & level of restriction can vary between each baby.

The tissues in the body all function together & interact with each other, so TOTs can frequently involve muscle, ligament, tendon & fascial tension, as well as joint dysfunctions - both in infancy & later into adulthood. When treating patients osteopathically, I would often see children & adult patients that had jaw, neck, even lower back & pelvic issues that could be linked to an undiagnosed, or unaddressed, tongue tie in infancy.

Reflux & tethered oral ties can go hand in hand, so early recognition & diagnosis are the best way to reduce the potential long-term effects they can cause if left undiagnosed, or untreated. That is not to say every tie MUST be released, but it is necessary to identify if it is symptomatic or causing dysfunction for your baby, restricting normal movement & therefore triggering compensated patterns, & often discomfort for baby too.

Let's quickly talk through the types of ties, helping you understand what to look for & how they can influence your baby's symptoms.

Some common symptomsof TOTs your baby might experience are:

👅 Reflux or posseting (spitting up)

👅 Difficulty latching or shallow latch, both to the breast & bottle

👅 Failure to thrive or gain weight

👅 Can't or won't use a dummy or pacifier

👅 Painful breastfeeding for mum

👅 Open mouth posture at night or mouth breathing

👅 Falling asleep at the breast or bottle

👅 Difficulty when weaning or starting solids

👅 Cluster feeding or feeding little & often

❗Myth Busting: just because your baby can stick their tongue out, doesn't rule out an oral tie

❗Myth Busting: a baby can have an oral tie & poor tongue function despite gaining weight & seemingly feeding well

❗Myth busting: it is not always a TOT if the tongue or mouth are not working as they should - it could be tension & chronic poor movement patterns that are mimicking it

Tongue Ties

The tongue has 8 strong muscles that allow it to be a flexible tissue. Before starting solids, infants predominantly move the tongue forward & backwards (a reflex called the tongue thrust), & it also moves in a wave-like motion up & down to allow babies to suck, feed & swallow. A tongue-tie can be anterior (when the tight frena is seen at the front half under the tongue) or, more commonly missed initially, posterior (when the tight frena is seen at the back 50% or less underneath the tongue).

When the tongue is restricted underneath by the tight or thickened tissue, your baby can struggle to lift their tongue up to sit the roof of their mouth, where it is meant to be. Instead, the tongue sits in the floor of the mouth. You will likely see this as mouth breathing, snoring or noisy breathing during sleep.

During a feed, if baby cannot get the tongue up to meet & hold the nipple or bottle teat, then they will struggle with their latch. In order to stabilise the nipple or bottle teat, baby now has to recruit surrounding tissues like the cheek, jaw or facial muscles during a feed. This can add to tension in these myofascial tissues, but they are not designed to do this for long periods of time so babies often get tired, have to bob on & off to have a rest, or start to get frustrated because it is uncomfortable using all this extra energy just to feed each time! It is also when the majority of air gets into the digestive system, contributing to reflux, spit up, colic, digestive discomfort, bloating & trapped wind.

Signs you may see include:

👅 Lips blisters

👅 Spilling milk from the sides of the mouth during a feed

👅 Cupped or 'heart' shape to the tongue

👅 Coughing, spluttering or choking when feeding

👅 Clicking or gulping noises when drinking

👅 Flattened or lipstick-shaped nipple after feeding

👅 Frequently slipping off the breast or bottle

👅 Open mouth posture, especially at night as noisy breathing or snoring

👅 Excessive gas or trapped wind

Lip Ties

A lip tie is when the tissues are restricting movement between the top lip & the upper gums. This commonly impacts how well a baby can flange their top lip when feeding, often preventing a proper seal with the lips around the nipple or bottle. As a result, you may see them spilling milk or bubbles appearing around the corners of the mouth, or difficulty getting them to get a wide, deep latch for suction.

Inevitably, this can let air get in to be swallowed (known as aerophagia) , which is one of the most common causes of reflux in infants. The same compensation patterns by the jaw, cheeks & upper body, as mentioned above, can also cause issues for your little one.

Lip ties are the second most common TOT & is almost always present with a tongue tie. This is worth noting if you go to an assessment for a lip tie, so you know to also ask about a possible tongue tie at the same time! It can even create a small gap between the front upper 2 teeth as infants get older if severe enough.

Signs you may see include:

👅 Lips blisters

👅 Coming on & off the breast or bottle

👅 Spilling milk from the sides of the mouth during a feed

👅 Gulping noises when swallowing milk

👅 Excessive gas or trapped wind

👅 Falling asleep at the breast or bottle

👅 Gap forming between front 2 upper teeth

Buccal or Cheek Ties

There are 4 buccal frena in the cheeks, 2 on each side. A buccal tie is when these tissues are abnormally tight, often restricting some movements of the cheek muscles & even into the jaw, face & neck muscles. You can sometimes see the tension & restriction in your baby's cheeks, including having dimples when they smile or sucking in their cheeks when trying to feed.

These are, however, the least likely of the 3 TOTs to cause symptoms for you baby, but they may remain part of the bigger picture.

Signs you may see include:

👅 Lips blisters

👅 Spilling milk from the sides of the mouth during a feed

👅 Excessive gas or trapped wind

👅 Cluster feeding or feeding little & often

👅 Falling asleep at the breast or bottle

If you suspect your baby has an oral tie based on their symptoms,it is important to get an oral assessment with a qualified practitioner in TOTs. In America, this may be a pediatric dentist, lactation consultant/IBCLC, feeding specialist, speech & language therapist (SLP), pediatric ENT, pediatric PT or OT. In an ideal situation, a combination of these providers will give the best possible results for your baby's outcomes, both before & afterwards.

❗A word of warning: unfortunately, not every practitioner is appropriately qualified to assess & diagnose oral ties, so it is hugely important to know who to reach out to.

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If you would like my help, you can email me, download my free reflux symptom tracker,

check out my social media pages, or see my posts on oral ties

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Please note: if you are concerned about your baby's symptoms, you should seek medical advice & contact your paediatrician or a qualified provider.

This is intended for educational purposes only & does not substitute for a medical diagnosis.