Frequently Asked Child Questions

Why should I do this?

I'm scared to put my child in pain; why is this worth it to do so young?

When we fix the ties early, we get the most movement in the mid-face including the jaw and sinuses. If there is a tongue tie connected to the jaw, then it is holding the jaw back and preventing normal growth of the jaw. The younger the child is to have this released, then the more forward movement of the jaw. The younger the child, the fewer teeth for biting parents fingers. We want spaces between all the teeth especially so there is room for the larger adult teeth to come in. Also, the older the child, the less likely they will change their feeding and speaking behaviors. They will often need further Occupational and Speech therapy and are prone to oral aversion. Younger children also forgive and forget better and are easily distractible. The lasered areas are well healed within two weeks. This is a very short time compared to the need for years of Orthodontics. If the tongue is not resting on the roof of the mouth, or palate, then the palate is not getting expanded naturally and the jaw and teeth will have to be moved later. Painful Orthodontics, including palatal expanders and orthodontic appliances, can be in the mouth for months to years. Jaw surgery for late teens needs to be done after puberty. The oral surgeon breaks the jaw and resets it forward to allow new bone to form. Yes, it is as awful as it sounds. Remember, when we get the sinus area to develop properly, then there will be fewer ear and sinus infections which means less pain and antibiotics. The list goes on and on…



Why choose a CO2 laser to repair the ties instead of just a pair of scissors or a simple diode laser?

Dr. Sacker has used all three and she knows first-hand! Scissors are sharp and make an even cut that can more likely reattach. It is also very common to not cut enough or not be able to cut enough because of the tie depth, location, or extent of restriction. The doctor can only cut what can be seen and what is safe to cut. Since the doctor cannot see what is under the area being clipped, he or she would have to stop short. It is very common for providers to cut the anterior, or front portion, of the tongue tie in front of the salivary glands and leave the posterior portion intact. The problem is that the posterior portion is what controls the middle and back portion of the tongue; which is the area that is needed for breastfeeding and swallowing. It is also very difficult to cut into a submucosal tie that is more of a sheath attached to the surface of the tongue. It will bleed and the doctor cannot open it fully as a result of the bleeding and safety issues. Buccal ties also cannot be cut with scissors because of their location and size. Upper lip ties can be partially cut by skimming the gumline with a sharp instrument. The upper lip tie is covered by a sheath of sensitive tissue so it always hurts and bleeds with scissors. The doctor would be unable to cut it completely into the groove between where the teeth form, leaving the remainder of the cord attached to the bony area and upper gumline. The clip with scissors does help elevate the lip for eating food off a spoon, but it often regrows and will affect teeth location and make teeth brushing difficult or painful. It is not safe to put sharp scissors in a child's mouth, so most providers will insist on sedating your child. Lasers can repair an incompletely released lip tie at a later date, but the area is more sensitive and has scarring from the previous clip so more laser energy is required, making the procedure itself and the healing more challenging. ​ The CO2 laser is the most gentle soft tissue laser on the market right now. Most of the time, there is no bleeding. Using this laser can also be faster than using scissors. It is safer than scissors because it works above the tissue, cauterizing while vaporizing the tissue in a bloodless field. This allows for a clear view of vessels and nerves. The diode laser works with heat and requires more energy to release the tissue, causing more scarring, especially with submucosal ties. The diode laser is also very hot and unsafe to use on buccal ties, unlike the CO2 laser. Just like our iPhones and other similar technology, we have better ways to do things now; we just need the medical community and insurance companies to catch up so our families can get the best care possible!



Procedure

Why fix all the ties at once and not one at a time?

It is very difficult for the child to figure out what to do with the tongue muscle if we do not take out the ability to use the lips and cheeks to compensate. Also, the lips and cheeks are the easy part of the procedure as far as a release, aftercare exercises, pain, and healing are concerned. The tongue tie is what takes skill to release, fully and properly, while using the type of equipment that causes the least amount of pain, scarring, and risk of reattachment.



Is my child going to be in pain during the procedure?

The topical gel works in a matter of seconds and lasts for 30-60 minutes. The release of the sites takes seconds. They are more scared than anything else. We try to entertain and distract as much as possible. We want you to be the rescue person so you are proud of them and know how brave they were. We will offer them a popsicle and they can continue to watch their media program. They can take a walk outside to look at the pretty plants in the courtyard and just have a little break. They tend to be more upset that their mouth is still numb and that they are drooling. Lots of cuddles and hugs from Mom and Dad are the big prize.



Post-Procedure/Aftercare

What kind of support is included during the procedure and aftercare?

Dr. Sacker will show you how to do the aftercare stretches. You will then practice so that we can make sure that you are doing them correctly. Dr. Berger will see you back in 2 to 4 days for an initial recheck to check the sites. The sites can be checked as often as needed, until the 2 week post-procedure visit. Anytime you feel that the sites are healing incorrectly, you may text us a picture or email us a video. The media can show talking, crying, or just lifting and moving the tongue around. Some children with weak tongue muscles will take 6-8 weeks to improve. We recommend starting our tongue strengthening exercises 2 days after the procedure. If your child continues to struggle, myofunctional therapy is highly recommended and will be discussed at your visits. For those children with continued muscle tension in the posterior tongue and neck, it is important to start bodywork with a pediatric chiropractor early and continue 1-2 times per week until muscle tension resolves which may take 6-8 weeks.



Why is aftercare is so important?

It is very important to start stretching the tongue and lip area at least 4 hours after the procedure to maintain patency of the opening. The mouth heals very rapidly and we don't want the diamond opening to close up or reattach to the inner gum line. We would like to see it stretched and expanded to help with eating and speech development. You may read elsewhere that stretches have not been taught or recommended or that they should be done differently. Each patient’s ties open differently and will want to close differently, so we will tailor the stretches as those areas heal. If the muscles in the tongue were strong enough and could coordinate perfectly after the release of the ties, then stretches may not be needed, but that is rarely the case. The tongue muscles are often underdeveloped. It takes time for the jaw and lip muscles to weaken as the tongue learns to lift. The tongue needs to get stronger and function independently. Just like any new workout, it takes about six to eight weeks to build new muscle.



Why is bodywork so important and recommended?

Bodywork includes therapy done by chiropractors, osteopaths, physical therapists, myofunctional therapists, speech therapists, and craniosacral therapists (CST). We tell parents that we have the easiest part of this equation because fixing ties with a skilled hand and using an amazing C02 laser is what we do. We cannot release the muscular tension that exists under the ties or from compensating for so long. It is often helpful for a hands-on treatment to reset the nervous system after the release. Chiropractors and cranial osteopaths that work on children use gentle pressure similar to checking if a piece of fruit is ripe. This type of therapy helps with releasing the tension from using the wrong muscles to compensate for inadequate tongue function.



What kind of pain should we expect after the procedure?

It does not hurt to touch the areas. The issue is that the muscle of the tongue is now sore because it has not developed properly and is now being used differently. This is a new workout for the tongue. It would be as if you were doing a series of twenty minutes of squats or lunges and then resting for a few hours and repeating the series over and over again. The affected muscles would become sore and by the third time or so, you would be fatigued. It would then feel better to move around and stretch, however, the affected muscles would still be sore. After a few days of doing this series of new exercises, relief would come. This is the same idea post-procedure. Ibuprofen will help during the healing. Patients tend to do better as far as pain and eating if they stay ahead of the pain instead of trying to catch up from behind. When parents are proactive and give the medication regularly for the first 2-3 days, we find better feeding, less cranky kids, and happier families. Ice cream and popsicles are always helpful! The goal with the aftercare is to get in quickly and stretch the areas; to get them moving and to help them to heal, while helping the sites to heal as open as possible.



How do I take a picture or video for you to review?

It is very challenging to get a good picture of the released areas. You can lift and pull in different directions and the area may look reattached, when it is not. It is very important for us to feel the area so we can tell whether there is an early reattachment or just muscular tension that is lifting the area. This tension can get worked on by your chiropractor and/or a trained physical therapist. We are always happy to look at videos or pictures to see how the stretches are going. To take a picture of the upper lip, lift with both hands on either side of the site and flip the lip up to the nose while another person takes the picture. As far as the tongue, put your index fingers on either side of the diamond and lift up to the roof of the mouth while someone takes the picture.



Why is there so much saliva after the procedure?

​The tongue tie is often holding down the salivary glands and when we release the tie, the salivary glands are free and tend to be overactive. It takes 7-10 days for this to better regulate. You also are pushing right along the duct with your stretches. This action stimulates and releases more saliva which does help the area heal. This saliva is therapeutic and should not be worrisome.



The sites started bleeding with the stretch, what does that mean?

In the first 2 days, there is often bleeding along the edges of the areas because they try to close in so fast. Just keep using firm pressure to stretch. You cannot push too hard or make the areas bigger. Remember, we had to open these with a laser. You will have to push even more firmly if your child is pushing against you. Be firm, quick, and fast. Often your last stretch was not hard enough and then if you get a good stretch, you are just opening what had closed in the past 4 hours. Make sure your stretches are frequent and with consistent firm pressure. Doing them more frequently actually feels better. Waiting longer makes the stretches hurt more. When the tongue is still resting on the floor of the mouth and there are still lip and cheek muscles that have formed and are tense, reattachment is more likely. The more the areas are functioning correctly and the more you are guiding the healing then the better the outcome and function will be.



Is it normal for the lip to be swollen after a lip tie release?

​Yes! When the lip is very tight from the tie, often there is some swelling in the evening after the procedure. That is why we use our cold laser first as it prevents pain and swelling. It would be much worse without that treatment. Our older kids and adults say that it is not uncomfortable, but that it just looks puffy. It is usually better within 1-2 days. Sometimes, we see the same thing with the buccal (cheek) tie release if they were very tight.



Is the yellow color of the healing areas a sign of infection?

When the lasered areas heal, the tissue may look white, gray, or yellowish. There has never been a reported infection after frenectomy. In thousands of these, I have never seen one either. But if the tongue is hot, red, and swollen or your child has a fever, then please reach out to us. You can always send a picture for us to look at too.



Why do the sites look so big and open?

The deeper or tighter the fibers of the ties, the bigger the diamond opening tends to be. This goes for upper and lower lip ties as well. We are only removing the thick collagenous fibers. We do not touch the muscles. This is what stretching, massage, and bodywork are for. We want full function of the area without restrictive fibers. The areas will contract in some and get covered with new soft tissue, which is why you are rubbing over the areas to keep them smooth, soft, and flat.



Is bad breath normal after the procedure?

​Yes! It is from the odor of the healing tissue and the fact that the mouth is open more because the tongue is tired. It gets better about a week after the procedure. Try running a cool mist humidifier at night to help with congestion and with keeping the healing tissue moist. Make sure you child is drinking enough water to help. Continue to brush your child's teeth twice a day as normal.



Is whitish peeling tissue around the sites normal?

Yes, the topical lidocaine and tetracaine gel can cause some irritation of the tissue. It is not painful, just unsightly. We see it more in older children and adults from the topical sitting on the areas to allow for proper anesthesia. Stay hydrated and use the coconut oil on the areas to help with healing.



Are there any activity restrictions?

No! Your child may play, swim, go to the beach and attend camp or school as normal. Have fun, just remember to do your exercises at least every 4 hours.



Educational

Why is my Pediatrician or Therapist not familiar with ties?

This is a very frustrating issue. Unfortunately, ties are still not being taught in Medical School or Dental School. We are probably years from this. Right now, it is all about Continuing Education. As doctors, we get to decide what we learn for continued education. The doctors that spend the time to learn about ties will be familiar with how to diagnose, understand the different treatment options, and know whom to refer to for treatment. Schooling teaches us how to identify disease, not how to make anatomy more functional. This is a specialized field, which is why this is all we do at Team Tongue Tie. What we hope is that your Pediatrician will see the red flags of tie issues and refer you to someone who specializes in ties. When there is a red flag for an eye problem, we refer to an eye specialist. Hopefully, ties will go in the same direction. We refer you to a Lactation consultant for breastfeeding problems or a Speech therapist for speech issues or an Occupation therapist for feeding issues but then they cannot make a diagnosis because it is not in their scope of practice. Also, if your therapist is not recently educated or continued their education in ties, then they may fall short there too. This is the disconnect. We are trying hard to fix this problem by educating providers and we hope you will too after you have learned from your experience with us.



Why was this not diagnosed in the hospital?

Especially with submucosal ties, there will not be any initial issues with breastfeeding. After birth, these babies will latch fine. Colostrum is thick and easy to transfer and the baby does not need to get much to be satisfied. Remember that a baby's stomach is the size of a marble at birth then grows as the volume of milk transfer increases. The more the baby exercises the tongue at the breast, the more fatigue sets in, especially when there is a thick restriction underneath the tongue. These Moms often have a delayed onset of milk production which causes jaundice and weight gain issues in the baby. It is very important to pick up these ties in the first 6 weeks of life as the milk supply is increasing. If your baby is not removing milk from the breast adequately then pumping the milk out will help to prevent supply issues in the future. If your baby is not strengthening the tongue, even with a release of ties, it may take 6-8 weeks to build the muscle of the tongue to breastfeed efficiently. It is not a magical procedure but a step in the right direction to provide a better function for breastfeeding, eating solids, speech, dental issues, sleep posture, and proper airway management.



Why are we seeing and hearing about ties so much more now? Is this a fad?

This is such a loaded question and there are so many factors that may be an issue here. We did not know what we did not know. Sleep medicine is a relatively new field and we are understanding how important the airway anatomy and tongue position affect sleep and behavior. Studies are done on adults and we are trying to extrapolate this data down to children and babies as we routinely do not do studies on this population. Adults also have additional issues related to sleep hygiene including excessive media time, poor diet, alcohol intake, and smoking that can interfere with sleep. Sleep specialists see the rise in sleep apnea is often related to tongue position and airway management. When we fix babies and young children, we see improvement in the anatomy to prevent these issues. We also know that it is not normal for babies or children to snore or be noisy breathers. During sleep, the tongue should be up and the lips sealed. Air should be moving from the nose to the lungs but if this cannot happen then the mouth will open to get the tongue out of the airway. When air is being filtered through the mouth, the tonsils and adenoids get irritated and grow which also pushes the tongue forward. And the cycle continues and progresses. With our patients, we have seen that fixing this positioning and changing the anatomy stops the cycle. It will take time for this clinical evidence to become proven research, especially since doctors frown on prospective studies. There are a few other reasons that we may be seeing more ties. We are looking for them to make a difference and parents are researching and questioning more about their children and themselves. This is where the internet and blogging have been helpful in the recent future. We encourage our families to share their stories! We follow our patients and have a great success rate because we make sure the procedure is done right and heals correctly to give our patients the best outcomes. Poor outcomes or repeated revisions often come from incomplete removal of ties or lack of aftercare and follow up which is so important. The body is amazing and can learn to compensate which can be fine for a while but may cause issues later. More parents are being proactive with their children to provide them better health for the future. This is why we are seeing a resurgence of breastfeeding in the first place. Parents want to provide better nutrition for their children and we know Breast is Best. We are coming out of the formula and bottle generation which produced less healthy children and adults with overeating issues, obesity, diabetes, and cancers to a new generation that will be healthier with less disease. There are certainly genetic and environmental issues that are in play to further confuse the issue. It will take years to figure out what in our environment (chemicals, preservatives, additives, synthetic vitamins, soil, bacteria, etc.) is turning on the genes to express where the ties form in the mouth. At this point, we have an easy procedure to fix the problem (and possibly prevent future issues) until we can prevent it from happening in the first place.



What do I look for in my kids that were not released to know if they need the procedure now?

We base our need for an initial assessment on symptoms. If you or your children are symptomatic, we are always happy to check their mouths in the office for ties. Most of the kids that we fix have speech issues, excessive drooling, eating issues, sleeping issues, dental/orthodontic issues, and/or chronic neck pain/headaches. Most adults that we release have sleep issues including apnea or snoring, chronic headaches/jaw/neck pain, speech issues, dental/orthodontic, and/or mouth fatigue after talking all day. Bottom line, the most important sign would be airway compromise. Children and adults should be sleeping with their mouths closed and breathing through the nose. If the mouth is closed then pull down the jaw and make sure the tongue stays suctioned up to the palate. If you do not see this, then we need to check your anatomy in the office. The tongue needs to stay up to the palate so it is out of the airway. We do not want even a partial obstruction affecting sleep, breathing, and oxygenation of the body. The pressure of the tongue on the palate will widen the hard palate making room for the teeth and allowing aeration of the sinuses, keep the soft palate firm and elevated, and prevent the tonsils from enlarging and moving forward over time.



What is Myofunctional Therapy and when is it recommended?

Myofunctional Therapists are specialized providers, usually speech therapists or registered dental hygienists, who train patients how to use their tongues and orofacial muscles how to function properly. Dr. Sacker and Dr. Berger have been trained in myofunctional therapy via an intensive educational course, but are not certified. We completed the course to better understand what myofunctional therapy is, how it works, and whom it can help. It is best designed for cooperative children over age 4, teenagers, and adults with weak tongue muscles or difficulty re-establishing the brain to tongue connection. We have a set of exercises to start with under the Aftercare eduction tab. When we find it is needed, we can refer you to a therapist. Feel free to check for certified therapists in your area on the AOMT website.



Insurance

What is a superbill and what do I do with it? How do I submit a claim to my insurance?

We take full payment for services at the time of the procedure which includes your follow-up visits. We provide you with a superbill, or paper invoice, for you to submit to your insurance for reimbursement for services. These superbills are available on your patient portal after the procedure and 2 week follow up visit. There will be an address on the back of your insurance card stating where to submit your claim. Your insurance company will have a form for you to fill out that you can find on their website or by calling their member services. Everything that they need to process the claim is documented on our superbills. We will provide 2 sets of superbills as we split up procedure coding from office visit coding for reimbursement. The amount of medical or dental reimbursement depends on the type of plan that you or your employer purchases so each plan will reimburse differently. There are hundreds of different plans out there which is why we cannot provide a reimbursement estimate for you. We find it does help, especially when making a medical appeal after an administrative denial, to write a personal letter explaining why the procedure was necessary for you or your child and include the before and after pictures that we have taken that are available on your patient portal. You can use the information on our website to help create the letter as well. Were you going to stop breastfeeding which you know was best for your baby? Is your baby having breathing or sleeping problems from the ties? Speech or feeding issues? Tell your story from the heart! Make sure to check the boxes correctly when you fill out the claim forms and sign the appropriate areas so that they send the reimbursement check to you and not to Team Tongue Tie.



Do you take insurance? Are you part of my insurance network?  Do I need a referral to see you? What about Medi-cal?

​We are not in any insurance network. We are not a preferred provider for any insurance. We are not a Medi-cal provider. This all means that we do not take your insurance card for payment or bill your insurance and you do not need a referral to be seen in our office. We take a payment upfront in the form of a credit card, HSA card that works like a credit card, Care Credit card, or cash. We provide you with a superbill (or invoice) to submit to your insurance to get reimbursement for services provided. It is always best to contact your medical and dental insurance company first to find out their process of reimbursement after seeing an out of network provider. We recommend speaking to more than one person if what they are telling you does not seem correct. Medi-Cal does not provide reimbursement to you for these services. We have looked into joining local insurance plans like Blue Shield, Aetna, and others, but it would mean that Dr. Sacker would have to be affiliated with local hospitals and take care of sick patients as well. We are not seeing regular pediatric patients in the office so we can focus on our specialty and we also want to provide a safe environment for our patients.



Don’t I pay less if I go to a provider that takes insurance?

​Often NOT! We are just taking a payment upfront and the other offices are taking your insurance copay or nothing upfront and then you pay the balance of the payment after insurance reimbursement. So, in the end, it ends up the same cost to you either way. We are not a preferred or in-network provider on any insurance so make sure that you know what your medical and dental insurance covers for your particular plan. Unfortunately, many medical and dental plans do not cover this procedure. Hopefully, in time, and with parent letters explaining why this is important and how this has helped, the insurance coverage will change. Insurance plans are never comprehensive for all conditions.



Eating

Are there any food restrictions after the procedure? Can food get stuck in the sites?

You may eat anything you like after the procedure once the topical anesthetic wears off. Softer foods, like oatmeal or yogurt, that do not require much chewing may be easier and less work for your tongue. Remember what is sore is the muscle of the tongue. Food that goes everywhere in your mouth like rice or salad, will require more movement of your tongue. There is a balance between pain and movement. Move your tongue enough so the muscle does not get too stiff, but not too much that it fatigues and you have trouble lifting. The amount of movement before fatigue is different for everyone. Spicy foods, vinegar, and alcohol may burn for some, but not for others. Even though the sites sometimes look like a hole, not to worry as food will not get stuck in the sites. Bottom line...there are no food restrictions so if you want it, you may eat it.