One of the questions I’m asked most often when I lecture is, “How do you decide whether someone actually has a tongue-tie?” It’s a fair question, and I understand why people ask it. At first glance, it seems like there should be a straightforward answer. Surely there’s a grading system, a measurement, or a checklist that tells us exactly who needs treatment and who doesn’t.
The longer I’ve evaluated and treated tongue-ties, however, the more I’ve realized that diagnosing a tongue-tie isn’t nearly that simple. In fact, I believe one of the biggest misconceptions in our profession is that the diagnosis begins by looking under the tongue. While the appearance of the frenulum certainly matters, I’ve found that beginning there often leads us down the wrong path. Before I ever examine a baby’s mouth, I want to understand why that family came to see me in the first place. We always start with a thorough history before looking in the mouth.
Why Patient History Comes First
By the time many parents arrive in my office, they’ve already been through quite a journey. They’ve spent weeks, and sometimes months, trying to figure out why feeding isn’t going well. They’ve met with lactation consultants, tried different nursing positions, changed bottles, pumped around the clock, and listened to advice from well-meaning friends and family. Many have already seen several healthcare providers, yet they still leave feeling that something hasn’t been fully explained.
One of the things I’ve learned over the years is that parents are usually excellent observers. They may not know the anatomy of the tongue or understand the mechanics of infant feeding, but they know their baby. They’ll tell me that breastfeeding hurts every single time. They’ll describe hearing a clicking sound throughout feedings or watching milk leak from the corners of their baby’s mouth. Some tell me their baby nurses for forty-five minutes, falls asleep exhausted, and then wakes up hungry again twenty minutes later. This is common but not normal! Others describe excessive gas, reflux, or a baby who simply never seems satisfied despite feeding almost constantly.
Those observations don’t diagnose a tongue-tie, but they often tell me where I need to begin looking. That’s why I believe every tongue-tie assessment starts with listening. The history frequently provides as much information as the examination itself.
Why Appearance Alone Isn’t Enough
Unfortunately, I think we sometimes reverse that process. We lift the tongue first and ask questions later. I understand why. The frenulum is something we can see, photograph, measure, and classify. It feels objective. The problem is that appearance and function don’t always match. Weekly, I see babies with very obvious frenula who feed well or have minimal symptoms. However, every DAY, I see babies whose tongues appear relatively unremarkable until we hear how they have a mountain of symptoms from the mother, and the baby and family are on the struggle bus. These babies with less obvious or posterior tongue-ties often have poor milk transfer, painful breastfeeding, prolonged feedings, swallow excessive amounts of air, or have an inability to maintain suction.
That’s one of the reasons I spend very little time asking whether a baby has a frenulum. Every baby has one. The more important question is whether that tissue is limiting normal tongue function enough to contribute to the symptoms the family is experiencing. That’s a much more difficult question, but it’s also the one that matters.
In my opinion, this is where experience becomes invaluable. A photograph can’t demonstrate tongue mobility. A grading system can’t capture how a baby coordinates the tongue, lips, jaw, and palate during feeding. Those things require observation, examination, and clinical judgment by trained professionals. They also require the humility to recognize that not every feeding problem is caused by a tongue-tie and that not every tongue-tie requires treatment.
Why I Created Tongue-Tied Academy
One of the reasons I created Tongue-Tied Academy was because I wanted to teach providers how to think through these evaluations rather than simply memorize classifications. The course follows the same approach I use every day in practice, emphasizing history, functional assessment, clinical reasoning, and multidisciplinary care before discussing laser treatment. If you’re a dentist or physician who wants to become more confident evaluating tongue-ties, I think you’ll find the course both practical and immediately applicable. You can learn more at TongueTie.com/Course.
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A Message for Parents
Parents occasionally find these articles while searching for answers about their baby’s feeding difficulties. If that’s what brought you here, I hope this helps explain why different providers sometimes reach different conclusions. A comprehensive evaluation should involve much more than a quick look under the tongue. If you’d like to discuss your baby’s feeding challenges, you’re welcome to send us a message to schedule an evaluation. We routinely treat patients from out of state, or even from other countries, at our office just south of Birmingham, Alabama.
How I Decide Whether Treatment Is Needed
One of the things that has become increasingly clear to me over the years is that no single examination finding should ever determine whether a child needs treatment. Treatment should never be based solely on weight gain. Every day, I hear that parents said their provider said the baby doesn’t need to have the tongue-tie treated because they are gaining weight.
I don’t believe in treating a number on a grading scale, nor a photograph. I treat patients. That may sound obvious, but it’s an important distinction. Every recommendation I make is based on how the history, the examination, and the patient’s symptoms fit together.
At the risk of oversimplifying…if a baby has an obvious restriction and lots of symptoms, that’s a slam dunk. If the tongue is clearly restricted and there are symptoms, it’s likely worth treating. The one that needs treatment (low-hanging fruit) that many people miss is a less obvious restriction that many providers overlook, even when they have a ton of symptoms. Those are the ones who fall through the cracks and don’t get timely treatment.
I’ve had babies whose tongue movement was moderately restricted, yet they were feeding efficiently, gaining weight appropriately, and their mothers were completely comfortable breastfeeding. In those situations, I’m often very comfortable recommending observation. However, if it is to-the-tip or significantly restricted, due to the high risk of later symptoms, it may still be best to release while the child is an infant.
On the other hand, literally every day, I see babies whose tongue-ties appear relatively subtle but who are struggling tremendously with painful breastfeeding, poor milk transfer, prolonged feedings, excessive air swallowing, and inadequate weight gain. Those are two very different clinical situations, even if the anatomy initially appears similar.
Why Tongue-Tie Diagnosis Can Be Controversial
That’s one of the reasons I think the conversation surrounding tongue-ties sometimes becomes unnecessarily polarized. Some people believe nearly every feeding problem is caused by a tongue-tie. Others believe tongue-ties are rarely responsible for feeding difficulties at all. In my experience, the truth usually lies somewhere in the middle. Tongue-ties are certainly not the cause of every feeding problem, but they’re also more commonly overlooked than many people realize.
I also think it’s important to recognize that feeding is far more complex than tongue movement alone. The tongue works together with the lips, jaw, palate, airway, muscles of the neck, neurologic development, and the rest of the body. That’s why I frequently collaborate with lactation consultants, speech-language pathologists, occupational therapists, physical therapists, pediatricians, ENTs, and other members of the healthcare team. Every provider brings a slightly different perspective, and I’ve found that some of the best outcomes occur when we’re all working toward the same goal rather than trying to solve every problem independently.
Also Read: What I Wish Every Pediatrician Knew About Tongue-Ties
Why Providers May Disagree
Parents occasionally ask me why different providers can examine the same baby and reach completely different conclusions. I understand why that’s frustrating. Some of those differences simply reflect varying levels of experience with tongue-ties. Others reflect differences in philosophy or training. Unfortunately, most medical and dental training programs devote relatively little (or no) time to functional infant oral assessments. As awareness of tongue-ties has grown, many providers have had to pursue continuing education on their own, and naturally not everyone has learned the same evaluation process.
My Mission as an Educator
That’s one of the reasons I enjoy teaching so much. Early in my career, I spent countless hours pursuing frenectomy continuing education, piecing together information from lectures, journal articles, mentors, and my own clinical experience. There wasn’t one place where I could learn a comprehensive approach to evaluating tongue function, understanding feeding mechanics, performing laser frenectomies, managing aftercare, and collaborating with therapists. I eventually realized that if I had struggled to find that education, many other providers probably had as well.
That realization ultimately led to Tongue-Tied Academy. My goal has never been to teach providers how to perform more procedures. My goal is to help them become better clinicians. Sometimes that means recommending a laser release. Sometimes it means recommending therapy first. Sometimes it means reassuring a family that a procedure isn’t necessary. Good clinical judgment isn’t about doing more procedures. It’s about making better decisions for the individual patient sitting in front of you.
Training for Healthcare Providers
If you’re a dentist or physician who would like to develop a more thoughtful, functional approach to tongue-tie evaluation and treatment, I’d encourage you to learn more about Tongue-Tied Academy. The course follows the same clinical reasoning process I’ve described in this article and includes tons of patient videos, dozens of clinical cases, and practical guidance that providers can begin using immediately. All broken into bite-sized lessons and modules.
If you’re an IBCLC, speech-language pathologist, occupational therapist, physical therapist, chiropractor, or another therapist who works with infants and children, Tongue-Tied Academy LITE was designed specifically for your role on the treatment team. Understanding how to recognize functional limitations and collaborate effectively with other providers can make an enormous difference for the families you serve.
Final Thoughts for Parents
For parents who may have found this article while searching for answers, I hope one message stands out above all the others: a good tongue-tie assessment should never be rushed. It should involve listening to your concerns, understanding your baby’s feeding history, carefully evaluating tongue function, and considering the entire clinical picture before anyone recommends treatment. If you’ve been told everything looks normal but feeding still doesn’t feel right, or if you’ve received conflicting opinions and aren’t sure what to believe, I’d encourage you to send us a message. I’d be happy to evaluate your child and help determine whether a tongue-tie, or something else entirely, may be contributing to the challenges you’re experiencing. We receive patients at our office in Alabama from other states and around the world. So you’re not too far away!
FAQ,s
Q1. Do you diagnose a tongue-tie by appearance alone?
Ans. No. The appearance of the frenulum is only one part of the evaluation. I believe treatment decisions should be based on function, symptoms, and the overall clinical picture.
Q2 Can two babies with similar anatomy need different treatment?
Ans. Absolutely. One baby may compensate very well while another struggles significantly. That’s why individualized evaluation is so important.
Q3. Why do different providers sometimes disagree about a tongue-tie diagnosis?
Ans. Training, experience, and evaluation methods vary considerably. Some providers focus primarily on anatomy, while others place greater emphasis on function and feeding.
Q4. Does every tongue-tie require a laser release?
Ans. No. Some patients benefit from observation or therapy, while others clearly benefit from treatment. The recommendation should always be individualized.
Q5. What is the most important part of a tongue-tie assessment?
Ans. If I had to choose one thing, I’d say understanding function. The goal isn’t simply to identify a frenulum. It’s to determine whether restricted tongue movement is actually contributing to the patient’s symptoms.
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The more I learn about tongue-ties, the more convinced I become that thoughtful evaluation is the foundation of good treatment. Procedures matter. Technique matters. Aftercare matters. But every one of those decisions depends on getting the assessment right. I believe our patients deserve nothing less.
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