spreecas tjune2013
TRANSCRIPT
How ankyloglossia can affect our lives
Lawrence Kotlow DDSBoar certified specialist in
Pediatric dentistry
The Surgeon General’s Report:2011
Lawrence Kotlow DDS
Statistics
1972 - 22 percent of US mothers breastfed their infants 1972=3,258,411 total births
716,850 breastfeed infants
2009 - breastfeeding report card from the CDC found that 74 percent of women start breastfeeding, 33 percent were still exclusively breastfeeding at three months and 14 percent were still exclusively breastfeeding at six months. 2009=4,131,019 total births
3,057,000 breastfed infants
1,363,00 after 3 months
578,000 after 6 months
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Lawrence Kotlow DDS
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Many Myth(stakes) & Fairy Tales
Myth(stakes)
Some times, we either fail to see the what is before our eyes and is obvious or we see it and fail to consider it.
A Myth is a fiction
something which is untrue.Lawrence Kotlow DDS
Common ideas and myths that interfere with proper care and treatment of newborns presenting with ankyloglossia
★Tongue-ties do not exist.★Tongue-ties will not effect nursing.(as recently
as February 2012 the Medical Director of an Insurance company with 45 years experience as a pediatrician told me “in his 45 years as a pediatrician he never saw one case where an infant was tongue tied and it caused any breastfeeding problems !”
★Tongue-ties will correct themselves. A tight lingual frenum will stretch or tear without treatment.★Ankyloglossia does not cause maternal discomfort.★Ankyloglossia does not effect developing speech.
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Lawrence Kotlow DDS
Common ideas and myths that interfere with proper care and treatment of newborns presenting with ankyloglossia
★Posterior tongue-ties do not exist. ★Revisions of tongue-ties are dangerous due to bleeding, cutting nerves or blood vessels.★Surgery requires the operating room and general anesthetics.★Revising the upper lip causes “floppy lips”.★The upper lip is not important in breastfeeding.★You need to wait until the baby is at least 4 years old.★Lasers do not work ★If you cut the upper lip it need to be tacked down.★The post surgical exercises are too difficult and stressful for parents.★The infant will pull out the stitches and not be able to handle the healing time.
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*Medically necessary care (MNC) is the reasonable and appropriate diagnostic, preventive, and treatment services and follow-up care as determined by qualified, appropriate health care providers in treating any condition, disease, injury, or congenital or developmental malformation. MNC includes all supportive health care services that, in the judgment of the attending dentist, are necessary for the provision of optimal quality therapeutic and preventive oral care.
*Academy of Pediatric Dentistry 2010
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Medically necessary care
Lawrence Kotlow DDS Introduction to Lasers and Breastfeeding course
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Why we need to be proactive in assisting mothers breastfeed
AnkyloglossiaLip-ties“Sling shot” finger habitsNon-orthodontic pacifiersBottle-feeding
Malocclusions High palates Narrow dental arches Receded chins
Sleep apneaBed wettingADHD,etcNoisy breathing,snoringHigh Blood pressureHeart disease
Brian Palmer December 27,. 2011 The evolution of malocclusion and sleep apnea
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Is the tongue a muscle, an organ or
Maybe a yet unknow or unnamed body system ? Maybe a yet unknow or
unnamed body system ?
• organa structural part of a system of the body that is
composed of tissues and cells that enable it to perform a particular function
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What exactly is our tongue ?
• The tongue consists of a complex group of muscles that gives it great mobility.
• Some important functions in which the tongue is involved include mastication, phonetic articulation, swallowing, taste.
• The tongue also serves as a natural means of cleaning one's teeth
• Its muscles are attached to the mandible, the palate, the hyoid bone and the styloid process.
frenum
Hyoid bone
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Our tongue is more than a muscle,it is also an “Organ”it is also an “Organ”
1.The four paired extrinsic muscles protrude, retract, depress, and elevate the tongue.
2.The four paired intrinsic muscles of the tongue originate and insert within the tongue, running along its length. These muscles alter the shape of the tongue by: lengthening and shortening it, curling and uncurling its apex and edges, and flattening and rounding its surface.
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What is a tongue-tie ?
Lawrence Kotlow DDS helping nursing mothers since 1974
As defined by the International Affiliation of Tongue-tie Professionals (www.tongue-tie.net)
The Embryologic remnant of the tissue in the midline of the undersurface of the tongue and the floor of the mouth.
An (abnormal) attachment of the membrane that fastens the tongue to the floor of the mouth which may interfere with the
normal mobility and function of the tongue
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What are the best criteria we can use to diagnose ankyloglossia ?
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Ankyloglossia can be defined in three ways
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Anatomic & clinical appearance
Ability to function
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Infant’s & mother’s
symptoms
Lawrence Kotlow DDS Introduction to Lasers and Breastfeeding course
The most important diagnostic
criteria
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Classification of newborn abnormal lingual frenums:based upon anatomic appearance
Type **I(4*) -total tip involvement
Type III (2) Distal to the midline.The tongue:may
appear normal
Type -II (3) Midline-area under tongue (creating a hump or cupping of the
tongue)
Type IV (I) Posterior area whichmay not be obvious and only palpable,Some are not visible if they are submucosally located *Numbers in parenthesis =Dr.Kotlow
** Numbers outside parenthesis= LCLawrence Kotlow DDS Introduction to Lasers and Breastfeeding course
Tight guitar string submucosal attachment
3.5
Classificazione del neonato linguale anomala frenums:basato sull'aspetto anatomico
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or should function ?
James G. Murphy, MD, FAAP, FABM
Assistant Prof of PediatricsF. Edward Hébert Medical School
USUHS Bethesda, Maryland
Total tie down resulting inNo up or down function
Cupping and hump
Unable to elevate andtouch the hard palate
Heart shape, pointed tip
Diagnosis based onfunction or lack of
function
unable to extend tongue pastalveolar ridge
Lawrence Kotlow DDS Introduction to Lasers and Breastfeeding course
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NORMAL RANGE OF MOTION
CLASS 1 12-16 mm MILD
CLASS II 8-12 mm MODERATE
CLASS III 4-8 mmSEVERE
Kotlow classification of tongue-ties (1999)
CLASS IV 0-4 mmCOMPLETE
Diagnosing problems related to an infant with ankyloglossia
(tongue-tied)
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Preliminary initial evaluationJust by running your finger under an infants tongue from
one side of the mouth the other side will give you an indication if the tongue attachment is a problem.
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Interpreting your assessment-completed in the delivery room
James G. Murphy, MD, FAAP, FABM
Assistant Prof of PediatricsF. Edward Hébert Medical School
USUHS Bethesda, Maryland
Use your finger moving under the tongue across the floor of the mouth.
A smooth mouth floor = No ProblemA small speed bump = Potential ProblemA large speed bump = Most likely will be a problemA small, medium or large membrane = Definitely will
develop into a problem. If the membrane feels very thin and strong like fine wire,
push on it and look for tongue tip indentation and a slight bow of the tongue tip.
Feel for problems !
A quick assessment to determine need for further evaluation
Lawrence Kotlow DDS Introduction to Lasers and Breastfeeding course
Examination of infants
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The key to correctly examining an infant is proper placement on you lap. Place his
face facing the mother.Lawrence Kotlow DDS
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Identifying the submucosal posterior tongue tie
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Identifying the submucosal posterior tongue tie
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“It is not just the tongue that allows for a good latch-on the upper lip must have adequate mobility to all the infant to complete the latch.”
My theory and treatment concerns
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What is a Lip-tie ?
A remnant of the tissue in the midline of the upper lip and the gum which holds the lip attached to the gum (gingiva) and may interfere with the normal mobility and function of the upper lip contributing to poor latch by the infant onto the breast and in some cases when mothers elect to at-will breastfeed during the night, without cleaning off the teeth after nursing, may contribute to decay formation on the front surfaces of the upper teeth.
Lawrence Kotlow DDS
Helping mothers breastfed since 1974
Latch Difficulties Caries Formation
Class IV: inserts
into anterior papilla
Class III: Beginning to insert into anterior papilla
Class II: inserting just above or in between central incisorsClass I: normal
Kotlow Classification of maxillary Lip-Tied attachments in children
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Classifying Infant Lip-TiesClass IV: inserts into anterior papilla
a
Class IV Attachment just into the hard palate or
papilla area 25
Kotlow Infant and newborn Lip-Tie classifications
Class IIAttachment primarily into the gingival tissue
Class III: Inserts just in front of anterior
papilla
Class I: No significant attachment
Lawrence Kotlow DDS
A simple surgical procedure
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Erbium:YAG
1064 Diode
Lawrence Kotlow DDS
Pediatric reflux-clicking-Aerophasia
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The tongue is held down in the center of the tongue causing the posterior tongue to hump up. The baby can not extend the tongue to remove it from the back of the mouth therefore causing gagging. The gagging causes the baby to regurgitate. This appears to be reflux. Release of the tongue may lead to elimination of gagging and and thus eliminate reflux. In infants when the frenum has not been released, suggested medical treatment may be to put the baby on medication. After a lingual frenectomy is completed the reflux often goes away immediately especially with the “posterior” tongue ties. if we wait until after the frenum is revised to treat the infant using medication, the physician may not have to place the infant on drugs.
a
Lawrence Kotlow DDS
Ankyloglossia with deviationn of the epiglittis and larynx
Ann otol rhinol laryngol 100:1991 Mukai et al Ankyloglossia & Dyspnea
In China The Frencetomy has been completed since 1050-BC
In japan, Suzuki & Katagili in 1989, noticed a pattern in infants displaying ankyloglossia of mild dyspnea as well as deviation of the epiglittis and larynx
The paper also discussies the relationship of ankyloglossia and SIDS
Signs and symptoms to evaluate in infants with suspected Obstructive Sleep Apnea
1. Loud or heavy breathing with snoring2. Hyperactivity3.Developmental delay4.Inability to concentrate5.Night terrors and / or bedwetting
Porblems which may occur with ankyloglossia
1.Incomplete examination of the tongue will result in missing deviation of the tongue’s movements the degree of mobility of the tongue maynot reflect the real state of the ankyloglossia
2. Displacement of the of the epiglittis and larynx resulted in difficulties during breastfeeding with choking resulting in a decrease in Oxygen saturation.
3.After revision of the lingual attachment position of the epiglittis and larynx as well as choking disappeared.
4.Dyspnea was the result of increased upper airway resistance caised by displacement and less abduction of the larynx as well as decrease in activities of respiration.
5.Interesting observation : after treatment and increased oxygen saturation the infant showed thicker hair (usually over a two week period)
4.Dyspnea was the result of increased upper airway resistance caised by displacement and less abduction of the larynx as well as decrease in activities of respiration.
5.Interesting observation : after treatment and increased oxygen saturation the infant showed thicker hair (usually over a two week period)
6. Signs and symptoms of hypoxia :dark foreheads, rounding of the lips, yawning, inactivity, difficulty in gazing at objects, light sleep , underdevelopment of the mandible and temporal muscles, choking and reflux, behavioral abnormalities (adhd).
Signs and symptoms of sleep apnea
The following are the most common symptoms of obstructive sleep apnea. However, every child is different and symptoms may vary. Symptoms may include:
✴Snoring — loud snoring or noisy breathing during sleep.
✴Periods of not breathing — although the chest wall is moving, no air or oxygen is moving through the nose or mouth into the lungs. The duration of these periods is variable and measured in seconds.
✴Mouth breathing — the passage to the nose may be completely blocked by enlarged tonsils and adenoids leading to the child only being able to breathe through his/her mouth.
✴Restlessness during sleep — the frequent arousals lead to restless sleeping or "tossing and turning" throughout the night.
✴Sleeping in odd positions — the child may arch his neck backwards (hyperextend) in order to open the airway or sleep sitting up.
✴Behavior problems or sleepiness — may include irritability, crankiness, frustration, hyperactivity, and difficulty paying attention.
✴School problems — children may do poorly in school, even being labeled as "slow" or "lazy."
✴Bed wetting — also known as nocturnal enuresis, although there are many causes for bedwetting besides sleep apnea.
✴Frequent infections — may include a history of chronic problems with tonsils, adenoids, and/or ear infections.
Thank you......