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Tying it All Together: Diagnosis, Implications, and Treatment of Tethered Oral TissuesA Peer-Reviewed Publication Written by Lori Cockley, DDS, FAGD

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AbstractWhile most dental clinicians are familiar with the term ankyloglossia and perhaps as familiar with the lay term tongue-tie, few are aware of the vast implications that these restrictions may create. This article will attempt to define and provide a clear understanding of this congenital condition as it relates to ideal tongue function, as well as offer ways to best assess and treat in a safe, predictable manner.

Educational ObjectivesAfter reading this article, the reader should be able to:1. Define Tethered Oral Tissue and understand

the anatomy and prevalence of this issue.2. Be able to identify the characteristics of this

condition.3. Have the ability to diagnose and classify the

various types of tethered oral tissue.4. Know the methods for treating this condition

including post-operative care.

Author ProfileLori Cockley, DDS, FAGD, earned her dental degree from of the University of Maryland, Baltimore College of Dental Surgery. She is a fellow of the Academy of General Dentistry and a member of the International Affiliation of Tongue-Tie Professionals. She maintains a full-time private practice in East Berlin, a small town in rural south central Pennsylvania.

Author DisclosureLori Cockley, DDS, FAGD, has no commercial ties with the sponsors or the providers of the unrestricted educational grant for this course.

Publication date: Sept. 2016 Expiration date: Aug. 2019

This educational activity was developed by PennWell’s Dental Group with no commercial support.This course was written for dentists, dental hygienists and assistants, from novice to skilled. Educational Methods: This course is a self-instructional journal and web activity. Provider Disclosure: PennWell does not have a leadership position or a commercial interest in any products or services discussed or shared in this educational activity nor with the commercial supporter. No manufacturer or third party has had any input into the development of course content.Requirements for Successful Completion: To obtain 3 CE credits for this educational activity you must pay the required fee, review the material, complete the course evaluation and obtain a score of at least 70%.CE Planner Disclosure: Heather Hodges, CE Coordinator does not have a leadership or commercial interest with products or services discussed in this educational activity. Heather can be reached at hhodges@pennwell.comEducational Disclaimer: Completing a single continuing education course does not provide enough information to result in the participant being an expert in the field related to the course topic. It is a combination of many educational courses and clinical experience that allows the participant to develop skills and expertise.Image Authenticity Statement: The images in this educational activity have not been altered.Scientific Integrity Statement: Information shared in this CE course is developed from clinical research and represents the most current information available from evidence based dentistry. Known Benefits and Limitations of the Data: The information presented in this educational activity is derived from the data and information contained in reference section. The research data is extensive and provides direct benefit to the patient and improvements in oral health. Registration: The cost of this CE course is $59.00 for 3 CE credits. Cancellation/Refund Policy: Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing.

PennWell designates this activity for 3 continuing educational credits.

Dental Board of California: Provider 4527, course registration number CA# 03-4527-15134 “This course meets the Dental Board of California’s requirements for 3 units of continuing education.”

The PennWell Corporation is designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing dental education programs of this program provider are accepted by the AGD for Fellowship, Mastership and membership maintenance credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from (11/1/2015) to (10/31/2019) Provider ID# 320452.

INSTANT EXAM CODE 15134

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Educational ObjectivesAfter reading this article, the reader should be able to:1. Define Tethered Oral Tissue and understand the anatomy

and prevalence of this issue.2. Be able to identify the characteristics of this condition.3. Have the ability to diagnose and classify the various types

of tethered oral tissue.4. Know the methods for treating this condition including

post-operative care.

AbstractWhile most dental clinicians are familiar with the term ankylo-glossia and perhaps as familiar with the lay term tongue-tie, few are aware of the vast implications that these restrictions may create. This article will attempt to define and provide a clear understanding of this congenital condition as it relates to ideal tongue function, as well as offer ways to best assess and treat in a safe, predictable manner.

Definition, anatomy, prevalenceFrenums (aka frena) are defined as remnants of embryological tissue primarily found along the oral midline on the maxillary or mandibular labial vestibular surface or on the ventral surface of the tongue. Their primary function is to keep the lips and tongue in harmony with the growing bones of the mouth during development.

On occasion, these oral tissues may be excessively short, thick, or inflexible, severely limiting movement and function. These are commonly referred to as tongue-ties and lip-ties. Fre-nums can also be found on the right or left sides of both the maxillary or mandibular buccal areas. These are less frequent and less impactful, but are nonetheless noted and are com-monly referred to as buccal-ties. A new term Tethered Oral Tissues (or TOTs) is emerging, which encompasses all of these. While all frenal attachments are mentioned in this article, we will primarily discuss those that affect the tongue.

Most muscles attach to bones with tendon, but there are a few exceptions and the tongue is perhaps the most extraor-dinary. The tongue is a remarkable organ with a very notable characteristic: It is the only muscle in the human body that is freely movable on one end while attached on the other. It is able to protrude, fold, invert, retract, or expand. As part of the larger organ system of the head and neck, it is attached to eight other muscles—four intrinsic and four extrinsic—allowing it to perform all of these unique actions. It is the organ of taste and is essential in the movement of food for effective mastication. It is the organ of phonetic articulation, with proper enunciation being a product of normal tongue function. The resting posture of the tongue affects the development of the upper jaw, the po-sition of the teeth in the arch, the shape of the face and upper airway nasal passages, and thus, it’s correct function is critical in the development of ideal airway and craniofacial growth and development.

The process by which this frenum is formed is known as sculpting apoptosis or predetermined programmed cell death. It is the same way fingers are formed, and just as some people may have webbed fingers, if this process fails, so, too, can excess oro-frenal tissue result. It is unknown how prevalent this condition is. According to a study by Hazelbaker, it is estimated to be found in 3-4% of the population, and sometimes noted to be as high as 12% with a slight male preponderance and a strong genetic com-ponent. The difficulty in identifying the precise incidence lies in the fact that there is a wide variance in degrees of severity and adaption, so that the majority of these cases never come to light. Symptoms associated with ankyloglossia and other TOTs may appear at any age of development, starting with difficulties from birth to problems that may exist over a lifetime.

Figure 1: Varying degrees of ankyloglossia.

BreastfeedingPerhaps the earliest symptom of TOTs is a difficulty in breast-feeding. The jaw movements and piston-like tongue elevations necessary for extracting milk from the breast provide stimula-tion for the growth of the temporomandibular joint, while encouraging forward growth and development of the facial regions of the maxilla and mandible. Together with genetic and environmental factors, this provides stability of the dental occlusion, function, and motor balance. While proper breast-feeding promotes good oral motor development, bottle-feeding is known sometimes to have a negative impact on dental health, so early identification of problems and their resolution is key. Breastfeeding benefits reach far beyond simple nourishment, and a greater understanding will help us to guide our patients as they navigate these oral conditions in their children.

Figure 2

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Tight or excessive frenum anomalies that affect breast-feeding are often overlooked in the early clinical settings, caus-ing detrimental effects to the newborn who is having difficulty latching on, which may be the very first symptom of a restricted tongue function. Diagnosis at this early age is often made on the basis of symptoms as well as clinical appearance. One of the most common signs that a problem exists is that the baby is not gaining weight or is “failing to thrive.” While this may indeed be an indication of a TOTs problem, weight gain alone is not an exclusively reliable method of diagnosis. Weight gain needs to be assessed as a part of the overall clinical picture, and other factors should be evaluated to arrive at a more definitive conclusion.

Oftentimes, the baby’s tight oral anatomy physically prevents him or her from opening wide enough to appropriately latch onto the breast. If able to latch, the infant will not be able to sustain a latch long enough to have any efficiency in breastfeeding with-out exerting a tremendous amount of energy. This results in an audible “clicking” off the breast or a gulping sound as the infant loses suction. Frequent or extended feeding sessions may ensue in which the baby cries, shows frustration, or even falls asleep at the breast from the exertion before a full feeding has taken place.

Babies who have a tongue-tie or lip-tie commonly take in significant amounts of air. With an inability to flange out the upper lip and/or an inability to appropriately cup the breast with the tongue comes a shallower, more bottle-like latch. This swal-lowed air can cause reflux-induced aerophagia, which results in frequent choking, gagging, hiccupping, spitting up, or projectile vomiting. As a result, significant abdominal discomfort from gas and colic may develop.

When physically unable to engage the tongue to maintain a proper latch, some very determined babies compensate by inap-propriately and aggressively using both lips as the primary means to hold suction. Since the newborn skin is very tender, “nursing tubercles,” commonly known as “lip blisters” develop. While these are not entirely uncommon in the newborn and may appear with-out being associated with TOTs, if they persist beyond the first few months, they could be indicative of both tongue- and lip-ties.

If the upper lip is restricted in movement and unable to suf-ficiently flange, the depth of the latch suffers as the infant is physically unable to avoid using his or her gums or lips to hold onto the nipple in this shallow latch. This frequently results in a “gumming” or “chewing” of the nipple. This can be a primary cause of nipple pain.5 Maternal pain while breastfeeding is com-mon and includes painful compression of the nipples, mastitis, engorgement, thrust, vasospasm, bleeding and cracked nipples, and low milk supply. Any of these can contribute to premature termination of breastfeeding, depriving the baby of maternal immunity as well as any of the aforementioned growth and cra-niofacial advantages.

Physical characteristicsThe tight lingual frenum will restrict elevation, resulting in a cupping of the tongue with the lateral borders lifting and pos-

sible dimpling in the center. There is often a white coating on the dorsal surface showing where the tongue is deficient in reaching the roof of the mouth. This leaves a milky residue fol-lowing feeding. The baby may be able to protrude the tongue past the gums, yet still will not be able to elevate. Therefore, it is important to note that up is more important than out in evaluating for these restrictions. Anterior tongue-tie results when the tip of the tongue is anchored to the floor of the mouth with a visually obvious frenum. However, there is a hidden part of the frenum that is less obvious but more significant. It is known as posterior tongue-tie and is found in the submucosal area of the tongue. This is seen when elevating the tongue with an instrument called a grooved director (or by elevating with two fingers) and compressing the lateral portions of the muco-sal area on either side of the frenum. This submucosal or poste-rior tongue-tie must be fully released to achieve a complete and successful frenectomy.

Figure 3: Tongue elevation before-and-after tongue-tie revision.

Eating, skeletal, speech, dentalAs the child grows and solids are introduced, more eating dif-ficulties may develop caused by poor coordination of the oral musculature. The tongue must be free to move food around the mouth, position the bolus of food in the center, reach the pal-ate to create a seal, and finally swallow properly. A tied tongue may have difficulty in the lateralization required in moving solid food around the mouth or in protrusion for accepting food or licking. Without the full range of motion, the child will compensate with accessory muscle movements. The child may require liquids to help cleanse the foods from the mouth to better facilitate swallowing. He or she may reject food that is difficult to chew, use fingers to move the food around the mouth, or dislodge its compaction within the vestibules. There may be a persistent gagging, choking, or dribbling habit due to the lack of control of the food bolus, enabling the food to easily divert into the airway. The child may become known as a “messy eater,” “picky eater,” or a “loud eater.” This may lead to behavioral problems and a declining self-image. Dental problems such as gingivitis and caries develop as food is not easily cleansed from the oral cavity following eating. The strain of the frenum pull may cause a lingual rotation of the mandibu-lar incisors or gingival recession.7

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Short frenums may lead to orofacial changes associated with abnormal anatomic support of the upper airway, allowing an increased risk of collapse during the change in muscle tone re-lated to sleep stages. Over time, muscular weakness may cause airway collapse and the formation of obstructive sleep apnea or sleep disordered breathing.4 The inability to form a lingual-palatal seal with swallowing can create a compensating tongue thrust that results in an open bite. There may be a low and forward tongue resting posture, an open mouth rest posture, primary mouth breathing, forward head posture, an imbalance in skeletal structure and postural development, and craniofacial development that includes a narrow palatal arch and convex profile. TMJ symptoms, migraine headaches, tension in the neck and shoulders, and orthodontic problems may develop as negative sequelae.

Figure 4: “V-shaped arch” and high palate as a result of low tongue pos-ture. Notice the residual food around the mouth, because the tongue is not in full control of food while eating.

Figure 5: Poor oral rest posture as a result of a tongue-tie. Notice the lip incompetence and bunched mentalis muscle.

Speech delays and poor enunciation are associated with poor range of lingual movements. Both children and adults may learn to speak with a small oral aperture so that they may access the oral landmarks necessary to facilitate the consonants of speech. Others speak slowly and deliberately, and they lose clarity when speaking rapidly. The articulation of “S,” “Th,” “N,” “L,” “R,” “D,” and “T” are prominently affected.

The tongue has a remarkable ability to compensate, many children have no discernable speech impediments. Evalua-

tion is generally needed if less than half of the child’s speech is understood outside the family circle by age three. Emotional factors and lowered self-esteem can begin to come into play as social situations such as communication, dining out, and kiss-ing are affected and the symptoms become more relevant and compensations more engrained.

Diagnosis, classificationIt is important to note that research indicates 30% of ties cause problems. Each situation is unique, and the condition lends it-self to a great deal of adaptation and compensation so that many less severe cases go undiagnosed, and the statistics of incidence remain undependable. Still, some physical characteristics are generally accepted.

Physical characteristics include• V-shaped notch at the tip of the tongue/heart shape seen

on protrusion or elevation• Inability to stick out the tongue past the lower incisors • A rolling under of the tongue on protrusion• Inability to touch the roof of the mouth• Inability to touch the maxillary molars with the tongue• Inability to lateralize the tongue/move from side to side

with ease• Frenum that blanches on elevation of the tongue• Cupping of lateral tongue borders • Central clefting or dimpling of the tongue

One of the barriers to diagnosing and categorizing with any consistency is the fact that there is no consensus on clear, measurable standardization.3,8 Currently, providers are using their own means of assessing, with no consistency among the professions. Classification systems primarily attempt to stan-dardize the degree of severity based on the attachment points, but do not consistently denote the degree of severity or neces-sity for treatment. The varying factors of length of frenum, thickness, and flexibility are more indicative of the extent of the problem, and these things must be carefully sorted out. This is why visualization alone is not sufficient and symptoms must be taken into consideration. Treatment must be based on both symptoms and clinical presentations.

Figure 6: Note tight attachment of lingual frenum to alveolar ridge, causing rotation of mandibular incisors.

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Figure 7: Note rolling under during protrusion.

Figure 8: Classic heart-shape on elevation.

Figure 9: Complete anterior tongue-tie shows blanching on attempt to elevate.

TreatmentHistorically, frenum revisions have been performed by cut-ting with blunt-end scissors. However, it is becoming more desirable by many parents to have the frenectomy performed by way of laser ablation. There are many who feel that the incidence of incomplete releases is more likely with scissors, since the posterior portion of the tie is submucosal and harder to visualize without the cauterizing ability of the laser. With the wide availability of affordable lasers and training, many clinicians are comfortable and proficient in using these tools in a number of capacities. The laser is gentle, precise, and bac-tericidal with virtually no chance of infection. There is little to no bleeding, the tissue is removed completely, and there are no sutures required. There is reduced risk of postsurgical swelling, pain, and discomfort. When a trained practitioner using proper safety precautions performs laser revision (i.e.,

laser safety goggles for everyone in the surgical area includ-ing the infant), the procedure is safe, quick, and nearly void of complications. There are no known contraindications; the procedure is safe and should take only a few moments to complete.

Figures 10 and 11: 36-year-old female patient reported release of ten-sion in back, neck, and shoulders as well as lessened migraine and TMJ symptoms.

Figures 12 and 13: 27-year-old. Note the depth of submucosal (pos-terior) release. Patient stated that she could breathe better and slept better following revision.

Generally there is no consensus on the use of topical and/or injection of local anesthetic. Many providers use neither on infants, while some use a mild topical placed with a cotton swab on each side of the frenum. In older children and adults a few drops of injected lidocaine may be used in addition to a topi-cal anesthetic. A grooved director is placed under the tongue, straddling the frenum and lifting so that the frenum is pulled taut. The tongue base as well as the fibers of the frenum should be fully visualized with the aid of magnification and ample lighting. The revision should be parallel to the grooved director and approximately midway between the floor of the mouth and the tongue so as to avoid damage to the submandibular ducts. The ablation should continue until the restrictive fibers are severed and the tongue lifts freely. A finger sweep at the base of tongue will confirm this.

Figures 14 and 15: Grooved director helps to elevate tongue for full access to frenum and helpful in visualization of posterior component as well.

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Questions

Online CompletionUse this page to review the questions and answers. Return to www.DentalAcademyOfCE.com and sign in. If you have not previously purchased the program select it from the “Online Courses” listing and complete

the online purchase. Once purchased the exam will be added to your Archives page where a Take Exam link will be provided. Click on the “Take Exam” link, complete all the program questions and submit your answers.

An immediate grade report will be provided and upon receiving a passing grade your “Verification Form” will be provided immediately for viewing and/or printing. Verification Forms can be viewed and/or printed

anytime in the future by returning to the site, sign in and return to your Archives Page.

1. Frena are found in what oral locations?a. Maxillary and mandibular labial b. Lingual c. Right and left buccald. All of the above

2. How many other muscles attach to the tongue?a. Twob. Fourc. Sixd. Eight

3. The rest posture of the tongue affects the development of what craniofacial structures?a. Upper jawb. Position of teeth in the archc. Shape of the faced. All of the above

4. At what age do ankyloglossia symptoms appear?a. Birthb. Age twoc. Age 18d. May appear at any age

5. What is the earliest possible symptom of TOTs?a. Breastfeeding difficultiesb. Speech delaysc. Feeding problemsd. Orthodontic concerns

6. Treatment of TOTS is based on what?a. Clinical appearanceb. Symptomsc. a and b d. None of the above

Follow-upAfter-care stretches and exercises will help limit reattachment as the tissues heal and preserve the newly gained range of motion. The tongue should be firmly but gently lifted and stretched (with a tongue blade, gauze, or even the parents’ clean fingers) while simultaneously pushing down on the lower jaw, such that the entire diamond shape of the wound is visible. This should be repeated three to five times per day for two to three weeks. Tongue exercises would include lifting the tongue toward the roof of the mouth with the mouth open, sticking the tongue out toward the nose and down toward the chin, and lateralizing the tongue toward the right and left cheeks as far as possible with the mouth closed. For the infants, mothers should be diligent in lifting and stretching the diamond of the lip or tongue several times per day as well as massaging and finger sweeping the lip and floor of the mouth to make sure no reattachment has developed.

If any tightness develops, the area should be stretched firmly and the wound opened so as to facilitate and encour-age healing by secondary intention. There may be some slight bleeding as the wound is opened. Post-op analgesics, ice packs, and a soft diet is suggested. A multidisciplinary approach is recommended in follow-up for full rehabilitation. This may in-clude chiropractic care, osteopathic manipulation, craniosacral therapy, myofascial release, acupressure, and others to restore overall muscle balance and function. In an infant, lactation con-sultants are a very key part of the process, whereas in an older child or adult, speech therapy and/or myofunctional therapy is critical in the restoration of full correct function, since compen-sating habits are likely well ingrained and may persist even after the restrictions are removed.

ConclusionProblems associated with a tight frenum may include diffi-culties that manifest at birth to other problems that manifest

over the course of a lifetime. Early identification of a lingual or labial restriction can prevent a host of cascading health effects.

References1. International Affiliation of Tongue-tie Professionals website. http://

tonguetieprofessionals.org. FAQ- Definition of tongue-tie. Published 2014. Accessed April 14, 2016.

2. Kotlow LA. Lasers and soft-tissue treatments for the pediatric dental patient. Alpha Omegan. 2008;101(3):140–151.

3. Hazelbaker A. Tongue-tie: Morphogenesis, Impact, Assessment and Treatment. Columbus, OH: Aidan and Eva Press. 2010.

4. Macaluso M, Hockenbury D. (2015) Lingual, labial frenums: Early detection can prevent health effects associated with tongue-tie. RDH website. http://www.rdhmag.com/articles/print/volume-35/issue-12/content/lingual-and-labial-frenums.html. Published December 2015. Accessed May 2016.

5. Ghaheri B. The misunderstanding of posterior tongue-tie anatomy and release technique. DrGhaheri.com blog: Tongue Tie/Tongue-Tie and Breastfeeding/Tongue-Tie and Laser Surgery. http://drghaheri.squarespace.com/blog/. Published August 19, 2015. Accessed April 14, 2016.

6. Seigel, S. Aerophagia-induced reflux associated with lip- and tongue-tie in breastfeeding infants. American Academy of Pediatrics. 2016;137(2)Suppl(3).

7. Huang Y, Quo S, Berkowski JA, Guilleminault C. (2015). Short lingual frenum and obstructive sleep apnea in children. International Journal of Pediatric Research. 2015;1:1.

8. Cockley L, Lehman A. The Orthodontic missing link. Could it be tied to the tongue? Journal of the American Orthodontic Society. 2015(Winter);18–21.

9. American Academy of Otolaryngology–Head and Neck Surgery website. Ankyloglossia “In Toddlers and Older Children- Speech, www.entnet.org/content/tongue-tie-ankyloglossia. Published 2015. Accessed April 14, 2016.

Author ProfileLori Cockley, DDS, FAGD, earned her dental degree from of the Univer-sity of Maryland, Baltimore College of Dental Surgery. She is a fellow of the Academy of General Dentistry and a member of the International Affiliation of Tongue-Tie Professionals. She maintains a full-time private practice in East Berlin, a small town in rural south central Pennsylvania.

Author DisclosureLori Cockley, DDS, FAGD has no commercial ties with the sponsors or the providers of the unrestricted educational grant for this course.

INSTANT EXAM CODE 15134

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7. Which of the following is not a sign and symptom of TOTs in an infant?a. Clicking off the breast, gas, spitting up, colic b. Extended, frustrating feeding sessionsc. Infrequent choking while breastfeedingd. Failure to thrive

8. What is true of “nursing tubercles”a. They are geneticb. They are always a sign of TOTsc. They are very rared. None of the above

9. Which of the following is not a TOTs maternal symptom? a. Vasospasmb. Mastitisc. Thrustd. Pruritic areolas

10. In evaluating for tongue function, which of the following statements is true?a. If the tongue can protrude past the gums, there

is definitively no tieb. Out is more important than upc. Up is more important than out d. If speech is normal, there is definitively no tie

11. Anatomically, ankyloglossia has a submucosal posterior component as well as: a. An anterior component b. A lateral swayc. A horizontal sheathd. None of the above

12. Which of the following is associated with an eating difficulty related to a tongue-tie?a. Drinking a lot while eatingb. Loud eatingc. Messy eatingd. All of the above

13. Which of the following is not associated with short lingual frena?a. Tongue thrustb. Sleep disordered breathingc. Migratory glossitisd. Open mouth posture

14. Which of the following is not related to short frena:a. TMJ symptomsb. Migrainesc. Tension in the neck and back d. None of the above (they are all related)

15. Which of the following are clinical characteristics of a tongue-tie?a. Heart-shaped tongueb. Frenum that blanches on lift

c. Inability to touch roof of mouth with tongued. All of the above

16. What is an advantage of laser revisions?a. Bactericidalb. Precisec. No bleedingd. All of the above

17. What are the contraindications for a tongue-tie revisiona. Infant less than one-week-oldb. Child with a speech impedimentc. Child in full-treatment orthodontics d. There are no contraindications

18. What is an instrument that will hold the tongue or lip taut while performing a frenectomy?a. Groovy Gracyb. Hemostatsc. Frenum elevatord. Grooved director

19. Which of the following will not help visualization of the revision area while performing a frenectomy? a. Extra gauzeb. Magnificationc. A grooved directord. Ample lighting

20. Which of the following is imperative in preserving the range of motion gained by the frenectomy and preventing reattachment? a. After-care stretchesb. Exercises c. a and bd. None of the above

21. The incidence of tongue-ties is:a. 50%b. 1:1000c. 1:50d. 3–4% and perhaps as high as 15%, but there are

no dependable statistics available

22. How long should post-op exercises and stretches be performed?a. 24–48 hoursb. Three to five daysc. Seven to 10 daysd. Two to three weeks

23. When assessing an infant for a tongue-tie, one should consider all of the following, except:a. Fordyce spots on dorsum of tongue where milk

poolsb. Cupping of lateral bordersc. Inability to lateralize

d. Dimpling or clefting

24. Weak musculature can cause airway collapse during the change in muscle tone during sleep cycles but is never related to: a. Vertigob. Obstructive sleep apneac. Chronic sinusitisd. Deviated septum

25. Which of the following may not be associated with restricted tongue and lip mobility in an adult?a. TMJ dysfunction and migrainesb. Eczemac. Dental and orthodontic issuesd. Shoulder, neck, and back tension

26. Which of the following is imperative in order to prevent reattachment?a. Suturing b. Tissue adhesivec. Perio pakd. None of the above

27. Once the patient has developed engrained patterns of dysfunction as a result of restricted lingual function, he or she may need additional treatment or therapy to relearn the correct functional patterns from a:a. Speech language pathologistb. Myofunctional therapistc. Lactation consultantd. All of the above

28. Which of the following postoperative instructions will be useful? a. Soft dietb. Icec. Analgesicsd. All of the above

29. Which of the following are not types of oral frena?a. Lingualb. Labialc. Buccald. Distal

30. Which gender has a slightly higher incidence of ankyloglossia? a. Maleb. Female c. They are equald. It’s hard to say

Questions (continued)

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.

16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30.

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Educational Objectives1. Define Tethered Oral Tissue and understand the anatomy and prevalence of this issue.

2. Be able to identify the characteristics of this condition.

3. Have the ability to diagnose and classify the various types of tethered oral tissue.

4. Know the methods for treating this condition including post-operative care.

Course Evaluation1. Were the individual course objectives met?

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Please evaluate this course by responding to the following statements, using a scale of Excellent = 5 to Poor = 0.

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TOT1016DE

COURSE EVALUATION and PARTICIPANT FEEDBACKWe encourage participant feedback pertaining to all courses. Please be sure to complete the survey included with the course. Please e-mail all questions to: hhodges@pennwell.com.

INSTRUCTIONSAll questions should have only one answer. Grading of this examination is done manually. Participants will receive confirmation of passing by receipt of a verification form. Verification of Participation forms will be mailed within two weeks after taking an examination.

COURSE CREDITS/COSTAll participants scoring at least 70% on the examination will receive a verification form verifying 3 CE credits. The formal continuing education program of this sponsor is accepted by the AGD for Fellowship/Mastership credit. Please contact PennWell for current term of acceptance. Participants are urged to contact their state dental boards for continuing education requirements. PennWell is a California Provider. The California Provider number is 4527. The cost for courses ranges from $20.00 to $110.00.

PROVIDER INFORMATIONPennWell is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, not does it imply acceptance of credit hours by boards of dentistry.

Concerns or complaints about a CE Provider may be directed to the provider or to ADA CERP ar www.ada.org/cotocerp/

The PennWell Corporation is designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing dental education programs of this program provider are accepted by the AGD for Fellowship, Mastership and membership maintenance credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from (11/1/2015) to (10/31/2019) Provider ID# 320452

RECORD KEEPINGPennWell maintains records of your successful completion of any exam for a minimum of six years. Please contact our offices for a copy of your continuing education credits report. This report, which will list all credits earned to date, will be generated and mailed to you within five business days of receipt.

Completing a single continuing education course does not provide enough information to give the participant the feeling that s/he is an expert in the field related to the course topic. It is a combination of many educational courses and clinical experience that allows the participant to develop skills and expertise.

CANCELLATION/REFUND POLICYAny participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing.

IMAGE AUTHENTICITYThe images provided and included in this course have not been altered.

© 2016 by the Academy of Dental Therapeutics and Stomatology, a division of PennWell

INSTANT EXAM CODE 15134