The PEEL Technique: A New Paradigm in Infant Tongue-Tie Release

INTRODUCTION

Infant ankyloglossia is a condition that can have serious adverse sequela if left untreated. Though Hogan et al¹ place the incidence at 10.7% of all infants, other studies place the incidence between 4.2% and 4.8%.^2,3 The reason for the disparity is simple: Segal et al⁴ state that “there is no well-validated clinical method for establishing a diagnosis of ankyloglossia.” Ganesan et al⁵ state that “knowledge of the condition by healthcare professionals and its potential effect on breastfeeding…seems to be limited.” Though there are many different assessment tools used by international board-certified lactation consultants (IBCLCs), these tools are only for assessment, not for diagnosis. IBCLCs are not permitted to diagnose—they may only assess. Diagnosis rests with either a physician or dentist or, in many states, a nurse practitioner. Among the assessment tools used by IBCLCs are the Hazelbaker Assessment Tool for Lingual Frenulum Function,⁶ the Bristol Tongue Assessment Tool,⁷ the Infant Breastfeeding Assessment Tool, the Mother-Baby Assessment Tool, and the LATCH scoring system.⁸ All of these assessment tools, along with others, have statistically significant positive correlations between the scores and presence of ankyloglossia. 

REVIEW OF THE LITERATURE

Though some pediatricians may be untrained or unaware of the condition and its implications, the medical literature regarding the need for prompt treatment is overwhelming. In September 2021, the medical journal Otolaryngology-Head and Neck Surgery, the official journal of the American Academy of Otolaryngology-Head and Neck Surgery, published a prospective randomized trial of 47 infants aged 3 to 16 weeks.⁹ Twenty-three infants were placed into the control/observational arm of the study, and 24 infants were placed into the interventional (surgical tongue-tie release) arm. At the day 10 time point, the interventional arm demonstrated statistically significant improvement in 11 objectively obtained feeding metrics, indicating faster tongue speed, more rhythmic and coordinated sucking motions, and a tongue more capable of adapting to varying feeding demands. Significant improvement in breastfeeding self-efficacy was reported in the interventional group, while poor self-confidence persisted in the observational group. Infant reflux symptoms improved in the interventional group but not in the control group. Nipple pain also persisted in the control group but improved in the surgical cohort. The paper’s conclusion was that “posterior tongue-tie is a valid clinical concern, and surgical release can improve infant and maternal symptoms.”⁹ O’Callahan et al¹⁰, writing in The International Journal of Pediatric Otorhinolaryngoly, followed 299 infants with posterior tongue ties. Infant latching significantly improved (P<0.001) from pre- to post-intervention for infants with posterior ankyloglossia. Both the presence and severity of nipple pain decreased from pre- to post-intervention among all classifications (P<0.001). Additionally, 92% of respondents breastfed exclusively post-intervention. The paper concluded that “breastfeeding difficulties associated with ankyloglossia in infants, particularly posterior, can be improved with a simple office-based procedure in most cases. The diagnosis and treatment of ankyloglossia should be a basic competency for all primary care providers and pediatric otorhinolaryngologists.”¹⁰ Other papers also discuss the fact that ankyloglossia release is beneficial to both mother and child.^11,12 Two important facts from the paper by O’Callahan¹⁰ et al that bear further discussion are that 64% of mothers reported nipple pain preoperatively, and the presence and severity of pain decreased post-intervention. This is quite significant because one of the most common reasons for mothers discontinuing breastfeeding is nipple pain. Using 2 years of data from the Pregnancy Risk Assessment and Monitoring System, an assessment of reasons for stopping breastfeeding was published in the journal Pediatrics, the official journal of the American Academy of Pediatrics. The reasons given included sore nipples and infants having latching difficulties—both of which can be corrected by ankyloglossia release.¹³ Other papers in peer-reviewed medical journals have also discussed sore nipples, pain during breastfeeding, and poor latching as reasons for discontinuing breastfeeding.^14,15 Once again, all of these symptoms have been shown in the peer-reviewed literature cited above to decrease significantly after release. 

HISTORY OF SURGICAL INTERVENTION

Tongue-tie release is not some new fad. This is a procedure that has been performed for literally thousands of years. The journal Neonatology points out that “Operative interventions were proposed in Greek medicine. In the Middle Ages, competition arose between midwives, some of which used their nails to detach the frenulum, and surgeons who were allowed to use instruments.”¹⁶ Avicenna (also known as Ibn Sina) published The Canon of Medicine in the year 1025 CE in Persia. He pointed out tongue-tie (ankyloglossia) “is a condition caused by an abnormally short lingual frenulum,” and he suggested surgical ligation of the lingual frenulum to allow for mobility of the tongue. Girolamo Fabrici d’Acquapendente, a physician in the 16th century, used a sharp fingernail to perform infant frenectomies.¹⁷

WHAT IF SURGICAL INTERVENTION IS NOT PERFORMED?

What are the implications of not performing ankyloglossia release? Siegal¹⁸ published a retrospective study of 1,000 infants. The study shows a correlation between aerophagia in infants with short maxillary labial frenula and ankyloglossia and reflux. He concluded that treatment of these infants with a relatively simple frenotomy may reduce or eliminate reflux. As a result, many of these infants may be spared from invasive testing or medications that have been shown to have potential side effects.¹⁸ Invasive testing of these infants may include endoscopic examination, something many parents would rather not have their infants undergo. When anti-reflux medications to treat gastrointestinal symptoms, including aerophagia, are given to infants and toddlers, the side effects can be quite damaging. In a landmark study in the journal Pediatrics, a 12-year retrospective study of more than 850,000 children given acid suppression therapy (AST) to combat reflux was published. Eleven percent (more than 90,000 children) were prescribed AST in the first year of life; 7,998 children (0.9%) were prescribed proton pump inhibitors (PPI), 71,578 (8%) were prescribed histamine type-2 receptor antagonists (H₂RA), and 17,710 (2%) were prescribed both a PPI and an H₂RA. Infants prescribed AST had an earlier median first fracture age (3.9 vs 4.5 years). After adjustment, increased fracture hazard was associated with PPI use (21%) and PPI and H₂RA use (30%). Longer duration of AST treatment and earlier age of first AST use were associated with an increased fracture hazard. The study concluded that “Infant PPI use alone and together with H₂RAs is associated with an increased childhood fracture hazard, which appears amplified by days of use and earlier initiation of ASTs. Use of AST in infants should be weighed carefully against possible fracture.”¹⁹

An ankylosed tongue prevents the normal growth and development of the palate and airway. Freely movable tongues prevent the formation of a high palatal vault. If the frenum is ankylosed, the upper jaw will not develop properly, resulting in less-than-ideal maxillomandibular jaw development and adverse craniofacial growth. Yoon et al²⁰ concluded that variations in tongue mobility may affect maxillomandibular development. Jang et al²¹ cite several reports suggesting that ankyloglossia may produce open bites and mandibular protrusion malocclusions.^22-24 Their study suggested a relationship between ankyloglossia and mandibular prognathism.²¹ Northcutt²⁵ postulates that ankyloglossia is the leading cause of non-skeletal orthodontic problems and believes that if the cause of the problem (ankyloglossia) is not surgically corrected, nobody should be surprised by a relapse of the case. Defabianis²⁶ discusses a case with a 7-year clinical and radiologic followup of a patient with ankyloglossia. He noted that spontaneous upper arch expansion occurred, and therefore, orthodontic treatment following surgical intervention was unnecessary.

THE PEEL TECHNIQUE

Healthcare practitioners who do not discuss the relationship between ankyloglossia and significant orthodontic/growth and development problems may be doing their patients a disservice. 

The PEEL Technique is an acronym for the 4 movements that a tongue must make in order to ensure successful breastfeeding:

• Peristalsis. Involuntary constriction and relaxation of the muscles within the GI tract. This wave-like momentum propels food boluses along their path.
• Elevation. By reflex, the tongue lifts up toward the roof of the mouth, capturing breast tissue and consequentially compressing it against the hard palate.
• Extension. Sticking the tongue forward, out past the vermillion border.
• Lateralization. Moving the tongue symmetrically side to side and following a finger placed on the vermillion border and moving from commissure to commissure.

Figures 1 to 4 show before and after photos from 2 cases illustrating the results of using the PEEL Technique. Part 2 of this article will discuss the procedure to perform infant tongue-tie release using the PEEL Technique.

Figure 1. Preoperative view of an ankylosed tongue. Note the lack of elevation and prominent tongue-tie.

Figure 2. Armor Tongue Guide Infant Pro (Armor Dental) tongue retractor in position. This device both retracts and accentuates the frenum for a faster, easier procedure.

Figure 3. Pre-op view of tongue-tie. Note the bowl shape of the tongue. The center of the tongue was tied down, but the edges were able to elevate, resulting in a typical bowl shape.

Figure 4. Postoperative view of a released tongue. Note the complete elevation of the tongue to the palate.

REFERENCES

1. Hogan M, Westcott C, Griffiths M. Randomized, controlled trial of division of tongue-tie in infants with feeding problems. J Paediatr Child Health. 2005;41(5-6):246–50. doi:10.1111/j.1440-1754.2005.00604.x 
2. Ricke LA, Baker NJ, Madlon-Kay DJ, et al. Newborn tongue-tie: prevalence and effect on breast-feeding. J Am Board Fam Pract. 2005;18(1):1-7. doi:10.3122/jabfm.18.1.1
3. Messner AH, Lalakea ML, Aby J, et al. Ankyloglossia: incidence and associated feeding difficulties. Arch Otolaryngol Head Neck Surg. 2000;126(1):36–9. doi:10.1001/archotol.126.1.36
4. Segal LM, Stephenson R, Dawes M, et al. Prevalence, diagnosis, and treatment of ankyloglossia: methodologic review. Can Fam Physician. 2007;53(6):1027–33.
5. Ganesan K, Girgis S, Mitchell S. Lingual frenotomy in neonates: past, present, and future. Br J Oral Maxillofac Surg. 2019;57(3):207–13. doi:10.1016/j.bjoms.2019.03.004
6. Amir LH, James JP, Donath SM. Reliability of the hazelbaker assessment tool for lingual frenulum function. Int Breastfeed J. 2006;1(1):3. doi:10.1186/1746-4358-1-3
7. Ingram J, Johnson D, Copeland M, et al. The development of a tongue assessment tool to assist with tongue-tie identification. Arch Dis Child Fetal Neonatal Ed. 2015;100(4):F344–8. doi:10.1136/archdischild-2014-307503
8. Altuntas N, Turkyilmaz C, Yildiz H, et al. “Validity and reliability of the infant breastfeeding assessment tool, the mother baby assessment tool, and the LATCH scoring system.” Breastfeeding Med. 2014 9(4): 191-195. doi: 10.1089/bfm.2014.0018. Epub 2014 Mar 20. PMID: 24650352.
9. Ghaheri BA, Lincoln D, Mai TNT, et al. Objective improvement after frenotomy for posterior tongue-tie: a prospective randomized trial. Otolaryngol Head Neck Surg. 2022;166(5):976–84. doi:10.1177/01945998211039784
10. O’Callahan C, Macary S, Clemente S. The effects of office-based frenotomy for anterior and posterior ankyloglossia on breastfeeding. Int J Pediatr Otorhinolaryngol. 2013;77(5):827–32. doi:10.1016/j.ijporl.2013.02.022
11. Steehler MW, Steehler MK, Harley EH. A retrospective review of frenotomy in neonates and infants with feeding difficulties. Int J Pediatr Otorhinolaryngol. 2012;76(9):1236–40. doi:10.1016/j.ijporl.2012.05.009
12. Buryk M, Bloom D, Shope T. Efficacy of neonatal release of ankyloglossia: a randomized trial. Pediatrics. 2011;128(2):280–8. doi:10.1542/peds.2011-0077
13. Ahluwalia IB, Morrow B, Hsia J. Why do women stop breastfeeding? Findings from the Pregnancy Risk Assessment and Monitoring System. Pediatrics. 2005;116(6):1408–12. doi:10.1542/peds.2005-0013
14. Odom EC, Li R, Scanlon KS, et al. Reasons for earlier than desired cessation of breastfeeding. Pediatrics. 2013;131(3):e726–32. doi:10.1542/peds.2012-1295
15. Li R, Fein SB, Chen J, et al. Why mothers stop breastfeeding: mothers’ self-reported reasons for stopping during the first year. Pediatrics. 2008;122 Suppl 2:S69–76. doi:10.1542/peds.2008-1315i
16. Obladen M. Much ado about nothing: two millenia of controversy on tongue-tie. Neonatology. 2010;97(2):83–9. doi:10.1159/000235682
17. Luchsinger R, Arnold GE. Voice-speech-language: Clinical communicology: Its physiology and pathology. Wadsworth Publishing; 1965.
18. Siegal SA. Aerophagia induced reflux in breastfeeding infants with ankyloglossia and shortened maxillary labial frenula (tongue and lip tie). Int J Clin Pediatr. 2016;5(1):6-8. doi:10.14740/ijcp246w
19. Malchodi L, Wagner K, Susi A, et al. Early acid suppression therapy exposure and fracture in young children. Pediatrics. 2019;144(1):e20182625. doi:10.1542/peds.2018-2625
20. Yoon AJ, Zaghi S, Ha S, et al. Ankyloglossia as a risk factor for maxillary hypoplasia and soft palate elongation: A functional-morphological study. Orthod Craniofac Res. 2017;20(4):237–44. doi:10.1111/ocr.12206
21. Jang SJ, Cha BK, Ngan P, et al. Relationship between the lingual frenulum and craniofacial morphology in adults. Am J Orthod Dentofacial Orthop. 2011;139(4 Suppl):e361–7. doi:10.1016/j.ajodo.2009.07.017
22. Proffit WR, Mason RM. Myofunctional therapy for tongue-thrusting: background and recommendations. J Am Dent Assoc. 1975;90(2):403–11. doi:10.14219/jada.archive.1975.0075
23. Whitman CL, Rankow RM. Diagnosis and management of ankyloglossia. Am J Orthod. 1961;47(6):423–8.
24. Hopkin GB. Neonatal and adult tongue dimensions. Angle Orthod. 1967;37(2):132–3. doi:10.1043/0003-3219(1967)037<0132:NAATD>2.0.CO;2
25. Northcutt ME. The lingual frenum. J Clin Orthod. 2009;43(9):557–65.
26. Defabianis P. Ankyloglossia and its influence on maxillary and mandibular development. (A seven year follow-up case report). Funct Orthod. 2000;17(4):25-33.

ABOUT THE AUTHOR

Dr. Convissar is a pioneer in the field of laser dentistry. He has close to 4 decades of experience with CO₂, diode, erbium, Nd:YAG, and PBM wavelengths. He has authored more than 20 peer-reviewed papers and 7 laser textbooks. An international lecturer, he has delivered close to 400 laser certification and laser tongue-tie certification courses worldwide. He is the only dentist in the world to have the following triad of awards: Diplomate of the American Board of Laser Surgery, Fellow of the American Society of Laser Medicine and Surgery, and Master of the Academy of Laser Dentistry. He is also a Fellow of the AGD. He practices laser dentistry in New York City, where he also serves as director of laser dentistry at the New York Presbyterian Hospital of Queens. He is the only dentist from the United States on the faculty of the world-famous Master’s Degree Program in Laser Dentistry at the University of Genoa (Italy). Dr. Convissar regularly teaches 2-day workshops on the PEEL Technique worldwide. He can be reached at laserbobdds@gmail.com.

Disclosure: Dr. Convissar has received honoraria from Armor Dental in the past.