Lingual Frenulum Protocol

Abstract

An efficient lingual frenulum protocol with scores is presented. From a specific lingual frenulum evaluation used until 2004, a new protocol was designed. Ten speech language pathologists experienced in orofacial myology used the new protocol with different groups of subjects. 1235 subjects were evaluated during 3 years. From the experience of these ten speech language pathologists, the protocol was re-structured, and a scoring system was added. Absence of alteration (normal tongue and frenulum) was scored zero. The alterations observed were scored in ascending order. Four additional speech language pathologists experienced in orofacial myology were trained by the researcher to administer the final version of the protocol. The protocol was administered in 2008 and 2009 to 239 subjects: 160 children between 7 years and 2 months old and 11 years and 7 months old; and to 79 adults from 16 years and 8 months or older. From the results of administration of the protocol, a new lingual frenulum protocol with scores was designed. According to the scores, the frenulum can be considered altered or normal. When the sum of general tests is equal or higher than 3, the frenulum may be altered. The interference of the lingual frenulum in the oral functions may be considered when the sum of the functional tests is equal or higher than 25. This new lingual frenulum protocol with scores was designed and has been an efficient tool to diagnose an altered lingual frenulum.

INTRODUCTION

When health professionals evaluate the lingual frenulum, they diagnose it as normal or altered depending on the criteria used. Usually, professionals evaluate the lingual frenulum by observing the appearance and the mobility of the tongue. When assessing babies, health professionals also observe breastfeeding. For an accurate evaluation, it is necessary to observe certain aspects of the tongue and frenulum, such as the mobility and habitual position of the tongue, as well as speech articulation. In general, existing protocols only evaluate the mobility of the tongue and frenulum by itself, and the results depend on what the evaluator considers normal or altered.

The lingual frenulum definitions found in the literature complement each other, without indicating divergent key aspects (Kenneth, 1998; Singh & Kent, 2000; Zemlin, 2000; Moore & Dalley, 2001; Galvão, 2001; Stedman, 2003). There is a wide variation of nomenclature to define the altered frenulum: tongue-tie, short frenulum, long frenulum, sticky tongue, anteriorized, ankyloglossia (full or partial), among others (Singh & Kent, 2000; Zemlin, 2000; Moore & Dally, 2001; Galvão, 2001; Stedman, 2003; Dorland, 2004; Marchesan, 2004). As the terminology varies, contradictory diagnoses may occur (Segal, Stephenson, Dawes, Feldman, 2007; Suter & Bornstein, 2009). Although there is no consensus about terminology, all professionals agree that, when the lingual frenulum is altered, feeding and speech are frequently altered functions. In the literature breastfeeding is the most often cited altered function; however, breastfeeding lasts approximately only one year, while chewing, swallowing and speech are life-long functions (Messner Lalakea, Macmahon, Bair, 2000b; Ballard, Auer, Khoury, 2002; Hogan, Westcott, Griffiths, 2005; Hall & Renfrew, 2006; Geddes, Langton, Gollow, Jacobs, Hartmann, Simmer, 2008; Karabulut, Sonmez, Turkyilmaz, Demirogullari, Ozen, Bagbanci, 2008; Miranda & Milroy, 2010; Post, Rupert, Schulpen, 2010; Forlenza, Black, McNamara, Sullivan, 2010; Merdad & Mascarenhas, 2010).

When the lingual frenulum is altered the greatest divergence from normal is in the area of speech production. Some studies claim that such alterations are rare or insignificant (Zemlin, 2000; Moore & Dalley, 2001). In addition, other authors claim that the incidence of speech disorders is low (Navarro & Lópes, 2002; Gonçalves & Ferreiro, 2006; Karabulut et al, 2008), while others say that it is difficult to relate altered frenulum to speech alterations (Suter & Bornstein, 2009; Merdad & Mascarenhas, 2010). In addition, other authors suggest that the occurrence of speech distortions in subjects with altered frenulum is present in 50% of the cases (Lalakea & Messner, 2003; Marchesan, 2004; Marchesan et al, 2009). Perhaps the authors who do not relate altered speech to altered frenulum are the ones who consider only omissions and substitutions as speech alterations, without considering distortions, which are the most frequent alterations.

The divergence of views is not only regarding terminologies, but also the consequences of the altered frenulum. Frenulum surgeries are also the subjects of divergence, since there are frequent questions about whether to perform surgery or not, when to perform surgery, what the best technique is for the surgery, and, even, who would be the most qualified professional to perform it (Messner & Lalakea, 2000; Navarro & Lopes, 2002; Hogan et al, 2005; Wallace & Clarke, 2006; Geddes et al, 2008; Suter & Bornestein, 2009; Miranda & Milroy, 2010; Knox, 2010; Tuli & Singh, 2010). This diversity of views, as well as the differences among the authors may be due to the lack of common parameters for evaluation and diagnosis, and lack of deeper knowledge about the consequences of frenulum alterations.

There are just a few protocols to evaluate this mucous median tunic fold, which restricts movements or functions performed by the tongue, and most of the published protocols do not show a detailed description of how to perform the evaluation. This is because the authors, in general, already have a predetermined concept of what a lingual frenulum alteration is. Consequently, few explanations provide adequate information for identifying an altered lingual frenulum.

Some of the existing protocols evaluate the size of the frenulum, where it is attached, and propose objective measurements (Marchesan, 2005; Ruffoli, Giambelluca, Scavuzzo, 2005). Other authors focus on one or another specific item which they considered a determining factor to diagnose frenulum alterations (Jorgenson, Shapiro, Salinas, Levin, 1982; Williams & Waldron, 1985; Lee, Kim, Lim, 1989; Notestine, 1990; Fleiss, Burger, Ramkumar, Carrington, 1990; Marmet, C., Shell, Marmet, R., 1990; Kotlow, 1999; Messner & Lalakea, 2000; Messer et al, 2000b; Hogan et al, 2005). There are two protocols designed to evaluate babies (Hazelbaker, 1993, Martinelli, Marchesan, Rodrigues, Berretin-Felix, 2012).

Diagnosing frenulum alterations can be difficult because the evaluator has to be aware of the anatomy of the tongue, including different aspects of the frenulum and adjacent regions. In addition, the evaluator must know what functions may be affected by the alterations of the lingual frenulum.

Considering the diversity of the points of view mentioned, this author has designed a protocol with scores to evaluate the tongue and the frenulum. As the tongue takes part in orofacial functions, aspects such as shape, size, and range of movements must be tested.

METHODS

From a previous lingual frenulum evaluation used by Marchesan (2005). A new protocol with history and clinical examination was designed. The history relates the subject's complaints and general identification questions. The specific questions investigate the relationship among the frenulum and other aspects, such as family history, breastfeeding, swallowing, chewing, oral habits, speech, voice and previous frenulum surgeries. The clinical examination was divided in two parts: the first investigates general aspects of the frenulum and tongue, and the second investigates the tongue’s mobility and position in the oral cavity, speech production and compensatory patterns used by the subject.

Ten speech language pathologists experienced in orofacial myology used the protocol with different groups of subjects. 1235 subjects were evaluated during 3 years. From the experience of these ten speech language pathologists, the protocol was re-structured, and scores were added. The absence of alteration (normal tongue and frenulum) was scored zero. The alterations observed were scored in ascending order. Four additional speech language pathologists experienced in orofacial myology were trained by the researcher to administer the final version of the protocol. The protocol was given to 239 subjects in 2008 and 2009: 160 children between 7 years and 2 months old and 11 years and 7 months old; and to 79 adults from 16 years and 8 months or older. Subjects with craniofacial abnormalities or with intellectual or motor limitations were not evaluated.

All participants were informed on the objectives of the study and signed a “Term of Free and Clarified Consent". The Committee of Ethics in Research of CEFAC - Health and Education, process No. 032-08, approved the project.

RESULTS

A new lingual frenulum protocol with scores was designed. According to the scores, the frenulum can be considered altered or normal. When the sum of general tests is equal or higher than 3, frenulum may be altered. The interference of the lingual frenulum in oral functions can be considered when the sum of functional tests is equal or higher than 25.

Appendix A shows the lingual frenulum protocol with history and clinical examination. Appendix B shows photographs of normal frenulum as well as different types of frenulum alterations that can be diagnosed during evaluation. Appendix C shows a table with the pictures used to evaluate speech, and a table for taking notes about the patient's speech production.

DISCUSSION

This study describes a lingual frenulum protocol with a specific history and a clinical examination with scores. The clinical examination has four general tests and four functional tests. The purpose of the protocol is to diagnose possible frenulum alterations, as well as to provide information to relate anatomical frenulum alterations to functional alterations.

The need for a specific frenulum protocol was due to divergences and doubts on how to evaluate, classify and name the alterations in the lingual frenulum (Messner & Lalakea, 2000; Messer et al, 2000; Singh & Kent, 2000; Zemlin, 2000; Galvão, 2001; Moore & Dalley, 2001; Ballard et al, 2002; Hogan et al, 2002; Navarro & Lópes, 2002; Lalakea & Messner, 2003; Stedman, 2003; Dorland, 2004; Marchesan, 2004; Gonçalves & Ferreiro, 2006; Hall & Renfrew, 2006; Ostapiuk, 2006; Segal et al, 2007; Brito, Marchesan, Bosco, Carrilho, Rehder, 2008; Geddes et al, 2008; Karabulet, 2008; Marchesan, Rehder, Martinelli, Costa, Araújo, Caltabellotta, Oliveira, 2009; Suter & Bornstein, 2009; Forlenza et al, 2010; Merdad & Mascarenhas, 2010; Miranda & Milroy, 2010; Post et al, 2010). Furthermore, the protocol should also establish possible relationships among the oral functions and the frenulum alteration, since that seemed to be a controversial point in scientific literature (Navarro & Lopez, 2002; Marchesan, 2004; Gonçalves & Ferreiro, 2006; Segal et al, 2007; Karabulut et al, 2008; Marchesan et al, 2009; Suter & Bornstein, 2009).

Since a lingual frenulum protocol evaluating simultaneously features of the tongue, frenulum and the oral functions with scores was not found in the literature (Jorgenson et al, 1982; Williams & Waldron, 1985; Lee et al, 1989; Fleiss et al, 1990; Marmet, et al, 1990; Notestine, 1990; Halzebaker, 1993; Kotlow, 1999; Messner & Lalakea, 2000; Messner et al, 2000; Ballard et al, 2002; Hogan et al, 2005; Marchesan, 2005; Ruffoli et al, 2005; Brito et al, 2008), this new protocol was designed. A consistent protocol with scores consistently applied by many evaluators specifically trained in its use, may reduce the number of controversies about possible lingual frenulum alterations (Marchesan, 2004; Suter & Bornstein, 2009).

The present protocol has been applied and tested consistently for many years. It has proven to be an efficient tool to evaluate lingual frenulum alterations.

CONCLUSION

This paper proposed a lingual frenulum protocol with scores, which enables health professionals, such as: speech language pathologists, dentists and physicians to evaluate and diagnose lingual frenulum alterations. This lingual frenulum protocol with scores has been an efficient tool to diagnose altered lingual frenulum.