Tethered Oral Tissues (TOTs)/Tongue Ties
Treatment for Tethered Oral Tissues (TOTs)
A whole-mouth, team-based approach to tongue and lip ties
At PediaSpeech, our approach to Tethered Oral Tissues (TOTs) is grounded in the training and protocols developed by Robyn Merkel-Walsh and Lori Overland through TalkTools — leaders in the functional assessment and treatment of TOTs. Their evidence-based framework guides how we evaluate, prepare for, and support recovery from tongue-tie, lip-tie, and related restrictions.
Because a tie affects the same oral sensory-motor system used for both feeding and speech, TOTs is best understood — and treated — as a whole-mouth issue, not an isolated snip of tissue.
What Is TOTs?
A tongue tie, also called Ankyloglossia, is a type of tethered oral tissue where a thick, tight, or short band of tissue (lingual frenum) tethers the bottom of the tongue to the floor of the mouth and restricts tongue movement. Infants, children, and adults with tongue ties will have functional limitations that may impact breast or bottle feeding, eating, swallowing, breathing, postural control, and/or speaking. There are two type of tongue ties:
- Anterior tongue ties: This type of tongue tie is relatively easy to see, as it is separated from the tongue itself. It is most obvious when raising the tongue to the roof of the mouth.
- Posterior tongue ties: This type of tongue tie is located within the tongue organ and is more difficult to see.
Common symptoms or functional limitations of TOTs are:
- Difficult or painful breastfeeding
- Difficulty transitioning to solids
- Picky eating
- Difficulty with articulation of speech
- Trouble with sleep
- Mouth breathing
- Acid reflux
- Tightness in the muscles of the head, neck, and shoulders
- Poor oral hygiene
- Separation or misalignment of the two middle (top and bottom) teeth
Our Approach: The Merkel-Walsh & Overland TOTs Protocol
The framework we follow treats the oral sensory-motor system as a single, connected whole — meaning a tongue or lip tie is never assessed or treated in isolation from how a child eats, drinks, and talks. This shapes our care in a few key ways:
Thorough functional assessment
We look beyond structure alone, evaluating how a restriction actually impacts breast, bottle, cup, spoon, solid, and straw feeding, as well as the oral placements needed for clear speech.
Pre-surgical preparation
When a release procedure is recommended, we prepare the oral musculature beforehand with targeted exercises, so the tissue and muscles are ready to heal and move well.
Post-surgical therapy
After a release, we guide families through active exercises that support proper healing and help prevent scarring or reattachment — a critical, often overlooked step in the TOTs journey.
A team-based perspective
TOTs care works best as a collaborative effort. We coordinate as needed with lactation consultants, dentists, ENTs, and oral surgeons, so each child has the right specialists involved at the right time.
Why We Use This Approach
TOTs can be a confusing and overwhelming topic for families, especially with how much conflicting information exists about when surgery is necessary and what care should look like before and after. A structured, evidence-based protocol gives us — and the families we work with — clarity and confidence at every stage, whether we’re helping determine if a functional assessment is warranted, preparing a child for a release procedure, or guiding recovery afterward so the results truly last.
By treating feeding and speech as connected, rather than separate concerns, we help ensure that addressing a tie leads to real, lasting functional improvement — not just a structural change.
Helpful Resources for Parents
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Take the First Step Toward Better Oral Function
If you have concerns about your child’s tongue or lip mobility, feeding, swallowing, speech, or oral function, our team can help. A comprehensive evaluation can help identify your child’s individual needs and determine whether therapy may be beneficial.