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Hot Topic Blog - Mouth Development & Function


A Commentary by Dr. Larry Kotlow in Albany, New York, USA

March 2017


If we look over the many procedures and methods we employ to treat infants and toddlers in dentistry as well as medicine and listen to the various blogs and groups, I find it interesting that there is no other topic that brings into play so many different professions and opinions than the treatment of ankyloglossia and lip-ties. These include methods of treatment, means of diagnosis, who should diagnose, who can diagnose, how to treat, and what is needed post-surgery to make sure the surgery is effective and successful.  A simple two-sided discussion on the benefits and safety of fluoride comes the closest to this debate.

I find it both comforting and, in some cases, sad that many of us in these discussions are individuals who saw the benefits of surgically treating these infants early and began treating them after visits to my office and observing how the use of laser is safe, efficient, and in most instances bloodless. Many of you have gone forward doing articles and research to validate what we have done and are doing. So, if we can eliminate personality and confrontational personalities and look at the major questions with a clear vision, I think the vast majority of us can agree on the following:

-At the present time there is a significant diversity of opinion on who can make the diagnosis of tethered oral tissues (TOTS). In the real world, the ideal person should be a well-educated and knowledgeable IBCLC (Internationally Board Certified Lactation Consultant). Yet their hands are tied by their professional certifying body which says they cannot make a diagnosis. The majority of ENT (Ear, Nose, and Throat) physicians and pediatricians have never been educated about the benefits and need to revise these tissues. In dentistry, it has never been a focus of dental school or residencies. Thus, because of so much confusion, too many parents suffer needlessly for too long and end up in our offices based on information they get through the internet.

-Of course, we all know that, for the most part, everyone has a lingual and maxillary attachment or frenum, so the idea of a faux tie is misleading. Again, for the most part, patients reach our offices after being misdiagnosed and not diagnosed correctly. Saying “there are no TOTS” is a diagnosis just as saying “there is a tie” is a diagnosis. Infant and mother symptoms, not necessarily the appearance of TOTS, are what drives a proper diagnosis. We all see infants with Class IV ties and where mothers claim there were no problems. We can also agree that some parents ask for information on a tie when they have no problem because someone said “Oh look your infant has a tie.“ Yet in some cases, that is how the parent discovers the cause of the problem.

-If an infant is diagnosed with TOTS, and weeks and sometimes months are wasted with non-surgical attempts to improve the breastfeeding experience without release of the tissues along with proper IBCLC or body work, that means the infant and mother have suffered since the day the baby was born. If after a few attempts at some type of body work and IBCLC consultations, the DYAD should not be made to suffer due to a lack of information from the other members of the breastfeeding team.

-Lip-ties: I get photos sent to me quite often asking if the baby has a lip-tie. Again, depending on the degree of an attachment, it may be normal or require some release depending on location and symptoms. We all have lip and tongue attachments. It is without question when I release a lip-tie, the mother always says, “WOW my baby could never get his or her upper lip to flange like that,” ignoring this is missing the right diagnosis.

-Post-surgery care has so many different opinions that discussing that alone would take much more time than this discussion can handle. Suffice it to say the key determining factors of success or failure is not how many times a day it is done, how gentle or firm it is done, but rather the one thing we cannot control and that is parent compliance to actually do what each of us recommends.

-Finally, I have used all the various lasers available for oral surgery since they became available in the late 1990s and early 2000s. In my opinion, Erbium was and is still an effective laser when used correctly. I used diodes for 5 years and never burned or created collateral damage which could be assessed in any surgical site. I now prefer CO2 because I feel it is cleaner and faster. That does not mean the other lasers are poor choices. I do not say that because I work with a laser company, since I worked with the other companies also. Determining which laser to use is dependent on what you want to do with a laser. For medical people, the diode used correctly is a great option and significantly less of an investment than either Erbium or CO2. For the pediatric dentist, in my opinion, you need both soft and hard tissue lasers, since restorative dentistry using lasers is a significant upgrade to using high and low speed headpieces.

-Other areas we could discuss in the future are ethics, fees, and exactly why many have chosen to treat infants. So at some point, I hope we can learn to have a good discussion and reach some degree of consensus on what range of care is best for our babies.

About the Author

Dr. Kotlow, a board certified specialist in pediatric dentistry, has been serving the needs of infants and children from birth through the early teen-aged years since 1974. His practice specializes in preventive dentistry, newborn and infant care, the use of lasers for restoring decayed teeth, and oral surgery. His work with mothers and infants with breastfeeding difficulties due to tethered oral tissues (tongue and lip ties) is respected worldwide. His practice, located in Albany, New York, serves the dental needs of all children, including children with special needs. He is a recognized international expert and lecturer on the use of lasers in treating children and pediatric dental care. Dr. Kotlow may be reached at His website is