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Question & Answer - Oral Sensory-Motor, Myofunctional, Vocal Tract, & Airway Information

Should we be using some type of topical or local anesthetics on our babies or, for that matter, anyone when releasing or revising tethered oral tissues?

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

April 2017


Not that we need more conflict when we are treating infants for tethered oral tissues, but the newest controversy revolves around the question, “Should we be using some type of topical or local anesthetics on our babies or, for that matter, anyone when releasing or revising tethered oral tissues?”

I am a firm believer that proper evaluation of an infant for oral restrictions requires the infant to be examined with the infant’s head on my lap and the mother viewing the oral cavity and other oral structures while I do my exam (i.e., the mother and I are knee-to-knee). We should be doing this exam not only for tongue or lip restriction, but we should also be looking at the hard and soft palates, buccal areas, and the entire area between the lips and the uvula. Doing this type of exam from the front of the infant is more difficult and may be why tongue ties are under-reported. If the person examines the infant in the parent’s lap and says there are no problems, get a second opinion. However, some practitioners do a fairly accurate evaluation with the infant in this position.

With more and more dentists and others purchasing lasers, many practitioners are attempting surgical procedures without proper training, understanding of how their lasers work, and why some lasers are so effective that numbing is no longer the golden rule. Some practitioners have purchased a diode laser with a wide range of wavelengths from which to choose. Some of these lasers are of such low power they can take minutes to ablate the soft tissue. In this case, I would agree that pain would be unacceptable.

On the other hand, some erbium lasers, when using the correct parameters, can be used with little or no anesthetic. Carbon dioxide lasers (both the 10,600 nm wavelength and especially the carbon dioxide laser 9300 nm wavelength) actually eliminate the need for any numbing in the vast majority of hard and soft tissue procedures due to their pattern of pulses. These lasers reduce the time from minutes to less than 10-15 seconds to revise any tethered oral tissue. In completing over 10,000 soft tissue procedures, I have never required any of my patients to undergo a z-plasty which would require numbing.

This latest technology eliminates the need for most numbing, and no sutures are needed for these babies and toddlers. I found that mother’s breast milk as well as glucose are effective in reducing symptoms associated with pain in newborns. These seem to be better than any topical anesthetic and eliminate the need for drugs or chemicals to be placed into the oral cavity of infants having the procedure.

So, why don’t we want to use topical anesthetics? Oral topical anesthetics raise a concern that babies will swallow the medicine. If this happens, the throat may become numb and the baby could have difficulty sensing liquids during swallowing. This can increase the risk of choking or put the baby at-risk for aspiration. Local anesthetics have added potential concerns for young infants as the tip of the tongue may be traumatized while the local anesthetic wears off.

Therefore, do infants need to be numbed during tethered oral tissue release? This depends on the surgeon’s choice of surgical release (e.g., scissors, electro-surgery, wavelength of laser). The answer may be yes or no. However, the ability to avoid introducing drugs or other chemicals into our infant’s systems with new laser techniques only increases the safety of our surgery.

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