Disclosures for today’s presentations Lawrence Kotlow DDS

Lawrence Kotlow DDS Dr.Kotlow is often asked to consult with and/or provide professional guidance in development of products for many laser and dental technology associated manufactures such as Technology 4 Medicine. For his professional expertise and /or product evaluation, he may receive an honorarium or should be fun new products to evaluate. For today’s lecture there are no companies or organizations promoting or contributing to his and enjoyable presentation .

Monday August 20,2012 6/10/12

Lawrence Kotlow DDS Albany, New York Download information available Diagnosis and treatment of and tied All of my articlesmaxillary & tonight’s fraenum in infants discussions using Er:YAG:diode lasers are available for Graduate of SUNY Buffalo,NY Dental School 1972 L. Kotlow downloading from my web site. www.Kiddsteeth.com decades of predominant bottle-feeding, ankyloglossia was relegated to the status of a ‘non-problem’ because of the lack Pediatric Dental Residency at Cincinnati Children’s Hospital 1972-74 Key words: Lasers, -tie, infants. Postal address: Dr L. Kotlow. 340 Fuller Road, Albany, New York, USA. Wiessinger and Miller described a case where an infant was Email: [email protected] and an abnormal attachment of the labial or maxillary frae- num (hereinafter as maxillary -tie). This paper reviews the Abstract diagnosis of both ankyloglossia and fraenum attachments in BACKGROUND: Newborn babies often present or oral infants, as well as a proposed approach to treatment using conditions of anykloglossia and tied maxillary fraena lasers in the newborn infant. (lip-ties) associated with problems that can be related to Figure 1. breastfeeding. Many breastfeeding problems experienced a. Began my practice in 1974 by mothers and their babies may be attributed to abnor- b. mal attachments of the tongue and/or a maxillary lip-tie. c. REVIEW: The various types of both lip and tongue ties Fuller Road are reviewed. The diagnostic tools for dental practitioners are evaluated and treatment options these affected infants A using either a 1064 InGaAsP semiconductor (diode) laser Albany,New York or a 2940 Er:YAG laser are described. CONCLUSION: This approach provides treatment without the need for hospitalisation or general anaesthesia.

Introduction A renewed interest in breastfeeding has brought to light new problems and challenges concerning infant feeding. After a B B Board Certified by the American mother and infant have learned the techniques of - feeding, there are still many mothers who experience sore , blocked ducts, and breast infection, and signs Board of Pediatric Dentistry of low supply. Some infants are unable to transfer milk adequately, or are unable to maintain a good and seal to the breast. These infants sleep and gain weight poorly and some are being diagnosed as ‘Failure to Thrive’. In C C misdiagnosed as a medical problem rather than an abnor- mal anatomical problem. This paper discusses the possible infant may have when breastfeeding due to abnormal attach- ment of the tongue and maxillary lip. Wright and Schanler [2001] reviewed the history of the resurgence of breastfeeding at the end of the 20th century Standard Proficiency in Nd:YAG & Diode lasers Maxillary fraenum. It is suggested that the maxillary frae- breastfeeding. In 2006, the USA Center for Disease Control Advanced Proficiency in Erbium:YAG lasers lip tissue extending from the inside portion of the upper lip Health Statistics Canada [2009] stated that over 85% of attaching to the alveolar mucosa of the maxillary arch. In cer- mothers elect to breastfeed. With the resurgence of breast- tain instances this attachment may become a factor in limiting Mastership Status, Approved RCP (recognized feeding, anatomical factors such as tongue-ties and fraenum/ the mobility and function of the upper lip, at other times this lip-ties need to be carefully considered as primary factors course provider ) by the ALD problems. In some infants, a prominent lip-tie may be the 2009] and many of today’s practicing physicians were taught result of this tissue being inserted into three low positions that treatment of tongue-tie, (ankyloglossia) is an outdated in the maxillary gingival area and be a factor affecting infant concept, a relic of times past and during the last several latch and breastfeeding. The lip tissue may insert into the

3 106 European Archives of Paediatric Dentistry 12 (Issue 2). 2011

Lawrence Kotlow DDS Lawrence Kotlow DDS Practice limited to pediatric Dentistry Practice limited to pediatric Dentistry WWW.KIDDSTEETH.COM WWW.KIDDSTEETH.COM 4 Oral care begins before your infant is born ! *Staggering Statistics • Dental caries is 5 times more common than asthma. • Dental caries is 7 times more common than hay fever. • **18% of children 2-4 years have decay. **Feb. 2009 ADA News Primary teeth caries inc. to 24 % of young children with decay. Breastfeeding Breastfeeding • 52% of children 6-8 have decay. should be enjoyable myths(takes) and • 67% of children 12-17 have decay. and pain free pain

*US Dept. of Health & Human Services. Oral Health America 2012 Lawrence Kotlow DDS A report of the Surgeon General 2000

Helping mothers breastfed since 1974 6

“For nearly all infants, breastfeeding is the best source of infant nutrition and immunologic protection, and it 2012 provides remarkable health benefits to mothers as well. Babies who are breastfed are less likely to become overweight and obese. Many mothers in the United States On May 25, 2000, Surgeon want to breastfeed, and most try. And yet within only three months after giving birth, more than two- thirds of General David Satcher breastfeeding mothers have already begun using released Oral Health in formula. By six months postpartum, more than half of America: mothers have given up on breastfeeding, and mothers who Regina M. Benjamin, M.D., M.B.A. Vice breastfeed one-year­ olds or toddlers are a rarity in our Admiral, U.S. Public Health Service Surgeon General society.” The first-ever Surgeon General's report on oral The message was clear and to the point health identifies a "silent epidemic" of dental and Message from the Secretary, U.S. Department of Health and Human oral disease. Services As one of the most universal and natural facets of motherhood, the ability to breastfeed is a great gift. Oral health means more than sound teeth. Breastfeeding helps mothers and babies bond, and it is vitally important to mothers’ and infants’ health. For much of the last century, America’s mothers were given poor advice and were discouraged from Proper Oral health and development is integral to breastfeeding, to the point that breastfeeding became an unusual choice in this country. However, in recent overall health. decades, as mothers, their families, and health professionals have realized the importance of breastfeeding, the desire of mothers to breastfeed has soared. More and more mothers are breastfeeding every year. In fact, Serious oral disorders may undermine self- three-quarters of all newborns in America now begin their lives breastfeeding, and breastfeeding has regained image and self-esteem, discourage normal social its rightful place in our nation as the norm—the way most mothers feed their newborns. interaction...

Lawrence Kotlow DDS Practice limited to pediatric Dentistry 7 8 WWW.KIDDSTEETH.COM Dr. Kotlow,This is what it is all about...why we are here today I'm hoping that you can help us. My son is 8 weeks old, and we have had issues with breastfeeding from the start. He has a very shallow latch, and simply chews rather than sucking. In addition to this, he's often gagging on my nipple itself. *“Infant breastfeeding should not be I have seen a total of five consultants and every one of them has told me that his latch is "perfect". I know that this is not the case because he leaves me with creased, bleeding, and blistered nipples after a single feed. (6 symptoms) considered as a lifestyle choice, but Something is very wrong with his latch. He definitely has a lip tie, and I'm about 90% tongue tie as well - from looking at your literature as well as other literature I've located. I've had all five lactation consultants as well as one pediatrician tell me that he is not tongue tied because he can move his tongue. I brought this to the attention of the second pediatrician, and she rather as a basic health issue.” agreed that it may be the case and gave us a referral to a local ENT doctor. We saw this ENT on Friday, and the visit was less than five minutes long. He told me that "posterior tongue ties do not exist. We do not call a tongue tie and anterior tie because there is no posterior *“As such, the pediatrician’s role in advocating and (tongue tie), it is simply a tongue tie" In addition, he told me that if we were having issues breastfeeding that it is me that is doing something wrong, and if I was too stupid to figure out how to feed my supporting proper breastfeeding practices is son that we should just put him on formula.

essential and vital for the achievement of this I did not share this with the ENT, but he is already on formula supplements because we just now got him back up to his birthweight - 7 weeks after he was born. The only way we accomplished this was with supplementing with formula that was preferred public goal.” mixed to be higher calorie and putting him on prevacid for severe reflux. (7 symptoms) I'm hoping that there is some hope left that we can get his tongue tie fixed and get him back to exclusively breastfeeding, but we are running out of options. My pediatrician will not give us another referral to an ENT. So, even if I could find someone local to cut the tongue tie, insurance wouldn't pay for it. Between the cost of the neocate formula, the five lactation consultants, and all of the supplements for me and breastfeeding aids....money is tight. I am hoping to find out whether there *Updated policy of the American Academy is even a possibility of help before I try and come up with the money for a trip up there. Added to this, I would need to see if we could expedite getting him seen, as I have a new job starting the first week of July. I cannot risk turning down this job because I have been out of work throughout my pregnancy due to my inability to take my of Pediatrics March 1, 2012 personal daily medicine as it was not safe during pregnancy.

Please let me know if there is anything that you can do or recommend to help us out.

Thank you, 10

Changing ideas , concepts and views My Private Dental Practice One Dentist, one assistant 5 Hygienists, 5 office Staff The first dental examination

American Academy of Pediatric Dentistry

Q. When should my child first see a dentist? "First visit by first birthday" sums it up. Your child should visit a pediatric dentist when the first tooth comes in, usually between 6 and 12 months of age. This visit will establish a dental home for your child. Early examination and preventive care will protect your child’s smile now and in the future.

The American Academy of Pediatrics (AAP) previously Raised Ranch Style house , 2 floors recommended first dental visit at age 3 and recently adopted Reception area a policy statement that advocates an oral health assessment BusinessSurgical office bay of infants by a pediatrician or other qualified pediatric health Consultation & Infant examination areas DigitalOralPreventive TreatingSpecialRadiology Hygiene needsinfants Panoramicmaintenancebay three-patient using &1064 four hygienistIntraoralexamination laserhygienists Radiographs care professional by 6 months of age. HappyFour handed patients, dentistry new under technology microscopes at work & laser Treating newborns using Er:YAG

Helping mothers breastfed Pediatric Dentistry Guidelines Reference manual 2012 since 1974 11 Lawrence Kotlow DDS Introduction to Lasers and Breastfeeding course 12 Misconceptions parents have Creating the Dental Home about oral health

★All my teeth were decayed so...... ★ My family all had soft teeth. ★ My child does not drink milk. ★ They are just baby teeth and they will fall out anyway. ★ No one told me I should brush my child’s baby teeth. ★ I was told that children do not need to see a dentist until they are 3-5 years old. The idea of the dental home is a way of assuring that all children have access to ★ Fluoride causes cancer. oral education,oral health evaluations, and oral care when required (both preventive and repair)

Helping mothers breastfed since 1974 13 Helping mothers breastfed since 1974 14

The Dental Home for breastfeeding mothers Pediatrician The start of Family Physician Lactation consultants pediatric oral care begins with mom ! Chiropractors

Family Public health system Poor oral health, periodontal Oral surgeon Pediatric & Family dentists disease is a cause of spontaneous Cranial facial teams abortions in pregnant women Plastic surgeon Educating the ENT private sector and premature births. This may be due to increase formation of biological fluids that induce labor.

Re-educating the Educating the public sector

medical and dental Multiple refs : www.health.state.ny professionals Oral health care during pregnancy and early childhood Teaching this in medical and dental schools

Lawrence Kotlow DDS 2012 15 Helping mothers breastfed since 1974 16 Xylitol for prenatal care Missed opportunities & delayed diagnoses

Some practitioners Some practitioners fail to look for uncommon • It is a sugar not used by bacteria. recognize and treat causes of infant problems • Cariogenic bacteria cannot feed on it. abnormal oral conditions. and miss the real cause • Xylitol gum or lozenges used daily may prevent the transmission of decay producing bacteria to infants. • Reduces plaque formation. Some practitioners • Increases salivary flow which may aid in choose to ignore repair of enamel surfaces. oral soft • Inhibits transfer of bacteria from person to abnormalities all person (!) by altering the way bacteria sticks together to tooth surfaces.

Helping mothers breastfed since 1974 17 Helping mothers breastfed since 1974 18

What do you think you What do you see ? see ?

Old Two Man Young Lovers

Not everyone sees the same thing !

19 Helping mothers breastfed since 1974 Helping mothers breastfed since 1974 20 An infant’s first dental visit no later than age one Beastfeeding should be fun and enjoyable

Complete oral evaluation Using our technology to improve infants’ ability to latch onto mothers’

The key to successful diagnosis

Lawrence Kotlow DDS 21 Lawrence Kotlow DDS Introduction to Lasers and Breastfeeding course 22

A good efective latch in one of Successful & comfortable the major components in breastfeeding is dependent on successful breastfeeding many components

There are many elements involved in breastfeeding The infant’s upper lip that need to work in sync to make it a pleasurable experience for the mother & a beneficial experience for the infant. The infant’s tongue Mother’s breast

For an INFANT it is instinctive

Careful observation and oral examinations by properly trained health professionals and lactation consultants are also important components for teaching mothers good latching techniques that will support innate infant nursing and help For a MOTHER it is a learned experience mothers learn the proper mechanics of breastfeeding.

23 24 Two often misdiagnosed & ignored developmental soft tissue Breastfeeding should be problems apparent at birth that may be the cause of poor latching during breastfeeding enjoyable,not painful !

The impact of Lingual and lip ties

Lip-tie without any upper lip flanging

Abnormal maxillary lip attachment Ankyloglossia(tongue-tied) (lip-tied)

Helping mothers breastfed since 1974 7 25

Nursing should be enjoyable Changing outdated ideas and myths

Our goal is to take breastfeeding mothers from excellent article : The resurgence of breastfeeding at the end of the second millennium Ann Wright & Richard this Schanler; Jr of nutrition 2001;131;4215-4255

To this ★The natural childbirth movement of the 1970’s began to place an emphasis on home midwife delivery, mental preparation over pain medications, and breastfeeding as the best source of newborn nutrition. ★With a resurgence of breastfeeding, ankyloglossia Bruised,cracked & bleeding resurfaced as factor in breastfeeding, although still nipples poorly recognized by many healthcare professionals. ★1975 increasing numbers up to 33.4% ★1980- 54% ( Martinez & Krieger 1985) ★1984- 59.7% ★1995- 60 %, 20 % after 6mo ★14.5 % after 12 mo ★ 2006 CDC 73% US babies ★ 2006 Health Statistics Canada 85% Engorgement biting

Helping mothers breastfed since 1974 Lawrence Kotlow DDS helping nursing mothers since 1974 27 28 A Bring on the Hippies ! Statistics

1972 - 22 percent of US mothers breastfed their infants 1972-3,258,411 total births Nature’s 720,000 breastfeed infants way is 2009 - breastfeeding report card from the CDC found that 74 percent of women start breastfeeding, 33 percent were still better ! exclusively breastfeeding at three months and 14 percent were still exclusively breastfeeding at six months. 2009-4,131,019 total births 3,057,000 breastfed infants 1,363,00 after 3 months 578,000 after 6 months

Lawrence Kotlow DDS

Medically necessary care We need to define anecdotal evidence vs evidence based care

*Medically necessary care (MNC) is the reasonable and Anecdotal- hearsay or evidence that is considered appropriate diagnostic, preventive, and treatment services untrustworthy. It may true...... but the conclusion needs to be and follow-up care as determined by qualified, appropriate established by scientific means. health care providers in treating any condition, disease, injury, or congenital or developmental malformation. MNC Evidence based: the best evidence gained from the includes all supportive health care services that, in the scientific method. Reviews the quality of evidence as well as judgment of the attending dentist, are necessary for the the risks and benefits of care. provision of optimal quality therapeutic and preventive oral care. *Academy of Pediatric Dentistry 2012

Lawrence Kotlow DDS Introduction to Lasers and Breastfeeding course 31 Lawrence Kotlow DDS Introduction to Lasers and Breastfeeding course 32 *Evidence-based dentistry(EBD) & Randomized Evidence-based dentistry(EBD) & Randomized controlled trials (RCTS) controlled trials (RCTS)

1. In treating infants it is not always possible to obtain evidence solely from RCTs 5. The uniqueness of treating newborns has very little ability to create RCTs to support routine procedures performed in oral care. when it is obvious that after treating 100’s of infants a large majority of them 2. For example”How do you use RCTS to determine whether parachutes are have significant breastfeeding improvements after revision of lingual and effective in preventing major trauma related to related to gravitational maxillary ties . challenge.” It would be difficult to find volunteers for such a randomized study ! or for that 6. It would be extremely difficult to develop a (control) placebo effect when matter if our present infection control methods are better than a placebo ! treating the infant unless you just tell one parent the surgery was performed when nothing was done. 3.There are ethical ,legal and practical considerations in clinical studies using human subjects for studies on newborns. 7. Sound professional judgement, past experience, and clinically repeatable good clinical results are also a key for EBD. 4.Replace RCTS with “Scientific plausibility or prior probability as building blocks when determining new data or procedures. 8. Complement our EBD with science based approaches that offer a more *Editorial JADA january 2012 Daniel Myers dean SUNY Buffalo School of Dental Medicine & Editor of JADA understanding of what constitutes excellent patient care. “Evidence or science based” 33 Helping mothers breastfed since 1974 34

Common ideas and myths that interfere with proper care and Many Myth(stakes) & Fairy treatment of newborns presenting with ankyloglossia ★Tongue-ties do not exist. ★Tongue-ties will not effect nursing.(as recently as February Some times, we 2012 the Medical Diretor of an Insurance company with 45 years experience as a pediatrician either fail to see told me “in his 45 years as a pediatrician he never saw one case where an infant was tongue tied the what is before and it caused any breastfeeding problems !” our eyes and is ★Tongue-ties will correct themselves. A tight obvious or we lingual frenum will stretch or tear without see it and fail to treatment. consider it. ★Ankyloglossia does not cause maternal discomfort. Myth(stakes) ★Ankyloglossia does not effect developing speech. A Myth is a fiction ★My dentist would rather wait till newborn is 16mo so he has more immunities built up.(July2012) Lawrence Kotlow DDS something which is untrue. Lawrence Kotlow DDS Common ideas and myths that interfere with proper care and treatment of newborns presenting with ankyloglossia Food for thought !

★Posterior tongue-ties do not exist. con=lict'with'old'school'clinical'practice'beliefs'and'embracing'old'outdated'beliefs'ignore'or'distain ★Revisions of tongue-ties are dangerous due to bleeding, collide'with'their'professional'education.'“reinforce'older'clinical'practice'preferences'or'biases cutting nerves or blood vessels. “While'many'dentists'and'physicians'outwardly' ★Surgery requires the operating room and general worship'at'the'alter'of'so'called'evidence7based' anesthetics. dentistry'and'medicine,'in'reality,'many'often'tend'to' ★Revising the upper lip causes “floppy ”. practice'selective'evidence7based'dentistry'or'medicine' ★The upper lip is not important in breastfeeding. by'adopting'and'embracing'old'outdated'beliefs'and' ★You need to wait until the baby is at least 4 years old. studies'with'results'that'reinforce'older'clinical'practice' ★Lasers do not work preferences'or'biases,'while'these'same'individuals'or' ★If you cut the upper lip it need to be tacked down. organizations'ignore'or'distain'the'results'of' reproducible'clinical'care'that'frequently'is'in'con=lict' ★The post surgical exercises are too difficult and stressful for with'old'school'clinical'practice'beliefs'and'collide'with' parents. their'professional'education.'“ ★The infant will pull out the stitches and not be able to Albany Time Union Newspaper 2/29/2012 Dr. Boden, Chief of Medicine Albany VA Hospital and vice-chairman of medicine at the handle the healing time. Albany medical Center Lawrence Kotlow DDS

Protection from diseases ,infant immunity Bottle feeding is a deviation from the biological norm Lars Hanson (sweden -1950s)

Dr. Katsumi Mizuno 2006 Japan- “Baby bottle feeding is Pioneer in the discovery that a completely different feeding method regardless of mother’s milk contains antibodies which mother’s have acquired over attempts to make bottle feeding more closely resemble their lifetime and can pass them breastfeeding.” onto their infants “Modern, non-breastfeeding nurturing,may be having a negative on our health and evolutionary destiny.”

Brian Palmer December 27,. 2012 39 The evolution of malocclusion and sleep apnea Placing an Infant on formula is like feeding your Why we need to be proactive in infant in a fast food restaurant assisting Mothers breastfeed Brian Palmer December 27,. 2012 The evolution of malocclusion and sleep apnea

Ankyloglossia Sleep apnea :SIDS ??? Lip-ties Bed wetting Non-orthodontic pacifiers ADHD,etc Noisy breathing,snoring Bottle-feeding High Blood pressure Heart disease Child abuse

Malocclusions High An infant will survive, but will not eat as healthy Narrow dental arches

as from a Mother’s home made meal. Brian Palmer December 27,. 2012 The evolution of malocclusion and sleep apnea

In Infants, bottles and pacifiers can create destructive forces and

life long problems They can Clinical examination of some infants will indicate the presence create of a high arched or deep palatal area. This can interfere with a pressure to The upper lip teeth may be reshape good latch. pushed upward and elevate the outward hard formation,with good The bottle may exert In some tongue placement abnormal pressure on Born with high palates the mandible preventing instances when forward growth. the infant is fed due to tongue pressure lying down, it in utero. can block off the Eustachian tube,leading to middle ear infections Protective positioning. Premature separation of epiglottis/ connection

Brian Palmer December 27,. 2012 Brian Palmer December 27,. 2012 The evolution of malocclusion and sleep apnea The evolution of malocclusion and sleep apnea 44 Our tongue is more than a muscle, What are the best criteria we can use to it is also an “Organ” diagnose ankyloglossia ? • The&tongue&consists&of&a&complex&group&of& muscles&that&gives&it&great&mobility.& Ankyloglossia can be diagnosed three 1.The&four&paired&extrinsic&muscles& ways protrude,&retract,&depress,&and& elevate&the&tongue. 2.The&four&paired&intrinsic&muscles& of&the&tongue&originate&and&insert& within&the&tongue,&running&along&its& length.&These&muscles&alter&the& shape&of&the&tongue&by:&lengthening& The most important and&shortening&it,&curling&and& Infant’s & uncurling&its&apex&and&edges,&and& diagnosticmother’s Anatomic & clinical symptomscriteria Ability to function fla?ening&and&rounding&its&surface. appearance 46 Lawrence Kotlow DDS Introduction to Lasers and Breastfeeding course 45 Lawrence Kotlow DDS Introduction to Lasers and Breastfeeding course

Diagnosing lip and tongue ties Diagnosing problems related to an infant with ankyloglossia (tongue-tied) When ? Preliminary initial evaluation A. The initial evaluation should be At birth Just by running your finger under an infants tongue from immediately after birth. one side of the mouth the other side will give you an B. Full evaluation in the dental office. indication if the tongue attachment is a problem. Where ? A. In the birthing or delivery area. B. During a knee to knee examination. How ? Using the finger sweep.

Lawrence Kotlow DDS Helping mothers breastfed since 1974 Lawrence Kotlow DDS 48 A quick assessment to determine need for further evaluation Feeling&a&good&latch Interpreting your assessment-completed in the delivery room 1.&When&you&place&your&finger&in&to&mouth,& extending&it&to&the&juncDon&of&the&hard&and&soC& palates,&the&part&furthest&into&the&mouth&has&very& Feel for problems ! li?le&compression,&indicaDng&the&infant&is&really& Use your finger moving under the tongue across the latching&onto&the&nipple¬&the&breast. floor of the mouth. 2.&When&a&infant&is&tongue&Ded,&you&feel&a&strong& A smooth mouth floor = No Problem compression&on&the&area&closest&to&the&lips&on&your& A small speed bump = Potential Problem finger. A large speed bump = Most likely will be a problem 3.ACer&the&release&of&the&frenum,& A small, medium or large membrane = Definitely will compression&can&be&felt&along&the&enDre& develop into a problem.!! ! ! ! ! length&of&your&finger. If the membrane feels very thin and strong like fine wire, push on it and look for tongue tip indentation and a slight bow of the tongue tip.

James G. Murphy, MD, FAAP, FABM Assistant Prof of Pediatrics F. Edward Hbert Medical School USUHS Bethesda, Maryland49 illustraDons:&M.Woolridge&Midwifery&1986&164M71&‘the&anatomy&of&infant&sucking” 50 Lawrence Kotlow DDS Introduction to Lasers and Breastfeeding course

Treating mothers and infants is not just a simple surgical correction... It is a process Examination of infants

Initial diagnosis and referral source

Pediatrician & Family MDS **Parents of prior patients The key to correctly examining an infant is proper placement on you lap. Place his face facing the mother.

Lawrence Kotlow DDS Initial patient evaluation information Dental office, ENT, Oral surgeon Statistics on 47 patients 1.Poor latch 43/47 improved Pre examination information questions 2.Slides off of nipple 36/39 improved Oral examination 3.Colic 21/21 improved Preview 12 minute Keynote presentation 4.Reflux 16/17 improved Answer questions 5. Chewing of nipples 32/33 improved Sign informed consent 6.Poor weight gain 19/19 improved Complete surgery Post operative directions, written, Ipad, website Email,text message follow up 2-3 x & 1 week obs

Referral to Laction consultant Referral to Chiropractor for Cranial -Sacral treatment Fax to physician

Lawrence Kotlow DDS Introduction to Lasers and Breastfeeding course 54

What is a tongue-tie (ankyloglossia)? Kotlow classification of tongue-ties (1999) As defined by the International Affiliation of Tongue-tie Professionals (www.tongue-tie.net) The Embryologic remnant of the tissue in the midline of the undersurface of the tongue and the floor of the mouth.

An (abnormal) attachment of the membrane that fastens the CLASS 1 NORMAL RANGE CLASS II 8-12 mm tongue to the floor of the mouth which may interfere with 12-16 mm MILD OF MOTION MODERATE the normal mobility and function of the tongue.

CLASS III 4-8 mm CLASS IV 0-4 mm SEVERE COMPLETE 56

Lawrence Kotlow DDS helping nursing mothers since 1974 55 Classification of newborn abnormal lingual frenums:based or should function ? upon anatomic appearance Diagnosis based on function or lack of function 3.5

Total tie down resulting in Cupping and hump No up or down function Type **I(4*) -total tip involvement Type -II (3) Midline-area under tongue (creating a hump or cupping of the tongue)

Type III (2) Distal to the Type IV (I) Posterior area which Tight guitar string unable to extend tongue past midline.The tongue:may Heart shape, pointed tip Unable to elevate and alveolar ridge may not be obvious and only palpable, submucosal attachment appear normal Some are not visible if they are touch the hard palate James G. Murphy, MD, FAAP, FABM submucosally located Assistant Prof of Pediatrics Type -two *Numbers in parenthesis =Dr.Kotlow F. Edward Hbert Medical School 57 USUHS Bethesda, Maryland 58 Mid portion of the Lawrence Kotlow DDS Introduction to Lasers and Breastfeeding course ** Numbers outside parenthesis= LC Lawrence Kotlow DDS Introduction to Lasers and Breastfeeding course tongue creating a hump or cupping of the tongue Diagnostic symptoms as an aid for ULTRASOUND OF PRE-SURGERY diagnosis ➡*Infant Factors to consider ➡Maternal Factors to consider ULTRASOUND OF POST-SURGERY ➡No latch ➡Un-sustained latch ➡Creased or blanched nipples ➡Slides off nipple after feeding: flattened ➡Prolonged feeding durations ➡Cracked, bruised or blistered ➡Unsatisfied after prolonged nipples: gives it up feeds ➡Bleeding nipples ➡Falls asleep on the breast ➡Severe pain with latch ➡Gumming or chewing on the ➡Incomplete breast drainage nipple ➡Infected nipples ➡Poor weight gain or failure to ➡Plugged ducts TEL AVIV MEDICAL GROUP 2007 thrive ➡Mastitis & nipple thrush ESTHER GRUNIS IBCLC EYAL BOTZER DMD ➡Unable to hold pacifier MABEL ZELICOVITCH [email protected] *Academy of Breast Feeding Medicine: SHAUL DOLLBERG MD Clinical Protocol #11: Guidelines for the Evaluation & management of neonatal Ankyloglossia under review and not up on the website. Presently under review.

http://www.bfmed.org/ 59 60

Lawrence Kotlow DDS Introduction to Lasers and Breastfeeding course Helping mothers breastfed since 1974 Why we need to treat abnormal ties My theory and treatment concerns

Problems that may evolve as newborn infants grow older

What we may not identify immediately ✴Nutritional problems ✴Colic or excessive gas ✴GI problems: reflux ✴ ✴Gagging ✴Sleep apnea (??SIDS) “It is not just the tongue that allows for a ✴Changes in sleep patterns good latch onto the breast, the upper lip ✴Speech problems ✴Jaw growth & development must have adequate mobility for the ✴Psychological problems infant to properly flange and latch..” Helping mothers breastfed since 1974 61 62 Helping mothers breastfed since 1974

Lawrence Kotlow DDS Signs of Good Attachment What is a Lip-tie ? Wide open mouth Chin indenting the breast (three chins) Rapid sucks initially turning to slow deep sucks with swallows A remnant of the tissue in the midline of the upper lip and Contented baby who stays on breast No pain for the mother the gum which holds the lip attached to the gum (gingiva) and may interfere with the normal mobility and function of the upper lip contributing to poor latch by the infant onto the breast and in Extended some cases when mothers elect to at-will breastfeed during the flanging of night, without cleaning off the teeth after nursing, may contribute upper lip to decay formation on the front surfaces of the upper teeth.

Triple chin

http://www.vabarnsley.org.uk/pdf/breastfeeding/attached_properly.pdf Latch Difficulties Caries Formation Gaps Helping mothers breastfed since 1974 63 Helping mothers breastfed since 1974 64 Kotlow Classification of maxillary a Classifying Infant Lip-Ties Lip-Tied attachments in children Class IV: inserts into anterior papilla

Class II: inserting just above Class I: normal or in between central incisors

Class III: Beginning to insert Class IV: inserts into anterior papilla into anterior65 papilla 66

Lawrence Kotlow DDS Introduction to Lasers and Breastfeeding course Lawrence Kotlow DDS Introduction to Lasers and Breastfeeding course

Lawrence Kotlow DDS Post surgery results Maxillary Lip-tie with central incisors showing decalcification

2//25/2012 7/17/2012

7/17/2012

8/9/2012 prior to surgery Class IV

3/4/2009 12/31/08 initial surgery Post 8/9/12

prior to surgery Class III prior to surgery Class III prior to surgery Class IV

2/3//11 initial surgery 2/3//11 initial surgery 12/14/10 initial surgery Post Post 7/23/12 Post 7/23/12 8/8/12 Helping mothers breastfed since 1974 68 Lawrence Kotlow DDS Lawrence Kotlow DDS Evaluating the exterior portion of the lip Kotlow Infant and newborn Lip-Tie classifications Prior to surgery upper lip cannot relax nor fully extend upward and properly flange to allow a good latch

! Class II Pre-surgery notice outside lip Class I: No significant attachment Attachment primarily into the gingival tissue Pre-surgery -lip not able to Post-surgery -lip extending crease extend upward upward Pre revision Post Revision Pre Revision Post Revision

! Class III: Class IV Inserts just in front of anterior Attachment just into the hard palate or papilla papilla area 69 70

Lawrence Kotlow DDS Lawrence Kotlow DDS Compare pre lip-tie release to post lip-tie A simple surgical procedure release

! ! Erbium:YAG

! ! 71 72 1064 Diode Incomplete Initial frenum revision using scissors Post surgery after previous scissor revision

This is not thrush, but dried milk Dimpling Incomplete revision Remaining posterior tie after prior revision Laser release

Lack of mobility and extension

Clefting

Untreated lip-tie Laser revision

73 74 Lawrence Kotlow DDS Introduction to Lasers and Breastfeeding course Identifying the submucosal posterior tongue tie Lawrence Kotlow DDS The Posterior Tongue-tie Identifying the submucosal posterior tongue tie Defining a posterior tongue-tie A fine thin attachment of the tongue to the floor of the mouth located at the base of the tongue.

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2 month old infant Posterior Tongue-tie Oral Diagnosis: Class 3-4 tongue-tie (LAK) and Class IV maxillary lip-tie

Heart shaped Dimple with cupping

Limited extension Three Days Post surgery

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Lawrence Kotlow DDS Four week old infant Severe Class IV lip-tie with tongue-tie Always start with the lingual frenum revision first

Entire upper lip with callous

Five days post surgery Healing nine days post surgery 80 79 a Lawrence Kotlow DDS Pediatric reflux-clicking-Aerophasia Infant having colic symptoms :Aerophagia ?

• Colic is an exhausting, unrelenting, and all consuming condition that causes an otherwise healthy infant to cry inconsolably. Occurs from about 2 weeks to 16 weeks. • Aerophagia is excessive swallowing of air. When excessive amounts of air reach the stomach .abdominal distention, belching, vomiting and excessive gas may result. The tongue is held down in the center of the tongue causing the posterior tongue to hump up. The baby can not extend the tongue to remove it from the back of the mouth therefore causing gagging. The gagging causes the baby to regurgitate. This appears to be reflux. Release of the tongue may lead to elimination of gagging and and thus eliminate reflux. In infants when the frenum has not been released, suggested medical treatment may be to put the baby on medication. After a is completed the reflux often goes away immediately especially with the “posterior” tongue ties. if we wait until after the frenum is revised to treat the The evening after surgery infant stopped crying ,mother infant using medication, the physician may not have to place the infant on 81 82 drugs. Lawrence Kotlow DDS nursed longer and was without discomfort

Lawrence Kotlow DDS Infant having colic symptoms :Aerophagia ? 3.5 week old infant 5 weeks premature with nursing difficulty. Maxillary frenectomy and posterior tongue tie revision

Pre-surgery Post-surgery

Post-surgery Pre-surgery

The evening after surgery infant stopped crying 84 83 mother nursed longer and was without discomfort Helping mothers breastfed since 1974 Emmy’s Maxillary lip-tie release 8 months of age

Emmy age 5 Post surgery Post pacifier Pre-op frenum

24 hours post surgery

48 hour post

one week post

Emmy age 9 one year post 85 86 Lawrence Kotlow DDS Lawrence Kotlow DDS Introduction to Lasers and Breastfeeding course

The&evolving&results&of&the&&untreated 5 year old with diastema due to tongue-tie maxillary&lipMDe

The&diastema Dental&decay&&&&DiastemaDental&decay

87 88 Lawrence Kotlow DDS Introduction to Lasers and Breastfeeding course Lawrence Kotlow DDS Introduction to Lasers and Breastfeeding course Lawrence Kotlow DDS Correcting an infant’s Soft tissue dental lasers tongue- tie and lip-tie Lasers used in this discussion Erbium:YAG 2940nm To protect and control infant’s movements during PowerLase AT Spa(Lares (Fotona) surgery we gently place the baby in an infant swaddler Fox 1064nm Diode (Technology4Medicine)

Laser is called by it’s active medium Diode laser InGaAsP removes tissue Erbium: removes tissue by photoacustical by a photothermal effect 1064nm explosion of tissue water. 2940nm 90 89 Lawrence Kotlow DDS Introduction to Lasers and Breastfeeding course

a Grooved Director Options & alternative to lasers

http://www.miltex.com

available through Dental Supply Dealers scissor

S U R G I C A L -Categories - Probes and Directors

10-70 MILTEX Grooved Director, with Tongue Tie, 5" (12.7 cm) Available $14.73 Electrosurgery 10-72 MILTEX Grooved Director, with Tongue Tie, 5-1/2" (14 cm) Available $14.73 10-74 MILTEX Grooved Director, with Tongue Tie, 6" (15.2 cm) Available $15.46 10-76 MILTEX Grooved Director, with Tongue Tie, 8" (20.3 cm)

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Lawrence Kotlow DDS Introduction to Lasers and Breastfeeding course Lawrence Kotlow DDS Advantages of lasers Correcting an infant’s tongue- tie & lip-tie

Excellent hemostasis: risk of bleeding Prior to surgery we do not use and drugs or injections for numbing, but place a cotton roll with some sugar water into the significantly reduced infant’s mouth. This calms the baby and allow me to see his or her sucking mechanism. Sugar water is clear and also can Bactericidal : little chance of reduce the discomfort of the surgery. ( also helps but any type of infection is white and may interfere with visualization of the frenum)

Has Photobiomdulation or Low Level Laser Effect :reduces inflamation, improves healing

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Lawrence Kotlow DDS Lawrence Kotlow DDS After surgery is completed Stretching the upper lip

To help an infant adjust to his or her Successful surgery,without reattachment is now dependent new found mobility and altered latch, parents can assist on the parent’s ability to forcefully stretch both the upper lip and tongue to prevent reattachments of the surgical areas. the infant by a variety of different massage techniques. Pull the upper lip upward until it touches the infant’s nose using enough

Slowly rotate fingers around the lips to entice your child to force to open the entire surgical site and prevent the lip from becoming suck on your finger and create a new sucking pattern. tied again. Post surgery a white area developing in the surgical area. This is normal and not an infection. This will disappear in another week.

95 96 Lawrence Kotlow DDS Lawrence Kotlow DDS Stretching the tongue Stretching the tongue Successful surgery and preventing reattachment is dependent Successful surgery and preventing reattachment is dependent on on a parent’s ability to forcefully stretch both the upper lip and tongue. a parent’s ability to forcefully stretch both the upper lip and tongue.

Method two: This is often easier for parents to reopen the surgical area by Method one: Place the index fingers on each side of the tongue and placing a tongue blade above the area and push the lower jaw down and the forcefully open the diamond shaped area with sufficient force to totally underside of the tongue backward and upward using sufficient force to open reopen the surgical site to prevent the reattachment. Push or pull the entire surgical area. downward towards the infant’s . Some bleeding may occur and this Post surgery a white area develops in the frenum area. This is normal is not a concern. and not an infection. This will disappear in another week.

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TIC-TONG Animal: colored and Explaining to parents flavored, non-latex, sugar free and no- toxic It is absolutely imperative that parents understand plastic tongue depressors the necessity of the reopening of the wound using adequate force

Stretch the middle finger and index finger with enough force to have the parent understand

100 Lawrence Kotlow DDS Introduction to Lasers and Breastfeeding course 99 Healing tongue revisions Lip , chin and breast positions

5 days post surgery six days post-surgery

six days post-surgery three years post-surgery The 2 chin nursing infant The 3 chin nursing infant 101 5 minutes post laser surgery

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The correct latch: The key to The benefit of lip and tongue tie revisions to the successful breastfeeding mother is also significant

When an infant is properly latched, his upper lip should be Presurgery nipple damage due 24 hours after surgery to both lip and tongue ties nipple damage is healing close to the mother’s nipple, covering more of the with his lower lip than with the upper lip. Baby’s lips should be flanged out, relaxed, and open wide at a large angle of over 24 hour follow-up by parent was an e-mail “Amazing “ 150 degrees.Baby’s chin should be close against the breast.

103 Potential problems surgery Food for thought

During surgery crying is actually a good thing ! “There are too many health care professionals and Care must be taken to make sure the infant breaths without problems,infants do not know politicians who will never let a how to breath through ther mouth ,during the good idea or concept stand in revision of the lip,if the nose is blocked, the way of the maintaining the breathing may be compromised. status quo !”

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a Learning curve for newborn care and The Occam’s Razor new technologies

It is a principle attributed to a 14th century logician and Franciscan Friar William Ockham simply stated “If we don’t change, we don’t grow ★ No elaborate solutions where simple ones do. If we don’t grow, ★ The explanation requiring the fewest assumptions is we aren’t Gail Sheehy most likely correct. really living !” ★When you have two competing theories that make Prepare yourself in every way you can by increasing your knowledge and adding to your experience, so that you can exactly the same predictions, the simpler one is better. make the most of opportunity when it occurs. - Mario Andretti

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Lawrence Kotlow DDS Practice limited to pediatric Dentistry WWW.KIDDSTEETH.COM107 Lawrence Kotlow DDS Introduction to Lasers and Breastfeeding course Thank you

Lawrence Kotlow DDS Kiddsteeth.com Albany, New York