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Tying it All Together: Diagnosis, Implications, and Treatment of Tethered Oral Tissues A Peer-Reviewed Publication Written by Lori Cockley, DDS, FAGD © Kran77 | Dreamstime.com © Kran77

Abstract Educational Objectives Author Profile While most dental clinicians are familiar with the term After reading this article, the reader should be Lori Cockley, DDS, FAGD, earned her dental degree from of the and perhaps as familiar with the lay term able to: University of Maryland, Baltimore College of Dental Surgery. She is tongue-tie, few are aware of the vast implications that 1. Define Tethered Oral Tissue and understand a fellow of the Academy of General Dentistry and a member of the these restrictions may create. This article will attempt to the anatomy and prevalence of this issue. International Affiliation of Tongue-Tie Professionals. She maintains define and provide a clear understanding of this congenital 2. Be able to identify the characteristics of this a full-time private practice in East Berlin, a small town in rural south condition as it relates to ideal tongue function, as well as condition. central Pennsylvania. offer ways to best assess and treat in a safe, predictable 3. Have the ability to diagnose and classify the manner. various types of tethered oral tissue. Author Disclosure 4. Know the methods for treating this condition Lori Cockley, DDS, FAGD, has no commercial ties with the sponsors or including post-operative care. the providers of the unrestricted educational grant for this course.

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Publication date: Sept. 2016 Supplement to PennWell Publications Expiration date: Aug. 2019

This educational activity was developed by PennWell’s Dental Group with no commercial support. This course was written for dentists, dental hygienists and assistants, from novice to skilled. Educational Methods: This course is a self-instructional journal and web activity. Provider Disclosure: PennWell does not have a leadership position or a commercial interest in any products or services discussed or shared in this educational activity nor with the commercial supporter. No manufacturer or third party has had any input into the development of course content. Requirements for Successful Completion: To obtain 3 CE credits for this educational activity you must pay the required fee, review the material, complete the course evaluation and obtain a score of at least 70%. CE Planner Disclosure: Heather Hodges, CE Coordinator does not have a leadership or commercial interest with products PennWell designates this activity for 3 continuing educational credits. or services discussed in this educational activity. Heather can be reached at [email protected] Educational Disclaimer: Completing a single continuing education course does not provide enough information to result Dental Board of California: Provider 4527, course registration number CA# 03-4527-15134 in the participant being an expert in the field related to the course topic. It is a combination of many educational courses “This course meets the Dental Board of California’s requirements for 3 units of continuing education.” and clinical experience that allows the participant to develop skills and expertise. Image Authenticity Statement: The images in this educational activity have not been altered. The PennWell Corporation is designated as an Approved PACE Program Provider by the Scientific Integrity Statement: Information shared in this CE course is developed from clinical research and represents Academy of General Dentistry. The formal continuing dental education programs of this the most current information available from evidence based dentistry. program provider are accepted by the AGD for Fellowship, Mastership and membership Known Benefits and Limitations of the Data: The information presented in this educational activity is derived from the data and information contained in reference section. The research data is extensive and provides direct benefit to the patient maintenance credit. Approval does not imply acceptance by a state or provincial board of and improvements in oral health. dentistry or AGD endorsement. The current term of approval extends from (11/1/2015) to Registration: The cost of this CE course is $59.00 for 3 CE credits. (10/31/2019) Provider ID# 320452. Cancellation/Refund Policy: Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing. Educational Objectives The process by which this frenum is formed is known as After reading this article, the reader should be able to: sculpting apoptosis or predetermined programmed cell death. It is 1. Define Tethered Oral Tissue and understand the anatomy the same way fingers are formed, and just as some people may and prevalence of this issue. have webbed fingers, if this process fails, so, too, can excess oro- 2. Be able to identify the characteristics of this condition. frenal tissue result. It is unknown how prevalent this condition is. 3. Have the ability to diagnose and classify the various types According to a study by Hazelbaker, it is estimated to be found of tethered oral tissue. in 3-4% of the population, and sometimes noted to be as high as 4. Know the methods for treating this condition including 12% with a slight male preponderance and a strong genetic com- post-operative care. ponent. The difficulty in identifying the precise incidence lies in the fact that there is a wide variance in degrees of severity and Abstract adaption, so that the majority of these cases never come to light. While most dental clinicians are familiar with the term ankylo- Symptoms associated with ankyloglossia and other TOTs may glossia and perhaps as familiar with the lay term tongue-tie, few appear at any age of development, starting with difficulties from are aware of the vast implications that these restrictions may birth to problems that may exist over a lifetime. create. This article will attempt to define and provide a clear understanding of this congenital condition as it relates to ideal Figure 1: Varying degrees of ankyloglossia. tongue function, as well as offer ways to best assess and treat in a safe, predictable manner.

Definition, anatomy, prevalence Frenums (aka frena) are defined as remnants of embryological tissue primarily found along the oral midline on the maxillary or mandibular labial vestibular surface or on the ventral surface of the tongue. Their primary function is to keep the and tongue in harmony with the growing bones of the mouth during development. On occasion, these oral tissues may be excessively short, thick, or inflexible, severely limiting movement and function. Breastfeeding These are commonly referred to as tongue-ties and -ties. Fre- Perhaps the earliest symptom of TOTs is a difficulty in breast- nums can also be found on the right or left sides of both the feeding. The jaw movements and piston-like tongue elevations maxillary or mandibular buccal areas. These are less frequent necessary for extracting milk from the breast provide stimula- and less impactful, but are nonetheless noted and are com- tion for the growth of the , while monly referred to as buccal-ties. A new term Tethered Oral encouraging forward growth and development of the facial Tissues (or TOTs) is emerging, which encompasses all of these. regions of the maxilla and . Together with genetic While all frenal attachments are mentioned in this article, we and environmental factors, this provides stability of the dental will primarily discuss those that affect the tongue. occlusion, function, and motor balance. While proper breast- Most muscles attach to bones with tendon, but there are feeding promotes good oral motor development, bottle-feeding a few exceptions and the tongue is perhaps the most extraor- is known sometimes to have a negative impact on dental health, dinary. The tongue is a remarkable organ with a very notable so early identification of problems and their resolution is key. characteristic: It is the only muscle in the human body that is Breastfeeding benefits reach far beyond simple nourishment, freely movable on one end while attached on the other. It is and a greater understanding will help us to guide our patients as able to protrude, fold, invert, retract, or expand. As part of the they navigate these oral conditions in their children. larger organ system of the head and neck, it is attached to eight Figure 2 other muscles—four intrinsic and four extrinsic—allowing it to perform all of these unique actions. It is the organ of taste and is essential in the movement of food for effective mastication. It is the organ of phonetic articulation, with proper enunciation being a product of normal tongue function. The resting posture of the tongue affects the development of the upper jaw, the po- sition of the teeth in the arch, the shape of the and upper airway nasal passages, and thus, it’s correct function is critical in the development of ideal airway and craniofacial growth and development.

2 www.DentalAcademyOfCE.com Tight or excessive frenum anomalies that affect breast- sible dimpling in the center. There is often a white coating on feeding are often overlooked in the early clinical settings, caus- the dorsal surface showing where the tongue is deficient in ing detrimental effects to the newborn who is having difficulty reaching the roof of the mouth. This leaves a milky residue fol- latching on, which may be the very first symptom of a restricted lowing feeding. The baby may be able to protrude the tongue tongue function. Diagnosis at this early age is often made on past the , yet still will not be able to elevate. Therefore, the basis of symptoms as well as clinical appearance. One of the it is important to note that up is more important than out in most common signs that a problem exists is that the baby is not evaluating for these restrictions. Anterior tongue-tie results gaining weight or is “failing to thrive.” While this may indeed when the tip of the tongue is anchored to the floor of the mouth be an indication of a TOTs problem, weight gain alone is not an with a visually obvious frenum. However, there is a hidden exclusively reliable method of diagnosis. Weight gain needs to be part of the frenum that is less obvious but more significant. It assessed as a part of the overall clinical picture, and other factors is known as posterior tongue-tie and is found in the submucosal should be evaluated to arrive at a more definitive conclusion. area of the tongue. This is seen when elevating the tongue with Oftentimes, the baby’s tight oral anatomy physically prevents an instrument called a grooved director (or by elevating with him or her from opening wide enough to appropriately latch onto two fingers) and compressing the lateral portions of the muco- the breast. If able to latch, the infant will not be able to sustain a sal area on either side of the frenum. This submucosal or poste- latch long enough to have any efficiency in breastfeeding with- rior tongue-tie must be fully released to achieve a complete and out exerting a tremendous amount of energy. This results in an successful frenectomy. audible “clicking” off the breast or a gulping sound as the infant loses suction. Frequent or extended feeding sessions may ensue Figure 3: Tongue elevation before-and-after tongue-tie revision. in which the baby cries, shows frustration, or even falls asleep at the breast from the exertion before a full feeding has taken place. Babies who have a tongue-tie or lip-tie commonly take in significant amounts of air. With an inability to flange out the upper lip and/or an inability to appropriately cup the breast with the tongue comes a shallower, more bottle-like latch. This swal- lowed air can cause reflux-induced aerophagia, which results in frequent choking, gagging, hiccupping, spitting up, or projectile vomiting. As a result, significant abdominal discomfort from gas and colic may develop. When physically unable to engage the tongue to maintain a proper latch, some very determined babies compensate by inap- Eating, skeletal, speech, dental propriately and aggressively using both lips as the primary means As the child grows and solids are introduced, more eating dif- to hold suction. Since the newborn skin is very tender, “nursing ficulties may develop caused by poor coordination of the oral tubercles,” commonly known as “lip blisters” develop. While these musculature. The tongue must be free to move food around the are not entirely uncommon in the newborn and may appear with- mouth, position the bolus of food in the center, reach the pal- out being associated with TOTs, if they persist beyond the first few ate to create a seal, and finally swallow properly. A tied tongue months, they could be indicative of both tongue- and lip-ties. may have difficulty in the lateralization required in moving If the upper lip is restricted in movement and unable to suf- solid food around the mouth or in protrusion for accepting ficiently flange, the depth of the latch suffers as the infant is food or licking. Without the full range of motion, the child physically unable to avoid using his or her gums or lips to hold will compensate with accessory muscle movements. The child onto the nipple in this shallow latch. This frequently results in a may require liquids to help cleanse the foods from the mouth “gumming” or “chewing” of the nipple. This can be a primary to better facilitate swallowing. He or she may reject food that cause of nipple pain.5 Maternal pain while breastfeeding is com- is difficult to chew, use fingers to move the food around the mon and includes painful compression of the nipples, mastitis, mouth, or dislodge its compaction within the vestibules. There engorgement, thrust, vasospasm, bleeding and cracked nipples, may be a persistent gagging, choking, or dribbling habit due and low milk supply. Any of these can contribute to premature to the lack of control of the food bolus, enabling the food to termination of breastfeeding, depriving the baby of maternal easily divert into the airway. The child may become known immunity as well as any of the aforementioned growth and cra- as a “messy eater,” “picky eater,” or a “loud eater.” This may niofacial advantages. lead to behavioral problems and a declining self-image. Dental problems such as and caries develop as food is not Physical characteristics easily cleansed from the oral cavity following eating. The strain The tight lingual frenum will restrict elevation, resulting in a of the frenum pull may cause a lingual rotation of the mandibu- cupping of the tongue with the lateral borders lifting and pos- lar incisors or gingival recession.7

www.DentalAcademyOfCE.com 3 Short frenums may lead to orofacial changes associated with tion is generally needed if less than half of the child’s speech abnormal anatomic support of the upper airway, allowing an is understood outside the family circle by age three. Emotional increased risk of collapse during the change in muscle tone re- factors and lowered self-esteem can begin to come into play as lated to sleep stages. Over time, muscular weakness may cause social situations such as communication, dining out, and kiss- airway collapse and the formation of obstructive sleep apnea ing are affected and the symptoms become more relevant and or sleep disordered breathing.4 The inability to form a lingual- compensations more engrained. palatal seal with swallowing can create a compensating tongue thrust that results in an open bite. There may be a low and Diagnosis, classification forward tongue resting posture, an open mouth rest posture, It is important to note that research indicates 30% of ties cause primary mouth breathing, forward head posture, an imbalance problems. Each situation is unique, and the condition lends it- in skeletal structure and postural development, and craniofacial self to a great deal of adaptation and compensation so that many development that includes a narrow palatal arch and convex less severe cases go undiagnosed, and the statistics of incidence profile. TMJ symptoms, migraine headaches, tension in the remain undependable. Still, some physical characteristics are neck and shoulders, and orthodontic problems may develop as generally accepted. negative sequelae. Physical characteristics include Figure 4: “V-shaped arch” and high as a result of low tongue pos- • V-shaped notch at the tip of the tongue/heart shape seen ture. Notice the residual food around the mouth, because the tongue is not in full control of food while eating. on protrusion or elevation • Inability to stick out the tongue past the lower incisors • A rolling under of the tongue on protrusion • Inability to touch the roof of the mouth • Inability to touch the maxillary molars with the tongue • Inability to lateralize the tongue/move from side to side with ease • Frenum that blanches on elevation of the tongue • Cupping of lateral tongue borders • Central clefting or dimpling of the tongue One of the barriers to diagnosing and categorizing with any consistency is the fact that there is no consensus on clear, 3,8 Figure 5: Poor oral rest posture as a result of a tongue-tie. Notice the lip measurable standardization. Currently, providers are using incompetence and bunched mentalis muscle. their own means of assessing, with no consistency among the professions. Classification systems primarily attempt to stan- dardize the degree of severity based on the attachment points, but do not consistently denote the degree of severity or neces- sity for treatment. The varying factors of length of frenum, thickness, and flexibility are more indicative of the extent of the problem, and these things must be carefully sorted out. This is why visualization alone is not sufficient and symptoms must be taken into consideration. Treatment must be based on both symptoms and clinical presentations.

Figure 6: Note tight attachment of lingual frenum to alveolar ridge, causing rotation of mandibular incisors.

Speech delays and poor enunciation are associated with poor range of lingual movements. Both children and adults may learn to speak with a small oral aperture so that they may access the oral landmarks necessary to facilitate the consonants of speech. Others speak slowly and deliberately, and they lose clarity when speaking rapidly. The articulation of “S,” “Th,” “N,” “L,” “R,” “D,” and “T” are prominently affected. The tongue has a remarkable ability to compensate, many children have no discernable speech impediments. Evalua-

4 www.DentalAcademyOfCE.com Figure 7: Note rolling under during protrusion. laser safety goggles for everyone in the surgical area includ- ing the infant), the procedure is safe, quick, and nearly void of complications. There are no known contraindications; the procedure is safe and should take only a few moments to complete.

Figures 10 and 11: 36-year-old female patient reported release of ten- sion in back, neck, and shoulders as well as lessened migraine and TMJ symptoms.

Figure 8: Classic heart-shape on elevation.

Figures 12 and 13: 27-year-old. Note the depth of submucosal (pos- terior) release. Patient stated that she could breathe better and slept better following revision.

Figure 9: Complete anterior tongue-tie shows blanching on attempt to elevate. Generally there is no consensus on the use of topical and/ or injection of local anesthetic. Many providers use neither on infants, while some use a mild topical placed with a cotton swab on each side of the frenum. In older children and adults a few drops of injected lidocaine may be used in addition to a topi- cal anesthetic. A grooved director is placed under the tongue, straddling the frenum and lifting so that the frenum is pulled taut. The tongue base as well as the fibers of the frenum should be fully visualized with the aid of magnification and ample lighting. The revision should be parallel to the grooved director Treatment and approximately midway between the floor of the mouth and Historically, frenum revisions have been performed by cut- the tongue so as to avoid damage to the submandibular ducts. ting with blunt-end scissors. However, it is becoming more The ablation should continue until the restrictive fibers are desirable by many parents to have the frenectomy performed severed and the tongue lifts freely. A finger sweep at the base of by way of laser ablation. There are many who feel that the tongue will confirm this. incidence of incomplete releases is more likely with scissors, since the posterior portion of the tie is submucosal and harder Figures 14 and 15: Grooved director helps to elevate tongue for full access to frenum and helpful in visualization of posterior component to visualize without the cauterizing ability of the laser. With as well. the wide availability of affordable lasers and training, many clinicians are comfortable and proficient in using these tools in a number of capacities. The laser is gentle, precise, and bac- tericidal with virtually no chance of infection. There is little to no bleeding, the tissue is removed completely, and there are no sutures required. There is reduced risk of postsurgical swelling, pain, and discomfort. When a trained practitioner using proper safety precautions performs laser revision (i.e.,

www.DentalAcademyOfCE.com 5 Follow-up over the course of a lifetime. Early identification of a lingual After-care stretches and exercises will help limit reattachment as or labial restriction can prevent a host of cascading health the tissues heal and preserve the newly gained range of motion. effects. The tongue should be firmly but gently lifted and stretched (with a tongue blade, gauze, or even the parents’ clean fingers) References 1. International Affiliation of Tongue-tie Professionals website. http:// while simultaneously pushing down on the lower jaw, such that tonguetieprofessionals.org. FAQ- Definition of tongue-tie. Published 2014. the entire diamond shape of the wound is visible. This should Accessed April 14, 2016. be repeated three to five times per day for two to three weeks. 2. Kotlow LA. Lasers and soft-tissue treatments for the pediatric dental patient. Tongue exercises would include lifting the tongue toward the roof Alpha Omegan. 2008;101(3):140–151. of the mouth with the mouth open, sticking the tongue out toward 3. Hazelbaker A. Tongue-tie: Morphogenesis, Impact, Assessment and Treatment. Columbus, OH: Aidan and Eva Press. 2010. the nose and down toward the chin, and lateralizing the tongue 4. Macaluso M, Hockenbury D. (2015) Lingual, labial frenums: Early detection toward the right and left cheeks as far as possible with the mouth can prevent health effects associated with tongue-tie. RDH website. http:// closed. For the infants, mothers should be diligent in lifting and www.rdhmag.com/articles/print/volume-35/issue-12/content/lingual-and- stretching the diamond of the lip or tongue several times per day labial-frenums.html. Published December 2015. Accessed May 2016. 5. Ghaheri B. The misunderstanding of posterior tongue-tie anatomy and as well as massaging and finger sweeping the lip and floor of the release technique. DrGhaheri.com blog: Tongue Tie/Tongue-Tie and mouth to make sure no reattachment has developed. Breastfeeding/Tongue-Tie and Laser Surgery. http://drghaheri.squarespace. If any tightness develops, the area should be stretched com/blog/. Published August 19, 2015. Accessed April 14, 2016. firmly and the wound opened so as to facilitate and encour- 6. Seigel, S. Aerophagia-induced reflux associated with lip- and tongue-tie in breastfeeding infants. American Academy of Pediatrics. 2016;137(2)Suppl(3). age healing by secondary intention. There may be some slight 7. Huang Y, Quo S, Berkowski JA, Guilleminault C. (2015). Short lingual frenum bleeding as the wound is opened. Post-op analgesics, ice packs, and obstructive sleep apnea in children. International Journal of Pediatric and a soft diet is suggested. A multidisciplinary approach is Research. 2015;1:1. recommended in follow-up for full rehabilitation. This may in- 8. Cockley L, Lehman A. The Orthodontic missing link. Could it be tied to the clude chiropractic care, osteopathic manipulation, craniosacral tongue? Journal of the American Orthodontic Society. 2015(Winter);18–21. 9. American Academy of Otolaryngology–Head and Neck Surgery website. therapy, myofascial release, acupressure, and others to restore Ankyloglossia “In Toddlers and Older Children- Speech, www.entnet.org/ overall muscle balance and function. In an infant, lactation con- content/tongue-tie-ankyloglossia. Published 2015. Accessed April 14, 2016. sultants are a very key part of the process, whereas in an older child or adult, speech therapy and/or myofunctional therapy is Author Profile Lori Cockley, DDS, FAGD, earned her dental degree from of the Univer- critical in the restoration of full correct function, since compen- sity of Maryland, Baltimore College of Dental Surgery. She is a fellow of the sating habits are likely well ingrained and may persist even after Academy of General Dentistry and a member of the International Affiliation the restrictions are removed. of Tongue-Tie Professionals. She maintains a full-time private practice in East Berlin, a small town in rural south central Pennsylvania. Conclusion Author Disclosure Problems associated with a tight frenum may include diffi- Lori Cockley, DDS, FAGD has no commercial ties with the sponsors or the culties that manifest at birth to other problems that manifest providers of the unrestricted educational grant for this course.

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Questions

1. Frena are found in what oral 3. The rest posture of the tongue 5. What is the earliest possible locations? affects the development of what symptom of TOTs? a. Maxillary and mandibular labial craniofacial structures? a. Breastfeeding difficulties b. Lingual a. Upper jaw b. Speech delays c. Right and left buccal b. Position of teeth in the arch c. Feeding problems d. All of the above c. Shape of the face d. Orthodontic concerns d. All of the above 6. Treatment of TOTS is based on 2. How many other muscles attach to 4. At what age do ankyloglossia the tongue? symptoms appear? what? a. Two a. Birth a. Clinical appearance b. Four b. Age two b. Symptoms c. Six c. Age 18 c. a and b d. Eight d. May appear at any age d. None of the above

6 www.DentalAcademyOfCE.com Questions (continued)

7. Which of the following is not a sign c. Inability to touch roof of mouth with tongue d. Dimpling or clefting and symptom of TOTs in an infant? d. All of the above 24. Weak musculature can cause airway a. Clicking off the breast, gas, spitting up, colic 16. What is an advantage of laser collapse during the change in muscle b. Extended, frustrating feeding sessions revisions? c. Infrequent choking while breastfeeding tone during sleep cycles but is never a. Bactericidal related to: d. Failure to thrive b. Precise a. Vertigo c. No bleeding 8. What is true of “nursing tubercles” b. Obstructive sleep apnea a. They are genetic d. All of the above c. Chronic sinusitis b. They are always a sign of TOTs 17. What are the contraindications for d. Deviated septum c. They are very rare a tongue-tie revision d. None of the above a. Infant less than one-week-old 25. Which of the following may not be 9. Which of the following is not a b. Child with a speech impediment associated with restricted tongue and TOTs maternal symptom? c. Child in full-treatment orthodontics lip mobility in an adult? a. Vasospasm d. There are no contraindications a. TMJ dysfunction and migraines b. Mastitis 18. What is an instrument that will b. Eczema c. Thrust hold the tongue or lip taut while c. Dental and orthodontic issues d. Pruritic areolas performing a frenectomy? d. Shoulder, neck, and back tension 10. In evaluating for tongue function, a. Groovy Gracy 26. Which of the following is which of the following statements is b. Hemostats imperative in order to prevent true? c. Frenum elevator reattachment? a. If the tongue can protrude past the gums, there d. Grooved director a. Suturing is definitively no tie 19. Which of the following will not b. Tissue adhesive b. Out is more important than up help visualization of the revision area c. Perio pak c. Up is more important than out while performing a frenectomy? d. None of the above d. If speech is normal, there is definitively no tie a. Extra gauze 27. Once the patient has developed 11. Anatomically, ankyloglossia has a b. Magnification submucosal posterior component as c. A grooved director engrained patterns of dysfunction as well as: d. Ample lighting a result of restricted lingual function, a. An anterior component 20. Which of the following is he or she may need additional b. A lateral sway imperative in preserving the range treatment or therapy to relearn the c. A horizontal sheath of motion gained by the frenectomy correct functional patterns from a: d. None of the above and preventing reattachment? a. Speech language pathologist 12. Which of the following is associated a. After-care stretches b. Myofunctional therapist with an eating difficulty related to a b. Exercises c. Lactation consultant tongue-tie? c. a and b d. All of the above a. Drinking a lot while eating d. None of the above 28. Which of the following b. Loud eating 21. The incidence of tongue-ties is: postoperative instructions will be c. Messy eating a. 50% d. All of the above useful? b. 1:1000 a. Soft diet 13. Which of the following is not c. 1:50 b. Ice associated with short lingual frena? d. 3–4% and perhaps as high as 15%, but there are c. Analgesics a. Tongue thrust no dependable statistics available d. All of the above b. Sleep disordered breathing 22. How long should post-op exercises 29. Which of the following are not c. Migratory and stretches be performed? types of oral frena? d. Open mouth posture a. 24–48 hours a. Lingual 14. Which of the following is not b. Three to five days related to short frena: c. Seven to 10 days b. Labial a. TMJ symptoms d. Two to three weeks c. Buccal d. Distal b. Migraines 23. When assessing an infant for a c. Tension in the neck and back tongue-tie, one should consider all of 30. Which gender has a slightly higher d. None of the above (they are all related) the following, except: incidence of ankyloglossia? 15. Which of the following are clinical a. Fordyce spots on dorsum of tongue where milk a. Male characteristics of a tongue-tie? pools b. Female a. Heart-shaped tongue b. Cupping of lateral borders c. They are equal b. Frenum that blanches on lift c. Inability to lateralize d. It’s hard to say www.DentalAcademyOfCE.com 7 INSTANT EXAM CODE 15134 ANSWER SHEET Tying it All Together: Diagnosis, Implications, and Treatment of Tethered Oral Tissues

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Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all information above. 3) Complete answer sheets in either pen or pencil. 4) Mark only one answer for each question. 5) A score of 70% on this test will earn you 3 CE credits. 6) Complete the Course Evaluation below. 7) Make check payable to PennWell Corp. For Questions Call 800-633-1681 If not taking online, mail completed answer sheet to Educational Objectives PennWell Corp. Attn: Dental Division, 1. Define Tethered Oral Tissue and understand the anatomy and prevalence of this issue. 1421 S. Sheridan Rd., Tulsa, OK, 74112 2. Be able to identify the characteristics of this condition. or fax to: 918-831-9804 3. Have the ability to diagnose and classify the various types of tethered oral tissue. 4. Know the methods for treating this condition including post-operative care. 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COURSE EVALUATION and PARTICIPANT FEEDBACK PROVIDER INFORMATION RECORD KEEPING We encourage participant feedback pertaining to all courses. Please be sure to complete the survey included PennWell is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental association PennWell maintains records of your successful completion of any exam for a minimum of six years. Please with the course. Please e-mail all questions to: [email protected]. to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP contact our offices for a copy of your continuing education credits report. This report, which will list all does not approve or endorse individual courses or instructors, not does it imply acceptance of credit hours credits earned to date, will be generated and mailed to you within five business days of receipt. INSTRUCTIONS by boards of dentistry. All questions should have only one answer. Grading of this examination is done manually. Participants will Completing a single continuing education course does not provide enough information to give the receive confirmation of passing by receipt of a verification form. Verification of Participation forms will be Concerns or complaints about a CE Provider may be directed to the provider or to ADA CERP ar www.ada. participant the feeling that s/he is an expert in the field related to the course topic. It is a combination of mailed within two weeks after taking an examination. org/cotocerp/ many educational courses and clinical experience that allows the participant to develop skills and expertise. COURSE CREDITS/COST The PennWell Corporation is designated as an Approved PACE Program Provider by the Academy of General CANCELLATION/REFUND POLICY All participants scoring at least 70% on the examination will receive a verification form verifying 3 CE Dentistry. The formal continuing dental education programs of this program provider are accepted by the Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing. credits. The formal continuing education program of this sponsor is accepted by the AGD for Fellowship/ AGD for Fellowship, Mastership and membership maintenance credit. Approval does not imply acceptance Mastership credit. Please contact PennWell for current term of acceptance. Participants are urged to contact by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from IMAGE AUTHENTICITY their state dental boards for continuing education requirements. PennWell is a California Provider. The (11/1/2015) to (10/31/2019) Provider ID# 320452 The images provided and included in this course have not been altered. California Provider number is 4527. The cost for courses ranges from $20.00 to $110.00. © 2016 by the Academy of Dental Therapeutics and Stomatology, a division of PennWell TOT1016DE

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