Understanding the Impact of Tethered Oral Tissues on Pediatric Bowel and Bladder Dysfunction

As a pediatric pelvic floor therapist, you pay attention to the contents a child puts into their mouth. After all, food and fluid intake directly affect the excreted and eliminated waste.

But have you ever considered how the structure and function of the mouth may affect a child’s bowel or bladder? The mouth and pelvic floor are intricately connected.

You assess distally looking down the chain at foot/ankle stability. But you may not finish examining up the chain, beyond the trunk/shoulders.

When treating pediatric pelvic floor dysfunction, have you ever looked inside a child’s mouth? After reading this blog, you may want to glance inside every child’s mouth. Because in this blog, you will learn how tethered oral tissue can affect your pelvic floor cases.

Tethered oral tissues (TOTs) are restricted or adhesive tissues inside the mouth that result in a restricted range of motion of the tongue, lips, and/or cheeks.

The presence of abnormal tissue is not diagnostic itself. For the tissue to be considered truly “tethered”, the restriction must contribute to the child’s symptoms and functional deficits. This is dependent on the location of the attachments and the length of the tissue.

There are 3 types of TOTs:

1. Ankyloglossia (tongue tie)
2. Ankylolabia (lip tie)
3. Buccal/cheek tie

These ties are often initially noticed in infants because TOTs impact how a baby feeds. But even when these restrictions go unnoticed further into childhood, they can continue to affect the function of a child.

By recognizing the signs and symptoms of TOTs, you will learn how the functions of feeding, eating, digestion, elimination, and sleep can be affected in children.

When infants are breastfeeding, TOTs may cause early issues. Normally, the back of the tongue must lift and drop to create a vacuum effect to get breast milk. If the tongue is tethered, a child may compensate by using their jaw or cheeks to create compression instead.

When babies with TOTs are breastfeeding, the child’s mother may note:

• Difficulty latching and sustaining latch
• Poor endurance
• Increased respiration
• Falling asleep early or not completing a feed
• Tongue making clicking sound
• Reflux or gas from swallowing air
• Flailing because not feeding
• Increased feeding
• Losing milk supply
• Overly strong suction

Bottle feeding may be easier for a baby with TOTs, but they can get lip blisters since they use their lips for suction instead of creating a seal with the tongue. A baby may also collapse the bottle nipple if clamping with the lips.

When eating solid foods, TOTs can cause choking and gagging. An older child can get reflux if they are not chewing food completely and instead swallow foods whole. This can lead to constipation if food is not digested completely.

A child may also pack food in his mouth or gravitate toward soft or dissolvable foods.

Of course, TOTs can affect speech. A posterior tongue tie can cause difficulty for a child to pronounce “K” and “G”. An anterior tongue tie can affect the pronunciation of “L”, “T”, and “D”.

The position of the tongue greatly affects the quality of sleep. The genioglossus muscle keeps the tongue forward and out of the airway. If TOTs prevent the tongue from keeping an open airway, the child’s sleep will be impaired.

Signs of impaired sleep include:

• Restless sleep
• Difficulty falling or staying asleep
• Chronic snoring or mouth breathing
• Waking up still tired
• Grinding teeth at night

A child with TOTs may also suck their thumb while sleeping. This may be a habit, but thumb sucking can also be a compensation to help pull the tongue forward and out of the airway.

An infant with TOTs may have torticollis or difficulty with tummy time. This is due to tightness in the deep front fascial line, which I’ll discuss in more depth in the next section.

A child with TOTs may demonstrate a forward head. This is a compensatory mechanism to pull the tongue out of the airway. A child may also demonstrate other postural deficits such as head tilt.

They may complain of headaches or neck/shoulder pain. TOTs can be accompanied by poor flexibility as well due to fascial restrictions. I will delve into these fascial connections in the next section, where you will learn how TOTs affect pelvic floor dysfunction.

You’ve heard that there is a functional connection between the jaw and pelvic floor. So how is this possible?

At about 3 weeks, the embryo forms two depressions next to each other. One depression is for the mouth and the other is for the later development of the urethra, anus, and reproductive organs. As the spine grows in utero, these neurological and fascial tissues remain connected.

After birth and throughout life, a fascial sling called the deep front line remains intact. This line is a web of fascia that runs from the jaw to the tongue→ throat→ diaphragm→pelvic floor→ adductors→ and into the foot.

When oral tissue is tethered, this can create a direct pull on the deep front fascial line. You may see tightness or dysfunction in one or many of the muscles covered by this fascial sling.

In infants, this may look like difficulty with tummy time. The adductors may have increased tone and affect crawling. TOTs could even contribute to toe walking in children.

Because the diaphragm normally modulates voice and swallowing, tightness in this fascial chain could restrict the diaphragm and further affect speech.

The diaphragm also regulates thoracic and abdominal pressures, which influences the function of the bowel and bladder. Let’s take a further look at how TOTs can directly contribute to pelvic floor dysfunction.

To honor the almighty respiratory diaphragm once again, let’s appreciate its role in regulating body pressures.

When the diaphragm pumps, it creates pressure changes in multiple areas throughout the body. If pressures are not properly regulated secondary to a restricted diaphragm, think of the effects it could possibly have on visceral and neurological structures:

• Thoracic cavity (heart, lungs, lymphatics, sympathetic ganglia)
• Abdomen (stomach, intestines, rectum, kidneys, bladder)
• Spine (thoracic sympathetic ganglia and lumbopelvic nerve roots)

To illustrate this, let’s explore an example of how TOTs can cause bedwetting. When a child has sleep apnea secondary to TOTs, the body may spontaneously gasp for breath. The sudden change in the thoracic pressure alerts the brain that the heart is fluid overloaded.

This signals the heart to release atrial natriuretic peptide to reduce the load on the heart. The kidneys also produce more urine via this hormone, increasing the volume of urine in the bladder.

Here’s a second mechanism of bedwetting. Children with airway obstruction mouth breathe more. Via the Bohr effect, mouth breathing causes oxygen to remain bound to hemoglobin and with less oxygen released into the body. This pH shift causes the relaxation of vascular smooth muscle in the bladder.

So would you now be surprised to hear that the literature significantly correlates enuresis and sleep apnea?

If you are treating a stubborn case of enuresis or constipation, consider screening the child for TOTs. This may be your golden ticket.

To briefly screen for TOTs, ask the child to open their mouth and lift their tongue. Just take a quick look for any tethering.

Ask the parents about the child’s developmental history:

• How did they feed as infants?
• Did they have or do they currently have difficulty eating or digesting food? Do they avoid or prefer certain foods?
• Did they or do they have speech impairments?
• What does their sleep look like? Ask specifics.

Busy parents commonly dismiss their child’s quality of sleep. You may have even had parents get defensive or shameful when asked about sleep quality. But sleep habits hold key information! Don’t be afraid to ask the hard questions.

If you find this information valuable, consider learning more by enrolling in my Pediatric Pelvic Health Virtual Summit. In this course, you will gain a deeper understanding of tethered oral tissue and its impact on pelvic floor function.