Celebrating our most popular post: ‘Dentist sheds light on tongue tie in infants’

This week on Our Milky Way, we are reposting our most popular article since the blog’s birth back in 2012: an interview with Greg Notestine, DDS on tongue tie published in May 2015 . The tongue-tie controversy continues to grow; in fact, Clinical Lactation dedicated its entire September 2017 issue to the issue.

For more on tongue-tie on Our Milky Way, read:

An overview of tongue tie with Dr. Evelyn Jain, MD, FCFP, FABM

UF Center for Breastfeeding and Newborns helps mothers reach breastfeeding goals

Viva la nipples

Thanks for your readership!


When a chef learns how to shuck an oyster in culinary school, she is unlikely to be receptive of new shucking methods presented thereafter. Ohio-based dentist Dr. Greg Notestine, DDS uses this analogy to explain many physicians’ refusal to learn about tongue and lip tie treatment as it relates to infant feeding problems and beyond.

“Because they weren’t taught in medical school, their minds are really, really closed to learning something new and that’s kind of true in anything,” he says. “We just close our minds once our formal education stops.  It’s human nature to do what we are taught.”

In a way, Dr. Notestine continues, he and others who practice frenotomy regularly are “rebels confronting the medical industry… because more women want to breastfeed.”

Discovering tongue tie in infants

In dental school, Dr. Notestine learned about tongue tie as it relates to children and adults, but never as it relates to infant feeding difficulties.

His introduction to tongue tie in infants was through La Leche League. His sister led a group where a mother of a three week old infant wasn’t breastfeeding as comfortably as her previous two children had. Dr. Notestine’s sister asked him if he would check the baby’s mouth. When he noticed a very obvious tie, his sister and the mothers expected he would release it.

“When you have seven crying women in your office, you better do something,” he says. “I was scared to death.”

So Dr. Notestine consulted his anatomy book and found that infants possess the same parts of the 80 year old mouth, just much smaller.

And then, “I cut it,” Dr. Notestine reports. “Immediately the breastfeeding got better.”

The influence of formula companies

After this experience, Dr. Notestine called the family’s pediatrician and obstetrician wondering why they hadn’t treated the child.

“We don’t do that anymore,” he remembers them replying.

Before the 1940s, tongue and lip ties were treated regularly, but as formula companies began to heavily influence doctors, the desire to treat ties for breastfeeding success diminished greatly. As a result, physicians learn almost nothing about the mouth in relationship to feeding in medical school today, Dr. Notestine explains.

Other than breastfeeding, tongue and lip tie can influence speech, dental hygiene, and oral-facial development which can lead to narrowed airways and sleep apnea.

These short or tight frenums, or frenulums, which also may include the cheek attachments–restrictions now referred to as Tethered Oral Tissues (TOTS)– should be examined at birth, Dr. Notestine explains.

TOTS are birth defects that require treatment, he goes on.

“A physician would not hesitate to recommend releasing webbed fingers or toes even though the person could in many cases lead a totally normal life functionally with this defect, it just wouldn’t be too pleasant cosmetically.Therefore it gets treated,” Dr. Notestine says.

Planting seeds

For 30 years, Dr. Notestine’s been on a quest to educate physicians about frenotomy as a simple intervention to help breastfeeding difficulty.

Dr. Notestine has also tried to become involved with the medical school just a couple miles down the road from his office with little welcoming, he says. Last year though, the school hired a female dean. She sent a few senior students interested in pediatric work to observe Dr. Notestine in action. The students were awed.

“At least I’ve planted seeds in their minds,” he says.

Dr. Notestine also lectures at Linda Smith’s Lactation Consultant Exam Prep Course yearly. Because there are usually three to four breastfeeding babies in the course, Dr. Notestine is able to offer a hands on learning experience for participants. Treating babies in the class allows participants to feel what they have been reading and hearing about up until this point in their studies.

Recently, Dr. Notestine spent time with second year medical students as part of an elective course where he briefly discussed the mechanics of a baby’s mouth and how proper function is necessary for proper milk removal.

“The entire idea of oral-facial muscle development depends on breastfeeding,” he explains. “You don’t use the same muscles with a bottle, so if we can help physicians learn the value of breastfeeding then perhaps they’ll look at why it’s not successful when it’s not successful… It’s not always the mom’s fault.”

Treating ties with the laser

For 25 years Dr. Notestine successfully performed releases with sharp scissors.  Now to release tongue and lip ties, he uses a relatively low level laser that seals the nerve endings and blood vessels along the way. The laser stimulates some pain, but as with most mouth wounds, heal quickly. Sometimes he uses topical anesthetic or injects local anesthetic. With the laser, the wound penetrates only a few cell layers deep whereas other methods can go as far as 100 cell layers deep, Dr. Notestine explains.

All babies fuss while they are restrained for the 30 to 60 seconds it takes to perform the release, but they calm down in one to two minutes. Then they go straight to the breast with their new “freedom,” Dr. Notestine reports.

Post-op care involved with the procedure includes sweeping and pressing on the tissue to prevent regrowth of the frenulum in its troublesome positioning. Dr. Notestine admits this post op care can be unpleasant for parents and infants, but he finds most parents are receptive because the alternative is repeat surgery.

Laser treatment offers parents psychological relief because there is less blood loss involved than other methods. This is especially true in the case of the posterior release.

Babies often develop very tense faces, necks, shoulders and backs while they struggle to feed with these oral restrictions.  Dr. Notestine recommends body work such as chiropractic care craniosacral therapy (CST), massage, acupressure and others to help restore overall muscle balance.

Having built “little networks all over the place,” Dr. Notestine receives 30 to 40 calls per day from families seeking help with suspected TOTS.

“I can’t treat them all immediately, I still have a general dental practice to run”, he says.

Dr. Notestine understands that breastfeeding challenges are time sensitive, so he refers out to a small handful of doctors he has trained in the area if necessary.

Most of his referrals come from Lactation Professionals, perinatal workers, or from satisfied moms of children that Dr. Notestine previously treated. There are a few pediatricians in his area that recognize the defect and refer to him.

Because his office experiences such high volumes and mothers usually want to share their detailed stories from the beginning, it can be stressful and difficult to accommodate so many patients.

Dr. Notestine and his staff encourage mothers to email him, or to simply make an appointment and share the details then.

This year, Dr. Notestine was recognized for his contributions to tongue and lip tie at a Dr. Kotlow seminar in Brunswick.

Learn more about Dr. Notestine’s work here.

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