High palate, restricted frenum and R problem

Hi Sandra, I am taking your /r/ e-course right now and have a question for you about a 9-year-old client who was diagnosed as an infant with a tongue tie but parents were advised not to have it clipped at the time. As a result, he had tremendous feeding problems which mom recalls were a “nightmare.”  His 2-year-old brother was also born with a tongue-tie but had it clipped at birth and subsequently had no feeding issues. This client has good range of motion with his tongue, (protrusion, retraction, elevation, etc.), however, I’ve noticed that when he retracts and elevates his tongue to produce a vocalic /r/, he raises his jaw and cannot keep his mouth open. I looked under his tongue and saw that the lingual frenum was anchored close to the floor of the mouth thus making it impossible for him to keep his mouth open while retracting and elevating the tongue.  He also has a high, narrow palate with a long narrow face. I advised his mother to speak to an ENT about the tongue tie to see if anything could be done.  She hasn’t gone yet so I wanted to ask you if you have any research on clipping the frenum and improving production of vocalic /r/.  Any other information you could provide would be very helpful.  I am the third SLP he has seen since he was 5 and the first one to point out the high palate and the fact that the tongue tie may be preventing progress on the vocalic /r/. I truly empathize with the frustration he has experienced in not being able to change this sound error.  When I told him that the difficulty he was experiencing may not have to do with his inability to work hard and do what is asked of him but rather something structural beyond his control, he was so relieved he let out a huge sigh. Thanks for your time.

 Hi, It is a shame that his pediatricians weren’t informed about this right at the time he was born.   You mention his brother was born with tongue tie but the early revision proved beneficial.  I’m seeing so very often a genetic component and others are finding it a common denominator, also.  You stated that this client has good range of motion with his tongue, (protrusion, retraction, elevation, etc.).  Somehow, I can’t imagine that he has a good range of motion, protrusion and elevation based on what you say in the next few sentences.  Maybe the mid portion of the body of the tongue is compensating for his other difficulties and it appears that these functions are within normal range, but I truly doubt it.  You wrote,“I’ve noticed that when he retracts and elevates his tongue to produce a vocalic /r/, he raises his jaw and cannot keep his mouth open. I looked under his tongue and saw that the lingual frenum was anchored close to the floor of the mouth thus making it impossible for him to keep his mouth open while retracting and elevating the tongue.”  We look at several things here.  First of all, look at where the frenum inserts into the floor of the mouth.  Is it on or right below the lower alveolar ridge?  Or is it fairly far back on the floor?  Also, look where the frenum inserts into the tongue itself.  Is it about midway or is it closer to the tip?  Or is it far down at the base of the tongue?  Now check and see if it seems to be embedded into the tongue tissue above the place where it appears to attach to the underside of the tongue.  Look at the length of it.  And check if it is thick or thin, flexible or inflexible.  All of these are considerations and how they “come together” is important.      He also has a high, narrow palate with a long narrow face. I have found so many /r/ kiddos with high narrow palates that I don’t need a study to tell me the two often go hand in hand.   I advised his mother to speak to an ENT about the tongue tie to see if anything could be done.  She hasn’t gone yet so I wanted to ask you if you have any research on clipping the frenum and improving production of vocalic /r/.  I don’t know of specific studies linking /r/ problems and restricted lingual frena.  I do trust my own clinical observations and experience since I have worked for so many years on this type of problem and it only makes sense that with a restricted tongue AND a high narrow palate that one cannot obtain and maintain the ER sound.  It is impossible and a study would probably be very easy to do if you have enough clients…since it is likely that close to 100% would have difficulties.   You said that you are the third SLP he has seen since age 5, but the others did not point out the high palate or the tongue tie.  It is a sad state of affairs that many SLPs and other professionals don’t bother to include these areas in a thorough examination because the child often ends up feeling like he is a loser who is doing something wrong since he can’t get the /r/ sound habituated.         I am so glad that you told him that the difficulty he was experiencing may not have to do with his inability to work hard and do what is asked of him but rather something structural beyond his control. It is no surprise that he was so relieved he let out a huge sigh.      Here is what I would do IF he has a restricted lingual frena:

•  I would not continue with therapy if he is tongue tied.
• I would not treat him for /r/ if he also has an extremely high palate
• Check to see if he can suction flat to his palate and see how much of the sides of the tongue overlap the arch/teeth.  If, in a short while you can get him to fit his tongue within his high narrow palate, you might have a shot at the ER but only IF the tongue tie is taken care of.  Otherwise, he will need the palate expanded, if an orthodontist also finds that it is high and narrow.

I think this young man and his family are very fortunate to have found you,  …truly.  You will be able to give him the right direction and I will help you…let me know your findings and …good for you for looking deeper than the others did, for seeking  information from the online course, for emailing me….we need more SLPs like you!