Helping families unknot tongue-tie surgery

Dentistry professor publishes an evidence-based decision tool

By Diane Peters

When a newborn can’t feed and the family suspects tongue-tie — where the tongue’s lingual frenulum is short or thick, formally known as ankyloglossia — they may show up, in tears, at the dentist.

They might request a frenotomy, where the dentist makes a cut with a laser or scalpel. (A lip tie, where the concern is the labial frenulum connecting the lip to the upper gum, has connections to similar issues and a similar surgical fix.)

However, Faculty of Dentistry associate professor Hashim Nainar says there is no evidence that tongue-tie surgery helps most infants with breastfeeding or with speech later — a secondary concern. “The surgery does work, but it is required only for a very small number of babies.”

Nainar, a pediatric dentist who specializes in preventive and evidence-based dentistry, recently published “Simplified patient decision-aid for tongue-tie surgery for breast-fed infants,” in the journal Paediatrics & Child Health.

The aid can be printed out and hung on a doctor’s wall. It uses graphics and simple language to give a green, yellow or red light to the procedure based on three basic questions.

He wants parents of newborns to think carefully before pursuing surgery. It’s costly with no fee guide to restrain prices, and most insurance plans don’t cover it. (When a physician does a frenotomy, it is usually free.) 

The surgery has risks. In 2021, Elise Graham, a pediatric head and neck surgeon then based at the London Health Sciences Centre, treated a six-week-old who went into shock after losing too much blood five days after a frenotomy performed by a dentist.

In 2023, a four-week-old baby in Montreal died immediately following a dentist doing a tongue-tie procedure, an incident that received media attention starting in early 2025.

This death — which is still under investigation — triggered the Canadian Academy of Pediatric Dentistry Society to issue a position statement on ankyloglossia and breastfeeding in March 2025. It recommends a multidisciplinary approach with the likes of lactation consultants, pediatricians and dentists working together and obtaining informed consent for a treatment plan.

This guidance puts Canada in line with 2024 American Academy of Pediatrics recommendations, which use the term “symptomatic ankyloglossia” and advise surgery only after lactation support does not help.

Nainar first became interested in the topic after attending a spring 2024 dentistry conference where vendors sold laser devices for upwards of $100,000, telling dentists they could quickly make their money back.  

He and his graduate students conducted a review of the literature, discovering minimal proof the procedure helps most newborns. Nainar has since published a letter in the European Archives of Paediatric Dentistry, making an evidence-based argument for frenotomy being a “last resort.” He’s discovered a small community of other researchers, including Graham, who is now at the IWK Health Centre in Halifax, who call for a more careful approach. 

The diagnosis of ankyloglossia and the use of frenotomy are on the rise. A Canadian 2017 study found diagnosis rates soared 229 per cent between 2002 and 2014 with procedures spiking 290 per cent. Data from the U.S. and Denmark show a similar dramatic increase.

Recent statistics are not yet available, while Graham thinks the numbers we have are incomplete. “There is hospital discharge data from several countries showing increased rates of diagnosis, but I suspect this is underestimating, as many patients are diagnosed in outpatient settings after hospital discharge. Though there’s no accurate data providing estimates of more recent rates of diagnosis, I suspect it is continuing to increase,” she says.

Social media is likely a factor in driving these upward trends. Studies show more people are talking about tongue tie and frenotomy online, and they’re receiving misinformation from “self-identified health care practitioners.”

Nainar says more procedures makes problems increasingly likely, especially since a newborn can have an underlying health condition no one has diagnosed yet. “The surgery is usually very safe. Let’s says if something bad happens in only one in 100,000 procedures. But if you increase the number of procedures, you come up to the 100,000 very fast.” (In fact, adverse reactions, ranging from continued feeding problems to death, happen in 14 per 100,000 frenotomies.) 

Graham thinks the appeal of a quick snip prevents families from having the full assessment they need. “I worry that overdiagnosis of ankyloglossia may delay skilled lactation care. I have seen cases of infants undergoing multiple frenotomies without improvement of symptoms. In those situations, the lingual frenulum likely wasn’t the root issue, and repeated procedures may have diverted attention from more effective support.”

“It’s a question of adapting and learning,” says Nainar. “It’s often a struggle in the first few days, People don’t realize that, so they assume that something is wrong.” He hopes his decision tool will offer straightforward guidance. There are other tools out there, he says, but they’re many pages long and use medical lingo.

Performing tongue-tie surgeries routinely without strong clinical justification may have unintended consequences for the profession. “It may contribute to a negative perception of dentistry,” says Nainar.

He no longer treats patients, but did so for decades, and never did a frenotomy. He thinks most pediatric dentists should be similarly doing none, or at least very few. “I see what the guidelines wanted to say, that some kids do need it, and they needed to be precise scientifically. But when you’re talking clinical practices, sometimes you have to be blunt,” he says. “Personally, I don't think it's worth the risk.”

Top photo: supplied by Ashley Nicole