A tethered oral tissue or TOT, commonly known as a tie, is a tissue that is restricted, resulting in poor range of motion and mobility.

TOTs can be hereditary.

Children are born with these restrictions. Tongue ties are the most commonly diagnosed TOT, however, ties can be present in other places of the mouth, including the middle, right, or left sides of the upper and/or lower lips and on the front and/or back of the tongue. Tongue-tie restrictions will anchor the tongue to the floor of the jaw. Lip-tie restrictions may not allow a child to smile.

Early identification is the key to preventing a variety of potential issues.

Many parents don’t know that their child has a TOT until the child is in elementary school and is experiencing difficulties. There are also many people who get revision surgeries as adults once a TOT has been identified.  

Possible Signs of a TOT:


Breastfeeding is painful for the mother

Latch is extremely shallow

Lips will not flange around nipple

Retracted jaw

May choke during sucking

May have difficulties turning neck (torticollis)

     Older Child:

Tongue thrusting

Mouth breathing

Poor breathing during sleep

Picky eating

Poor jaw, lip, & tongue patterns while eating

Teeth grinding

Elongated face

Poor speech clarity

How can we help?

Occupational therapy (OT) and craniosacral therapy (CST) can loosen TOT restrictions, allow for greater ease of movement, strengthen muscles, and improve food tolerance by bringing increased success to jaw, tongue, cheek, and lip movements.

If therapy is provided before a revision, a child’s recovery is faster; this is because a TOT is a muscle that never got a chance to work, thus resulting in poor muscle control due to weakness. Pre- and post-surgery treatment provides the best chance for success and strengthening skills.

If you have concerns and suspect that your child may have a TOT, talk to your child’s pediatrician to see if a referral to an occupational therapist is warranted. It may also be helpful to consult with your lactation consultant as many have experience with TOTs. Michigan Pediatric Therapy has occupational therapists that are trained in Tethered Oral Tissues Specialty TOTS Training®, NOMAS®, Beckman Protocol, and Talk Tools and we are here to help.

Magda Girao, OTRL, CST-D, NDT, Founder

Magda has more than 20 years of experience as a licensed occupational therapist. Magda has a Diplomate (advanced) certification in craniosacral therapy through the Upledger Institute. She is certified in neurodevelopmental techniques, is an expert in the treatment of children with breastfeeding and other feeding issues, and is certified in therapeutic listening. Magda has extensive training in feeding issues and is trained in tethered oral tissues, SOS Approach, Beckman Protocol, Talk Tools, Nomas, mealtime misery, and AFRID. 

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Nestled in Farmington Hills, Michigan, our space exudes a homely ambiance, providing a welcoming contrast to a typical medical setting. Vibrant and inviting, our facility is designed to make children feel at ease and foster their well-being. The treatment rooms boast comfort and color, creating a pleasant environment. Additionally, our beloved play-based sensory room adds an element of excitement, making therapy sessions something children eagerly anticipate.

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