Intro

All content of this blog is my own opinion only. It does not represent the views of any organisation or association I may work for, or be associated with. Nothing within this blog should be considered as medical advice and you should always consult your Doctor.

5 Points About Treating Tongue Ties - Laser V Scissors

1)  Claim:  Laser is the gold standard for treating tongue tie.

Fact: As far as I'm aware, we don't have evidence to categorically state that laser is superior to scissors for tongue tie release in babies, because no studies have been completed.  Please email me if you know otherwise.

We do know that frenulotomy has been performed very successfully with scissors for decades and my feelings are that actually an awful lot comes down to the practitioner.  If insufficient frenulum is removed it doesn't really matter what implement they did it with.

Secondly which laser is the gold standard?  Dentists can use a Nd:YAG, diode or waterlase - the first cauterizing the area with heat, sometimes requiring baby's eyes are covered for safety.  Others like the waterlaser vapourise tissue whilst staying cold   We need to explore experience and outcomes for all the different options.

We also need to consider that if a laser is found to be slightly lower in terms of pain scores, it does takes slightly longer ie around 30 seconds compared to 2/3 seconds - for older babies the separation from parents and restraint could be as upsetting as the procedure itself.  It's definitely a case of looking at the big picture and what is right for each family.

There is a big difference in the results depending on the skill of the practitioner.  Here we can see two laser wounds from different laser practitioners:
Example of a laser wound site (image copyright Dr Ghaheri)
Example of a laser wound site (image courtesy of UK parent)


2)  Claim:  Babies don't bleed if laser is used.

Fact:   I've witnessed some who have had slightly more bleeding than typical, and others who haven't bled at all - following both laser and scissors.  Either way it's typically a negligible amount.

I found this on the site of a laser dentist:
"You may notice some dark streaks of blood in your baby’s diaper in the 24hrs after the procedure. This is from the small amount of blood that your baby may swallow during the procedure, and it is not a cause for concern. If a laser or electrocautery tool was used for the procedure, you may notice small burns on your child’s lips or tongue (small white areas). Although every effort is make to ensure that this does not happen, the potential for these small burns is unavoidable since babies don’t understand the need to stay still during the procedure. These burns heal quickly and don’t cause any lasting damage."
Note: these burns are not a risk associated with the waterlase.

Not sure about the above practitioner, but often someone supports the baby's shoulders from behind, preventing them moving suddenly/turning their head during the procedure.

3)  Claim: Ties are less likely to scar or reattach if treated with laser - often with the adage they "obliterate tissue".

Fact:  As far as I'm aware no studies currently exist that compare outcome when treating babies.  Purely anecdotally from extensive experience of both, I couldn't with any accuracy guess which had a lower rate of reattachment.  Suffice to say I've seen reattachment, scar tissue or further visible frenulum via both methods.
It is absolutely incorrect to say scarring cannot occur using laser.   If this is true why is an extensive "aftercare" regimen of stretching and rubbing the wound numerous times per day for weeks prescribed by many laser providers to prevent reattachment?  Note this video originally had sound, the baby crying continuously proved distressing for many and then the sound vanished. You can read my thoughts on aftercare here.

In fact the importance of this aftercare is often stressed: "Your baby’s mouth heals quickly, and stretching exercises are very important after the
procedure to make sure that the area that was released doesn’t heal back together"

Handheld device
If the laser causes less inflammation compared to scissors - does rubbing the wound increase it, negating this plus?   In practice some babies are very fussy in the couple of days following laser revision and the same with scissors, so I would question whether inflammation occurs in the hours that follow the procedure via either method.

I personally believe that what happens post procedure is much more complex than we realise, with numerous things impacting on whether the wound will reattach (we've discussed this in more detail on the Facebook UK infant tongue tie group)

4)  Claim:  Laser is less painful

Fact:  As far as I'm aware, no independent studies currently exist that compare pain levels for frenulotomy.

NICE guidelines state up to 18% of babies slept through revision with scissors, with the NHS adding "some babies sleep through it, whilst others cry for a few seconds" (using blunt ended scissors). In my experience some give a quick shout, others cry more - I've witnessed the same with laser.  Similarly some babies appear to experience discomfort when using the tongue for a couple of days post procedure with either method. We need research specific to babies rather than older children.

5)  Claim: Laser is sterile so less risk of infection

Fact: No studies exist that compare infection risk.  What we do know is that risk of infection from a pair of sterile, single use disposable scissors is so low most practitioners have never witnessed an infection.  I believe Southampton estimate a rate of 1 in 10,000.

It can be easy to think that something new and expensive is automatically better than something free and
offered by the NHS.  I also don't want this to sound like an "anti laser" post as that's not the case - I may well get my own older children treated with laser as for those over 12 months it may be the only option without general anaesthetic, or even available at all if the NHS don't provide a service in that area.

I feel practitioner skill and feeding support - both in terms of technical help and peer support are as significant as the method used.  I find it strange anyone would release ties for feeding purposes, without assessment from someone suitably trained to confirm the frenulum is the root cause and also working with parents post procedure to help resolve said feeding problems!  I see a worrying number of people (treated both by the NHS and otherwise) who had a treatment that consisted of a five minute consult, treatment and out the door within minutes.  For some mums this may be all they need, for others it's just the start of a journey.

For every person thrilled with scissors, there is another who had success with laser.  Ultimately until we have unbiased, independent controlled studies - it's really all a matter of opinion.  If you're offered local NHS treatment, don't necessarily rule it out - speak to people involved with all options, establish whether the focus is simply treating the tie or helping resolve a feeding problem.  Are follow up appointments available and what does this involve?  Some offer a feeding support session at the time of revision (both NHS and private), others offer to check healing at a later date, whilst for some once it's treated it's done.   Make sure you know what to expect, and follow your gut instinct :)