Landmark consensus statement on Ankyloglossia released

5 June 2020

In 2019, the ADA began the process of creating a consensus statement on ankyloglossia as part of the association’s work in health promotion and advocacy. The multidisciplinary statement has now been released, and promises to be a great resource for members of both the dental and wider community.

Recently finalised, the Ankyloglossia and Oral Frena Consensus Statement provides a multidisciplinary,
evidence-based consensus regarding the diagnosis and management of short, tight labial and lingual frena and ankyloglossia.

The consensus statement, available now in its entirety on the ADA website, is intended to guide best practice; it is based on existing evidence, including a systematic Cochrane Review, an updated broader literature review and the expert opinion of the working group.

Neonates, infants, and young children are the focus of the consensus statement; however, implications for older
children and adults are also addressed. Although frenotomies can be performed on any age, the most common group to undergo treatment is 0–4 year olds, as reported by Medicare data from 2006–2016, which reported a 420% increase in treatment over the 10-year period. This data is based on treatment performed in public settings by medical practitioners and does not account for treatment performed in private hospitals or health clinics, nor treatments provided by dentists. Therefore, the true number of treatments performed is likely to be considerably higher.

These patterns of increased surgical treatment are not only reported in Australia, but also in North America and
Canada. Many professionals speculate as to the reason for the increase in diagnosis and treatment and this may include both patient-driven and health professional-driven reasons. Concerns and interest from health professionals in various disciplines regarding this increase and feedback from the membership led to the ADA developing this statement.

The Statement is made up of two parts: the Statement of Consensus, and Supporting Evidence. The Statement of Consensus includes definition, diagnosis, associated health issues, non-surgical management, surgical management, complications, and post-operative care, as well as a suggested management pathway for infants with feeding issues diagnosed with ankyloglossia.

The statement conveys the importance of thorough patient assessment, where diagnosis is based on frenum appearance in combination with a functional limitation, such as issues experienced when breastfeeding. Without a tangible functional limitation, neonates, infants, children nor adults should undergo surgical management of the lingual frenum or other intra-oral frena based on anatomic appearance alone. Importantly, surgical intervention should not be undertaken as a precautionary measure against possible future problems. Other key findings include:

- Breastfeeding issues can be associated with ankyloglossia but can also be due to other causes;

- There is no evidence to suggest that buccal or labial frenacan lead to problems with feeding or speech;

- Malocclusion, in a minority, may be associated with a prominent lingual or labial frenum. However, malocclusion, gingival recession and dental caries cannot be predicted based on the anatomic appearance of the frenum in infancy or early childhood;

- Non-surgical management strategies should be considered an effective first-line therapy for the management of functional limitations related to ankyloglossia, especially with regards to feeding problems;

- Surgical management of the lingual frenum may be indicated after:
1. Diagnosis of ankyloglossia by an appropriately trained health professional using appropriate diagnostic assessments;

2. Failure of non-surgical management; and

3. Full informed consent is obtained.

- If surgical intervention is deemed necessary, the age of the patient influences the surgical approach. Cold steel frenotomy using scissors is recommended in neonates;

- Although surgical management of ankyloglossia may be regarded a simple procedure to perform, both acute and chronic complications can occur and can be potentially life threatening; and

- Surgical management of neonates should only be undertaken in an established healthcare facility or tertiary setting with access to neonatal resuscitation equipment and the ability to manage acute airway and/or bleeding complications.

The supporting evidence includes research studies published prior to December 2019. A small number of studies published since the completion of the synthesis of the evidence document, support and align with the consensus and evidence included in the statement.

The Ankyloglossia and Oral Frena Consensus Statement highlights the importance of multidisciplinary care and communication between treating health professionals. In developing the consensus statement, 14 health professionals from various disciplines formed the multidisciplinary working group, representing 10 health organisations and associations.

Those who endorse the Statement include:
- Australasian Academy of Paediatric Dentistry (AAPD)

- Australasian Council of Dental Schools (ACDS)

- Australian Chiropractors Association (ACA)

- Australian College of Midwives (ACM)

- Australian Dental and Oral Health Therapists’ Association (ADOHTA)

- Australian and New Zealand Academy of Periodontists (ANZAP)

- Dental Hygienists Association of Australia Ltd (DHAA)

- Lactation Consultants of Australia and New Zealand (LCANZ)

- Osteopathy Australia (OA)

- Royal Australasian College of Dental Surgeons (RACDS)

- Speech Pathology Australia (SPA)

- The Australian and New Zealand Association of Oral and Maxillofacial Surgeons (ANZAOMS)

The diversity of health professionals engaged in the development of this statement demonstrates the importance of inter-disciplinary care, particularly for the mother-infant dyad. The participating associations and organisations as well as additional groups were invited to endorse the completed statement.

This resource will be regularly reviewed to represent new evidence as it arises. Further research is required to clarify many issues relating to ankyloglossia, particularly the effects of surgical management on improving functional limitations and the long-term effects of surgical intervention on neonates.