Myers Pediatric Dentistry & Orthodontics -
Frenectomy
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3200 Old Jennings Rd.
Middleburg FL 32068
(904) 505-2010
3267 Hodges Blvd. #13
Jacksonville FL 32224
(904) 361-3370
Lip and Tongue Tie Assessment
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Myers Pediatric Dentistry & Orthodontics | 3200 Old Jennings Rd., Middleburg, FL
Myers Pediatric Dentistry & Orthodontics | 3267 Hodges Blvd. #13, Jacksonville, FL
Has your child experienced any of the following problems or treatment?
1. Has the infant experienced any of the following?
Poor Latch
Falls asleep while attempting to nurse
Slides off the nipple when attempting to latch
Colic symptoms
Reflux symptoms
Poor weight gain
Gumming/chewing of your nipple when nursing
Milk coming out the nose or side of mouth when nursing
Unable to hold a pacifier in his/her mouth
Short sleep cycles
Feedings every 2 hours or less
Clicking while nursing
2.
Yes
No
2.
Has the infant received any cranio-sacral therapy (CST)?
3.
Yes
No
3.
If so, was there improvement?
4.
Yes
No
4.
If so, was the improvement lasting?
5.
Yes
No
5.
Is your infant under the care of a Chiropractor?
6.
Yes
No
6.
If so, was there improvement?
7.
Yes
No
7.
If so, was the improvement lasting?
8. Does the mother have any of the following signs or symptoms?
Creased, flattened or blanched nipples after nursing
Cracked, bruised or blistered nipples
Bleeding nipples
Severe pain when your infant attempts to latch
Poor or incomplete breast drainage
Infected nipples or breasts
Plugged ducts
Mastitis or nipple thrush
9. Other comments on nursing?
Clinically/Visually
10.
Yes
No
10.
Does the upper lip flange out while feeding at the breast?
11.
Yes
No
11.
Does the upper frenum attach near the wet/dry line of the upper lip?
12.
Yes
No
12.
Upper frenum attaches at the bottom of the gum ridge?
13.
Yes
No
13.
Does the lower frenum attach at the anterior 1/3 of the tongue?
14.
Yes
No
14.
Is there a "speed bump" when you sweep your finger side to side under the tongue?
15.
Yes
No
15.
If yes, does it physically stop your finger from crossing the midline?
16.
Yes
No
16.
Is there a "piano wire" or tight rope that pops out when you run your index finger from the gum ridge towards the back of the throat under the tongue along the midline?
17.
Yes
No
17.
Does the tongue stay low in the mouth when crying or look spoon shaped when crying?
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