1.

Swallowing studies by imaging are performed by: foods and liquids mixed
with barium (radiopaque) and then swallowed. This imaging technique is called
VideoFluorographic swallowing study.

2. Elderly patients often have a difficulty time taking medications. Reasons for this
includes:

Structural: Head, neck, or esophageal cancer; Thyromegaly; damage from GERD

Neurologic Diseases: Parkinsons Disease, Multiple Sclerosis, Amyotrophic
Lateral Sclerosis, Myastenia Gravis, Dementias
Strokes and other cerebral vascular accidents
Traumatic brain injury, spinal cord injury
Medications:
Other: Psychogenic (Anxiety), Cerebral Palsy, Polymyositis

A way we as dental providers can help is by:

Dietary modification (textures)
Specific swallowing technique/maneuvers
Oral Hygiene maintenence
Minimize water used during dental treatment.
Have patients less recumbent in dental chair for treatment
Mindful of suctioning
More frequent breaks during procedures for patients to swallow or take a
breathe
Medications can be prescribed in liquid form
Additional airway protection (throat screen, rubber dam, floss on dental
appliances) for the patient with dystonia/hypotonia, patients without gag
reflex, or patients with ineffective cough as they may be more likely to
aspirate dental materials

3. If you have a patient who is high risk for aspiration and they have already been
diagnosed with a swallowing and feeding impairment, who might already be involved in
the patients care and how are they involved:

Disciplines include, but not limited to:

Nurses & Nurse Practitioners
Physicians and Physician Assistants
Dentists & Dental Hygienists
Dietitians
Pharmacists

Speech-Language Pathologists
Occupational Therapists
Social Workers
Psychologists
Volunteer Feeding Assistants

4. Cranial nerves involved with the swallowing mechanism are:

The function of each involved CN is:
Cranial Nerves V, VII, IX, X, and XII involved

5. Looking at a diagram of the oral pharynx, be able to describe the 4 phases of

swallowing and the function of anatomically involved structure during each phase.

Four phases:
oral preparatory (often referred to as preparatory)
oral propulsive (often referred to as oral or oral transit)
pharyngeal
esophageal
Oral Preparation Phase
Voluntary (controlled by brain)
Process of rendering the bolus to be swallowable
CN V controls general sensation to face and motor supply to muscles of
mastication
CN VII controls taste to anterior 2/3 of tongue and motor function to lips
CN XII controls motor supply to intrinsic and extrinsic muscles of the tongue

 Can indirectly affect swallowing

Oral Propulsion Phase

Elevation of the
tongue to the palate
and propulsion of the
bolus by the tongue
into the oropharynx
Closure of the soft palate against the pharyngeal wall to prevent nasal reflux
CN IX provides general sensation to the posterior third of the tongue and motor
function to pharyngeal constrictors

Pharyngeal Phase

Soft palate elevates

Closure of the vocal folds and the laryngopharyngeal vestibule
Tongue pushes backwards and downwards into pharynx to propel bolus down
Elevation of hyoid bone and larynx upward and forward
Lowering of the epiglottis over the laryngeal vestibule
The bolus
flows into two streams around each side of the epiglottis to
the piriform fossa and then unite to enter the esophagus
The vocal cords, aryepiglottic folds, and ventricular folds are closed preventing
entry of food into the larynx
Peristaltic contraction of the pharyngeal constrictor muscles
Relaxation of the cricopharyngeus muscle
Upper esophageal sphincter relaxes and is pulled opened

Esophageal Phase

Peristaltic propulsion of bolus down the esophagus

Lower esophageal sphincter relaxes and allows propulsion of the bolus into the
stomach

6. Dysphagia may develop from anatomical changes from:

Or dysphagia may develop from physiological/functional changes as a result of these
neurological diseases or events:

Disordered Swallowing
Includes failure to:
Initiate
Close Nasopharynx
(nasal reflux)

Close Larynx
(aspiration)
Clear Pharynx
Oral Preparatory and Oral Propulsion Phases
Impaired control of tongue
Difficulty Chewing solid foods and initiating swallows
Cavities, defective fillings, dental/oral pain
Difficulty containing liquids in mouth before swallowing
Liquids can spill prematurely into unprepared pharynx leading to
aspiration
Delayed Initiation of reflex
Weakness of tongue
Numbness of posterior palate and pharynx
Pharyngeal Phase
Obstruction of pharynx by stricture, web or tumor
Weakness or incoordination of the pharyngeal muscles (may also lead to nasal
regurgitation)
Poor opening of the esophageal sphincter
If pharynx cannot be cleared, overflow aspiration after swallowing
If pharyngeal clearance severely impaired, may not be able to ingest sufficient
food or drink to sustain life
Nasal Reflux
Weakness of palatal elevators
Weakness of
superior pharyngeal constrictors

Aspiration
Weakness of pharyngeal and laryngeal muscles
Numbness of pharynx

Difficulty Clearing Pharynx

Weakness of laryngeal elevators

Weakness of pharyngeal constrictors
Esophageal Phase
Impaired function can result in retention of food and liquid in esophagus after
swallowing
Retention from
Mechanical obstruction (web, stricture, tumor)
Motility disorder (weakness or incoordination of esophageal musculature,
or overactivity of esophageal muscles can lead to esophageal spasms)
Impaired opening of the lower esophageal sphincter
GERD is related problem as can lead to reflux esophagitis and an
increased risk for peptic strictures

7. The relationship between a patients gag reflex and their aspiration risk is:

Though presence or absence of a gag reflex is not a predictor of a

swallowing disorder but additional airway protection is required for the
patient without gag reflex, as they may be more likely to aspirate dental
materials.

8. Mrs. Smith is one of your nursing home patients with dementia. She sees you
regularly for cleanings and check-ups every 6 months. The last time you saw her was 8
months ago though. The nursing staff states she has been pointing to her mouth and
holding her cheek the last week. Mrs. Smith suffered a stroke two months ago and had so
much difficulty swallowing her foods, that a percutaneous endoscopic gastric feeding
tube was placed a month ago for nutrition. Before you take x-rays of any of her
remaining 20 teeth to help you diagnose the source of her pain, you start thinking about
possible differentials. Given what you know about strokes, dementia, dysphagia, and
nursing home care, the differentials include:

Structural: Head, neck, or esophageal cancer; Thyromegaly; damage from GERD

Neurologic Diseases: Parkinsons Disease, Multiple Sclerosis, Amyotrophic
Lateral Sclerosis, Myastenia Gravis, Dementias
Strokes and other cerebral vascular accidents
Traumatic brain injury, spinal cord injury

9. For people with a mechanical cause of swallowing difficulties, a more liquid diet is
less of an aspiration risk. For people with a neurological cause of swallowing difficulties,
a less liquid diet is less of an aspiration risk.
Hence, the patient with a neurological cause of dysphagia will be at more of an aspiration
risk in the dental chair.