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DEGLUTITI ON

Dr. Shiji Joseph


Ist MDS Department of Prosthodontics
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Mar Baselios Dental College Kothamangalam

Contents
1. Definition 2. Mechanism 3. Theories of Deglutition 4. Stages of Deglutition 5. Infantile Swallows 6. Mature Swallow 7. Dysphagia 8. Prosthodontic Dysphagia 10. management of

9. Tongue thrust swallow Dental Consideration 11. Importance of Deglutition in Prosthodontics 12. References
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Definition
The food after mastication is carried to the stomach by a complex co-ordinated movements of muscles of mouth, pharynx and esophagus. This process is called deglutition.

Mechanism
Deglutition is a reflex response that is triggered by afferent impulses in the trigeminal, Glossopharyngeal and Vagus nerves. These impulses are integrated in the nucleus of the Tractus solitarius and the nucleus ambiguous. The efferent fibres pass to the pharyngeal musculature and the tongue via the trigeminal, facial and hypoglossal nerves. Swallowing is initiated by the voluntary action of collecting the oral contents on the tongue and propelling them backward into the pharynx.

This starts a wave of involuntary contraction in the pharyngeal muscles that pushes the material into the esophagus. Inhibition of respiration and glottic closure are part of the reflex response. A peristaltic ring contraction of the esophageal muscle forms behind the material which is then swept down the esophagus at a speed of approximately 4 cm per seconds. Swallowing is difficult or impossible when the mouth is open, that is how a patient sitting on the dental chair during treatment feels the saliva collected in the throat. Total number of swallows in an adult is about 600 times out of which 200 times while eating and drinking and the 350 times while awake without food and 50 times while sleeping.

Theories of Deglutition
There are two theories of deglutition i ii Theory of constant proportion Theory of Integral Function

Theory of constant proportion: It states that in oral phase, the bolus is formed and transported under voluntary control to the pharynx. In pharyngeal phase; following receipt of the bolus, the pharynx is activated to propel the food to the esophagus and in esophageal phase; Passage of bolus down the esophagus to the stomach by esophageal contraction.

Theory of integral function: This is based on cinefluorographic, myometric and electromyographic studies. This considers that the act of deglutition is a total dynamic process. This is the currently accepted theory. Deglutition can be divided into 4 stages
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i ii iii iv

Preparatory stage Oral stage/Buccal stage (Voluntary stage) Pharyngeal stage (involuntary stage) Esophageal stage (Involuntary stage)

PREPARATORY STAGE OF SWALLOW: This starts as soon as liquid food in taken in and has been masticated. The bolus is taken to the dorsum of tongue. In infant, bolus accumulation may be seen also between the base of tongue and the epiglottis. The oral cavity is sealed by lips and tongue. ORAL STAGE OF SWALLOWING: In this state once the bolus reaches the Oropharynx by the action of tongue and strong contraction of myoglosus muscle, afferent and efferent impulses pass to and from the swallowing centre in lower pons and Medulla.

PHARYNGEAL STAGE: This stage is initiated when food comes in contact with the posterior pharyngeal wall. This stimulates the sensory receptors located in these areas and initiates a reflex stimulation of pharyngeal wall, with a series is propelled down the oropharynx.
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Contraction of superior constrictor muscle of pharynx initiates peristaltic wave which moves the bolus through the pharynx into the esophagus by relaxing the upper esophageal sphincter. Afferent fibres go through 5th, 9th, 10th and 12th cranial nerves in this stage.

Four possible outlets for the exit of food in this stage are: Back into mouth which is prevented by approximation of tongue against roof of mouth, Nasopharynx, here food is prevented from entering the Nasopharynx by pressing the soft palate against the posterior pharyngeal wall, larynx were food is prevented from entering the respiratory passage by the various mechanism. Swallowing centre inhibits respiratory centre in medulla during swallowing leading to arrest of respiration known as Deglutition apnoea, tight approximation of vocal cords closes the laryngeal opening, horizontal deflection of epiglottis during swallowing covers the laryngeal opening and forward and upward movement of larynx. Other possible entry is esophagus.

Entrance of food into esophagus occurs by the combined effect of various factors * Upward movement of larynx stretches the opening of the esophagus * Relaxation of upper 3-4 cms of esophagus , this part is formed by the cricopharyngeal muscle and is called upper esophageal sphincter. * Peristaltic contraction starts in the pharynx due to contraction of pharyngeal muscles * Elevation of larynx lifts the glottis away from the food passage. All the factors act together so that the bolus moves easily into the esophagus. This process is purely involuntary.

ESOPHAGEAL STAGE: Function of esophagus is to transport the food from the pharynx to the stomach, the movement of esophagus which is responsible for this is the peristaltic waves. Peristalsis is a wave of contraction followed by the wave of relaxation of muscle fibres of gastro intestinal tract which travels in an aboral direction. By this movement the contents are propelled down along with gastro intestinal tract.

Two types of peristaltic contractions produced in esophagus are i Primary peristaltic contraction
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ii

Secondary peristaltic contraction

Primary peristaltic contraction occurs when the bolus reaches the upper part of esophagus peristalsis starts. This is known as primary peristalsis. The pressure developed during the primary peristaltic contractions is important to propel the bolus. Initially the pressure becomes negative in the upper part of esophagus because of the stretching of the closed esophagus by the elevation of larynx, immediately the pressure becomes positive and increases up to 10 to 15 cms of H2O.

Secondary peristaltic contraction occurs due to the distension of upper esophagus by the bolus. If primary peristaltic contractions are unable to propel the bolus into the stomach the secondary peristaltic contraction appear and push the bolus into the stomach.

The tonic activity of lower esophagal sphincter between meals prevent reflux of gastric contents into the esophagus. The lower esophageal sphincter is made up of three components. i Intrinsic sphincter at the junction with the stomach.

ii Skeletal muscle fibres at the crural portion of a diaphragm surrounds the esophagus forms the extrinsic sphincter which exerts a pinchcock like action on the esophagus.
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iii Oblique or sling fibres of the stomach wall create a flap valve that helps close off the esophagus gastric junction and prevent regurgitation when intragastric pressure rises.

INFANTILE

SWALLOW (Visceral swallow)

This swallowing can be elicited in human foetus at 20 weeks in utero although full swallowing and suckling begin only after approximately 32 to 36 weeks. Features: There is lowering of jaw with forward and downward displacement of body of tongue and elevation of jaw by upward and backward displacement of tongue. Moyers lists characteristic of infantile swallow as a The jaws are apart that is tongue placed between gum pad. b The mandible is stabilized primarily by contraction of muscles of VIIth cranial nerve and interposed tongue. c This swallow is guided and to a great extent controlled by sensory interchange between the lips and the tongue.

TRANSITIONAL PERIOD
There is a change to adult swallow pattern which occurs gradually. This period is from 6 to 12 months. Various conditioning factors during this period are neuromuscular maturation, gravitational effects on mandible and change in head posture.

MATURE SWALLOW (Somatic Swallow)


This is seen after 18 months of age
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Mature swallow characteristics listed by Moyer are the teeth are together, mandible is stabilized by contraction of the mandibular elevators, the tongue tip is held against the palate above and behind the incisors. There are minimal contractions of the lips during the mature swallow. Anterior mandibular thrust has disappeared at this stage.

RETAINED INFANTILE SWALLOW


There is a persistence of infantile swallow Features * Anterior and lateral thrusting, inexpressive face due to use of facial muscle for swallowing, difficulty in mastication due to occlusive discrepancy, low gag threshold, excessive anterior face height. This is usually associated with cranio facial developmental syndromes and neural deficits. The prognosis is considered poor in this situation.

MANAGEMENT SWALLOW
* *

OF

RETAINED

INFANTILE

Habit interception e.g.: Fixed and removable cribs Treatment of malocclusion

* Muscle exercises of tongue to adopt to a new swallowing pattern.

DYSPHAGIA
Difficulty in swallowing is referred to as dysphagia. Dysphagia can be divided as oral dysphagia, pharyngeal dysphagia and esophageal dysphagia

Oral dysphagia : There is disturbance of Oral stage


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Pharyngeal dysphagia: There is disturbance of pharyngeal stage Esophageal dysphagia: There is disturbance of esophageal stage

ETIOLOGY
Oral Dysphagia Inflammation of mouth and pharynx

Glossitis - inflammation of tongue, prevents elevation of tongue. e.g.: Iron deficiency anaemia, Pernicious anaemia Cleft lip and palate

Aptyalism : Absence of saliva Muscular disorders Apthous stomatitis

Bechets syndrome - Vascular disorder with multiple ulcerations in the mouth.

Lichen planus Pharyngeal Dysphagia Pharyngitis Tonsillitis Diphtheria Tetanus Rabies


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Paresis of soft palate Nasopharyngeal carcinoma

Palatal cleft tumours

Esophageal Dysphagia

Achalasia Cardia: In this condition the food accumulates in the lower end of esophageal and this area becomes greatly distended. This is diagnosed by barium swallow.

Gastro Esophageal reflux disease: In this condition there is a reflex of gastric contents into the esophagus leading to esophageal ulcerations, esophagitis, scarring and stricture of esophagus.

Carcinoma of esophagus Inflammation of esophagus Spasm of cricopharyngeous

PROSTHODONTIC MANAGEMENT OF DYSPHAGIA

Dysphagia can be managed prosthodontically by replacement of missing teeth and bony supporting tissues. Treating with over dentures placed over remaining teeth or roots and provide

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proprioception during mastication and swallowing through periodontal ligaments. Provisional guide plane or Ramp appliance can be anchored to maxillary teeth and used to direct mandible into its presurgical occlusal position. This prosthesis enable hemimandbulectomy patients to re-established occlusal function. Treating with obturators in case of hard palate deficit, complete denture obturator in edentulous state and meatal obturator for patients with extensive soft palate defects. Maxillary reshaping prosthesis is fabricated from an impression of maxillary arch and palatal contour is developed utilizing soft moulded wax.

TONGUE THRUST SWALLOW


It is defined as placement of tongue tip forward between incisors during swallowing Etiology Genetic factors

Habit e.g.: prolonged thumb sucking, Prolonged tonsillitis and tenderness of gums.

Mechanical restriction e.g.: Macroglossia, Enlarged tonsil and adenoids


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Maturational factors, late

maturation from infantile

pattern of swallow, late maturation from immature pattern of general oral behaviour. Neurological disturbance, represents hypersensitive palate and disruption in tactile sensory control and coordination of swallowing. Psychological factors.

Classification Tongue thrust swallow is classified into simple tongue thrust swallow and complex tongue thrust swallow Simple Tongue thrust swallow This is defined as tongue thrust with teeth together swallow. There is contraction of lips, mentalis and mandibular elevators, Teeth are in occlusion as tongue protrudes into the open bite created by thumb sucking. There is well circumscribed open bite. This diminishes with age and the treatment is simple and prognosis is good. Complex Tongue thrust swallow This is defined as tongue thrust with a teeth apart swallow. There is contractions of lip, facial and mentalis muscle with lack
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of contraction of mandibular elevators. Teeth are apart during swallowing. There is a more diffuse open bite. Occlusion is poor and does not diminish with age. The prognosis is poor.

DENTAL CONSIDERATIONS
The greatest force acting on the teeth are normally produced during mastication and deglutition and they are essentially

vertical in direction. During deglutition, tooth contacts for a longer duration than those during mastication. In healthy dentitions the teeth are in occlusion only during the functional movements of chewing and deglutition and during the

movements associated with parafunctions. Functional forces of mastication and deglutition in an entire day is approximately 17.5 minutes and more than half of the time is during deglutition. The act and frequency of swallowing are important influences in the movement of teeth within the muscle matrix. This movement determines the tooth position and occlusal relations.

IMPORTANCE PROSTHODONITICS

OF

DEGLUTITION

IN

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Majority of patients unconscious swallowing is carried out with the mandible at or near centric relation position. The occlusion of complete dentures is designed to harmonise with the primitive and unconditioned reflex of the patients unconscious swallow. Tooth contacts and mandibular bracing against the maxilla occur during swallowing by complete denture patients. This suggests that complete dentures occlusion must be compatible with the forces developed during deglutition to prevent disharmonious occlusal contracts that could cause trauma to the basal seat of dentures.

The position of the mandible at the beginning of the swallowing act is used as the guide to the vertical dimension of occlusion. The teeth come together with a very light contact at the beginning of the swallowing cycle. If denture occlusion is continually missing during swallowing, dimension of occlusion may be insufficient. Record of relation of two jaws at the point of swallowing is used as indicator of vertical dimension of occlusion.

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Record of establishing vertical dimension during swallowing has been studied by various people. Tallgreen used a combination of mild fatigue followed by a swallow and relaxation with eyes closed. He used various other methods but this is the most preferred method. Atwood used a combination of swallowing and phonetics in cephalometric studies of rest position. Shanahan indicated that the mandibular pattern of movement during deglutition in the same for the edentulous infant as it is for the edentulous adult. He mentioned that eruption of teeth is held at the occlusal plane by the act of swallowing which established the vertical dimension of occlusion. When

constructing complete dentures, the swallowing technique believe that soft wax on the occlusion rim is reduced during deglutition to give the correct vertical dimension of occlusion.

Techniques Cones of wax are build on the lower denture base in such a way that they contact the upper occlusion rim, when the jaws are open too wide. The flow of saliva in stimulated by food. The repeated action of swallowing the saliva will gradually

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reduce the height of the wax cones to allow the mandible to reach the level of vertical dimensions of occlusions.

Ismail and George checked the swallowing method by using cephalometric radiographs to record the vertical dimension of occlusion before the teeth were extracted and after dentures were inserted. The swallowing technique produced an increase of 0 to 5 mm (mean 2.8 mm) in the vertical dimension of occlusion in the edentulous group. He found that the increase was directly proportional to the number of missing posterior teeth prior to extraction of the teeth. Finnegan used a

hydraulic system to measure the force exerted by the lower teeth on the upper during swallowing. Niswonger referred swallowing to attain physiological rest position for determining the facial dimension at which occlusion should be established.

Conclusion:
Deglutition plays an important role in prosthodontics, since it is used as a reference for various records.
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References

Medical Physiology: William F Ganong

Medical Physiology: Guyton and Hall


Boucher's Prosthodontic treatment for edentulous patients Prosthodontic management of swallowing disorders:

Dysphagia 3:199-205; 1989 by John W. Davis

Clinical assessment of vertical dimension: Journal of prosthetic dentistry: August 2006; 96:79-83

Effect of denture fabrication and wear on closest space and interocclusal distance during deglutition: Journal of prosthetic dentistry; June 2007 Vol. 97 issues 6.

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