Contents: Introduction Theories of deglutition Neuro- physiology of deglutition Phases of deglutition Types of swallowing Deglutition in cleft patients References

Deglutition or Swallowing Introduction Deglutition/ swallowing is an innate unlearned behavior first occurring in the Fetus. Swallowing is complicated mechanism principally because the pharynx subserves respiration as well as swallowing. Swallowing can be initiated voluntarily but there after it is almost entirely under reflex control. One of the important physiological functions of the human body that has long been recognized to influence the positions of teeth and the jaws in relation to the rest of the head is DEGLUTITION

Definition The taking in of a substance through the mouth and pharynx, past the cricopharyngeal constriction through the esophagus and into the stomach. A complicated act usually initiated voluntarily but always completed reflexively whereby food is moved from the mouth through the pharynx & esophagus to the stomach. Teeth are moved physiologically by the growth of investing tissues, especially the bone and that to obtain bone growth we must stimulate it through pressure. This pressure may be normal and tend to the teeth into their proper positions of occlusions, or the pressure may be abnormal and tend to move the teeth into improper positions of malocclusion.

Some Antagonistic Forces Acting on the Masticatory Apparatus Lip tongue Cheeks tongue Eruption of teeth masticatory musclesmasseter, temporalis and medial pterygoid

 Air pressure of the skin - tongue (in closed mouth) Air pressure in nasal cavity tongue (open mouth) Masseter elasticity of periodontal ligament (particularly of molars). Internal pterygoid same as masseter in vertical movement External pterygoid in anterior movement posterior one third of temporalis, suprahyoid group, digastric and muscles of neck. External pterygoid in lateral movement external pterygoid of opposite side

Theories of deglutition: 1) Theory of constant propulsion 2) Theory of oral expulsion 3) Theory of negative pressure 4) Theory of integral function

THEORY OF CONSTANT PROPULSION: Early concepts of deglutition is based on the knowledge of anatomy and the experiments carried on the animals. They assumed that the various structures involved in deglutition acted upon the bolus of food consecutively to propel it from the mouth through the pharynx into the esophagus. In the classical work of Magendie 3 stages of propulsion were noted with certain important modifications this theory is closely related to modern concepts of swallowing THEORY OF ORAL EXPULSION: (1880) kronecker et al in 1880 suggested that the bolus was ejected from the mouth directly into the stomach by the piston like action of tongue and mylohyoid musculature.

 Cannon in 1911 believed that kroneckers theory applied to only fluids & semifluids,he believed that solids and semisolids were handled by a consequtive peristaltic type action , similar to that of magendie Oral expulsion theory is not supported by current findings Manometric and flouroscopic techniques used by the authors in proposing this theory were unable to detect the rapid changes in the pharynx

THEORY OF NEGATIVE PRESSURE: Barclay used flouroscopy and observed a moment of radiolucency in the hypopharynx immediately preceeding the decent of the bolus. He postulated that this radiolucent area indicating pharyngeal dilation was evident of the negative pressure, which he felt was the primary propulsive force in deglutition. This negative pressure was obtained by simultaneous lowering of larynx and forward motion of the tongue while the opclosedenings of the pharynx were In an experiment by Atkinson 1956 he found double peaked positive air pressure in pharynx, first peak corresponded to the entrance of bolus into pharynx and the second wave corresponded to the constrictor action.the presence of these positive pressures refutes the suction action to be the source of bolus transmission. Further palato-pharyngeal valve is often open for a moment at the beginning of normal deglutition. So negative pressure cannot be present to propel the bolus while the palatopharyngeal valve is open.

THEORY OF INTEGRAL FUNCTION: Cineflourography allows visualization of the dynamics of deglutition.

 Studies using this method supports the magendies concept Bolus passes distally through a series of muscular valves by highly integrated reflexes Reflexes Storey (1976) considers swallowing to be essentially an airway protective reflex and has classified the reflex events associated with maintaining the integrity of the airway and alimentary canal where they cross in pharynx as a. Protective reflexes : - These are concerned with preventing entry into or alimentary canal (eg. Sniffing, sneezing, coughing, ganging, swallowing) b. Supportive reflexes: - These are concerned with obtaining air & food (eg. Suckling, mastication, airway maintenance) - The hierarchical organization is : - Protective reflexes before supportive reflexes - Airway maintenance reflexes before alimentary canal reflexes. - Under normal circumstances deglutition is preprogrammed & reflexly controlled and once triggered is an all or none response. Indications of reflex nature of swallowing: Swallowing occurs during sleep During general anaesthesia it is increased. Grandma epileptic seizures are characterized by vigorous swallowing. Variations in swallowing occur with Degree of lubrication of food with saliva eg. Problems arise in the event of salivary gland dysfunction & in diseases where there is reduced salivary flow. The state of mucous membrane eg. Friable, atrophic tissues associated with chronic disease. The material swallowed eg. Solid & liquids are handled differently as are solids of varying consistency.

Phases of swallowing: Fletcher divided the Deglutitional Cycle into 4 phases, which are highly integrated and synergistically co-ordinate. 1) Preparatory swallow 2) Oral phase of swallowing 3) Pharyngeal phase of swallowing 4) Esophageal phase of swallowing Preparatory swallow: Initiated when the tip of tongue separates a bolus of food from the remaining mass of food in the mouth. Pharyngeal phase of swallowing Involuntary & constitutes passage of food through the pharynx into esophagus. Esophageal phase of swallowing Another involuntary phase that promotes Passage of food from the pharynx to the stomach. 1) Preparatory swallow: Preparatory phase starts as soon as liquids are taken in or after the bolus has been masticated. The liquid or bolus is taken in swallow preparatory position on the on the dorsum of tongue. In the infant, bolus accumulation may be seen also between the base of tongue & the epiglottis. The oral cavity is sealed by lip & tongue.

2) Oral phase of swallowing Soft palate moves upwards & the tongue drops downwards & backwards. At the same time the larynx & hyoid bone move upward. These combined movements create a smooth path for bolus as it is pushed from oral cavity by wave like rippling of tongue. In case of liquid it flows ahead of lingual constrictions. Oral cavity stabilized by muscles of mastication maintain an anterior & lateral seal during this phase.

Distal movement of the bolus begins with - depression of pharyngeal portion of the tongue - elevation of the soft palate distal squeezing action of tongue against hard palate Ardran described it as tooth paste This analogy more accurate for solids than liquids. Ramsay observed progressive narrowing and obliteration of lumen behind bolus and called it stripping wave. lingual pressure in the anterior and lateral peripheral seal areas were similar

3) Pharyngeal phase of swallowing Begins as the bolus passes through the fauces.

 The pharyngeal tube is raised upward en-mass & the nasopharynx is sealed off by closure of soft palate against the posterior pharyngeal wall (i.e. Passavants ridge)

Hyoid bone & the base of tongue move forward as both pharynx & tongue continue their peristaltic movement of bolus. Occurs in less than 2 seconds. As the bolus passes from oral cavity to the upper end of esophagus through the oral and laryngeal portions of the pharynx there are 4 openings to be closed - Nasopharynx - Eustachian tube - Glottis Naso-pharynx - closed of from oropharynx approximation of posterior pillars of fauces - palatopharygeous muscle elevation of the uvula - levator palatini

Auditory tube - salpingo-pharyngeal muscle

Epiglottis minor role in protection of laryngeal air way adduction of vocal cords cricoarytenoids aryepigloticus larynx pulled up apposed to tongue stylopharyngeal salpingopharyngeal palatopharyngeal inferior constrictor Deglutition apnea: Momentary arrest of breathing during pharyngeal stage of deglutition . Occurs when bolus is pushed from pharynx into esophagus Protective mechanism When at rest the pharynx is closed by the approximation of the anterior and posterior walls of the pharynx

Posterior wall is firmly attached to the prevertebral fassia Anterior wall of the laryngo-pharynx is formed by the larynx To open the pharynx larynx must be elevated, which is assisted by the hyoid bone elevation Movement of the hyoid: Hyoid bone suggest as a posterior pedestal for the attachment of the tongue

 Shelton et al described 3 phases of hyoid movement Phase 1: simultaneous cephalad movement of hyoid elevation of larynx dorsad movement of pharyngeal portion of tongue Occurs prior to the descent of bolus Phase 2: cephaloventrad Occurs as the bolus descends through the pharynx into esophagus Phase 3: return of hyoid to pre swallow position posterior belly of digastric , stylohyoid obliquely postero-inferiorly

Ramsay stated that movements of the hyoid bone depends on size of the bolus The bolus is literally crammed down the pharynx , past larynx - backward downward action of tongue - hyoglossus, inferior lingualis Pharynx is elevated at the same time Later pharynx descends infra hyoid muscles Middle and superior constrictors of pharynx - peristaltic wave - Bolus passes into esophagus - bolus carried down and prevented from regurgitation

4) Esophageal phase of swallowing Commences as food passes the cricopharyngeal spincter. While peristaltic movements carry the food through esophagus, hyoid bone, palate & tongue return to their original position. Esophagus normally exhibits 2 types of peristaltic movements i. Primary peristalsis ii. Secondary peristalsis 1) Primary peristalsis Passes all over from pharynx to stomach in about 8-10sec. Food swallowed by person who is in upright position is usually transmitted to the lower end of esophagus even more rapidly than peristaltic wave itself in about 58sec, due to additional effect of gravity pulling the food downwards. 2) Secondary peristalsis If primary wave fails to move all the food entered the esophagus into stomach secondary peristaltic wave results from distention of esophagus by retained food & continue until all food has emptied into stomach.

Clinical conditions affecting swallowing : Oral Dysphagias : - Clinical conditions affecting oral mucous membrane particularly Tongue causing Glossitis preventing its elevation which may prevent the development of required intraoral pressure gradient Conditions include 1) Iron deficiency anaemia Leading to glossitis & may be associated with candidial infection. 2) Pernicious anaemia Glossitis may be first sign 3) Other conditions include, apthous stomatitis, bechets syndrome & lichen planus. - Pharyngeal dysphagias - With a palatal cleft, paresis of soft palate or nasopharngeal carcinoma, closure of nasoparynx may not occur satisfactorily & liquid, food may pass into nasal cavity. - After palatal clefts tumors responsible for majority of pharyngeal dysphagias. - Esophagial dysphagias: - Hysterical spasm of cricopharngeous or emotional esophageal dysphagias may accompany emotional stress. Eg. Students undergoing oral examinations/ viva. - Salivary flow is reduced due to stress leading to dry mouth & cricopharngeal muscle spasm as well. - Speaking & swallowing become difficult.

Frequency of swallowing: - The average individual swallows about once a minute between meals & 9 times a minute. - Even during sleep swallowing act is performed at infrequent intervals. - Over 24 hours period, swallowing occur as many as 1000 times. Suckling: - Newborn & infants feed by a process called suckling in which the intakes consists of fluids. - Suckling is complex process involving development of negative pressure or suction in oral cavity combined with jaw movement to express milk from the nipple. - Can ber elicited in human fetus at 20 weeks in utero although full swallowing & suckling begin only after approx 32-36 weeks. - Indication of their responsiveness & vigour & neurological maturation. Divided in 2 phases 1. Lowering of jaw with forward & downward displacement of body of tongue. 2. Elevation of jaw upward & Backward displacement of tongue. Infantile swallow (visceral swallow) Moyers lists characteristic of infantile swallow as follows: The jaws are apart i.e. tongue placed between gum pads. The mandible is stabilized primarily by contraction of muscles of VII cranial nerve & interposed tongue. This swallow is guided & to a great extent controlled by sensory interchange between the lips & the tongue. Mechanism Gum pads not in contact during the act of swallowing. . Plunger like action is associated with nursing. Cheek pads flow between posterior gum pads during nursing, unopposed by the peripheral portion of tongue. Associated with tongue thrust is the anterior positioning of mandible. Condyles may be felt gliding rhythmically forward & backward in the nursing

act. Concave midline contour of dorsum. Parsed lips due to perioral sphincter action. Transitional period: With the change of semisolid & solid food & the eruption of teeth there Transitional period: is also a modification of the swallowing act. The tongue no longer is forced into the space between gum pads or incisal surfaces of teeth which contact momentarily during swallowing. Diminishing of buccinators activity & appearing contractions of definition mandibular elevators during swallow. The change to adult swallow pattern occurs gradually which is called as transitional period. Conditioning Factors Neuromuscular maturation Change in head posture Gravitational effect on mandible This transitional period is of 6 to 12 months. Mature swallow (somatic swallow) : Seen after 18 months of age Mature swallow characteristics listed by moyers are readily observable. 1. Teeth are together 2. The mandible is stabilized by contractions of mandibular elevators, which are primarily v th cranial nerve muscles. 3. The tongue tip is held against the palate above & behind incisors. 4. There are minimal; contractions of lips. 5. There are minimal contractions of lips. Mechanism - Dorsum is less concave & approx the palate during deglutition. - Tip of tongue is contained behind incisors periphery flow between apposing posterior segments. - Anterior mandibular thrust has disappeared

Abnormal swallowing: Tongue thrust Definition Profit defined tongue thrust swallowing as placement of tongue tip forward between incisors during swallowing. PROFFIT and MASON (1975) Tongue thrusting is one or a combination of 3 conditions: Forward placement of tongue during swallowing so that the tip of the tongue contacts the lower lip. Inappropriate placement of the tongue between or against the anterior dentition during speech. Forward positioning of the tongue at rest so that the lip is against or between the anterior teeth Norton & Gellin. A condition in which the tongue protrudes between anterior & posterior teeth during swallowing with or without affecting tooth position SUBTENLEY and SUBTELNY (1962) Tongue thrust pattern of swallowing, is marked by: a) Contraction of circumoral musculature b) Separation of maxillary and mandibular posterior teeth. c) Protrusion of tongue between incisors

Etiology Fletcher (1975) 1. Genetic factors : They are specific anatomic or neuromuscular variations in orofacial regions that can participate in tongue thrust. 2. Learned behavior (Habit): Improper bottle feeding prolong thumb sucking prolonged tonsillar & upper

respiratory tract infections, prolonged duration of tenderness of gums & teeth result in change in swallowing pattern to avoid pressure or tender zone. 3. Maturational factors: Late maturation from infantile pattern of swallow. Late maturation from immature pattern of general oral behavior. 4. Mechanical restrictions: Macroglossia Enlarged tonsils & adenoids 5. Neurological disturbances: Hypersensitive palate precipitate crude pattern of manipulation & swallowing. Disruption in tactile sensory control & coordination of swallowing. Moderate motor disability & loss of preceision in oral function. 6. Psychological factors Substitution of tongue thrust for forcibly discontinued thumb sucking. Exaggerated motor image of tongue. Modern view: Tongue thrust is seen in 2 circumstances 1. Younger children with reasonably normal occlusion: it is a transitional stage in normal physiologic maturation. 2. Individual of any age with displaced incisors : as an adaptation for overket & overbite. Simple tongue thrust swallow: Definition: It is defined as tongue thrust with teeth together swallow - Displays contractions of lips, mentalis & mandibular elevators. - Teeth are in occlusion as tongue protrudes into open bite teeth together swallow with thrust. - History of digit sucking adaptive mechanism to maintain open bite created by thumb sucking. - Well circumscribed open bite. - Also found with hypertrophy of tonsils which are enlarged enough to prompt a tooth apart swallow. - Precise secure interception reinforced by simple tongue thrust swallowing.

- Diminishes with age . - Treatment is simple, prognosis is certain.

Complex Tongue Thrust: - Definition: tongue thrust with a teeth apart swallow - combined contractions of lips facial & mentalis muscles. - Lack of contractions of mandibular elevators. - Teeth appear swallowing. - H/O breathing or chronic nasorespriratory diseases & allergies. - More diffuse open bite. - Seen in cases where tonsils are so inflamed to cause tooth apart swallow. - Poor occlusion fit & intercuspation(distinguishing feature) - Dose not diminished with age. - Poor prognosis. - Generalized anterior open bite (distinguishing factors) Retained infantile swallow: - Definition : undue persistance of infantile swallow well post clinical features the normal time for this departure massive grimace. - Anterior & lateral thrusting. - Inexpressive face due to use of facial muscles for swallowing. - Difficulty in mastication since they only occlude on one molar each quadrant. - Low gag threshold. - Poor prognosis.

- Usually associated with craniofacial developmental syndromes & neural deficit. - Excessive anterior face height. Management - Habit interception - Since tongue thrust is age related management involve habit interception followed by treatment of malocclusion. - 3-11 years - Normal occurrence. Not to be concerned, reassure parents. - If under 7 years there is no need to be concern since speech sound that elicits a lisp are not matured until 7-8 years. - Both fixed and removable cribs or rakes are valuable acids in breaking habit. - Child tongue to correct method of swallowing. - Muscle exercises of tongue to adopt to a new swallowing pattern. - 11 years or older not a normal pattern. Methods of examination of tongue thrust - Electro-myography - Tongue pressure changes intraorally - Roentgeno-cephalometric analysis - Cineradiography - Palatography

Electromyography: Moyers investigated functional movements of the orofacial musculature using the electromyograph. Since then, Tulley,Marx and many others have contributed. Although the labial musculature can be studied in this way, and an important contribution has been made to our understanding of lip posture, it is quite impossible to study the tongue musculature by electromyography.

Measurement of intraoral pressures: With the introduction of small transducers, intraoral pressures can be measured more accurately than with other methods previously described. Winders21 was probably the first in this field, and he has been followed by many other investigators who have confirmed that the tongue is probably more important than the surrounding musculature in its effect. Lear and Luffingham23 showed that the speed and intensity of the rapid movements of the tongue in speech and swallowing were probably not so significant as the resting posture, which will be seen to confirm many clinical observations.

Cinefluoroscopy: Ardran and Kemp, Cleall, Tulley and others have shown that this technique has limitations in terms of speed and is only two dimensional. It does not lend itself to serial studies because, although the dosage is small using image intensifiers, it is difficult to persuade patients that it is clinically necessary.

Cephalometric head films: Peat and others have shown the possible differences between the relaxed and habitual postures of the tongue and this, in turn, has made some contribution to our knowledge. However, this technique is subject to variation.

Neurophysiologic experiments: Bosma and his co-workers, Grossman,Berry,and Fawcus, have carried out various neurologic tests on the behavior of the tongue. So far, the use of stereognostic tests has indicated very considerable individual differences in lingual sensorimotor factors, and I am sure that this work will continue. Serial cinephotography: This is difficult to analyze scientifically, but it does highlight the individual variations. Although cinephotography cannot display the intraoral movements of the tongue, work by Whillis and other film studies carried out by the Veterans Organization have shown tongue movements through surgical defects in the face. This longitudinal approach has proved to be of great value, as will be seen later.

Muscle activity during swallowing in cleft patients The electromyographic activity of the thyrohyoid muscle (TH), the geniohyoid muscle (GH), and the myohyoid muscle (MH) of patients with CLP when compared with noncleft subjects during swallowing and drinking water with and without artificial nasal obstruction. In the normal situation without nasal obstruction, a significant difference in muscle activity between the two groups was found only for TH. In normal subjects, the duration and magnitude of muscle activity were significantly larger in all the muscles when a nasal obstruction was applied. Meanwhile, in the CLP patients these values exhibited a significant increase in GH and MH only. With nasal obstruction, the burst durations of GH and MH are significantly longer in the normal cases than in the CLP patients.This suggest that in CLP patients during swallowing, TH working from the pharyngeal stage compensates for the weakness of GH and MH working in the oral phase. This may cause a premature transfer of the bolus to the pharynx before making it properly into the oral cavity. The influence of maximum perioral and tongue force on the incisor teeth Pressure the lips influence the position of the incisors along with the antagonistic of tongue. Posen used pomometer to measure the muscular activity of the lips.

 Perioral muscle force increases with age Perioral force is considered to be maximum in class II DIV 2 subjects A Significant relation exists between maximum strength and force of the lips and final angulation of the incisors Peri-oral musculature is classified based on their tonicity as 8-9 yrs patients 90-120 gm hypotonic 120- 150 - normal 150 -180 hypertonic

REFERENCES: 1) Text book of physiology Gyton 2) Human Anatomy Chaurasia 3) Patterns of deglutition A.J Wildman et al AO oct 1964 4) Muscle contraction patterns in swallowing AO VOL 42 5) Malocclusions, orthodontic corrections and orofacial muscle adapatations vol 40 no 3 6) deleterious effects of oral habits Ind. J. dent sciences 2009 7) A Cineradiographic Study of Deglutitive Tongue Movement and Nasopharyngeal Closure in Patients with Anterior Open Bite - Angle Orthod 2000;70: 8)Pressure from the lips on the teeth and malocclusion : Urs Ther, and Bengt Ingerva - AJO 1986 Sept 9) AJO-DO, Volume 1969 Jun (94 - 104): A critical appraisal of tongue thrusting - Tulley 10) AJO-DO, Volume 1963 Jun (418 - 450): The "three M's": Muscles, malformation, and malocclusion - T. M. GRABER 11) Alderisio, J. P., and Lahr, Roy: An Electronic Technique for Recording the Hypodynamic Forces of Lip, Cheek, and Tongue, J. D. Res. 32: 548-553, 1953 12) Baker, R. E.: Tongue and Dental Function, AM. J. ORTHOD 40 : 927-939, 1954.