DEPARTMENT OF ORTHODONTICS

AND DENTOFACIAL ORTHOPEDICS

 INTRODUCTION
Deglutition involves co-ordinated activity of muscles of oral cavity,
pharynx, larynx & esophagus

The whole process is partly under voluntary control & partly

reflexive in nature

Voluntary control of deglutition involves control of jaw, tongue, degree

of constriction & length of pharynx

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DEFINITION
Complex series of voluntary and involuntary neuromuscular
contractions proceeding from the mouth to the stomach & is
commonly divided into oropharyngeal & esophageal
stages.
 COMPONENTS OF
DEGLUTITION
Deglution has 3 components

Passage of bolus from oral cavity to stomach

Protection of airway

Inhibition of air entry into the stomach

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THEORIES
OF
DEGLUTITI
ON
THEORY OF CONSTANT
PROPORTION
Describes passage of bolus through upper GIT in three phases

 ORAL PHASE : voluntary control

 PHARYNGEAL PHASE : pharynx is activated to propel the bolus

 ESOPHAGEAL PHASE : by esophageal contraction

THEORY OF ORAL
EXPULSION
This theory states that “the oral expulsion arising from contraction
of tongue & Mylohyoid throws bolus into the stomach”
 THEORY OF NEGATIVE
PRESSURE
According to this theory :
“the tongue is brought forward to create a negative pressure
which is accentuated by the descent of the larynx & therefore the
food
is sucked into the esophagus.”
 THEORY OF INTEGRAL
FUNCTION
This theory is based on myometric & electromyographic studies &
considers the act of swallowing as a total dynamic process.

• It is the most accepted theory.

DEGLUTITION -
PHASES
ORAL

PHARYNGEAL

ESOPHAGEAL

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 ORAL
PHASE
Tongue plays a vital role
Food is prepared for swallowing
Divided into Oral preparatory phase & Oral phase proper

Under voluntary control

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 MASTICATION OR
CHEWING
CHEWING is a program of mandibular movements patterned in a
sequence of distinctive recurring cycles.

Co-ordination of chewing process matures at about 4 years of age

after the deciduous dentition has fully erupted
MASTICATORY CYCLE : 1st MOVEMENT
THE OPENING MOVEMENT :
• Mandible is lowered mainly by gravity

• Contraction of anterior belly of Digastric

• Jaw is prevented from dropping by gradual relaxation of Temporalis

& Masseter

• Usually deviates to the non–working side

 MASTICATORY CYCLE : 2nd MOVEMENT
THE CLOSING MOVEMENT
• Mandible is rapidly raised until trapped food is felt

• It swings swiftly & rather widely to the working side

• Contraction of Masseter & medial pterygoid muscles

• Teeth are brought into initial contact with the food

THE POWER STROKE :
• The food is compressed, punctured, crushed & sheared

• The teeth meet in lateral occlusion & then slide into

centric relation

• There is further contraction of Masseter & Temporalis

 MUSCLES
ASSOCIATED
WITH
SWALLOWING
The muscles that play an important role in the process of swallowing
includes :

• MUSCLES OF THE TONGUE

• THE MUSCLES OF THE SOFT PALATE : during swallowing it

separates nasopharynx from oropharynx.

• THE MUSCLES OF PHARYNX : which helps in passage of bolus

to the stomach.
 MUSCLES OF THE TONGUE
Narrows oropharyngeal isthmus. shortens the tongue & makes the dorsum
Retracts & elevates the posterior third of the concave.
tongue.
broadens & flattens the tongue.
.
Makes dorsum convex

Protrude the tongue.

narrows & elongates the tongue

shortens the tongue & makes the dorsum

convex
APPLIED
ANATOMY
• Injury to hypoglossal nerve produces paralysis of the muscles of
the tongue on the side of lesion

• In cases of acute glossitis tongue fills the oral cavity & protrudes
out of it causing difficulty in mastication

• In unconscious patients tongue may fall back & obstruct the air
passage. This can be prevented by lying the patient in semi
reclined position with head down.
 SOFT PALATE
Movable, muscular fold suspended from posterior border of hard palate.

It is composed of :
•Mucous membrane
•Palatine aponeurosis
(forms fibrous basis)
•Muscles
MUSCLES OF THE SOFT PALATE
 ORAL PREPARATORY PHASE
Involves breaking down of food in the oral cavity

Food is chewed & mixed with saliva making it into a bolus which
can be swallowed

The elevators of lower jaw play an important role in bolus

preparation

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Tongue –helps in bolus formation by the action of its intrinsic muscles
which alters its shape. Its extrinsic muscles changes its position within
the oral cavity thereby helping in chewing the food by dental
occlusion

Occlusal action of the lips - seal & prevent the bolus from dribbling
out of the oral cavity

Buccinator muscle – Push the bolus out of the vestibule into the oral
cavity proper
 ORAL PREPARATORY PHASE
(CONTD)
SALIVARY GLANDS:
Salivary glands -ducts – saliva- mouth

Saliva contains:
 Mucin- holds food together.
 Salivary amylase- starts
digesting carbohydrates.
 Bicarbonates-maintain PH level of
saliva & protect teeth.
 Lysozymes-inhibits bacterial
growth.

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 BOLUS FORMATION
Most important function of preparatory
phase

This involves repeated transfer of

food from oral cavity to
oropharyngeal surface of tongue

Bolus accumulates on the

oropharyngeal surface of tongue due to
repeated cycles of upward & downward
movement of the tongue

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 ORAL PHASE
PROPER
The contraction of soft palate prevents nasal regurgitation
The bolus is moved towards the back of the tongue
The soft palate also prevents premature
movement of bolus into the oropharynx

Once the bolus is of suitable consistency,the transit

from mouth to oropharynx just takes a couple of
seconds

Tongue & the elevation of the mandible plays a vital

role
during this [Link] muscles of tongue contracts & reduces its
Whenwhile
size, the mandible is elevated
genioglossus muscletheelevates
suprahyoid muscles
the tongue raises the hyoid
towards 27
bone
palate.
 PHARYNX
• Wide muscular tube situated behind nose, mouth & larynx.

• Length = 12 cm.
• Width = 3.5 cm & narrows as it goes down.

Divided into
 MUSCLES OF PHARYNX
• STYLOPHARYNGEUS
elevates larynx during swallowing
• SALPINGOPHARYNGEUS
elevates larynx
• PALATOPHARYNGEUS

CONSTRICTORS
• SUPERIOR CONSTRICTOR
Aids soft palate in closing the nasopharynx,
propels bolus downwards
• MIDDLE CONSTRICTOR
propels bolus downwards
• INFERIOR CONSTRICTOR
propels bolus downwards & forms sphincter at lower end
(cricopharyngeus)
 PHARYNGEAL PHASE
(PUMPINGACTION OF TONGUE & HYPOPHARYNGEAL SUCTION)
Reflexive & involuntary in nature

It just takes a second for the bolus to traverse the pharynx & reach
the cricopharyngeal area

Contraction of diaphragm is inhibited making simultaneous breathing

& swallowing impossible

During this stage ,bolus from pharynx can enter into 4 paths:
1. Back to mouth
2. Upwards into nasopharynx
3. forwards into larynx
4. Downwards into esophagus 30
Back into mouth
Position of tongue
High intra oral pressure developed by the movement of tongue

Upwards into nasopharynx

Prevented by elevation of soft palate along with its extension
uvula

Forwards into larynx

Approximation of vocal cord
Forward & upward movement of laryx
Backward movement of epiglottis to seal the opening of the larynx
Temporary arrest of breathing
 FUNCTIONS OF TRIGGER POINTS IN
OROPHARYNX

Stimulation of trigger points - starts off at

the pharyngeal reflexive stage of
swallowing

Trigger points -present at the faucial

arches & mucosa of the posterior
pharyngeal wall

Trigger points are innervated by IXth

CN

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Stimulation of these trigger points causes dilatation of pharynx due
to
relaxation of the constrictors, &
elevation of pharynx & larynx due to contraction of
longitudinal muscles

The pharynx constricts behind the bolus thereby propelling it

Contraction of the inferior constrictor moves the bolus towards

the oesophagus.
 ESOPHAGEAL
This is STAGE
purely reflexive &
involuntary

This phase begins by relaxing

the cricopharyngeal
sphincter

The time taken for

esophageal
transit is 10-15 seconds

Primary / secondary / tertiary

peristaltic waves play active
roles in this phase 34
Means a wave of contraction followed by a wave of relaxation of
muscle fibres of GIT ,which travel in aboral directon(away from
mouth)
With this ,contents are propelled down along GIT
Weaker Waves

Controlled by deglutition centre

Starts when bolus reaches upper part of us

esophag Propels food towards the stomach

Initially negative pressure is created in the upper part of esophagus-

due to the stretching of closed esophagus by elevation of pharynx

But immediately pressure becomes positive

 Arise in esophagus locally due to the distention of upper
esophagus by the bolus

Produces a positive pressure

If primary peristaltic contractions are unable to propel the bolus into

the stomach,the secondary peristaltic contractions appear & push
the bolus into stomach
Eg :cheese

Controlled locally by myenteric plexus by releasing Acetyl Choline

Irregular, non propulsive contractions involving long segments which
occur during emotional stress
Distal 2-5cm of esophagus acts like a sphincter.

It is called lower esophageal sphincter

When bolus enters this part , the sphincter relaxes , so that the
content enter the stomach.

Later, the sphincter contracts

Relaxation & contraction of sphincter occurs in sequence with

the arrival of peristaltic contractions of esophagus
Beginning of swallowing

Initially -Voluntary act……….Later-involuntary act

Occurs through reflex action called deglutition reflex

NEURAL
CONTROL
Initiated when food comes in contact with certain trigger areas
like fauces, mucosa of posterior pharyngeal wall

Via Glossopharyngeal Nerve to brainstem

 Fourth ventricle in the medulla oblongate of brain

Travel through glossopharyngeal & vagus nerves(parasympathetic

motor fibers) & reach soft palate ,pharynx & esopahgus

Glossopharngeal nerve is concerned with pharyngeal stage

of swallowing .

Vagus nerve is concerned with esophageal stage

Reflex causes upward movement of soft
palate to close nasopharynx & upward
movement of larynx to close respiratory
passage so that bolus enters the
esophagus
PHASE OF RESPIRATION &
SWALLOWING
Swallowing occurs during expiratory phase of respiration

This helps in clearing food material left in the vestibule. Thus

it should be considered to be a protective phenomenon

The rhythm of respiration is reset after a successful swallow

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APPLIED
PHYSIOLOGY DEGLUTITION
DYSPHAGIA
APNEA
ODYNOPHAGIA
ASPIRATION
GLOBUS HYSTERICUS
CRICOPHARYNGEA
PHAGOPHAGIA L DYSFUNCTION

PRESBYDYSPHAGIA CHOKING

VOMITING ANTIPERISTALSI

S GAG REFLEX
 Difficulty in swallowing…….Coexist with heart burn & vomiting
Pathophysiology Of Dysphagia
Lack of coordination or strength of muscles Or Mechanical
obstruction

If contractions fail to develop progress ,bolus distends the

oesophageal lumen & causes discomfort

Low amplitude of 1O& 2O peristaltic activity is insufficient to clear

oesophagus as in elderly individuals

Mechanical narrowing of oesophageal lumen obstructs passage of

bolus despite adequate contractions

Abnormal sensory perception in oesophagus may cause sensation

Is highly integrated & complex reflex invloving both autonomic &
somatic neural pathways

Synchronous contraction of diaphragm ,intercoastal muscles &

abdominal muscles raises intra abdominal pressure & combined with
LES –forcible ejection of gastric contents

Imp to distinguish between vomiting & regurgitation

Associated symptoms: abdominal pain,fever,diarrhoea

 Arrest of breathing during deglutition.

Occurs reflexly during pharngeal stage.

When bolus is pushed into esophagus from pharynx during pharyngeal

stage,there is possibility for the bolus to enter the respiratory passage
through trachea...........which may cause choking

To prevent this,there is apnea along with approximation of vocal cords ,

forward & upward movement of larynx &
backward movement of epiglottis to close the larynx
Defined as the inhalation of oropharyngeal or gastric contents into
the larynx & lower respiratory tract

Aspiration Pneumonitis (Mendelson’s Syndrome) chemical

injury caused by the inhalation of sterile gastric contents
Aspiration Pneumonia is an infectious process caused by the inhalation
of oropharyngeal secretions that are colonized by pathogenic
bacteria.

Risk Factors For Oropharyngeal Aspiration

Elderly, neurologic dysphagia, GERD
Poor oral hygiene-colonization by respiratory tract pathogens
Silent aspiration is common in stroke.

Management :
Failure of the tonically contracted upper esophageal sphincter to relax
and open when one swallows.

Symptoms
pills or solid food begin to lodge at the level of the lower part of
the larynx.

Treatment
Resolved through surgical procedure Cricopharyngeal Myotomy
 Mechanical obstruction of the flow of air from the environment into
the lungs that prevents breathing
Prolonged choking-asphyxa-anoxia-fatal

Causes:
Foreign body,respiratory disease,compression of laryngopharynx

Signs & symptoms

Person cannot speak or cry, Violent cough
Difficult in breathing ,produce wheezing sounds, Clutches throat
If respiration not restored ,then cyanosis

Treatment
BLS & ALS
Heimlich maneuver
Wave of contraction in digestive tract that moves toward the oral
end of tract -regurgitation
 Characteristic changes in the swallowing mechanism of
otherwise healthy older adults.

AGE ASSOCIATED CHANGES

Demonstrate delay in onset of specific pharyngeal events
Swallowing is slow
Larger duration
Upper Esophageal Sphincter
opening is delayed
Chance of Aspiration-more
• Painful swallowing

• Sensation of a lump lodged in throat

• Fear of swallowing as in rabies, tetanus, pharyngeal paralysis due

to fear of aspiration
GAG REFLEX
Stimulation of sensitive areas of pharynx, soft palate, uvula, tongue
Stimulation of Trigeminal & Glossopharyngeal & Vagus nerves

Uncoordinated & spasmodic movements of swallowing muscles

Gagging
Causes
chemical irritants, toxic materials, specific drugs, severe pain,
mild stimulation of pharynx etc.
Treatment
• Removal of factors
• Local anesthetic may be used while working
• Drugs like atropine along with a sedative may be prescribed
• Acupressure
STUDY OF
SWALLOWING
Plain X-Ray
Barium swallow
CT & MRI
Videofluroscop
y
 PLAIN X-
RAY
X-RAY SOFT TISSUE NECK
Lateral view &AP view
LATERAL VIEW(taken in full inspiration with neck extention)
Examine patency of airway
Examine soft tissues of neck
Examine the cervical
vertebra Foreign body

AP VIEW
For glottic & subglottic areas

CHEST X-RAY
PA View
Lateral View
Prevertebral
abscess
 BARIUM SWALLOW
PROCEDURE
Patient is given liquid barium(Barium suphate)to swallow while bolus
is followed fluroscopically.

Look for-Filling defect , Obliterative lesions , Extrinsic compression

ADVANTAGES:
 Inert,Suspendable in water
 Very minimal absorption in GIT

DISADVANTAGES:
Outside the lumen of GIT acts as foreign body
Contrast leak in mediastinum leads to inflammatory reaction
 Diffuse Esophageal Esophagea
AchalasiaCardia Spasm l
Carcinoma
 AIR CONTRAST
OESOPHAGRAM
Performed like barium swallow but with addition of effervescent
granules to barium

Advantages:
Better anatomical details especially edge contra st
Disadvantages:
Irradiation
Documented on plain film

Normal
Fungal
Plagues
 VIDEOFLUOROSCOPY
Definition
Dynamic fluoroscopic imaging procedure that enables visualization
of rapid & integrated movements involved in all phases of
deglutition
Equipment
 X-Ray screening facility
 Digital/video recorder with microphone & timer
CT &
MRI
CT used to stage the disease in malignant

MRI used to detect intracranial lesions and vascular abnormalities

DISADVANTAGES
Expensive
Patient has to be in supine which does not reflect stages of
swallowing
SPECIAL
TECHNIQUES
Manometry

Manofluroscopy

Direct pharyngoscopy

Endoscopy

Bolus scintigraphy

24 hr oesophageal ph
monitoring
 MANOMETR
Y
Definition
Technique used to measure intraluminal pressure & coordination of
pressures in 3 regions
 Lower esophageal sphinchter(LES)
 Oesophageal body
 Upper esophageal sphinchter(UES)

To assess oesophageal peristalsis & oesophageal motor

dysfunction
MANOFLUROSCOPY
Similar to videofluroscopy & manometry

Advantages
Combines pressure & bolus information simultaneously

Disadvantages
Not widely used
Costly
DIRECT
PHARYNGOSCOPY
Done under general anaesthesia

Used to visualize the pharynx & upper oesophagus

To take biopsy and staging tumors of pharynx & upper

oesophagus

To examine postcricoid area

 Endoscopy /
Fibreoptic Endoscopic Evaluation Of Swallowing
( FEES
Done in acute stages of dysphagia,Persistent dysphagia )
Assesment of pharyngeal and laryngeal anatomy and physiology with
normal food and drink

Procedure
Patient sits upright,nose examined for any septal deviation
Decongestants & lubrication of nasal passages along with
topical anaesthesia
Scope passed between inferior turbinate & floor of nose
Examine nasopharynx for nasal reflux, oropharynx and
BOLUS
SCINTIGRAPHY
Short lived isoptope mixed with single swallow bolus
Gamma camera registers the radiation
Bolus transit & aspiration assessed

Advantages
 Aspiration assessed

Disadvantages
 Oropharyngeal anatomy not assessed
 Cannot perform multiple swallows
 Technical expertise needed
ULTRASOUN
D Submental transducers used to image
Structures
Mobility of bolus transit
Vallecular status
Advantages
Avoids irradiation
Normal food used(no barium)
Disadvantages
 Cannot be used to visualize larynx & pharynx due to
skeletal interference
Not effective for esophageal phase
 OESOPHAGEAL PH
MONITORING
24hrs ambulatory Ph monitoring –reliable for GERD
Procedure
 Proximal probe placed below UES
 Distal probe placed 5cm above LES(position detected
by manometry)
 Reflux measured along entire length of esophagus

Disadvantage
 Invasive
 Provokes relux