Deglutitionfinal

DEGLUTITION
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CONTENTS
 Introduction
 Organs involved in deglutition
 Physiology of deglutition
 Techniques for studying deglutition
 Disorders of deglutition
 Clinical considerations in orthodontia
 Facts about deglutition
 Conclusion
 References

INTRODUCTION

Deglutition = Swallowing
Definition:
Deglutition is the complex process that moves bolus of
food from mouth through pharynx into esophagus and
then to stomach

ORGANS INVOLVED IN
DEGLUTITION

ORGANS INVOLVED IN DEGLUTITION
Oral cavity

palate

tongue

pharynx

larynx

Mandible and related musculature

PHYSIOLOGY OF
DEGLUTITION

PHYSIOLOGY OF DEGLUTITION
 Deglutiton is a
continuous process
from oral cavity to
Stomach
 Divided into 3
stages
1.Oral stage
2.Pharyngeal stage
3.Esophageal stage

ORAL STAGE
 Voluntary Stage
 Bolus placed over postero-dorsal surface of tongue
– preparatory position
 Initially anterior part of tongue raised and rests
against hard palate
 Later posterior part elevated
 Positive pressure in posterior part of oral cavity

PHARYNGEAL STAGE
 Involuntary stage
 Bolus can enter in 4 ways from pharynx:
1. Back into mouth
2. Upwards into nasopharynx
3. Forwards into larynx
4. Downwards into esophagus

PHARYNGEAL STAGE
1. Back into mouth
 Prevented by:
• Posterior position of
tongue
• High intraoral pressure

PHARYNGEAL STAGE
2. Upwards into nasopharynx
 Prevented by elevation of soft palate

PHARYNGEAL STAGE
3. Forwards into larynx
 Prevented by:
• Approximation of
vocal cords
• Forward and upward
movement of larynx

PHARYNGEAL STAGE
• Backward movement
of epiglottis
• Deglutition apnea

PHARYNGEAL STAGE
4. Entrance of bolus into esophagus
 Upward movement of larynx
 Relaxation of cricopharyngeal sphincter
 Peristaltic contractions
 Gravity and contractions of superior and middle
constrictors

PHARYNGEAL STAGE
 The pharyngeal stage of swallowing is
principally a reflex act. It is almost always
initiated by voluntary movement of food-
DEGLUTITION REFLEX

PHARYNGEAL STAGE
Nervous control of the pharyngeal stage
of deglutition:
 Sensitive tactile areas- tonsillar pillars
 Impulses transmitted through trigeminal and
glossopharyngeal nerves
 Deglutition / swallowing center- medulla oblongata
and lower pons
 Motor impulses- 5th , 9th , 10th , 12th cranial nerves

PHARYNGEAL STAGE

PHARYNGEAL STAGE
Effect of the pharyngeal stage of
swallowing on respiration:
Entire pharyngeal stage occurs in less than 2
seconds.
The swallowing center inhibits the respiratory
center of the medulla during this time, halting
respiration at any point in its cycle to allow
swallowing to proceed- DEGLUTITION APNEA

ESOPHAGEAL STAGE
 Involuntary stage
 Transport of food from lower part of pharynx to
stomach through peristaltic waves.

ESOPHAGEAL STAGE
PERISTALSIS:
A wave like progression of alternate contraction and
relaxation of muscle fibers of gastrointestinal tract.
By this type of movement, the contents are
propelled along the gastrointestinal tract.

ESOPHAGEAL STAGE
Two types of peristaltic waves:
1. Primary peristaltic contractions
2. Secondary peristaltic contractions

ESOPHAGEAL STAGE
Receptive relaxation of the stomach-
 Wave of relaxation transmitted through the
peristalsis.
 Stomach relaxes

ESOPHAGEAL STAGE
Role of lower esophageal sphincter:
 At lower end of esophagus, esophageal circular
muscle functions as a lower esophageal sphincter
 Normally constricted- intraluminal pressure of
30mm Hg
 Peristaltic wave – “receptive relaxation” of lower
esophageal sphincter.
 Failure of relaxation- ACHALASIA

 Fletcher: deglutition into 4 phases
 Preparatory phase

 Gwynne-Evans, Ballard, Bjork- deglutition cycle – 4
phases
 Tongue position important
 Stage1 :
 Anterior part of tongue flat
 Posterior arched, contacts soft palate
 Swallowing cannot take place

 Stage 2:
 Tongue tip moves up, dorsum drops
 Slight contractions of lip, teeth contact and mandible
raised
 Symptoms of tongue thrust observed during this stage

 Stage 3
 Posterior part of tongue drops more
 Soft palate displaced up and rearward
 Tongue thrust- tip narrowed to maintain lip seal

 Stage 4
 Dorsum of tongue moves posteriorly and superiorly
 Pushes against soft palate- squeezing put residual food

Swallowing complete

TECHNIQUES FOR STUDYING
DEGLUTITION

TECHNIQUES FOR STUDYING DEGLUTITION
 Imaging methods:
• Ultrasound
• Videoendoscopy
• Videofluoroscopy
 Non-imaging methods
• Electromyography
• Auscultation
• Pharyngeal manometry

 Videofluoroscopy:
 Most frequently used method.
 Barium swallow
 Visualization of the movement of the oral cavity
structures, larynx, hyoid, tongue base,
pharyngeal walls and cricopharyngeal region,
along with monitoring the bolus position.
 Images recorded on a videotape.

videofluoroscopy

Videoendoscopy
 Cannot visualize the events happening in
the pharyngeal swallow.
 Investigation of anatomy of oral cavity, pharynx and
esophagus.

DISORDERS OF DEGLUTITION

1. Dysphagia:
 Difficulty in swallowing
 Types:
I. Oropharyngeal dysphagia
II. Esophageal dysphagia

 Investigations:
i. Endoscopy
ii. Barium swallow (videofluoroscopy)

 Management:
 Endoscopic
 Surgical

Odynophagia:
 Burning sensation during swallowing

2. ACHALASIA:
 Hypertrophic lower esophageal sphincter which
fails to relax
 Uncommon- 1 : 100 000 people
 Dysphagia - worse for solids, eased by drinking
liquids

 Investigations:
i. Chest X-ray
ii. Barium swallow

 Management:
i. Endoscopic
ii. Surgical

4. Paralysis of swallowing mechanism
 Damage to 5th , 9th , 10th nerves
 Poliomyelitis, Muscle dystrophy, Myasthenia
gravis
 Following abnormalities can occur:
i. Complete abrogation of swallowing
ii. Passage of food into lungs
iii. Passage of food into posterior nares

DISORDERS OF DELGUTITION
5. Patients under deep anesthesia
 Deglutition reflex mechanism blocked
 Suck vomitus into trachea- may cause death

 Deglutition syncope:
• Definition:- a transient alteration or loss of
consciousness during swallowing.
• Local change in esophagus enhanced
sensitivity of nervous receptors vasovagal
reflex

CLINICAL CONSIDERATIONS IN
ORTHODONTIA

CLINICAL CONSIDERATIONS IN ORTHODONTIA
TYPES OF SWALLOW: (Moyers)
1. Normal infantile swallow
2. Normal mature swallow
3. Simple tongue-thrust swallow
4. Complex tongue-thrust swallow
5. Retained infantile swallow

Infantile swallow

Infantile (visceral)
swallow
Characteristics: (Moyers)
•Jaws apart, tongue
interposed between gum
pads
•Mandible stabilized by
facial muscles
•Swallow guided by
sensory exchange
between lips and tongue

 Strong buccinator muscle
 Disappears with eruption of teeth

 Transitional swallow:
• 6-18 months
• Diminishing buccinator activity
• Appearance of contractions of mandibular
elevators

Mature swallow

Mature (somatic) swallow
 Appears by 18 months
of age
Characteristics:
(Moyers)
•Teeth together
•Mandible stabilized
by contractions of
mandibular elevators
•Tongue tip against
palate, above and
behind the incisors
•Minimal contractions

Simple tongue thrust swallow:
 Contractions of lips, mentalis and mandibular
elevators
 Normal teeth-together swallow, but a “tongue-
thrust” is present to seal the open bite
 “tongue-thrust” an adaptive mechanism
 Open bite well- circumscribed

Complex tongue thrust swallow:
 Tongue thrust with teeth-apart swallow
 Contractions of facial and mentalis muscle, Lack of
contraction of mandibular elevators
 Open bite diffuse
 Instability of intercuspation and occlusal
interferences

Retained infantile swallow
 Definition: predominant persistence of the
infantile swallowing reflex after the arrival of
permanent teeth
 Tongue thrusts strongly between the teeth in
front and on both sides.
 Strong contractions of buccinator
 Occlude on only one molar in each quadrant

 Inexpressive face
 Mastication occurs between tongue tip and
palate

METHODS OF EXAMINATION

 Observe, unnoticed, several unconscious
swallows
 Patient asked to swallow water- mandibular
movements noticed

 Palpation of temporalis
muscle

 Tongue depressor or mouth mirror placed on the
lower lip and patient asked to swallow

SOME INTERESTING FACTS

 We swallow 1,200 – 3,000 times in a day.
 Maximum swallowing does not occur during meals.
 During waking hours we swallow about 2 times /
minute
 During sleep we swallow about 1 time in a minute

 “Belching” is caused by swallowing air during
eating and drinking.
 The sound of burping is caused due to vibration of
the upper esophageal sphincter

 In birds, the esophagus is largely merely a gravity
chute, swallowing consists largely of the bird lifting
its head with its beak pointing up and guiding the
prey with tongue and jaws so that the prey slides
inside and down.

 In fish, the tongue is largely bony and much less
mobile and getting the food to the back of the
pharynx is helped by pumping water in its mouth
and out of its gills.
 In snakes, the work of swallowing is done by raking
with the lower jaw until the prey is far enough back
to be helped down by body undulations.

CONCLUSION

 Deglutition is generally safest when the
person is sitting straight, with head upright or
slightly forward
 Must be awake and alert
 Must not talk while eating
 Always make sure that one mouthful has
gone before offering the next

REFERENCES

 Textbook of medical physiology-
Guyton and Hall, 11th edition
 Essentials of medical physiology-
K. Sembulingam, 2nd edition
 Davidson’s principles and practice of medicine-
20th edition
 Review of medical physiology-
William F. ganong, 19th edition
 Graber’s textbook of orthodontics- basic principles
and practice- 4th edition

 Handbook Of Orthodontics- Robert E. Moyers, 4th
Edition
 Contemporary Orthodontics- sWilliam R. Proffit, 4th
Edition
 Dentofacial Orthopedics With Functional
Appliances – Thomas M. Graber, Thomas Rakosi,
Alexandre G. Petrovic, 2nd Edition
 Color Atlas Of Dental Medicine- Thomas Rakosi,
Irmtrud Jonas And Thomas M. Graber

Articles Referred
 The “ Three M’s”: Muscles, Malformation And
Malocclusion- T.M. Graber, AJODO, June 1963
 Clinical and instrumental functional analysis for
Diagnosis and Treatment Planning: part 3- clinical
functional analysis- JCO 1988; August
 Swallowing patterns in patients with and without
Temporomandibuar dysfunction-
AJODO 1990; 98: 507-11
 Effects of form and function on swallowing and the
developing dentition- AJODO 1973; 69:63-82
 Deglutition syncope- Br. Med J 1975 Sept 27; 3
(5986)
 Adverse muscle forces- their diagnostic significance-

THANK YOU

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