Mastication, Deglutition & Dysphagia PDF

Mas$ca$on, Deglu$$on & Dysphagia Oral and Dental Science Miss Felix GDC Learning Outcomes 1.1.5 Describe relevant and appropriate dental, oral, craniofacial and general anatomy and explain their applica;on to pa;ent management 1.1.6 Describe relevant and appropriate physiology and explain...

Mas$ca$on, Deglu$$on & Dysphagia Oral and Dental Science Miss Felix GDC Learning Outcomes 1.1.5 Describe relevant and appropriate dental, oral, craniofacial and general anatomy and explain their applica;on to pa;ent management 1.1.6 Describe relevant and appropriate physiology and explain its applica;on to pa;ent management Related topics:  Muscles of mas;ca;on  Tongue  Saliva & Saliva;on  Palate  Xerostomia  Regional anatomy Intended Learning Outcomes By the end of this lecture you should be able to: 1. Describe the processes of mas;ca;on and deglu;;on, in both health and disease 2. Outline the structures involved in both processes 3. Outline the disorders that may aJect the normal process of deglu;;on 4. Outline considera;ons in the dental management of pa;ents with dysphagia Mas$ca$on What do you understand by the term ‘mas$ca$on’? Chewing food and Preparing food ready for swallowing Why is it important? To ensure the ingested food is broken down into pieces and prepared for digestion. What role do these structures play in this process? Muscles of Teeth Tongue Lips mas$ca$on Tear/rip/ grind Intrinsic muscles move tongue Keeps food where it needs to be Keep mouth closed and Food down physically and move food ready for and move mandible to aid in food in place for chewing. swallowing chewing. If a pa;ent is limited by one or more of these structures, how might this impact on their ability to eat? Mas$catory Cycle Occurs in 3 phases: Opening Phase Isotonic contraction of the depressor muscles of jaw. Opening of the mouth Closing Phase Elevator muscles cause the action to close the mouth. Occlusal Phase Contact of mandibular and maxilla teeth produced by isometric muscles contractions.  Food is broken down by the teeth and the diges;ve process begins Which enzyme is present in saliva to start the diges$ve process? Amylase Mixing with saliva, the food is formed into a bolus ready for swallowing The length of ;me that food stays in the mouth is greatly dependent on the consistency of the food Deglu$$on [The normal swallow] Deglu$$on (the normal swallow) The ac$on of swallowing It takes about 7 seconds for the bolus to go from the oral cavity into the stomach Simultaneously, the openings between the oropharynx & nasopharynx and between the laryngopharynx & larynx are closed Two types of swallow: Automa;c swallow (dry swallow) Voluntarily ini;ated swallow (food and drink) The co-ordina;on of the components of swallowing is considered to be the func;on of a swallow centre situa;on in the medulla (brain stem) Swallowing is a reYex ini;ated by the s;mula;on of tac;le receptors in the area of the oropharynx AJerent impulses travel through the trigeminal and glossopharyngeal nerves to the swallow centre Here they ini;ate motor s;muli and accessory nerves to the so[ palate and pharynx to start rising so as to close oJ the nose and pharynx  Approx 25 different skeletal muscles of the pharynx, larynx, and upper oesophagus, and smooth muscles of the lower oesophagus Swallowing begins The inhibition of breathing The arousal of appetite, increased saliva flow, thought and smell of food, the taste buds responding to solid food, the sensation of food on the tongue- these are all involved in this complex component of swallowing Similarly a loss of appetite can lead to dysphagia (difficulty swallowing) This involves: 25 skeletal muscles Mul;ple components working together: Arousal of Food Saliva flow appetite stimulates Taste buds Sensation on the tongue Swallowing Structures  Structures involved in swallowing Lips Closure of the mouth and lips is necessary to create intra-oral pressure Tongue Forms bolus of food and channels it down a groove made in the tongue and propels the bolus towards the fauces SoP palate Rises to block oJ the nasopharynx Hyoid bone A horseshoe shaped bony arch It supports the tongue and gives During swallowing the larynx is suspended from the ;p of the a\achment to its numerous elevated by contrac;on of the styloid process of the temporal muscles hyoid musculature bone by stylohyoid ligaments EpigloSs Is lowered by the moving bolus to help protect the airway Vocal cords Close Cricoid car$lage (cricopharyngeal sphincter) Relaxes to allow food to enter the oesophagus Phases of Swallowing 1. Ninja Nerd Lectures- this video gives a good level of detail about each of the swallowing stages without being overwhelming incorpora;ng the use of great diagrams. Would recommend watching before con;nuing! It also incorporates other regional anatomy such as: Muscles of Muscles of Nerve the tongue mastication innervations 2. This video by Sam Webster is a good one to follow on from a[er the one above as he uses anatomical models in his explana;on which helps give a 3D perspec;ve. He also takes a look at the gag reVex. Swallowing occurs in three phases Swallowing occurs in three phases: 1. Oral phase 3. 2. Pharyneal (inc execu;ve Oesophageal phase phase) phase It is ini;ated voluntarily and then completed by an involuntary (reYex) ac;on. Where do you think the process moves from voluntary in involuntary? Oral Phase (feeding stage) Lips are closed & the bolus is Nasal breathing prepared con;nues, the (mas;ca;on and larynx is open and drenching in saliva the hypopharyngeal shapes the bolus) sphincter is closed Voluntary- can be It is kept to the So[ palate is stopped at will front of the mouth lowered away from the discouraging food nasopharynx area from the nasopharynx Oral Phase (execu$ve phase) The bolus is propelled backwards along tongue. When it arrives on the base of the From now on the subsequent tongue it is projected past the pillars of 01 the fauces into the pharynx. The fauces contract and the swallow reYex is ac;vity is controlled by reYex and cannot be interrupted 04 ac;vated (ini;a;ng the pharyngeal phase) voluntarily The so[ palate rises and 02 blocks oJ the nasopharynx Respira;on ceases 03 Pharyngeal Phase (swallowing phase) The swallow reYex has been ini;ated by receptors in the pillars of fauces in the oropharynx Breathing has ceased and the so[ palate has closed the nasopharynx The larynx is elevated by the raising of the hyoid bone and associated muscles The globs is closed (the opening between vocal cords). As the tongue forces food back, the bolus also ;lts the epiglobs backwards for further protec;on of the trachea At the same ;me the hypopharyngeal sphincter is opened by contrac;on of the skeletal muscles at the beginning of the oesophagus and allows the bolus to pass The sphincter is closed when not swallowing by passive elas;c tension Oesophageal Phase Bolus is transported down the oesophageal tube to the stomach by ‘perastal;c waves’ of the smooth muscle Nerve Innerva$on Olfactory Nerve I Smell Trigeminal Nerve V Sensa;on from the face and muscles of mas;ca;on Motor func;on to the muscles of mas;ca;on Facial Nerve VII Taste from the anterior two thirds of the tongue Motor func;on to the muscles of the face Glossopharyngeal Nerve IX General sensa;on from the: posterior one third of the tongue so[ palate pala;ne tonsils pillars of fauces pharynx Taste sensa;on from the posterior one third of the tongue Motor func;on to the: pharyngeal constrictors stylopharyngeus muscle Vagus Nerve X General sensa;on from the larynx Motor func;on to the: Palate pharynx (part) Larynx Autonomic to the oesophagus Accessory Nerve XI Motor func;on supply supplementary to vagus Motor func;on supply to the: Sternomastoid trapezius (muscles of head control) Hypoglossal Nerve XII Motor func;on to the intrinsic and extrinsic muscles of the tongue Dysphagia [Swallowing di]cul$es] What do you understand by the term ‘dysphagia’? Difficulty swallowing What do you think the most common cause of dysphagia might be? Throat infection Clue: When might you have experienced problems with swallowing? The most common cause is due to infec;on of the throat, producing pain on swallowing and inYammatory swelling of the mucosa. According to the Stroke Associa;on, some of the possible signs of dysphagia include: Food or drink going Coughing when S;ll having food or down the wrong Feeling that food is drink le[ in your you’re ea;ng or way stuck in your throat mouth a[er you’ve drinking swallowed Taking a long ;me Having to Being short of Dribbling to swallow or gnish swallowing a lot to breath while a meal clear your throat swallowing A croaky or ‘wet’ Not being able to sounding voice chew food properly Causes Dysphagia can be caused by: A condi;on that results in weakening, or damaging, the muscles and nerves used in swallowing Stroke Cerebral Palsy Parkinson’s disease Head Injury A structural abnormality Cle[ Palate Bony outgrowths Can you come up with an example for each cause? Other causes include: Head and neck cancer, including their treatments Infec;ons or irrita;ons Demen;a, memory loss and cogni;ve decline Bony outgrowth Drugs (professional and recrea;onal) and alcohol use Age related changes Disorders of the Pharyngeal Stage If there is a delay in the swallow reYex this can lead to material being able enter the pharynx before the reYex has been triggered. This leaves the pa;ent at risk of items falling into an unprotected airway. What protec;ve measures won’t have occurred? Larynx won’t have elevated and hasn’t closed of airway, epiglottis isn’t tilted backwards and closed Reduced pharyngeal peristalsis can lead to residue remaining in the pharynx and then poten;ally entering the airway a[er the swallow has been completed and normal breathing resumes. Disorders of the Oesophageal Stage If there is reduced peristalsis then material remaining in the oesophagus may be reYuxed leading to poten;al aspira;on. This is also a risk if the pa;ent is posi;oned poorly during or a[er ea;ng- why? Abnormal Swallow [Associated Problems] Infec$on Aspira;on occurs when food or liquids enters the larynx and passes through the vocal chords which can result in a chest infec;on Whilst microscopic amounts may be aspirated in normal individuals, if a large volume of food or liquid is aspirated then there is an increased risk of pneumonia Aspira;on can occur at any stage during swallowing: Before (if there is an impairment preven;ng material being maintained in the mouth) During (if there are any impairments, for example, to the ;l;ng of the epiglobs or closing of the vocal chords) A[er (if residue remains in pharynx it may be inhaled) Dehydra$on If unable to swallow safely this may lead to an insuhcient intake of Yuids Why might this be? Person may avoid drinking due to risk of aspiration Dehydra;on can lead to other complica;ons such as an increased suscep;bility to infec;on, mental confusion and reduced saliva Yow. Malnutri$on Similar to dehydra;on, malnutri;on (or a reduc;on in adequate nutri;on) may result if an individual is unable to swallow safely leading to an insuhcient intake. They may be embarrassed by their swallowing dihcul;es, which may cause them to withdraw from social interac;on during meal;mes, or worry about choking. Risk of malnutri;on may be compounded by the psychological eJects of dysphagia. * May not enjoy food Feel they can’t go out to eat Anxiety around eating This can lead to deprrssion Gastric reVux and heartburn Contents from the stomach can be forced past the cardiac sphincter into the lower end of the oesophagus, to be returned to Cardiac sphincter the stomach by reYux peristalsis. The stra;ged squamous epithelium of the oesophagus has no protec;on against the acid contents of the stomach, and acid reYux produces inYamma;on and even ulcera;on of the oesophagus. This is felt as burning pain in the epigastrium and behind the sternum. Dental Management of Dysphagia Dental considera$ons What impacts do you think dysphagia can have on oral health? Dysphagia can contribute to: Increase plaque Reduced oral Increased caries and calculus Dry mouth clearance risk deposits Did you get anything else? Dental Management Based on your current knowledge and experience, what considera;ons would you make to the following areas for a pa;ent presen;ng with dysphagia? Provision of Treatment Pa;ent Assessment (Periodontal/Restora;ve) Pa;ent Posi;oning Addi;onal Considera;ons Preventa;ve Advice This lecture by Grace Kelly might help get you started Pa;ent Assessment Pa;ent Posi;oning Provision of Treatment What is most Is dysphagia part of a wider (Periodontal/Restora;ve) medical condi;on? comfortable for the Careful use of water: What is the extent of their pa;ent? Power driven scaler Semi-supine dysphagia? 3-in-1 Altered diet/OH Fast handpiece dihcul;es/impact on day-to- …avoid where possible day etc Good suc;on (saliva ejector Preventa;ve Advice and HVS) Preven;on is key to avoid Rubber dam to protect lengthy/complex dental airway procedures Fast sebng materials Consider: Non-foaming toothpastes Not webng toothbrush Addi;onal Considera;ons Consider liquid prepara;ons if AB needed Avoid mouthwashes Care with viscosity when taking impression Aspira;ng toothbrushes Communica;on/signalling Diet analysis and advice Frequent breaks Pa;ent’s ability to swallow saliva Addi$onal Resources LeaVets Dealing with swallowing problems. The Stroke Associa;on. Available at: h\ps://www.stroke.org.uk/sites/default/gles/publica;ons/f05_swallowing_proble ms_v3.1_may_2020.pdf A Complete Guide to Swallowing Problems A[er a Stroke. The Stroke Associa;on. Available at: h\ps://www.stroke.org.uk/sites/default/gles/publica;ons/f05cg_cg_to_swallowin g_problems_v2_may_2020.pdf YouTube Sam Webster- Swallowing anatomy (pharynx) h\ps://youtu.be/0HklsPDqkmg Websites h\ps://swallowingdisorderfounda;on.com/ References Stroke Associa;on. Available at: h\ps://www.stroke.org.uk/ Dysphagia. Na;onal Ins;tute on Deafness and Other Communica;on Diseases (updated March 2017). Accessed 1st Feb 2021. Available at: h\ps://www.nidcd.nih.gov/health/dysphagia Matsuo, K., & Palmer, J. B. (2008). Anatomy and physiology of feeding and swallowing: normal and abnormal. Physical medicine and rehabilita4on clinics of North America, 19(4), 691–vii. h\ps://doi.org/10.1016/j.pmr.2008.06.001