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Journal of Oral Rehabilitation

Journal of Oral Rehabilitation 2017 44; 6572

Application of a barometer for assessment of oral functions:


Donders space
K. HIRAKI*, Y. YAMADA, M. KUROSE, W. OFUSA, T. SUGIYAMA* &
R . I S H I D A * *Department of Oral Health and Clinical Science Division of Dysphagia Rehabilitation, Tokyo Dental College, Tokyo,

Oral Health Science Center, Tokyo Dental College, Tokyo, Division of Oral Physiology, Niigata University Graduate School of Medical and
Dental Sciences, Niigata, Department of Geriatric Dentistry, Tsurumi University School of Dental Medicine, Yokohama, and Department
of Physiology, Tokyo Dental College, Tokyo, Japan

SUMMARY We developed a barometer applicable to a swallowing, the pressure in STP showed more
small space, to assess oral and pharyngeal functions. negative value ( 050  059-kPa). There is a
Negative oral pressure during rest and pressure significant difference between the values in open
changes during swallowing were measured in a condition and after swallowing (P < 0001) and
space between the palate and tongue (STP). Twenty between values after swallowing and final open
volunteers were asked to sit in a chair in a relaxed condition (P < 005). Twin sensor showed almost the
upright position. A sensor was placed on the same trajectories of pressure changes for all the
posterior midline of hard palate. Recording recordings. Obtained negative pressure might
commenced just before subjects closed their lips generate about 071-N of force and would be enough
and continued. Subjects were asked to swallow to keep the tongue in the palatal fossa at rest. The
saliva and keep the apposition. Finally, subjects system detected large negative/positive pressure
were asked to open their mouth. Recordings were changes during swallowing. We conclude this
performed five times, and 5 s of continuous data in system may be a tool to evaluate oral functions.
each phase was averaged. To verify the reliability of KEYWORDS: barometric pressure, swallowing, jaw
the system, the same procedure was accomplished position, velopharyngeal insufficiency, Donders space
with twin sensors. When the jaw and lips were
closed, the pressure slightly decreased from Accepted for publication 6 November 2016
atmospheric pressure ( 017  024-kPa). After

(5, 6). To accomplish these functions, the oral cavity


Introduction
is constructed with hard and soft parts and is divided
Pre-gastric food processing begins with food intake into small spaces (7).
and ends with deglutition. Five stages comprise the One other function of the tongue is maintaining
process: recognition stage, masticatory stage, oral the mandibular rest position (810). The lips are
stage, pharyngeal stage and oesophageal stage (1, 2). closed at the physiological rest position, but the upper
The tongue is quite important for the sequence (3, 4). and lower jaws maintain a stable position with a gap
At the time of food intake, the food is received by the of several millimetres called free-way space. Tension
tongue from the hand or tableware. Thereafter, the of the closing muscles, elasticity of the connecting tis-
tongue mixes the food with saliva, classifies the food sues between the upper and lower jaws (11, 12), head
by its size and transports the food bolus backwards for posture (13) and negative pressure generated in a
swallowing, in collaboration with other oral organs space described by Donders (10) are candidate factors

2016 John Wiley & Sons Ltd doi: 10.1111/joor.12456


66 K . H I R A K I et al.

to determine the position. The tip of the tongue Recent technology has produced a factory calibrated
touches the incisive papilla or lingual surface of the absolute pressure sensor small enough to fit into a
maxillary incisor and acts as an anchor for the tongue very low volume, have enough resolution both in
posture. More than one hundred years ago, Donders time and in pressure measurement and equipped with
claimed that there was a space in the upper part of a compensation circuit for temperature. The aim of
the dorsum of the tongue when the mandible is at this study was to evaluate this barometer as a tool for
rest (10). Recently, Bourdiol et al. (8) successfully oral pressure and to measure the pressure in STP at
evaluated the volume of the space (in-mouth air cav- rest.
ity) at rest as nominally 12-mL with a range of 10
18 mL.
Methods
Donders described the mechanism of negative pres-
sure in a space built between tongue and palate while
Barometer
the jaw was at rest (10). The pressure was measured
using a manometer and flexible tube. He reported 2 We have developed a barometer to assess oral and
4 mmHg of negative pressure in the space and specu- pharyngeal functions that can measure atmospheric
lated that the space might be surrounded by the root pressure in a small space with a 3-ms sampling inter-
of tongue and hard palate. As the pressure was small val. The system consists of a sensor (Freescale Semi-
in value, he estimated the space might be small in conductor: MPL115A1), flexible cables, a
volume. The space might be completely closed at the microprocessor to control the sensor and a PC for data
anterior part of oral cavity with tongue and hard collection. The absolute pressure sensor is
palate. The phenomenon might be emphasised by 15 9 3 9 5 mm in size and provides accurate pres-
changing the tongue shape flat and then bending the sure measurements from 50 to 115-kPa. An integrated
tongue tip backwards. Finally, he considered that the analog-to-digital converter (10-bits resolution) con-
jaw at rest was supported by the negative pressure verts pressure and temperature sensor readings to
generated in the small space (10). In this study, we digitised outputs via a serial peripheral interface (SPI)
call the space STP (a space formed between the dor- port. Factory calibration data are stored internally in
sum of tongue and the palate). an on-board Read Only Memory. Utilising the raw
Faigenblum explored the pressure in STP with a sensor output and calibration data, the host micropro-
manometer for four subjects. He reported cessor executes a compensation algorithm to render
97  05 mmHg of negative pressure on average after compensated absolute pressure with 1-kPa of accuracy
swallowing (14). He then calculated a possible force and 015-kPa of resolution. The microprocessor can
of about 300-g from the value of negative pressure handle up to three sensors simultaneously.
and the area of the palate. The negative pressure was Two types of sensor were fabricated: a single type
definite after a swallow with larger changes (positive and a twin type. The single type consists of one sensor
and negative) in pressure; however, the change dur- as seen in Fig. 1a. The twin type is composed of two
ing swallowing was rather small in amplitude and had sensors, arranged side by side in point symmetry so
a short duration compared with those of recent that the distance between sensing windows is 4 mm
reports (3, 7). as seen in Fig. 1b.
Pressure in the oral cavity has been measured by
many studies (3, 7, 1416); however, most of the
Subjects
methods employed were conventional in that the
pressure in a space was measured with a tube con- Twenty young volunteers (aged 2636 years) were
nected to a sensor placed outside of the oral cavity. recruited from the postgraduate student body at
Inconveniently, the tube may resist air flow during Tokyo Dental College. This study was conducted with
measurement, and thus, the response resolution the approval of the Ethics Committee of the Tokyo
may be low. In this respect, Woda et al. (17) sug- Dental College (approval number: 659). Subjects were
gested in their review that the nature of the space asked to sit in a chair in a relaxed upright position
might need to be confirmed in a modern scientific without head support. Measurements were taken in a
context. space between the tongue dorsum and posterior hard

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PRESSURE MEASUREMENTS IN ORAL CAVITY 67

(a) pressure, was recorded for about 15 s while the sub-


jects opened their mouth (period indicated by phase-
1 in Fig. 3). After instruction, the subject closed their
jaw and lips and then a 15-s recording (period indi-
cated by phase-2) was made. The subjects were then
asked to swallow saliva and to keep the apposition for
15 s (period indicated by phase-3) for recording.
Finally, the subjects were asked to open their mouth
and the atmospheric pressure was again recorded for
15 s (period indicated by phase-4). The recording
was ended with calibration signals. Recordings were
performed five times over the four phases for all sub-
jects. For further analyses, 5 s of continuous data was
selected from the middle of 15 s of recording in each
phase was averaged.
(b)
Experiment 1. All the subjects participated in this ses-
sion. The single type of sensor was placed on the pos-
terior midline of the hard palate. As the dental
adhesive material gradually dissolved in saliva, some
of the recordings were affected by the influx of the
adhesive onto the sensor. This caused the pressure
readings to be increased or decreased. We thus
excluded recordings in which pressure measured in
phase-4 was low or high comparing with that in
phase-1, as values in phase-1 and phase-4 should be
equal if no influx occurred. Also, all other unstable
recordings were excluded. A total of fourteen record-
ings were advanced for further analyses to evaluate
the pressure change in STP.
Fig. 1. (a) An absolute pressure sensor with thin wires. The
sensor is 15 9 3 9 5 mm with a 1-mm-diameter hole in the Experiment 2. In this experiment, the reliability of
metal case. (b) A twin sensor. Twin type is composed of two measurement system was evaluated, to determine
sensors arranged side by side so that the distance between sens-
whether there was a difference in pressure in a small
ing holes is 4 mm.
space surrounded by soft tissue or not. The pressure
change in a small space was measured with the twin
palate (Fig. 2a) to test for the negative pressure sensor. Because the twin sensor was technically diffi-
described by Donders (10). Sensor was placed on the cult to make, the number of subjects was limited.
posterior midline of the hard palate using an adhesive Eight subjects were measured with the twin sensor.
material for dentures (Denture adhesives Correct:* )
to measure pressure change (Fig. 2b).
Analyses

Experimental protocols For statistical analyses, pressure waveform (5 s) just


prior to each task was selected as typical pressure
Our recording procedure followed that of Faigen- change of each phase. The average value of the wave
blums study (14). Recordings started with calibration (kilopascal, kPa) was analysed. Effect of jaw position
signals. Then, the control pressure, that is atmospheric and tasks on pressure was analysed statistically with
Friedman test and post hoc comparisons (Dunns test)
*SIONOGI Co., LTD, Osaka, Japan as necessary. T-test was used for comparison of

2016 John Wiley & Sons Ltd


68 K . H I R A K I et al.

(a) (b)

Fig. 2. (a) An illustration of the


measured space (STP). Filled arrow
indicates the STP region. (b)
Experimental set-up. A pressure
sensor was placed on the posterior
midline of the hard palate using an
adhesive material for dentures.

Lips Lips Lips


open close open

Phase-1 Phase-2 Phase-3 Phase-4

20 kPa

Swallow
0 10 20 30 40 50 60 (s)

Fig. 3. An example of pressure recording measured in STP. Calibration signals were added into the waveform at start and end of
recordings (filled arrow head: 90 and 110 kPa). Ordinate axis represents pressure changes in kPa. One recording is composed of four
recording phases (15 s each). Dashed line indicates the time point of postural change of lips. Dotted line indicates onset and offset of
saliva swallowing task.

pressure value between outputs from twin sensors. To (kPa)


show the analogous outputs of the twin sensor, the 05
*** *
correlation coefficient was calculated: one sensor out- 0
put is set on X-axis and the other sensor output is set
on Y-axis. The data were expressed as average  s.d. 10
P < 005 was considered statistically significant.
20
Results 25
Phase-1 Phase-2 Phase-3 Phase-4

Experiment 1 Fig. 4. Effect of lip position and swallow task on averaged pres-
sure. Pressure changes in STP divided into four phases: lips open
Figure 3 shows a typical recording of pressure change (phase-1), lips closed (phase-2), lips closed after swallowing
in STP. When the mouth is open (phase-1), pressure (phase-3) and final lips open (phase-4). ***P < 0001 *P < 005.
should be equivalent to that of the atmosphere.
Therefore, the reference pressure was set at phase-1.
The pressure value slightly decreased accompanying interval (Fig. 3). A typical swallowing event was char-
with jaw and lips closing (phase-2: 017  024- acterised by a negative pressure followed by a positive
kPa). These negative pressures in phase-2 did not pressure. Many of the pressure peaks were more than
show significant differences between those in phase-1 15-kPa. After swallowing (phase-3), the pressure
(Fig. 4, P > 005). When subjects swallowed saliva, value changed to more negative direction compared
large pressure changes were observed in a short to phase-2. The average pressure in phase-3 was

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PRESSURE MEASUREMENTS IN ORAL CAVITY 69

050  059-kPa. When the subject was instructed Discussion


to open his/her lips (phase-4), the pressure value
returned to atmospheric pressure (P > 005, compared Methodological consideration
to phase-1).
There are two methods available to measure pressure
Jaw position and swallowing task produced a signif-
in the small spaces of an oral cavity. One is an indi-
icant change in pressure value (Fig. 4, P < 0001
rect method combining a tube and a pressure-measur-
Friedman test). Multiple group comparisons (Dunns
ing device. For the indirect method, one end of the
test) revealed a significant decrease in pressure value
tube is placed in a target space and the other end is
in phase-3 when compared to phase-1 and phase-4
connected to an extraoral pressure-measuring device
(P < 0001, P < 005, respectively). As described in
that is either a manometer or an electrical sensor. The
Methods, in six of the twenty recordings, sensor error
other method is direct measurement, where a small
was suspected due to adhesive influx, in that values
pressure sensor is set in the target space. To measure
in phase-4 did not return to atmospheric pressure
the pressure change in an oral cavity, it is necessary
(within the resolution of sensor). Therefore, data from
to consider four important properties. These are accu-
these six recordings were excluded from the analyses.
racy, resolution, temperature stability and compatibil-
ity with the surroundings such as soft tissue, saliva
Experiment 2 and food.
It is important to rule out the possibility of error in
pressure measurements that could be caused by soft Table 1. Correlation coefficients obtained from sensor outputs
tissue interference with the sensing port. To validate of twin sensor
our pressure measurements, twin sensors were tested
Subject 1 08930952
with eight subjects. As shown in Fig. 5, twin sensor
Subject 2 07450952
showed nearly identical trajectories of pressure Subject 3 06960976
change for the duration of the recordings. To show Subject 4 07850954
the similarity of recordings from twin sensors, the cor- Subject 5 07100893
relation coefficient was calculated. As a result, the Subject 6 05040786
Subject 7 00650620
correlation coefficients obtained from eight recordings
Subject 8 04060572
are high (Table 1).

Lips Lips Lips


open close open

Sensor-1 20 kPa

Phase-1 Phase-2 Phase-3 Phase-4

Sensor-2 20 kPa

Swallow

0 10 20 30 40 50 60 (s)

Fig. 5. An example of pressure recording in STP with twin sensor. Recordings were carried out with two sensors (upper and lower
traces) simultaneously. Calibration signals were added into the waveform at start and end of recordings (filled arrow head: 90 and
110 kPa). Ordinate axis represents pressure changes in kPa. One recording is composed of four recording phases (15 s each). Dashed
line indicates the time point of postural change of lips. Dotted line indicates onset and offset of saliva swallowing task.

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70 K . H I R A K I et al.

Using indirect methods, pressure changes may be saliva (i.e. phase-3), the average negative pressure
transmitted by the movement of air/liquid in the was measured as 050  059-kPa. The negative
tube. As the tube is soft and thin, it acts as a capacitor value might be enhanced by the tongue reposition-
and a resistor for the measurement system, dampen- ing during swallowing. The negative value was simi-
ing high-frequency components in the pressure lar to that described by Donders (10), that is 2
changes. Therefore, large positive pressure changes 4 mmHg (=027053 kPa). In 2011, Engelke et al.
occurring in a short time may not be detected by the reported negative pressure of about 82 kPa in the
system. In fact, Faigenblum (14) could not record space equivalent to STP of this study when the jaw
large negative and positive pressure changes in the is at rest (7). They employed the method with a
short time associated with swallowing as seen in our tube and electrical sensor. The negative pressure
results (Figs 3 and 5). One other concern with the during rest is stable for a while, and thus, pressure
indirect method is a rectifying function of the tube. in the space and the manometer may reach equilib-
This will be discussed later. rium. As a result, the signal dampening properties
Although the sensor we employed in this experi- of the tube did not disturb the measurement even
ment has excellent characteristics for pressure mea- with the indirect method.
surements in an oral cavity, its drawback is that it Donders theorised that the jaw at rest was supported
is likely to be affected by mechanical disturbance by the negative pressure generated in the space (10).
such as by food. The sensor is enclosed in a small Faigenblum confirmed the negative pressure of
case, and pressure changes reach the sensing ele- 97 mmHg (= 129 kPa) and estimated the negative
ment through a small hole (1 mm in diameter) in pressure acting over the area of the subjects hard
the case. When adhesive substance contacts the palate would be capable of exerting forces ranging
sensing element, the measurements may be dis- between 100 and 350-g (14). The force can be calcu-
torted. Saliva, which has a slight adhesive character, lated with the negative pressure and the area of palate.
may have a minor effect on the sensor. Adhesives We did not measure the area of palate; however, we
used to fix the sensor on palatal mucosa may dis- have found literature in which the average palate area
solve in saliva and thus the sensor output may be in the Asian population is reported as 142 cm2 (18).
distorted. This problem can be eliminated easily by Therefore, 050-kPa of negative pressure might gener-
covering the sensor with thin rubber. The larger ate about 071-N (=71 gf) of force to support the tongue
pressure changes during mastication and swallowing while the jaw is at rest. This would be enough to keep
can be accurately measured by our system. How- the tongue in the palatal fossa.
ever, in this experiment we did not use the rubber
cover, as the pressure change in STP is so small that
Pressure changes during swallowing
even thin rubber may affect the measurements. For-
tunately, this error can be recognised when the We did not measure pressure changes during swal-
value of phase-4 is far from that of phase-1. We lowing as it was not a focus of this experiment. We
excluded data when difference in values of phase-1 did, however, observe gross negative/positive pressure
and phase-4 exceeded 015-kPa (the resolution of changes during saliva swallowing. Engelke et al. and
the sensor) even though the incidence was limited. Santander et al. (7, 16) reported only negative pres-
We concluded that the sensor employed in this sure during swallowing. We agree that negative pres-
study could effectively measure the small pressure sure could be generated in the space during
changes in STP during the jaw at rest. swallowing (as seen in Figs 3 and 5). However, we
cannot explain why they could not record positive
pressure. As swallowing starts with propelling of food
Verification of the Donders report
by the tongue (19), there must be positive pressure
As shown in Fig. 4, we obtained statistically signifi- between the tongue and palate. Kieser et al. (3) mea-
cant negative pressures in STP when the jaw is at sured pressure changes at the palatal vault (anterior
rest. Just after the jaw and lips were closed (phase- and posterior) during swallowing. They recorded not
2), the pressure slightly decreased 017  024-kPa only a large positive pressure but also significant neg-
from the reference (phase-1). After swallowing ative peak amplitude, before both rise to their

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PRESSURE MEASUREMENTS IN ORAL CAVITY 71

maximum. These findings were confirmed in our Acknowledgments


experiment and in other studies (20, 21).
Unlike Faigenblum (14), Engelke et al. (7) used a We thank Patrick M Steusloff for language editing.
modern system (semiconductor sensor) for pressure Funding for this study was provided by MEXT
measurement; however, a tube is used to connect KAKENHI Grant Number 26463181 (to Masayuki
the space and the sensor outside of oral cavity. The Kurose), 15K11055 (to Yoshiaki Yamada) and
method with a tube has an advantage, avoiding the 16K15808 (to Wataru Ofusa).
influence of temperature change; however, for posi-
tive pressure, there may be miss-measurement. In Disclosures
fact, Engelke et al. (7) stated that This observation
is basically contradictory to the findings of many The authors have stated explicitly that there are no
authors who observed positive pressures during competing financial and conflict of interests in con-
chewing, during swallowing and at rest. They also nection with this article.
made the point that any closed compartment with
elastic walls and an inwardly directed pressure gra- References
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