ve onowing) is the process by which rencad into the stomach from the oral cay. Pes of slowing involves preparatory MES, pharyngeal phase and eesopha si Fauld into mass calle ole ire fomed bolus & pushed towards the ats ant into the stomach inthe process Zs Sensory input from the era cavity ay oesophagus terminates inthe andl trigeminal sensory ue din the initiation of swale “ig Mor output of the centre derives from sean within the nucleus annbiguus, facta, coal and hypoglossal motor nuclei as well as sr wens int the cervical spinal cord, Other kar activities similar to swallowing ane on gaging. MRODUCTION “gition (allowing) is the process by which pus into the stomach fiom the oral cavity sualoing i a reflex activity consisting of mus. ssetrations and relaxations that help push the etl food and saliva from the mouth to the uh This rellex activity occu in coordination “A ranerous motor neurons, ‘he swallowing “spre programmed as well a8 inated in the sol the brainstem known 3s the swallowing, % although swallowing can be initiated vel ‘th, much of the swallowing occuts without nso elon. The swallowing rate i highest “evecting and least during seep, and sallow Su around 600 times per day. The volume “2 illow in drinking, and probbly hn bois ‘tt varies from 5 mpl. im a child to 10-14 ml “alvomen and 15-20 mal. adult men Nesides helping ta move ‘mouth (0 the stomach, ‘portant protective Uraet and the dig pharyn and lar ‘sone! Liga ‘mechanisms. conty dutelents from the swallowing has. many functions, As the respltatory pestive tract ate atthe level of the YHx, Ht becomes crcl that sol Hot enter the larynx, Protective ‘ol or Inhibit breathing dari ‘wallowing, Vigorous set of reflexes such as cough ing or choking are tnitlated if food or fluid enters ‘he opening of the trachea PHASES OF SWALLOWING Swallowing ean be divided into prepara (uckle, pharyngeal and oesophageal phas a Preparatory Phase —Cparatory Phase Formation of food bplus oceurs during Food bolus fs «round or oval-shaped mass of food formed inthe mouth after thorough chewing. ‘The food bolus is formed as a prepatatory event for swallowing, this phase, Oral Phase (Buccal Phase) eee ccal Phase) Once the bolus is positioned on the tongue dor sum, the oral phase begins, ‘The lips close and the maxillary and mandible incisors come closer together, ‘The anterior two-third of the tongue clevate against the maxillary alveolar the anterior hard palate prope de ancl ng the bolus towards the pharymx. ‘the masopharynx is shut ‘oft by the upward movement of the soft pal: ate and the forward movement of the posterior ‘pharyngeal wall to preverit regurgitation of food through the nose. This isa voluntary phase and respi on is stopped for a while inthis phase 2.10)Pl yo haryngeal PE og ofthe Pryngeal phase, he pos Tongue male a pd pe pel the bolus througir jopharynx.” The pharyngeal ipwards “ahd forwards and ig the bolus through the pharynx 3 ie contractions. The upper oesaph- 5 the help of gravity:"The lower Gesop {er opens to allow the bolus into the stomach. Physiology and Tooth Morphlog forphal ay Oesophageal Phase tions (i the Bolys to the stomach with ageaTsphine-_ s ereer opens, and the bois enter the DRINKING : hg aa _ @ = hharyngeal phase, the laryn- J j : ng NE ee ae awe It is possible to ingest fluids without any oral bale oats. st to a horizontal position (Fig, 27.1b) ‘of the elevation of the hydid bone and vs the contraction af the thyrohyoid vt Mparther muscle contraction causes the sf the epighottis 10 rotate over the laryngeal le The ePiglttis does not have to cover a iaryngeal opening 0 prevent aspiration To. Aspiration of food generally does not | det, individuals with’ an excised epigltts, fever the epiglottis does direct the bolus into |e piform sinuses and, therefore, around the | pring ofthe airway into the oesophagus (Fig, | gucand a). | several mechanisms operate to prevent aspira- | ign of the bolus into the airway during the pha- rngeal phase of swallowing, During this phase, repiation is inhibited, Elevation of the larynx and upper oesophageal sphincter shortens the dis- ‘tae the bolus must travel and hence the time the ‘sis present at the entry of the airway. Intrinsic auscles of the glottis forcefully approximate the ‘wcal cords, ‘The piriform sinuses create lateral food channels so that the bolus generally devi- 1 aes around the laryngeal opening. Any residual tos material trapped in the piriform sinus after sellowing is normally at a lower level than the huryngeal vestibule, making aspiration of residual >. "aterial unlikely, "The epiglottis first moves fom Forcing food and liquids into the nasal cavity 'sknown as nasal regurgitation. It can occur in Patients with palatal clefts or paralysis of soft pal- H¢ where the nasal cavity cannot be sealed off from the oropharynx. Activity. If the head is tipped back so’ that the oral MUSCLE ACTIVITY _ Cavity and the oesophagus present a straight path- ‘ay, fluid may be poured down this pathway. ‘The ingestion of fluids proceeds as follows: Accumulation of fluid takes place in the ante- Part of the oral cavity with the tongue hollowed at the tip but raised posteriorly. ‘Tip of the tongue raises to touch the palate behind the upper incisors. ‘The muscles of the tongue contract progres- sively to bring it back along the palate. The posterior part ofthe tongue drops down. ‘The pharyngeal phase of fluid intake is mostly similar to the pharyngeal phase of swallowing ‘of food bolus produced by mastication, Fluid can pass down the oesophagus under the influence of gravity when a person is in an upright position; even then, there is contraction of the stiperior pharyngeal constrictor and initiation of peristaltic waves in the oesophagus. ‘Thirty-one paired muscles are involved in ihe various phases of swallowing, Muscle ‘patterns differ with the type of food that is swallowed ‘Muscle activity in the preparatory and oral phases involves various muscles controlling the face and mandible-The medial pterygoid, masseter and temporalis muscles are actively involved in these phases. Facial muscles that control the lips and the cheeks contribute to the development of an oral seal’and stabiliza- tion of the mandible, ‘The pharyngeal phase of swallowing is com- plex, and once it begins, the muscles controllingtongue, pharynx and larynx ye! wee contractions, relaxations and : rete remyiohyoid, geniohyoid, palato. i M toglossus, superior constrictor, pte xd stylohyoid lead the activity at fag ofa sallow. ob aged constrictors act in an over. juBmtence. The leading complex ig yettjend consists of set of muscles Zoot mylohyoid, genichyoid, poste. i alatopharyngeus, palatoglossus, Oe constrictor, styloglossus and stylo. ey are s0 called because they show ig rahe initiation of a swallow, rine activation of the leading com. the middle and the inferior constrictor ave in a sequential order. fetohpid thyroarytenoid and the cco. ij muscles begin to contract after the actv- Peleg complex begins to subside, ne thsi “gmusees used for swallowing are different firteeth eruption. Inthe infantile swallow, the ‘squats ors and buccinator muscles are very {ore and the levator muscles of the mandible jpratpaticipate in swallowing. After eruption of ah his pattern is altered and the activity in the tisland buccinator muscles decreases, Retained isnilepatter causes malocclusion in adults (NTROL OF SWALLOWING siloving can be initiated either voluntarily or ijsimulation of various areas in the oropharynx. Tepeparatory and oral phases of swallowing are slay Whereas the pharyngeal and oesopha- {alplases are involuntary. ‘The swallowing motor ‘Sunce including the motility ofthe smooth mus- dof the oesophagus, depends on the swallowing, ‘ete. The interneurons in this centre organize the vile sequence of muscle contractions of swallow- igs that the control of swallowing is the property pecsely interconnected set of neurons. The swallowing centre comprises three ‘omponents: |. Sensory ipput from the oral cavity, pharynx, yax and oésophagus terminates in the Chapter 27. Degluttion + 607 nucleus tractus solitarius and trigeminal sen- sory nucleus that are involved in the initiation of swallowing, especially the afferent activ- ity in the glossopharyngeal and the superior laryngeal branch of the vagus nerves. Motor output of the centre derives from motor TeGrOns within the nucleus ambiguus, facial, ‘trigeminal and hypoglossal motor nuclei as well, 88 motor neurons in the cervical spinal cord. Between the sensory input and motor output of the centre is an interneuronal network that pro- Grams the entire'sequence of events in a swallow through excitatory and inhibitory connections. ‘The swallowing centre, therefore, is a not a dis- rele anatomical entity but consists of brainstem setisory and motor nuclei interconnected by a jeuronal network. Applied Physiology Dysphagia (difficulty in swallowing) can occur when the oral cavity, pharynx and oesophagus are affected by any inflammation, infection or ‘nutritional deficiency (iron deficiency anaemia). Occurrence of tumour can also lead to dysphagia, Further stenosis and strictures in the oesophageal lumen can also cause dificulty in swallowing, The common causes of dysphagia are as follows: 1. Oropharyngeal disorders (@) Scarlet fever (0) Mumps (0) Periotonsilar abscess (@) Carcinoma (e) Syphilis (0) Intubation during surgeries Neurological disorders {@) Paralysis of one or both vocal cords (0) Disorders of basal ganglia, cerebellum. (2) Any infections of brainstem (@) Stroke (e) Parkinsonism (f) Tetanus (@ Cerebral palsy 3. Mechanical disorders (2). Surgical reconstruction of structures after carcinoma (b) Loose dentures (0 Mactoglossia 2ok of Oral Anatomy, Hi _ totbo* Pra on tng ‘phology JROMUSCULAR Actp i a NEU! ITY init oft e910 SWALLOWING | ingestion can lead to a vom- pater z th ink is POEES, the nt eet Esa CONS of devdopmment Rea Ae oF suction inthe oral cy combing i movement expres mi jy ing activity in infants and gro chiles, ced by suction and lowering theo a ifaw se eound the nip ; v2 Fair into the oral cavity, mt infant first forms a teat fr sucking the nipple deep inns it the mouth to the junetion of Ei pte By levating the jn and on sent compresses, lengthens and shone the pao express milk for swallowing, sealing inthe newborn is loud slow sited (0 sucking. No teeth ae pay satalory movements do not occur anf sen” ald bous isnot formed, The anatomig oe jnyxand larynx are alo diferent rom aes ie Inthe neonate, the st palate nes sah of te volume of the upper pharma ws se compact than inthe adult, The einen gates the larynx upwards behind the soft pal, ueand remains there during respiration, During darlopment, the epiglottis descends and assumes lunalure functional ole during swallowing, Because of the anatomical relationships of the tlaryox and larynx in the newborn, it has been ‘vgested thal infants can swallow without inter. nption of breathing, ‘Om ils mothers Occurrence of cleft palate or cleft lip in infants ‘ffects suckling. Cleft lip prevents formation of lip sealing and creation of negative pressure while Clftpalate can cause aspiration of fluid along with interference in the development of negative pres Sue essential for suckling, ~—— “Gagging or Retching aad oF Retching When the posterior part of the mouth is one 4d, a swallowing pattern of reflex i setup. Any a owing reflex pattern could be "my sis held open and the cricopha- at ey tincter and the nasopharynx are eed rat to expel the stimulating mate- ™overnents of the tongue, . This iste 2 oF the mouth and move for, s(ermed gagging or retching. The retch- Stage of reflex protection oF” ing. deglutition, is of aspiration inthe elderly. Probability of dyspha- 8i increases with age asthe hyoid bone lowers in Position Upper oesophageal sphincter opening rests due to anterior displacement of the hyoid bone whereas laryngeal closure results in superior displacement, Anterior displacement of the hyotd bone is primarily due to the movement of the geniohyoid, and the anterior belly of the digastric ‘muscle works as auxiliary. Superior displacement of the hyoid bone involves mylohyoid as the pri- sary muscle and the posterior belly of the digas- tric muscle work asthe auxiliary muscle (excerpts from Shinozaki etal. 2017). Sensory Topography of Oral Structures Sensory Topography of Oral Structures Oral cavity and oropharynx sensory innervation is mediated by 2 vatiely of receptors that have aChapter 27 Deglutition + 509 jg sponse © OUCH, PESSUEe, baton, ae in, emperature and taste, Tactile gon” ip caical role than other sensation fy ihe degli mn. ee sensory funk and palatal excursions to produce nuanced vocal @xPressons. The complex synchronicity of oral cav- ity sensorimotor function can be impaired by pri- ‘mary diseases or secondary treatment effects such is needed in identifi. eae | ntifica- a5 chemotherapeutic, radiotherapeutic or surgical geod ovjects action selection in mastication, (eitment for head and neck malignant conditions. po ion making (0 tigger a swallow sequence pce degltition, tactile integrity involved Sensory dysfunction may also occur with snoring 4 iit apposition of the lips, tongue movements is if and obstructive sleep apnoea disorders (excerpts from Bearelly and Cheung 2017), ‘pe swallowing rate is highest during eating, least dun «ihe orl phase, the nasopharynx is shut off byt the soft palate and the forward "aye of the posterior pharyngeal wall io prevent regugiatn opie through the nose. Ate muscles, called the leading comples, show actvty athe begining of svallow. 1 fresvallowing centre is a not a discrete anatomical entity but consists of brainstem sensory and motor iudelinterconnected by a neuronal network, s saowing In a newborn is aliquid swallow and is related to suc {hen the posterior part of the mouth is stimula * Gyaumstances,iritation or noxious stimulation cy ted, a swallowing pattern of reflex is set up. In some n lead to a vomiting reflex, Mind Map SWALLOWING it Preparatory x —| [oa Pharyngeal_|<— Sensory input from rectus | oral cavity and pharynx solitarius Nucleus ambiguus, Facil - [—>|__Motoroutput | —*] ypogiossal and Oesophageal }~—! trigeminal nuclei 1 >| Internueronal network