Dysphagia: oral phase disorders

Question 1

oral phase

Answer 1

The food enters the mouth and mastication occurs; the food is formed into a bolus in preparation for swallow. This phase requires biting, sucking, chewing/munching of food. Bilabial seal prevents food from spilling from mouth. Tongue lateralization moves the food over the molars for mastication, then back to the center of the tongue for transit to the posterior oral cavity where the swallow is initiated. Anterior – posterior lingual movement.

Question 2

issues to address

Answer 2

• Positioning and proper alignment of the head, neck, and trunk
• Structural integrity of oral cavity
• Muscle tone of oral musculature
• Oral reflexes
• Oral motor control and development

Question 3

positioning

Answer 3

Proper alignment of the head, neck, trunk, and extremities is important to feeding performance. The optimal position for feeding

Question 4

positioning examples

Answer 4

• upright
• level pelvis and BOS
• supported, balanced
• positional devices/straps/safety chairs

Question 5

alignment and symmetry

Answer 5

When eating in a seated position, the individual

should be positioned so that proper alignment and symmetry are maintained.

Question 6

proper positioning for alignment and symmetry

Answer 6

1. If an imaginary line were drawn down the middle of the individual’s body,
   both sides would look the same.
2. The nose, navel, knees, and toes should all be pointing in the same
   direction.
3. The legs should be parallel.
4. The neck should not be hyperextended.
5. The head should have a slight chin tuck which helps prevent the airway
   from opening during a swallow.

Question 7

alternative positioning techniques

Answer 7

1. The inclined side lying position allows for fair body alignment. With support, the head may be positioned with a slight chin tuck.
2. Gravity helps the food go to the stomach when swallowed.
3. Food is less likely to pool at the posterior wall of the stomach where it can
   be regurgitated several hours after eating.

Question 8

oral facial anomalies

Answer 8

cleft lip
cleft palate
Micrognathia
Pierre-Robin malformation sequence

Question 9

cleft lip

Answer 9

failure of fusion of the upper lip in the fifth week of embryonic development.

does not affect feeding from bottle as much as cleft palate

Question 10

cleft palate

Answer 10

failure of the palatal shelves to meet and fuse in the midline during the seventh to eighth week of intrauterine development.

Question 11

cleft lip repair - age

Answer 11

6 weeks to 4 months of age

Question 12

cleft palate repair

Answer 12

usually occurs between 12 and 18 months of age following rapid craniofacial growth and enlargement of the palatal surfaces

Question 13

Micrognathia (retrognathia)

Answer 13

• small or posteriorly positioned mandible. - the chin appears recessed.
• Internally, the tongue is also posteriorly positioned in relation to the oral cavity. This may lead to glossoptosis (obstruction of the pharyngeal airway).

In utero, an abnormally small mandible can lead to the development of other anomalies:
• The tongue cannot descend into the oral cavity appropriately, remaining elevated against the base of the cranium and interfering with fusion of the palatal shelves, potentially leading to a cleft palate.

Question 14

Pierre Robin Sequence

Answer 14

• a birth defect that involves an abnormally small lower jaw, and a tendency for the tongue to “ball up” and fall backward toward the throat (glossoptosis).
• could have a cleft palate, but not a cleft lip

The exact cause of Pierre Robin Sequence is unknown, but during the early stages of fetal development, the lower jaw fails to fully develop. The small jaw seems to prevent the tongue from descending into the oral cavity, and this in turn prevents the palate from closing completely.

Question 15

jaw problems

Answer 15

 Exaggerated jaw movements
 Clinching and tooth grinding
 instability

Question 16

tongue problems

Answer 16

 Retraction
 Protrusion or thrusting
 Poor tongue mobility

Question 17

facial muscle problems

Answer 17

 Low muscle tone

 High muscle tone

Question 18

oral motor exercises for jaw stability

Answer 18

• Assure comfortable positioning during feeding to improve success biting soft/hard solid foods
• Use placing or holding exercises to work on jaw strength and stability (i.e. using a chewy tube)
• Provide physical cue/support to jaw during chewing (remove cue as child becomes more skilled at chewing)

Question 19

oral motor exercises for tongue

Answer 19

• Assure comfortable positioning during feeding to improve success using tongue to move food in mouth
• Head stability is important for controlled tongue movement
• Oral motor play can encourage child to move tongue to R or L cheek pocket (between teeth and gums). Place a small piece of food in pocket for child to retrieve with tongue.
• Bite-chew games – place strips of food over child’s back teeth and to bit and chew food. The tongue should remain on the same side as food to help keep the food in pace. You can also use fruit or food placed in a gauze pouch (caregiver holds end of pouch while food remains on teeth)
• Chewy tubes – place a small amount of food on chewy tube. Encourage bite on chewy tube and tongue to food

Question 20

oral motor exercises for facial muscles

Answer 20

• “Wake up” facial muscles – tactile stimulation and deep pressure stimulation to peri-oral area with hands or soft washcloths, toy, massager.
• Intra-oral stimulation with Infa-dent toothbrush, NUK brush, or gum massager
• Vary temperature of food – cool temperature facilitates pursing, bilabial seal
• Oral games: for older children using blow toys, bubbles may stimulate facial muscle and breath support for eating