Pediatric  Dental  Health

• Swallowing is a complex act involving the coordination of the mouth, pharynx, larynx, and esophagus.
• Swallowing has three phases:
  oral, pharyngeal, and esophageal.
• The oral phase of swallowing:
  The oral phase is voluntary, and is controlled by the cerebral cortex and corticobulbar tracts of the brain. It is divided into the oral preparatory and oral propulsive phases.
  The oral preparatory phase prepares the bolus of food, so that it is “swallowable.”
  The oral propulsive phase propels the food from the oral cavity into the oropharynx.
• The paryngeal phase of swallowing:
  This is the shortest, but most complex phase. This phase is involuntary and is triggered by contact of the bolus with the tonsillar pillars and pharyngeal wall. It takes place in less than one second.
  The swallow reflex involves high cortical centers, brain stem centers, and cranial nerves V (trigeminal), VII (facial), IX (glossopharyngeal), X (vagus) and XII (hypoglossal).
  There are 29 muscle pairs which are involved in this phase of swallowing. First, the soft palate moves upward to seal the nasal cavity. Then the larynx and hyoid bone move forward and upward. The epiglottis fold back to protect the airwary. The tongue pushes the bolus of food downward into the pharynx.
• The esophageal phase of swallowing:
  This final phase of swallowing is controlled by the brainstem and myenteric plexus.
  The bolus of food is moved down by a peristaltic wave that begins in the pharynx and ends at the lower esophageal sphincter. The lower esophageal sphincter (LES) allows the bolus to enter the stomach.
  
  WHAT TYPES OF SWALLOWING DISORDERS CAN CHILDREN HAVE?
• Children can have swallowing disorders in the oral phase, pharyngeal phase, or esophageal phase. They can also experience aspiration of food into the airway.
• Oral phase swallowing disorders:
  These disorders are usually caused by impaired control of the tongue during swallowing.
  There may be: difficulty keeping liquid in the mouth, difficulty chewing food, pocketing of food in the vestibule of the mouth, or aspiration of food during inhalation.
• Pharyngeal phase swallowing disorders:
  Food is retained in the pharynx, and may not reach the esophagus. As a result, some of the food may be aspirated into the airway.
• Esophageal phase swallowing disorders:
  This can be caused by a motility disorder, mechanical obstruction, or impaired opening of the lower esophageal sphincter.
  This results in retention of food and liquid in the esophagus.
  Zenker diverticulum may cause difficulty swallowing , with possible aspiration during sleep.
  Achalasia can cause faulty gastroesophageal junction relaxation, or faulty esophageal peristalsis.
• Aspiration:
  This is the passage of food or liquid through the vocal cords and into the trachea. It can be caused by the overflow of food or liquids which are retained in the pharynx. Aspiration may result in aspiration pneumonia, which is very serious.
  
  WHAT CAUSES SWALLOWING DISORDERS IN CHILDREN?
• Structural lesions, neurologic disorders, connective tissue diseases, psychiatric disorders, and iatrogenic problems can cause swallowing disorders.
• Structural lesions causing dysphagia (swallowing problems):
  Neoplasm, ingested caustic material, Zenker’s diverticulum, esophagitis, GERD, esophageal strictures, and Plummer-Vinson syndrome.
• Neurologic disorders causing dysphagia:
  Cerebral infarction, intracranial hemorrhage, multiple sclerosis, brain-stem infarction, cerebral palsy, myelominigocele, Moebius syndrome, and stroke.
• Connective tissue diseases:
  Muscular dystrophy and polio.
• Psychiatric disorders causing dysphagia:
  Psychogenic dysphagia.
• Iatrogenic causes (medical treatment) causing dysphagia:
  Medications such as: nitrates, calcium tablets, aspirin, Vitamin C, anticholinergic agents, iron tablets, calcium channel blockers, and tetracycline.
  
  WHAT ARE THE SIGNS AND SYMPTOMS OF IMPAIRED SWALLOWING IN CHILDREN?
• Drooling.
• Choking during swallowing.
• Recurrent pneumonia.
• Food sticking in the throat.
• Voice change.
• Pocketing of food in the mouth.
• Nasal regurgitation.
• Impaired gag reflex.
• Unexplained weight loss.
  
  HOW ARE SWALLOWING DISORDERS EVALUATED?
• The most important step in treating a swallowing disorder is establishing an accurate diagnosis.
• A multidisciplinary team provides the best method of establishing a diagnosis and providing treatment. The team often includes members from: speech pathology, nutrition, otolaryngology, gastroenterology, psychology, and occupational therapy.
• The evaluation of swallowing disorders begins with the child’s feeding history. Weight, caloric intake, and vital signs are assessed to determine if they are appropriate for the child.
• Medical comorbidities such as recurrent pneumonia, stridor, choking, stroke, or traumatic brain injury are noted.
• During the physical examination, abnormal voice or abnormal speech are noted – as they are signs of motor dysfunction. Lungs should be checked for wheezing, rales/crepitations, or ronchi.
• A full head and neck examination is done, including inspection of cranial nerve function. During the examination phase, the thyroid cartillage is gently moved to either side. The anterior part of the neck is palpated for masses. Laryngeal movement is evaluated by placing two fingers on the larynx during swallowing. Any facial symmetry is noted, as it may indicate cranial nerve involvement.
• The oral cavity, soft palate, and pharynx are examined for abnormalities. Ankyloglossia, cleft lip or palate, and macroglossia need to be excluded.
• A water swallow test may be used to check for abnormal drooling or coughing.
• Examination of: pace of feeding, ability to handle oral secretions, tongue and jaw movements, emesis, coughing, the number of swallows required to clear a bolus of food, and noisy airway during swallowing.
• The presence of a normal gag reflex may be verified by touching the pharynx with a cotton-tipped applicator. Some patients with dysphagia may have a normal gag reflex, however. During the gag reflex test, the palate should pull evenly and symmetrically. Lateral movement of the mucosa of the posterior pharynx suggests weakness on the opposite side.
• Nasal obstructions such as choanal atresia or choanal stenosis may cause feeding difficulties in children.
• The videofluorographic swallowing study (VFSS) is the gold standard for evaluating swallowing disorders. During this diagnostic procedure, the patient eats and drinks foods which are mixed with barium to make them radiopaque. The VFSS shows the motions of the anatomic structures of the oral cavity, pharynx, and esophagus.
• Any patient who experiences aspiration during feeding, in addition to showing cranial nerve IX or X involvement, should have MR imaging done to diagnose a possible brain stem lesion or a Chiari malformation.
  
  WHAT IS THE TREATMENT FOR IMPAIRED SWALLOWING IN CHILDREN?
• The goals of treatment are to maintain adequate nutrition, and to maximize airway protection.
• Swallowing disorders are usually managed by dietary modification, training in swallowing techniques, and exercises. Swallowing is usually the best therapy for swallowing disorders.
• The decision to allow oral feeding depends on balancing the convenience of oral feeding versus the potential risks for aspiration.
• For children with gastroesophageal reflux disease (GERD), a dietary modification such as pureed food may be useful. For children who have stroke or multiple sclerosis, dietary modification and swallow therapy may be useful.
• For some patients, holding the breath or tucking the chin may decrease aspiration of food during swallowing. Other compensatory techniques are: head rotation, head tilt, supraglottic swallow, and the Mendelsohn maneuver. Exercises can increase muscle tone of the lips, jaws, tongue, cheek, vocal cords, and soft palate.
• In children with severe disorders, it may be necessary to provide enteral or parenteral nutrition. The percutaneous endoscopic gastrostomy tube (PEG) is a safe way to provide nourishment in these severe cases. With PEG, the child is being fed directly into the stomach.
• Surgical treatment, such as esophageal dilation, or esophageal resection may be needed.
• Periodic reevaluation of a child’s pulmonary status and ability to feed are essential.
  
  An article in American Family Physician reviews normal and abnormal swallowing, methods of evaluating dysphagia, and treatment options for the problem. The article describes the physiology of swallowing, including the oral, pharyngeal, and esophageal phases of swallowing.
  
  Palmer JB, Drennan JC, Baba M: Evaluation and treatment of swallowing impairments. American Family Physician. April 15, 2002.
  
  
  

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