Palatal and lingual augmentation prosthesis for patients with dysphagia and functional problems: A clinical report

Palatal and lingual augmentation prosthesis for patients with dysphagia and functional problems: A clinical reportPresented byMujtaba AshrafMDS IIJournal Club PresentationTomohisa Ohno, DDS, PhD and Ichiro Fujishima, MD, PhDThe Journal of Prosthetic DentistryAvailable online 12 November 20161

INTRODUCTIONDysphagia: difficulty in swallowingIt may be a sensation that suggests difficulty in the passage of solids or liquids from the mouth to the stomach, a lack of pharyngeal sensation, or various other inadequacies of the swallowing mechanism.2

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Oropharyngeal dysphagia (high dysphagia)The problem is in the mouth and/or throat, sometimes caused by tongue weakness after a stroke, or due to a difficulty making saliva. Issues in the throat are often caused by a neurological problem that affects the nerves (such asParkinson's disease, stroke, oramyotrophic lateral sclerosis).

Esophageal dysphagia (low dysphagia)The problem is in the esophagus. This is usually because of a blockage or irritation lumen. Often, a surgical procedure is required.3

1.Tonsillitis. Xerostomia, tongue cancer2.3

Dysarthria is a motor speech disorder resulting from neurological injury of the motor component of the motor speech system and is characterized by poor articulation.In other words, it is a condition in which problems effectively occur with the muscles that help produce speech, often making it very difficult to pronounce words.4

Dys="hard, difficult, bad +arthrosis=articulation".4

Cause:Neurological injury due to damage in the central or peripheral nervous system may result in weakness, paralysis, or a lack of coordination of the motor speech system.

These effects in turn hinder control over the tongue, throat, lips or lungsDegenerative diseases include Parkinsonism, Amyotrophic lateral sclerosis (ALS), Multiple sclerosis, Huntington's disease, NiemannPick disease, and Friedreich ataxia.5

Palatal augmentation prosthesis:A removable maxillofacial prosthesis which alters the hard and/or soft palates topographical form adjacent to the tongue.It allows reshaping of the hard palate to improve tongue/palate contact during speech and swallowing due to impaired tongue mobility as a result of surgery, trauma, or neurological/ motor deficits.GPT-8

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Lingual agumentation prosthesis:A lingual augmentation prosthesis (LAP) attached to the mandible to assist swallowing, which resulted in improved swallowing function.

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A palatal augmentation prosthesis (PAP) is an intraoral prosthesis used to improve dysarthria and dysphagia by supporting contact between the tongue and palate.In patients with dysphagia, PAP improves the oral to pharynx bolus transportation and basal tongue pressure.8

The provision of a PAP in patients with oral cancer was first reported by Cantor et al.

Since then, it has been mainly used for patients with oral cancer.Recently PAP has been widely used to address functional problems associated with dysphagia caused by cerebrovascular disease and neurodegenerative disease, where its effectiveness has also been recognized.9

FabricationTechniques for making an interim palatal augmentation prosthesis include the use of incremental additions of wax, modeling compound, or tissue-conditioning material to an acrylic resin base.By using a light-cured resin that can be added incrementally to a prepared acrylic resin baseplate and functionally molded.10

Functional impression techniqueThe softened modeling compound/wax added layer by layer to the palatal part of the denture and the patient was asked to swallow several times and pronounce some letters.Linguoalveolar sounds/ Palatolingual soundsThe wax model was processed into heat cured acrylic resin using the normal wax elimination technique.

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TDNL, S11

The augmentation plate was polished, finished.The denture rechecked inside the oral cavity for ease of swallowing, deglutition and speech functions and further enhancement may be made if required.12

Using light cure resin.The reshaped addition was polymerized with the lightcuring unit. Incremental addition of resin was continued until linguo-palatal contact was adequate to produce a swallowing reflex.After curing, the prosthesis can be evaluated immediately, which makes adjustments or additions possible during the same appointment.Evaluation with pressure indicator paste revealed a uniform surface contact on completion.

13Meyer JB Jr, Knudson RC, Myers KM. Light-cured interim palatal augmentationprosthesis. A clinical report. J Prosthet Dent 1990;63:1-3.

14CLINICAL REPORT

15A 61-year-old institutionalized man with a history of bilateral hypoglossal nerve injury was admitted for dysphagia.The consciousness of this patient was clear.His injury had been caused by attempted suicide with a chain saw. The tongue presented no external organic problem.Two months later, after the acute stage, he was transferred to the rehabilitation ward and dysphagia rehabilitation was initiated.

abnormal psychology,refers to deficits or disabilities in social and life skills, which develop after a person has spent a long period living inmental hospitals,prisons, or other remote institutions.Cranial nerve 12, controls most of tongue movements motor

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At first, he could not eat orally because of penetration and aspiration. Because his tongue movement was insufficient, he experienced dysphagia involving transportation of the bolus from the oral to the pharynx.

The issues related to the tongue included noncontact of the tongue with the palate during swallowing, displacement of the tongue to the right posterior, and limited tongue motion range.16

He was trained to eat jelly orally, but he mainly alimented by nasogastric tube feeding. Oral residue and insufficient bolus transportation were revealed to be the main problems of dysphagia in a videofluoroscopic swallowing examination.17

The videofluorographic swallowing study (VFSS), also known as a modified barium swallowing (MBS) examination. It allows visualization of bolus flow in relation to structural movement throughout the upper aerodigestive tract in real time. Videofluorography with approximately 10 mL of a 2-fold dilution of 60 w/v%liquid barium (BARITOP 120; Kaigen Pharma Co) was used to evaluate the swallowing function.17

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Barium is a dry, white, chalky powder that is mixed with water to make barium liquid. Barium is an X-ray absorber.18

The oral residue of the patient after eating jelly; the jelly remained in the left sublingual region. Therefore, in the upright position, he turned his head upward a little to transport the bolus from the oral cavity to the pharynx using gravity.

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To improve bolus transportation and clearance of the oral residue, a PAP was provided.

A mandibular intraoral prosthesis (lingual augmentation prosthesis, LAP) was also inserted to improve oral residue in the left lingual region

The PAP and LAP were fabricated using denture lining material (Tissue Conditioner II; SHOFU Corp).20

Acrylic resin plates were first placed on the palatal side of the maxilla and the lingual side of the mandible, and the material was added on the palatal side and lingual side.Then a functional impression of the tongue during swallowing was made.

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At first, only the PAP was delivered, and the bolus (jelly containing barium and thickened liquid containing barium) entered into the left lingual space; the patient experienced difficulty in transporting the bolus from the oral cavity to the pharynx, as revealed by videofluoroscopic swallowing examination

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Then only the LAP was inserted. The patient could swallow well, but he needed to turn his head upward to assure bolus transportation

Videofluoroscopic swallowing examination with LAP only. Patient swallowed well but needed to turn his head upward for bolus transportation. Occlusal plane is upward.23

Finally, both the PAP and LAP were provided, after which he could swallow well and actively without requiring head extension.

Videofluoroscopic swallowing examination with both PAP and LAP in place.Patient could swallow well without turning his head upward. Occlusal plane is almost horizontal.24

Furthermore, although penetration was observed before providing the 2 prostheses on videofluoroscopic swallowing examination, it was not observed thereafter.The prostheses were worn in the daytime. The patients swallowing was easier with the prostheses.25

After provision of these 2 prostheses, dysphagiarehabilitation with PAP and LAP by a speech language pathologist and nurse was continued on virtually a daily basis.Approximately 1 month later, the patient could eat 3 meals orally, excluding food that was particularly difficult to swallow, and he no longer required nasogastric tube feeding.26

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DISCUSSIONBoth PAP and LAP were provided for a patient with bilateral hypoglossal nerve palsy. To our knowledge, this is the first report of a patient in which PAP and LAP were provided for a patient with dysphagia of functional problems.To improve dysphagia due to oral to pharynx bolus transportation difficulties, a PAP is usually provided.In this patient, the use of PAP alone yielded insufficient outcomes, and little improvement was obtained with only a LAP; however, insertion of both prostheses was highly effective.27

This improvement would not have occurred with the PAP or LAP alone. The problems in this patient were insufficient bolus transportation from the oral cavity to the pharynx and tongue displacement to the right posterior.Both prostheses were necessary to address these problems.28

Furthermore, the posture during swallowing was also improved with the PAP and LAP; the patient no longer needed to turn his head upward a little to use gravity for bolus transportation. This head extension posture increased the risk of aspiration. Because the provision of these 2 prostheses eliminated the need for head extension, the chin-tuck maneuver could be done, and the risk of aspiration and penetration was reduced.29

chin tuck during swallow it improves the closure of the larynx and thereby decreasing the risk of aspiration29

The provision of intraoral prostheses can be useful for improving dysphagia. This clinical report suggests that it is important to carefully observe oral cavity status and the process of swallowing and to consider provision of prostheses on the basis of these observations.30

SUMMARYPAP and LAP were provided for a patient with dysphagia due to bilateral hypoglossal nerve palsy.These 2 prostheses improved bolus transportation from the oral cavity to the pharynx, reduced oral residue, and freed the patient from requiring a head extension posture during swallowing.A combination of these prostheses may help improve bolus transportation in patients with dysphagia of bilateral hypoglossal nerve palsy.31

REFERENCESCantor R, Curtis TA, Shipp T, Beumer J III, Vogel BS. Maxillary speech prostheses for mandibular surgical defects. J Prosthet Dent 1969;22:253-60.Logemann JA, Kahrilas PJ, Hurst P, Davis J, Krugler C. Effect of intraoral prosthetics on swallowing in patients with oral cancer. Dysphagia 1989;4:118-20.Wheeler RL, Logemann JA, Rosen MS. Maxillary reshaping prostheses: effectiveness in improving speech and swallowing of postsurgical oral cancer patients. J Prosthet Dent 1980;43:313-9.Robbins KT, Bowman JB, Jacob RF. Postglossectomy deglutitory and articulatory rehabilitation with palatal augmentation prostheses. Arch Otolaryngol Head Neck Surg 1987;113:1214-8.Ono T, Hamamura M, Honda K, Nokubi T. Collaboration of a dentist and speech-language pathologist in the rehabilitation of a stroke patient with dysarthria: a case study. Gerodontology 2005;22:116-9.Light J, Edelman SB, Alba A. The dental prosthesis used for intraoral muscle therapy in the rehabilitation of the stroke patient. N Y State Dent J 2001;67: 22-7.Okuno K, Nohara K, Tanaka N, Sasao Y, Sakai T. The efficacy of a lingual augmentation prosthesis for swallowing after a glossectomy: a clinical report. J Prosthet Dent 2014;111:342-5.Ekberg O. Posture of the head and pharyngeal swallowing. Acta Radiol Diagn 1986;27:691.32

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