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

1. Palatal and lingual augmentation
prosthesis for patients with
dysphagia and functional
problems: A clinical report
Presented by
Mujtaba Ashraf
MDS II
Journal Club
Presentation
Tomohisa Ohno, DDS, PhD and Ichiro Fujishima, MD, PhD
The Journal of Prosthetic Dentistry
Available online 12 November 2016
1

2. INTRODUCTION
 Dysphagia: difficulty in swallowing
 It 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

3. •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 as Parkinson's disease, stroke,
or amyotrophic 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

4.  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

5. 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 lungs
Degenerative diseases include Parkinsonism,
Amyotrophic lateral sclerosis (ALS), Multiple
sclerosis, Huntington's disease, NiemannPick disease,
and Friedreich ataxia. 5

6. Palatal augmentation prosthesis:
A removable maxillofacial prosthesis which alters the hard
and/or soft palate’s 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
6

7. Lingual agumentation prosthesis:
A lingual augmentation prosthesis (LAP) attached
to the mandible to assist swallowing, which resulted
in improved swallowing function.
7

8. 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

9. 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

10. Fabrication
 Techniques 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

11.  Functional impression technique
 The 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 sounds
 The wax model was processed into
heat cured acrylic resin using the
normal wax elimination technique.
11

12.  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

13.  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 augmentation
prosthesis. A clinical report. J Prosthet Dent 1990;63:1-3.

14. 14
CLINICAL REPORT

15. 15
 A 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.

16. 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

17. 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

18. 18

19. 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.
19

20. 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

21. 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.
21

22. 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
22

23. 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

24. 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

25. 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
patient’s swallowing was easier with the
prostheses.
25

26. After provision of these 2 prostheses, dysphagia
rehabilitation 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

27. DISCUSSION
Both 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

28. 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

29. 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

30. 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

31. SUMMARY
 PAP 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

32. REFERENCES
 Cantor 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.
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