2. CONTENTS
• DEFINITION
• ANATOMY OF ORAL STRUCTURE
• PHYSIOLOGY OF ORAL STRUCTURE
• WHAT IS ORAL DYSFUNCTION?
• CAUSES OF ORAL DYSFUNCTION
• SYMPTOMS OF ORAL DYSFUNCTION
• EVALUATION
• TREATMENT
• TRAINING FOR FEEDING IN PREMATURE INFANTS
• REFERENCES
3. FEEDING: DEFINITION
• Feeding can be defined as placement
of food in the mouth, manipulation of
food in oral cavity prior to initiation of
swallow, including mastication and
oral stage of swallow when the bolus is
propelled backward by the tongue.
5. Oral Phase of Swallowing
Oral Preparatory phase
Oral phase
B
Food is held within the mouth A bolus is formed in the central portion of the tongue
At same time, the base of the tongue and the soft palate close the oral cavity to prevent food
spilling into the open larynx and trachea.
Tongue pushes bolus posteriorly toward the pharynx with an anterior-to-posterior tongue
elevation.
As the bolus enters the pharynx the actual swallow or pharyngeal reflex is triggered.
6. Pharyngeal Phase
Esophageal Phase
This phase is a reflex action. The bolus passes through the pharynx quickly and then enters the esophagus.
This takes place in less than a second.
The initiation of this process starts when the bolus passes the anterior faucial arch and reaches the posterior
pharyngeal wall.
Elevation of the soft palate prevents material from entering the nasal cavity.
This stage is followed by the pharyngeal constrictor muscles pushing the bolus further into the pharynx, toward
the cricopharyngeal sphincter.
The larynx prevents material from entering the trachea by respectively closing the true vocal cords.
Contraction of the lower pharyngeal constrictor is followed by relaxation of the cricopharyngeal muscle, allowin
the bolus to pass into the esophagus.
7. WHAT IS ORAL DYSFUNCTION?
• Children with hypersensitive oral dysfunction may be very
picky eaters and may possibly one eat one type of food.
• Many children with oral dysfunction may resist eating solid
foods and may gag when trying to eat foods with a lot of
texture.
• They may also prefer bland food and dislike using toothpaste.
• In addition, they may also have
a fear of choking.
• Those with hyposensitive oral dysfunction may put all kinds of
food and nonfood items in their mouths. In addition, they may
chew on their clothing or fingers. They may also prefer flavorful
food.
8. CAUSES OF ORAL DYSFUNCTION
• Some of the conditions:
o Cerebrovascular accident(CVA),
o Head injury ,
o Brain tumor,
o Anoxia,
o Guillain-Barre syndrome,
o Parkinson disease,
o Quadriplegia.
9. SYMPTOMS OF ORAL DYSFUNCTION
• Symptoms reported by patient (check all that apply):
o Drooling
o Coughing
o Choking
o Difficulty swallowing:
• Solids
• Liquids
o Pain on swallowing
o Weight loss
o History of aspiration or pneumonia
10. EVALUATION
• Mental status:
o Alert or oriented
o Direction following
• Physical status(symmetry, control, tone):
o Head control
o Trunk control
o Endurance
o Respiratory
o Suctioning required
o Tracheostomy
11. EVALUATION
• Outer oral status:
o Facial expression
o Jaw movement
o Lip movement
o Sensation
o Abnormal reflexes
• Inner oral status(symmetry, control ,tone) :
o Dentition
o Tongue
• Appearance
• Tone
• Movement
o Protrusion
o Lateralization
o “ ng”-”ga”
12. EVALUATION
• Soft palate/Gag reflex
• Cough (reflexive / voluntary)
• Swallow
o Spontaneous
o Voluntary
o Laryngeal movement
• Tongue
• Elevation
13. EVALUATION
• Food management
o Puree
o Mechanical soft
o Chopped/ground
o Regular diet
o Liquids
• Thick
• Semi thick
• Thin
14. TREATMENT: GOALS
1. To improve motor control at each stage of swallow
through normalization of tone and the facilitation of
quality movement
2. To maintain an adequate nutritional intake
3. To prevent aspiration
4. To re-establish oral eating to the safest , optimum level.
5. To facilitate appropriate positioning during eating
15. PRINCIPLES OF FEEDING
1. Patient is looking at and reaching for food
o Visual field
o Normal hand to mouth movement patterns
o As much control of the situation-adjustment
o Patient’s intake is monitored –avoid too much food in
to the mouth.
o To monitor for sign of aspiration
o Assesse voice quality upon completion of the swallow
2. After completing the feeding process, the
patient should remain in an upright position for
15-30 min to reduce the risk of reflexing
16. DURING ORAL FEEDING
• Patient must:
1) Be alert,
2) Be able to maintain adequate maintain trunk and
head positioning with assistance,
3) Have a beginning tongue control,
4) Manage secretion with a minimal drooling and
5) Have a reflexive cough
17. DIET SELECTION
• Food chosen should
1) Be uniform in consistency and texture,
2) Provide sufficient density and volume,
3) Remain cohesive,
4) Provide pleasant test and temperature and
5) Be easily removed and suctioning when necessary
18. DIET PROGRESSION
• Stage – I food level( pureed form):
1) best for a patients with little or no jaw control, moderate or delayed
swallow.
2) Pureed food move more slowly, allowing time for the swallow response to
trigger.
3) It helps to increase the oral intake and patient should be advanced to
the next level as soon as possible.
• Stage – II food level( mechanical soft / cohesive):
1) Best for a patients with a beginning rotatory chew, enough tongue
control with assistance to propel food back toward the pharynx, and a
minimal delayed swallow.
2) Reduce the risk of aspiration and start of the swallow response as the
back of the tongue elevates toward the hard palate,
3) Patient improve tongue control.
19. DIET PROGRESSION
• Stage – III food level(chopped / ground food):
1) This stage require chewing, controlled bolus formation, and a fair
swallow.
2) This food group offers a wider variety of consistencies
3) Patient should progress to a regular diet
• When a patient is ready to progress to next diet level the
therapist can adjust the meal by requesting one or two item
from the higher group, enabling assessment at new level
20. Treatment - Oral preparatory stage
Struct Symptoms Problem Pre-feeding technique Feeding technique
ure
Trunk Leaning to ↓trunk tone, Facilitate trunk strength Assist patient to hold
one side Ataxia , Exercises : patient clasp correct position as a
↑trunk tone, hands, lean down, touch head control,
Poor body food provide perceptual
awareness Arm raise to 90’ shoulder boundary ,lateral
flection moves arm trunk support
turning side 2 side
Hips sliding Adjust positioning so
forward out ↑tone in hip Provide firm sitting that patient lean
of chair extensors surface slightly forward
Head Inability to ↓tone Facilitate strength Assist with head
hold head in Weakness through neck & head control
mid line flexion ,extension lat.flex
Inability to ↑tone , Tone reduction of head As above
move head Poor ROM shoulder and trunk
21. Treatment: Oral preparatory stage
Stru. Sympt. Problem Pre-feeding technique Feeding technique
UE Spillage ↓tone Facilitate tone through weight Guide correct
of food Apraxia bearing , taping muscle belly movement pattern :
from ↓ co- consider adoptive
utensil ordination Reduce proximal tone from equipment
scapula mobilization weight
Inability ↑tone bearing See above
to self- Abnormal
feed movt.
pattern
Face Droolin ↓lip Place weight blade between Use side hand grip for
g , food control , patient’s lips head control , the
spillage poor Ask patient to hold trunk blade therapist assist lip
from sensation, while therapist tries to pull it close & jaw closer
mouth apraxia out. Use straw when
Vibrate lips with electric tooth drinking liquid
↓sensation brush Place food to
Lip exercises 2-3 times daily , unimpaired side.
Blow bubble in to glass of liquid Use cold food / liquid
23. Treatment: Oral preparatory stage
Struct. Symptoms Problem Pre-feeding technique Feeding technique
Tongue Pocketing of ↓sensation Tongue exercise Avoid crumbly foods
food in Poor tongue Stroke patient
cheeks. control outside cheek where
Poor bolus pocketing occur with
formation index finger back
and up towards
patient’s ear.
Retracted Increased Tongue ROM , wrap tip Reduce tone as
tongue tone, of tongue , gently pull needed during meal
Retracted tongue forward, side to
jaw side and up down
Vibrate tongue back &
side ways to decrease
tone & facilitate
protrusion
Normalize neck tone &
jaw tone
24. Treatment: oral stage
Struct. Symptoms Problem Pre-feeding Feeding
technique technique
Tongue slow oral transit,
Poor anterior to Practice “ng-ga” Tuck chin toward
Inability to make posterior sounds chest.
a “ng-ga” sound movements. As above Avoid crumbly
:↓tone, food.
Poor sensation, Use warm vs.
Tongue retraction ↑tone hot/cold food.
Slow oral transit Inability to form Grasping tongue
time central groove in wrapped in gauze, As above
Inability to tongue, pull forward to
channel food Apraxia front teeth; stock
back toward firmly down
pharynx middle of edge of
tongue blade
25. Treatment: oral stage
Struct. Symptoms Problem Pre-feeding technique Feeding technique
Tongue Repetitive Tongue Facilitate tongue Correct positioning.
movt. Of thrust retraction to bring tongue Place food away from
tongue; food back into normal position; midline of tongue
is pushed out vibrate on either side of toward back of
front of mouth the frenulum, with a mouth.
finger. Provide pressure to
Increase jaw control; teach back of tongue with a
isolated tongue spoon after food
movement. placement
Food falls off Poor Ice tongue; ice in gauze to Use food with a high
tongue into sensation prevent from slipping into density.
cheeks or food the pharynx; brush tongue Alternate presentation
remain on with a tooth brush to of foods- cold, hot
tongue stimulate receptors. during meal.
without
patient
awareness.
26. Treatment: oral stage
Struct. Symptoms Problem Pre-feeding technique Feeding technique
Tongue Slaw oral Poor Ask patient to practice Give correct
transmit tongue k,g,n,d,t sounds. position with
time; food elevation; Lightly touch tongue blade or finger under chin
remains on decrease soft tooth-brush to roof of with base of
hard palate; tone mouth at back of tongue, tongue, move
coughing instruct patient to press finger upward and
before tongue, resist movt with forward to
swallow brush. facilitate elevation.
Vibrate tongue at below chin;
provide quick stretch by
pushing down on base of
tongue.
Slow oral Decrease Tone reduction: vibrate base Adjust correct
transit time. tone, of tongue, wrapped tongue by position to ↓ tone.
Food ↑ tone, wet gauze pull tongue Reduce tone by
remain on ↓ LOA forward. giving rest during
back of Weakness exercise.
tongue
27. Treatment: oral stage
Structure Symptoms Problem Pre-feeding technique Feeding technique
Tongue Coughing ↓ sensation Grasping base of With finger under
before tongue under chin chin at a base of
swallow; between two fingers tongue, move
retracted move it back and forth finger.
tongue. to ↓ tone.
28. Treatment: pharyngeal stage
Struct Symptoms Proble Pre-feeding technique Feeding
ure m technique
Soft Tight voice; Inadeq Facilitate normal head and neck Facilitate
palate nasal uate position normal
regurgitation soft Have patient tuck chin into positioning
Air felt palate therapist cupped hand and Patient have
through nose. movt; applies resistance afterwards tuck chin
↓ tone, ↓ tone, patient says “ah” slightly to ↓
nasal speech rigidity, Speed and height of uvula, rate of food
↑ tone elevation should ↑ followed by entering into
thermal application. pharynx
Delayed ↓ Thermal application repeat up to ten Alternate
swallow triggerin times a day presentation
g of start with cold
respons substances
e followed by hot.
29. Treatment: pharyngeal stage
Struct. Symptoms Problem Pre-feeding tech Feeding technique
Hyoid Delayed Delayed ↑ tongue humping Place index finger
elevation of swallow as elevation of under chin and
hyoid bone, Incomplete tongue and hyoid facilitate tongue
Poor tongue swallow stimulates elevation
elevation, Abnormal triggering of
Tongue tongue tone; response
retraction poor ROM Tone reduction
Phary Coughing after ↓ pharyngeal None Alternate presentation
nx swallow movement, of stage II & stage III
Penetration into foods.
laryngeal Tilt head to stronger
vestibule side.
Coting of If patient with law
pharynx seen Unilateral tone, patient use
on pharyngeal compensatory
videofluroscop movements. technique: patient turn
y, head toward affected
Gurgly(hoarse) side during swallow to
voice prevent pooling in
affected pyriform
30. Treatment: pharyngeal stage
Struct Symptom Problem Pre-feeding technique Feeding technique
ure s
Larynx Coughing, ↓ laryngeal Quick ice up sides of Teach to clear throat
chocking elevation; larynx; ask patient to immediately after
after ↓ tone, swallow. swallow.
swallow Weakness Vibrate laryngeal Use effortful swallow.
musculature from under
chin
Noisy ↑ tone, ROM—side to side, back Placing finger and
swallow Rigidity, and forth. thumb along both side
Uncoordinat Using ice chipped or pack of larynx, assist with
ed swallow in wash cloth and place upward elevation before
around larynx for 5 swallow.
minutes
31. Treatment: pharyngeal stage
Structu Symptoms Problem Pre-feeding technique Feeding technique
re
Trachea Continuou Aspiration – Teach to produce Encourage patient to
s coughing if before: voluntary cough :ask keep coughing; facilitate
during, poor tongue to take deep breath reflexive cough.
before and control, followed by cough, Push downward on
after if during therapist uses palm of sternum when patient
delayed hand to push breath out.
swallow, downward on the Suction patient if
if after : ↓ sternum. problem increase.
pharyngeal
movement.
Blocked none Push into patient sternal
airway notch to assist with
cough.
Seek medical assistance
32. Esophageal Phase
Peristaltic muscle action pushes food through
esophagus to stomach OR aspiration occurs
Oral cavity doesn’t close When larynx opens,
Due to insufficient closure
well in preparatory phase of the larynx in delayed ↓ pharyngeal movt,
due to poor tongue control swallow bolus enters into trachea
33. Treatment : Esophageal stage
Structure Symptoms Problem Pre-feeding Feeding
technique technique
Esophagus Frequent Esophageal Requires a medical Report
regurgitation of diverticulum diagnosis; problem symptoms to
food or liquid can be seen medical staff.
and coughing or through traditional (therapist
choking after barium x-ray cannot treat)
swallow; study.
Material Surgical correction
collecting in a is needed
side pocket in a
esophagus.
Inability to pass Partial or total
through the obstruction of
pharynx or the pharynx or
esophagus esophagus
34. TRAINING FOR FEEDING IN PREMATURE
INFANTS
• Therapeutic positioning and handling are used to
enhance development of normal oral-motor skills.
• Placing the infant in an upright position with the neck
elongated is encourage.
• Hyper-flexion of the neck must be avoided because
occlusion of the airway must be result.
• The infant’s respiration, heart rate and color should be
monitored constantly, when first attempting oral feeding.
36. Facilitating Suck
• The position in which a baby is held during feeding, can
influence a baby’s ability to suck.
• Holding babies in the proper position not only helps them
relax and better control their shoulders, trunks, and hips,
but also helps them control their jaws, cheeks, lips, tongue
movements, & overall smoothness of swallowing.
• Proper positioning can affect the baby’s strength,
organization, and energy for sucking, increasing the time
of efficiently sucks on the nipple
• In the chin tuck sets up the neck & jaw muscles for the
strongest sucking
38. Shoulders & Trunk
• Ideally, the baby’s arms should be forward, with hands
resting on or near the bottle. The position in which the
baby’s shoulders are drawn back in a tight or retracted
position can lead to tension in the shoulders, neck, jaw,
and throat. Swallowing is more difficult, and the baby
has to work harder. The harder the baby has to work, the
less formula or breast milk will be consumed.
• When trying to improve baby’s shoulder and arm
position, remember that some babies cannot handle
both arms forward at first. They may need to start with
one arm and over time progress to both arms. Gradually,
your baby may comfortably rest both hands on the
bottle or may hold your hands while you are holding the
bottle
40. Tongue Lateralization
• Tongue lateralization is necessary for placing food over the teeth and
keeping it there during the whole chewing process. Without good sideways
tongue movement, food falls off the teeth and isn’t well-chewed.
• You can use the NUK brush with the child, or let the child use it while you
supervise. But a child should NEVER be left alone with the brush because
choking can occur.
• Infa-Dent Finger Toothbrush
41. Choosing a nipple and Cup
• Developmental Skills
• Size
• Shape & Design
• Safety
• Lid Cover
• Handles
• Weight
• Training System
42. References
Pediatric physical therapy, 3rd edition, by:
Jan Stephen Tecklin
Occupational therapy, 4th edition, by:
Lorraine Williams Pedretti
Starting again, by: Patricia M. Davies
