Journal Club

Presentation
and lingual augmentation

Palatal
Palatal and lingual augmentation
prosthesis
prosthesis for
for patients
patients with
with
dysphagia
and
functional
dysphagia
and
functional
problems:
problems:AAclinical
clinicalreport
report
Tomohisa Ohno, DDS, PhD and Ichiro Fujishima, MD,
Tomohisa Ohno, DDS, PhD and Ichiro Fujishima, MD,
PhD
PhD
The Journal of Prosthetic Dentistry
Available online 12 November 2016

Presented by
Mujtaba Ashraf
MDS II
1

INTRODUCTION

Dysphagia: difficulty in swallowing

Dysphagia:
difficulty in swallowing

may be a sensation that suggests difficulty in

ItItmay
be a sensation that suggests difficulty in

the passage of solids or liquids from the mouth

the passage of solids or liquids from the mouth
to the stomach, a lack of pharyngeal sensation,
to the stomach, a lack of pharyngeal sensation,
or various other inadequacies of the
or various other inadequacies of the
swallowing mechanism.
swallowing mechanism.

Oropharyngeal dysphagia (high dysphagia)

Oropharyngeal
dysphagia (high dysphagia)
The problem is in the mouth and/or throat,
The problem is in the mouth and/or throat,
sometimes caused by tongue weakness after a stroke,
sometimes caused by tongue weakness after a stroke,
or due to a difficulty making saliva. Issues in the
or due to a difficulty making saliva. Issues in the
throat are often caused by a neurological problem that
throat are often caused by a neurological problem that
affects the nerves (such as Parkinson's disease, stroke,
affects the nerves (such as Parkinson's disease, stroke,
or amyotrophic lateral sclerosis).
or amyotrophic lateral sclerosis).
Esophageal dysphagia (low dysphagia)
Esophageal
dysphagia (low dysphagia)
The problem is in the esophagus. This is usually
The problem is in the esophagus. This is usually
because of a blockage or irritation lumen. Often, a
because of a blockage or irritation lumen. Often, a
surgical procedure is required.
surgical procedure is required.
3

 Dysarthria
Dysarthria

is a motor speech disorder

is a motor speech disorder
resulting from neurological injury of the motor
resulting from neurological injury of the motor
component of the motor speech system and is
component of the motor speech system and is
characterized by poor articulation.
characterized by poor articulation.

other words, it is a condition in which

InInother
words, it is a condition in which
problems effectively occur with the muscles
problems effectively occur with the muscles
that help produce speech, often making it very
that help produce speech, often making it very
difficult to pronounce words.
difficult to pronounce words.

Cause:
Cause:
Neurological injury due to damage in the central or
Neurological injury due to damage in the central or
peripheral nervous system may result in weakness,
peripheral nervous system may result in weakness,
paralysis, or a lack of coordination of the motor
paralysis, or a lack of coordination of the motor
speech system.
speech system.
These effects in turn hinder control over the tongue,
These effects in turn hinder control over the tongue,
throat, lips or lungs
throat, lips or lungs
Degenerative
diseases
include
Parkinsonism,
Degenerative
diseases
include
Parkinsonism,
Amyotrophic lateral sclerosis (ALS), Multiple
Amyotrophic lateral sclerosis (ALS), Multiple
sclerosis, Huntington's disease, NiemannPick disease,
sclerosis, Huntington's disease, NiemannPick disease,
and Friedreich ataxia.
and Friedreich ataxia.
5

Palatal augmentation prosthesis:

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

Lingual agumentation prosthesis:

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

A palatal augmentation prosthesis (PAP) is an

A palatal augmentation prosthesis (PAP) is an
intraoral prosthesis used to improve dysarthria and
intraoral prosthesis used to improve dysarthria and
dysphagia by supporting contact between the
dysphagia by supporting contact between the
tongue and palate.
tongue and palate.

In patients with dysphagia, PAP improves the oral

In patients with dysphagia, PAP improves the oral
to pharynx bolus transportation and basal tongue
to pharynx bolus transportation and basal tongue
pressure.
pressure.

The provision of a PAP in patients with oral cancer

The provision of a PAP in patients with oral cancer
was first reported by Cantor et al.
was first reported by Cantor et al.
Since then, it has been mainly used for patients
Since then, it has been mainly used for patients
with oral cancer.
with oral cancer.
Recently PAP has been widely used to address
Recently PAP has been widely used to address
functional problems associated with dysphagia
functional problems associated with dysphagia
caused
by
cerebrovascular
disease
and
caused
by
cerebrovascular
disease
and
neurodegenerative disease, where its effectiveness
neurodegenerative disease, where its effectiveness
has also been recognized.
has also been recognized.

Fabrication
Fabrication
Techniques for making an interim palatal augmentation
Techniques
for making an interim palatal augmentation

prosthesis include the use of incremental additions of

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

10

 Functional impression technique

Functional
impression technique
The
softened
modeling
The
softened
modeling

compound/wax added layer by layer

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

11

 The augmentation plate was polished, finished.

The
augmentation plate was polished, finished.
The denture rechecked inside the oral cavity for ease of
The
denture rechecked inside the oral cavity for ease of

swallowing, deglutition and speech functions and further

swallowing, deglutition and speech functions and further
enhancement may be made if required.
enhancement may be made if required.

12

 Using light cure resin.

Using light cure resin.
The reshaped addition was polymerized with the
The
reshaped addition was polymerized with the

lightcuring unit. Incremental addition of resin was

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

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

CLINICALREPORT
REPORT
CLINICAL

14


61-year-old institutionalized man with a history of
AA61-year-old
institutionalized man with a history of

bilateral hypoglossal nerve injury was admitted for

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

At first, he could not eat orally because of

At first, he could not eat orally because of
penetration and aspiration. Because his tongue
penetration and aspiration. Because his tongue
movement was insufficient, he experienced
movement was insufficient, he experienced
dysphagia involving transportation of the bolus
dysphagia involving transportation of the bolus
from the oral to the pharynx.
from the oral to the pharynx.
The issues related to the tongue included
The issues related to the tongue included
noncontact of the tongue with the palate during
noncontact of the tongue with the palate during
swallowing, displacement of the tongue to the right
swallowing, displacement of the tongue to the right
posterior, and limited tongue motion range.
posterior, and limited tongue motion range.

16

He was trained to eat jelly orally, but he mainly

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

17

18

The oral residue of the patient after eating jelly; the

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

19

To
improve
bolus
To
improve
bolus
transportation and clearance
transportation and clearance
of the oral residue, a PAP
of the oral residue, a PAP
was provided.
was provided.
A mandibular intraoral
A mandibular intraoral
prosthesis
(lingual
prosthesis
(lingual
augmentation
prosthesis,
augmentation
prosthesis,
LAP) was also inserted to
LAP) was also inserted to
improve oral residue in the
improve oral residue in the
left lingual region
left lingual region

The PAP and LAP were fabricated using denture

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

Acrylic resin plates were first

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

21

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

22

Then only the LAP was inserted. The patient could

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

Videofuoroscopic 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

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

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

25

After provision of these 2 prostheses, dysphagia

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

26

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

This improvement would not have occurred with the PAP

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

28

Furthermore, the posture during swallowing was also

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

29

The provision of intraoral prostheses can be

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

30

SUMMARY
SUMMARY
PAP and LAP were provided for a patient with
PAP
and LAP were provided for a patient with

dysphagia due to bilateral hypoglossal nerve palsy.

dysphagia due to bilateral hypoglossal nerve palsy.
These 2 prostheses improved bolus transportation
These
2 prostheses improved bolus transportation
from the oral cavity to the pharynx, reduced oral
from the oral cavity to the pharynx, reduced oral
residue, and freed the patient from requiring a head
residue, and freed the patient from requiring a head
extension posture during swallowing.
extension posture during swallowing.

combination of these prostheses may help improve

AAcombination
of these prostheses may help improve
bolus transportation in patients with dysphagia of
bolus transportation in patients with dysphagia of
bilateral hypoglossal nerve palsy.
bilateral hypoglossal nerve palsy.
31

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