Oral cavity consists of the maxilla (upper jaw), the mandible (lower jaw), upper and lower lips, cheeks, tongue, teeth, floor of the mouth, hard and soft palates, uvula, and anterior and posterior faucial arches. The tongue



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Dysphagia Intervention in School Settings: Team Development and Management Strategies

Additional Resources



Compiled by



Rita L. Bailey, Ed.D., CCC-SLP, BRS-S





  • The oral cavity consists of the maxilla (upper jaw), the mandible (lower jaw), upper and lower lips, cheeks, tongue, teeth, floor of the mouth, hard and soft palates, uvula, and anterior and posterior faucial arches.




  • The tongue assists in mastication (chewing) and transportation of the bolus through the oral cavity.




  • The hard palate is the relatively hard, bony anterior portion of the palate. Tongue contraction against the hard palate assists in transporting the bolus to the back of the mouth for swallowing.




  • The soft palate is a muscular structure that separates the cavity of the mouth from the pharynx with swallowing or speaking. One of its roles is to close off the back of the nose during swallowing. This keeps food and fluids from moving into the nose when a person eats and drinks and helps establish pressures that assist in bolus transport.




  • The nasopharynx is the area of the upper pharynx that lies behind the nose.




  • The oropharynx is the area in the mid portion of the pharynx behind the soft palate.




  • The hypopharynx is the area of the lower pharynx that lies behind the hyoid bone.




  • The epiglottis is the top structure in the system of airway protection. It is structurally at the top of the system and sits behind the base of the tongue. It functions to help divert the bolus around the airway during swallowing.




  • The valleculae are two pockets formed by the approximation of the base of the tongue and the epiglottis. These valleculae, together with the pyriform sinuses, form small cavities or recesses into which food can collect before or after the swallow is triggered. Food usually does not remain in these pockets when the swallow is normal.




  • The esophagus is a hollow muscular tube that is enclosed by a sphincter at each end. The upper esophageal sphincter allows the bolus (food) to enter the esophagus, and the lower esophageal sphincter allows the bolus to leave the esophagus so it can enter into the stomach.




  • The larynx is primarily a valve that works to keep food from entering the airway in normal swallowing. Layers of airway protection consist of: the true vocal folds, the false vocal folds, and the epiglottis to aryepiglottic folds. Acting together with the epiglottis, this forms three levels of valving above the trachea that can close the airway and protect it from the intrusion of food or liquid during swallowing.




  • The trachea is a tube extending from the larynx to the bronchi, and its function is to carry air to the lungs. It shares a wall with the esophagus.



During swallowing the goal of the system is to move food into the digestive system and keep it out of the respiratory system. The following events occur rapidly to support this goal.


Oral Preparatory Phase:

  • Timing: variable

  • Voluntary

  • The food enters the mouth and chewing breaks it down into smaller and smaller pieces while mixing with saliva

  • This makes food easier to swallow and increases the surface area of food on which saliva can act

  • The tongue, lips and cheeks assist the teeth in the process by allowing the food to be moved around the oral cavity

  • This phase ends when the food is formed into a bolus









Oral Transport Phase:


  • Timing: 1-1.5 seconds

  • Voluntary

  • Begins when tongue is in tipper (tip on alveolar ridge) or dipper (bolus on floor of mouth in front of tongue) position & first backward A-P movement

  • Tongue and sides contact alveolar ridge

  • Center portion of tongue elevates from front to back and forces bolus to move to back of mouth (A.K.A. stripping action)

  • Phase ends when bolus passes faucial arches


Pharyngeal Phase:


  • Timing: 1 second or less

  • Involuntary, but appears to have a voluntary initiation component

  • Begins when the swallow response is triggered at the area of the faucial arches until the bolus passes through the upper esophageal sphincter (UES)

  • As bolus reaches the epiglottis it usually splits in half and the two halves rejoin at the pyriform sinuses.

  • Larynx moves anteriorly and superiorly and closes at 3 levels (true v-f’s, false v-f’s and epiglottis to a-e folds

  • UES opening signals start of esophageal phase

  • Most critical phase of swallowing because it is the “airway protection phase”






Esophageal Phase:


  • Timing: 12-20 seconds in adults

  • Involuntary

  • Begins when the bolus passes through the UES until it passes through the lower esophageal sphincter (LES) to the stomach

  • Wavelike movements in the esophagus push the food downward (A.K.A. peristalsis)

Web Resources:



http://images.google.com/imgres?imgurl=http://www.dysphagiaonline.com

http://greenfield.fortunecity.com/rattler/46/images/Eat4.gif

NORMAL ORAL-MOTOR AND SWALLOWING DEVELOPMENT

(Adapted from Guerra & Vaughn, 1994)

Below is an outline of the Stages of normal oral-motor development in the young child, ages birth to three. The listing includes the developmental steps shown in the video and other steps which were difficult to portray. Be aware that there is overlap from one age range to another. Children who are still within the normal range of development progress at different speeds. Therefore, consider this a general guideline which each child will not follow exactly.



0-3 Months

  1. Nose breathing due to tongue filling oral space

  2. Primitive reflexes present

    1. Sucking Reflex

    2. Rooting Reflex

    3. Mouth-opening Reflex

    4. Phasic Bite Reflex

    5. Gag

  3. Swallow triggered by the suck

  4. Ease of initiating the sucking pattern

  5. Tongue flat and cupped

  6. Perfecting an efficient sucking pattern

  7. Jaw, tongue, and lips do not move independently

  8. May cough and squirm with everything but a nipple in the oral cavity

  9. Immature digestive tract and possible allergic reactions to formulas and/or solid foods

  10. Becoming aware of new sensations of taste, touch, etc.

Bottle and Breast

  1. Increased tongue cupping

  2. Corners of lips are more active; sucking pads provide stability

  3. Child orients towards the bottle/breast with body

  4. Recognizes the bottle/breast by touch

  5. Liquid loss, coughing and gagging common due to incoordination of swallowing and breathing

Spoon

(Authors do not recommend feeding solids at this age, but, if given solids, this is the way the child will perform)



  1. Easy tongue protrusion

  2. Top lip comes forward

  3. Lip does not close around spoon

  4. Mouth functions as a single unit

  5. Child regulates feeding

  6. Child will try to force a swallow with tongue protrusion when given thick consistencies (tongue is not ready to manipulate solids).

4-6 Months

Bottle and Breast



  1. Infantile reflexes become integrated

  2. Suck is strong and rhythmical

  3. Suck-wallow pattern with easy protrusion of tongue

  4. Tongue cupped around the nipple

  5. Child can hold mouth open in anticipation of nipple

Cup and Spoon

  1. Approaches cup as if it were a bottle

  2. Difficulty coordinating suck-swallow-breathing

  3. Lips close on spoon and cup

  4. Tongue movement is mainly forward and backward

  5. Tongue shows some up and down movements

Solids

  1. Sucks solids

  2. Tongue may lateralize inside the mouth

  3. Diagonal jaw movements occur

  4. Loss of semisolid food

  5. May have difficulty propelling bolus to posterior oral cavity and on to the pharynx

  6. Gagging on the bolus is common

7-9 Months

Bottle and Breast



  1. Begins to hold bottle independently

  2. Strong lip closure and tongue cupping

  3. Rhythm of suck varies

  4. Swallow occurs independently of a preceding suck

  5. No longer loses liquid

Cup

  1. Begins to hold cup independently

  2. Regulates flow of liquid

  3. Coordinated suck-swallow-breathing pattern

  4. While drinking, child may place tongue under cup rim for stability

  5. Tongue moves with jaw

  6. Child pushes cup back into mouth

  7. Liquid loss is great

  8. Up and down jaw movements begin to decrease

Spoon

  1. Body moves forward toward spoon

  2. Upper lip cleans spoon

  3. Jaw opens wide and stabilizes

  4. Lower lip pulls in to remove food

  5. Begins to bite on spoon for stability (more common at seven months, especially when solids are introduced later)

Solids

  1. Can hold jaw in a closed position

  2. Oral exploration of food

  3. Tongue moves food from side to center and center to side

  4. Integrated diagonal jaw movements

  5. Lips show lateral closure, closing tightly at the corners

  6. Jaw movements separate from tongue and lip activity

  7. Up and down munching pattern

10-12 Months

Bottle and Breast



  1. Strong, rhythmical suck predominates

  2. Longer sequences of suck-swallow-breathing

Cup

  1. Child moves forward to meet cup

  2. May stabilize by biting down on cup

  3. No tongue protrusion under cup

  4. Decrease in up and down jaw movements when drinking from a cup

  5. Sucks rhythmically when jaw is stable

  6. Liquid loss continues

  7. Lip closure occurs when swallowing liquids

  8. Possibly up to 6 swallows with one breath

Spoon

  1. Overgeneralizes biting for stability

  2. Teeth are new sensory receptors

Solids

  1. May show diagonal rotary jaw movements

  2. Bites through cookie in a controlled manner

  3. Grades jaw movement for biting

  4. Oral explorations of food more apparent

  5. Begins to clean lower lip with upper incisors

  6. Tongue protrusion during the swallow common

  7. Lips closed when swallowing solids

13-15 Months

Bottle and Breast

*Child usually off the bottle and/or being weaned from breast

Cup


  1. Refining swallowing skills present at 10-12 months

  2. External jaw stabilization begins

  3. Long drinking/swallowing sequences, up to one ounce at a time

  4. Able to suck through a straw when frequently exposed to straws

Spoon

  1. Refining swallowing skills present at 10-12 months

  2. Lower lip draws inward; food cleaned and/or retrieved with upper incisors

Solids

  1. Refining swallowing skills present at 10-12 months

  2. Beginning to have a controlled bite with a hard cookie

  3. Lip closure when chewing large mouthfuls of food

  4. Cleaning movement with upper incisors becomes integrated with chewing

16-18 Months

Cup


  1. Stabilizes externally on rim of cup

  2. Better lip and tongue control

  3. Drinks in long sequences

  4. Lips contain liquid in mouth

  5. Tongue can move separately from jaw

Spoon

1. May push spoon down on tongue

Solids


  1. Removes food from lips with tongue, teeth, or fingers

  2. Tongue tip elevates for the swallow

  3. Better grading of movements

  4. Opens mouth very little to bite

  5. Vertical tongue movements with solids

  6. May still drool if cutting teeth

  7. Controlled bite with a hard cookie

  8. Minimal loss of food when chewing and swallowing

19-24 Months

  1. Excellent coordination of swallowing with breathing pattern

  2. Better lip control

  3. Develops internal jaw stabilization

  4. Drinks from a straw regardless of amount of exposure to straws

  5. Uses tongue to clean lips

  6. No longer loses liquid when drinking from a cup

  7. May begin transferring bolus across midline of the tongue

25-36 Months

  1. Consistent use of internal jaw stability

  2. Tongue used to clear lateral sulci

  3. Food is easily transferred from side to side in the mouth

  4. Grades jaw opening for different thicknesses of food

Guerra, M. G., & Vaughn, S. (1994). Normal oral-motor and swallowing



development: Birth to 36 months. Bizbee, AZ: Imaginart International.

Related Development and Skills that Facilitate Self-Feeding Development


    • Physical stability

    • Increased ability to plan and control distal movements

    • Visual perception, hand-eye coordination, or predictable and supported settings

    • Others?

    • The biggest factor is supported OPPORTUNITY!

Interdisciplinary Consultation


Student:____________________________________________ Age:____________DOB:______________________________

Consultation date:____________________________________ Physician:__________________________________________

Diagnosis:_______________________________ Exceptionality:_____________________________________

Case Manager:____________________________ Present diet:_______________________________________­

Medical Hx:_______________________________________________________________________________________

___________________________________________________________________________________________

Present positioning during meal:________________________________________________________________

School:____________________________Teacher:_________________________________________________

SLP____________________OT:_____________________PT:_______________________________________

Other school support personnel and/or services:____________________________________________________




Intake Observations

Yes

No

Unknown

Comments

Current nutritional intake appears adequate













Remains alert and oriented for duration of meal













Voluntary swallowing (on command)













Requires increased time to eat













“wet” vocal sound, cough, vocal changes













Respiratory changes with eating













Gag reflex













Specific food avoidance behaviors













Other limiting mealtime behaviors













Oral apraxia













History of dysarthria













History of frequent upper respiratory infection, BPD, CLD, pneumonia













Hx of cleft













Documented aspiration













Hx prolonged intubation/tracheostomy













Neurological impairment













Hx of non-oral feeding













Known food allergies













PEG tube













Other: (please list)















Interdisciplinary Consultation
General observations:

Behavior: _______ cooperative ________resistant

Alertness:______ no deficit ________mild deficit________moderate deficit______severe deficit

Follows directions: ________verbal __________gestural________visual_________none

1-step__________ 2+ step_______________

Vision: _____no known deficit _____mild deficit______moderate deficit _____ severe deficit


General Physical Observations:

Abnormal reflexes:_______________________________________________________________


Trunk:

_______excessive extension________ hypertonic (increased tone) _______dystonia

_______scoliosis________kyphotic _______asymmetric _________hypotonic (low tone)

________benefits from external positioning support(s) as listed:___________________________

______________________________________________________________________________
Head control:

________excessive head/neck hyper extension ______poor head control _______ excessive head

movements

Facial:

_______asymmetrical __________contortions __________jaw extension _______

_______ open mouth posture ________increased tone __________decreased tone
Breathing patterns:

________mouth breather ________audible inhalation ___________ other: _________________


Observation of feeding:

Indicate functioning by checking (+) for appears adequate, and (-) for appears inadequate for each food texture.










Thin Liquid

Nectar liquid

Honey liquid

Pureed

Soft

Solid


Comments:







+ or -

+ or -

+ or -

+ or -

+ or -

+ or -




Accept

























Lip closure

























Tongue movements

























Jaw movements

























Swallow appears timely

























Residue in mouth following swallow

























Symptoms of airway compromise (i.e., cough, wet vocal quality, etc)
























Interdisciplinary Consultation


During this assessment, student was fed __________________ by________________________

_________________positioning supports___________________________________Equipment


Observations:
__________drooling _________excessive oral secretions

__________gagging _________food spillage from lips

__________residue in oral cavity _________bite reflex

__________tongue thrust _________oral apraxia

__________gag _________cough

__________clears throat _________wet or hoarse vocal quality

__________apparently delayed swallow _________absent tongue lateralization

__________tongue thrust _________cued swallow

__________poor jaw control _________fatigues quickly

__________other (describe):_________________________________________________________________________________

__________________________________________________________________________________________
Self-feeding observations: (if applicable) ____________________________________________________________________________________________________________________________________________________________________________________
Comments: __________________________________________________________________________________________

__________________________________________________________________________________________


Recommendations:

  1. _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

  2. _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

  3. _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

  4. _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

_______parent consult requested _________date

_______nursing consult _________date

_______physician contact _________date

_______received signed physician approval _________date

_______other referrals/consults recommended: ________________________________________


Signature:

______________________________ _______________________________________

Speech-language pathologist Occupational therapist, Physical therapist, other

Student Name: ___________________ Date: __________________


Speech-language pathologist (SLP): __________________________________________

Feeding Plan Recommendations


SLP recommended diet texture: (i.e., pureed advancing to soft as tolerated) _____________________________
SLP recommended liquid consistency: (i.e., nectar thickened liquids) __________________________________

*School personnel may add thickener to liquids when indicated per child symptoms (i.e., when child appears fatigued, with increased liquid loss at lips, or if cough or hard swallow, etc., are observed)


SLP/OT/PT recommended positioning for feeding/swallowing: (i.e., upright in wheelchair, headrest and pillow supports for arms.)___________________________________________________________________________
SLP/OT/PT recommended adaptive/assistive equipment for use with feeding/swallowing:

(i.e., spoon with built-up handle and rimmed bowl with suction cup to table placed at students midline).

__________________________________________________________________________________________
Please specify the following medical information related to student’s diet (when applicable):
Tube feeding (specify type and amount)_______________________ is or is not required ______X’s daily when the student is in attendance at school.
Food allergies:______________________________________________________________________________

Calorie needs: ______________________________________________________________________________

Supplements:_______________________________________________________________________________
Additional comments, precautions, and/or recommendations:

__________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________
Please check one:
_______I am in agreement with these recommendations as listed.

_______I am in agreement with these recommendations with the following addition(s) and/or clarifications:_________________________________________________________________

____________________________________________________________________________

Physician Name (please print):____________________________________

Date:__________________________

_______________ ____________ _______________

Physician signature Physician phone Physician fax

*Forms adapted from Homer, E. M. (2002). An interdisciplinary team approach to providing dysphagia treatment in the schools. Seminars in Speech and Language, 24(3), 215-234.

Case History Information

Feeding/Swallowing Evaluation

Illinois State University

Department of Communication Sciences and Disorders


Please answer the following questions as thoroughly as possible:


  1. Child’s Name ______________________

  2. Date of birth ______________________

  3. Birth weight_______________________

  4. Birth complications___________________________________________________________________________

______________________________________________________________________________________________________________________________________________________________________________________________

  1. Diagnosis____________________________________________________________________

  2. Primary caregiver(s)____________________________________________________________

  3. Other children in the home:______________________________________________________

  4. Does your child have: allergies?________ asthma?_______other medical complications?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Feeding History:



  1. In infancy, child was _______________(breast fed, bottle fed, tube fed). If tube fed, why and for how long?______________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________



  1. Was s/he on a ventilator? ______________ If yes, how long?__________________________

  2. How long did early feedings last?________________________________________________

  3. Were any strategies (i.e., positioning, external jaw/cheek support, different bottles/nipples, etc.) used to help with early feeding?________________________________________________________________

If so, please explain:___________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________


If your child is fed orally,

  1. When did s/he transition from formula/breast milk to baby foods (pureed)?________________

  2. When did s/he transition to textured foods?_________________________________________

  3. When did s/he transition to soft solids?_____________________________________________

  4. When did s/he transition to solid foods?____________________________________________

  5. What is his/her current diet? (Please provide amounts and types of a typical day’s intake-both orally and by tube)_______________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Behavioral Checklist

Check the following descriptions of behaviors/actions that are consistently exhibited (at least once per week) at the mealtime:
_______a poor appetite _______"messy" eating; frequent

spills
_______disinterest in food _______has ability, but doesn't use

napkin

_______food refusal _______prefers liquids over solid



food
_______extreme food "pickiness" _______poor eye contact with

communication partner or

_______talks with mouth full feeder
_______gagging with or without vomiting _______doesn't keep hands to self

_______mealtime tantrums _______eats too fast


_______unusual food habits _______eats too slow
_______food-texture selectivity _______doesn't orient to feeder, but

orients at other times

_______excessive overeating _______expelling of food
_______yells _______takes bites that are too large
_______whining or fussing at mealtimes _______exhibits self-stimulatory

behavior at mealtime

_______requests for non-served foods _______talks too much at mealtime
_______takes food from another's tray/plate _______takes bites that are too small
_______gets out of seat _______drinks too fast
_______easily distracted from eating _______ignores communication

partner/feeder


_______throws food _______chews with mouth open

Check the following reactions that have been observed with eating:


Coughing ________ How often per week, month, etc.?____________________

Gagging ________ How often per week, month, etc?_____________________

Slow eating ________ How often per week, month, etc?_____________________

Choking ________ How often per week, month, etc?_____________________

Wet vocal quality______ How often per week, month, etc?_____________________

Noisy breathing associated with feeding ______________ How often per week, month, etc?_____________________ (yes - no)

Upper respiratory

infections,

pneumonias, etc._______ How often in the past year? _____________________

Other physical

signs associated with

eating (i.e., heart rate,

color changes,

respiratory changes,

weight loss, etc) ________ Describe what has been observed and how often it has

occurred in the past year: ___________________________

________________________________________________

________________________________________________ ________________________________________________ ________________________________________________

Hospitalizations in

the past year? __________ Why?___________________________________________

________________________________________________

________________________________________________

________________________________________________

How long?_______________________________________

What is your child’s current weight & height (if known)___________________________
Feeding Preferences and Current Practices:

What is your child’s preferred temperature for liquids?_________

For foods traditionally served warm?__________

For foods traditionally served cold?___________

Does your child prefer foods with strong tastes?_________ Foods with bland tastes?_______ Both_______

Please list 4-5 of your child’s favorite foods:___________________________________________________________

_______________________________________________________________________________________________

Please list 4-5 foods your child doesn’t like:____________________________________________________________________________________________

_______________________________________________________________________________________________
Is your child’s food modified for him/her (i.e., chopped, ground, pureed, etc)? If so, please explain:______________________________________________________________________________________________________________________________________________________________________________________________

Does your child receive any nutritional or vitamin/mineral supplements? If so, please describe:_______________________________________________________________________________________________________________________________________________________________________________________________

Does your child use any particular bowls, utensils, cups, etc? If so, please describe:_______________________________________________________________________________________________________________________________________________________________________________________________

Does your child sit in a special chair for meals?__________ If so, please describe:_______________________________________________________________________________________________________________________________________________________________________________________________

What positioning supports are used in this chair?____________________________________________________________

Does your child ‘help’ with self-feeding?_________________________________________________

With utensils?_______With fingers?________

Does your child feed himself/herself?____________________________________________________

Is your child fed by others nearly 100% of the time?_________________________________________
Communication:

Is your child’s primary mode of communication-

Verbal________________ facial expressions____________

Vocalizations__________ points/gestures______________

AAC devices __________ other__________________________________________________________________________________________________________________________________________________________________________________________________
What are your goals for your child related to feeding/swallowing?

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


What are your primary concerns for your child related to feeding/swallowing?

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________






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