Deglutitive movement of the tongue under local anesthesia
Tatsuya
Fujiki1,
Teruko
Takano-Yamamoto1,
Keiji
Tanimoto2,
Jorge Nicolas Pereira
Sinovcic1,
Shouichi
Miyawaki1, and
Takashi
Yamashiro1
1 Department of Orthodontics, Okayama University Dental
School, Okayama 700-8525; and 2 Department of Oral and
Maxillofacial Radiology, Hiroshima University School of Dentistry,
Hiroshima 734-8553, Japan
 |
ABSTRACT |
The
purpose of the present study was to investigate whether or not sensory
input from the tongue affects deglutitive tongue movement. Subjects
were seven healthy volunteers with anesthetic applied to the surface of
the tongue (surface group) and seven healthy volunteers with the
lingual nerve blocked by anesthetic (blocked group). We established six
stages in deglutition and analyzed deglutitive tongue movement and the
time between the respective stages by cineradiography before and after
anesthesia. After anesthesia in both surface and blocked groups,
deglutitive tongue movement slowed and bolus movement was delayed. The
deglutitive tongue tip retreated in the blocked group. These results
suggest that delay of tongue movement by anesthesia causes weak bolus propulsion and that deglutitive tongue tip position is affected by
sensory deprivation of the tongue or the region innervated by the
inferior alveolar nerve.
sensory deprivation; bolus propulsion; cineradiography
 |
INTRODUCTION |
DEGLUTITIVE TONGUE
MOVEMENT is important for bolus propulsion (6, 7,
17). Although this movement is affected by the variables of the
bolus swallowed, such as volume and viscosity (5, 26), no
data exist on the neurophysiological control of deglutitive tongue
movement. The tongue, having a high density of mechanical receptors,
may be the main sensory region for recognizing the variables of the
bolus swallowed (25), but this hypothesis has not been
fully examined.
The relationship between sensation and function has been investigated
using local anesthesia, such as block anesthesia (1, 18,
29) and surface anesthesia (2, 24). Although
surface anesthesia incompletely removes sensation (15,
30), block anesthesia completely removes sensation of the region
distal to the site of injection. For example, it is possible to extract teeth painlessly by using block anesthesia (3).
The purpose of the present study was to investigate whether sensory
input from the tongue affects deglutitive tongue movement. Deglutitive
tongue movement was analyzed by cineradiography under conditions of
block and surface anesthesia of the tongue.
 |
METHODS |
Effect of surface anesthesia on tongue.
The subjects were 48 healthy male and female volunteers ranging in age
from 23 to 36 yr. They were examined for two-point discrimination and
stereognostic ability before and after application of 8% Xylocaine
spray or 2% Xylocaine jelly (Fujisawa Pharmaceutical, Osaka, Japan) to
the tongue. A filter paper with either 700 mg of 8% Xylocaine spray or
1 ml of 2% Xylocaine jelly was applied to the tongue. The filter paper
was a square of 4 × 4 cm, and one of the sides of the square had
an arc with a radius of 7.5 cm. Each anesthetic was applied for
5 min. If both 8% Xylocaine spray and 2% Xylocaine jelly were used on
the same subject, there was a 24-h interval between applications of the
anesthetics. Two-point discrimination was tested using a sliding
caliper. The two points of the calipers were placed with equal pressure
on the mucosa of the dorsal tongue. The caliper points were closed by 1 mm from 5 mm until the threshold was reached at which two points could be identified. Stereognostic ability was tested using 10 geometric plastic shapes (13). One of the pieces was placed on the
subject's dorsal tongue. The subject was then asked to select the
picture (from 10 pictures) that best corresponded to the shape on the dorsal tongue. To aid in identification, the subject was allowed to
manipulate the shape in the oral cavity but without making contact with
the teeth. These tests were performed before, immediately after, and 5, 10, and 15 min after anesthesia. The percentage of correct responses
before and after anesthesia was compared using the Wilcoxon
signed-ranks test.
Deglutitive movement of tongue under local anesthesia.
Subjects were seven healthy volunteers (ages 23-25 yr) with
surface anesthesia (surface group) and seven healthy volunteers (ages
24-29 yr) with block anesthesia (blocked group). They were without
remarkable malocclusion and swallowing problems. Ethical approval was
granted by the Ethics Committee of Okayama University Dental School in
1996, and all subjects gave informed consent. In the surface group, the
surface of the tongue was anesthetized for 5 min with a filter paper
with 700 mg of 8% Xylocaine spray. In the blocked group, the bilateral
lingual nerve in the pterygomandibular space was blocked by 3.6 ml of
2% Xylocaine and 1:80,000 epinephrine (Fujisawa Pharmaceutical). The
adequacy of block anesthesia was confirmed by assessing the absence of
touch sensation on the dorsal tongue.
For the cineradiographic recording, a lead marker was fixed at the
tongue tip, and barium paste (100% wt/vol, Barytgensol, Fushimi
Pharmaceutical, Kagawa, Japan) was applied to the nasal part of the
pharynx of each subject. Each subject was seated on a chair and
turned lateral to the face of the image intensifier. The subject's
head was stabilized by a cephalostat attached to the chair. Subjects
were each asked to swallow 10 ml of liquid barium diluted 10% (wt/vol)
with water, while looking at their own eyes in a mirror.
Cineradiographic recordings were obtained at 68-84 keV with a
9-in. image intensifier (Shimadzu, Digitex 2400UX, Kyoto, Japan) and
appropriate collimation so that a lateral image could be obtained of
the entire mouth and pharynx. A cineradiographic image was recorded on
35-mm imaging film (Fuji Film, MI-CF, Tokyo, Japan) at 30 frames/s.
These swallowing events were recorded three times, both before and
after anesthesia. The swallowing events after surface anesthesia were
recorded within 5 min of 8% Xylocaine spray application.
The cineradiographic image was analyzed in slow motion and by
single-frame analysis using the playback capability of a Cineangio projector (Cap35B, Elk, Aichi, Japan). We established the following six
stages of deglutition: stage 1, contact of the tongue tip with the maxillary incisors or the palatal mucosa; stage 2,
loss of contact of the dorsal tongue with the soft palate; stage
3, passage of the bolus head across the posterior or inferior
margin of the ramus of the mandible; stage 4, passage of the
bolus head through the opening of the esophagus; stage 5,
passage of the bolus tail across the posterior or inferior margin of
the ramus of the mandible; and stage 6, passage of the bolus
tail through the opening of esophagus. By modification of oral
and pharyngeal transit time (21), we measured the times
between each stage. Furthermore, after cineradiographic images were
traced on tracing paper and standard points and reference planes were
established (Table 1), the measurements
of deglutitive tongue movement were analyzed at several stages (Fig.
1; Ref. 10). As deglutitive tongue movement was highly variable among different individuals (11), the data recorded three times in each subject were
averaged.

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Fig. 1.
Measurements of deglutitive tongue movement. AP~E and
AP~PP are distances on the palatal mucosa. MP-MT, MP-MS, PP-PT,
PP-PS, C1-D, C1-Me, and PS-I are straight distances. P'-Ti is the
shortest distance from the line crossing at a right angle to the
palatal plane through PNS to Ti. See Table 1 for further explanation of
abbreviations. a: contact of tongue and palate,
AP~E/AP~PP × ~100 (%); b: front part of dorsal
tongue, MP-MT/MP-MS × ~100 (%); c: middle part of
dorsal tongue, PP-PT/PP-PS × ~100 (%); d: rear part
of dorsal tongue, C1-D/C1-Me × ~100 (%); e: tongue
tip, P'-Ti/PS-I × ~100 (%).
|
|
Tracings and measurements were performed by one investigator. To
evaluate the intraexaminer error in tracing and measurements, one frame
of cineradiographic images was traced and measured twice during
deglutition in each subject on two separate occasions at least 1 mo
apart. The method error was determined by Dahlberg's formula of ME
=
where n
is the number of subjects and d is the difference between
two measurements of a pair. The method error did not exceed 0.01. The
measurements of deglutitive tongue movement and time were compared
before and after anesthesia by Wilcoxon's signed-ranks test.
 |
RESULTS |
Effect of surface anesthesia on tongue.
Two-point discrimination was not statistically significantly different
before and after using either 8% Xylocaine spray or 2% Xylocaine
jelly. Stereognostic ability significantly declined with application of
8% Xylocaine spray when the percentage of correct responses
immediately after anesthesia was compared with that before anesthesia
(P < 0.005; Fig. 2).
However, 5 min after anesthesia, stereognostic ability recovered to the
level of that before anesthesia. Stereognostic ability with 2%
Xylocaine jelly was not significantly different before and after
anesthesia (Fig. 2).

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Fig. 2.
The % of correct responses in stereognostic ability with
each anesthesia. Values are means ± SD in 8% Xylocaine spray
( ) and 2% Xylocaine jelly ( ). There
was significant decline with 8% Xylocaine spray when the % of correct
response before anesthesia was compared with that immediately after
anesthesia. * P < 0.005, before vs. immediately
after anesthesia.
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|
Deglutitive movement of tongue under local anesthesia.
After going across the posterior or inferior margin of the ramus of the
mandible (stage 3), the bolus head passed late through the
opening of the esophagus (stage 4) after anesthesia in both the surface and blocked groups (P < 0.05; Tables
2 and 3).
Furthermore, in the blocked group, the period from passage of the bolus
head through the opening of esophagus (stage 4) to passage
of the bolus tail across the posterior or inferior margin of the ramus
of the mandible (stage 5) extended after anesthesia
(P < 0.05; Table 3).
In measurements of deglutitive tongue movement, the contact between
tongue and palate was shorter after versus before anesthesia at the
time the dorsal tongue lost contact with the soft palate (stage
2) and the bolus head passed across the posterior or inferior margin of the ramus of the mandible (stage 3) in both the
surface and blocked groups (P < 0.02, P < 0.05) (Figs.
3A and
4A). Furthermore, in the blocked group, the contact between the tongue and palate was
shorter, and the front and rear parts of the dorsal tongue were larger
after than before anesthesia at the time the bolus head passed through
the opening of the esophagus (stage 4) (P < 0.05) (Fig. 4, A, B, and D). The
tongue tip retreated after versus before anesthesia at the time the
bolus head passed through both the posterior or inferior margin of the
ramus of the mandible (stage 3) and the esophageal opening
(stage 4) in the blocked group (P < 0.05;
Fig. 4E).

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Fig. 3.
Measurements of deglutitive tongue movement in surface group.
Values are average ± range (%) before ( ) and
after anesthesia ( ). A: contact of tongue
and palate; B: front part of dorsal tongue; C:
middle part of dorsal tongue; D: rear part of dorsal tongue;
E: tongue tip. Contact of tongue and palate was shorter
after than before anesthesia at the times of the dorsal tongue losing
contact with the soft palate and the bolus head passing across the
posterior or inferior margin of the ramus of the mandible.
** P < 0.02, after vs. before anesthesia.
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Fig. 4.
Measurements of deglutitive tongue movement in blocked
group. Values are average ± range (%) before ( )
and after anesthesia ( ). A: contact of
tongue and palate; B: front part of dorsal tongue;
C: middle part of dorsal tongue; D: rear part of
dorsal tongue; E: tongue tip. Contact of tongue and palate
was shorter, front and rear parts of dorsal tongue were larger, and
tongue tip was smaller after than before anesthesia at several times.
* P < 0.05, ** P < 0.02, after
vs. before anesthesia.
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|
 |
DISCUSSION |
Methods of removing superficial sensation from the tongue include
infiltration anesthesia, surface tongue anesthesia, and block
anesthesia for the lingual nerve. Infiltration anesthesia for the
tongue was not used in the present study, because such anesthesia
affected intrinsic muscle activity in a preliminary experiment. The
effects of surface anesthesia on the tongue were evaluated by oral
stereognostic ability. This ability is defined as the ability to detect
tactile stimuli from three-dimensional shapes placed on the dorsal
tongue and to identify them (19), and it depends primarily
on the sensory input from the lingual surface (12). In the
present study, the surface tongue anesthesia induced by 8% Xylocaine
spray affected oral stereognostic ability immediately after anesthesia
but did not affect it by 5 min after anesthesia. This result indicated
that 8% Xylocaine spray had an influence on the tongue that was not
sustained more than 5 min. Therefore, the swallowing events after
surface anesthesia were recorded within 5 min of 8% Xylocaine spray
application. We also used block anesthesia in our study of deglutitive
movement of the tongue under local anesthesia because surface
anesthesia induced by 8% Xylocaine spray may incompletely remove
superficial sensation from the tongue (30). Block
anesthesia of the bilateral lingual nerve in the pterygomandibular
space removes almost all superficial sensation from not only the tongue
but also the region innervated by the inferior alveolar nerve
(29). Furthermore, it may block the mylohyoid nerve, which
innervates the mylohyoid muscle and the anterior belly of the digastric
muscle (14), although all subjects in the present study
could perform mandibular movements such as opening, lateral, forward,
and backward motions after block anesthesia the same as before anesthesia.
In the present study, after crossing the posterior or inferior
margin of the ramus of the mandible, the bolus head passed late through
the esophageal opening after anesthesia in both the surface and blocked
groups. Furthermore, in the blocked group, the period from passage of
the bolus head through the esophageal opening to passage of the bolus
tail across the posterior or inferior margin of the ramus of the
mandible was extended after anesthesia. These results suggest that
bolus transport is delayed with a decrease in sensitivity of the tongue
surface at these times. At variance with the present study, Ali et al.
(2) applied 2% viscous Xylocaine to the oral mucosa and
demonstrated no change in bolus transit time after anesthesia compared
with that before anesthesia. However, the 2% viscous Xylocaine used in
that study (2) was the same concentration as the 2%
Xylocaine jelly used in the present study, and oral stereognostic
ability with 2% Xylocaine jelly did not change. Therefore, we suppose
that the anesthestic for the tongue was inadequate in their study.
In the present study, the contact between the tongue and palate was
shorter after versus before anesthesia when the dorsal tongue lost
contact with the soft palate and the bolus head passed across the
posterior or inferior margin of the ramus of the mandible in both the
surface and blocked groups. These results suggest that deglutitive
tongue movement became slower due to a decrease in sensitivity of the
tongue surface at these times. As deglutitive tongue movement causes
bolus propulsion (6, 7, 17), the delay of deglutitive
tongue movement caused by anesthesia may have caused weak propulsion of
the bolus, resulting in delayed bolus transport.
The contact between tongue and palate during deglutition changes
according to the form of the oral cavity (9, 27) and bolus
consistency (26, 28, 31). The superficial and
proprioceptive sensation of the tongue may recognize and modulate this
contact (25). In the present study, the surface and block
anesthesia removed superficial sensation in the tongue, but left the
proprioceptive afferents of the tongue, which travel in the hypoglossal
nerve and not in the lingual nerve (1, 8). Therefore, a
decrease in contact between the tongue and palate might indicate that
proprioceptive sensation, not superficial sensation, in the tongue
mainly carried the sensory information about the form of the oral
cavity and the variables of the bolus.
At the time the bolus head passed through the esophageal opening,
the contact between the tongue and palate was shorter, and the front
and rear parts of the dorsal tongue were larger after versus before
anesthesia in the blocked group, but not in the surface group.
Therefore, the deglutitive tongue movement became slower with block
anesthesia at this time, which might affect the inferior alveolar nerve
and the mylohyoid nerve, differing from surface anesthesia. The
inferior alveolar nerve block removes the sense of perception but does
not affect the motor (29, 34). On the other hand,
the mylohyoid nerve block affects the motor of the mylohyoid muscle and
the anterior belly of the digastric muscle (32), which
elevate the hyoid and the larynx during deglutition (33).
The elevation of the hyoid and the larynx begins at the onset of the
pharyngeal swallow that is activated when the bolus head passes across
the posterior or inferior margin of the ramus of the mandible
(20). The movement of the tongue, hyoid, and larynx
coordinates swallowing (11). Therefore, the delay
of deglutitive tongue movement when the bolus head passes through the
esophageal opening may be affected by the mylohyoid nerve block.
Peripheral sensory information from several regions of the oral
mucosa has been shown (14, 16, 22, 23) to participate in a
reflex response involving tongue musculature and movement, suggesting
these reflex responses are related to deglutitive tongue movement
(16, 22). In the present study, the rising threshold of
the superficial sensation in the tongue with local anesthesia may
affect these reflex responses to alter tongue movement.
In the blocked group, the tongue tip retreated after versus
before anesthesia when the bolus head passed through both the posterior
or inferior margin of the ramus of the mandible and the opening of the
esophagus. Cook et al. (4) reported that a complex of
tongue tip and base movement occurred in a tight temporal relationship
at the inception of swallowing. In the present study, the change in the
tongue tip position with block anesthesia may have been involved in the
delay in the movement of the dorsal tongue during deglutition.
The neurophysiological control of deglutition depends on a medullary
swallow center, which modifies the intensity and duration of activity
by peripheral feedback (25). However, peripheral feedback
has not been well understood (e.g., the intraoral sensation used to
recognize the variables of the bolus to be swallowed). In the
present study, sensory input from the tongue affected deglutitive tongue movement and bolus transit time, suggesting that sensory input
from the tongue plays the role of peripheral feedback to modulate some
aspects of the central nervous system control of deglutition, thus
affecting the neurophysiological control of deglutitive tongue movement.
 |
ACKNOWLEDGEMENTS |
This study was supported in part by Grants 11672047 and 12671999 from the Grant-in-Aid program for Scientific Research from the Ministry
of Education, Science, and Culture of Japan.
 |
FOOTNOTES |
This work was presented at the Third Asian Pacific Orthodontic
Conference, in November 1998, in Taipei, Taiwan.
Address for reprint requests and other correspondence: T. Takano-Yamamoto, Dept. of Orthodontics, Okayama Univ. Dental School, 2-5-1 Shikata-Cho, Okayama City, Okayama 700-8525, Japan (E-mail: t_yamamo{at}dent.okayama-u.ac.jp).
The costs of publication of this
article were defrayed in part by the
payment of page charges. The article
must therefore be hereby marked
"advertisement"
in accordance with 18 U.S.C. Section 1734 solely to indicate this fact.
Received 29 June 2000; accepted in final form 22 December 2000.
 |
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