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Perio Reports

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Perio Reports  Vol. 26, No. 3
Perio Reports provides easy-to-read research summaries on topics of specific interest to clinicians. Perio Reports research summaries will be included in each issue to keep you on the cutting edge of dental hygiene science.
How Many Times Do You Swallow Every Hour?

Swallowing frequency varies widely among individuals. Exactly what initiates the swallowing reflex is unknown. It might be related to the amount of saliva accumulating or when saliva reaches specific receptors. The absolute size of the oral cavity will influence how much saliva accumulates and how soon it reaches receptors. Measuring how often someone swallows is difficult as the person knows the swallows are being measured and they become more aware of them and perhaps bias the results.

Researchers at the University of Minnesota evaluated 128 first-year dental students to determine the relationship between saliva flow and frequency of swallowing. The group consisted of 76 males and 52 females. A microphone was taped to the neck, near the larynx, to record swallowing noises. Subjects were asked to sit quietly and read for 30 minutes and push a button every time they noticed themselves swallowing.

To estimate saliva volume swallowed, subjects were asked to swallow and then hold the saliva in their mouth for their par ticular average time between swallows and then expectorate all the saliva into a tube. This was repeated four times for each individual.

The average number of swallows per hour was 122, with a range of swallows per hour from 18 to 400 – quite a wide variation. Saliva flow was greater in males compared to females. Those who swallowed frequently had high flow rates with small saliva volumes. Those who waited a long time between swallows had low flow rates with high volume.

Clinical Implications: The number of times a person swallows each day depends on saliva flow and volume.

Rudney, J., Ji, Z., Larson, C.: The Prediction of Saliva Swallowing Frequency in Humans from Estimates of Salivary Flow Rate and the Volume of Saliva Swallowed. Arciv Oral Biol 40:(6) 507-512, 1995.

How a Person Swallows Impacts Dentofacial Development

There is much debate in the orthodontic community about the influence of the tongue on facial development. Some believe the tongue muscle function influences bone and jaw development while others believe the tongue merely adapts to the genetically predetermined oral environment by changing swallowing and speech patterns to fit. If the tongue muscle does in fact exert forces on bone through abnormal swallowing patterns, this should be taken into consideration before beginning orthodontic treatment, to prevent relapse.

Researcher in Taipei, Taiwan evaluated 112 adults during swallowing to determine the impact on dentofacial morphology. They used computer-aided ultrasonography, cephalometreic radiography and study models. The cushion scanning technique (CST) used a framework that the patient leaned his/her forehead against and a cushion under the chin and on the front of the throat that did not interfere with swallowing.

Swallowing was divided into five phases, depending on which part of the tongue was in contact with the palate. Swallowing was done with saliva only.

There was significant correlation between tongue movements during swallowing and the structure of the face and jaw. Swallowing for a longer time when the back of the tongue contacted the palate, the end of swallowing, led to increased arch length and increased palatal depth.

Despite significant correlations, they failed to show a cause-and-effect relationship between swallowing and dentofacial form. More factors need to be considered together with swallowing, including genetics, other forces from the lips and cheeks, resistance of the teeth and alveolar arch and resting posture of the tongue.

Clinical Implications: The relationship between the teeth, tongue, bone and development is both complex and inconclusive.

Cheng, C., Peng, C., Chiou, H., Tsai, C.: Dentofacial Morphology and Tongue Function During Swallowing. Am J Orthod Dentofacial Orthop 122: 491-9, 2002.

Maxillary Lip-tie Can Impede Breastfeeding

Breastfeeding requires that the infant can successfully latch onto mother’s breast. The primary oral condition preventing this is ankyloglossia or tongue-tie. Another area to be checked is the attachment of the upper lip to the maxillary gingival tissues. Historically this has had several names: labial frenum, median labial frenum and maxillary labial frenum.

The attachment of the upper lip to the anterior maxillary arch is loose connective tissue. It is not attached to bone and there is no muscle within this tissue. In severe cases, this frenum is attached around the maxillary arch and into the incisive papilla.

The lip-tie restricts movement of the upper lip and can make latching onto the breast difficult for the infant. To latch on properly, the infant must be able to suckle both the nipple and the areola. Taking only the nipple into the mouth may be painful for the mother and cause irritation to the nipple tissue. The baby’s lips and cheeks are part of creating a good seal to allow adequate milk to be suckled from the breast. The nipple must be positioned at the junction of the hard and soft palates, otherwise the gum pads of the infant compress the nipple. Loud clicking sounds means the infant is sucking in air.

Various degrees of lip-tie and tongue-tie exist, some slight and others severe. When breastfeeding problems arise and the infant fails to thrive, the labial and lingual frenums should be checked and surgically corrected to allow for comfortable and effective breastfeeding.

Clinical Implications: Both tongue-tie and lip-tie will interfere with successful breastfeeding.

Kotlow, L.: Diagnosing and Understanding the Maxillary Lip-tie (Superior Labial, the Maxillary Labial Frenum) as it Relates to Breastfeeding. J of Human Lactation 29(4): 1-7, 2013.

Maxillary Frenums Linked to Caries in Breastfeeding Infants

In years past, first dental visits for children were at age three, and now the Academy of Pediatric Dentistry recommends seeing children by their first birthday or within six months of the first tooth erupting. Children, as young as six months, can develop early infant dental caries. In 1977 it was reported that infants exclusively breastfeeding, sleeping next to the mother and engaging in at-will nursing developed caries on the anterior teeth. Lower anterior teeth are protected from caries formation in infants as the normally functioning tongue will rest over these teeth.

While rare, breastfeeding-induced dental caries is associated with a tight maxillary frenum. Immediately after nursing, inspection of the maxillary teeth will show evidence of retained milk. The tight maxillary frenum is also seen in cases of early childhood caries when there is no history of breastfeeding or sleeping with a bottle.

A pediatric dentist, evaluated 350 infants from newborns to three year olds and developed a classification system for maxillary frenums. Class I is little or no frenum attachment. Class II is a frenum attachment at or above the mucogingival margin. Class III is at or into the interproximal space between the central incisors. Class IV is a frenum that wraps around to the lingual, attaching to palatal tissue.

Caries is most often associated with frenums of Class III and IV. Revision of the maxillary frenum can be done in the dental office using a laser.

Clinical Implications: Both maxillary and lingual frenums should be checked in newborns and when teeth erupt.

Kotlow, L.: The Influence of the Maxillary Frenum on the Development and Pattern of Dental Caries on the Anterior Teeth in Breastfeeding Infants: Prevention, Diagnosis, and Treatment. J Human Lactation 26: 304-308, 2010.

Swallowing Air Causes Problems for Newborns

When a newborn is unable to breastfeed due to inadequate latching onto the breast, problems arise. Clicking sounds and nipple pain may indicate inadequate attachment to the breast. This can lead to failure to thrive, prolonged or frequent breastfeeding with poor milk transfer, colic and reflux. Problems for the mother include plugged ducts, pain, flattened, compressed or injured nipples and mastitis.

Aerophagia, directly translated from Greek means to “eat air.” Infants experiencing problems with breastfeeding often swallow air. This causes abdominal distention, belching and flatulence. Colic, crying and screaming frequently for long periods of time, can happen in an otherwise healthy baby. Reflux or GERD are also seen in infants, producing intense pain and discomfort.

Tight maxillary lip-ties and ankyloglossia can be the cause of some of these problems. These tight attachments of lip and tongue can prevent successful breastfeeding, leading to the infant swallowing air and not getting enough milk.

More than 50 infants were treated with revisions of lip-tie and tongue-tie resulting in a significant reduction or total elimination of the symptoms of reflux. Many of the infants had suffered for several months, as had their parents being unable to console their newborn babies. Physicians recommended a battery of tests and prescribed medications for the infants. In some cases, breast milk was blamed for the problems, but switching to a bottle formula did not resolve the symptoms. Surgical revision of these lipand tongue-ties allowed for successful latching on and breastfeeding.

Clinical Implications: Infants suffering from colic or reflux symptoms may benefit from a dental examination to check for lip-tie and tongue-tie.

Kotlow, L.: Infant Reflux and Aerophagia Associated with the Maxillary Lip-tie and Ankyloglossia (Tongue-tie). Clinical Lactation 2(4):25-29, 2011.

Horizontal Brushing for Deciduous Teeth

Toothbrushing or the lack thereof is considered a caries risk factor. Toothbrushing effectiveness is determined by both frequency and technique. Several techniques are taught to children. The scrubbing technique involves simple horizontal, vertical or circular movements. More complex movements are taught in the Bass technique or the roll method. National and international dental associations make varying recommendations for method and frequency on their websites.

Researchers in Paris, France performed a systematic review of randomized controlled studies of toothbrushing effectiveness based on method and frequency. Plaque scores were the measurement used to determine effectiveness. Of 534 articles that appeared in their search, they identified six studies to include in their analysis.

Two studies focused on deciduous teeth and consistently showed the horizontal technique superior to the roll technique. This was true when either the child or the parent did the brushing. In mixed dentition, the horizontal technique is more effective performed by the parent rather than the child. In late mixed dentition, there was no difference between three toothbrushing methods: horizontal, Bass and roll. None of the studies measured the effect of frequency.

When dental association websites were analyzed, the U.S. and European sites did not recommend a particular toothbrushing method, but did recommend twice-daily brushing. France recommends the horizontal method for those under six years of age, an intermediate method for ages six to eight and the roll method for those over nine years of age. In New Zealand, the Bass method is recommended in general and the horizontal method for children.

Clinical Implication: The horizontal scrub method works best for children, with modifications of the Bass method for permanent dentition.

Muller-Bolla, M., Courson, F.: Toothbrushing Methods to Use in Children: A Systematic Review. Oral Health Prev Dent 11: 341-347, 2013.
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