Effects of bilateral lingual and inferior alveolar nerve anesthesia effects on

masticatory function and early swallowing

Kanchu Tei, DDS, PhD,a Yutaka Yamazaki, DDS, PhD,b Masaaki Kobayashi, DDS,a
Yuri Izumiyama, DDS,a Mitunobu Ono, DDS, PhD,a and Yasunori Totsuka, DDS, PhD,a
Sapporo, Japan
HOKKAIDO UNIVERSITY

Objective. To determine whether bilateral lingual and inferior alveolar nerve anesthesia affects the onset of swallowing
including masticatory function.
Study design. Twenty young male volunteers were asked to chew and swallow corned beef and then a mixture of corned
beef and liquid in their usual manner before and after local anesthesia. The oral and pharyngeal swallowing was
investigated using videofluoroscopic examination in a lateral plane. Eight objective indicators including oral
containment time, swallowing threshold, and pharynx-to-swallow interval were measured.
Results. Oral containment time and total sequence duration, total number of chews, and total number of swallows for the
2 test foods varied significantly between those before and after anesthesia. Individual pharynx-to-swallow intervals
varied with both foods without remarkable increases or decreases in the swallow duration and cricopharyngeal opening
time.
Conclusion. Bilateral lingual and inferior alveolar nerve anesthesia may affect early swallowing; changes in the onset of
swallowing varied among the participants.
(Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004;97:553-8)

The basic pattern of chewing and swallowing is
produced by the activity of the brainstem rhythm/pattern
generator. The rhythm generator may be driven by nerve
impulses descending from higher centers or by nerve
impulses arriving as sensory input from the periphery.1-3
Swallowing is preceded by an oral preparatory stage, and
during this stage food is readied for swallowing and
propelled to the posterior oral cavity.4 The swallowing
itself has 3 stages, the oral, pharyngeal, and esophageal
stages based on the location of the bolus.5,6 The oral
stage begins when the food is ready for swallowing,
when the anterior tongue pushes against the palate. The
area of tongue-palate contact expands from front to back,
squeezing the bolus through the faucial pillars and into
the pharynx.4
The establishment of the onset of the swallowing is
complicated and not fully elucidated. It has been pro-
posed that sensory input from the mucosal receptors in
the oral cavity, or oropharynx and larynx are responsible
for controlling chewing and swallowing. Some in-
vestigators reported that normal humans hold the bolus
in the oral cavity until the onset of swallowing.5,6 Linden
et al7 have reported that contrast material is commonly
present in the pharynx at the onset of swallowing in
normal subjects and there are reports that the hypophar-
ynx is the most sensitive area for triggering the
swallowing reflex.8-12 Reported factors in the onset of
swallowing include the relationship between the size
of food particles,13 viscosity of foods14 or lubrication of
foods,15 and the swallowing threshold. Palmer et al4
have reported that differences in onset of swallowing
may be attributed to food consistency or to the subjects
being commanded to swallow or not.
Much has been reported about the onset of
swallowing, but only one report16 has been concerned
with whether reduced sensory input from the mouth by
regional blocking affects oropharyngeal swallowing.
The primary objective of the present study was to
determine whether bilateral lingual and inferior nerve
anesthesia affects the onset of swallowing, with a secon-
dary objective to define the masticatory function before
and after bilateral lingual and inferior nerve anesthesia.

This work was supported by The Ministry of Education, Culture,
Sports, Science and Technology, Japan. KAKENHI(13877334).
a
Oral and Maxillofacial Surgery, Graduate School of Dental
Medicine, Hokkaido University.
b
Oral Diagnosis and Oral Medicine, Graduate School of Dental
Medicine, Hokkaido University.
Received for publication Aug 12, 2003; returned for revision Oct 7,
2003; accepted for publication Nov 25, 2003.
1079-2104/$ - see front matter
2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.tripleo.2003.11.009
MATERIALS AND METHODS
Subjects
Twenty healthy, male volunteers (24-30 years old)
were enrolled in this study. All participants were ques-
tioned carefully to exclude subjects with difficulty in
swallowing, change in voice, history of neurologic
disease, major medical illnesses, or surgery of the head
and neck. Oral examinations were also performed to
exclude subjects with dental or periodontal ailments. All

553
554 Tei et al
subjects had more than 24 functional teeth. No subjects
had removable partial dentures. Ethical approval was
secured from the Hokkaido University Ethics Com-
mittee, and informed consent was obtained in writing
from each participant.
Data collection
Solid food and a mixture of solid food and liquid were
used in this examination. The solid food consisted of 4 g
of corned beef and 4 g of barium liquid, mixed by heating
and stirring, and cooled to room temperature. During the
heating process, the liquid was evaporated leaving the
solid corned beef covered in barium. The mixture of
solid food and liquid had the same components as the
solid food, but the corned beef and barium liquid were
stirred together just before the examination. Initially, all
participants were asked to first place the solid food in the
mouth, then chew and swallow in their usual manner.
Then they were asked to do the same for the mixture of
solid food and liquid. After completion of this first trial,
local anesthesia of the bilateral lingual and inferior
alveolar nerve was induced with injection of 2 mL of
2% lidocaine (Xylocaine, AstraZeneca, Osaka, Japan).
Before the second trial, one of the authors examined the
sensation on the dorsal surface of the tongue by touching
with a pair of tweezers as described by Tanimoto et al,16
and additional lidocaine was given in the cases where
sensation remained. Then the participants were asked to
chew and swallow the foods described above, all in the
same order. All participants ate each food twice in
a sitting both before and after the bilateral lingual and
inferior alveolar nerves were blocked. After the
participants ate a food sample, they rested for 1 to 2
minutes to rinse the food pathway with adequate
volumes of water before eating the next sample.
Fluorography started just before each food sample
entered into the mouth and ended after the participant
indicated that all food had been swallowed. The
videofluoroscopic results of the oral and pharyngeal
swallowing before and after the bilateral lingual nerves
were anaesthetized were recorded on videotape and
converted to digital data.
Data analysis
Eight objective indicators for chewing and oropha-
ryngeal swallowing were measured with Premiere soft-
ware (Adobe Systems Incorporated, San Jose, Calif)
and analyzed statistically in this study: (1) oral contain-
ment time4 (the interval from the beginning of a se-
quence until contrast medium passed the inferior border
of the mandible: OCT); (2) swallowing threshold13
(number of chews before the first swallow: ST); (3)
pharynx-to-swallow interval4 (the interval from contrast
reaching the inferior border of the mandible until the
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
May 2004
onset of the swallowing: PSI); (4) swallow duration4 (the
interval from start of swallowing to end of swallowing:
SwaD); (5) cricopharyngeal opening time5 (CPO); (6)
total sequence duration4 (the interval from the start of
a sequence to the end of final swallowing: TSD); (7) total
number of chews (total number of chews from start of
a sequence until the end of final swallowing: NC); (8)
total number of swallows (total number of swallows in
a total sequence: NS).
The onset of swallowing was defined as the sudden,
rapid superior and anterior motion of the hyoid bone and
end of swallowing was defined as the moment the hyoid
completed its return phase.4 The cricopharyngeal
opening time was defined as the duration from onset of
opening of the upper esophageal sphincter to the com-
plete closing of the muscle.5 Oral containment time, swal-
lowing threshold, pharynx-to-swallow interval, swallow
duration, and the cricopharyngeal opening time were
measured for the first swallowing. For individual
assessments, the difference and percentage of change
compared to the value before anesthesia, and the median
of the differences (absolute value) were determined.
Only subjects with more than 50% change or more than
the median of the differences (absolute value) were re-
garded as increased or decreased.
The statistical analysis was performed with Statview
software (SAS Inc, Cary, NC). Each value of the
indicators obtained from the participants were averaged
and differences in the 8 parameters before and after the
bilateral lingual and inferior alveolar nerves were
anaesthetized, for the solid food, and the mixture of
solid food and liquid were analyzed using bilateral paired
t-tests to assess the changes in the oral and pharyngeal
swallowing. Only P values smaller than .05 were
considered statistically significant.
RESULTS
Differences between the foods
Before the bilateral lingual and inferior alveolar
nerves were anesthetized, the oral containment time
and pharynx-to-swallow interval varied significantly be-
tween that for solid food and the mixture of solid food
and liquid. However, after the bilateral lingual and in-
ferior alveolar nerves were anesthetized, none of the in-
dicators varied significantly between the foods (Table I).
Differences between the parameter values before
and after bilateral lingual and inferior alveolar
nerve were anesthetized
The oral containment time, total sequence duration,
total number of chews, and total number of swallows
varied significantly before and after the bilateral lingual
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Tei et al 555
Volume 97, Number 5

Table I. Oropharyngeal swallowing indicators for solid food and the mixture of solid food and liquid before and after
bilateral lingual and inferior alveolar nerves were anesthetized
OCT ST PSI SwaD CPO TSD NC NS
*z y {
Solid food before 10.18 6 4.16 14.80 6 6.93 0.047 6 0.91 1.11 6 0.25 0.46 6 0.19 19.81 6 6.65 18.55 6 8.15 2.30 6 0.92**
anesthesia
Solid food after 15.19 6 8.67z 17.45 6 8.90 0.60 6 1.55 1.16 6 0.36 0.40 6 0.08 38.77 6 16.25 26.30 6 11.83{ 3.65 6 2.41**
anesthesia
Mixture before 7.35 6 3.99*yy 12.30 6 5.57 1.05 6 1.74y 1.05 6 0.26 0.47 6 0.10 19.99 6 6.99zz 18.10 6 6.34 2.90 6 1.12{{
anesthesia
Mixture after 12.67 6 8.54yy 16.00 6 8.87 2.42 6 4.44 1.12 6 0.26 0.45 6 0.11 42.92 6 14.79zz 28.95 6 12.41 4.30 6 2.27{{
anesthesia

The values are the mean 6 standard deviation. OCT, oral containment time before first swallowing (sec); SwaD, swallowing duration (sec); NC, total number of
chews; ST, swallowing threshold (number of chews before first swallowing); CPO, cricopharyngeal opening time (sec); NS, total number of swallows; PSI, pharynx-to-
swallow interval (sec); TSD, total sequence duration (sec).
*P = .0343, OCT between solid food and mixture of solid food and liquid before anesthesia,
y
P = .0277, PSI between solid food and mixture of solid food and liquid before anesthesia,
z
P = .0251, OCT between before and after anesthesia for solid food,

P = 0.001, TSD between before and after anesthesia for solid food,
{
P = .0207, NC between before and after anesthesia for solid food,
**P = .0248, NS between before and after anesthesia for solid food,
yy
P = .0159, OCT between before and after anesthesia for mixture of solid food and liquid,
zz
P = .001, TSD between before and after anesthesia for mixture of solid food and liquid,

P = .0013, NC between before and after anesthesia for mixture solid food and liquid,
{{
P = .0181, NS between before and after anesthesia for mixture of solid food and liquid.

nerves were anaesthetized, both for the solid food and the
mixture of solid food and liquid. However, the swallow-
ing threshold, swallow duration, cricopharyngeal open-
ing time, and pharynx-to-swallow interval did not vary
before and after anesthesia both for the solid food and
mixture of solid food and liquid (Table I).
Outcomes of individual pharynx-to-swallow
intervals by the bilateral lingual and inferior
alveolar nerve anesthesia
The differences in the interval before and after
anesthesia varied individually (from
3.87 to +5.60
seconds) and the median of the absolute value of the
differences was 0.40 seconds with the solid food. There
was an increase in the interval of more than 0.40 seconds
in 8 participants and a similar decrease in 3 as shown in
Table II. For 4 participants where the onset of the
swallowing reflex occurred after the bolus had entered
the oropharynx before anesthesia (the pharynx-to-
swallow interval was above zero), 2 participants showed
an increased interval, and the other 2 showed a decreased
interval. The differences in the pharynx-to-swallow
interval before and after anesthesia varied individually
(from
5.00 to +11.74 seconds) and the median of the
absolute value of the differences was 0.75 seconds with
the mixture of solid food and liquid. An increased
interval was observed in 5 participants and there was
a decrease in 5 as shown in Table II. For 12 participants
where the onset of the swallowing was after the bolus had
entered the oropharynx before anesthesia (the pharynx-
to-swallow interval was above 0), 3 participants showed
an increased interval, 5 showed a decreased interval, and
the remaining 4 showed smaller changes in the interval.
These changes in individual pharynx-to-swallow in-
tervals did not correlate with the changes in oral
containment time.
Altogether, the results in Table II show that 6
participants show neither increases nor decreases
(changes smaller than the median) in both the solid food
and mixture of solid food and liquid, and 7 show changes
in intervals with both test foods. Of these 7, 2 showed
decreased intervals and 3 showed increased intervals in
both test foods, and the other 2 showed increased
intervals in the solid food and decreased intervals in the
mixture of solid food and liquid. The remaining 7
participants showed increased or decreased intervals in
either solid food or the mixture of solid food and liquid.
With solid food the interval increased in 3 participants
and decreased in 1. There was an increased interval in 2
participants and decrease in 1 with the mixture of solid
food and liquid (Table II).
Outcomes of individual swallowing threshold and
swallow duration, cricophryngeal opening time
after bilateral lingual and inferior alveolar nerves
were anesthetized
The swallow duration and cricopharyngeal opening
time did not change after anesthesia in both test foods as
shown in Tables III and IV. Only 1 participant showed
a 51% decrease in crocopharyngeal opening time for the
solid food. The swallowing threshold tended to increase
after anesthesia for both test foods as shown in Tables III
556 Tei et al ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
May 2004

Table II. Difference in the pharynx-to-swallow in- Table III. Difference in the indicators before and after
terval before and after anesthesia for the solid food and anesthesia for solid food
mixture of solid food and liquid Subject number ST SwaD CPO
Subject number Difference for solid food Difference for mixture 1
8 (0.72) +0.13 (1.16)
0.13 (0.71)
1 +5.60
0.31 2 +1 (1.11)
0.20 (0.83)
0.17 (0.75)
2 +2.60
1.20 3 0 (1.00) +0.13 (1.11)
0.03 (0.91)
3 +0.97 +9.90 4
9 (0.47)
0.10 (0.90)
0.10 (0.79)
4 +0.87 0 5 +6 (1.43) +0.13 (1.12) 0 (1.00)
5 +0.14 +10.43 6
1 (0.80) +0.17 (1.20) +0.03 (1.09)
6 0 0 7 +4 (1.80)
0.33 (0.69)
0.60 (0.49)
7
0.03
0.10 8 +2 (1.29) +0.17 (1.20)
0.03 (0.89)
8
0.06
0.97 9 +1 (1.08) +0.33 (0.97)
0.10 (0.77)
9 +2.00
2.10 10 +5 (1.55)
0.03 (1.38)
0.03 (0.92)
10 +1.73 +0.90 11 +3 (1.30) 0 (1.00) 0 (1.00)
11 +0.97 +5.83 12
13 (0.41) +0.03 (1.03) +0.07 (1.22)
12
0.40
2.36 13
2 (0.83) +0.23 (1.23)
0.10 (0.81)
13
0.23
0.20 14 +9 (1.43) +0.17 (1.18)
0.07 (0.86)
14 +0.03 +0.54 15 +3 (1.17)
0.07 (0.95) +0.07 (1.17)
15 +0.03 +0.06 16 +5 (1.19)
0.53 (0.69) +0.07 (1.17)
16
3.87
5.00 17 +14 (2.27)
0.17 (0.83) 0 (1.00)
17 +1.33 +0.27 18 +15 (1.71) +0.57 (1.47)
0.13 (0.71)
18
0.40 +0.47 19 +10 (1.77)
0.30 (0.76)
0.10 (0.77)
19
0.03
0.60 20 +8 (1.62) +0.67 (1.40) +0.13 (1.33)
20
0.27 +11.74
ST, swallowing threshold (no. of chews); SwaD, swallow duration (seconds);
The median of the absolute value of the differences for solid food and mixture CPO, cricopharyngeal opening time (seconds). The difference is the value after
of solid food and liquid were 0.40 seconds and 0.75 seconds, respectively. anesthesia minus that before anesthesia and the ratio after anesthesia/before
Interval increases or decreases larger than the median of the difference shown anesthesia is shown in parenthesis. ST, CPO increases or decreases larger than
in bold. median of the difference shown in bold.

These individual outcomes suggest that bilateral lingual

and IV. More than 50% of increase was observed in 6
participants with the solid food and in 9 with the mixture
of solid food and liquid.
Throughout the swallowing, no participant showed
retainment of the test foods in the valeculla or piriform
sinus after swallowing, and no participant showed pene-
tration or aspiration of the test foods.
DISCUSSION
The results of the present study indicate that the oral
containment time and pharynx-to-swallow interval
varied significantly between the solid food and the
mixture of solid food and liquid before the bilateral
lingual and inferior alveolar nerves were anesthetized.
However, these differences were not observed after the
anesthesia. The results of the present study also indicate
that oral containment time and total sequence duration,
total number of chews, and total number of swallows
varied significantly after anesthesia for both the solid
food and the mixture of solid food and liquid. There were
no significant differences (Table I) in the swallowing
threshold, swallow duration, cricopharyngeal opening
time, and pharynx-to-swallow interval. However, the
outcomes of individual pharynx-to-swallow intervals
showed increases in 8 participants and decreases in 3
with the solid food, and increases in 5 participants and
decreases in 5 with the mixture of solid food and liquid.
and inferior alveolar nerve anesthesia may affect the
onset of swallowing and that those altered onsets varied
among the participants.
Anesthesia of the lingual nerve simultaneously affects
the inferior alveolar nerve. Consequently, both the
mucosa of the dorsal surface of the tongue, and the
mucosa of the lower lip, lower gingival mucosa, and
periodontal ligament of premolars and molars are
anesthetized. By the anesthetic injection, the sensory
inputs from the mouth were reduced and the sensory
feedback systems of the mastication were confused and
had been disrupted, as reported by Kapur et al.17 The
prolongation of the oral containment time and total
sequence duration, and the increase in total number of
chews and swallows shown in the present study clearly
demonstrate that mastication after anesthesia is altered.
It is concluded that the swallowing threshold and the
oropharyngeal swallowing including the onset of
swallowing were determined by the consistencies of
the foods.4,18 Nevertheless, the results of the present
study showed that after anesthesia there were no
differences between the solid food and the mixture of
solid food and liquid. These results indicate that sensory
input from the mouth plays an important role in dis-
tinguishing the different consistencies of the foods
and that this leads to different patterns of oropharyngeal
swallowing.
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Tei et al 557
Volume 97, Number 5

The swallowing threshold, swallow duration, crico- Table IV. Difference in the indicators before and after
pharyngeal opening time, and pharynx-to-swallow inter- anesthesia for the mixture of solid food and liquid
val before and after anesthesia did not vary significantly. Subject number ST SwaD CPO
However, individual swallowing thresholds showed a
1
10 (0.57)
0.03 (0.97)
0.07 (0.86)
tendency to increase after anesthesia. Moreover, al- 2
1 (0.93) +0.20 (1.20)
0.03 (0.95)
though the individual swallow duration and the crico- 3 +12 (1.75) +0.20 (1.21) +0.07 (1.18)
pharyngeal opening time showed smaller changes 4
3 (0.70) +0.03 (1.04) +0.03 (1.06)
among the participants, the individual pharynx-to- 5 +7 (1.39) +0.27 (1.29) 0 (1.00)
swallow intervals in the before and after anesthesia 6 +1 (1.50) +0.13 (1.17) +0.10 (1.27)
7
2 (0.60)
0.13 (0.85)
0.30 (0.53)
conditions varied considerably in some participants. 8 +3 (1.27) +0.23 (1.28)
0.03 (0.92)
The reasons for the onset of swallowing are 9
4 (0.60)
0.10 (0.89)
0.10 (0.79)
complicated and not fully elucidated. It is possible that 10 +5 (2.00) +0.07 (1.07) +0.07 (1.17)
sensory input from mucosal receptors in the oral cavity, 11 +12 (2.20) +0.10 (1.10) +0.07 (1.18)
or oropharynx and larynx are responsible for controlling 12
4 (0.60) +0.10 (1.11) +0.03 (1.09)
13 0 (1.00) +0.53 (1.47) +0.07 (1.11)
chewing and swallowing.2 Pommerenke19 found that the 14 +8 (1.73)
0.07 (0.94)
0.03 (0.93)
anterior faucil arches were the most sensitive areas for 15 +3 (1.25) 0 (1.00) +0.03 (1.07)
initiating the swallowing reflex. Some investigators 16 +10 (1.50) +0.10 (1.11) 0 (1.00)
reported that normal humans hold the bolus in the oral 17 +2 (1.25)
0.83 (0.52) +0.03 (1.15)
cavity until the onset of swallowing.5,6 Differently, 18 +11 (1.52) +0.23 (1.17)
0.07 (0.85)
19 +10 (1.71) +0.23 (1.25)
0.13 (0.73)
Linden et al7 have reported that contrast material is 20 +14 (2.56) +0.03 (1.02) +0.03 (1.06)
commonly present in the pharynx at the onset of
swallowing in normal subjects. Others8,9 have reported ST, swallowing threshold (no. of chews); SwaD, swallow duration (seconds);
CPO, cricopharyngeal opening time (seconds). The difference is the value after
that fluid infusion in the hypopharynx induces the onset anesthesia minus that before anesthesia and the ratio after anesthesia/before
of swallowing in experimental animals, and Pouderox10 anesthesia is shown in parenthesis. ST increases or decreases larger than median
ascertained these findings in humans. Others have of the difference shown in bold.

reported that the hypopharynx may be a crucial trigger

point in the elicitation of the pharyngeal swallowing in
sequential straw drinking12 and Dua et al11 reported that
the epiglottis was the main site for the elicitation of the
onset of swallowing. Palmer et al4 has reported that these
differences may be attributed to the food consistency and
whether the subject has been commanded to swallow or
not, and that multiple receptor sites within the orophar-
ynx must be stimulated to achieve the threshold
necessary to evoke pharyngeal swallowing. Although
much has been reported about the onset of swallowing,
except for Tanimoto et al16 little has been concerned with
whether bilateral lingual and inferior alveolar nerve
anesthesia affects the onset of swallowing. Despite
Tanimoto et al16 only using liquid test foods in the
experiments and a small number of subjects, the results
of the present study are in partial agreement with their
findings.
The results of the present study suggest that the upset
in mastication by bilateral lingual and inferior nerve
anesthesia in adult males affects the onset of swallowing
with relatively unchanged swallow duration and crico-
pharyngeal opening time.
The altered onset of swallowing shown in the present
study also indicates that more attention must be paid to
the reestablishment of mastication in the treatment of
patients with swallowing disorders. Although the mecha-
nism of the inhibitory or promotive onset of swallow-
ing needs further study, the results here shed new light on
the correlation between the masticatory sequence and the
onset of swallowing.
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Reprint requests:
Kanchu Tei, DDS, PhD
Assistant Professor
Oral and Maxillofacial Surgery
Graduate School of Dental Medicine
Hokkaido University
Kita-13, Nishi-7, Kita-ku
Sapporo 060-8586, Japan
teik@den.hokudai.ac.jp