【Objective】It might be useful to evaluate the effectiveness of changes in bolus viscosity using videofluoroscopic swallowing examination (VF) for patients with dysphagia，because an increase in viscosity can change the speed of bolus flow and thus control the occurrence of aspiration．Compensatory postural maneuvers have been applied to reduce aspiration or improve pharyngeal clearance．Therefore，the purpose of this retrospective study was to evaluate the influence of the bolus viscosity and the position of the patient's head on the speed of bolus flow by means of VF images．

【Material and Methods】VF images of 133 patients with dysphagia were reviewed to examine the phenomenon of bolus trickling from the oral cavity into the vallecule．21 patients including those with cerebral palsy，after stroke， and after treatment for oral cancer were selected as subjects．The speed of bolus trickle on the base of tongue (anterior wall of mid-pharynx) and the angle of the anterior-posterior inclination of the tongue base were measured in each subject's VF images．The viscosities of materials given to the patients were measured with a rotational viscometer．The materials included barium liquid，thickened barium liquid，and puree or paste foods．

【Results and Discussion】The average speed of bolus flow was 155 ± 78 mm/sec in lower-viscosity （under 1000 mPa・s）liquid materials，and 42 ± 31 mm/s in thickened higher-viscosity (over 1000 mPa・s) materials．In the higher-viscosity material，the speed of bolus flow was infｌuenced by the angle of the tongue base inclination．However，the effect of the change of tongue base inclination on the speed of bolus flow was not significant in liquid materials．These results were broadly consistent with the results of a previously reported in-vitro model simulation study．By improving the model simulation system，it may become possible to predict the speed of bolus flow in a patient's pharynx．

【Objective】Many physical functions including feeding/swallowing are affected by aging．It has been reported that the function of the tongue and masticatory muscles declines with age．However，the alteration related to normal labial force，which has been achieved through the process of long-term physical development，has not been clarified．Thus，we considered it significant to document the variation in labial function．The purpose of this study was to examine the relationship between vertical labial-closing pressure and age in elderly people．

【Subjects and Methods】One hundred and thirty seven subjects who had no feeding/swallowing disorders were chosen from among 311 senior citizens who participated as volunteers over the age of 60．They consisted of 31 men (mean age 69.5 ± 5.3 years) and 106 women (69.3 ± 5.5years)，all of whom maintained posterior occlusal support with their natural dentition and had no defect in the front teeth．Water-repellent pressure sensors that employed a strain gauge transducer were embedded in a smooth-surface acrylic plate．The device was used to measure the labial-closing pressure when taking food，and effortful maximum labial pressure．The maximum lingual pressure against the bubbleshaped sensors on the palatal palate was evaluated，using the “Handy Manometer” developed by Hiroshima University．In addition，grip strength as an indicator of physical ability and height and weight as a constitutional indicator were also measured．

【Results】The mean value of vertical labial-closing pressure when taking food and effortful maximum labial pressure showed no relation to age．However，the mean value of lingual pressure and grip strength showed significant decreases with age (lingual pressure：r ＝ －0.346，p＜0.001，grip strength：r ＝ －0.201，p＜0.05)．We presumed that vertical labialclosing pressure was maintained at a constant level even in the elderly，because the sequence of labial-closing movement，necessary for feeding from ingestion to swallowing，is greatly repeated over a period of time．Moreover，we presumed that the labial force is maintained to compensate for the decline in lingual function with age．

【Conclusion】This study suggested that labial function is difficult to be influenced by age．

In an attempt to establish clinical criteria for starting direct therapy for dysphagia，we retrospectively detected significant factors that influenced decision-making of the therapy initiation．We included 21 patients with stroke transferred to our hospital for multidisciplinary rehabilitation with prohibited oral intake in acute hospitals because of dysphagia．Direct therapy was subsequently started in 14 patients (oral intake group) but not in 7 patients （non-oral intake group） after a few weeks of intensive swallowing therapy． Factors we hypothesized to influence the starting of direct therapy included 1．alertness，2．gross motor function，3．cognitive function，4．history of pneumonia，5．oral motor function，6．saliva swallowing，7．findings of repetitive saliva swallowing test，8．findings of revised water swallowing test (3 ml)，and 9．VF/VE findings．Significantly different factors between two groups were 1．Alertness (p＜0.05)，4．history of pneumonia (p＜0.01)，5．oral motor function (p＜0.05)，6．saliva swallowing (p＜0.01)，and 9．VF/VE findings (p＜0.05)． Discrimination of two groups by a single factor appeared to be insufficient since concordance rate of each factor was not high enough (CR ＝ 0.71～0.81，mean 0.76)．Thus we set 26 compound factor sets that consisted of some of the 5 significant factors．Using compound factors，We tried to discriminate two groups．To increase number of factors included in the sets improved concordance rate (ANOVA：df ＝ 3，F ＝ 16.001，p＜0.0001)．This finding is in accordance with our clinical impression that decision-making of starting direct therapy should be based on comprehensive perspective regarding multiple factors． Compound factor sets that were effective for the discrimination were set V (factor 1，4，5，9，cut-off point 13-14，sensitivity 1.00，specificity 0.92，CR 0.95)，set W (1，4，6，9，cut-off point 13-14，sensitivity 1.00，specificity 0.92，CR 0.95) and set Z (1，4，5，6，9，cut-off point 13-14，sensitivity 1.00，specificity 0.92，CR 0.95) To optimize the decision-making in an environment where VF and VE are unavailable， we investigated relevant compound factor sets that consisted of factors other than VF/VE findings．Relatively satisfactory levels were obtained from the set of 6 factors (CR greater than 0.90)．Those factors might be helpful in making a decision to start direct therapy in the situation．

We report on a 67-year-old male with severe swallowing disorder after stroke．He had not taken food orally for about 18 months after the onset．Intensive dysphagia treatments were applied including rehabilitation therapy and a palatal augmentation prosthesis (PAP)．After 2.5 months，he became able to take food orally．One of the main factors contributing to improvement of swallowing was effective training with the PAP．The PAP was constructed by a dentist in cooperation with a speech language therapist．To evaluate the effect of PAP，the tongue pressure was measured using two types of sensor．After training，the posterior tongue pressure was markedly increased with PAP and also without the device．We concluded (it is obvious) that tongue pressure was facilitated by training with PAP．There are few reports about applying PAP to a patient with severe swallowing disorder after stroke．In our case， it was effective to apply the PAP to stroke patient．The important factors indicating the potential usefulness of a PAP are considered to be (1) dysarthria of lingtial sounds； (2) oral residue of food and vertical distance between the tongue dorsum and the palate during swallowing demonstrated by videofluoroscopic study； and (3) the anatomical form of the palate such as a highly arched palate．