Specialist article on swallowing
Swallowing and swallowing disordersA pattern, not just a reflex
The bolus reaches the stomach, and yet the pattern behind it may be altered. Here you will learn how the act of swallowing works, how to recognise incorrect swallowing and tongue pressing, and when swallowing difficulties should be checked by a doctor.
Does this sound familiar?
You swallow, but how?
What applies to you?
Tap whatever applies to you.
The first five points suggest an altered swallowing pattern. This is rarely noticeable when eating, and it can be trained. The last point is different. If you often choke, food gets stuck or swallowing hurts, a medical assessment comes first.
How to recognise your swallowing patternWhen swallowing difficulties should be checkedThe key points at a glance
- Swallowing is a fixed sequence of several phases, controlled in the brainstem and coordinated with breathing. It happens many hundreds to a thousand times a day.
- An altered swallowing pattern, such as tongue pressing, gets the bolus safely into the stomach. It shows in the tongue, lips, chin and teeth, not in difficulties when eating.
- With dysphagia too, for example after a stroke, the aim is to train the correct swallowing pattern again. FaceFormer training can be used as a complement to medical and speech therapy treatment, coordinated with the treatment team.
Video
Swallowing: why the swallowing pattern matters
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Fundamentals
Swallowing: more than a reflex
Swallowing is one of the processes you hardly think about. That is precisely why it is worth taking a close look at what happens.
You swallow when eating and drinking, but above all in between, when saliva collects in your mouth, during the day as well as at night. This happens many hundreds to a thousand times a day1. With every swallow, the lips, tongue, jaw, soft palate, pharynx, larynx and oesophagus work together in a fixed sequence.
The distinction matters, because the term swallowing disorder covers two different things. Many people swallow with a deviant pattern and notice nothing, because the bolus reliably reaches the stomach. Others often choke or can no longer get food down safely. This article shows where the line lies.
Swallowing is not just a reflex. It is a pattern that your nervous system has learned.The sequence in the throat is laid down in the brainstem. How the tongue, lips and jaw initiate it in the mouth became established in childhood and has run without thinking ever since.
Act of swallowing
The phases of the act of swallowing
A swallow lasts only a moment. In that time, several phases take place, from the voluntary part in the mouth to the automatic transport in the oesophagus.
Oral preparatory phase
Chewing, mixing with saliva, portioning. The tongue forms the food into a swallowable mouthful, the bolus. The lips are closed; you still control this phase voluntarily.
Oral transport phase
The tip of the tongue finds its contact at the front of the palate. From there, the tongue presses against the palate from front to back and pushes the bolus towards the throat.
Pharyngeal phase
When the bolus touches the trigger zones at the base of the tongue and on the wall of the throat, the brainstem takes over. The soft palate seals off the nose, the hyoid bone and larynx rise, the epiglottis folds over the entrance to the larynx, and breathing pauses.
Oesophageal phase
The upper entrance to the oesophagus opens, and a wave of muscle contractions carries the bolus into the stomach. This part runs without any input from you.
The transition from the second to the third phase is the decisive point. Up to then you can still hold the mouthful back; after that, you can no longer do so. Where the tongue starts, how the bolus is formed and whether the lips are sealed set the starting conditions for the brainstem.
Two pathways cross in the throat. Air travels from the nose down into the larynx, food from the mouth into the oesophagus behind it. For the moment of swallowing, the airway therefore has to be closed.
If something does get into the entrance to the larynx, in everyday language we speak of something “going down the wrong way” or choking. The cough that follows is a protective response. Occasionally this is normal; if it happens often, it is worth taking a closer look.
Swallowing apnoea
Swallowing and breathing share a space
Because the airway and the food pathway cross in the throat, swallowing and breathing have to be precisely coordinated.
Swallowing and breathing cannot take place at the same time. With every swallow, breathing stops briefly. This pause is called swallowing apnoea. It is not merely a consequence of the closed larynx but is specifically ordered by the nervous system. This was shown by a study of people whose larynx had been removed. Although their airway no longer ran through the throat, the pause during swallowing remained2.
were measured in Boston while swallowing and breathing at the same time. In all of them, swallowing reset the breathing rhythm, and the breathing pause was followed by an exhalation3
showed, in a study from South Carolina, four patterns in which breathing and swallowing interlock. With increasing age, these patterns shifted4
So after the swallow, air first flows outwards before the next inhalation. This makes sense, because residues in the throat are more likely to be carried out than breathed in. Swallowing and breathing run via shared networks in the brainstem. They share muscles, nerves and pacemakers and, in our view, are two sides of one process.
Like a level crossing
At a level crossing, road and railway share one area. When a train comes, the barrier closes for a moment, and then the traffic rolls on. It is similar in the throat. During the swallow, the airway closes briefly, and afterwards breathing resumes with an exhalation. If the barrier works reliably, you notice nothing of it.
Swallowing pattern
Correct and incorrect swallowing: what matters in the mouth
The sequence in the throat is firmly laid down in the brainstem. Differences show up in the mouth, where the swallow is initiated.
In the reference pattern, the swallow starts at the front. The tip of the tongue rests on the small elevation behind the upper incisors, the papilla incisiva, and does not touch the teeth. The lips rest loosely together. Starting from the tip of the tongue, the tongue presses against the palate from front to back and pushes the bolus backwards. The head balances over the body and stays still during swallowing.
Just before the swallow, the back teeth come into contact. This bite gives the lower jaw support, the chewing muscles stabilise, the tongue has a firm abutment, and the lips hardly have to exert any force. Immediately afterwards, the teeth loosely come apart again.
After the swallow, the tongue stays against the palate. With closed lips and nasal breathing, a slight negative pressure holds it there, without any holding effort. This is how the tongue reference position is established after the swallow.
Reference pattern
- Tip of the tongue at the front of the palate, the teeth stay free
- Brief bite of the back teeth
- Lips relaxed, chin relaxed
- Head balances and stays still during swallowing
- Afterwards, tongue against the palate, breathing through the nose
Compensatory pattern
- Tip of the tongue presses against or between the incisors
- Teeth stay apart, there is no bite
- Lips press, the chin tenses
- The head nods or pushes forwards during swallowing
- Afterwards the tongue lies low, the mouth opens slightly
Both patterns get the bolus safely into the stomach. They differ in which muscles carry the work.
Try it out. Swallow your saliva once with a brief bite and once with your teeth slightly apart. What do you notice?
Tongue pressing
Tongue pressing when swallowing: a compensatory solution
If the tongue presses against or between the incisors during swallowing, this is called tongue pressing, tongue push or tongue thrust. In our view, it is generally a compensatory solution. If the tongue lies low and lacks contact with the front of the palate, the swallow still needs a seal. The nervous system shifts it forwards, to the teeth, lips and chin.
with an open bite and a deviant swallowing pattern showed, in Giessen, more activity of the lip muscles and less activity of the chewing muscles during swallowing than 15 people with an unremarkable pattern5
of this group were measured again after orthodontic closure of the open bite. Their swallowing pattern in the muscle profile had not normalised5
The tooth position had been corrected, but the pattern continued as before. The group was small, and there was no untreated control group. Nevertheless, the finding fits our view: a swallowing pattern does not change with the shape of the teeth, but only when the sequence itself is re-learned.
In children, a tongue thrust is part of development. A review concluded that under the age of ten it is the rule rather than the exception, and found no close link with tooth misalignments6. We state this honestly. In our view, what matters is therefore not the individual finding, but whether the pattern sorts itself out with growth or becomes entrenched.
The front reference point is missing
The tip of the tongue lies low, often since childhood, for example with mouth breathing, prolonged dummy use or thumb sucking.
The tongue seeks support on the teeth
When swallowing, it braces itself at the front against the incisors instead of against the palate.
Lips and chin provide the seal
The ring muscle of the mouth and the chin muscle take over the sealing. The chewing muscles are hardly needed any more when swallowing.
The pattern becomes ingrained
Many hundreds to a thousand repetitions a day reinforce the compensatory solution until it feels right.
Consequences become visible
Misaligned teeth, an open mouth posture, mouth breathing or tension in the jaw and neck can stand at the end of many such chains. Hardly anyone connects them with swallowing.
These consequences are usually treated individually: the tooth position, the tension, the jaw. Swallowing is rarely looked at, even though it takes place many hundreds to a thousand times a day. As the finding from Giessen shows, the pattern can continue even when the teeth have been corrected. In our view, a deviating swallowing pattern is usually a link in these chains, and often the link that nobody addresses.
The triad
Swallowing in combination with breathing and head balance
Swallowing never runs on its own. It shares space, muscles and control with breathing and with head balance.
The nose is part of this too. Nasal breathing constantly supplies the olfactory mucosa with stimuli, and smelling prepares for swallowing. In 105 nursing home residents after a stroke, one minute of smelling black pepper oil shortened the time until the swallowing reflex was triggered7.
The hyoid bone is a bone without a joint. It hangs from muscles that run to the lower jaw, to the base of the skull and down to the chest, and it carries the tongue and larynx. How the head balances therefore changes the directions of pull under which swallowing takes place. 18 older women swallowed water faster when sitting upright than when slumped with the head pushed forwards8.
of children with moderate to severe sleep apnoea in the mixed dentition swallowed with a tongue thrust at a Paris children’s hospital; in the permanent dentition it was 38%9
Both studies show a joint occurrence, not a cause. But they fit our picture. In our view, a deviating swallowing pattern usually does not stand alone. It is part of a pattern in which breathing, swallowing and head balance fall out of balance together. This triadic functional circuit stands at the start of many causal chains that can extend to snoring, ear pressure, reflux or neck complaints.
Dysphagia
Swallowing difficulties: when to see a doctor
Dysphagia must be clearly distinguished from an altered swallowing pattern. Here it is not only the sequence that is altered; swallowing itself no longer works safely.
In dysphagia, food gets stuck, fluid enters the airways, or swallowing is painful. The causes are varied. They include stroke, Parkinson’s disease and other neurological conditions, narrowings, inflammation or other changes in the oesophagus, as well as side effects of medication. This should be examined by a doctor so that it is clear where the disorder comes from and how safely eating and drinking are currently possible.
of people after a stroke had dysphagia, according to a Toronto review of 24 studies, when examined only with simple screening tests11
was the figure with a clinical examination11
was the figure with instrumental examination. The more closely one looks, the more often the disorder shows up11
Frequent choking
You regularly cough or clear your throat when eating or drinking.
Food gets stuck
Mouthfuls or tablets get stuck in the throat or behind the breastbone.
Gurgly voice
After eating, your voice sounds wet or husky.
Pain when swallowing
Swallowing hurts, even beyond an infection.
Unintended weight loss
You eat less because swallowing is an effort, and you lose weight.
Sudden onset
The symptoms appear newly and suddenly.
Not every instance of choking makes itself noticed. If the protective cough reflex does not occur, food, fluid or saliva can get into the airways unnoticed. This is called silent aspiration. Because neither coughing nor throat-clearing draws attention to it, it can go undetected for a long time. After a stroke, the risk of pneumonia is markedly increased with swallowing disorders and especially with aspiration11. This is another reason why even a suspected swallowing disorder should be checked by a doctor or a speech and language therapist. Your own training does not replace this assessment.
If a swallowing disorder appears suddenly, together with a drooping side of the face, slurred speech or weakness in an arm or leg, call the emergency number 112. These can be signs of a stroke. Once the cause has been clarified, the aim with neurologically caused dysphagia, too, is to re-learn the swallowing pattern. FaceFormer training addresses exactly this and can be used as a complement to medical and speech therapy treatment. Agree this with your treatment team, especially if eating or drinking do not yet work safely. With degenerative neuromuscular diseases such as ALS or advanced Parkinson’s, the rule is: only after consulting your doctor.
3D film
The basic exercise: press, bite, swallow
In 45 seconds, the animation shows how FaceFormer training embeds the swallow in an orderly sequence, with the head upright, the lips closed and a brief bite.
Training
Training the swallowing pattern: you learn to swallow by swallowing
A swallowing pattern cannot be changed by a resolution. As soon as your attention is elsewhere, in conversation or in sleep, the habitual pattern carries on. Re-learning requires repetition in the right context. In our view, this means practising the swallow as a whole, together with lip closure, tongue reference position, nasal breathing and head balance.
For an altered swallowing pattern, isolated tongue strengthening exercises therefore fall short. A review from Toronto evaluated seven studies that assessed tongue strength training with X-ray recordings of swallowing. The effect on the swallowing sequence was inconsistent, and a pooled analysis was not possible12. In the treatment of dysphagia, strength training can have its place. For the pattern, what counts is the sequence, not the strength.
In FaceFormer training, the FaceFormer sits in the oral vestibule, behind the lips and in front of the teeth. The tip of the tongue rests at the reference point, you breathe through your nose, and your head is upright.
In the basic exercise you press the lip wedge together with your lips for six seconds, bite down briefly with your back teeth and swallow once. Then you relax your lips, your teeth come apart again, and the tip of your tongue stays where it is.
- From day 1
Basic exercise
Three times a day, with 8 repetitions in week 1, 14 in week 2 and 20 from week 3, with the FaceFormer ZERO.
- From around week 3
Pull exercise and night
The pull exercise is added. At night you wear the FaceFormer ZERO as soon as you have the basic exercise down.
- After a few weeks
Switching to the ONE
During the day, you train with the FaceFormer ONE. It is the same size and shape as the ZERO, just made of firmer material.
- From around week 6
Extended modules
Depending on your needs, further modules are added, for example the breathing exercise, which combines swallowing and calm nasal breathing.
- Over months
The pattern runs by itself
The exercise manual allows six to twelve months until the new sequences run without thinking.
The free FaceFormer app guides you through the basic exercises; you will find all modules on the exercise pages. If swallowing with the FaceFormer is difficult at first, that is common, especially after a long period of mouth breathing. Start gently and at first swallow only on every second repetition. There is a separate exercise plan for children; more under FaceFormer for children.
Everyday life
The swallowing pattern in everyday life
Tip of the tongue to the reference point
Between swallows, the tip of your tongue rests on the small elevation behind the upper incisors. Resting, not pressing.
Bite briefly
When swallowing saliva, make sure your back teeth briefly make contact. Afterwards, they loosely come apart again.
Lips closed, nose open
With loosely closed lips and nasal breathing, the negative pressure holds the tongue against the palate after the swallow.
Eat and drink sitting upright
Sit upright to eat, with your head balancing over your body. When slumped, swallowing is slower.
Continue ongoing treatment
If you are receiving medical or speech therapy treatment for a swallowing disorder, do not stop anything on your own, and raise the training there.
Questions
Frequently asked
What is a swallowing disorder?
The term refers to two different things. In the medical sense it means dysphagia, in which eating and drinking no longer work safely, for example after a stroke. Often, however, what is meant is an altered swallowing pattern. In that case the bolus reaches the stomach without any problem, but the tongue, lips and chin work differently from the reference pattern.
What does incorrect swallowing mean?
In everyday language it means choking on something, when saliva, food or a drink gets into the entrance to the larynx and a cough expels it again. Occasionally this is normal. In specialist terminology, by contrast, incorrect swallowing refers to a deviant swallowing pattern, for example when the tongue presses against the incisors during swallowing.
How often does a person swallow each day?
Many hundreds to a thousand times, when eating and drinking and above all in between, when saliva is swallowed. Because of this number of repetitions, a swallowing pattern becomes firmly established, regardless of whether it matches the reference pattern or not.
How can I recognise tongue pressing when swallowing?
Typical signs are a tense chin muscle with small dimples in the skin, pressing lips and teeth that stay apart during swallowing. You can then feel the tip of your tongue against or between the incisors instead of at the front of the palate. Place a finger lightly on your chin the next time you swallow, and you will feel whether it is working along.
When should I have swallowing difficulties checked by a doctor?
If you often choke, food or tablets get stuck, swallowing hurts, your voice sounds gurgly after eating or you lose weight without meaning to. If swallowing difficulties appear suddenly, together with a drooping side of the face, slurred speech or weakness in an arm or leg, call the emergency number 112.
What is silent aspiration?
Normally, choking triggers a cough reflex that expels food, fluid or saliva from the airways again. In silent aspiration, this reflex does not occur. What has been swallowed the wrong way gets into the airways without you coughing or noticing anything. After a stroke, the risk of pneumonia is markedly increased with swallowing disorders and aspiration11. If you suspect a swallowing disorder, you should therefore have it checked by a doctor or a speech and language therapist. Your own training does not replace this assessment.
Can a swallowing pattern be trained?
A swallowing pattern is a learned sequence and can be re-learned through repetition. In our view, this is most likely to succeed when the swallow is practised as a whole, together with lip closure, tongue reference position, nasal breathing and head balance. In FaceFormer training, this happens in the basic exercise. The exercise manual allows six to twelve months until the new pattern runs without thinking.
Does reflux have anything to do with swallowing?
With reflux, often only the entrance to the stomach is considered. But swallowing, the oesophagus and the stomach share their control via the vagus nerve and the control centre in the brainstem. During sleep, swallowing frequency and saliva flow drop sharply, so that the acid remains on the mucous membrane for longer13. Whether a deviating swallowing pattern during the day contributes to reflux has not been studied. But in our view, the connection suggests itself via the shared control.
Can I also train with the FaceFormer after a stroke?
Yes, as a complement. With neurologically caused dysphagia, too, the aim is to re-learn the correct swallowing pattern, and that is exactly what the FaceFormer trains, together with breathing and head balance. How and from when, you agree with your medical and speech therapy treatment team, especially as long as eating or drinking do not yet work safely. You do not stop ongoing treatments on your own. With degenerative neuromuscular diseases such as ALS, advanced Parkinson’s or bulbar palsy, the training only makes sense after consulting your doctor.
More articles from the knowledge section
Experiences on this topic
Where to go next
Sources
- Lear CS, Flanagan JB Jr, Moorrees CF (1965). The frequency of deglutition in man. Archives of Oral Biology 10:83-100. PMID 14262163. Source
- Hiss SG, Strauss M, Treole K, Stuart A, Boutilier S (2003). Swallowing apnea as a function of airway closure. Dysphagia 18(4):293-300. PMID 14571335. Source
- Paydarfar D, Gilbert RJ, Poppel CS, Nassab PF (1995). Respiratory phase resetting and airflow changes induced by swallowing in humans. Journal of Physiology 483(Pt 1):273-288. PMID 7776238. Source
- Martin-Harris B, Brodsky MB, Michel Y, Ford CL, Walters B, Heffner J (2005). Breathing and swallowing dynamics across the adult lifespan. Archives of Otolaryngology Head and Neck Surgery 131(9):762-770. PMID 16172351. Source
- Störmer K, Pancherz H (1999). Electromyography of the perioral and masticatory muscles in orthodontic patients with atypical swallowing. Journal of Orofacial Orthopedics 60(1):13-23. PMID 10028785. Source
- Lebrun Y (1985). Tongue thrust, tongue tip position at rest, and sigmatism: a review. Journal of Communication Disorders 18(4):305-312. PMID 3894438. Source
- Ebihara T, Ebihara S, Maruyama M, Kobayashi M, Itou A, Arai H, Sasaki H (2006). A randomized trial of olfactory stimulation using black pepper oil in older people with swallowing dysfunction. Journal of the American Geriatrics Society 54(9):1401-1406. PMID 16970649. Source
- Nakamura K, Nagami S, Fukunaga S, Shinonaga A, Kodani Y, Obama N, Kanai S (2024). Influence of Spinal Sagittal Alignment in Sitting Posture on the Swallowing Speed of Older Adult Women: A Cross-Sectional Study. Dysphagia 39(5):772-782. PMID 38280027. Source
- Bokov P, Dahan J, Boujemla I, Dudoignon B, Delclaux C (2024). The role of atypical deglutition in children and adolescents with moderate to severe obstructive sleep apnea syndrome. Journal of Sleep Research 33(5):e14175. PMID 38369922. Source
- Ralli G, Ruoppolo G, Mora R, Guastini L (2011). Deleterious sucking habits and atypical swallowing in children with otitis media with effusion. International Journal of Pediatric Otorhinolaryngology 75(10):1260-1264. PMID 21802155. Source
- Martino R, Foley N, Bhogal S, Diamant N, Speechley M, Teasell R (2005). Dysphagia after stroke: incidence, diagnosis, and pulmonary complications. Stroke 36(12):2756-2763. PMID 16269630. Source
- Smaoui S, Langridge A, Steele CM (2020). The Effect of Lingual Resistance Training Interventions on Adult Swallow Function: A Systematic Review. Dysphagia 35(5):745-761. PMID 31612288. Source
- Orr WC, Heading R, Johnson LF, Kryger M (2004). Review article: sleep and its relationship to gastro-oesophageal reflux. Alimentary Pharmacology and Therapeutics 20 Suppl 9:39-46. PMID 15527463. Source
Get started
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The free FaceFormer app guides you through the basic exercises, counts along and reminds you of your sessions. If you wish, a practice from the practitioner directory can support you.
FaceFormer ZERO + ONE
Both material hardnesses for getting started, day and night. The set for adults.
FaceFormer ZERO
The softer FaceFormer for getting started, for children and for the night.
FaceFormer ZERO Children’s Set
ZERO with hygiene box, plush bag and success book with stamp.
FaceFormer training aims to restore the physiological setting of the basic functions of breathing, swallowing and head balance, with lip closure and the tongue reference position, thereby creating the conditions under which symptoms can improve. It does not replace a medical assessment. You can find practitioners near you in the practitioner directory.
