Fellus. P. *

*Qualified Specialist.

Former Consultant Attaché to the Paris Hospitals

Full member of the French National Academy of Dental Surgery. Conflict of interest as inventor of Froggymouth

Professor Jean DELAIRE wrote in 2005: “the results of orthopedic treatments can only be stable if, at the end of the treatment of dentofacial DYSMORPHOSIS, the manducatory functions (chewing + swallowing + good movements of the tongue and lips…) have been perfectly normalized, as soon as possible”.

He had already understood that it was not just the rehabilitation of a single praxis that needed to be addressed – swallowing for us orthodontists, breathing for sleep medicine, inner ear drainage for ENT specialists, speech for speech therapists – but the whole range of orofacial praxis to ensure overall dynamic balance.

Breathing rehabilitation is therefore a prerequisite for

language rehabilitation, which is a prerequisite for

respiratory rehabilitation. Let’s not forget that “the nasal cavities and mouth are built from a common cavity, the stomodeum”.( Couly )*

Fortunately, nature can come to our aid if we respect physiological acquisition processes. Takashi Ono* even includes the need to integrate diaphragm commands by connecting the phrenic nerve.

Background

 

The neural circuits that manage sucking and swallowing are formed in utero at around 14ème weeks. They will initially be reflexes.

The newborn will be fed in this way until the second half of the year, when the second neurological center for oral feeding, i.e. the praxis center of the brain located in the frontal cortex, comes into operation.

“The mandibular gesture of mastication involves a slow neurological organization and maturation whose centers are in the frontal cortex of the brain and whose control is ensured, on the one hand, by the geniculate bundle dependent on the pyramidal pathway and, on the other hand, by the efficiency of the nerves of the brain stem,” (Couly)*

SETTING UP MASTICATION

Sixty per cent of children will spontaneously discover a new swallowing program when they start chewing, in a totally natural way, without having to resort to exercises: this is a bottom-up, ANOETIC approach. Genes and epigenesis occur spontaneously around the age of four, and the increase in Neuron Growth Factor will produce new neurons and therefore new neuronal circuits.

“Memory is not based on the properties of nerve cells as such, but on the nature of the connections between neurons and the ways in which they process the sensory information they receive”. KANDEL*

The information is constantly analyses and is generally ignored very quickly, but it can lead to reorganization by ANOETIC means if it is relevant.

The trigeminal nerve takes control of a function previously managed mainly by the facial nerve. Eumorphic growth can then establish an aesthetic and functional dentition. These children will not require orthodontic treatment.

Contraction of the tensor tympani, the hammer muscle, which is also innervated by the trigeminal nerve, allows the middle ear to be ventilated by dilating the Eustachian tube and reduces the problems of serous otitis.

However, for reasons that are mainly epigenetic in origin, 40% of children will continue to use the swallowing-suction programs that are the cause of the majority of DYSMORPHOSIS .

They will have to be paid for at the time of the orthodontist’s operation.

“Learning will consist of tracing new circuits, and this plasticity will be achieved either by reshaping existing programs or by creating new ones” Kandel*.

THE DIFFERENT STRATEGIES AVAILABLE

Many practitioners prefer to ignore the correction of orofacial dyspraxia in their treatment plans, and hope that the normalization of dental occlusion will allow the spontaneous acquisition of a balanced functional plan at the end of treatment, which will ensure the stability of results by correcting the damage caused by dysfunctions.

This random approach has been defended by Pimenidis,* it too will be anoetic.

-The use of functional educators.

They are frequently prescribed, but wearing them all night plus two hours during the day is rarely respected

by patients, particularly young children. They disrupt the quality of sleep that is so important throughout school to consolidat learning.( Druckman and Bork) *have shown that you can’t learn anything while you’re asleep.

Encoding takes place during the day, but for consolidation to be effective, the information must be transferred to other areas of the brain during sleep (neuronal replay: Jouvet, 1992); “Functional brain imaging revealed an electrical reactivation during sleep, as if the brain were replaying the neuronal sequences activated during the day” Euston 2007*.

By combining functional magnetic resonance imaging

(fMRI) and electroencephalography (EEG), Sophie

Schwartz and Virginie Sterpenich from the University

of Ugine (2021) have developed a decoder capable of

deciphering brain activity during deep sleep, proving

that the work of sorting out the thousands of pieces of

information processed during the day takes place during

deep sleep. Schwartz *

.

-However, the most commonly used therapy at present

involves a voluntary approach to these acquisitions.

Practitioners, speech therapists and physiotherapists will try to make the patient aware of the gestures he/she usually performs and then the gestures he/she needs to learn. This is a top-down (voluntary, noetic) approach, where the orders come from the cortical part and go down to the motor effectors.

Eric Kandel,* winner of the2000 Nobel Prize for Medicine, has shown that effectiveness will depend on the frequency of these stimulations and the daily practice of the prescribed exercises. If the sessions are spaced out, they will modify the messages transmitted to the synapses, but this will only involve short-term memory. On the other hand, if the synaptic information is repeated regularly, specific proteins (AMP Kinases) will reach the nucleus, which will be modified to ensure passage into long-term memory.

-A new approach is emerging: the inhibition of dysfunctional motor circuits which will open up a new mode of immediate recording in long-term memory, which researchers call ‘now print’, by acting on the basolateral part of the amygdala.( *Robert Burr Livingston )

McGaugh’s work *in 2003 showed that a highly emotional state can short-circuit normal biochemical constraints and produce a sufficient quantity of MAP kinase molecules (Martin)* which will be sent to the nuclei to inactivate CREB-2 molecules and facilitate the activation of CREB-1 and the direct impression and maintenance of this experience in long-term memory.

However, Joëls, Pu, Wiegert, Oitzl and Krugers (2006) *highlighted the fact that stress facilitated memory mechanisms only when it was experienced at the moment when the organism had to memories the event, and only when the hormones and neurotransmitters activated the same networks as those activated by learning. *

It is therefore essential that there is a convergence in time and space between the learning and the cause of the stress.

All these conditions are met when the patient uses Froggymouth for the very first time. The absence of a seal prevents the motor sequence of sucking and swallowing from taking place, causing major stress to the brain stem, as swallowing is a vital activity. The inhibition of facial nerve activity caused by the impossibility of pressing the lips together will, by activating the trigeminal nerve, allow dental occlusion and the lingual dome to move towards the palatal vault. In order to swallow, all that is required is a slight peristaltic movement, which also stimulates the transverse growth of the maxilla. This is more economical for the brain than sucking and swallowing.

A hypothesis confirmed by Fabio Scoppa *in fMRI studies of the two forms of swallowing, “despite similar activations between the tongue protrusion and swallowing elevation tasks, the size of the brain activation cluster for the protrusion task was larger than the elevation task and distributed differently.

This may have occurred because protrusion involved greater motor effort than elevation”.

INTERACTION BETWEEN DIFFERENT CIRCUITS

Other neuronal circuits managing other orofacial functions will also be affected by this method of rehabilitation thanks to the communication between these different elements known as “connectionism”, a role played by glial cells, which outnumber neurons by a factor of 4 to 5 and play an essential role in learning.(AGID MAESTRATI) *

Around the synapse, the glial cells pick up the conversation as if listening in on a telephone and broadcast the information to all the other neuronal circuits via gliotransmitters, as if the information were being broadcast by radio to all the circuits.

This will enable other circuits that were not involved in the rehabilitation process to benefit from this information to improve their effectiveness.

Our study shows that glial cells are essential for the transmission of signals between neurons,” observes Steven Goldman from the University of Rochester (2013). Above all, it reveals that the elaborate cognitive abilities of our species do not just come from our sophisticated neural networks: they also reflect the evolution of our glial cells, which are more abundant, complex and diverse than in any other species.” *

Pascal Mettens makes Sigmund Freud the founding father of connectionism, and the way psychotherapy works sheds light on the processes involved: how repressed circuits can act to modify cognitive circuits.

This ‘connectionist’ system is reminiscent of the way falling dominoes work, and the simple act of controlling labial posture will activate the circuit managing lingual posture, which in turn will affect the swallowing program, which will activate the nasal breathing circuit, and so on, enabling functional rehabilitation that is difficult to achieve by voluntary means. Restoring deep breathing will inhibit the meta-circuits which had taken advantage of episodes of nasal congestion to establish mouth breathing. (Couly )

These interactions are necessary to establish a permanent equilibrium. “Functional equilibrium is not a stable state, but one that is constantly changing”.

I often hear opponents argue that half-open lips will facilitate nasal breathing and that the lips must be closed to swallow.

Let’s refer to Uziel and Guerrier :*

“In children, when breathing is normal, the orofacial musculature is not involved, the lips are in contact without contraction of the orbicularis.

Many children have labial incompetence, but this does not mean that they are mouth-breathers; contact with the tongue and soft palate provides a second closing system.

It is important to remember that the trigeminal nerve also controls the respirator CENTERS in the pontine tegmentum via its sensory nucleus, so it will also encourage a return to nasal breathing.

Labial incompetence is not an obstacle, but rather the key to our strategy.

Let’s also take a look at the writings of Maryvonne Fournier:*

“There are several types of difficulty:

the tongue works correctly but the lips are still involved in swallowing. The patient must be made to work with lips half-open, otherwise lingual interposition is inevitable. It is perfectly possible to swallow saliva without pressing or joining the lips together.

Let’s stop imposing lip coaptation as the first condition for functional rehabilitation.

AUTOMATION

Here again we refer to Maryvonne Fournier:

“It has to be said that neuro-muscular, lingual, labial and functional rehabilitation frequently leads to recurrence. But is it really a recurrence? That would presuppose a cure. Instead, it seems that the desired goal, i.e. to automate the posture of the function, has not been achieved”.

That’s why we need to pay as much attention to automation as we do to ENGRAM, a stage that the work of Robert Bjork* (UCLA) is helping us to understand better.

He described 4 learning protocols:

A.A.A.A. E

A.A.A.T. E

A.A.T.T. E

A.T.T.T. E

A representing, for example, a classic learning session, T intermediate tests to assess progress and E the final assessment.

He asked the participants to choose the best protocol in their opinion. The majority chose program 1, while the most effective was program 4.

This strategy 4 will be used in game programs

managed by artificial intelligence.

“It’s usually only at the end of a game that you know whether you’ve won or lost… The trick that computer scientists have found is to learn 2 things at the same time: to act and to evaluate yourself. One half of the system, called the critic, learns to predict the final score. At each moment, this neural network evaluates the state of the game and tries to predict the reward: am I winning or losing? Thanks to the criticisms it builds up over the trials, the system has an assessment of its actions at every moment and not just at the end of the game. The other half of the network, the player, can then use this evaluation to correct itself. With each trial, the player and the critic progress together, one learning to act wisely by focusing on the most effective actions while the other learns to assess the consequences of its actions”.

Dehaene *confirms this approach: “dozens of scientific publications demonstrate its effectiveness …. retrieval practice is one of the most effective teaching strategies.

These control sessions can be entrusted to the parents, who will have to tell the child three times a day whether his lips are in the correct position (the correct circuits will be unconsciously reinforced by the release of dopamine) and three times a day if they notice a contraction of the orbicularis. The lips will play the role of a computer mouse, clicking on the icon to activate the correct program.

Under the control of the premotor and motor cortexes, the motor sequence is managed by circuits in the grey matter of the spinal cord and the tegmentum of the brainstem (alpha motor neurons). It will be controlled by the cerebellum, which detects and corrects the difference between the movement performed and the desired movement, and by the basal ganglia, which suppresses erroneous data and prepares future movements.

A further element validating this connectionist approach is the control of phonation. Many authors had written that speaking time was too limited to have an influence on growth. In reality, what is at stake is the influence of phonation on lingual posture.

There is a correlation between dietary orality and verbal orality in that the anatomical pathways are similar but used in opposite directions.( Couly*

“To speak, you must neither inhale nor swallow at the same time: these three actions must be intertwined, and therefore regulated finely, automatically, without ever being simultaneous. The pathologies of speech and those of swallowing, which share many anatomical structures, are inextricably intertwined” (Mazeau, Pouhet, Plouet, Plouffe, et al., 2004). (Mazeau, Pouhet, Ploix-Maes) *

A simple test will enable us to judge whether our reeducation has been effective: ask the child to count from 1 to 20 out loud and observe the position of the tongue: if the sounds are made by the lips, the tongue will not appear outside the dental arches; when it comes to swallowing, the child will simply have to clench his teeth and use the new program. On the other hand, if you see the tongue appear between the dental arches, this means that the sounds are modulated by the tongue; you can be sure that when it comes to swallowing, it will be much more comfortable for the child to return to the old program than to clench his teeth, retract his tongue to avoid biting, swallow, leave the occlusion and retract his tongue to continue speaking.

Two simple exercises to overcome this stigma: make the child count once a day for a week from 1 to 20, with teeth clenched; he will be obliged to move his lips and feel and understand the importance of this lip dynamic. The following week, have the child count from 1 to 20, not with teeth clenched, but with teeth clenched between each number, speeding up the pace.

Initially, the tongue will be able to protrude laterally and then retract, but very soon the speed of speech will leave it no time and, for fear of being bitten, it will find its place inside the dental arches.

The next exercise will be to ask the child, during conversations, to suddenly clench his teeth, the aim being to make the tongue feel insecure if it were to get in the way again.

You will have noticed that this new strategy emphasises inhibition: inhibition of the old swallowing program in our case.

“Learning is not just about the ability to produce behavior that was previously unknown to us, it is also a process that aims to inhibit automatic mental processes” (Lledo Pierre-Marie). *

Daniel Kahneman,* winner of the Nobel Prize in Economics in 2002, published “System 1, System 2. The two speeds of thought”, a book in which he describes two systems of thought in the human brain, “one heuristic, approximate and fast, System 1, the other analytical, exact but slower, System 2”.

• System 1 dominates our thinking via unconscious cognitive automatisms that can be demonstrated by fMRI studies. System 2 is a reflexive system that can counteract some of the automatisms of system 1 by replacing it, but at the cost of a slower, conscious effort.

Olivier Houdé* has reinterpreted Kahneman’s theory, by adding a system 3, which inhibits system 1, and which must intervene to allow system 2 to take place.

Its epicenter is located in the inferior frontal gyrus.

A McGill University research team led by Vijendra Sharma * has discovered that, during memory consolidation, at least two distinct processes take place in two brain networks: the network of excitatory neurons and the network of inhibitory neurons.

All this led me to imagine that these modes of action could explain the way Froggymouth works.

Clinical sequence of rehabilitation sequences

Ensure that the anatomical setting is compatible with a high position of the posterior part of the tongue, which will inhibit mouth breathing. Make sure that the nasal cavities are patent, using the Delaire AEROPHONOSCOPE avoids the need for a systematic visit to the ENT.

If any obstacles become apparent, you will need to consult a specialist.

In the event of insufficient success at this stage, I would add a few days later a small perfume recognition exercise which, here again, uses connectionism to reinforce the engrams by stimulating the olfactory nerve. In fact, the air is odorless and the route taken does little to stimulate the spatial map. The olfactory zones are among the oldest in the brain, and in humans the olfactory sense has atrophied considerably, so using it will enrich the body schema.

“Transport from the respiratory epithelium via the trigeminal nerve is considerably slower than transport from the olfactory epithelium via the olfactory bulb” (Yamashita Chikamasa .Tokyo University of Science,)*.

An initial clinical trial* published in “NEUROSCIENCES ET REEDUCATION DE LA DEGLUTITION” was carried out by Dr Cornut from the University of Lille and showed very encouraging results, confirmed by publications by Di Vecchio* and Manzini.P *. However, a double-blind trial will be essential to confirm these initial clinical data.

RAJOUT BIBLIO

33

P.MANZINI,M.ROSMARINI,E.FRATI,M.SEVERINO, S. CARUSO

TONGUE REHABILITATION THROUGH THE

FROGGY MOUTH DEVICE: CASE SERIES

JOURNAL OF BIOLOGICAL REGULATORS

& HOMEOSTATIC AGENTS Vol. 34,no1(s1),142-

150(2020)

 

AGID.Yves, MAGISTRETTI.Pierre L’homme

glial.Editions Odile Jacob.2018

BJORK.Robert

Self-regulated learning: Beliefs, techniques, and illusions

RA Bjork, J Dunlosky, N Kornell

Annual review of psychology 64, 417-444

CHAUVOIS.Alain,FOURNIER.Maryvonne, GIRARDIN .FrançoiseEditions S.I.D.1991

COULY Gérard, “Les oralités humaines. Avaler et crier : le geste et son sens”, Doin, 2010.

COULY Gérard ” Fetal orality ” Saurap Medical 2015

DEHAENNE Stanislas . Learning

Editions Odile Jacob.2018

S.DiVecchio,P.Manzini,E.CandidaFroggymouth: a new myofunctional approach to atypical swallowing EuropEan Journal of pediatric dEntistry vol. 20/1-2019 (P32-35)

EUSTON .DR, M Tatsuno, and BL McNaughton. Science, 2007. 318(5853): p. 1147-50.FELLUS p

GOLDMAN SA, Nedergaard M, Windrem MS. “Glial progenitor cell-based treatment and modeling of neurological disease.” Science.. 2012 Oct 26; 338(6106):491-5.

HOUDE Olivier. “Human intelligence is not an

algorithm” Editions Odile Jacob.2019

JOUVET.M. Le Sommeil, la Conscience et l’Éveil, Paris, Odile Jacob, 2016.

Joëls, Pu, Wiegert, Oitzl and Krugers, 2006)///C|/Users/Olivier/site%20web/EFFETSDUSTRESS.htm (1 of 10)2009-11-05 08:56:08

KANDEL Eric, “In search of memory. A new

theory of the mind”,Éd. Odile Jacob, 2007.

Livingston Robert Burr : Sensory Processing, Perception and Behavior [1]” The Register of Robert B. Livingston Papers 1935 – 1990″. University of California, San Diego.

LLEDO Pierre, “The brain, the machine and the

human. The brain of the 21st century”,

Éd. Odile Jacob, 2017.

McGaugh JL. Science. 2000;287:248-251. 2000.P.MANZINI,M.ROSMARINI,E.FRATI,M.SEVERINO , S. CARUSO FROGGY MOUTH DEVICE: CASE SERIES JOURNAL OF BIOLOGICAL REGULATORS& HOMEOSTATIC AGENTS Vol. 34,no1(s1),142-150(2020)

MARTIN K.C., MICHAEL D. et al, “MAP kinase translocates into the nucleus of the presynaptic cell and is required for long-term facilitation in Aplysia”, in Neuron, 1997 Jun; 18(6) : 899-912.

MAZEAU.M, POUHET.A, PLOIX MAES.ENeuropsychologie et troubles des apprentissages chez l’enfant .

ELISEVIER MASSON BOOK Third Edition 2021ONO Takashi

PIMENIDIS Margaritis Z., “The Neurobiology of Orthodontics. Treatment of Maloccution Through Neuropasticity”, Springer, 2009.

 

METTENS Pascal – Psychoanalysis and cognitive sciences

De Boeck Superieur. Collection(s): Oxalis. 2006

PURVES Dale, AUGUSTINE George J.,FITZPATRICK David, HALL William, LAMANTIA Anthony-Samuel, WHITE Léonard, “Neurosciences”, De Boeck 2015.

Fabio Scoppa , Sabina Saccomanno, Gianluca Bianco and Alessio Pirino

Tongue Posture, Tongue Movements, Swallowing, and Cerebral Areas Activation: A Functional Magnetic Resonance Imaging Study Appl. Sci. 2020, 10, 6027; doi:10.3390/app10176027

SHORS T.J., SERVATIUS R. J., “Sress-induced sensitization and facilitated learning require NMDA receptor activation” in Neuroreport, 1995/6: 677-680.

Shors T.J. (2004). Learning during stressful times, Learning & Memory. 11, p.137-144

Sophie Schwartz, Sterpenich Virginie. JOURNAL Nature Communications DOI 10.1038/s41467-021-24357-5 Department of Basic Neuroscience, Faculty of Medicine, UNIGE Nature Communications UZIEL.A,GUERRIER.Y

Physiology of the upper aerodigestive tract, Masson 1983.

Yamashita

Tomomi Akita, Yusuke Oda, Ryosuke Kimura, Mio Nagai, Ayano Tezuka, Mizuki

Shimamura, Kaho Washizu, Jun Ichiro Oka, Chikamasa Yamashita

Involvement of trigeminal axons in nose-to-brain delivery of glucagon-like peptide-2 derivative Journal of Controlled Release Volume 351, November 2022, Pages 573-580

SUMMARY

Delaire had already understood in 2005 that it is not the rehabilitation of a single praxis that must be taken into account in functional rehabilitation, but all the oro-facial praxis to ensure an overall dynamic balance. Thus, breathing rehabilitation is a necessary condition for language rehabilitation, which is a necessary condition for respiratory rehabilitation.

Fortunately, nature can come to our aid if we respect the physiological processes that integrate the environment.

We should not forget that “learning is not just about the ability to produce behaviour that was previously unknown to us, it is also a process that aims to inhibit automatic mental processes” (Lledo Pierre-Marie).

Key words :

Connexionism

Engramming

Automation

inhibition