Professional Documents
Culture Documents
Fel Cio 2017
Fel Cio 2017
Descritores RESUMO
Idoso Objetivo: Desenvolver um protocolo de avaliação abrangente para identificar, classificar e graduar as mudanças
Sistema Estomatognático nos componentes e funções do sistema estomatognático em pessoas idosas, determinar suas propriedades
psicométricas e verificar a associação com a saúde oral e a idade. Método: A validade de conteúdo do protocolo
Mastigação de Avaliação Miofuncional Orofacial com Escores para Idosos (AMIOFE-I), que contém três domínios, aparência/
Deglutição postura, mobilidade e funções do sistema estomatognático, foi estabelecida com base na literatura. Oitenta e dois
Saúde Oral voluntários idosos (média de idade 69±7,24 anos) foram avaliados usando o AMIOFE-I. Um teste de triagem de
distúrbios miofuncionais (referência) foi empregado para as análises de validade concorrente (teste de correlação),
Avaliação
sensibilidade, especificidade e acurácia (Receiver Operating Characteristic Curve: curva ROC) do AMIOFE-I.
Também foi analisada a associação dos escores do AMIOFE-I com o índice de saúde oral (ISO), determinado
na amostra, e à idade. Resultados: Houve uma significante correlação entre o AMIOFE e o teste de referência.
Os coeficientes de confiabilidade variaram de bom a excelente. O AMIOFE apresentou sensibilidade de 82,9%,
especificidade de 83,3% e acurácia de 0,83. Os escores do AMIOFE-I foram significantemente menores em
indivíduos com piores ISO (≤ 61%), contudo aqueles com adequada saúde oral (ISO ≥ 90%) também tinha
prejuízos miofuncionais. Os preditores ISO e idade explicaram respectivamente 33% e 30% da variância no escore
total do AMIOFE-I. Conclusão: O protocolo AMIOFE-I, o primeiro específico para a avaliação miofuncional
de idosos, mostrou-se válido, confiável e seu escore total foi associado à saúde oral e à idade.
Correspondence address: Study carried out at Department of Ophthalmology, Otorhinolaryngology and Head and Neck Surgery, School
Cláudia Maria de Felício of Medicine of Ribeirão Preto, University of São Paulo – USP in partnership with Department of Elderly Health
Departamento de Oftalmologia, Care of the City of Juiz de Fora, Clinic of Prevention and Monitoring of Hypertension and Faculty of Speech
Otorinolaringologia, e Cirurgia de Therapy of the Center for Higher Education de Juiz de Fora - Juiz de Fora (MG), Brazil.
Cabeça e Pescoço, Faculdade de 1
Departamento de Oftalmologia, Otorrinolaringologia e Cirurgia de Cabeça e Pescoço, Faculdade de Medicina
Medicina de Ribeirão Preto – FMRP, de Ribeirão Preto, Universidade de São Paulo – USP - Ribeirão Preto (SP), Brazil.
Universidade de São Paulo – USP, 2
Núcleo de Apoio à Pesquisa em Morfofisiologia Craniofacial, Universidade de São Paulo – USP - Ribeirão
Av. dos Bandeirantes, 3900, Ribeirão Preto (SP), Brazil.
Preto (SP), Brazil, CEP: 14049-900. 3
Centro Universitário Planalto do Distrito Federal – UNIPLAN - Brasília (DF), Brazil.
E-mail: [email protected] 4
Departamento de Clínica Infantil, Faculdade de Odontologia de Ribeirão Preto, Universidade de São Paulo –
USP - Ribeirão Preto (SP), Brazil.
Received: February 23, 2017 Financial support: Provost’s Office for Research of University of São Paulo, Brazil, Process nº 11.1.21626.01.7.
Conflict of interests: nothing to declare.
Accepted: June 24, 2017
de Felício et al. CoDAS 2017;29(6):e20170042 DOI: 10.1590/2317-1782/20172017042 1/12
INTRODUCTION reject the null hypothesis (one-tailed test). Previously obtained
descriptive statistics were used to estimate the minimum number
The older population is growing in worldwide. Older people of individuals required for statistical analysis with 80% statistical
have decreased sensitivity, muscle force/strength, oral motor power (type II error, beta) and with alpha (type I error) set
ability and salivary flow(1-8). These changes combined with at 5%. The minimum number of individuals required for the
dental problems, either acquired or degenerative disease, impair OMES-Elders total score was 15.
functions such as mastication, deglutition, and speech, and are Inclusion criteria were: no hearing or visual impairments,
risk factors for malnutrition, dehydration, health problems, or understanding or expression difficulties that could affect the
disabilities, social isolation, and poor quality of life, resulting tests, no intellectual disabilities, no emotional or neurological
in additional health care costs(7,9-14). disorders (including motor speech disorders); no diabetes; and
Thus, health programs aimed at promoting orofacial functions no dental or orofacial pain, or history of trauma and surgery in
are needed due to the physiological and functional decline of the head and neck.
the stomatognathic system caused by aging. In general, safe Participants provided information about comfort (absence of
swallowing and efficient mastication are the ultimate goals of pain or sensitivity), aesthetics (contentment with appearance),
these programs(2,3,9,10). functionality (ability to eat unrestricted diet). They were
Even though objective measures such as bite force, tongue assessed by a dentist for the Oral Health Index (OHX)(21)
strength, masticatory performance, electromyography, and determination, as follows: Presence/absence of active carious
ultrasonography help understand the problems that affect the lesions, secondary caries around restorations; periodontal (pocket
stomatognathic system(1,4,8,9), clinical evaluation is indispensable depth, inflammation and subgingival calculus); wear and tear,
for the diagnosis of orofacial myofunctional disorders (OMD)(15-18). loss by wear of enamel, dentine or cementum, loss of dimension
Several scales have been developed and validated to reliably or integrity of restoration; occlusion (presence of a minimum
measure physical performance, functional disability, comorbidity, of ten pairs of articulating teeth, natural or prosthetic); mucosa
nutrition status and cognitive function in older people(19). Although inflammation, ulceration or other pathology; dentures, if present,
orofacial functions and dysfunctions are in general measured using lack of retention, stability, presence of wear and freeway space.
either a screening tool (e.g. The Nordic Orofacial Test‑Screening, Each item assessed could be either acceptable (positive score)
NOT-S)(15) or highly specific instruments, such as the clinical or unacceptable (zero score). After the assessment, the sum of
evaluation of oropharyngeal dysphagia(3,7). Furthermore, the the scores was divided by the maximum score possible, and
effects of aging and oral health status on orofacial functions then multiplied by 100 in order to obtain the OHX. The larger
have not been concomitantly assessed in a comprehensive way. the OHX, the better is the oral health.
The biopsychosocial importance of mastication, deglutition,
Construction of the OMES-Elders protocol
facial expression and speech, and the absence of an instrument
to evaluate orofacial structures and functions which enable The previously validated OMES-Expanded protocol(18) was
the examiner to express his/her perception of the physical the basis for the development of the OMES-Elders protocol
characteristics and orofacial behaviors of older people based on (Appendix A). The content validity of the OMES-Elders, which
an ordinal scale, have prompted us to develop a new protocol. involves the definition of the object of interest and the judgment
The validation of methods for clinical assessment is recommended of the relevance of each variable for the age groups, was
for evidence-based practice. The validity of an instrument is established based on the literature(1-3,7,9,10,22). The OMES‑Elders
an estimate of how well it performs the assessment, and the scales were based on the psychophysical method, i.e., the level
criterion validity is determined by comparing the instrument of measurement depends on pre-established conditions, so that
in question to another taken as reference(20). the relationships between attributes will be represented by the
The objectives of this study were to develop the Orofacial relationships between numbers(23).
Myofunctional Evaluation with Scores for Elders protocol
(OMES-Elders), to determine its psychometric properties, and Orofacial myofunctional evaluation
verify the association of its scores with an oral health index
and with elderly’s age. The evaluations were performed during one session and later
complemented by analysis of recorded images. The participants
METHODS sat on a chair with a backrest and with their feet resting on the
floor at a standardized distance (1m) from the lens of the camera
Participants (GR-SXM357UM JVC Compact VHS CAMCORDER, Manaus,
Brazil), which was mounted on a tripod set at face, neck and
Eighty-two elder volunteers participated in the study (12 men, shoulders height(16,18).
70 women, aged 60-90 years, mean age = 68.8±7.2 years). The OMES-Elders protocol is presented in Appendix A.
All participants performed daily functions independently. Predetermined scores of the OMES-Elders protocol were
The protocol study was approved by the ethical review board of attributed to the following items, with the highest scores indicating
the University (Process N. 192.14.11.2008). All individuals gave normal patterns without deviation:
written informed consent to participate in the study and there Appearance/posture of face, cheeks, maxillo-mandibular
was no dropout in this study. The sample size was calculated to relationship (vertical and horizontal), mentalis muscle, lips,
Table 1. Orofacial myofunctional evaluation with scores for elders protocol (OMES-Elders), according to the oral healthy Index (OHX). Mean and
standard error (SE) of scores of orofacial items and categories
N = 82 Group I Group II Group III
N 23 35 24
OHX (%) 33 to 61 62 to 89.9 90 to 100
Women (n) 17 29 24
Mi. Mx. Mean(SE) Mean(SE) Mean(SE) P
Age 69.6(1.5) 69.2(1.2) 67.5(1.5) 0.47
Appearance/Posture
Face 2 8 5.0(0.2) 5.1(0.2) 5.6(0.2) 0.08
Cheeks 2 8 6.0(0.2) 6.2(0.1) 6.5(0.2) 0.19
Jaws 3 12 9.8(0.2)a 10.9(0.2)b 11.0(0.2)b <0.001
Mentalis muscle 2 8 6.2(0.2) 6.4(0.2) 6.5(0.2) 0.57
Lips 3 12 8.0(0.4)a 8.6(0.3)a,b 9.4(0.4)b 0.03
Tongue 2 8 5.9(0.2) 6.3(0.2) 6.0(0.2) 0.21
Palate* 1 4 3.9(0.1) 3.7(0.1) 3.8(0.1) --------
Parcial score 15 56 44.7(0.1)a 47.2(0.8)ab 48.8(0.9)b 0.011
Mobility
Lips 4 24 17.3(0.6) 17.5(0.5) 18.7(0.6) 0.15
Tongue 6 36 19.2(1.2) 20.8(1.0) 22.0(1.2) 0.27
Jaw 5 30 20.5(0.9) 20.5(0.7) 19.2(0.9) 0.45
Cheeks 4 24 18.0(0.8) 17.5(0.6) 19.4(0.7) 0.15
Parcial score 19 114 75.1(10.5) 76.4(1.9) 79.4(2.3) 0.42
Functions
Breathing* 1 4 3.9(2.4) 3.8(1.9) 3.8(3.8) --------
Swallowing 10 34 25.5(0.1) 27.5(0.1) 27.7(0.1) 0.09
Mastication 5 18 11.0(0.1)a 13.5(0.1)b 15.5(0.1)b <0.0001
Speech 5 20 18.0(0.6) 19.2(0.5) 18.7(0.6) 0.12
Parcial score 21 76 58.4(0.4)a 64.0(0.3)b 65.7(0.4)b 0.0001
Total score 55 246 178.3(1.2)a 187.6(1.0)ab 194.6(1.2)b 0.003
*No composite scores were not individually included in the ANOVA due to level of measurement
Caption: P: probability in the one-way ANOVA. P < 0.05 indicates statistically significant difference. Medians with different superscript (a, b) differ at post-hoc test;
Mi.: Minimum score, Mx: Maximum score in the OMES-Elders protocol
coefficient was 0.89 for the evaluations performed using the We adopted the NOT-S as a reference test in this study
NOT-S. The weighted kappa values showed good (0.61-0.80) because this is the only instrument validated to screen a set of
and very good (0.81-1.00) agreement in the test–retest with the orofacial characteristics and abilities, over a wide range of age(15).
OMES-expanded protocol and between examiners. The items evaluated clinically in the NOT-S and OMES‑Elders
protocols are different, thus preventing a redundancy that would
Criterion validity of the OMES-elders protocol tend to inflate validity estimates(16). For example, NOT-S does
not include a clinical examination of deglutition and mastication,
There was a significant correlation between the OMES‑Elders which are determined based on patient self-report during the
and NOT-S protocols (r = -0.81, p < 0.001). The correlation interview.
was negative because the two scales are inverse.
A detailed analysis of movement precision and orofacial
functions by an examiner, as proposed in the OMES-Elders
Sensitivity and specificity of OMES-elders protocol
protocol, provides more accurate and relevant information about
The ROC analysis showed that the OMES-Elders total score functional adaptations (or maladaptations) associated with oral
was significantly different than chance for the detection of the status and physiological changes.
presence of OMD [AUC = 0.826, P < 0.001, CI: 0.73-0.90], Unlike the NOT-S(15) that involves dichotomous judgments
with the score of 202 as the cut-off point. The sensitivity and based on an absence/presence scale (zero/one), the OMES‑Elders
specificity values were, respectively, 82.89% (CI: 72.5-90.6%) protocol enables the ranking of orofacial myofunctional status
and 83.33% (CI: 35.9-99.6%). because it uses an ordinal level of measurement with at least
four response options. This is advantageous in clinical practice
Association of OMES-elders scores with the providing additional diagnostic and therapy-relevant information,
OHX and age as well as it may be useful for intervention follow-up. Moreover,
the categories (appearance/posture, mobility or functions) can be
The groups divided according to the OHX had no significant analyzed by combining their items(16). When multiple items are
difference in mean age (P > 0.05). The group I had mean scores combined for analysis, the composite scores may be treated as
significantly lower than the group III in the category appearance/ continuous variables(24) which enable the use of more powerful
posture and total OMES-Elders (P < 0.01), and significantly statistical techniques(23,24).
lower scores than the other two groups in stomatognathic A validation study also requires reliability estimates(18). In our
system functions. There was no statistical difference between study, the OMES-Elders proved to be a reliable instrument for
the groups II and III. OMD diagnosis, according to the test-retest and inter-examiner
There was no significant difference between groups in the evaluations. Moreover, the protocol showed good ability to
category mobility. In general, all groups had reduced mobility correctly recognize individuals with and without OMD.
of stomatognathic system components, with the lowest score for The orofacial myofunctional status was associated with both
tongue, whose scores ranged from 53% (group I) to 61% (group III) OHX and age. The multiple regression analysis showed that age
in relation to the maximum score of the protocol (Table 1). had the strongest effect on the appearance/posture (31%), while
The multiple regression analysis showed that the participants’ oral health had the strongest effect on the functions category
oral health and age were significantly associated with the categories (40%). Overall, the higher the OHX and the lower the age, the
appearance/posture, functions, and total OMES-Elders. There better are the OMES-elders scores.
was no significant association between predictors and mobility The analysis of the groups with different OHX and similar
category. Table 2 shows the degree to which the predictors are mean age shows that the group I (lowest OHX), had significantly
related to the OMEs-Elders scores. lower scores than group III for appearance/posture (highest OHX),
and lower scores than groups II and III for category functions.
DISCUSSION The impairments were more pronounced in the jaw and
lip appearance/posture, and mastication function. These items
This study showed that the OMES-Elders protocol is valid are greatly influenced by the dental (e.g. number of remaining
and reliable for OMD assessment. The analysis revealed a clear teeth, vertical dimension of occlusion, pairs of functional
influence of both oral health and age on orofacial functional status. occlusal contacts, edentulism, presence of removable or fixed
FACE Scores
Symmetry between sides Normal (4)
Light (3)
Dysfunction: Asymmetry Moderate (2)
Severe (1)
Greater side Right | Left
Nasolabial sulcus Normal (4)
Light (3)
Dysfunction: Marked nasolabial sulcus Moderate (2)
Severe (1)
SUM [Maximum Score (MS) = 08]
CHEEK Scores
Volume Normal (4)
Light (3)
Dysfunction: Asymmetry between right and left sides Moderate (2)
Severe (1)
Tension Normal (4)
Light (3)
Dysfunction: Flaccid / Drooping Moderate (2)
Severe (1)
SUM (MS = 08)
LIPS Scores
Sealing with no apparent muscles contraction Normal (4)
Light (3)
Dysfunction: Sealing With effort or no labial closure Moderate (2)
Severe (1)
Volume Harmonious Normal (4)
Light (3)
Dysfunction: Reduced volume and stretched Moderate (2)
Severe (1)
Labial commissures
At the level of the rima of the mouth and symmetric Normal (4)
Light (3)
Dysfunction: Below of the rima of the mouth and/or asymmetrics Moderate (2)
Severe (1)
SUM (MS = 12)
TONGUE Scores
Position
Contained in the oral cavity Normal (4)
Dysfunction: (a or b)
(a) Compressed by tense dental occlusion/ clenching Light (3)
Compressed by tense dental occlusion/ clenching plus marks Moderate (2)
Compressed by tense dental occlusion/ clenching with marks and pain Severe (1)
(b) Between teeth (3)
Light
At limit of the incisal surfaces, with reduced occlusion vertical dimension (OVD)
At limit of the incisal surfaces or on the floor of mouth, with normal freeway space Moderate (2)
Exceeds the incisal surfaces, vestibular cusps or edges Severe (1)
Volume/Size
Compatible with the oral cavity Normal (4)
Light (3)
Dysfunction: Increased Moderate (2)
Severe (1)
SUM (MS = 08)
PALATE Scores
Width Normal (4)
Light (3)
Dysfunction: Decreased width Moderate (2)
Severe (1)
SUM (MS = 04)
MOBILITY PERFORMANCE
Horizontal Lateral
LIPS
Protrusion Retrusion To right To left
Normal (6) (6) (6) (6)
Insufficient ability (IA) (5) (5) (5) (5)
IA and associated movements (4) (4) (4) (4)
IA with tremor (3) (3) (3) (3)
IA, associated movement and tremor (2) (2) (2) (2)
Task no performed (1) (1) (1) (1)
SUM (MS = 36)
FUNCTIONS
Scores
SWALLOW: Other behaviors and signs of alteration
Present (1) Absent (2)
Movement of the head and other parts of the body
Sliding jaw
Food escape
Gagging
Noise
Altered posture
Food escape
Jaw opening-closing
Speech Phonetic inventory Place of articulation Sound Intelligibility
movement
Normal Adequade (4) Precise (4) Precise (4) Normal range (4) Clarity (4)
Distortion Reduced
Alterations Changed Changed (frequency) Reduced
(frequency) displacement
Light (3) (3) (3) (3) (3)
Moderate (2) (2) (2) (2) (2)
Severe (1) (1) (1) (1) (1)
SUM (MS = 20)