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Oral diadochokinesia and lisp in speech production in children with surgically repaired cleft lip and palate

Abstracts

Purpose

To correlate the performance of the oral motor tasks of diadochokinesis in children with repaired cleft lip and palate to the type of cleft and to the presence of lisp.

Methods

We studied 30 children, aged 9 to 12 years, with complete unilateral cleft lip and palate and 30 with isolated cleft palate. Two speech language pathologists analyzed repetition phrases with the phones [s] and [z] to identify the presence of lisp. The analysis of diadochokinesis was performed by registering the repetition of the syllables “ta” and “ka” and the sequence “pataka”. The Kappa test was used to verify agreement between the evaluators, the Chi-square test was used to compare the lisp frequency between the groups, and the t-test was used to compare the diadochokinesis values between the same groups as well as between individuals with and without lisp.

Results

The mean number of emissions per second and the mean time between emissions were not significantly different between groups. Good agreement was observed between the examiners for the presence of lisp in [s] and [z], with the most evident agreement in the complete unilateral cleft lip and palate group. The comparison between the diadochokinesis values and the presence of lisp revealed no significant difference.

Conclusion

The performance of diadochokinesis tasks did not change according to the type of cleft. Further, the presence of lisp speech was higher in patients with complete unilateral cleft lip and palate, but this did not affect performance of diadochokinesis tasks.

Cleft lip; Cleft palate; Speech disorders; Child; Evaluation


Objetivo

Correlacionar o desempenho motor oral nas tarefas de diadococinesia, de acordo com o tipo de fissura e com a presença de ceceio na fala, em crianças com fissura labiopalatina, operadas.

Métodos

Foram estudadas 30 crianças com fissura completa unilateral de lábio e palato e 30 com fissura isolada de palato, operadas, com idade entre 9 e 12 anos. Dois fonoaudiólogos analisaram a repetição de frases com os fones [s] e [z] para identificar a presença de ceceio e a análise da diadococinesia ocorreu a partir do registro da repetição das sílabas “ta” e “ca” e da sequência “pataca”. Na análise, o teste Kappa verificou a concordância entre os avaliadores, o teste Qui-quadrado a frequência de ceceio entre os grupos e o teste t os valores da diadococinesia, segundo o tipo de fissura e a presença de ceceio.

Resultados

O número de emissões por segundo e os tempos médios entre as emissões não demonstraram diferença significativa entre os grupos. Houve boa concordância entre os avaliadores quanto à presença de ceceio, com maior frequência nos casos com fissura completa unilateral de lábio e palato. A comparação entre os valores da diadococinesia e a presença de ceceio não evidenciou diferença significativa.

Conclusão

O desempenho nas tarefas da diadococinesia não sofreu alteração segundo o tipo de fissura labiopalatina. A presença de ceceio na fala foi maior no grupo com fissura completa unilateral de lábio e palato, sem modificação, porém, no desempenho das tarefas da diadococinesia.

Fenda labial; Fissura palatina; Distúrbios da fala; Criança; Avaliação


INTRODUCTION

In general, a cleft lip and palate compromises speech because this physiological function requires anatomical and functional integrity of the associated organs, adequate articulation, and proper functioning of the velopharyngeal valve(1Silva RN, Nascimento EM, Santos G. Ocorrência de alterações da motricidade oral em indivíduos com fissuras labiopalatinas. Rev Bras Prom Saúde. 2004;17(1):27-30.,2Genaro KF, Yamashita RP, Trindade IEK. Avaliação clínica e instrumental na fissura labiopalatina. In: Fernandes FDM, Mendes BCA, Navas ALGP, organizadores. Tratado de fonoaudiologia. 2a ed. São Paulo: Roca; 2010. p. 488-503.). In these cases, speech alteration occurs due to compromised velopharyngeal function(3Marino VCC, Dutka JCR, Pegoraro-Krook MI, Lima-Gregio AM. Articulação compensatória associada à fissura de palato ou disfunção velofaríngea: revisão de literatura. Rev CEFAC. 2012;14(3):528-43. http://dx.doi.org/10.1590/S1516-18462011005000077
https://doi.org/10.1590/S1516-1846201100...
,4Freitas JA, Trindade-Suedam IK, Garib DG, Neves LT, Almeida AL, Yaedú RY et al. Rehabilitative treatment of cleft lip and palate: experience of the Hospital for Rehabilitation of Craniofacial Anomalies/USP (HRAC/USP) - Part 5: institutional outcomes assessment and the role of the Laboratory of Physiology. J Appl Oral Sci. 2013;21(4):383-90. http://dx.doi.org/10.1590/1678-775720130290
https://doi.org/10.1590/1678-77572013029...
), such as obligatory disturbances and compensatory articulations, as well as the dento-occlusal balance condition(5Amaral AS, Genaro KF. Análise da fala em indivíduos com fissura labiopalatina operada. Pró Fono.1996;8(1):36-46.

Vallino LD, Tompson B. Perceptual characteristics of consonant errors associated with malocclusion. J Oral Maxillofac Surg. 1993;51(8):850-6. http://dx.doi.org/10.1016/S0278-2391(10)80101-6
https://doi.org/10.1016/S0278-2391(10)80...

Niemeyer TC. Cirurgia ortognática e produção de fala [dissertação]. Bauru: Universidade de São Paulo. Hospital de Reabilitação de Anomalias Craniofaciais; 2004.
-8Alves TCNV. Análise da produção da fala nas correções cirúrgicas da deformidade dentofacial [tese de doutorado]. Bauru: Universidade de São Paulo. Hospital de Reabilitação de Anomalias Craniofaciais; 2008.), which aids functional adaptation of the tongue and lips. In individuals with a cleft lip and palate, regardless of age and the surgical technique used for repair, the dento-occlusal balance condition affects lingual-alveolar phoneme production, i.e., [s] and [z], the lingual-dental phonemes [t], [d], and [n], and the alveolar phoneme [ℓ], with interdentalization of the tongue and lisp, which account for the observed alterations(5Amaral AS, Genaro KF. Análise da fala em indivíduos com fissura labiopalatina operada. Pró Fono.1996;8(1):36-46.,7Niemeyer TC. Cirurgia ortognática e produção de fala [dissertação]. Bauru: Universidade de São Paulo. Hospital de Reabilitação de Anomalias Craniofaciais; 2004.

Alves TCNV. Análise da produção da fala nas correções cirúrgicas da deformidade dentofacial [tese de doutorado]. Bauru: Universidade de São Paulo. Hospital de Reabilitação de Anomalias Craniofaciais; 2008.
-9Hanayama EM. Distúrbios de comunicação nos pacientes com sequela de fissura labiopalatina. Rev Bras Cir Craniomaxilofac. 2009;12(3):118-24.).

The condition of the muscle or oral motor ability is of great importance during the speech production process, and these characteristics can be evaluated by using the diadochokinesis (DDK) test. This test is used to evaluate neuromotor maturation and integration, thereby providing an acoustic index of movement speed and articulatory positioning through quick repetitions of opposite muscular contraction patterns(1010 Baken RJ, Orlikoff RF. Speech movements. San Diego: Singular Thomson Learning; 2000. Clinical measurement speech and voice; p.511-57.,1111 Modolo DJ, Berretin-Felix G, Genaro KF, Brasolotto AG. Oral and vocal fold diadochokinesis in children. Folia Phoniatr Logop. 2011;63(1):1-8. http://dx.doi.org/10.1159/000319728
https://doi.org/10.1159/000319728...
). In order to judge the obtained values, the Motor Speech Profile Advanced (MSP) software, KayPENTAXTM, automatically provides parameters that are used for 2 types of analyses: quantitative and qualitative. The quantitative analysis refers to the amount and duration of the emissions. The amount, which corresponds to the number of emissions per second, is represented by the average DDK rate, and the duration is represented by the mean time between such emissions. The qualitative analyses takes into account the parameters of the emissions, such as regularity, rhythm, and/or stability, and is represented by the standard deviation of the DDK period, coefficient of variation of the DDK period, perturbations of the DDK period, and coefficient of variation of the DDK peak intensity(1111 Modolo DJ, Berretin-Felix G, Genaro KF, Brasolotto AG. Oral and vocal fold diadochokinesis in children. Folia Phoniatr Logop. 2011;63(1):1-8. http://dx.doi.org/10.1159/000319728
https://doi.org/10.1159/000319728...
).

Several previous studies, evaluated children without cleft lip and palate who had a speech disorder(1010 Baken RJ, Orlikoff RF. Speech movements. San Diego: Singular Thomson Learning; 2000. Clinical measurement speech and voice; p.511-57.

11 Modolo DJ, Berretin-Felix G, Genaro KF, Brasolotto AG. Oral and vocal fold diadochokinesis in children. Folia Phoniatr Logop. 2011;63(1):1-8. http://dx.doi.org/10.1159/000319728
https://doi.org/10.1159/000319728...

12 Dworkin JP. Protusive lingual force and lingual diadochokinetic rates: a comparative analysis between normal and lisping speakers. Lang Speech Hear Serv Sch. 1978;19(1):8-16. http://dx.doi.org/10.1044/0161-1461.0901.08
https://doi.org/10.1044/0161-1461.0901.0...

13 Dworkin JP. Characteristics of frontal lispers clustered according to severity. J Speech Hear Disord. 1980;45(1):37-44. http://dx.doi.org/10.1044/jshd.4501.37
https://doi.org/10.1044/jshd.4501.37...

14 Dworkin JP, Aronson AE. Tongue strength and alternate motion rates in normal and dysarthric subjects. J Commun Disord. 1986;19(2):115-32. http://dx.doi.org/10.1016/0021-9924(86)90015-8
https://doi.org/10.1016/0021-9924(86)900...

15 Wertzner HF, Alves RR, Ramos ACO. Análise do desenvolvimento das habilidades diadococinéticas orais em crianças normais e com transtorno fonológico. Rev Soc Bras Fonoaudiol. 2008;13(2):136-42. http://dx.doi.org/10.1590/S1516-80342008000200007
https://doi.org/10.1590/S1516-8034200800...
-1616 Alves RR. Diadococinesia oral em crianças com e sem transtorno fonológico [dissertação]. São Paulo: Faculdade de Filosofia, Letras e Ciências Humanas, Universidade de São Paulo; 2010.). These studies demonstrated that children with a speech disorder produced most of the emissions at a slower rate(1515 Wertzner HF, Alves RR, Ramos ACO. Análise do desenvolvimento das habilidades diadococinéticas orais em crianças normais e com transtorno fonológico. Rev Soc Bras Fonoaudiol. 2008;13(2):136-42. http://dx.doi.org/10.1590/S1516-80342008000200007
https://doi.org/10.1590/S1516-8034200800...
,1616 Alves RR. Diadococinesia oral em crianças com e sem transtorno fonológico [dissertação]. São Paulo: Faculdade de Filosofia, Letras e Ciências Humanas, Universidade de São Paulo; 2010.), with a significant positive correlation between age, percentage of correct consonants, and speed of speech(1717 Folha GA, Felício CM. Relação entre idade, porcentagem de consoantes corretas e velocidade de fala. São Paulo: Pró Fono. 2009;21(1):39-44. http://dx.doi.org/10.1590/S0104-56872009000100007
https://doi.org/10.1590/S0104-5687200900...
). Further, an increase in the speed of syllable emission was observed with increased age(1111 Modolo DJ, Berretin-Felix G, Genaro KF, Brasolotto AG. Oral and vocal fold diadochokinesis in children. Folia Phoniatr Logop. 2011;63(1):1-8. http://dx.doi.org/10.1159/000319728
https://doi.org/10.1159/000319728...
).

A few studies analyzed the correlation between DDK and tongue protrusion strength in children with an anterior lisp and in those without a speech disorder. The results showed a higher tongue protrusion strength and greater number of emissions in children without speech alterations, while children with a lisp presented with lower tongue protrusion strength and were slower in accomplishing the tasks evaluated by the DDK test(1212 Dworkin JP. Protusive lingual force and lingual diadochokinetic rates: a comparative analysis between normal and lisping speakers. Lang Speech Hear Serv Sch. 1978;19(1):8-16. http://dx.doi.org/10.1044/0161-1461.0901.08
https://doi.org/10.1044/0161-1461.0901.0...
,1414 Dworkin JP, Aronson AE. Tongue strength and alternate motion rates in normal and dysarthric subjects. J Commun Disord. 1986;19(2):115-32. http://dx.doi.org/10.1016/0021-9924(86)90015-8
https://doi.org/10.1016/0021-9924(86)900...
). According to the authors of one of these studies, this finding indicates that a correlation exists between anterior lisp, tongue weakness, and reduced DDK speed with low speech intelligibility(1414 Dworkin JP, Aronson AE. Tongue strength and alternate motion rates in normal and dysarthric subjects. J Commun Disord. 1986;19(2):115-32. http://dx.doi.org/10.1016/0021-9924(86)90015-8
https://doi.org/10.1016/0021-9924(86)900...
).

Although several studies analyzed DDK in children without a cleft lip and palate who had different speech disorders, only a few used this test to evaluate individuals with a cleft lip and palate(1818 Howard S. Compensatory articulatory behaviours in adolescents with cleft palate: comparing the perceptual and instrumental evidence. Clin Linguist Phon. 2004;18(4-5):313-40. http://dx.doi.org/10.1080/02699200410001701314
https://doi.org/10.1080/0269920041000170...

19 Kummer AW, Lee L, Stutz LS, Maroney A, Brandt JW. The prevalence of apraxia characteristics in patients with velocardioiofacial syndrome as compared with other cleft populations. Cleft Palate Craniofac J. 2007;44(2):175-81. http://dx.doi.org/10.1597/05-170.1
https://doi.org/10.1597/05-170.1...
-2020 Véliz VLB. Tasa de diadococinesia en sujetos con fissura [Memoraria para Licenciado em Fonoaudiología]. Chile: Universid de Talca. Faculdade de Ciencias de la Salud; 2007.). One study evaluated 3 teenagers with a cleft lip and palate by using electropalatography and the DDK test. The teenagers had difficulties elevating the tongue tip and showed decreased speed of tongue movements when a cleft was associated with the Robin Sequence(1818 Howard S. Compensatory articulatory behaviours in adolescents with cleft palate: comparing the perceptual and instrumental evidence. Clin Linguist Phon. 2004;18(4-5):313-40. http://dx.doi.org/10.1080/02699200410001701314
https://doi.org/10.1080/0269920041000170...
). Another study evaluated 10 children with a complete cleft lip and palate, 10 with a cleft palate, 7 with velocardiofacial syndrome, and 47 without a cleft. This study reported similar results among the groups, thereby verifying that children with a complete cleft lip and palate did not show apraxic characteristics, unlike those with a cleft palate and those with velocardiofacial syndrome(1919 Kummer AW, Lee L, Stutz LS, Maroney A, Brandt JW. The prevalence of apraxia characteristics in patients with velocardioiofacial syndrome as compared with other cleft populations. Cleft Palate Craniofac J. 2007;44(2):175-81. http://dx.doi.org/10.1597/05-170.1
https://doi.org/10.1597/05-170.1...
). Another study evaluated children and young adults with and without a cleft lip and palate, and the results indicated lower speed in the group with a cleft, thereby explaining the alterations in intraoral pressure(2020 Véliz VLB. Tasa de diadococinesia en sujetos con fissura [Memoraria para Licenciado em Fonoaudiología]. Chile: Universid de Talca. Faculdade de Ciencias de la Salud; 2007.).

Consequently, one can conclude that, even though these few studies included individuals with a cleft lip and palate, they used limited and heterogeneous samples, despite the use of distinct DDK parameters. Therefore, it is unclear whether the DDK parameters were altered in these populations. Clarifying these questions would facilitate adequate therapeutic planning with regard to the inclusion of activities for motor abilities. In individuals without a cleft lip and palate, the DDK is altered when speech disorders are present. A structurally compromised oral cavity is a long-term condition present in people with a cleft lip and palate even after surgery, thereby resulting in functional speech adaptations. This study aimed to correlate oral motor performance in DDK tasks based on the type of cleft and the presence of a lisp in the speech of children who had undergone surgery for a cleft lip and palate.

METHODS

This retrospective, non-randomized study was approved by the Human Research Ethics Committee of the Hospital for Rehabilitation of Craniofacial Anomalies at the Universidade de São Paulo (USP) under the number 406,375. Further, this study was part of a wider prospective research project that was approved by this committee under the number 288/2009. Administration of the Free and Informed Consent Form was not required because previously collected data were evaluated in this study. The documents from the complete sample population in the larger study were analyzed. The study comprised 60 children, aged between 9 and 12 years, who were randomly selected and distributed into 2 groups: 1 group comprised 30 children (14 girls and 16 boys) with a unilateral cleft lip and palate (UCLP) and the other group comprised 30 children (18 girls and 12 boys) with an isolated cleft palate (CP).

The children underwent primary surgeries for lip repair until they were 6 months of age and palate repair surgery between 12 and 24 months of age in the same institution where the study was designed. Children were excluded from the study if the following criteria applied: secondary lip repair surgeries; intraoral braces that interfered with execution of the required tasks; oronasal fistulas; moderate to severe dysphonia; lingual frenulum with short or fixed extension in close proximity to the tongue tip; neurologic conditions or syndromes; compensatory articulations while pronouncing plosive phonemes [t] and [k], and speech disfluency.

Diadochokinesis test

The number of emissions produced per second (s) as well as the mean time between the emissions in milliseconds (ms) were analyzed by using data obtained from the DDK test. The DDK test was conducted in an acoustically appropriate room, where the individuals remained seated with a microphone (AKG, C420) laterally positioned at 60°, 10 cm from the labial commissure. The microphone was adapted to a sound table (Behringer® 8 channels, XENYX/X1204USB) connected to an Intel® Pentium® 4 computer (CPU 1.80 GHz and 256 MB RAM; sound module Audigy II, Creative).

Sample speech recordings of repetitions of the monosyllables “ta” and “ka” and the sequence “pataka” were acquired for 6 seconds each(1111 Modolo DJ, Berretin-Felix G, Genaro KF, Brasolotto AG. Oral and vocal fold diadochokinesis in children. Folia Phoniatr Logop. 2011;63(1):1-8. http://dx.doi.org/10.1159/000319728
https://doi.org/10.1159/000319728...
). The “pa” syllable was not tested because it is a bilabial articulatory point and the objective was to study the lisp, which is a disorder that involves the motor ability of the tongue rather than the lip. All children had been previously instructed and trained to produce emissions as fast as possible during the evaluation with clear and precise articulation(1111 Modolo DJ, Berretin-Felix G, Genaro KF, Brasolotto AG. Oral and vocal fold diadochokinesis in children. Folia Phoniatr Logop. 2011;63(1):1-8. http://dx.doi.org/10.1159/000319728
https://doi.org/10.1159/000319728...
). After training, the emissions were recorded 2–3 times, and the samples were stored by using the SoundForge 8.0 software (Sony®) at a sampling rate of 44.100 Hz, mono-channel in 16-bit.

One person performed and edited the recordings for subsequent analyses of the emissions of both the monosyllables “ta” and “ka” and the “pataka” sequence. The first 2 seconds of the emissions of “ta” and “ka” were excluded from the analyses by using the MSP software Model 5141, version 2.5.2 (KayPENTAXTM), and the number of emissions was considered in 3-second intervals(1111 Modolo DJ, Berretin-Felix G, Genaro KF, Brasolotto AG. Oral and vocal fold diadochokinesis in children. Folia Phoniatr Logop. 2011;63(1):1-8. http://dx.doi.org/10.1159/000319728
https://doi.org/10.1159/000319728...
). The same software, which automatically provides the number of emissions per second and the mean time between the emissions, was used to perform the analyses. For the “pataka” sequence, both editing and quantitative analysis were performed by using the SoundForge 8.0 (Sony®) editing software, excluding the first 2 seconds and retaining the next 3 seconds. The number of emissions per second was manually counted by using visual and auditory tracks because the MSP software considers the trisyllabic sequence to be 3 separate monosyllables rather than a single emission(1111 Modolo DJ, Berretin-Felix G, Genaro KF, Brasolotto AG. Oral and vocal fold diadochokinesis in children. Folia Phoniatr Logop. 2011;63(1):1-8. http://dx.doi.org/10.1159/000319728
https://doi.org/10.1159/000319728...
).

The emission for the “pataka” sequence was not registered when the child could not perform the emissions correctly even after training.

Analysis of the presence of lisp speech

We analyzed speech samples that were recorded with an audio-visual system by using a digital camera recorder (Sony® DCR-DVD810) supported by a tripod placed 1 meter from the seated patient. Such samples involved the repetition of sentences that comprised words belonging to a script of target sounds, each of which contained 10 occurrences: 4 in the initial syllable, 3 in the middle syllable, and 3 in the final syllable(8Alves TCNV. Análise da produção da fala nas correções cirúrgicas da deformidade dentofacial [tese de doutorado]. Bauru: Universidade de São Paulo. Hospital de Reabilitação de Anomalias Craniofaciais; 2008.). The alveolar phonemes [s] and [z] in a total of 20 emissions were taken into account during the analysis. The speech samples were stored on portable devices in ascending order according to the case number of the study, and were given to each evaluator.

Two experienced speech evaluators received verbal and written instructions to analyze the samples and register the presence of a lisp when an audible phonetic distortion was detected during production of phonemes [s] and [z](2121 Whitaker ME, Freitas JAS, Pegoraro-Krook MI, Ozawa TO, Lauris RCMC, Lauris JRP et al. Relationship between occlusion and lisping in children with cleft lip and palate. Cleft Palate Craniofac J. 2012;49(1):96-103. http://dx.doi.org/10.1597/09-139
https://doi.org/10.1597/09-139...
). To this end, an individual and separate analysis was conducted in a quiet environment with the use of headphones. The results were subsequently analyzed. In cases with contradictory results, a third experienced person who was informed that he/she served as a third experienced evaluator, was required to analyze the speech samples in order to resolve the impasse. Therefore, considering the agreement between the 2 evaluators, the presence of a lisp was registered in at least 5 out of 10 emissions of each phoneme(2222 Wertzner HF, Sotel MB, Amaro L. Analysis of distortions in children with and without phonological disorders. Clinics. 2005;60(2):93-102. http://dx.doi.org/10.1590/S1807-59322005000200004
https://doi.org/10.1590/S1807-5932200500...
). It is important to note that sample randomization was not performed for data analysis.

The agreement of the evaluators was verified with a Kappa test, which revealed good agreement, i.e., 85% (Kappa=0.85) and 90% (Kappa=0.90) for the phonemes [s] and [z], respectively. Because the agreement between the evaluators was satisfactory, the intra-evaluator reliability was not verified. The analysis of speech disorder frequency according to the cleft type was verified by using the Chi-square test. The DDK results between the 2 cleft groups, as well as between groups with and without a lisp, were compared by using the t-test for independent samples. In all analyses, p values <0.05 were considered significant.

RESULTS

The DDK results between the UCLP and CP groups with regard to the number of emissions per second and the mean time between emissions in milliseconds were compared by using the t-test for independent samples. No significant differences were observed between the groups in either comparison (Table 1).

Table 1
Comparison between the means and standard deviations of the number of emissions per second and mean time per second between the groups

Analysis of the frequency of a lisp based on the type of cleft revealed a higher frequency (60%) in the UCLP group (p=0.00882) (Table 2).

Table 2
Lisp speech frequency according to the type of cleft

No significant differences were observed while comparing the values of the DDK parameters between groups with and without a lisp when the group was considered as a whole, regardless of the type of cleft (Table 3), or when each group was considered individually (Tables 4 and 5).

Table 3
Comparison of the diadochokinesis values according to the presence of lisp in speech while considering the whole group
Table 4
Comparison of the diadochokinesis values according to the presence of lisp in speech in the UCLP group
Table 5
Comparison of the diadochokinesis values according to the presence or absence of lisp in speech in the CP group

DISCUSSION

Evaluating the oral motor function of patients with a cleft lip and palate is critical since these individuals have a structurally compromised oral cavity from birth, and this condition can persist for a long time during rehabilitation. Structural alterations of the oral cavity favor functional adaptations, especially of the tongue, in order to perform orofacial functions(2Genaro KF, Yamashita RP, Trindade IEK. Avaliação clínica e instrumental na fissura labiopalatina. In: Fernandes FDM, Mendes BCA, Navas ALGP, organizadores. Tratado de fonoaudiologia. 2a ed. São Paulo: Roca; 2010. p. 488-503.,6Vallino LD, Tompson B. Perceptual characteristics of consonant errors associated with malocclusion. J Oral Maxillofac Surg. 1993;51(8):850-6. http://dx.doi.org/10.1016/S0278-2391(10)80101-6
https://doi.org/10.1016/S0278-2391(10)80...

Niemeyer TC. Cirurgia ortognática e produção de fala [dissertação]. Bauru: Universidade de São Paulo. Hospital de Reabilitação de Anomalias Craniofaciais; 2004.
-8Alves TCNV. Análise da produção da fala nas correções cirúrgicas da deformidade dentofacial [tese de doutorado]. Bauru: Universidade de São Paulo. Hospital de Reabilitação de Anomalias Craniofaciais; 2008.). In addition, the presence of velopharyngeal dysfunction and dento-occlusal alterations cause specific speech disorders(1Silva RN, Nascimento EM, Santos G. Ocorrência de alterações da motricidade oral em indivíduos com fissuras labiopalatinas. Rev Bras Prom Saúde. 2004;17(1):27-30.,2Genaro KF, Yamashita RP, Trindade IEK. Avaliação clínica e instrumental na fissura labiopalatina. In: Fernandes FDM, Mendes BCA, Navas ALGP, organizadores. Tratado de fonoaudiologia. 2a ed. São Paulo: Roca; 2010. p. 488-503.,5Amaral AS, Genaro KF. Análise da fala em indivíduos com fissura labiopalatina operada. Pró Fono.1996;8(1):36-46.,9Hanayama EM. Distúrbios de comunicação nos pacientes com sequela de fissura labiopalatina. Rev Bras Cir Craniomaxilofac. 2009;12(3):118-24.,2323 Campillay PL. Perfil de fala em pacientes com fissura labiopalatina atendidos em um hospital de Porto Alegre [trabalho de conclusão de especialização]. Porto Alegre: Universidade Federal do Rio Grande do Sul. Hospital de Clinicas de Porto Alegre; 2012.).

Therefore, evaluating oral motor performance in individuals with a cleft lip and palate could help clarify whether the functional adaptations developed by the individual to compensate for the structural deformity would compromise this ability. DDK analysis enables evaluation of oral motor ability by using tasks that involve quick repetitions of syllables and syllabic sequences(1010 Baken RJ, Orlikoff RF. Speech movements. San Diego: Singular Thomson Learning; 2000. Clinical measurement speech and voice; p.511-57.,1111 Modolo DJ, Berretin-Felix G, Genaro KF, Brasolotto AG. Oral and vocal fold diadochokinesis in children. Folia Phoniatr Logop. 2011;63(1):1-8. http://dx.doi.org/10.1159/000319728
https://doi.org/10.1159/000319728...
).

In order to obtain homogeneous groups, children who had undergone surgery in the same institution at the ages recommended in the literature were selected for this study. This study group included children who had mastered the analyzed phonemes and had precise articulation; further, the selected children had mixed dentition with the central and lateral incisive teeth already present(2121 Whitaker ME, Freitas JAS, Pegoraro-Krook MI, Ozawa TO, Lauris RCMC, Lauris JRP et al. Relationship between occlusion and lisping in children with cleft lip and palate. Cleft Palate Craniofac J. 2012;49(1):96-103. http://dx.doi.org/10.1597/09-139
https://doi.org/10.1597/09-139...
) because the absence of these teeth could cause false results.

The analysis of the obtained results revealed a similarity between the UCLP and CP groups with regard to the parameters of the mean time between emissions (ms) and number of emissions per second for all tested repetitions. Low variation was observed in the values for both the groups, as indicated by the standard deviation. This result indicates that, despite the more extensive structural alterations in the UCLP group, these alterations did not affect motor ability with regard to production of the syllables “ta” and “ka” and the “pataka” sequence.

Even though a control group was not included, the results of the present study were consistent with the previously reported values for individuals (aged 5–93 years) without a cleft when the number of emissions per second was compared(1010 Baken RJ, Orlikoff RF. Speech movements. San Diego: Singular Thomson Learning; 2000. Clinical measurement speech and voice; p.511-57.,1111 Modolo DJ, Berretin-Felix G, Genaro KF, Brasolotto AG. Oral and vocal fold diadochokinesis in children. Folia Phoniatr Logop. 2011;63(1):1-8. http://dx.doi.org/10.1159/000319728
https://doi.org/10.1159/000319728...
). The values obtained for the syllable “ta” were 4.66 ± 0.61 in the CP group and 4.65 ± 0.48 in the UCLP group, with a possible variation between 3.33 and 7.1. The values for the syllable “ka” were 4.06 ± 0.46 and 3.86 ± 0.58 for the CP and UCLP group, respectively, with a possible variation between 3.18 and 6.6.

For emission of the trisyllabic sequence “pataka,” the values of 1.64 ± 0.16 and 1.67 ± 0.16 obtained for the CP and UCLP group, respectively, are consistent with those reported in previous studies(1010 Baken RJ, Orlikoff RF. Speech movements. San Diego: Singular Thomson Learning; 2000. Clinical measurement speech and voice; p.511-57.,1111 Modolo DJ, Berretin-Felix G, Genaro KF, Brasolotto AG. Oral and vocal fold diadochokinesis in children. Folia Phoniatr Logop. 2011;63(1):1-8. http://dx.doi.org/10.1159/000319728
https://doi.org/10.1159/000319728...
).

Lisp frequencies of 60% and 23.33% were observed during speech production in the UCLP and CP groups, respectively, with a significantly higher alteration frequency in the group with a cleft lip and palate. This result can be explained by the incorrect positioning of the tongue, which affects articulatory points and is occasionally found as a result of the dento-occlusal balance condition, structural alteration, and reduced intraoral cavity, even after surgical repair(1Silva RN, Nascimento EM, Santos G. Ocorrência de alterações da motricidade oral em indivíduos com fissuras labiopalatinas. Rev Bras Prom Saúde. 2004;17(1):27-30.,5Amaral AS, Genaro KF. Análise da fala em indivíduos com fissura labiopalatina operada. Pró Fono.1996;8(1):36-46.

Vallino LD, Tompson B. Perceptual characteristics of consonant errors associated with malocclusion. J Oral Maxillofac Surg. 1993;51(8):850-6. http://dx.doi.org/10.1016/S0278-2391(10)80101-6
https://doi.org/10.1016/S0278-2391(10)80...

Niemeyer TC. Cirurgia ortognática e produção de fala [dissertação]. Bauru: Universidade de São Paulo. Hospital de Reabilitação de Anomalias Craniofaciais; 2004.
-8Alves TCNV. Análise da produção da fala nas correções cirúrgicas da deformidade dentofacial [tese de doutorado]. Bauru: Universidade de São Paulo. Hospital de Reabilitação de Anomalias Craniofaciais; 2008.,1010 Baken RJ, Orlikoff RF. Speech movements. San Diego: Singular Thomson Learning; 2000. Clinical measurement speech and voice; p.511-57.

11 Modolo DJ, Berretin-Felix G, Genaro KF, Brasolotto AG. Oral and vocal fold diadochokinesis in children. Folia Phoniatr Logop. 2011;63(1):1-8. http://dx.doi.org/10.1159/000319728
https://doi.org/10.1159/000319728...

12 Dworkin JP. Protusive lingual force and lingual diadochokinetic rates: a comparative analysis between normal and lisping speakers. Lang Speech Hear Serv Sch. 1978;19(1):8-16. http://dx.doi.org/10.1044/0161-1461.0901.08
https://doi.org/10.1044/0161-1461.0901.0...

13 Dworkin JP. Characteristics of frontal lispers clustered according to severity. J Speech Hear Disord. 1980;45(1):37-44. http://dx.doi.org/10.1044/jshd.4501.37
https://doi.org/10.1044/jshd.4501.37...

14 Dworkin JP, Aronson AE. Tongue strength and alternate motion rates in normal and dysarthric subjects. J Commun Disord. 1986;19(2):115-32. http://dx.doi.org/10.1016/0021-9924(86)90015-8
https://doi.org/10.1016/0021-9924(86)900...

15 Wertzner HF, Alves RR, Ramos ACO. Análise do desenvolvimento das habilidades diadococinéticas orais em crianças normais e com transtorno fonológico. Rev Soc Bras Fonoaudiol. 2008;13(2):136-42. http://dx.doi.org/10.1590/S1516-80342008000200007
https://doi.org/10.1590/S1516-8034200800...

16 Alves RR. Diadococinesia oral em crianças com e sem transtorno fonológico [dissertação]. São Paulo: Faculdade de Filosofia, Letras e Ciências Humanas, Universidade de São Paulo; 2010.

17 Folha GA, Felício CM. Relação entre idade, porcentagem de consoantes corretas e velocidade de fala. São Paulo: Pró Fono. 2009;21(1):39-44. http://dx.doi.org/10.1590/S0104-56872009000100007
https://doi.org/10.1590/S0104-5687200900...

18 Howard S. Compensatory articulatory behaviours in adolescents with cleft palate: comparing the perceptual and instrumental evidence. Clin Linguist Phon. 2004;18(4-5):313-40. http://dx.doi.org/10.1080/02699200410001701314
https://doi.org/10.1080/0269920041000170...
-1919 Kummer AW, Lee L, Stutz LS, Maroney A, Brandt JW. The prevalence of apraxia characteristics in patients with velocardioiofacial syndrome as compared with other cleft populations. Cleft Palate Craniofac J. 2007;44(2):175-81. http://dx.doi.org/10.1597/05-170.1
https://doi.org/10.1597/05-170.1...
, 2323 Campillay PL. Perfil de fala em pacientes com fissura labiopalatina atendidos em um hospital de Porto Alegre [trabalho de conclusão de especialização]. Porto Alegre: Universidade Federal do Rio Grande do Sul. Hospital de Clinicas de Porto Alegre; 2012.

24 Monteiro VR, Brescovici SM, Delgado SE. A ocorrência de ceceio em crianças de oito a 11 anos em escolas municipais. Rev Soc Bras Fonoaudiol. 2009;14(2):213-8. http://dx.doi.org/10.1590/S1516-80342009000200012
https://doi.org/10.1590/S1516-8034200900...
-2525 Oliveira JTN, Oliveira ZSB. Desvio fonético X desvio fonológico: algumas considerações. J Bras Fonoaudiol. 2004;5(20):172-6.).

On the other hand, the presence of a lisp was not expected in the CP group because this type of cleft does not require extensive occlusal alterations. However, while evaluating 40 children aged 4–10 years without a cleft, a single study reported that the phonemes most frequently distorted were [s] and [z](2121 Whitaker ME, Freitas JAS, Pegoraro-Krook MI, Ozawa TO, Lauris RCMC, Lauris JRP et al. Relationship between occlusion and lisping in children with cleft lip and palate. Cleft Palate Craniofac J. 2012;49(1):96-103. http://dx.doi.org/10.1597/09-139
https://doi.org/10.1597/09-139...
).

Analysis of oral motor performance during DDK tasks while considering lisp interference in both of the studied groups did not reveal any differences between the values for individuals with and without a lisp. This result indicates that, despite a more anterior tongue position to compensate for structural alteration and to enable the production of alveolar phonemes, motor ability was not affected according to the DDK evaluation. This may be due to the functional adaptation acquired by these individuals during their lifetime. This finding is inconsistent with those of previous studies in which DDK was compared between individuals with different types of articulatory disorders and individuals without speech problems(1212 Dworkin JP. Protusive lingual force and lingual diadochokinetic rates: a comparative analysis between normal and lisping speakers. Lang Speech Hear Serv Sch. 1978;19(1):8-16. http://dx.doi.org/10.1044/0161-1461.0901.08
https://doi.org/10.1044/0161-1461.0901.0...
,1313 Dworkin JP. Characteristics of frontal lispers clustered according to severity. J Speech Hear Disord. 1980;45(1):37-44. http://dx.doi.org/10.1044/jshd.4501.37
https://doi.org/10.1044/jshd.4501.37...
,1616 Alves RR. Diadococinesia oral em crianças com e sem transtorno fonológico [dissertação]. São Paulo: Faculdade de Filosofia, Letras e Ciências Humanas, Universidade de São Paulo; 2010.).

This study had several limitations. First, we were not able to study a large sample because of the specific inclusion criteria; this was especially true for the criterion regarding the presence of compensatory articulations during the production of phonemes that are the most affected in this population, i.e., [t], [k], [s], and [z](1Silva RN, Nascimento EM, Santos G. Ocorrência de alterações da motricidade oral em indivíduos com fissuras labiopalatinas. Rev Bras Prom Saúde. 2004;17(1):27-30.,3Marino VCC, Dutka JCR, Pegoraro-Krook MI, Lima-Gregio AM. Articulação compensatória associada à fissura de palato ou disfunção velofaríngea: revisão de literatura. Rev CEFAC. 2012;14(3):528-43. http://dx.doi.org/10.1590/S1516-18462011005000077
https://doi.org/10.1590/S1516-1846201100...
,9Hanayama EM. Distúrbios de comunicação nos pacientes com sequela de fissura labiopalatina. Rev Bras Cir Craniomaxilofac. 2009;12(3):118-24.). Furthermore, because only a few published studies used DDK to evaluate individuals with a cleft lip and palate, our ability to compare our results with those of previous studies was limited.

CONCLUSION

DDK task performance was not altered by the type of cleft palate. The presence of a lisp was more frequent in children with a complete UCLP. However, the presence of a lisp during speech production did not affect DDK task performance.

REFERÊNCIAS

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    Silva RN, Nascimento EM, Santos G. Ocorrência de alterações da motricidade oral em indivíduos com fissuras labiopalatinas. Rev Bras Prom Saúde. 2004;17(1):27-30.
  • 2
    Genaro KF, Yamashita RP, Trindade IEK. Avaliação clínica e instrumental na fissura labiopalatina. In: Fernandes FDM, Mendes BCA, Navas ALGP, organizadores. Tratado de fonoaudiologia. 2a ed. São Paulo: Roca; 2010. p. 488-503.
  • 3
    Marino VCC, Dutka JCR, Pegoraro-Krook MI, Lima-Gregio AM. Articulação compensatória associada à fissura de palato ou disfunção velofaríngea: revisão de literatura. Rev CEFAC. 2012;14(3):528-43. http://dx.doi.org/10.1590/S1516-18462011005000077
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    Freitas JA, Trindade-Suedam IK, Garib DG, Neves LT, Almeida AL, Yaedú RY et al. Rehabilitative treatment of cleft lip and palate: experience of the Hospital for Rehabilitation of Craniofacial Anomalies/USP (HRAC/USP) - Part 5: institutional outcomes assessment and the role of the Laboratory of Physiology. J Appl Oral Sci. 2013;21(4):383-90. http://dx.doi.org/10.1590/1678-775720130290
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    Amaral AS, Genaro KF. Análise da fala em indivíduos com fissura labiopalatina operada. Pró Fono.1996;8(1):36-46.
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    Vallino LD, Tompson B. Perceptual characteristics of consonant errors associated with malocclusion. J Oral Maxillofac Surg. 1993;51(8):850-6. http://dx.doi.org/10.1016/S0278-2391(10)80101-6
    » https://doi.org/10.1016/S0278-2391(10)80101-6
  • 7
    Niemeyer TC. Cirurgia ortognática e produção de fala [dissertação]. Bauru: Universidade de São Paulo. Hospital de Reabilitação de Anomalias Craniofaciais; 2004.
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    Alves TCNV. Análise da produção da fala nas correções cirúrgicas da deformidade dentofacial [tese de doutorado]. Bauru: Universidade de São Paulo. Hospital de Reabilitação de Anomalias Craniofaciais; 2008.
  • 9
    Hanayama EM. Distúrbios de comunicação nos pacientes com sequela de fissura labiopalatina. Rev Bras Cir Craniomaxilofac. 2009;12(3):118-24.
  • 10
    Baken RJ, Orlikoff RF. Speech movements. San Diego: Singular Thomson Learning; 2000. Clinical measurement speech and voice; p.511-57.
  • 11
    Modolo DJ, Berretin-Felix G, Genaro KF, Brasolotto AG. Oral and vocal fold diadochokinesis in children. Folia Phoniatr Logop. 2011;63(1):1-8. http://dx.doi.org/10.1159/000319728
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  • 12
    Dworkin JP. Protusive lingual force and lingual diadochokinetic rates: a comparative analysis between normal and lisping speakers. Lang Speech Hear Serv Sch. 1978;19(1):8-16. http://dx.doi.org/10.1044/0161-1461.0901.08
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  • 14
    Dworkin JP, Aronson AE. Tongue strength and alternate motion rates in normal and dysarthric subjects. J Commun Disord. 1986;19(2):115-32. http://dx.doi.org/10.1016/0021-9924(86)90015-8
    » https://doi.org/10.1016/0021-9924(86)90015-8
  • 15
    Wertzner HF, Alves RR, Ramos ACO. Análise do desenvolvimento das habilidades diadococinéticas orais em crianças normais e com transtorno fonológico. Rev Soc Bras Fonoaudiol. 2008;13(2):136-42. http://dx.doi.org/10.1590/S1516-80342008000200007
    » https://doi.org/10.1590/S1516-80342008000200007
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    Alves RR. Diadococinesia oral em crianças com e sem transtorno fonológico [dissertação]. São Paulo: Faculdade de Filosofia, Letras e Ciências Humanas, Universidade de São Paulo; 2010.
  • 17
    Folha GA, Felício CM. Relação entre idade, porcentagem de consoantes corretas e velocidade de fala. São Paulo: Pró Fono. 2009;21(1):39-44. http://dx.doi.org/10.1590/S0104-56872009000100007
    » https://doi.org/10.1590/S0104-56872009000100007
  • 18
    Howard S. Compensatory articulatory behaviours in adolescents with cleft palate: comparing the perceptual and instrumental evidence. Clin Linguist Phon. 2004;18(4-5):313-40. http://dx.doi.org/10.1080/02699200410001701314
    » https://doi.org/10.1080/02699200410001701314
  • 19
    Kummer AW, Lee L, Stutz LS, Maroney A, Brandt JW. The prevalence of apraxia characteristics in patients with velocardioiofacial syndrome as compared with other cleft populations. Cleft Palate Craniofac J. 2007;44(2):175-81. http://dx.doi.org/10.1597/05-170.1
    » https://doi.org/10.1597/05-170.1
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    Véliz VLB. Tasa de diadococinesia en sujetos con fissura [Memoraria para Licenciado em Fonoaudiología]. Chile: Universid de Talca. Faculdade de Ciencias de la Salud; 2007.
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    Whitaker ME, Freitas JAS, Pegoraro-Krook MI, Ozawa TO, Lauris RCMC, Lauris JRP et al. Relationship between occlusion and lisping in children with cleft lip and palate. Cleft Palate Craniofac J. 2012;49(1):96-103. http://dx.doi.org/10.1597/09-139
    » https://doi.org/10.1597/09-139
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    Wertzner HF, Sotel MB, Amaro L. Analysis of distortions in children with and without phonological disorders. Clinics. 2005;60(2):93-102. http://dx.doi.org/10.1590/S1807-59322005000200004
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    Campillay PL. Perfil de fala em pacientes com fissura labiopalatina atendidos em um hospital de Porto Alegre [trabalho de conclusão de especialização]. Porto Alegre: Universidade Federal do Rio Grande do Sul. Hospital de Clinicas de Porto Alegre; 2012.
  • 24
    Monteiro VR, Brescovici SM, Delgado SE. A ocorrência de ceceio em crianças de oito a 11 anos em escolas municipais. Rev Soc Bras Fonoaudiol. 2009;14(2):213-8. http://dx.doi.org/10.1590/S1516-80342009000200012
    » https://doi.org/10.1590/S1516-80342009000200012
  • 25
    Oliveira JTN, Oliveira ZSB. Desvio fonético X desvio fonológico: algumas considerações. J Bras Fonoaudiol. 2004;5(20):172-6.
  • Research carried out in the Physiology Laboratory, Hospital for Rehabilitation of Craniofacial Anomalies, Universidade de São Paulo – USP – Bauru (SP), Brazil, with supported by scholarship Program of Scientific Initiation – Rectory of the Universidade de São Paulo (PIBIC-RUSP).

Publication Dates

  • Publication in this collection
    Mar 2015

History

  • Received
    9 July 2014
  • Accepted
    19 Jan 2015
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