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Orofacial Myofunctional Evaluation Protocol for older people: validity, psychometric properties, and association with oral health and age

Protocolo de Avaliação Miofuncional Orofacial para pessoas idosas: validade, propriedades psicométricas e associação com saúde oral e idade

ABSTRACT

Purpose

To develop a comprehensive assessment protocol for identifying, classifying and grading changes in stomatognathic system components and functions of older people, to determine its psychometric properties and verify its association with oral health and age.

Methods

The content validity of the Orofacial Myofunctional Evaluation with Scores for Elders protocol (OMES-Elders) was established based on the literature. The protocol contains three domains: appearance/posture, mobility, and functions of the stomatognathic system. Eighty-two healthy elder volunteers (mean age 69±7.24 years) were evaluated using the OMES-Elders. A test-screening for orofacial disorders (reference) was used to analyze the concurrent validity (correlation test), sensitivity, specificity and accuracy (Receiver Operating Characteristic Curve: ROC curve) of the OMES-Elders. The association of the OMES-Elders scores with the Oral Health Index (OHX) and age in the sample was tested.

Results

There was a significant correlation between the OMES-Elders and the reference test (p < 0.001). Reliability coefficients ranged from good (0.89) to excellent (0.99). The OMES-Elders protocol had a sensitivity of 82.9%, specificity of 83.3% and accuracy of 0.83. The scores of the protocol were significantly lower in individuals with worse oral health (OHX ≤ 61%), although individuals with adequate oral health (OHX ≥ 90%) also had myofunctional impairments. The predictors OHX and age explained, respectively, 33% and 30% of the variance in the OMES-Elders total score.

Conclusion

As the first specific orofacial myofunctional evaluation of older people, the OMES-Elders protocol proved to be valid, reliable and its total score was associated with oral health and age.

Keywords
Aged; Stomatognathic System; Mastication; Deglutition; Oral Health; Evaluation

RESUMO

Objetivo

Desenvolver um protocolo de avaliação abrangente para identificar, classificar e graduar as mudanças 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 de Avaliação Miofuncional Orofacial com Escores para Idosos (AMIOFE-I), que contém três domínios, aparência/postura, mobilidade e funções do sistema estomatognático, foi estabelecida com base na literatura. Oitenta e dois 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), 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.

Descritores
Idoso; Sistema Estomatognático; Mastigação; Deglutição; Saúde Oral; Avaliação

INTRODUCTION

The older population is growing in worldwide. Older people have decreased sensitivity, muscle force/strength, oral motor ability and salivary flow(11 Kikutani T, Tamura F, Nishiwaki K, Kodama M, Suda M, Fukui T, et al. Oral motor function and masticatory performance in the community-dwelling elderly. Odontology. 2009;97(1):38-42. PMid:19184296. http://dx.doi.org/10.1007/s10266-008-0094-z.
http://dx.doi.org/10.1007/s10266-008-009...

2 Cho EP, Hwang SJ, Clovis JB, Lee TY, Paik DI, Hwang YS. Enhancing the quality of life in elderly women through a programme to improve the condition of salivary hypofunction. Gerodontology. 2012;29(2):e972-80. PMid:22126433. http://dx.doi.org/10.1111/j.1741-2358.2011.00594.x.
http://dx.doi.org/10.1111/j.1741-2358.20...

3 Santoro P, Silva IL, Cardoso F, Dias E Jr, Beresford H. Evaluation of the effectiveness of a phonoaudiology program for the rehabilitation of dysphagia in the elderly. Arch Gerontol Geriatr. 2011;53(1):e61-6. PMid:21093069. http://dx.doi.org/10.1016/j.archger.2010.10.026.
http://dx.doi.org/10.1016/j.archger.2010...

4 Clark HM, Solomon NP. Age and sex differences in orofacial strength. Dysphagia. 2012;27(1):2-9. PMid:21350818. http://dx.doi.org/10.1007/s00455-011-9328-2.
http://dx.doi.org/10.1007/s00455-011-932...

5 Logemann JA, Curro FA, Pauloski B, Gensler G. Aging effects on oropharyngeal swallow and the role of dental care in oropharyngeal dysphagia. Oral Dis. 2013;19(8):733-7. PMid:23574512. http://dx.doi.org/10.1111/odi.12104.
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6 Ohara Y, Yoshida N, Kono Y, Hirano H, Yoshida H, Mataki S, et al. Effectiveness of an oral health educational program on community-dwelling older people with xerostomia. Geriatr Gerontol Int. 2015;15(4):481-9. PMid:24796714. http://dx.doi.org/10.1111/ggi.12301.
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7 Di Pede C, Mantovani ME, Del Felice A, Masiero S. Dysphagia in the elderly: focus on rehabilitation strategies. Aging Clin Exp Res. 2016;28(4):607-17. PMid:26589905. http://dx.doi.org/10.1007/s40520-015-0481-6.
http://dx.doi.org/10.1007/s40520-015-048...
-88 Park T, Kim Y. Effects of tongue pressing effortful swallow in older healthy individuals. Arch Gerontol Geriatr. 2016;66:127-33. PMid:27318884. http://dx.doi.org/10.1016/j.archger.2016.05.009.
http://dx.doi.org/10.1016/j.archger.2016...
). These changes combined with dental problems, either acquired or degenerative disease, impair functions such as mastication, deglutition, and speech, and are risk factors for malnutrition, dehydration, health problems, disabilities, social isolation, and poor quality of life, resulting in additional health care costs(77 Di Pede C, Mantovani ME, Del Felice A, Masiero S. Dysphagia in the elderly: focus on rehabilitation strategies. Aging Clin Exp Res. 2016;28(4):607-17. PMid:26589905. http://dx.doi.org/10.1007/s40520-015-0481-6.
http://dx.doi.org/10.1007/s40520-015-048...
,99 Ibayashi H, Fujino Y, Pham TM, Matsuda S. Intervention study of exercise program for oral function in healthy elderly people. Tohoku J Exp Med. 2008;215(3):237-45. PMid:18648184. http://dx.doi.org/10.1620/tjem.215.237.
http://dx.doi.org/10.1620/tjem.215.237...

10 Hakuta C, Mori C, Ueno M, Shinada K, Kawaguchi Y. Evaluation of an oral function promotion programme for the independent elderly in Japan. Gerodontology. 2009;26(4):250-8. PMid:19555360. http://dx.doi.org/10.1111/j.1741-2358.2008.00269.x.
http://dx.doi.org/10.1111/j.1741-2358.20...

11 Quandt SA, Chen H, Bell RA, Savoca MR, Anderson AM, Leng X, et al. Food avoidance and food modification practices of older rural adults: association with oral health status and implications for service provision. Gerontologist. 2010;50(1):100-11. PMid:19574543. http://dx.doi.org/10.1093/geront/gnp096.
http://dx.doi.org/10.1093/geront/gnp096...

12 Hsu KJ, Lee HE, Wu YM, Lan SJ, Huang ST, Yen YY. Masticatory factors as predictors of oral health-related quality of life among elderly people in Kaohsiung City, Taiwan. Qual Life Res. 2014;23(4):1395-405. PMid:24241772. http://dx.doi.org/10.1007/s11136-013-0574-7.
http://dx.doi.org/10.1007/s11136-013-057...

13 Werle RW, Steidl EMS, Mancopes R. Oropharyngeal dysphagia and related factors in post-cardiac surgery: a systematic review. CoDAS. 2016;28(5):646-52. PMid:27683826. http://dx.doi.org/10.1590/2317-1782/20162015199.
http://dx.doi.org/10.1590/2317-1782/2016...
-1414 Dai R, Lam OL, Lo EC, Li LS, Wen Y, McGrath C. Orofacial functional impairments among patients following stroke: a systematic review. Oral Dis. 2015;21(7):836-49. PMid:25041135. http://dx.doi.org/10.1111/odi.12274.
http://dx.doi.org/10.1111/odi.12274...
).

Thus, health programs aimed at promoting orofacial functions are needed due to the physiological and functional decline of the stomatognathic system caused by aging. In general, safe swallowing and efficient mastication are the ultimate goals of these programs(22 Cho EP, Hwang SJ, Clovis JB, Lee TY, Paik DI, Hwang YS. Enhancing the quality of life in elderly women through a programme to improve the condition of salivary hypofunction. Gerodontology. 2012;29(2):e972-80. PMid:22126433. http://dx.doi.org/10.1111/j.1741-2358.2011.00594.x.
http://dx.doi.org/10.1111/j.1741-2358.20...
,33 Santoro P, Silva IL, Cardoso F, Dias E Jr, Beresford H. Evaluation of the effectiveness of a phonoaudiology program for the rehabilitation of dysphagia in the elderly. Arch Gerontol Geriatr. 2011;53(1):e61-6. PMid:21093069. http://dx.doi.org/10.1016/j.archger.2010.10.026.
http://dx.doi.org/10.1016/j.archger.2010...
,99 Ibayashi H, Fujino Y, Pham TM, Matsuda S. Intervention study of exercise program for oral function in healthy elderly people. Tohoku J Exp Med. 2008;215(3):237-45. PMid:18648184. http://dx.doi.org/10.1620/tjem.215.237.
http://dx.doi.org/10.1620/tjem.215.237...
,1010 Hakuta C, Mori C, Ueno M, Shinada K, Kawaguchi Y. Evaluation of an oral function promotion programme for the independent elderly in Japan. Gerodontology. 2009;26(4):250-8. PMid:19555360. http://dx.doi.org/10.1111/j.1741-2358.2008.00269.x.
http://dx.doi.org/10.1111/j.1741-2358.20...
).

Even though objective measures such as bite force, tongue strength, masticatory performance, electromyography, and ultrasonography help understand the problems that affect the stomatognathic system(11 Kikutani T, Tamura F, Nishiwaki K, Kodama M, Suda M, Fukui T, et al. Oral motor function and masticatory performance in the community-dwelling elderly. Odontology. 2009;97(1):38-42. PMid:19184296. http://dx.doi.org/10.1007/s10266-008-0094-z.
http://dx.doi.org/10.1007/s10266-008-009...
,44 Clark HM, Solomon NP. Age and sex differences in orofacial strength. Dysphagia. 2012;27(1):2-9. PMid:21350818. http://dx.doi.org/10.1007/s00455-011-9328-2.
http://dx.doi.org/10.1007/s00455-011-932...
,88 Park T, Kim Y. Effects of tongue pressing effortful swallow in older healthy individuals. Arch Gerontol Geriatr. 2016;66:127-33. PMid:27318884. http://dx.doi.org/10.1016/j.archger.2016.05.009.
http://dx.doi.org/10.1016/j.archger.2016...
,99 Ibayashi H, Fujino Y, Pham TM, Matsuda S. Intervention study of exercise program for oral function in healthy elderly people. Tohoku J Exp Med. 2008;215(3):237-45. PMid:18648184. http://dx.doi.org/10.1620/tjem.215.237.
http://dx.doi.org/10.1620/tjem.215.237...
), clinical evaluation is indispensable for the diagnosis of orofacial myofunctional disorders (OMD)(1515 Bakke M, Bergendal B, McAllister A, Sjögreen L, Asten P. Development and evaluation of a comprehensive screening for orofacial dysfunction. Swed Dent J. 2007;31(2):75-84. PMid:17695052.

16 Felício CM, Medeiros AP, de Oliveira Melchior M. Validity of the ‘protocol of oro-facial myofunctional evaluation with scores’ for young and adult subjects. J Oral Rehabil. 2012;39(10):744-53. PMid:22852833. http://dx.doi.org/10.1111/j.1365-2842.2012.02336.x.
http://dx.doi.org/10.1111/j.1365-2842.20...

17 Ercolin B, Sassi FC, Mangilli LD, Mendonça LI, Limongi SC, de Andrade CR. Oral motor movements and swallowing in patients with myotonic dystrophy type 1. Dysphagia. 2013;28(3):446-54. PMid:23460343. http://dx.doi.org/10.1007/s00455-013-9458-9.
http://dx.doi.org/10.1007/s00455-013-945...
-1818 Folha GA, Valera FC, de Felício CM. Validity and reliability of a protocol of orofacial myofunctional evaluation for patients with obstructive sleep apnea. Eur J Oral Sci. 2015;123(3):165-72. PMid:25780946. http://dx.doi.org/10.1111/eos.12180.
http://dx.doi.org/10.1111/eos.12180...
). Several scales have been developed and validated to reliably measure physical performance, functional disability, comorbidity, nutrition status and cognitive function in older people(1919 Rozzini R, Frisoni GB, Ferrucci L, Barbisoni P, Sabatini T, Ranieri P, et al. Geriatric index of comorbidity: validation and comparison with other measures of comorbidity. Age Ageing. 2002;31(4):277-85. PMid:12147566. http://dx.doi.org/10.1093/ageing/31.4.277.
http://dx.doi.org/10.1093/ageing/31.4.27...
). Although orofacial functions and dysfunctions are in general measured using either a screening tool (e.g. The Nordic Orofacial Test-Screening, NOT-S)(1515 Bakke M, Bergendal B, McAllister A, Sjögreen L, Asten P. Development and evaluation of a comprehensive screening for orofacial dysfunction. Swed Dent J. 2007;31(2):75-84. PMid:17695052.) or highly specific instruments, such as the clinical evaluation of oropharyngeal dysphagia(33 Santoro P, Silva IL, Cardoso F, Dias E Jr, Beresford H. Evaluation of the effectiveness of a phonoaudiology program for the rehabilitation of dysphagia in the elderly. Arch Gerontol Geriatr. 2011;53(1):e61-6. PMid:21093069. http://dx.doi.org/10.1016/j.archger.2010.10.026.
http://dx.doi.org/10.1016/j.archger.2010...
,77 Di Pede C, Mantovani ME, Del Felice A, Masiero S. Dysphagia in the elderly: focus on rehabilitation strategies. Aging Clin Exp Res. 2016;28(4):607-17. PMid:26589905. http://dx.doi.org/10.1007/s40520-015-0481-6.
http://dx.doi.org/10.1007/s40520-015-048...
). Furthermore, the effects of aging and oral health status on orofacial functions have not been concomitantly assessed in a comprehensive way.

The biopsychosocial importance of mastication, deglutition, facial expression and speech, and the absence of an instrument to evaluate orofacial structures and functions which enable the examiner to express his/her perception of the physical characteristics and orofacial behaviors of older people based on an ordinal scale, have prompted us to develop a new protocol.

The validation of methods for clinical assessment is recommended for evidence-based practice. The validity of an instrument is an estimate of how well it performs the assessment, and the criterion validity is determined by comparing the instrument in question to another taken as reference(2020 Menezes PR, Nascimento AF. Validity and reliability of rating scales in psychiatry. In: Gorenstein C, Andrade LHS, Zuardi AW, editors. Rating scales in psychiatry and clinical psychopharmacology. 1st ed. São Paulo: Lemos; 2000. p. 23-28.).

The objectives of this study were to develop the Orofacial Myofunctional Evaluation with Scores for Elders protocol (OMES-Elders), to determine its psychometric properties, and verify the association of its scores with an oral health index and with elderly’s age.

METHODS

Participants

Eighty-two elder volunteers participated in the study (12 men, 70 women, aged 60-90 years, mean age = 68.8±7.2 years). All participants performed daily functions independently. The protocol study was approved by the ethical review board of the University (Process N. 192.14.11.2008). All individuals gave written informed consent to participate in the study and there was no dropout in this study. The sample size was calculated to reject the null hypothesis (one-tailed test). Previously obtained descriptive statistics were used to estimate the minimum number of individuals required for statistical analysis with 80% statistical power (type II error, beta) and with alpha (type I error) set at 5%. The minimum number of individuals required for the OMES-Elders total score was 15.

Inclusion criteria were: no hearing or visual impairments, or understanding or expression difficulties that could affect the tests, no intellectual disabilities, no emotional or neurological disorders (including motor speech disorders); no diabetes; and no dental or orofacial pain, or history of trauma and surgery in the head and neck.

Participants provided information about comfort (absence of pain or sensitivity), aesthetics (contentment with appearance), functionality (ability to eat unrestricted diet). They were assessed by a dentist for the Oral Health Index (OHX)(2121 Burke FJ, Wilson NH. Measuring oral health: an historical view and details of a contemporary oral health index (OHX). Int Dent J. 1995;45(6):358-70. PMid:8666462.) determination, as follows: Presence/absence of active carious lesions, secondary caries around restorations; periodontal (pocket depth, inflammation and subgingival calculus); wear and tear, loss by wear of enamel, dentine or cementum, loss of dimension or integrity of restoration; occlusion (presence of a minimum of ten pairs of articulating teeth, natural or prosthetic); mucosa inflammation, ulceration or other pathology; dentures, if present, lack of retention, stability, presence of wear and freeway space. Each item assessed could be either acceptable (positive score) or unacceptable (zero score). After the assessment, the sum of the scores was divided by the maximum score possible, and then multiplied by 100 in order to obtain the OHX. The larger the OHX, the better is the oral health.

Construction of the OMES-Elders protocol

The previously validated OMES-Expanded protocol(1818 Folha GA, Valera FC, de Felício CM. Validity and reliability of a protocol of orofacial myofunctional evaluation for patients with obstructive sleep apnea. Eur J Oral Sci. 2015;123(3):165-72. PMid:25780946. http://dx.doi.org/10.1111/eos.12180.
http://dx.doi.org/10.1111/eos.12180...
) was the basis for the development of the OMES-Elders protocol (Appendix A Appendix A Orofacial Myofunctional Evaluation with Scores for Elders Protocol (OMES-Elders) APPEARANCE AND POSTURE/ POSITION FACE Scores Symmetry between sides Normal (4) Dysfunction: Asymmetry Light (3) Moderate (2) Severe (1) Greater side Right | Left Nasolabial sulcus Normal (4) Dysfunction: Marked nasolabial sulcus Light (3) Moderate (2) Severe (1) SUM [Maximum Score (MS) = 08] CHEEK Scores Volume Normal (4) Dysfunction: Asymmetry between right and left sides Light (3) Moderate (2) Severe (1) Tension Normal (4) Dysfunction: Flaccid / Drooping Light (3) Moderate (2) Severe (1) SUM (MS = 08) MAXILLO-MANDIBULAR RELATIONSHIPS Scores Vertical: Mandibular posture with freeway space Normal (4) Dysfunction: Teeth in occlusion or contact edges Clenching (3) Dysfunction: Open mouth Light (3) Moderate (2) Severe (1) Anteroposterior Maxilla Normal (4) Dysfunction: Maxilla Protrusion Light (3) Moderate (2) Severe (1) Mandible Normal (4) Dysfunction: Mandible Protrusion Light (3) Moderate (2) Severe (1) SUM (MS = 12) MENTALIS MUSCLE Scores Contraction not apparent (with lips closure) Normal (4) Dysfunction: contraction apparent Light (3) Moderate (2) Severe (1) Volume: Adequate Normal (4) Dysfunction: Increased Light (3) Moderate (2) Severe (1) SUM (MS = 08) LIPS Scores Sealing with no apparent muscles contraction Normal (4) Dysfunction: Sealing With effort or no labial closure Light (3) Moderate (2) Severe (1) Volume Harmonious Normal (4) Dysfunction: Reduced volume and stretched Light (3) Moderate (2) Severe (1) Labial commissures At the level of the rima of the mouth and symmetric Normal (4) Dysfunction: Below of the rima of the mouth and/or asymmetrics Light (3) 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 teethAt limit of the incisal surfaces, with reduced occlusion vertical dimension (OVD) Light (3) 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) Dysfunction: Increased Light (3) Moderate (2) Severe (1) SUM (MS = 08) PALATE Scores Width Normal (4) Dysfunction: Decreased width Light (3) Moderate (2) Severe (1) SUM (MS = 04) MOBILITY PERFORMANCE TONGUE Horizontal Lateral Vertical Protrusion Retrusion To right To left Raising Lowering Normal (precise) (6) (6) (6) (6) (6) (6) Insufficient ability (IA) (5) (5) (5) (5) (5) (5) IA plus associated movements (4) (4) (4) (4) (4) (4) IA with tremors (3) (3) (3) (3) (3) (3) IA, associated movement and tremor (2) (2) (2) (2) (2) (2) Task no performed (1) (1) (1) (1) (1) (1) SUM (MS = 36) LIPS Horizontal Lateral 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) JAW Vertical Lateral Horizontal Opening Closing Right Left Protrusion Normal (6) (6) (6) (6) (6) Insufficient ability (IA) (5) (5) (5) (5) (5) IA and associated movements (4) (4) (4) (4) (4) IA with tremor (3) (3) (3) (3) (3) IA, associated movement and tremor (2) (2) (2) (2) (2) Task no performed (1) (1) (1) (1) (1) SUM (MS = 30) CHEEKS To Inflate To Suck To Retract To transfer the air from 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 = 24) FUNCTIONS BREATHING (mode) Scores Nasal breathing Normal (4) Dysfunction: Mouth breathing Light (3) Moderate (2) Severe (1) Result (MS = 04) SWALLOW: Lips behavior Scores Consistence Liquid Solid Lips closure Without effort (6) (6) Dysfunction: Lips closure with effort Light (4) (4) Moderate (3) (3) Severe (2) (2) Dysfunction: Absence of lips closure Does not perform the function (1) (1) Result (MS = 12) SWALLOW: Tongue behavior Scores Contained in the oral cavity Normal (4) Between alveolar margins (without prosthesis) and/or follow jaw position To compensate reduced occlusion vertical dimension (OVD) (3) Between dental arches (with prosthesis) and/or follow jaw position To compensate reduced OVD (3) No OVD reduction (2) Exceeds the incisal surfaces and/or vestibular cusps (1) Interposition place Right Left both Anterior Posterior Total Result (MS = 04) SWALLOW: Other behaviors and signs of alteration Scores Present (1) Absent (2) Movement of the head and other parts of the body Sliding jaw Tension of facial muscles Food escape Gagging Noise SUM (MS = 12) SWALLOW: Efficiency Scores Consistency Liquid Solid Does not repeat swallowing the same food (3) (3) One repetition (2) (2) Multiple swallows (1) (1) SUM (MS = 06) Result Deglutition (scores sum) (MS = 34) Masticatory Type (according to distribution of chew strokes) Scores Bilateral Alternate (Chew strokes occurring 50% of the times on each side of the oral cavity, or 40% on one side and 60% on the other) (10) Simultaneous chews on both sides (only for user of stable removable denture) (10) Unilateral Preference-grade 1 – (61% to 77% of the times on the same side) (7) Preference-grade 2 – (78% to 94% the times on the same side) (5) Chronic (95% or more of the time on the same side) (3) Anterior Masticatory strokes occurring in the region of the incisors and canines (2) Function not performed Individual did not chew (1) Result (MS = 10) Masticatory Type: with prosthesis displacement Scores Bilateral Simultaneous (8) Alternate (50%/50% or 40%/60%) (7) Unilateral Preference-grade 1 – (61% to 77%) (5) Preference-grade 2 – (78% to 94%) (3) Chronic (95% to 100%) (2) Anterior (1) Function not performed Individual did not chew (1) Result (MS = 08) Mastication: other behaviors and signs of alteration Scores Present (1) Absent (2) Movement of the head and of other parts of the body Altered posture Contraction of facial muscles that do not contribute to chew Food escape SUM (MS = 08) Mastication Result (scores sum) (MS = 18) Time spent to ingest the food = Speech Phonetic inventory Place of articulation Sound Jaw opening-closing movement Intelligibility Normal Adequade (4) Precise (4) Precise (4) Normal range (4) Clarity (4) Alterations Changed Changed (frequency) Distortion(frequency) Reduced displacement Reduced Light (3) (3) (3) (3) (3) Moderate (2) (2) (2) (2) (2) Severe (1) (1) (1) (1) (1) SUM (MS = 20) OMES-Elders total score - SUM (MS = 246): ). The content validity of the OMES-Elders, which involves the definition of the object of interest and the judgment of the relevance of each variable for the age groups, was established based on the literature(11 Kikutani T, Tamura F, Nishiwaki K, Kodama M, Suda M, Fukui T, et al. Oral motor function and masticatory performance in the community-dwelling elderly. Odontology. 2009;97(1):38-42. PMid:19184296. http://dx.doi.org/10.1007/s10266-008-0094-z.
http://dx.doi.org/10.1007/s10266-008-009...

2 Cho EP, Hwang SJ, Clovis JB, Lee TY, Paik DI, Hwang YS. Enhancing the quality of life in elderly women through a programme to improve the condition of salivary hypofunction. Gerodontology. 2012;29(2):e972-80. PMid:22126433. http://dx.doi.org/10.1111/j.1741-2358.2011.00594.x.
http://dx.doi.org/10.1111/j.1741-2358.20...
-33 Santoro P, Silva IL, Cardoso F, Dias E Jr, Beresford H. Evaluation of the effectiveness of a phonoaudiology program for the rehabilitation of dysphagia in the elderly. Arch Gerontol Geriatr. 2011;53(1):e61-6. PMid:21093069. http://dx.doi.org/10.1016/j.archger.2010.10.026.
http://dx.doi.org/10.1016/j.archger.2010...
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,99 Ibayashi H, Fujino Y, Pham TM, Matsuda S. Intervention study of exercise program for oral function in healthy elderly people. Tohoku J Exp Med. 2008;215(3):237-45. PMid:18648184. http://dx.doi.org/10.1620/tjem.215.237.
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,1010 Hakuta C, Mori C, Ueno M, Shinada K, Kawaguchi Y. Evaluation of an oral function promotion programme for the independent elderly in Japan. Gerodontology. 2009;26(4):250-8. PMid:19555360. http://dx.doi.org/10.1111/j.1741-2358.2008.00269.x.
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,2222 Sansone KM, Nary H Fo, Berretin-Félix G, Brasolotto AG. Oral myofunctional and vocal characteristics in subjects subjected to oral rehabilitation with osseointegrated implants. Clin Oral Implants Res. 2006;17(3):328-30. PMid:16672029. http://dx.doi.org/10.1111/j.1600-0501.2005.01221.x.
http://dx.doi.org/10.1111/j.1600-0501.20...
). The OMES-Elders scales were based on the psychophysical method, i.e., the level of measurement depends on pre-established conditions, so that the relationships between attributes will be represented by the relationships between numbers(2323 Stevens SS. Psychophysics: introduction to its perceptual, neural, and social prospects. New York: Wiley-Interscience; 1975. 329 p.).

Orofacial myofunctional evaluation

The evaluations were performed during one session and later complemented by analysis of recorded images. The participants 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 (GR-SXM357UM JVC Compact VHS CAMCORDER, Manaus, Brazil), which was mounted on a tripod set at face, neck and shoulders height(1616 Felício CM, Medeiros AP, de Oliveira Melchior M. Validity of the ‘protocol of oro-facial myofunctional evaluation with scores’ for young and adult subjects. J Oral Rehabil. 2012;39(10):744-53. PMid:22852833. http://dx.doi.org/10.1111/j.1365-2842.2012.02336.x.
http://dx.doi.org/10.1111/j.1365-2842.20...
,1818 Folha GA, Valera FC, de Felício CM. Validity and reliability of a protocol of orofacial myofunctional evaluation for patients with obstructive sleep apnea. Eur J Oral Sci. 2015;123(3):165-72. PMid:25780946. http://dx.doi.org/10.1111/eos.12180.
http://dx.doi.org/10.1111/eos.12180...
).

The OMES-Elders protocol is presented in Appendix A Appendix A Orofacial Myofunctional Evaluation with Scores for Elders Protocol (OMES-Elders) APPEARANCE AND POSTURE/ POSITION FACE Scores Symmetry between sides Normal (4) Dysfunction: Asymmetry Light (3) Moderate (2) Severe (1) Greater side Right | Left Nasolabial sulcus Normal (4) Dysfunction: Marked nasolabial sulcus Light (3) Moderate (2) Severe (1) SUM [Maximum Score (MS) = 08] CHEEK Scores Volume Normal (4) Dysfunction: Asymmetry between right and left sides Light (3) Moderate (2) Severe (1) Tension Normal (4) Dysfunction: Flaccid / Drooping Light (3) Moderate (2) Severe (1) SUM (MS = 08) MAXILLO-MANDIBULAR RELATIONSHIPS Scores Vertical: Mandibular posture with freeway space Normal (4) Dysfunction: Teeth in occlusion or contact edges Clenching (3) Dysfunction: Open mouth Light (3) Moderate (2) Severe (1) Anteroposterior Maxilla Normal (4) Dysfunction: Maxilla Protrusion Light (3) Moderate (2) Severe (1) Mandible Normal (4) Dysfunction: Mandible Protrusion Light (3) Moderate (2) Severe (1) SUM (MS = 12) MENTALIS MUSCLE Scores Contraction not apparent (with lips closure) Normal (4) Dysfunction: contraction apparent Light (3) Moderate (2) Severe (1) Volume: Adequate Normal (4) Dysfunction: Increased Light (3) Moderate (2) Severe (1) SUM (MS = 08) LIPS Scores Sealing with no apparent muscles contraction Normal (4) Dysfunction: Sealing With effort or no labial closure Light (3) Moderate (2) Severe (1) Volume Harmonious Normal (4) Dysfunction: Reduced volume and stretched Light (3) Moderate (2) Severe (1) Labial commissures At the level of the rima of the mouth and symmetric Normal (4) Dysfunction: Below of the rima of the mouth and/or asymmetrics Light (3) 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 teethAt limit of the incisal surfaces, with reduced occlusion vertical dimension (OVD) Light (3) 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) Dysfunction: Increased Light (3) Moderate (2) Severe (1) SUM (MS = 08) PALATE Scores Width Normal (4) Dysfunction: Decreased width Light (3) Moderate (2) Severe (1) SUM (MS = 04) MOBILITY PERFORMANCE TONGUE Horizontal Lateral Vertical Protrusion Retrusion To right To left Raising Lowering Normal (precise) (6) (6) (6) (6) (6) (6) Insufficient ability (IA) (5) (5) (5) (5) (5) (5) IA plus associated movements (4) (4) (4) (4) (4) (4) IA with tremors (3) (3) (3) (3) (3) (3) IA, associated movement and tremor (2) (2) (2) (2) (2) (2) Task no performed (1) (1) (1) (1) (1) (1) SUM (MS = 36) LIPS Horizontal Lateral 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) JAW Vertical Lateral Horizontal Opening Closing Right Left Protrusion Normal (6) (6) (6) (6) (6) Insufficient ability (IA) (5) (5) (5) (5) (5) IA and associated movements (4) (4) (4) (4) (4) IA with tremor (3) (3) (3) (3) (3) IA, associated movement and tremor (2) (2) (2) (2) (2) Task no performed (1) (1) (1) (1) (1) SUM (MS = 30) CHEEKS To Inflate To Suck To Retract To transfer the air from 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 = 24) FUNCTIONS BREATHING (mode) Scores Nasal breathing Normal (4) Dysfunction: Mouth breathing Light (3) Moderate (2) Severe (1) Result (MS = 04) SWALLOW: Lips behavior Scores Consistence Liquid Solid Lips closure Without effort (6) (6) Dysfunction: Lips closure with effort Light (4) (4) Moderate (3) (3) Severe (2) (2) Dysfunction: Absence of lips closure Does not perform the function (1) (1) Result (MS = 12) SWALLOW: Tongue behavior Scores Contained in the oral cavity Normal (4) Between alveolar margins (without prosthesis) and/or follow jaw position To compensate reduced occlusion vertical dimension (OVD) (3) Between dental arches (with prosthesis) and/or follow jaw position To compensate reduced OVD (3) No OVD reduction (2) Exceeds the incisal surfaces and/or vestibular cusps (1) Interposition place Right Left both Anterior Posterior Total Result (MS = 04) SWALLOW: Other behaviors and signs of alteration Scores Present (1) Absent (2) Movement of the head and other parts of the body Sliding jaw Tension of facial muscles Food escape Gagging Noise SUM (MS = 12) SWALLOW: Efficiency Scores Consistency Liquid Solid Does not repeat swallowing the same food (3) (3) One repetition (2) (2) Multiple swallows (1) (1) SUM (MS = 06) Result Deglutition (scores sum) (MS = 34) Masticatory Type (according to distribution of chew strokes) Scores Bilateral Alternate (Chew strokes occurring 50% of the times on each side of the oral cavity, or 40% on one side and 60% on the other) (10) Simultaneous chews on both sides (only for user of stable removable denture) (10) Unilateral Preference-grade 1 – (61% to 77% of the times on the same side) (7) Preference-grade 2 – (78% to 94% the times on the same side) (5) Chronic (95% or more of the time on the same side) (3) Anterior Masticatory strokes occurring in the region of the incisors and canines (2) Function not performed Individual did not chew (1) Result (MS = 10) Masticatory Type: with prosthesis displacement Scores Bilateral Simultaneous (8) Alternate (50%/50% or 40%/60%) (7) Unilateral Preference-grade 1 – (61% to 77%) (5) Preference-grade 2 – (78% to 94%) (3) Chronic (95% to 100%) (2) Anterior (1) Function not performed Individual did not chew (1) Result (MS = 08) Mastication: other behaviors and signs of alteration Scores Present (1) Absent (2) Movement of the head and of other parts of the body Altered posture Contraction of facial muscles that do not contribute to chew Food escape SUM (MS = 08) Mastication Result (scores sum) (MS = 18) Time spent to ingest the food = Speech Phonetic inventory Place of articulation Sound Jaw opening-closing movement Intelligibility Normal Adequade (4) Precise (4) Precise (4) Normal range (4) Clarity (4) Alterations Changed Changed (frequency) Distortion(frequency) Reduced displacement Reduced Light (3) (3) (3) (3) (3) Moderate (2) (2) (2) (2) (2) Severe (1) (1) (1) (1) (1) SUM (MS = 20) OMES-Elders total score - SUM (MS = 246): .

Predetermined scores of the OMES-Elders protocol were attributed to the following items, with the highest scores indicating normal patterns without deviation:

Appearance/posture of face, cheeks, maxillo-mandibular relationship (vertical and horizontal), mentalis muscle, lips, tongue, and hard palate width. The scores were attributed using a four-point scale.

Mobility: Participants were asked to perform movements with their lips, tongue, mandible, and cheeks following the examiner’s model. A six-point scale was used to assess mobility; 1 indicated a task that was not performed and 6 normal mobility.

Breathing Mode: The examiner determined whether the participants inspired and expired through the nostrils or the mouth, or through both pathways during situations of rest and mastication. A four-point scale from 1 (severe alteration) to 4 (normal) was used.

Deglutition was evaluated with the liquids as follows:

Task 1: Firstly, participants were asked to bring a cup containing 200 mL of room temperature water to their mouth and, after placing water in the mouth, to lower the cup so that their entire face could be seen. Then, participants were asked to swallow in the usual manner. This task aimed to determine lip behavior and identify other signs of alterations.

Task 2: Participants were asked to repeat the procedures described in Task 1, but this time the examiner placed the index finger under individual’s chin and the thumb under individual’s lower lip (in the mentalis muscle region) and immediately after deglutition, the examiner separated the individual’s lips. This task aimed to observe tongue position.

In addition, the presence of other signs of swallowing disorders such as movement of the head or other parts of the body, sliding jaw, facial muscle tension, food escaping from the lips, coughing, and noise during swallowing were also recorded. A presence/absence scale (1/2) was used for each sign.

Deglutition efficiency, defined as the ability to impel the bolus from the oral cavity into oropharynx, was assessed separately for solid and liquid boluses. A scale of 1-3 was used; 1 indicated four or more swallowing events, 2 indicated two to three deglutition repetitions, and 3 indicated no more than one deglutition repetition of the same bolus.

Deglutition of solid food was evaluated during chewing, but the task 2 was not performed.

Mastication: Participants were instructed to chew a Bono® chocolate-filled cookie (Nestle, São Paulo, Brazil) in the usual manner. The masticatory type was evaluated by the percentage of chewing strokes occurring on each side of the oral cavity. Participants with natural teeth or with removable dentures that remain stable during chewing were evaluated using a 10-point scale with 1 indicating a failure to chew and 10 indicating bilateral and alternate chewing.

When the displacement of the prosthesis during chewing was observed, the scores assigned would range from 8-1 (see Appendix A Appendix A Orofacial Myofunctional Evaluation with Scores for Elders Protocol (OMES-Elders) APPEARANCE AND POSTURE/ POSITION FACE Scores Symmetry between sides Normal (4) Dysfunction: Asymmetry Light (3) Moderate (2) Severe (1) Greater side Right | Left Nasolabial sulcus Normal (4) Dysfunction: Marked nasolabial sulcus Light (3) Moderate (2) Severe (1) SUM [Maximum Score (MS) = 08] CHEEK Scores Volume Normal (4) Dysfunction: Asymmetry between right and left sides Light (3) Moderate (2) Severe (1) Tension Normal (4) Dysfunction: Flaccid / Drooping Light (3) Moderate (2) Severe (1) SUM (MS = 08) MAXILLO-MANDIBULAR RELATIONSHIPS Scores Vertical: Mandibular posture with freeway space Normal (4) Dysfunction: Teeth in occlusion or contact edges Clenching (3) Dysfunction: Open mouth Light (3) Moderate (2) Severe (1) Anteroposterior Maxilla Normal (4) Dysfunction: Maxilla Protrusion Light (3) Moderate (2) Severe (1) Mandible Normal (4) Dysfunction: Mandible Protrusion Light (3) Moderate (2) Severe (1) SUM (MS = 12) MENTALIS MUSCLE Scores Contraction not apparent (with lips closure) Normal (4) Dysfunction: contraction apparent Light (3) Moderate (2) Severe (1) Volume: Adequate Normal (4) Dysfunction: Increased Light (3) Moderate (2) Severe (1) SUM (MS = 08) LIPS Scores Sealing with no apparent muscles contraction Normal (4) Dysfunction: Sealing With effort or no labial closure Light (3) Moderate (2) Severe (1) Volume Harmonious Normal (4) Dysfunction: Reduced volume and stretched Light (3) Moderate (2) Severe (1) Labial commissures At the level of the rima of the mouth and symmetric Normal (4) Dysfunction: Below of the rima of the mouth and/or asymmetrics Light (3) 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 teethAt limit of the incisal surfaces, with reduced occlusion vertical dimension (OVD) Light (3) 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) Dysfunction: Increased Light (3) Moderate (2) Severe (1) SUM (MS = 08) PALATE Scores Width Normal (4) Dysfunction: Decreased width Light (3) Moderate (2) Severe (1) SUM (MS = 04) MOBILITY PERFORMANCE TONGUE Horizontal Lateral Vertical Protrusion Retrusion To right To left Raising Lowering Normal (precise) (6) (6) (6) (6) (6) (6) Insufficient ability (IA) (5) (5) (5) (5) (5) (5) IA plus associated movements (4) (4) (4) (4) (4) (4) IA with tremors (3) (3) (3) (3) (3) (3) IA, associated movement and tremor (2) (2) (2) (2) (2) (2) Task no performed (1) (1) (1) (1) (1) (1) SUM (MS = 36) LIPS Horizontal Lateral 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) JAW Vertical Lateral Horizontal Opening Closing Right Left Protrusion Normal (6) (6) (6) (6) (6) Insufficient ability (IA) (5) (5) (5) (5) (5) IA and associated movements (4) (4) (4) (4) (4) IA with tremor (3) (3) (3) (3) (3) IA, associated movement and tremor (2) (2) (2) (2) (2) Task no performed (1) (1) (1) (1) (1) SUM (MS = 30) CHEEKS To Inflate To Suck To Retract To transfer the air from 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 = 24) FUNCTIONS BREATHING (mode) Scores Nasal breathing Normal (4) Dysfunction: Mouth breathing Light (3) Moderate (2) Severe (1) Result (MS = 04) SWALLOW: Lips behavior Scores Consistence Liquid Solid Lips closure Without effort (6) (6) Dysfunction: Lips closure with effort Light (4) (4) Moderate (3) (3) Severe (2) (2) Dysfunction: Absence of lips closure Does not perform the function (1) (1) Result (MS = 12) SWALLOW: Tongue behavior Scores Contained in the oral cavity Normal (4) Between alveolar margins (without prosthesis) and/or follow jaw position To compensate reduced occlusion vertical dimension (OVD) (3) Between dental arches (with prosthesis) and/or follow jaw position To compensate reduced OVD (3) No OVD reduction (2) Exceeds the incisal surfaces and/or vestibular cusps (1) Interposition place Right Left both Anterior Posterior Total Result (MS = 04) SWALLOW: Other behaviors and signs of alteration Scores Present (1) Absent (2) Movement of the head and other parts of the body Sliding jaw Tension of facial muscles Food escape Gagging Noise SUM (MS = 12) SWALLOW: Efficiency Scores Consistency Liquid Solid Does not repeat swallowing the same food (3) (3) One repetition (2) (2) Multiple swallows (1) (1) SUM (MS = 06) Result Deglutition (scores sum) (MS = 34) Masticatory Type (according to distribution of chew strokes) Scores Bilateral Alternate (Chew strokes occurring 50% of the times on each side of the oral cavity, or 40% on one side and 60% on the other) (10) Simultaneous chews on both sides (only for user of stable removable denture) (10) Unilateral Preference-grade 1 – (61% to 77% of the times on the same side) (7) Preference-grade 2 – (78% to 94% the times on the same side) (5) Chronic (95% or more of the time on the same side) (3) Anterior Masticatory strokes occurring in the region of the incisors and canines (2) Function not performed Individual did not chew (1) Result (MS = 10) Masticatory Type: with prosthesis displacement Scores Bilateral Simultaneous (8) Alternate (50%/50% or 40%/60%) (7) Unilateral Preference-grade 1 – (61% to 77%) (5) Preference-grade 2 – (78% to 94%) (3) Chronic (95% to 100%) (2) Anterior (1) Function not performed Individual did not chew (1) Result (MS = 08) Mastication: other behaviors and signs of alteration Scores Present (1) Absent (2) Movement of the head and of other parts of the body Altered posture Contraction of facial muscles that do not contribute to chew Food escape SUM (MS = 08) Mastication Result (scores sum) (MS = 18) Time spent to ingest the food = Speech Phonetic inventory Place of articulation Sound Jaw opening-closing movement Intelligibility Normal Adequade (4) Precise (4) Precise (4) Normal range (4) Clarity (4) Alterations Changed Changed (frequency) Distortion(frequency) Reduced displacement Reduced Light (3) (3) (3) (3) (3) Moderate (2) (2) (2) (2) (2) Severe (1) (1) (1) (1) (1) SUM (MS = 20) OMES-Elders total score - SUM (MS = 246): ). The presence of other behaviors and signs of alteration in the masticatory pattern was also analyzed. A presence/absence scale (1/2) was used for each sign.

Speech was evaluated using a recorded sound and images sample of each participant. Participants were asked to count from 1-10 and to repeat the syllables /pa/, /ta/, /ka/ three times. We observed the speech production and intelligibility. A scale of 1-4 was used, with 1 indicating severe alteration, 2 moderate, 3 mild and 4 a normal pattern.

Reference test

The Nordic Orofacial Test-Screening (NOT-S) used as reference in the study contains 12 domains of which six are interview-based, and six are based on clinical orofacial examination. During the examination, the score 0 (zero) represented normal condition and the score 1 (one) was assigned when impairments⁄ impediments were observed in the domain evaluated. A final score of 12 represented alteration in all items (15).

Examiners

Two examiners, speech-language pathologists, previously trained and non-familiar with the individuals, participated in the study. Examiner 1 performed all evaluations using the OMES-Elders and NOT-S protocols, whereas Examiner 2, who has confirmed reliability values for orofacial assessment in a previous study(1616 Felício CM, Medeiros AP, de Oliveira Melchior M. Validity of the ‘protocol of oro-facial myofunctional evaluation with scores’ for young and adult subjects. J Oral Rehabil. 2012;39(10):744-53. PMid:22852833. http://dx.doi.org/10.1111/j.1365-2842.2012.02336.x.
http://dx.doi.org/10.1111/j.1365-2842.20...
) and was blind to the outcome of the other examiner’s, performed the evaluations in a percentage of the sample for reliability analysis. Forty percent of the sample were randomly selected (20% for each protocol) and reevaluated by examiner 1, using video-recorded images(1616 Felício CM, Medeiros AP, de Oliveira Melchior M. Validity of the ‘protocol of oro-facial myofunctional evaluation with scores’ for young and adult subjects. J Oral Rehabil. 2012;39(10):744-53. PMid:22852833. http://dx.doi.org/10.1111/j.1365-2842.2012.02336.x.
http://dx.doi.org/10.1111/j.1365-2842.20...
,1818 Folha GA, Valera FC, de Felício CM. Validity and reliability of a protocol of orofacial myofunctional evaluation for patients with obstructive sleep apnea. Eur J Oral Sci. 2015;123(3):165-72. PMid:25780946. http://dx.doi.org/10.1111/eos.12180.
http://dx.doi.org/10.1111/eos.12180...
), and by examiner 2 using the OMES-Elders protocol. An interval of at least 15 days between evaluations performed by the same examiner was observed to avoid memory effects. These data were used to determine intra- and inter-examiner reliability and agreement.

Data analysis

Reliability and agreement

Examiner reliability was calculated using the split-half method to determine the consistency and stability of the intra- and inter-results. Weighted kappa coefficients were calculated to estimate intra and inter-examiner agreement.

Analysis of validity criteria of the OMES-elders protocol

To determine whether the OMES-Elders protocol measured the parameters for which it was proposed, concurrent validity was calculated against the examination part of the NOT-S protocol(1515 Bakke M, Bergendal B, McAllister A, Sjögreen L, Asten P. Development and evaluation of a comprehensive screening for orofacial dysfunction. Swed Dent J. 2007;31(2):75-84. PMid:17695052.), using the Spearman’s correlation coefficient.

Analysis of sensitivity and specificity

Firstly, it should be noted that the NOT-S score equal to 12 indicates an alteration in all items and zero indicates no change in any item, whereas the OMES-Elders score of 246 indicates total absence of OMD and the score of 55 indicates the highest degree of OMD. So, it is necessary to select a cut-off point score for the OMES-Elders to indicate positive diagnosis of OMD, as well as the accuracy of the method. Therefore, the receiver operating characteristic (ROC) curve was used to determine the cut-off point and the ability of the OMES-Elders to predict OMD (sensitivity) and asymptomatic controls (specificity). The ROC was constructed with the grouping of the NOT-S score of 0 to 3 compared with the NOT-S score of 4 to 12. On original study(1515 Bakke M, Bergendal B, McAllister A, Sjögreen L, Asten P. Development and evaluation of a comprehensive screening for orofacial dysfunction. Swed Dent J. 2007;31(2):75-84. PMid:17695052.), 37% of the healthy controls groups had false positive diagnostic when NOT-S scores different from zero were assumed to indicate OMD: 30% of the healthy controls had one point, and 7% had two points. Thus, scores up to 3 were adopted as an absence of relevant OMD.

Analysis of association of OMES-elders scores with the OHX and age

Participants were divided into three groups according to the OHX: I (33 to 61%), II (62 to 89.99%) and III (90 to 100%). Their data were analyzed by One-way ANOVA; Tukey’s significant difference was used as post-hoc test. Items with no composite scores (appearance of palate and breathing) were included for calculation of the OMES-Elders total score, but not individually analyzed due to level of measurement.

Additionally, the effect of predictors OHX and age on categories and total OMES-elders scores of the whole sample was examined by multiple regression analysis.

Statistical analysis

The MedCalc software (Ostend, West Flanders, Belgium) was used to calculate weighted kappa coefficients to estimate intra and inter-examiner agreement, as well as the accuracy, sensitivity and specificity values of the OMES-Elders protocol by ROC curve analysis.

The Spearman’s correlation coefficient, examiner reliability, one-way ANOVA and multiple regression analysis (General Linear Models) were performed using the Statistica 13 software (Dell Software Inc., Aliso Viejo, United States of America). For all analysis, the significance level was set at 0.05.

RESULTS

Demographic characteristics and the OMES-Elders scores (mean ± standard error) for the orofacial items evaluated according to OHX classification are listed in Table 1. According to clinical examination, forty-six participants used mucosa-supported prostheses and 17 used implanted or tooth-supported prostheses; four had a minimum of ten pairs of articulating teeth, natural or prosthetic, and 15 had more than ten pairs of articulating teeth, but only four of them had complete dentition.

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

Reliability and agreement

The reliability coefficients for the evaluations performed using the OMES-Elders protocol were 0.91 (between examiners) and 0.99 (intra-examiner, test and retest). The intra-examiner 1 reliability coefficient was 0.89 for the evaluations performed using the NOT-S. The weighted kappa values showed good (0.61-0.80) and very good (0.81-1.00) agreement in the test–retest with the OMES-expanded protocol and between examiners.

Criterion validity of the OMES-elders protocol

There was a significant correlation between the OMES-Elders and NOT-S protocols (r = -0.81, p < 0.001). The correlation was negative because the two scales are inverse.

Sensitivity and specificity of OMES-elders protocol

The ROC analysis showed that the OMES-Elders total score was significantly different than chance for the detection of the presence of OMD [AUC = 0.826, P < 0.001, CI: 0.73-0.90], with the score of 202 as the cut-off point. The sensitivity and specificity values were, respectively, 82.89% (CI: 72.5-90.6%) and 83.33% (CI: 35.9-99.6%).

Association of OMES-elders scores with the OHX and age

The groups divided according to the OHX had no significant difference in mean age (P > 0.05). The group I had mean scores significantly lower than the group III in the category appearance/posture and total OMES-Elders (P < 0.01), and significantly lower scores than the other two groups in stomatognathic system functions. There was no statistical difference between the groups II and III.

There was no significant difference between groups in the category mobility. In general, all groups had reduced mobility of stomatognathic system components, with the lowest score for tongue, whose scores ranged from 53% (group I) to 61% (group III) in relation to the maximum score of the protocol (Table 1).

The multiple regression analysis showed that the participants’ oral health and age were significantly associated with the categories appearance/posture, functions, and total OMES-Elders. There was no significant association between predictors and mobility category. Table 2 shows the degree to which the predictors are related to the OMEs-Elders scores.

Table 2
Effects of the oral health index (OHX) and age on the categories and OMES-Elders scores

DISCUSSION

This study showed that the OMES-Elders protocol is valid and reliable for OMD assessment. The analysis revealed a clear influence of both oral health and age on orofacial functional status.

We adopted the NOT-S as a reference test in this study because this is the only instrument validated to screen a set of orofacial characteristics and abilities, over a wide range of age(1515 Bakke M, Bergendal B, McAllister A, Sjögreen L, Asten P. Development and evaluation of a comprehensive screening for orofacial dysfunction. Swed Dent J. 2007;31(2):75-84. PMid:17695052.). The items evaluated clinically in the NOT-S and OMES-Elders protocols are different, thus preventing a redundancy that would tend to inflate validity estimates(1616 Felício CM, Medeiros AP, de Oliveira Melchior M. Validity of the ‘protocol of oro-facial myofunctional evaluation with scores’ for young and adult subjects. J Oral Rehabil. 2012;39(10):744-53. PMid:22852833. http://dx.doi.org/10.1111/j.1365-2842.2012.02336.x.
http://dx.doi.org/10.1111/j.1365-2842.20...
). For example, NOT-S does not include a clinical examination of deglutition and mastication, which are determined based on patient self-report during the interview.

A detailed analysis of movement precision and orofacial functions by an examiner, as proposed in the OMES-Elders protocol, provides more accurate and relevant information about functional adaptations (or maladaptations) associated with oral status and physiological changes.

Unlike the NOT-S(1515 Bakke M, Bergendal B, McAllister A, Sjögreen L, Asten P. Development and evaluation of a comprehensive screening for orofacial dysfunction. Swed Dent J. 2007;31(2):75-84. PMid:17695052.) that involves dichotomous judgments based on an absence/presence scale (zero/one), the OMES-Elders protocol enables the ranking of orofacial myofunctional status because it uses an ordinal level of measurement with at least four response options. This is advantageous in clinical practice providing additional diagnostic and therapy-relevant information, as well as it may be useful for intervention follow-up. Moreover, the categories (appearance/posture, mobility or functions) can be analyzed by combining their items(1616 Felício CM, Medeiros AP, de Oliveira Melchior M. Validity of the ‘protocol of oro-facial myofunctional evaluation with scores’ for young and adult subjects. J Oral Rehabil. 2012;39(10):744-53. PMid:22852833. http://dx.doi.org/10.1111/j.1365-2842.2012.02336.x.
http://dx.doi.org/10.1111/j.1365-2842.20...
). When multiple items are combined for analysis, the composite scores may be treated as continuous variables(2424 Zumbo BD, Zimmerman DW. Is the selection of statistical methods governed by level of measurement? Can Psychol. 1993;34(4):390-400. http://dx.doi.org/10.1037/h0078865.
http://dx.doi.org/10.1037/h0078865...
) which enable the use of more powerful statistical techniques(2323 Stevens SS. Psychophysics: introduction to its perceptual, neural, and social prospects. New York: Wiley-Interscience; 1975. 329 p.,2424 Zumbo BD, Zimmerman DW. Is the selection of statistical methods governed by level of measurement? Can Psychol. 1993;34(4):390-400. http://dx.doi.org/10.1037/h0078865.
http://dx.doi.org/10.1037/h0078865...
).

A validation study also requires reliability estimates(1818 Folha GA, Valera FC, de Felício CM. Validity and reliability of a protocol of orofacial myofunctional evaluation for patients with obstructive sleep apnea. Eur J Oral Sci. 2015;123(3):165-72. PMid:25780946. http://dx.doi.org/10.1111/eos.12180.
http://dx.doi.org/10.1111/eos.12180...
). In our study, the OMES-Elders proved to be a reliable instrument for OMD diagnosis, according to the test-retest and inter-examiner evaluations. Moreover, the protocol showed good ability to correctly recognize individuals with and without OMD.

The orofacial myofunctional status was associated with both OHX and age. The multiple regression analysis showed that age had the strongest effect on the appearance/posture (31%), while oral health had the strongest effect on the functions category (40%). Overall, the higher the OHX and the lower the age, the better are the OMES-elders scores.

The analysis of the groups with different OHX and similar mean age shows that the group I (lowest OHX), had significantly lower scores than group III for appearance/posture (highest OHX), and lower scores than groups II and III for category functions.

The impairments were more pronounced in the jaw and lip appearance/posture, and mastication function. These items are greatly influenced by the dental (e.g. number of remaining teeth, vertical dimension of occlusion, pairs of functional occlusal contacts, edentulism, presence of removable or fixed prostheses) and periodontal status (pocket depth, inflammation and subgingival calculus)(11 Kikutani T, Tamura F, Nishiwaki K, Kodama M, Suda M, Fukui T, et al. Oral motor function and masticatory performance in the community-dwelling elderly. Odontology. 2009;97(1):38-42. PMid:19184296. http://dx.doi.org/10.1007/s10266-008-0094-z.
http://dx.doi.org/10.1007/s10266-008-009...
,55 Logemann JA, Curro FA, Pauloski B, Gensler G. Aging effects on oropharyngeal swallow and the role of dental care in oropharyngeal dysphagia. Oral Dis. 2013;19(8):733-7. PMid:23574512. http://dx.doi.org/10.1111/odi.12104.
http://dx.doi.org/10.1111/odi.12104...
,66 Ohara Y, Yoshida N, Kono Y, Hirano H, Yoshida H, Mataki S, et al. Effectiveness of an oral health educational program on community-dwelling older people with xerostomia. Geriatr Gerontol Int. 2015;15(4):481-9. PMid:24796714. http://dx.doi.org/10.1111/ggi.12301.
http://dx.doi.org/10.1111/ggi.12301...
,1111 Quandt SA, Chen H, Bell RA, Savoca MR, Anderson AM, Leng X, et al. Food avoidance and food modification practices of older rural adults: association with oral health status and implications for service provision. Gerontologist. 2010;50(1):100-11. PMid:19574543. http://dx.doi.org/10.1093/geront/gnp096.
http://dx.doi.org/10.1093/geront/gnp096...
,2525 Rugh JD, Drago CJ. Vertical dimension: a study of clinical rest position and jaw muscle activity. J Prosthet Dent. 1981;45(6):670-5. PMid:6941018. http://dx.doi.org/10.1016/0022-3913(81)90426-1.
http://dx.doi.org/10.1016/0022-3913(81)9...
).

In contrast, mobility was neither different between groups nor significantly associated with both age and OHX in the 82 participants. In fact, all groups had reduced score in this category. Particularly, the tongue was more negatively affected than other components and its weakness associated with aging has been linked to sarcopenia(44 Clark HM, Solomon NP. Age and sex differences in orofacial strength. Dysphagia. 2012;27(1):2-9. PMid:21350818. http://dx.doi.org/10.1007/s00455-011-9328-2.
http://dx.doi.org/10.1007/s00455-011-932...
,88 Park T, Kim Y. Effects of tongue pressing effortful swallow in older healthy individuals. Arch Gerontol Geriatr. 2016;66:127-33. PMid:27318884. http://dx.doi.org/10.1016/j.archger.2016.05.009.
http://dx.doi.org/10.1016/j.archger.2016...
). Moreover, mobility tasks encompass combined sensory ability, muscle strength, and precision of movement, which are in general reduced in older adults and can impair orofacial functions, negatively affecting the nutritional status and systemic health(11 Kikutani T, Tamura F, Nishiwaki K, Kodama M, Suda M, Fukui T, et al. Oral motor function and masticatory performance in the community-dwelling elderly. Odontology. 2009;97(1):38-42. PMid:19184296. http://dx.doi.org/10.1007/s10266-008-0094-z.
http://dx.doi.org/10.1007/s10266-008-009...
,33 Santoro P, Silva IL, Cardoso F, Dias E Jr, Beresford H. Evaluation of the effectiveness of a phonoaudiology program for the rehabilitation of dysphagia in the elderly. Arch Gerontol Geriatr. 2011;53(1):e61-6. PMid:21093069. http://dx.doi.org/10.1016/j.archger.2010.10.026.
http://dx.doi.org/10.1016/j.archger.2010...

4 Clark HM, Solomon NP. Age and sex differences in orofacial strength. Dysphagia. 2012;27(1):2-9. PMid:21350818. http://dx.doi.org/10.1007/s00455-011-9328-2.
http://dx.doi.org/10.1007/s00455-011-932...

5 Logemann JA, Curro FA, Pauloski B, Gensler G. Aging effects on oropharyngeal swallow and the role of dental care in oropharyngeal dysphagia. Oral Dis. 2013;19(8):733-7. PMid:23574512. http://dx.doi.org/10.1111/odi.12104.
http://dx.doi.org/10.1111/odi.12104...

6 Ohara Y, Yoshida N, Kono Y, Hirano H, Yoshida H, Mataki S, et al. Effectiveness of an oral health educational program on community-dwelling older people with xerostomia. Geriatr Gerontol Int. 2015;15(4):481-9. PMid:24796714. http://dx.doi.org/10.1111/ggi.12301.
http://dx.doi.org/10.1111/ggi.12301...

7 Di Pede C, Mantovani ME, Del Felice A, Masiero S. Dysphagia in the elderly: focus on rehabilitation strategies. Aging Clin Exp Res. 2016;28(4):607-17. PMid:26589905. http://dx.doi.org/10.1007/s40520-015-0481-6.
http://dx.doi.org/10.1007/s40520-015-048...
-88 Park T, Kim Y. Effects of tongue pressing effortful swallow in older healthy individuals. Arch Gerontol Geriatr. 2016;66:127-33. PMid:27318884. http://dx.doi.org/10.1016/j.archger.2016.05.009.
http://dx.doi.org/10.1016/j.archger.2016...
).

The OMES-Elders protocol is specific for the identification and grading of OMD, without determining the underlying etiology. Therefore, it may be used for health promotion planning and for measuring the outcome of strategies aimed at reducing oral functional disorders. Further studies could investigate the effect of physical and mental problems on OMES-Elders scores.

CONCLUSION

In conclusion, the OMES-Elders protocol is valid for the assessing orofacial myofunctional status in older people without physical or cognitive impairment. It enables determination of disorder degree and has adequate psychometric properties. The scores were associated with both the oral health index (OHX) and age. The higher the OHX and the lower the age, the better the OMES-elders scores on the categories appearance/posture, functions, and total OMES-Elders.

Appendix A Orofacial Myofunctional Evaluation with Scores for Elders Protocol (OMES-Elders)

APPEARANCE AND POSTURE/ POSITION

FACE Scores
Symmetry between sides Normal (4)
Dysfunction: Asymmetry Light (3)
Moderate (2)
Severe (1)
Greater side Right | Left
Nasolabial sulcus Normal (4)
Dysfunction: Marked nasolabial sulcus Light (3)
Moderate (2)
Severe (1)
SUM [Maximum Score (MS) = 08]
CHEEK Scores
Volume Normal (4)
Dysfunction: Asymmetry between right and left sides Light (3)
Moderate (2)
Severe (1)
Tension Normal (4)
Dysfunction: Flaccid / Drooping Light (3)
Moderate (2)
Severe (1)
SUM (MS = 08)
MAXILLO-MANDIBULAR RELATIONSHIPS Scores
Vertical: Mandibular posture with freeway space Normal (4)
Dysfunction: Teeth in occlusion or contact edges Clenching (3)
Dysfunction: Open mouth Light (3)
Moderate (2)
Severe (1)
Anteroposterior
Maxilla Normal (4)
Dysfunction: Maxilla Protrusion Light (3)
Moderate (2)
Severe (1)
Mandible Normal (4)
Dysfunction: Mandible Protrusion Light (3)
Moderate (2)
Severe (1)
SUM (MS = 12)
MENTALIS MUSCLE Scores
Contraction not apparent (with lips closure) Normal (4)
Dysfunction: contraction apparent Light (3)
Moderate (2)
Severe (1)
Volume: Adequate Normal (4)
Dysfunction: Increased Light (3)
Moderate (2)
Severe (1)
SUM (MS = 08)
LIPS Scores
Sealing with no apparent muscles contraction Normal (4)
Dysfunction: Sealing With effort or no labial closure Light (3)
Moderate (2)
Severe (1)
Volume Harmonious Normal (4)
Dysfunction: Reduced volume and stretched Light (3)
Moderate (2)
Severe (1)
Labial commissures
At the level of the rima of the mouth and symmetric Normal (4)
Dysfunction: Below of the rima of the mouth and/or asymmetrics Light (3)
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
At limit of the incisal surfaces, with reduced occlusion vertical dimension (OVD)
Light (3)
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)
Dysfunction: Increased Light (3)
Moderate (2)
Severe (1)
SUM (MS = 08)
PALATE Scores
Width Normal (4)
Dysfunction: Decreased width Light (3)
Moderate (2)
Severe (1)
SUM (MS = 04)

MOBILITY PERFORMANCE

TONGUE Horizontal Lateral Vertical
Protrusion Retrusion To right To left Raising Lowering
Normal (precise) (6) (6) (6) (6) (6) (6)
Insufficient ability (IA) (5) (5) (5) (5) (5) (5)
IA plus associated movements (4) (4) (4) (4) (4) (4)
IA with tremors (3) (3) (3) (3) (3) (3)
IA, associated movement and tremor (2) (2) (2) (2) (2) (2)
Task no performed (1) (1) (1) (1) (1) (1)
SUM (MS = 36)
LIPS Horizontal Lateral
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)
JAW Vertical Lateral Horizontal
Opening Closing Right Left Protrusion
Normal (6) (6) (6) (6) (6)
Insufficient ability (IA) (5) (5) (5) (5) (5)
IA and associated movements (4) (4) (4) (4) (4)
IA with tremor (3) (3) (3) (3) (3)
IA, associated movement and tremor (2) (2) (2) (2) (2)
Task no performed (1) (1) (1) (1) (1)
SUM (MS = 30)
CHEEKS To Inflate To Suck To Retract To transfer the air from 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 = 24)

FUNCTIONS

BREATHING (mode) Scores
Nasal breathing Normal (4)
Dysfunction: Mouth breathing Light (3)
Moderate (2)
Severe (1)
Result (MS = 04)
SWALLOW: Lips behavior Scores
Consistence Liquid Solid
Lips closure Without effort (6) (6)
Dysfunction: Lips closure with effort Light (4) (4)
Moderate (3) (3)
Severe (2) (2)
Dysfunction: Absence of lips closure Does not perform the function (1) (1)
Result (MS = 12)
SWALLOW: Tongue behavior Scores
Contained in the oral cavity Normal (4)
Between alveolar margins (without prosthesis) and/or follow jaw position To compensate reduced occlusion vertical dimension (OVD) (3)
Between dental arches (with prosthesis) and/or follow jaw position To compensate reduced OVD (3)
No OVD reduction (2)
Exceeds the incisal surfaces and/or vestibular cusps (1)
Interposition place Right Left both
Anterior Posterior Total
Result (MS = 04)
SWALLOW: Other behaviors and signs of alteration Scores
Present (1) Absent (2)
Movement of the head and other parts of the body
Sliding jaw
Tension of facial muscles
Food escape
Gagging
Noise
SUM (MS = 12)
SWALLOW: Efficiency Scores
Consistency Liquid Solid
Does not repeat swallowing the same food (3) (3)
One repetition (2) (2)
Multiple swallows (1) (1)
SUM (MS = 06)
Result Deglutition (scores sum) (MS = 34)
Masticatory Type (according to distribution of chew strokes) Scores
Bilateral Alternate (Chew strokes occurring 50% of the times on each side of the oral cavity, or 40% on one side and 60% on the other) (10)
Simultaneous chews on both sides (only for user of stable removable denture) (10)
Unilateral Preference-grade 1 – (61% to 77% of the times on the same side) (7)
Preference-grade 2 – (78% to 94% the times on the same side) (5)
Chronic (95% or more of the time on the same side) (3)
Anterior Masticatory strokes occurring in the region of the incisors and canines (2)
Function not performed Individual did not chew (1)
Result (MS = 10)
Masticatory Type: with prosthesis displacement Scores
Bilateral Simultaneous (8)
Alternate (50%/50% or 40%/60%) (7)
Unilateral Preference-grade 1 – (61% to 77%) (5)
Preference-grade 2 – (78% to 94%) (3)
Chronic (95% to 100%) (2)
Anterior (1)
Function not performed Individual did not chew (1)
Result (MS = 08)
Mastication: other behaviors and signs of alteration Scores
Present (1) Absent (2)
Movement of the head and of other parts of the body
Altered posture
Contraction of facial muscles that do not contribute to chew
Food escape
SUM (MS = 08)
Mastication Result (scores sum) (MS = 18)
Time spent to ingest the food =
Speech Phonetic inventory Place of articulation Sound Jaw opening-closing movement Intelligibility
Normal Adequade (4) Precise (4) Precise (4) Normal range (4) Clarity (4)
Alterations Changed Changed (frequency) Distortion
(frequency)
Reduced displacement Reduced
Light (3) (3) (3) (3) (3)
Moderate (2) (2) (2) (2) (2)
Severe (1) (1) (1) (1) (1)
SUM (MS = 20)
OMES-Elders total score - SUM (MS = 246):
  • Study carried out at Department of Ophthalmology, Otorhinolaryngology and Head and Neck Surgery, School of Medicine of Ribeirão Preto, University of São Paulo – USP in partnership with Department of Elderly Health Care of the City of Juiz de Fora, Clinic of Prevention and Monitoring of Hypertension and Faculty of Speech Therapy of the Center for Higher Education de Juiz de Fora - Juiz de Fora (MG), Brazil.
  • Financial support: Provost’s Office for Research of University of São Paulo, Brazil, Process nº 11.1.21626.01.7.

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Publication Dates

  • Publication in this collection
    2017

History

  • Received
    23 Feb 2017
  • Accepted
    24 June 2017
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