Movimentos mandibulares na fala

Movimentos mandibulares na fala

(Parte 1 de 5)

7 Pró-Fono Revista de Atualização Científica, v. 19, n. 1, jan.-abr. 2007

Movimentos mandibulares na fala: interferência das disfunções temporomandibulares segundo índices de dor

Movimentos mandibulares na fala: interferência das disfunções temporomandibulares segundo índices de dor****

Mandibular movements in speech: interference of temporomandibular disfunction according to pain indexes

*Fonoaudióloga. Doutora em Ciências - Fisiopatologia Experimental - Faculdade de Medicina da Universidade de São Paulo. Professora do Mestrado Profissional em Fonoaudiologia da Universidade Veiga de Almeida - RJ. Endereço para correspondência: Alameda Jaú, 1767 - Cj. 51 - São Paulo - SP - CEP 11420-020 (esther.bianchini@uol.com.br).

**Cirurgião-Dentista. Especialista em Dor Orofacial e ATM. Diretor do Centro de Diagnóstico e Tratamento da ATM – São Paulo.

***Fonoaudióloga. Professora Titular do Departamento de Fisioterapia, Fonoaudiologia e Terapia Ocupacional da Faculdade de Medicina da Universidade de São Paulo.

****Pesquisa Realizada na Faculdade de Medicina da Universidade de São Paulo.

Artigo de Pesquisa Artigo Submetido a Avaliação por Pares Conflito de Interesse: não

Recebido em 18.1.2006. Revisado em 15.03.2007. Aceito para Publicação em 15.03.2007.

Esther Mandelbaum G. Bianchini* Guiovaldo Paiva** Claudia Regina Furquim de Andrade***

Abstract Background: temporomandibular disorders can cause general alterations of the mandibular movements due to modification in the condition of muscles and articulations. Electrognathography, a computerized exam used to complement the diagnosis of these disorders, allows the objective delineation and record of the mandibular movements, determining their amplitude and speed. Aim: to verify the characteristics of mandibular movements of individuals with temporomandibular dysfunction and in asymptomatic individuals during speech, through computerized electrognathography, analyzing possible interferences of this dysfunction and severity implications regarding pain indexes. Method: 135 adults were divided in four groups based on their pain indexes, using a numeric scale: zero for pain absence, one for mild pain, two for moderate pain and three for severe pain. Mandibular movements were observed during the sequential naming of balanced pictures taking in consideration the occurrence of phonemes in the Brazilian Portuguese language. Records were obtained using computerized electrognathography (BioEGN - BioPak system). Results: the analysis of the results point that differences indicated as significant for mandibular opening amplitude and mandibular closing speed occurred between index zero and all of the other pain indexes. Regarding mandibular opening speed during speech, statistically significant differences were obtained between index zero and index three. It was observed that mandibular movements in speech are discreet, with an anteroposterior component and deviations in laterality. Conclusion: the presence of temporomandibular dysfunctions causes reduction in the values of maximum mandibular opening and a reduction in both mandibular opening speed and mandibular closing speed during speech The different pain indexes: mild, moderate and severe do not seem to determine larger reduction of these values. Key Words: Temporomandibular Joint Disorders; Arthralgia; Kinesiology Applied; Speech, Language and Hearing Sciences.

Resumo Tema: as disfunções temporomandibulares podem acarretar alterações gerais nos movimentos mandibulares devido à modificação nas condições musculares e articulares. A eletrognatografia, exame computadorizado utilizado para complementar o diagnóstico dessas disfunções, permite delinear e registrar de maneira objetiva os movimentos mandibulares, determinando sua amplitude e velocidade. Objetivo: verificar as características do movimento mandibular na fala em indivíduos com disfunções temporomandibulares e em assintomáticos, por meio de eletrognatografia computadorizada, analisando possíveis interferências dessas disfunções e as implicações de severidade quanto ao índice de dor. Método: 135 participantes adultos foram divididos em quatro grupos com base nos graus de dor, utilizando-se escala numérica, sendo: zero para ausência de dor, um para dor leve, dois para dor moderada e três para dor grave. Os movimentos mandibulares foram observados na nomeação seqüencial de figuras balanceadas quanto à ocorrência dos fonemas da língua. Os registros foram obtidos com eletrognatografia computadorizada (BioEGN – sistema BioPak). Resultados: a análise dos resultados mostrou que as diferenças apontadas como significantes para amplitude de abertura e para velocidade de fechamento mandibular, ocorrem entre o grau zero e todos os outros graus de dor. Para velocidade de abertura mandibular na fala, foi obtida diferença estatisticamente significante entre grau zero e grau três. Constatou-se que os movimentos mandibulares na fala são discretos, com componente anteroposterior e desvios em lateralidade. Conclusão: a presença de disfunções temporomandibulares acarreta redução das amplitudes máximas de abertura e redução da velocidade tanto de abertura quanto de fechamento dos movimentos mandibulares durante a fala. Os diferentes graus de dor: leve, moderado e grave, parecem não determinar maior redução desses valores. Palavras-Chave: Transtornos da Articulação Temporomandibular; Artralgia; Cinesiologia Aplicada; Fonoaudiologia.

Referenciar este material como:

BIANCHINI, E. M. G.; PAIVA, G.; ANDRADE, C. R. F. Mandibular movements in speech: interference of temporomandibular disfunction according to pain indexes (original title: Movimentos mandibulares na fala: interferência das disfunções temporomandibulares segundo índices de dor). Pró-Fono Revista de Atualização Científica, Barueri (SP), v. 19, n. 1, p. 7-18, jan.-abr. 2007.

Pró-Fono Revista de Atualização Científica, v. 19, n. 1, jan.-abr. 2007

Bianchini et al.8

Introduction

The speech articulation is a sensory-motor process which involves the active regulation of strengths among the muscular system and the vocal tract (Andreatta et al.,1996; Hillis et al., 2004) relating itself with structures conformation and amplitude of movements developed in order to allow the several articulation postures proper to each sound (Marchesan, 2000). The mandible participation, more specifically the mandibular movements, enables spaces modification allowing free tongue and soft tissues movements (Smith & Zelaznik, 2004; Bianchini & Andrade, 2006).

The speech neuromotor control, which is highly dynamic, involves the participation of cortical and sub-cortical brain regions directed to the movement preparation and execution (Van Turennout et al., 2003) and it may be altered due to peripheral structural changes, as well as by training and repetitive experiences inducing plasticity (Jurgens, 2002; Van Turennout et al., 2003).

Studies with electromagnetic articulography

(EMA) showed that the speech control development is not uniform; accordingly, the synergic relation between movements of the tip and the body of the tongue with the mandible is not the same during this process (Smith & Zelaznik, 2004; Murdoch et al., 2006).

Subjective data indicate discrete highly coordinated and synchronized mandibular movements during speech, slight antero-posterior movements without deviations along its course (Felicio,1999; Rodrigues Garcia et al.,2003). Objective studies concerning mandibular movements during speech for the Brazilian Portuguese language are recent (Bianchini et al.,2003, Bianchini & Andrade, 2006). Analysis of asymptomatic individuals using electromyography revealed approximate values of 1 m for opening amplitude during speech with protrusive components: 1,2 m, retrusive components: 5,67 m, and lateral deviations around 1,5 m (Bianchini & Andrade, 2006).

It is verified that the mandibular movements amplitude is related to the integrity of the temporomandibular joint (TMJ), and to the action of skeletal muscles (Bianchini, 2001, Bianchini & Andrade, 2006). However, unfavorable conditions are frequent once the articulation needs to support and accommodate occlusion, muscular and cervical adaptations (Okeson, 1997; Goldstein, 1999). If the functional adaptations demand exceed the structural and functional tolerance of the TMJ, a temporomandibular joint dysfunction (TMJD) may be triggered (Okeson, 1997; Nassif & Talic, 2001), resulting in mandibular movements alteration and consequent stomatognathic functions disorders (Bianchini,2004). The presence of pain leads to a reduction in the amplitude of mandibular movements in speech articulation (Palácios- Moreno et al.,1997, Bianchini, 2000b, Felício & Bortolin, 2001, Bianchini et al., submitted)

The pain description, its diagnosis and associations seem to be of difficult accuracy due to its subjectivity. The pain threshold is individual, differentiated and it modifies the transmitted information a lot (Assencio-Ferreira, 2000). The facial pain intensity depends on the central nervous system modulation, on the attention, on the attitude and on the individual's character, thus resulting in a great variety according to the studied person specially concerning patients with diffuse and recurrent pain, who constitute a group of difficult diagnosis and treatment (Assencio- Ferreira 2000). The pain characteristics, specially concerning intensity, and the presence of associate psychological disorders lead to greater psychological suffering among patients with chronic headaches and myofascial pain (Vazquez- Delgado et al., 2004).

There are several scales, with different validity and reliability levels, aiming to quantify the pain intensity. At first, the most used ones seem to be those with numeric categories and those with nonnumeric representations such as adjectives, colors and expressions (Assencio-Ferreira, 2000). The numeric scales are easy to apply and to understand. Despite the existence of variation in the scales proposition, studies refer the use of scales from zero to three, zero meaning absence of pain and three, severe pain (Rodrigues, 2000; Bianchini, 2000a; Manfredi et al., 2001).

In order to obtain objective data concerning mandibular movements used in speech in an attempt to enable quantitative parameters of diagnostic, the purpose of this study was to verify the characteristics of mandibular movements during speech concerning speed, amplitude and lateral deviations in individuals with temporomandibular dysfunction and in asymptomatic ones, using computerized electromyography and analyzing possible interferences of those dysfunctions and the severity implications as to the pain index.

9 Pró-Fono Revista de Atualização Científica, v. 19, n. 1, jan.-abr. 2007

Movimentos mandibulares na fala: interferência das disfunções temporomandibulares segundo índices de dor

Method

This research was previously approved by the

Research Ethics Committee of the Institution (CAPPesq nº116/03) and the informed consent terms of all participants were signed, according to resolution 196/96 (BRASIL, Resolution MS/CNS/ CNEP nº 196/96, 10/10/96).

One hundred and thirty five male and female adults participated on this study. Subject's age ranged from 18 to 57 years old. All of them resided at the metropolitan area of Sao Paulo city. The selection criteria included no missing teeth in a proportion higher than one tooth per quadrant; no crossed occlusion; no dentofacial deformities; no removable dental prosthesis; no prior speechlanguage therapy including vocal refining; and no communication, neurological or cognitive deficits. Such criteria were necessary, since those particular situations may interfere on mandibular movements involved in speech production.

Initially, participants were distributed in two groups: GI and GII. The research group (GI) comprised 90 consecutive patients spontaneously referred to Center of Diagnosis and Treatment of Temporomandibular Disorder for a computerized diagnosis, once they presented signs and symptoms of TMJD. All of them agreed to perform the speech task and fulfilled the selection criteria. The diagnosis of TMJD was established according to criterion described at literature (Luz et al., 1997; Golstein, 1999; Luz, 2000), such as: presence of painful symptoms in masticatory muscles; pain in the pre-auricular region and in the TMJ; articulation noises; limitations of functional or directed mandibular movements; articulation blocking episodes. The inclusion criterion for this group was to present at least 3 of the described TMJD signals including pain as a determinant for the dysfunction.

The control group (GII) consisted of 45 participants who fulfilled the selection criteria, in a proportional relation to the research group concerning age and gender. The inclusion criterion for this group included absence of TMJD, that is no pain or any other previously described indicative symptoms or signals of TMJD. Participants without signs and symptoms of TMJD who met the selection criteria and who agreed to participate of this research performed the same tasks as GI, in the same period of 12 months.

The data mentioned above were obtained by a questionnaire application and by a physical examination and were registered in a Speech-

Pathology protocol concerning signal and symptoms of TMJD (Annex A).

In order to raise data on the pain index, a physical examination was accomplished to verify the presence of pain during extra-oral palpation of masticatory muscles: temporal, masseter and suprahyoid muscles. The patient was asked to verbally score the pain degree at the palpation moment. This numeric analogical scale was established as a pain gradation criterion which was previously explained to the participant with the following equivalence: 0 (zero) for absence of pain; 1 (um) for mild pain; 2 (two) for moderate pain; 3 (three) for severe pain (Rodrigues, 2000; Bianchini, 2000a, Manfredi et al. 2001). The participants who reported pain degree zero correspond to GII components, control group. Participants with pain degrees of 1, 2, and 3 correspond to the components of GI.

For analyzing the interference of the pain index on the characterization of mandibular movements during speech, the participants were subdivided in four groups as follows: G0, corresponding to the group of participants with a pain degree of zero, that is absence of pain; G1, corresponding to the group of participants with a pain degree of 1, that is mild pain; G2, corresponding to the group of participants with a pain degree of 2, that is moderate pain; and G3, corresponding to the group of participants with a pain degree of 3, that is severe pain.

Table 1 describes the patients' distribution according to the pain degree.

In order to register mandibular movements an electrognathography equipment was used (BioEGN - BioPak system, Bio-Research Associates, Inc., Milwaukee, WI, USA).This equipment allows to monitor and record the spatial position and the course of mandibular movements through a magnet signal capturing. Signals are captured by sensors of an antennae supported on the patient's head, without touching the mandibular region in order to avoid interferences or restrictions of the mandibular movements. This system is connected to a compatible computer with an electrognathography interpretation software installed, registering the magnet's position variation and analyzing the clinical data of mandibular movements.

For verifying the mandibular movements performed during speech, an easily- recognizable picture list, comprising all the Brazilian Portuguese language phonemes in several positions, was used

Pró-Fono Revista de Atualização Científica, v. 19, n. 1, jan.-abr. 2007

Bianchini et al.10

(Marchesan, 1998; Bianchini & Andrade, 2006), to be named sequentially with no interruptions. (Figure 1).

The test was performed with the patient sitting in a chair on a rubber isolation floor. The magnet was centralized from the inferior labial frenum and accommodated above it, at the anterior and inferior region of the lower central incisors without interfering in the occlusion. The magnet was fixed with an adhesive plate type Stomahesive of approximately 0,5 m high and 0,7 m width.

The antennae support was placed on the glabella region with the upper temple parallel to the interpupil line. The lateral temples were positioned above the ears, parallel to the ground and adjusted by the strap located in the back of the head. After the equipment adjustment and calibration, the participant was invited to initiate the specific speech test. The participant was instructed to make a slightly teeth contact, in order to eliminate some possible interference. The test was then started by capturing mandibular movements observed in three planes: sagittal, frontal and horizontal, generated by the magnet and captured by the BioEGN antennae.

The XY window of the software was selected in the computer screen. This window registers mandibular movements in graphs and in millimeters, in different planes. The sagittal plane registers show the opening and closing mandibular movements (vertical scale), associated to protrusive and retrusive movements (horizontal scale). Registers at the frontal plane show opening and closing mandibular movements (vertical scale) associated to lateral movements (horizontal scale). Registers at the horizontal plan show lateral movements (vertical scale) associated to anteroposterior movements (horizontal scale). All registers were printed in standardized paper, with measures and analysis in m (Figure 2).

Data regarding the mandibular movements performance during words utterance were quantified according to: maximum mandibular opening and closing speed; maximum amplitude in the sagittal and frontal planes (in m); maximum protrusion amplitude (in m); maximum retrusion amplitude (in m); maximum opening amplitude in the frontal plane (m); maximum amplitude of lateral deviations (in m); and type of lateral translation, if it was uni or bilateral.

The statistical analysis used two-tailed tests based on presumed normal distribution. The descriptive analysis comprises the calculation of summary-measures, as follows:

(Parte 1 de 5)

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