effects of two types of orofacial sd
Post on 03-Jun-2018
217 Views
Preview:
TRANSCRIPT
-
8/12/2019 Effects of Two Types of Orofacial Sd
1/13
111
The British Journal of Developmental Disabilities
Vol. 53, Part 2, JULY 2007, No. 105, pp. 111-123
EFFECTS OF TWO TYPES OF
APPLIANCES ON OROFACIAL DYSFUNCTIONSOF DISABLED CHILDREN
Alev Alacam and Nalan Kolcuolu
*Alev Alacam, DDS, Ph. D.
Professor, Gazi University, Faculty of Dentistry, Department of Pedodontics,Ankara,06510,TurkeyTel:+90-312-2126220/288 Fax:+90-312-223 9226 e-mail: alacam@gazi.edu.tr
Nalan Kolcuolu, DDS, Ph. D.Research Assistant, Gazi University, Faculty of Dentistry, Department of Pedodontics,Ankara,06510,Turkey
* For Correspondence
Introduction
The importance of preventive therapiesin disabled patients have been understood
in dentistry also as in every step of theirmedical therapies. Oral-health educationof the family and the child, motivationand preventive applications starting fromearly ages, will probably solve most of theoro-dental health problems of this specialgroup. Otherwise, periodontal problems,missing teeth due to caries, malocclusionsand orofacial muscle dysfunctions of the
patients will make the treatment morecomplicated.
Orofacial dysfunctions mostly seen inDown syndrome (DS) or Cerebral palsy(CP) cases create a social problem for chil-dren besides their physical problems. How-ever these dysfunctions are not accepted
This study was presented in the 18th Congress of International Association for Disabilityand Oral Health, Gteborg, Sweden, August 23-26 2006.
as a serious or primary health problem bymost physcians. The extra-oral appearancewith an open mouth called dull lookcauses negative effects on the physicologi-
cal development of children, affecting theirsocial acceptance. Habitual mouthbreath-ing, feeding disorders, lack of mastication,protrusion of the tongue, lip incompetence,drooling, swallowing and speech disor-ders are the problems most often seen inthis special group. Usually patients havemouthbreathing which causes upper re-spiratory system problems and xerostomiaresulting in periodontal destruction anddental loss. All these problems need early
stage orofacial muscle treatment.It is known that lack of lip closure is not
abnormal in children under 3 years of ageand normal tongue posture developmenttakes place at approximately 4 years of
-
8/12/2019 Effects of Two Types of Orofacial Sd
2/13
-
8/12/2019 Effects of Two Types of Orofacial Sd
3/13
113
TABLE I
Criteria for clinical examination of orofacial muscle dysfunctions (Oreland et al., 1989)
Swallowing:normal, infantile, special feeding (have swallowing
reflex), style feeding (impaired or no swallowing reflex)
Chewing:0 stroke; < 3 strokes; 3 < strokes < 5; 5 < strokes < 10;> 10 strokes; not cooperating
Mouthbreathing (habitual): yes, no, undeterminable
Lip seal:competent, incompetent, undeterminable
Tongue posture:normal, interdental, various
Drooling:yes, no, undeterminable
TABLE II
Pretreatment examination results of orofacial functions
Swallowing
normal 20 children
infantile 30 children
special feeding 27 children have swallowing reflex (semi-solid foods)
style feeding 3 children
impaired or no swallowing reflex (liquids only)
Chewing
16 children 0 strokes
32 children 3 < strokes < 5
2 children 5 < strokes < 1
41 children had chewing problems (eg. mashing on palate)
Mouth Breathing
nose breathing 29 children
mouth breathing 21 children
Lip Seal
incompetent 43 children
competent 7 children
Tongue Posture
interdental 34 children
extra-oral 8 children normal 8 children
Drooling
All the patients had drooling in various degrees
-
8/12/2019 Effects of Two Types of Orofacial Sd
4/13
114
the form of a pacifier with a rolling pearlpart (PICTURE 1). Castillo-Morales pala-tal plate was applied to 23 children whorefused to use a Dr.Hinz oral-screen (PIC-TURE 2). Castillo-Morales palatal plates
were prepared at the laboratory from indi-vidual impressions. A therapeutic buttonstimulator with an external diameter of 7-8mm and height of 4-8 mm was mounted onthe palatal surface of each plate. In somecases, dental retainers were used forsupport; otherwise, plates were preparedlike overdentures. If there was an incoor-dination of the appliance, the palatal platerenewed. Patients were motivated to use
the appliances continuously for an hourper application. A total of 3-4 hours a daywas recommended.
Parents recorded the daily usage time ofthe appliances and the improvements that
they observed in childrens orofacial dys-functions (chewing and feeding problems,drooling, lip seal, and tongue posture).
Patients were controlled clinically at 3-month intervals, for 12 months. At the endof 12 months, children stopped using theappliances and were evaluated for relapsefor an additional 3 months. Treatment of8 children had to be interrupted becauseof change of address, lack of compliance
PICTURE 1
Dr. Hinz oral-screen
PICTURE 2
Castillo-Morales palatal plate
-
8/12/2019 Effects of Two Types of Orofacial Sd
5/13
115
80%
33%
64%
9%
and loss of follow-up because of distance.Ultimately, 42 children were evaluated atthe end of the original 12-month treatmentperiod, while 36 were evaluated at the endof 3-month additional relapse period.
Statistical analysis of the treatment re-sults according to usage time and type ofappliance was evaluated with a sign test.The differences between the two appli-ances according to orofacial functional de-velopment effectiveness were determinedwith a proportion for difference-normalapproximation test.
Results
Daily usage times of the appliancesaccording to appliance type are given inTABLE III.
The results of the effects of the appli-ances on swallowing are presented in FIG-URE 1, chewing (FIGURE 2), tongue pos-ture and lip seal (FIGURE 3), and drooling(FIGURE 4).
The data revealed that Castillo-Moralespalatal plates were significantly more effi-cient (p < 0.05) at improving swallowing
TABLE III
Daily usage times of the appliances
Daily usage times Dr. Hinz Castillo-Morales
< 1 hour 7 4
1-2 hours 11 4
2-3 hours 3 8
3-4 hours 6 7
FIGURE 1
Effects of therapy on swallowing
0%
20%
40%
60%
80%
100%
25%
14%
Style feeding tospecial feeding
Special feeding tonormal
Infantile to normalswallowing
Castillo-Morales appliances
Dr. Hinz appliances
Pe
rcentofchildren
-
8/12/2019 Effects of Two Types of Orofacial Sd
6/13
116
90%
71%
FIGURE 2
Effects of therapy on chewing
0%
20%
40%
60%
80%
100%
80%
33%
Transfer tochewing
Increasing inchewing stroke
Castillo-Morales appliances
Dr. Hinz appliances
Percentofchildren
FIGURE 3
Effects of therapy on tongue posture and lip seal
0%
20%
40%
60%
80%
100%
100%
Tongue transfer
to interdentalposition
Castillo-Morales appliances
Dr. Hinz appliances
Percentofchildren
75%
69%
Tongue transfer to
intra-oral position
83%
77%
Lip seal
development
53%
33%
Lip seal
competency
-
8/12/2019 Effects of Two Types of Orofacial Sd
7/13
117
after 2-3 hours and 3-4 hours usage times.However the number of chewing strokeswas not affected by the appliance typeused (p < 0.05).
The effects on tongue posture was im-
portant for the Castillo Morales palatal plate(p0.05).
For lip seal competency, 1-2 hours and2-3 hours usage of the appliances did notresult in a statistically significant differ-ence. Usage of Dr. Hinz oral-screen for 3-4hours was effective after 3 months (p
-
8/12/2019 Effects of Two Types of Orofacial Sd
8/13
118
PICTURE 3Pre-treatment and post-treatment appearance of a 2 year old child with Down syndrome who
used a Castillo-Morales appliance
PICTURE 4
Pre-treatment and post-treatment appearance of a 4 year old child with Down syndrome who
used a Castillo-Morales appliance
-
8/12/2019 Effects of Two Types of Orofacial Sd
9/13
119
PICTURE 5
Pre-treatment and post-treatment appearance of a 5 year old child with cerebral palsy who used
a Dr. Hinz appliance
PICTURE 6
Pre-treatment and post-treatment appearance of a 3 year old child with cerebral palsy who used
a Dr. Hinz appliance
-
8/12/2019 Effects of Two Types of Orofacial Sd
10/13
120
DS (Castillo-Morales et al., 1982; Chapmanet al., 1983; Hoyer and Limbrock, 1990;Limbrock et al., 1990a; Schuster and Giese,2001; Backman et al., 2003; Carlsted et al.,2003). On the other hand, the oral screen
appliances were suggested as good alter-natives for lip exercises also. Between thefour commercially available types of Dr.Hinz oral screen appliances, the pearl-oralscreen which is in the form of a pacifierwith a rolling pearl part, was selected forthis study. The advantage of this applianceis that it is commercially available in twodimensions for primary and mixed denti-tion. The manufacturer stated that the roll-ing pearl improved the tongue position at
rest, controlled drooling and prevented theposition and strength of the lips. (Dr. HinzDental). Also, it is concluded that 3 -8 yearsof age is ideal to begin the therapy with Dr.Hinz oral screen (Hinz, 1986).
The children attending a lasting phys-iotherapy programme for orofacial stimula-tion in their institutions with an age range
between 3 -7 years were randomly selectedfor this study. All the children who par-
ticipated the study were guided to use aDr. Hinz oral-screen for a 2 week periodinitially, but 23 children out of 50 refusedit and were transferred to use the Castillo-Morales palatal plate. It became apparentthat the physiological development of handcoordination of the older children was adisadvantage for the pacifier form of Dr.Hinz oral-screen usage since older childreneasily removed the appliance and it becameharder to control the usage time. The ad-
vantage of the Castillo-Morales palatal platewas that it is an individual appliance that isharder to remove and the children showed
better compliance, contrary to the findingsof Castillo-Morales et al. (1982) who statedthat in children above the age of 4 years ofage the treatment would be unsuccessful
because of rejection of the plate.Most of the studies on orofacial regula-
tion therapies demonstrated that the bestresults have followed very early interven-tion between 6 months and 4 years of ageand stressed a dual concept of physiothera-peutic exercises for the oral region besides
a stimulator plate. It is known that activefacial muscular activity is evident in normalprenatal development and orofacial influ-ence starts with thumb-sucking at four tofive months before birth. However, thishabit seldom develops even after birth inDown syndrome cases (Carr, 1970; Fischer-Brandies et al., 1986). It is because of thisthat most of the studies on Castillo-Moralesorofacial regulation therapy were startedat a young age in children with Down syn-
drome (Limbrock et al., 1990a,1991; Carlstedet al., 2003; Backmann et al., 2003; Hunn,2000). On the other hand, Gerek and iy-iltepe (2005) successfully treated 7 chil-dren with cerebral palsy, at ages between8-17, with Castillo-Morales palatal plateswhereas Limbrock et al., (1991) stated thatthere was no effect of age on results of thetreatment in their Down syndrome studygroup of children aged 0-6. In our study
31 children had CP and the others had DSand MMR. Altough the wide age range be-tween 3-7 years did not affect the results,the importance of mental age in diagnosisand treatment planning rather than chron-ological age, must not be neglected.
The results of the study showed bothof the appliances had similar improving ef-fects on most of the parameters of orofacialdysfunctions at different time periods. TheCastillo-Morales palatal plate was found
significantly to be effective for only swal-lowing, lip seal and drooling parametersat 3-4 hours usage time at the end of a 12month period. So the importance of dailyusage times of the appliances rather thanthe appliance type became the most impor-tant criteria for success in the evaluation atthe end of the study. Gerek and iyiltepe(2005) had followed a different schedule
-
8/12/2019 Effects of Two Types of Orofacial Sd
11/13
121
starting with a 1 hour on, 10 minute off for6 hours regime when awake at first week,2 hours on, 10 min off for 8 hours in thesecond week, 4 hours on, 10 min off for 8hours at the third week and all day when
awake for 10-12 weeks. However there isthe risk that the child may become accus-tomed to the appliances for all day usagefor such a long time. On the other hand,the instructed usage time of at least onehour twice a day, by Carlsted et al. (2003)was thought to be in limits for success ac-cording to our results. Limbrock et al.(1991)preferred a schedule starting with onehour each day and quickly progressing toone hour three or four times a day whichwas similar to our study protocol. At theend of a 3 month relapse period withoutusing the appliances, 44.6% of the childrenremained stable while 41.6% who used theappliances more than 2 hours had contin-ued development in orofacial functions inthis study. These results were in correla-tion with the study of Korbmacher et al.(2004) who stated that improved orofacialappearance resulting from the early treat-
ment had remained stable after 12 yearswhereas initially slight improvements re-sulted in only slight improvements or un-changed findings in the longer term. Theregression in orofacial functions of childrenwho used the appliances less than 2 hourssupported the idea of Hoyer and Limbrock(1990) who suggested that relapse wouldhave happened if the usage of the appli-ance was neglected for a period of time inthe early stages of the treatment.
The most impressive results of thisstudy were the improvement in the feed-ing style and the development of facialexpression. Positive effects of therapy onswallowing and the increase in the numberof chewing strokes were found to directlyinfluence feeding types. 80 % of childrenin Castillo-Morales group were transferredfrom special to normal feeding and 90 %
of the same group increased their chewingstroke number. The ability to advance frommashing the food on palate to a more nor-mal feeding was very pleasing for the fami-lies of the children. On the other hand,
development of facial expression is closelyconnected with the total (motor, cogni-tive and social) development of the childand it is known that children with Downsyndrome have a slower than normal mo-tor development during the first 2 years,related to general hypotonia including theorofacial muscles (Carr, 1970; Limbrock etal., 1990a, Limbrock et al., 1991, Limbrock etal., 1993; Carlsted et al., 1996). Pre-treatmentand post-treatment photographs and videoregistrations of all of the children that par-ticipated in the study showed a significantdifference in orofacial development on a12 month follow-up period. However thelack of a control group limited our abilityto evaluate the effect of the appliances in-dependently from normal development. Insuch functional therapies, the lack of a con-trol group raises the same ethical problemsas dismissing the control group from treat-
ment. According to our results, it is thoughtthat the children who used their appliancesless than 1 hour could be controls in futurestudies.
The results of the study showed vastimprovement in the quality of the chil-drens orofacial functions, instilled happi-ness in their families and made their livesmore enjoyable in this respect. It is clearthat supporting the physiothearpy pro-grammes with a regularly applied prosth-
odentical appliance for a sufficiently longlasting treatment period (at least 3-4 hrs/day for one year) will achieve the desiredpermanent results in addition to a consci-entious and wishful family.
-
8/12/2019 Effects of Two Types of Orofacial Sd
12/13
122
Conclusions
Both appliances had positive effects onthe development of oral functions.
Appliance effectiveness was directly
related to the length of daily usage pe-riod.
There was no improvement in oral
functions in children who used theappliances less than an hour in bothgroups.
The Castillo-Morales palatal plate wasmore effective in the swallowing, lipseal and drooling parameters, with 3-4hours of daily use throughout the 12-month evaluation period.
Relapse evaluations showed that theusage time was effective on the func-tional regression whereas 44.6% of thepatients showed stability in their ac-quired functions in this study.
Summary
Habitual mouth-breathing, feedingdisorders, lack of mastication, protrusionof the tongue, lip incompetence, droolingas well as swallowing and speech disor-ders are the problems most often seen indisabled children with orofacial muscledysfunction. The aim of this study wasto improve these functional problems byusing either the Castillo-Morales palatalplate or the Dr. Hinz oral screen and eval-uate their effects on this special group.
Thirty one children with cerebral palsy,6 children with Down syndrome and 13children with mental motor retardation,at ages between 3-7, participated to thisstudy. The Dr.Hinz oral screen and Castillo-Morales palatal plate were used by thechildren for 12 months. Photographs andvideo images were taken at the beginningand at the end of the study. The changes in
oral functions were recorded on standard-ized forms by the parents and the doctor.At the end of the therapy period, relapsewas evaluated without the appliances for3 months more.
Statistical analysis of oral functions werecalculated using the 'sign test' and 'propor-tion for difference'. Both of the applianceswere observed to efficiently aid the devel-opment of oral functions. However patientswho used the appliances 3-4 hrs/day were
found to have a more favorable outcomethan patients using the appliances for 1-2hrs/day. Also the Castillo-Morales palatalplate was found to be more effective andeasily accepted in this study group. Relapse
results showed that in 44. 6 % of the chil-dren there was stability in the acquiredoral functions. 13. 8 % of the children whoused the appliances less than 2 hours in thestudy period showed a regression in theiracquired oral functions.
In this study, both of the applianceswere found to have a positive role on theimprovement of orofacial dysfunctionswhich affects the social acceptence of this
special group negatively. Conscientiousnessof the family and daily usage times werefound important factors on the success.
References
Backman, B., Grever Sjolanger, A.C. , Holm,A. K. and Johansson, I. (2003).Children
with Down Syndrome: Oral developmentand morphology after use of palatal platesbetween 6 -18 months of age. InternationalJournal of Paediatric Dentistry, 13, 327-335.
Carlsted, K., Henningsson, G. and Dahllf, G.(2003).A four-year longitudinal study ofpalatal plate therapy in children with Downsyndrome: effects on oral motor function,articulation and communication preferences.
Acta Odontologica Scandinavica, 61, 39-46.
-
8/12/2019 Effects of Two Types of Orofacial Sd
13/13
123
Carlsted, K., Dahllf, G., Nilsson, B. AndModer, T. (2006).Effect of a palatal platetherapy in children with Down syndrome.
Acta Odontologica Scandinavica, 54, 122-125.
Carr, J. (1970).Mental and motor developmentin young mongol children.Journal of MentalDefficiency and Research, 14, 205-220.
Castillo Morales R., Crotti, E., Avalle, C. andLimbrock G. (1982).Orofaziale regulationbeim Down-Syndrom durch Gaumenplatten.Sozialpdiatrie4, 10-17.
Chapman, E., Fischer-Brandies, H. andStahl A. (1983). Vorlufige ergebnisseder funktionellen frhbehandlung zurverbesserung der kiefer-gesichts-beziehungbe i kleink inde rn mi t mo rb us Down .Fortschritte der Kieferorthopdie, 44, 452.
Dr. Hinz Dental. http://www.dr-hinz-dental.de/Cataloge
Fischer-Brandies, H., Schmidt, R.G. andFischer-Brandies, E. (1986). Craniofacialdevelopment in patients with DownSyndrome from birth to 14 years of age.European Journal of Orthodontics, 8, 35-41.
Gerek, M. and iyiltepe, M. (2005).Dysphagiamanagement of paediatric patientswith cerebral palsy. The British Journal ofDevelopmental Disabilities, 51, 57-72.
Glatz-Noll E. and Berg R. (1991). Oraldysfunction in children with DownsSyndrome: an evaluation of treatment effectsby means of videoregistration. EuropeanJournal of Orthodontics, 13, 446-451.
Hennequin, M., Faulks, D., Veyrune, J. L.and Bourdiol P. (1999).Significance of oralhealth in persons with Down Syndrome: aliterature review. Developmental Medicine andChild Neurology, 41, 275-283.
Hinz, R. (1986). Erfahrungsbericht ber dieanwendung der genormten mundhofplatte
und deren variationen. Kieferortopadie, 2, 1-4.
Hinz, R. (1995). Habits and their prevention.Dsseldorf: HPPS-Gmbh
Hoyer, H. and Limbrock G.J. (1990).Orofacialregulation therapy in children withDown syndrome, using the methods andappliances of Castillo-Morales. Journal ofDentistry for Children, 57, 442-445.
Hunn, J.H. (2000). Drooling: review of theliterature and proposals for management.
Journal of Oral Rehabilitation, 27, 735-743.
Korbmacher, H., Limbrock, J. and Kahl-Nieke,B. (2004).Orofacial development in childrenwith Downs syndrome 12 years after earlyintervention with a stimulating plate.Journalof Orofacial Orthopedics, 65, 60-73.
Limbrock, G.J., Hoyer H. and Scheying H.(1990a). Regulation therapy by Castillo-Morales inchildren with Down syndrome:primary and secondary orofacial pathology.
Journal of Dentistry for Children, 57, 437-441.
Limbrock, G.J., Hoyer H. and Scheying H.(1990b).Drooling, chewing and swallowingdysfunctions in children with cerebral palsy:treatment according to Castillo-Morales.
Journal of Dentistry for Children, 57, 445-451.Limbrock, G. J., Fischer-Brandies, H. and
Avalle, C. (1991).Castillo-Morales orofacialtherapy: treatment of 67 children with DownSyndrome. Developmental Medicine and ChildNeurology, 33, 296-303.
Limbrock, G.J., Castillo-Morales, R., Hoyer,H., Stver, B. and Onufer C. N. (1993).TheCastillo-morales approach to oral-facialpathology in down syndrome. International
Journal of Orofacial Myology, 19, 30 -37.
Oreland, A. Heijbel, I., Jagell, S. and Persson,M. (1989). Oral function in the physicallyhandicapped with and without severemental retardation. Journal of Dentistry forChildren, 56, 17-25.
Schuster G. and Giese R. (2001).RetrospectiveClinical investigation of the impact ofearly treatment of children with Downssyndrome according to Castillo-Morales.
Journal of Orofacial Orthopedics, 4, 255-263.
Sipahier, M., Alaam, A. and Akal, N. (1992).The role of oral dysfunctions on the
development of dental maloclusion in thenormal and mentally retarded children. (inTurkish) Trk Ortodonti Dergisi, 5, 32-36.
top related