International Journal of Pediatric Otorhinolaryngology (2008) 72, 367—375

www.elsevier.com/locate/ijporl

Protocol of orofacial myofunctional evaluation

with scores
Cláudia Maria de Felı́cio *, Cláudia Lúcia Pimenta Ferreira

Faculty of Medicine of Ribeirão Preto, University of São Paulo, Department of

Otorhinolaryngology, Ophthalmology and Head and Neck Surgery, Av. dos Bandeirantes 3900,
Ribeirão Preto 14049-900, SP, Brazil

Received 17 August 2007; received in revised form 26 November 2007; accepted 26 November 2007
Available online 9 January 2008

KEYWORDS Summary
Orofacial
Objective: In the literature there is no validated instrument for the clinical evalua-
myofunctional
tion of the orofacial myofunctional condition of children that will permit the examiner
evaluation;
to express numerically his perception of the characteristics and behaviors observed.
Stomatognathic
The proposal of this study is to describe a protocol for the evaluation of children aged
system;
6—12 years in order to establish relations between the orofacial myofunctional
Mobility;
conditions and numerical scales. The protocol validity, reliability of the examiners
Respiration;
and agreement between them was analyzed.
Mastication and
Methods: Eighty children aged 6—12 years participated in the study. All were
deglutition;
evaluated and 30 were selected at random for the analyses (age range: 72—149
Scales evaluation;
months, mean = 103.3, S.D. = 23.57). Individuals with and without orofacial myofunc-
Orofacial
tional disorders were included. The examiners were two speech therapists properly
myofunctional
calibrated in orofacial myofunctional evaluation. Two protocols were constructed.
disorders
One, based on traditional models, was called traditional orofacial myofunctional
evaluation (TOME), and the other, with the addition of numerical scales, was called
orofacial myofunctional evaluation with scores (OMES). The clinical conditions
included were: appearance, posture and mobility of lips, tongue, cheeks and jaws,
respiration, mastication and deglutition. Statistical analysis was performed using the
split-half reliability method. Means, standard deviations and the Spearman correla-
tion coefficient were also calculated.
Results: There was a statistically significant correlation between the evaluations
of 30 children assessed with the TOME and OMES protocols (r = 0.85, p < 0.01). The
reliability between protocols was 0.92. The test—retest reliability of the
OMES instrument was 0.99 and the correlation was 0.98. Reliability between
examiners 1 and 2 using the OMES protocol was 0.99, and the correlation was
0.98 ( p < 0.01).

* Corresponding author. Tel.: +55 16 36022523; fax: +55 16 36022860.

E-mail address: cfelicio@fmrp.usp.br (C.M.d. Felı́cio).

0165-5876/$ — see front matter # 2007 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.ijporl.2007.11.012
368 C.M. Felı́cio, C.L.P. Ferreira

Conclusion: The OMES protocol proved to be a valid and reliable instrument for
orofacial myofunctional evaluation, permitting the grading of orofacial myofunc-
tional conditions within the limits of the selected items.
# 2007 Elsevier Ireland Ltd. All rights reserved.

1. Introduction ment. The validity of the protocol, the reliability of

the examiners and agreement between them were
The oral motor system is traditionally evaluated by analyzed.
speech therapists and by other health professionals
both when speech is the main complaint and in
specific cases of orofacial myofunctional disorder. 2. Material and methods
Orofacial myofunctional disorders include specific
conditions or behaviors that can have a negative 2.1. Subjects
impact on oral postures and functions [1]. Tongue
thrusting, deviate swallowing, mouth breathing, The project was approved by the Human Research
orofacial muscle imbalance, deviate mandibular Ethics Committee of the Institution and all subjects
movement are the most important orofacial dys- gave written informed consent to participate.
functions underlying disorders of articulation [2]. Eighty consecutive children on the university
Several authors have defined procedures for such waiting list for various treatments, aged 6—12 years,
evaluation [1,3—14] and revised previously pro- whose specific complaint was not a communication
posed procedures [15—17]. The objective of using or orofacial myofunctional disorder, participated in
protocols for evaluation is to establish parameters the study (mean age = 104.35 months). Thirty of
that will permit the study of a case for the definition them were selected at random using the GraphPad
of treatment and for later determination of the Software, for validity analyses (age range: 72—149
outcomes [8]. When we record data on a protocol months, mean = 103.3, S.D. = 23.57). Individuals
we can detect a configuration or certain regularities with and without orofacial myofunctional disorders
that lead us to identify certain categories of known were included since several degrees of alteration, as
problems [12]. well as normal standards were needed for scale
The data of an evaluation can be recorded by construction.
means of detailed descriptions or by semantic qua- Orofacial myofunctional disorders were defined
litative analysis; however, quantitation of the data as alterations/dysfunctions of the appearance, pos-
may be necessary, especially for research purposes. ture and/or mobility of the lips, tongue, mandible
In the literature, except for The Nordic Orofacial and cheeks and of respiration, deglutition and mas-
Test-Screening (NOT-S), which involves a structured tication functions.
interview and clinical examination for the screening Individuals with hearing loss, mental retardation,
of orofacial dysfunction [18], there is no validated neurological or emotional disorders were excluded.
instrument for the clinical evaluation of orofacial
structures and functions of children that will permit 2.1.1. Examiners
the examiner to express numerically his perception Two speech therapists properly calibrated in orofa-
of the characteristics and behaviors observed, i.e., cial myofunctional evaluation. Examiner 1 (C.M.F.),
an instrument that will permit the measurement of a speech pathologist and professor of orofacial
the impressions of the clinician. Also, intra- and myofunctional therapy, prepared examiner 2 for
inter-examiner reliability has not been widely orofacial myofunctional evaluation before the study
explored regarding orofacial myofunctional evalua- during teaching and research activities and concor-
tion and, as pointed out by McCullough et al. [19], dance between them was previously tested.
without this analysis the usefulness of clinical mea-
sures may be questioned. 2.2. Procedures
Thus, the objective of the present study was to
describe a protocol for the evaluation of children 2.2.1. Definition of the clinical methodology
aged 6—12 years in order to establish relations for orofacial myofunctional evaluation
between numerical scales and the orofacial myo- The methods for the evaluation of structure and
functional conditions, i.e., physical characteristics function were defined before data collection based
and orofacial behaviors. The proposed protocol may on a literature survey [3—14,16,17]. The items that
be administered within a short period of time and appeared more frequently in the publications
does not require the use of special measuring equip- consulted were included as follows: aspect/
OMES protocol 369

appearance/posture of lips, jaws, cheeks, face, the same side of the oral cavity), or anterior; uni-
tongue and palate, mobility of lips, tongue, jaws lateral chewing preference (66% of the time on the
and cheeks, and functions–—respiration, deglutition same side), or anterior, and total time needed to
and mastication. The protocol for evaluation based consume the food measured with a Cronobios digital
on traditional models was called traditional orofa- chronometer [8,9,17].
cial myofunctional evaluation (TOME). In addition to being described in the specific
protocol, chewing and deglutition functions were
2.2.2. Elaboration of the protocol with a scored as normal (3), mild dysfunction (2), or severe
numerical scale dysfunction (1). Other behaviors were defined as
A protocol was constructed based on same previous normal when they received a score of 2 and altered
models of evaluation, with the addition of numerical when they received a score of 1.
scales that would reflect the physical characteristics The same children were evaluated by examiner 2,
and orofacial behaviors of the subjects. This proto- who used the TOME.
col was called orofacial myofunctional evaluation For the analysis of inter-examiner reliability both
with scores (OMES) (Appendix A). examiners used the OMES.

2.2.3. Data collection 2.4. Statistical analysis

The children were evaluated individually (orofacial
myofunctional evaluation) by visual inspection during For statistical analysis the results of the TOME pro-
the session and the evaluation was later complemen- tocol were transformed to numerical values, with a
ted by the analysis of images recorded on videocas- value of 2 being attributed to normal results and a
sette (JVC model GR-AX720 movie camera and JVC value of 1 to altered results. For chewing behavior,
8 mm cassettes). For the evaluation of mobility, the the values were as follows: alternated bilateral
children were asked to perform separate movements chewing = 4, bilateral simultaneous = 3, unilateral
of the lips, tongue, jaws, and cheeks. preference = 2, and chronic unilateral = 1.
In the analysis, separate movements of each The data obtained by the evaluation of 30 subjects
component, precise and without tremors, were were used for the validation of the OMES protocol.
considered to be normal. Dysfunction was consid- The OMES and TOME protocols were then compared.
ered to be present when lack of precision in the The validity [20] and reliability of the instrument
movement, tremor, associated movements of other was analyzed according to the criteria described [21].
components (e.g., lips accompanying the move- The data used for the validation of the protocol (test)
ments of the tongue) and inability to perform the and obtained from the selected subgroups (20% of the
movement were observed. Using the OMES Protocol, samples) were used to test the reliability of the
the examiner attributed scores on a 3 point scale: instrument — test—retest — and the examiners con-
3 = normal, 2 = insufficient ability, and 1 = absence ducted new analyses of the videos of these subjects,
of ability or being unable to perform the task. each using the protocol of the first evaluation (retest).
Complementing the analysis, for jaw movements, The test—retest reliability was also calculated for
extension measurements (in mm) were also consid- the TOME protocol because of the lack of a validated
ered and carried out using a Mitutoyo caliper. protocol for orofacial myofunctional evaluation that
would contain all the items considered in the pre-
2.3. Functions sent study.
An additional 20% of the sample was re-evaluated
For respiration, the pattern was considered to be on the basis of the videos for the analysis of inter-
nasal when the subject presented labial closure examiner reliability when both used the OMES in
without effort during rest. order to determine inter-examiner agreement
For deglutition, the pattern was considered to be regarding application and/or interpretation.
normal when the subject presented the tongue A 6-month interval was scheduled, on average, for
contained in the oral cavity, contraction of elevator the second evaluation in order to avoid memory
muscles, and anterior sealing of the oral cavity effects on the results. The images recorded on video
without effort. were used for this purpose. Thus, the items that req-
For mastication, the subject was instructed to uired live observation, such as jaw movement exten-
chew the food (a stuffed cookie) in his habitual sion measurements (in mm) and palate configuration
manner. In the analysis of images recorded on video, (appearance) were not analyzed in this phase.
the following parameters were considered: chew- Statistical analysis was performed using the Sta-
ing, whether alternated bilateral, simultaneous tistics software based on the split-half reliability
bilateral, chronic unilateral (95% of the time on method. Means, standard deviations and the Spear-
370 C.M. Felı́cio, C.L.P. Ferreira

man correlation coefficient were also calculated. mentioned in the literature [3—14,16,17] consulted
The level of significance was set at p < 0.05. were selected for the elaboration of the TOME and
OMES Protocols. The psychophysical methodology
[22] was used for the development of the OMES pro-
3. Results tocol since it has been extensively used for the scaling
of social and clinical attributes, among them the
3.1. Validation of the OMES protocol subjective sensation of dyspnea, the perception of
difficulty of pronounciability (articulation difficulty),
There was a statistically significant correlation and the perception of speech and voice. Although the
between the evaluations of 30 children assessed with use of the ratio scale has been defended [23], in the
the TOME and OMES protocols (r = 0.85, p < 0.01). present study we opted for a numerical interval scale.
The reliability between protocols was 0.92. Several authors have previously defined the
The following significant correlations were aspects to be evaluated in an investigation of myo-
observed between the data obtained with the TOME functional disorders [3—14,16,17], as well as the
and OMES protocols: posture/appearance of the lips protocols [8,12], and have attempted to transform
(r = 0.59), of the cheeks (r = 0.55), of the face semantic descriptions into numerical data
(r = 0.65), and of the hard palate (r = 0.37); mobility [3,5,10,11,13,14,16]. However, the score ranges
of the lips (r = 0.56), tongue (r = 0.46), cheeks (r = from zero to (1), with no grading for each item.
0.61), jaws (visual inspection) (r = 0.54), and mea- The validity of an instrument can be defined as its
sures in mm — opening (r = 0.71), right laterality (r = real capacity to measure what it proposes to mea-
0.66), left laterality (r = 0.66), and protrusion sure [24] and the validation of an instrument is
(r = 0.83); Functions — breathing (r = 0.56), degluti- performed by comparing it to a previously existing
tion and tongue behavior (r = 0.76), and type of chew- external criterion, generally with the use of statis-
ing (r = 0.77). The p-values ranged from 0.001 to 0.05. tical methods. The gold standard often is the clinical
diagnosis or some type of criterion previously estab-
3.1.1. Reliability of the OMES instrument lished as a reference standard [20,21].
The test—retest reliability of OMES (examiner 1) was The OMES protocol proved to be valid for orofa-
0.99. The test—retest correlation was 0.98. The cial myofunctional evaluation since there was cor-
following results were obtained in the test: relation and concordance of the results with the
mean = 138.24, sum = 829.47, standard devia- TOME. Also, it was found to be a reliable instrument
tion = 27.11, and variance = 735.11. In the retest when multiple applications were compared (test—
the results were: mean = 136.07, sum = 816.43, retest), with reliability between examiners [25—
standard deviation = 28.20, and variance = 795.06. 27]. Indeed, without this analysis, the usefulness
of clinical measurements may be questioned [19].
3.1.2. Reliability of the TOME instrument
The test—retest reliability of TOME (examiner 2) was
0.98. The test—retest correlation was 0.98. The 5. Conclusion
following results were obtained in the test:
mean = 99.78, sum = 598.67, standard devia- The OMES protocol proved to be a valid and reliable
tion = 24.44, and variance = 597.29. In the retest instrument for orofacial myofunctional evaluation
the results were: mean = 104.70, sum = 628.20, that can be administered without special equipment
standard deviation = 33.15, and variance = 1098.96. and in a brief manner, permitting the grading of
Reliability between Examiners 1 and 2 using the specific orofacial myofunctional disorders within
OMES protocol was 0.99, and the correlation was the limits of the selected items.
0.98. The following results were obtained: examiner
1, mean = 151.38, sum = 908.27, standard devia-
tion = 17.28, and variance = 298.63. Examiner 2: 6. Conflict of interest statement
mean = 156.15, sum = 936.88, standard devia-
tion = 18.82, and variance = 354.21. None.

4. Discussion Acknowledgment

A review of protocols for orofacial myofunctional This work was supported in part by Conselho Nacio-
disorders was completed prior to developing the nal de Pesquisa (CNPq) do Ministério da Ciência e
protocols. Items and tests that are more frequently Tecnologia do Brazil.
OMES protocol 371

Appendix A
372 C.M. Felı́cio, C.L.P. Ferreira

Appendix A (Continued )
OMES protocol 373

Appendix A (Continued )
374 C.M. Felı́cio, C.L.P. Ferreira

Appendix A (Continued )

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