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  • Oral motor performance in spastic cerebral palsyindividuals: are hydration and nutritional status associated?

    Maria Teresa Santos1, Renato Batista1, Elisangela Previtali1, Adriana Ortega1, Oliver Nascimento2,Jose Jardim2

    1Universidade Cruzeiro do Sul, Persons with Disabilities Division; 2Universidade Federal de Sao Paulo, Respiratory Diseases

    BACKGROUND: Previous studies reported alterations in

    salivary parameters in cerebral palsy (CP) individuals;

    however, none of these considered oral motor perfor-

    mance as possibly responsible for these conditions. The

    aim of this study was to investigate the influence of oral

    motor performance on the nutritional status and salivary

    parameters in individuals with CP.

    METHODS: Forty-three individuals aged 1119 years-

    old, with spastic CP were included in this study. Oral

    motor performance was evaluated using the Oral

    Motor Assessment Scale, which classified the individuals

    into two groups: subfunctional or functional. Unstimu-

    lated saliva was collected and the flow rate was

    calculated (ml min). Salivary osmolality was measuredusing a freezing point depression osmometer. Blood

    samples were collected to evaluate complete blood

    count, total protein, albumin globulin ratio and trans-ferrin levels.

    RESULTS: The subfunctional (n = 21) and the functional

    group (n = 22) did not differ regarding sex (P = 0.193),

    however the functional group was older (P = 0.023) and

    had a higher mean BMI (P < 0.001). The subfunctional CP

    group presented a reduction in salivary flow rate (36.4%)

    (P < 0.01) and an increase in salivary osmolality (35.5%)

    (P < 0.001) compared to the functional group. Slightly

    lower values for red blood cells (millions mm3)(P < 0.001), hemoglobin (g dl) (P < 0.009), hematocrit (%)(P = 0.001), number of platelets (N mm3), total protein(g dl) and albumin globulin ratio (P = 0.003 and P = 0.036,respectively) were determined for the subfunctional

    group, but within the normal range of normality.

    CONCLUSION: Cerebral palsy individuals appear to

    present impaired adequate hydration due to compro-

    mised oral motor performance.

    J Oral Pathol Med (2012) 41: 153157

    Keywords: cerebral palsy; saliva; salivary parameters; osmolality;

    hydration; oral motor performance; nutritional status


    Individuals with functional neurological damage, par-ticularly those with cerebral palsy (CP), often presentseveral disorders that are accompanied by disharmonicmovements, including oral motor performance ofspeech, mastication and swallowing (1).The limited motor performance of mastication and

    swallowing in children with CP, a neurodevelopmentaldisability (2), results in feeding dysfunctions thatinclude several interacting variables, including dys-functional oral motor control (weak sucking, persis-tent tongue thrusting and poor lip closure), abnormalneurological maturation (presence of oral pathologicalreexes), and poor seating posture during feeding.These abnormalities may result in reduced dietaryintake, prolonged feeding times and poor nutri-tional status with their attendant physical compromise(37).It has been reported that children with CP can present

    low salivary ow rate, pH and buer capacity (8).Increased salivary osmolality and total protein concen-tration (9), as well as increased salivary, urine andplasma osmolalities were also veried in these individ-uals, characterizing impaired adequate hydration status(10). These ndings lead us to believe that the dailyamount of liquid intake is usually reduced in theseindividuals. These conditions could be due either to alow amount of liquid oered to these individuals, or tocompromised oral motor performance that may hamperthe liquid diet intake. If it were the case that thehypohydration status was due to the insucient oer bytheir caregivers, then subnutritional status should alsobe observed.Considering the points raised above, the aim of this

    study was to investigate the inuence of oral motorperformance on the nutritional status and salivaryparameters in individuals with spastic cerebral palsy. It

    Correspondence: Maria Teresa B. Santos DDS, PhDAssociate Professor, Individuals with Special Needs, UniversidadeCruzeiro do Sul, Rua Constantino de Souza, 454, apto 141 Zip code:04605-001 Sao Paulo, Brazil. Tel: +551199722301, Fax: +551150930865, E-mail:drsantosmt@yahoo.com.brAccepted for publication August 4, 2011

    doi: 10.1111/j.1600-0714.2011.01074.x

    J Oral Pathol Med (2012) 41: 153157

    2011 John Wiley & Sons A/S All rights reserved


  • was hypothesized that compromised oral motorperformance interferes in liquid and solid dietintake, resulting in diminished health status for theseindividuals.

    MethodsSubjectsThis project was approved by the Cruzeiro do SuIUniversity Institutional Review Board (IRB) underprotocol number 045 2010. After being informed ofthe aim of the investigation, written informed consentfor participation and publication was obtained from theadult responsible for each individual.Forty-three male and female individuals, aged

    1119 years old, diagnosed with spastic cerebral palsy,who attended the Fraternidade Irma Clara Institution,in Sao Paulo, Brazil, were included in this study. Theinclusion criteria were: individuals with a clinical med-ical diagnosis of spastic cerebral palsy; and the exclusioncriteria were use of any drug that could interfere withsaliva secretion (anticholinergic and neuroleptic drugs,benzodiazepines) for at least 72 h prior to examination,a history of head and neck radiation and surgicalprocedures to reduce drooling.The patients medical records were reviewed for

    demographic and clinical data and body mass index(BMI).

    Oral motor performancePatient oral motor performance was evaluated duringthe feeding process using the Oral Motor AssessmentScale (11). The following topics were evaluated: mouthclosure, lip closure onto the utensils, lip closure duringdeglutition, control of food during swallowing(solid semisolid), mastication, straw suction and controlof liquids during deglutition.A score was given for each topic of the oral motor

    skill assessed. A nal classication of the oral motorskill was obtained based on the most frequent score.The individuals were classied as: passive (severelycompromised oral motor performance), subfunctional(moderately compromised oral motor performance),semi-functional (slightly compromised oral motor per-formance) and functional (very slightly compromisedoral motor performance) (11).

    Saliva collectionUnstimulated whole saliva was collected using slightsuction through a soft plastic catheter. The salivaproduced in the rst 10 s was discarded and allsubsequent saliva was collected for exactly 5 min in agraduated cylinder in order to calculate the ow rate(ml min). During the collection period, all the childrenremained comfortably seated in a ventilated and illumi-nated room. When it was not possible to collect salivafrom a child due to crying, they were excluded. Soonafter collection, the saliva sample was frozen in dry ice,transported to the laboratory and stored at )80C untilanalysis. Salivary osmolality was measured using afreezing point depression osmometer (Model Wide-

    Range Osmometer 3W2; Advanced Instruments, Need-ham, MA, USA).

    Body mass index calculationSince individuals with CP present diculties instanding straight, height was measured by the tibiasegment length in centimeters and the estimatedstature was determined from segmental measures usingthe equation: Stature = (3.26 x tibia segment) +30.8 cm (12). For individuals seated in a wheelchair,weight was measured with the patient sitting in theirwheelchair in a digital balance, and later the weightof the chair was subtracted from the total. Finally,body mass index was calculated as weight stature2(kg m2).

    Blood collectionBlood samples were collected to evaluate completeblood count, total protein, albumin globulin ratio andtransferrin levels using venostasis from an antecubitalvein into separate Vacuteiner tubes containing ethylen-ediaminetetraacetic acid (EDTA) (Becton Dickson, Juizde Fora, Brazil).

    Statistical analysisTo evaluate proportional dierences between the groupsstudied, the chi-square test was used. The Studentst-test was used to verify the hypothesis of equalitybetween the two groups. Spearmans correlation coe-cient was used to associate the behavior of fourvariables. The signicance level was set at P < 0.05.


    Individuals determined as having a nal predominancetype of passive and subfunctional (severely and moder-ately compromised oral motor performance) were clas-sied into a single group that was denominated thesubfunctional group (n = 21), while the semi-functionaland functional individuals (slightly and very slightlycompromised oral motor performance) were denomi-nated the functional group (n = 22).The individuals from both groups did not dier

    regarding sex (P = 0.193), but the functional group was

    Table 1 Descriptive characteristics of individuals with cerebral palsywith subfunctional and functional oral motor performance groups

    Individual variables

    Subfunctionalcerebral palsy(n = 21)

    Functionalcerebral palsy(n = 22) P value*

    Sex, n (%) 0.193a

    Female 15 (71.4) 17 (77.3)Male 6 (28.6)) 5 (22.7)Age, mean [SD] years 14.2 2.8 16.2 2.9 0.023*b

    BMI (kg m2) 14.2 2.1 16.9 0.83

  • signicantly older (P = 0.023) and had a signicantlyhigher BMI (P < 0.001) (Table 1).Data of salivary ow rate (ml min) and salivary

    osmolality (mOsm kgH2O) from the subfunctional andfunctional CP groups are presented in Table 2. Thesubfunctional CP group pr


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