oral motor performance in spastic cerebral palsy individuals: are hydration and nutritional status...
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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:firstname.lastname@example.orgAccepted for publication August 4, 2011
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
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