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THE JOURNAL OF PROSTHETIC DENTISTRY MAHANNA ET AL

312 VOLUME 79 NUMBER 3

upper trace represents an audio signal (in volts) for eachsound of the utterance. This signal assists in the segmenta-tion of the speech sample into individual sounds.

The middle trace in Figure 2, A displays the nasal airflow (in cm3/s) during this utterance. A trace of 0 cm3/srepresents no nasal airflow. A positive number indicatesexhalation of air through the nose and a negative numberrepresents inhalation of air through the nose. Because thespeaker has normal velopharyngeal closure, there is es-sentially no nasal air escape during the production of theutterance, although there is the expected release of air atthe conclusion of the utterance.

The lower trace reveals the levels of intraoral air pres-sure during the utterance. A trace of 0 cmH20 (baseline)represents intraoral air pressure that equals atmosphericpressure, whereas a positive number represents intraoral

pressure greater than the atmospheric pressure present.During the production of most consonant sounds of English (p, b, t, d, k, g, s, z, sh, ch, and so on) by anormal speaker, intraoral air pressure is positive. Forexample, during the production of /p/, the average oralair pressure of an adult is +5 to +8 cmH20. When aspeaker’s mouth is opened for vowels, air pressure quickly drops to baseline.

The aerodynamic tracings in Figure 2, B illustratescontours frequently seen in a speaker with an acquiredpalatal defect secondary to cancer surgery. The palatedoes not adequately separate the oral and nasal cavities

during speech production of consonant sounds that re-quire the generation of high intraoral pressure. Palataldefects create a condition that permanently couples theoral and nasal cavities resulting in excessive nasal air flow during utterances with predominately pressure conso-nants such as /Buy Bobby a Puppy/.

In this assessment strategy, aerodynamic studies arecompleted at several different intervals of treatment.Because patient performance can be measured and ana-lyzed in approximately 4 minutes, these studies can becompleted during the course of a palatal obturator orspeech aid prosthesis modification. Aerodynamic stud-ies are also made when the definitive obturator is com-pleted to document the effectiveness of oral and nasal/nasopharyngeal separation. Because of the efficiency of this measurement, aerodynamic assessment can be com-pleted during follow-up visits to determine the ongoingeffectiveness of the obturator.

Nasality. Nasality is perceptually rated from the au-dio tape recordings used for the intelligibility assessment.Three judges rate the speakers performance on the 13-point scale shown in Figure 3.9,10 Balanced nasality is

the desired outcome as it reflects the degree of oral andnasal resonance that is expected or normal in a givendialect.

Excessive hypernasality reflects nasal resonance dueto a speaker’s excessive coupling of the oral and nasalcavities. Hyponasality is indicative of excessive oral andreduced nasal resonance given a speaker’s dialectic back-ground. For research purposes, nasality is typically ratedby three to five speech-language pathologists. In relatedresearch using the nasality rating procedures previously described, for a large sample of persons fitted with ob-turator prostheses or speech aid prostheses, theinterjudge reliability revealed that 97% of each of the

nasality ratings of one judge were within one point of the ratings of the second judge.11

Functional limitation

Speech intelligibility and speaking rate are the twoprimary measures of functional limitation used in theprotocol.

Speech intelligibility. Speech intelligibility andspeaking rate are obtained with the software program,Sentence Intelligibility Test for Windows.12 This pro-gram randomly generates sentences of variable wordlength, which are read aloud by the patient and audio

Fig. 2. Results of normal (A) and abnormal (B) aerodynamic

study.

Fig. 3. Nasality rating scale.


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MAHANNA ET AL THE JOURNAL OF PROSTHETIC DENTISTRY

MARCH 1998 313

recorded. The audio tapes are transcribed by judgesunfamiliar with the patient and the passages. Judgescan be any adult with normal hearing who is a nativespeaker of English and need not be a speech-languagepathologist. After listening to each sentence, judgestranscribe the sentence by entering (typing) the per-

ceived words into the computer. The computer thencompares the actual words with the perceived wordsand computes an intelligibility score. In this protocol,speech intelligibility is measured before treatment andafter the definitive obturator has been completed.Speech intelligibility scores for normal speakers rangebetween 98% and 100%.12

Speaking rate. While listening to the audio tape, a judge measures speaking rate by activating the mouse atthe beginning and end of each sentence. The computertallies the total speaking duration in hundredths of sec-onds. The speaking rate is obtained by dividing the totalnumber of words spoken by the total speaking duration

of the sample. According to the Sentence Intelligibility Test Manual, the speaking rate for the average normalspeaker on this task is 190 words per minute.13

Disability

Disability is assessed with a Modified Communica-tion Effectiveness Index (Modified CETI) adapted fromthe work of Lomas and colleagues in 1989.14 Originally,the CETI was developed for use with persons who ex-perience aphasia, a language disorder, as a result of stroke.The original CETI contained 16 assessment items asso-ciated with common communicative contexts. For this

protocol, 9 of the 16 items were selected to sample so-cial contexts frequently experienced by persons after oralcancer. Seven items were excluded because they sampledcommunicative tasks, such as gaining attention, giving

yes and no answers, and indicating that they understood what was spoken. Excluded items were considered ex-cessively easy for patients with palatal cancer to achieveeven with their obturators removed. In this protocol,patients complete this brief questionnaire after they havespoken with the definitive obturator for at least 2 months.The respondents rate their communication effectivenessin nine contextual settings using a visual analog scale(Fig. 4). An “X” is placed on the 140 mm horizontal

line as a response for each setting. A far left (0 mm)response indicates the patient is not able to communi-cate and a far right response indicates that the patient isable to communicate as well as before the illness. A per-centage for each response was calculated. The nine con-textual settings are averaged to determine the patient’smean communication effectiveness index score. Thisindex compares patients’ perceived communicative ef-fectiveness with an obturator or speech aid prosthesis totheir communication before their illness. A prior com-munication disorder would impact the CETI results,therefore it is useful to interview patients and their fam-

ily members to identify communication disorders that were present before the onset of cancer.

CLINICAL REPORT: HARD PALATEDEFECT

The following clinical reports illustrate the applica-

tion of this speech outcome assessment protocol for twotypes of palatal defects. The first report describes a 58-

year-old man who was a salesperson with extensive pub-lic interaction, often in noisy environments. He was diag-nosed with squamous cell carcinoma of the hard palateand the entire left side of the hard palate was surgically removed. He was restored with a Class I obturator re-movable partial denture design. His outcome assessmentrevealed the following results.

Tissues

Oral tissues tolerated the obturator prosthesis satis-factorily. Visual or palpable signs of soft tissue irritationcaused by wearing the prosthesis were not evident. There

was no sign of infection adjacent to the defect.


The patient’s intelligibility scores were 57.5% with-out the obturator and 95.6% with the obturator inserted.His speaking rate improved from 143 words per minute

with the obturator removed to 160 words per minute with the obturator inserted. Although there was a 17 words per minute improvement after prosthesis intervention, this patient’s speaking rate was still 30 wordsper minute slower than the average rate of 190 words

per minute for a nonimpaired adult speaker on this task.The hypernasality rating of +5.3 (on a 13-point scale)improved to normal range (+0.66) with the prosthesisinserted.

Impairment

This patient’s aerodynamic studies for the utterance/apapapapa/ are summarized, and the values reflectthe average of the two greatest oral air pressures asso-ciated with pressure consonant production and the si-multaneous nasal airflow and resistance measures. Withthe obturator removed, the mean oral pressure duringthe production of /p/ was 2.4 cmH2O, the mean na-

sal air flow rate was 1201.4 cm3

/s, and the mean aero-dynamic resistance was 1.1 Ω. With the obturator in-serted, his mean oral pressure was 7.9 cmH2O, themean nasal air flow rate was 10.5 cm3/s, and 719 Ω of aerodynamic resistance. The results revealed a markedimprovement in oral and nasal/nasopharyngeal sepa-ration as a result the prosthodontic intervention. Nor-mal speakers often achieve complete closure equiva-lent to infinite resistance during the production of pres-sure consonants. Netsell et al.15 tested 100 normalspeakers (4 to 45 years of age) and reported no resis-tance measures of less than 100 Ω.


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Fig. 4. Modified Communication Effectiveness Index.


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Disability

The patient completed the Modified CETI question-naire 4 months after the fitting of his definitive obtura-tor prosthesis. His score of 74% reflects that his percep-tion of communication competence with the prosthesisinserted was notably less than before the cancer was di-agnosed and treated.

DISCUSSION OF CLINICAL REPORT 1

The value of a multidimensional outcome assessmentis illustrated with this patient. Despite a relatively highspeech intelligibility score and near normal hypernasality rating, this patient rated his communication effectivenessat a surprisingly low level as compared with his speechbefore surgical intervention. In response to these out-come measures, this patient was interviewed to betterunderstand the disparity in his results. Several factors may have contributed to his reduced overall CETI ratings,

including the extensive communication demands of hisemployment setting, intermittent decreased retention of the obturator (which did not occur during the outcometesting), and radiation-induced xerostomia. In our opin-ion, alteration in the prosthesis design or further modifi-cation in the existing prosthesis would not have improvedhis communication effectiveness perceptions.

CLINICAL REPORT: HARD AND SOFTPALATE DEFECT WITH ASSOCIATEDFACIAL DEFECT

A 52-year-old man was diagnosed with squamous cellcarcinoma of the right maxillary antrum superior toOghren’s Line. The surgical resection included approxi-mately 40% of the right hard palate, resected from theposterior aspect of the right maxillary tuberosity to thedistal of the right maxillary canine tooth. The defectextended superior and included an orbital exenteration.The pterygoid plate and posterior soft palate were main-tained. The patient received a surgical obturator whenthe tumor was resected. Radiation therapy included68 Gy to the tumor site. Outcome studies were com-pleted after the delivery of his definitive obturator. Theseprocedures were repeated 12 months after the comple-tion of the definitive obturator.

Tissue

The results of this treatment revealed that the oraltissue tolerated the prosthesis well and no infection orirritation was evident.

Impairment

The results of his aerodynamic studies for the speak-ing task /apapapa/ reflect the mean values associated

with the two primary oral air pressure peaks. With theobturator removed, the escape of air through the nasalcavity during the production of /p/ was extensive at

553.5 cm3/s and intraoral air pressure was 4.68 cmH20.His aerodynamic resistance was minimal at 1.91 Ω. Withthe obturator inserted, average nasal airflow rate was173.8 cm3/s, and mean intraoral air pressure was4.1 cmH20 and mean aerodynamic resistance was 43Ω.

Although the obturator was effective by allowing the

patient to develop much greater aerodynamic resistancethan with the obturator removed, clearly, he was notachieving appropriate oronasal cavity separation. Theescape of air through the nasal cavity was caused by changes in tissue adaptation of the prosthesis that oc-curred during the 12 months that the definitive obtura-tor was worn.


The intelligibility score with the obturator removed was 74%, and the patient’s speaking rate was 142 wordsper minute. With the obturator in place, intelligibility

was 98% and speaking rate was 163 words per minute.

Obturator revision

The obturator was temporarily modified with Tru-Soft reline material (Bosworth Co., Skokie, Ill.) becauseof reduced aerodynamic resistance provided by the origi-nal obturator contours. The patient was experiencingexcessive nasal air escape during speech. After wearingthe modified obturator for 1 week, an aerodynamic as-sessment was completed and revealed a successful fit-ting. His nasal airflow during the production of pres-sure consonant sounds was eliminated, yet appropriatenasal resonance was present during the production of nasal sounds. With the obturator inserted, the patient

was able to breathe through his nose with his lips closed.This confirmed that the prosthesis was not excessively obturating the defect or occluding normal nasal air ex-change.

As a result of this successful assessment, the definitiveobturator modifications were converted to acrylic resin.

A full assessment was readministered. For the final aero-dynamic study, average nasal airflow rate during the ut-terance /apapapa/ was 00 cm3/s, mean intraoral airpressure was 6.6 cmH20, and mean aerodynamic resis-tance was 10,000 Ω (infinite).

Function limitation and disability

Speech intelligibility scores were 99% with a speakingrate of 168 words per minute. The results of the patient’snasality ratings revealed that the nasality was rated asnormal to mildly hypernasal (hypernasality = +1.9) withthe obturator in place. The patient completed a Modi-fied CETI and scored 100 points. He rated each of nineitems as he would have before his illness. These finalresults revealed that the patient’s prosthetic treatmenthad been extremely effective. After cancer surgery, ra-diation, and obturator fitting, the patient judged him-self to perform as a normal speaker.


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SUMMARY

The assessment protocol described in this article hasbeen useful, in our experience, in guiding the treatmentprograms of individual patients with maxillary and softpalate defects secondary to cancer surgery and also todocument the speech outcomes for patients who useobturator or speech aid prostheses. The chronic disabili-ties framework encourages the documentation of out-comes at several levels thereby providing a database thataddresses a range of issues regarding the effectiveness of obturator prosthesis treatments.

REFERENCES

1. Pope A, Tarlov A. Disabilit y in America: toward a national agenda for pre-

vention (executive summary). Washington (DC): National Academy Press;

1991. p. 1-31.

2. Warren D. A quantitative technique for assessing nasal airway impairment.

Am J Orthod 1984;86:306-14.

3. Moon W, Weinberg B. Two simplified methods for estimating velopharyngeal

orifice area. Cleft Palate J 1985;22:1-10.

4. Warren DW. Regulation of speech aerodynamics. In: Lass N, editor. Prin-ciples of experimental phonetics. St Louis: Mosby Year Book; 1996. p. 46-

92.

5. Barlow SA. High-speed data acquisition system for clinical speech physiol-

ogy. In: Yorkston K, Beukelman D, editors. Recent advances in clinical dys-

arthria. Austin: Pro-ed; 1989. p. 39-52.

6. Warren DW, DuBois AB. A pressure flow technique for measuring

velopharyngeal orifice area during continuous speech. Cleft Palate J

1964;1:52-71.

7. Warren DW, Ryon WE. Oral port constriction, nasal resistance, respiratory

aspects of cleft palate speech. An analog study. Cleft Palate J 1967;4:38-49.

8. Warren DW, Wood MT, Bradley DP. Respiratory volumes in normal and

cleft patients. Cleft Palate J 1969;6:449-60.

9. Darley FL, Aronson AE, Brown JR. Differential diagnostic patterns of dysar-

thria. J Speech Hear Res 1969;12:246-69.

10. Darley FL, Aronson AE, Brown JR. Motor speech disorders. Philadelphia:

WB Saunders; 1975.

11. Sullivan M, Beukelman D, Marshall J, Mahanna G, Gaebler C. Speech out-comes for speakers with oral cancer fitted with obturator prostheses and

speech aid prostheses. Final Report 1996. Lincoln (NE): Nebraska Depart-

ment of Health; 1996.

12. Yorkston K, Beukelman D. Manual of the assessment of intelligibility of

dysarthric speech. Austin: Pro-ed; 1981.

13. Yorkston K, Beukelman D, Tice, R. Sentence intelligibility test manual. 1996

ed. Lincoln (NE): Tice Technology Services; 1996.

14. Lomas J, Pickard L, Bester S, Elbard H, Finalyson A, Zoghaib C. The commu-

nication effectiveness index: development and psychometric evaluation of

a functional communication measure for adult aphasia. J Speech Hear Res

1989;54:113-23.

15. Netsell R, Lotz W, Barlow S. A speech physiology examination for individu-

als with dysarthria. In: Yorkston K, Beukelman D, editors. Recent advances

in clinical dysarthria. Austin; Pro-ed; 1989. p. 3-38.

Reprint requests to:

DR

. GORDON

MAHANNA

DEPARTMENT OF OTOLARYNGOLOGY-HEAD AND NECK SURGERY

UNIVERSITY OF NEBRASKA MEDICAL CENTER

600 SOUTH 42ND ST.

OMAHA, NE 68198-9310

Copyright © 1998 by The Editorial Council of The Journal of Prosthetic Den-

tistry.

0022-3913/98/$5.00 + 0. 10/1/87777

Noteworthy Abstractsof theCurrent Literature

The future of dental amalgam: A review of the literature.Part 7: Possible alternative materials to amalgam for therestoration of posterior teethEley BM. Br Dent J 1997;183:11-4 .

Purpose. This last article in a series on the future of amalgam considers the possible alternativematerials to amalgam for the restoration of posterior teeth.Discussion. The author described the use of gold inlays, gold foil, gallium alloys, and tooth-colored nonmetal alternatives to amalgam such as glass ionomer cements, resin composite, glassionomer-resin hybrids, compomers, and ceramics. The clinical indications for these restorations,

then their potential clinical problems and mean survival rates in comparison with dental amalgam were described. The safety of the resin composites was also considered and the potential toxicity and hypersensitive effects of this class of materials was discussed.Conclusions. The author concluded that current evidence does not demonstrate that dental amal-gam is dangerous to the health of the general population. However, even as dental caries rates aredeclining worldwide and amalgam use is diminishing, this material will still be used for furtheramalgam repair and use in selected clinical situations. Therefore strict mercury hygiene proceduresshould be used to avoid risk to the dentist and staff and to prevent contamination of the environ-ment. It is believed that any future government action against the continued use of dental amal-gam by the dental profession will be directed toward mercurial environmental contamination. 22References.— RP RENNER

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