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Laryngeal dysfunction and oral hygiene: Any relation?
Auris Nasus Larynx 39 (2012) 284–287
Contents lists available at SciVerse ScienceDirect
Auris Nasus Larynx journal homepage: www.elsevier.com/locate/anl
Laryngeal dysfunction and oral hygiene: Any relation?§ Esra Eryaman a, Banu Oter Ilhan b,* a b
Baskent University School of Medicine, Department of Otorhinolaryngology and Head and Neck Surgery, Bahcelievler, Ankara, Turkey Baskent University School of Medicine, Department of Pedodontics, Bahcelievler, Ankara, Turkey
A R T I C L E I N F O
A B S T R A C T
Article history: Received 5 February 2011 Accepted 24 June 2011 Available online 8 September 2011
Objective: The purpose of this study is to establish a relation between poor oral hygiene and laryngeal dysfunction. Methods: 43 adult patients were divided into two groups according to caries activity and oral hygiene. 18 patients with oral hygiene index score (OHI-S) 0-1 were grouped as the control group (good oral hygiene). 25 patients with OHI-S 2-3 were grouped as the study group (poor oral hygiene). Larygostroboscopic examination, aerodynamic measures by defining maximum phonation time (MPT) and s/z ratio and the pitch level measurements were done. Patients with gastroesophageal reflux disease (GERD), laryngopharyngeal reflux (LPR), previously confirmed laryngeal diseases or pathologies, systemic other diseases, or smokers were excluded from this study. Results: The average MPT values of the study group were found to be statistically very significantly lower than those of the control group (p < 0.01). In the stroboscopic findings, the proportion of normal closure levels were meaningfully higher in the control group than in the study group (p < 0.05). The supraglottic involvement was found statistically meaningfully higher in the study group than in the control group (p < 0.05). The proportion of normal closure phase incidences were meaningfully higher in the control group than in the study group (p < 0.05). Conclusion: So, our findings of high glottic closure impairment, supraglottic involvement and low MPT scores in the poor oral hygiene group correlate with LPR findings such as muscle tension dysphonia. Poor oral hygiene may aggravate potential LPR in people. ß 2011 Published by Elsevier Ireland Ltd.
Keywords: Poor oral hygiene Laryngopharyngeal reflux Stroboscopy Voice disorders
1. Introduction Dental caries is deformation of the tooth enamel whereas periodontal disease is the damage in the tissues surrounding and supporting the teeth. Streptococcus Mutans is the most effective bacteria in formation of these caries and Lactobacillus plays a very important role in continuation of the caries. Anaerobes and some spirochetes also contribute to periodontal disease. Even if the teeth had recently been brushed, millions of bacteria happen to be on the dental plaque. The effects of stomach acids in the esophagus and the larynx has been a very popular topic recently. Apart from gastroesophageal reflux disease (GERD), where 40% of the patients have H. pylori infection, laryngopharyngeal reflux (LPR) produces respiratory and laryngeal manifestations [1]. In GERD, the
§
This study was approved by the Baskent University Institutional Review board (project no: KA 10/56) and supported by the Baskent University Research Fund. * Corresponding author. Baskent Universitesi Istanbul Saglik Uygulama ve Arastirrma Merkezi Hastanesi KBB Hastaliklari A.D., Mahir Iz cad., No. 43, 34662, Altunizade, Istanbul, Turkey. Tel.: +90 5322418222; fax: +90 2166513882. E-mail address: [email protected] (B.O. Ilhan). 0385-8146/$ – see front matter ß 2011 Published by Elsevier Ireland Ltd. doi:10.1016/j.anl.2011.06.003
esophagus has certain mechanisms for protection against mucosal damage (bicarbonate production, mucosal barrier, peristalsis) but the larynx and the pharynx do not. As generally known, muscle tension dysphonia (MTD, granulomas, nodules, Reinke’s edema, pseudosulcus, paroxysmal laryngospasm, laryngeal stenosis, and even cancer, may be seen as a result of LPR [1]. Dental erosion is a common finding in patients with LRP, GRP [2]. In addition to all the above factors affecting laryngeal mucosa, we think that poor oral hygiene may be a factor by itself. For this reason, in this study we explored the larynxes of patients with poor oral hygiene by stroboscopic findings, aerodynamic and acoustic measures, and discussed the results. 2. Materials and methods 43 adults who consulted with the Dentistry and Ear Nose & Throat (ENT) clinics between January and September 2010 at Baskent University Istanbul Hospital were included in this study. The low oral hygiene index score group of 18 (17 female, 1 male) patients was designated as the control group. The high oral hygiene index score group of 25 (20 female, 5 male) patients was
E. Eryaman, B.O. Ilhan / Auris Nasus Larynx 39 (2012) 284–287
designated as the study group. Patients with previously confirmed GERD, LPR, laryngeal diseases or pathologies, vocal hygiene problems including hydration, pulmonary diseases and systemic other diseases, or smokers and previous smokers were excluded from this study [3]. The clinical consultations with respiratory diseases clinic were carried out for each patients and the ones requiring lung function tests were excluded from the study. Reflux Symptom Index (RSI) scores greater than 10 and Voice Handicap Index-10 score greater than 4 were not included to the study [4,5]. The oral health status was determined by assessing caries status and oral hygiene status by a single examiner. For data analysis of dental caries, teeth were examined under proper light and with dental mirror according to WHO (World Health Organization) criteria DMFT index for permanent teeth (D = decayed, M = missing due to caries, F = filled, T = teeth). The DMFT score for any individual may range from 0 to 32 in whole numbers [6]. The oral hygiene status was determined by using the Simplified Oral Hygiene Index of Greene and Vermillion [7]. The six surfaces were stained with basic fuchsin and subsequently examined from four posterior and two anterior teeth. In the posterior region, the first fully erupted tooth, usually the first molar, no. 16, was examined. The buccal surfaces of the selected upper molars and the lingual surfaces of the selected lower molars were inspected. In the anterior region of the mouth, the labial surfaces of the upper right, no 11, and the lower left, no. 31, central incisors were scored. The oral hygiene index scores (OHI-S) range from 0 to 3 as follows [6,7]: OHI-S 0 = No debris or stain present OHI-S 1 = Soft debris covering not more than one third of the tooth surface or presence of extrinsic stains without other debris regardless of surface area covered OHI-S 2 = Soft debris covering more than one third but not more than two thirds of the exposed tooth surface. OHI-S 3 = Soft debris covering more than two thirds of the exposed tooth surface After the scores for debris were recorded, the index values were calculated. For each individual, the debris scores were totalled and divided by the number of surfaces scored. The patients were divided into two groups according to caries activity and oral hygiene. Patients with OHI-S 0-1 were grouped as the control group (good oral hygiene). Patients with OHI-S 2-3 were grouped as the study group (poor oral hygiene). Larynx was examined with Richard Wolf magnifying laryngoscope 70 degrees. Assessment of vibratory behavior was performed by Richard Wolf stroboscope, ‘‘Strobe View 5570’’. The results were marked on the ‘‘stroboscopic assessment form’’ [8]. Closure level, vocal fold edge, supraglottic involvement, amplitude, mucosal wave, non-vibrating portion and closure phase were observed and marked. Aerodynamic measures of voice was defined by Maximum phonation time (MPT) and s/z ratio. MPT was measured by a stopwatch through maximum prolongation of single vowel/a/in one breath. The s/z ratio was calculated by measuring the MPTs of single consonants/s/and/z/in two separate breaths. The acoustic analysis was made by measuring the pitch levels by the Strobe View 5570. The habitual pitch level was determined using the strobe unit as the patients read the words ‘‘gidiyorum Adanayaaaaa’’ and prolonged the final vowel/a/[9]. Finally, the results of the control and the study groups were compared through calculating statistical values. NCSS (Number Cruncher Statistical System) 2007&PASS 2008 Statistical Software (Utah, USA) program was used for statistical analyses for evaluating the study findings. Student’s t-test was used for comparative evaluations of quantitative data in evaluating the study data, in addition to definitive statistical methods (Mean,
285
Table 1 Evaluation of acoustic and aerodynamic analysis results by groups.
MPT Habitual pitch s/z <1 1 a b c
Low OHI
High OHI
Mean SD
Mean SD
20.50 6.31 202.28 27.28 n (%) 10 (55.6%) 8 (44.4%)
14.28 4.63 187.16 44.39 n (%) 11 (44.0%) 14 (56.0%)
a
p
0.001c 0.208 b p 0.455
Student’s t-test. Chi-Square test. p < 0.01.
Standard deviation, frequency). Chi-square test and Fisher’s exact Chi-square test were used for comparative analyses of qualitative data. Meaningfulness level was evaluated as p < 0.05. 3. Results This study was made with 43 subjects, 37 (86%) of whom were female and 6 (14%) were male. The age of the subjects ranged from 19 to 77 with average age 36.77 13.79. The subjects were divided into two groups, as ‘‘Low OHI’’ (n = 18) and ‘‘High OHI’’ (n = 25). The Low OHI group’s age average was 29.4 7.0, the High OHI group’s age average was 42.0 15.1. The average MPT values of the High OHI group were statistically very significantly lower than those of the Low OHI group (p < 0.01). There was no statistically significant difference between the mean habitual pitch levels of the Low OHI and the High OHI groups (p > 0.05). There was no statistically significant difference between the s/z value distributions of the Low OHI and the High OHI groups (p > 0.05) (Table 1). The closure level distributions showed statistically significant difference between the Low OHI and the High OHI groups (p < 0.05). The proportion of normal closure levels were meaningfully higher in the Low OHI group than in the High OHI group. The incidences of hourglass and bowing in the High OHI group were meaningfully higher than those of the Low OHI group. There was no statistically meaningful difference between the incidence of vocal edge fold between the two OHI groups (p > 0.05). There was a statistically meaningful difference between the incidences of supraglottic involvement between the two OHI groups (p < 0.05). The incidence of normal supraglottic involvement was meaningfully higher in the Low OHI group than in the High OHI group. The supraglottic involvement with false vocal cord compression was meaningfully higher in the High OHI group than in the Low OHI group. The amplitude distributions of the two OHI groups were not meaningfully different although they were close to being so (p > 0.05). It is noteworthy that, despite there being no meaningful difference in amplitude distributions, the incidence of normal amplitude was higher in the Low OHI group and the incidences of moderate and slight amplitude decreases were higher in the High OHI group. There was no statistically meaningful difference between mucosal wave incidence between the two OHI groups (p > 0.05). The closure phase distributions of the two OHI groups showed a statistically meaningful difference (p < 0.05). The proportion of normal closure phase incidences were meaningfully higher in the Low OHI group than in the High OHI group. The proportion of 2 closure phase values were meaningfully higher in the High OHI group than in the Low OHI group (Table 2). 4. Discussion Objective measurements of laryngeal function and phonation is made by aerodynamic and acoustic measures, and stroboscopic imaging.
E. Eryaman, B.O. Ilhan / Auris Nasus Larynx 39 (2012) 284–287
286 Table 2 Evaluation of stroboscopic results by groups.
Low OHI
High OHI
n (%)
n (%)
(66.7%) (11.1%) (22.2%) (0%) (0%)
8 4 4 4 5
(32.0%) (16.0%) (16.0%) (16.0%) (20.0%)
0.048*
Closure level
Normal Minimally incomplete Posterior chink Hourglass Bowing
12 2 4 0 0
Vocal fold edge
Normal Smooth irregular
18 (100%) 0 (0%)
23 (92.0%) 2 (8.0%)
Normal False vocal cord compression
18 (%100) 0 (0%)
18 (%72,0) 7 (28.0%)
Amplitude
Normal Moderate decrease Slight decrease
17 (94.4%) 1 (5.6%) 0 (0%)
16 (64.0%) 5 (20.0%) 4 (16.0%)
0.058
Mucosal wave
Normal Moderate decrease Slight decrease
17 (94.4%) 1 (5.6%) 0 (0%)
17 (68.0%) 3 (12.0%) 5 (20.0%)
0.082
Closure phase
Normal 1 2 3
12 6 0 0
0.502 0.030*
Supraglottic involvement
(66.7%) (33.3%) (0%) (0%)
8 6 9 2
(32.0%) (24.0%) (36.0%) (8.0%)
0.012*
Chi-square and ve Fisher’s exact test were utilised. * p < 0.05. ** p < 0.01.
The degree of glottal efficiency is measured by MPT, 15–20 s for adults. The s/z ratio measures respiration and phonation efficiency. s represents the duration of respiration, z represents the duration of phonation during exhalation. If z time is shorter, the problem is related to poor laryngeal control or lesions that increase mass. Actually, MPT and s/z ratios assess the patient’s glottal efficiency and the interaction between respiratory and laryngeal function [9]. Habitual pitch is the regular and consistent tone of voice used automatically for speaking but it may not necessarily be the best vocal quality. In our results, the average MPT values of the High OHI group were statistically very lower than those of the Low OHI group (p < 0.01). Since the impairment in closure levels are high in the High OHI group, the prolongation in MPT was considered as normal. The parameters evaluated during the course of the stroboscopic examination are very important for diagnosing voice disorders [6]. In our study, our analysis were based on closure level, vocal fold edge, supraglottic involvement, amplitude, mucosal wave, and closure phase. Glottic closure is the closure pattern of the musculomembranous portion of the vocal folds during the vibratory cycle. In our results, the closure phase degrees and closure levels in the High OHI group were found to be statistically meaningfully different from the Low OHI group. The supraglottic involvement was also statistically meaningfully higher in the High OHI group. It was our crucial observation that incidences of both MTD type 1; the failure of glottic closure and posterior chink due to simultaneous contraction of the posterior cricothyroid muscle, and type 2; the supraglottic involvement, were significantly higher in the High OHI group than in the Low OHI group. Incidences of minimally incomplete closure, hourglass and bowing ratios were also higher in the High OHI group. The High OHI group contained three eldest patients with ages 77, 70 and 60; the rest were younger than 50. Bowing which may be influenced from age was not seen in stroboscopic results of these three elder patients, instead consecutively; hourglass, incomplete and complete closure levels were remarked. Posterior chink was observed in 22% of the Low OHI group and in 16% of the High OHI group. In a study, LPR has been shown to be present in 70% of the patients with MTD [10]. The stroboscopic findings of hourglass and smooth irregular vocal folds edges showed local edema of vocal cords, which again may be due to asymptomatic
LPR. Also in other precious study, 64% of the subjects presenting bowing have been demonstrated to have at least one incidence of LPR [11]. As we mentioned before, MTD, granulomas, nodules, Reinke’s edema, pseudosulcus, paroxysmal laryngospasm, laryngeal stenosis, and even cancer, may be seen as a result of LPR [1]. So, poor oral hygiene may provoke LPR or the coexisting asymptomatic LPR. Poor oral hygiene may cause this through malfunction of the chewing process of food. The relationship between oral hygiene and infectious diseases has been observed in many studies. It has been suggested that dental plaque may act as a reservoir of respiratory pathogens, especially in patients with periodontal disease. Scannapieco has found that the subjects having the median OHI value were 1.3 times more likely to have a chronic respiratory disease relative to those with OHI value of 0 [12]. It has been proposed that poor oral hygiene and periodontal disease promote oropharyngeal colonization by potential respiratory pathogens, including Enterobacteriaceae, Pseudomonas aeruginosa, and Staphylococcus aureus [13]. Paju also supports that oral bacteria, poor oral hygiene, and periodontitis seem to influence the incidence of pulmonary infections, especially nosocomial pneumonia episodes in high-risk subjects [14]. Associations between oral health and cancer has been examined for a number of specific cancers, like oral, upper gastrointestinal, lung, and pancreatic. These associations persisted after adjustment for major risk factors, including cigarette smoking and socioeconomic status [14–16]. Chronic inflammation is induced by periodontal pathogens, which cause breakdowns in normal cell growth in already initiated cells, inducing carcinogenesis. Also in poor oral hygiene and periodontal diseases, endogenous carcinogenic nitrosamines are produced by nitrate reducing bacteria [16]. Conversely, the effects GERD on oral hygiene have been observed. In a study by Ersin, the prevalence of dental erosion and the salivary yeast and salivary Mutans streptococci colonization in GERD children was found to be significantly higher than in healthy subjects [17]. The damage of laryngeal mucosa by gastric acids and pepsin has been the subject of several experimental and clinic studies [18,19]. Having taken all the above discussions into
E. Eryaman, B.O. Ilhan / Auris Nasus Larynx 39 (2012) 284–287
consideration, we hypothesized that oral hygiene may also influence laryngeal function and phonation. The various studies cited in above discussions all conclude that varying degrees of associations exist between laryngeal dysfunction and anomalies of the esophagus and of the stomach, including gastric secretions. The fundamental reason why these studies studied such relationships is the natural proximity of the larynx with the esophagus and the stomach. The parallel proximity of the larynx and the mouth led us to think that similar associations exist between laryngeal dysfunction and oral hygiene. We could not find any published analyses of such an association. Accordingly, we decided to make a study, which focused on the influence of oral hygiene on laryngeal dysfunction. Our thoughts were that poor oral hygiene would have effects on the laryngeal mucosa, impeding laryngeal function. Our aim was to put poor oral hygiene firmly in the list of etiological factors to check for in patients with laryngeal disorders. Our findings of high glottic closure impairment, supraglottic involvement and low MPT scores in the High OHI group correlate with LPR findings such as MTD. Although we chose our subjects to be without diagnosed and symptomatic LPR, our stroboscopic and aerodynamic results showed important similarity with LPR findings. So, poor oral hygiene may provoke LPR or the coexisting asymptomatic LPR. 5. Conclusion Our findings of high glottic closure impairment, supraglottic involvement and low MPT scores in the poor oral hygiene group correlate with LPR findings such as muscle tension dysphonia. Poor oral hygiene may aggravate potential LPR in people. This relationship deserves further detailed work including objective measures of LPR in asymptomatic people with poor oral hygiene. Thinking in parallel, some dysfunctions or diseases of the larynx may be avoided by simply preventing poor oral hygiene through dental consultations. Conflict of interest None.
287
References [1] Koufman JA, Amin MR, Panetti M. Prevalence of reflux in 113 consecutive patients with laryngeal and voice disorders. Otolaryngol Head Neck Surg 2000;123:385–8. [2] Lazarchik DA, Frazier KB. Dental erosion and acid reflux disease: an overview. Gen Dent 2009;57:151–6. [3] Behlau M, Oliveira G. Vocal hygiene for the voice professional. Curr Opin Otolaryngol Head Neck Surg 2009;17:149–54. [4] Mesallam TA, Stemple JC, Sobeih TM, Elluru RG. Reflux symptom index versus reflux finding score. Ann Otol Rhinol Laryngol 2007;116: 436–40. [5] Rosen CA, Lee AS, Osborne J, Zullo T, Murry T. Development and validation of the voice handicap index-10. Laryngoscope 2004;114:1549–56. [6] WHO: World Oral Health County, Area Profile World Health Organization. Oral health surveys. Basic methods, 4th ed., Geneva: World Health Organization; 1997. [7] WHO: Oral Health Country, Area Profile Programme Oral Hygiene Indices [on web] http://www.whocollob.od.mah.se/expl/ohiintrod.html. [8] Hirano M, Bless MD. Videostroboscopic examination of the larynx. San Diego: Singular Publishing; 1993. p. 90. [9] Andrews ML. Manuel of voice treatment pediatrics through geriatrics. San diego: Singular Pub.; 1997. pp. 32–61. [10] Koufman JA, Blalock PD. Functional voice disorders. Otolaryngol Clin North Am 1991;24:1059–73. [11] Reulbach TR, Belafsky PC, Blalock PD, Koufman JA, Postma GN. Occult laryngeal pathology in a community-based cohort. Otolaryngol Head Neck Surg 2001;124:448–50. [12] Scannapieco FA, Papandonatos GD, Dunford RG. Associations between oral conditions and respiratory disease in a national sample survey population. Ann Periodontol 1998;3:251–6. [13] Scannapieco FA, Mylotte JM. Relationships between periodontal disease and bacterial pneumonia. J Periodontol 1996;67:1114–22. [14] Paju S, Scannapieco FA. Oral biofilms, periodontitis, and pulmonary infections. Oral Diseases 2007;13:508–12. [15] Velly AM, Franco EL, Schlecht N, Pintos J, Kowalski LP, Oliveira BV, et al. Relationship between dental factors and risk of upper aerodigestive tract cancer. Oral Oncol 1998;34:284–91. [16] Conway D. Oral health, mouthwashes and cancer—what is the story? Evid Based Dent 2009;10:6–7. [17] Meyer MS, Joshipura K, Giovannucci E, Michaud DS. A review of the relationship between tooth loss, periodontal disease, and cancer. Cancer Causes Control 2008;19:895–907 [Epub. 2008 May 14]. [18] Ersin NK, Oncag O, Tumgor G, Aydogdu S, Hilmioglu S. Oral and dental manifestations of gastroesophageal reflux disease in children: a preliminary study. Pediatr Dent 2006;28:279–84. [19] Erickson E, Sivasankar M. Simulated reflux decreases vocal fold epithelial barrier resistance. Laryngoscope 2010;120:1569–75.
Contents lists available at SciVerse ScienceDirect
Auris Nasus Larynx journal homepage: www.elsevier.com/locate/anl
Laryngeal dysfunction and oral hygiene: Any relation?§ Esra Eryaman a, Banu Oter Ilhan b,* a b
Baskent University School of Medicine, Department of Otorhinolaryngology and Head and Neck Surgery, Bahcelievler, Ankara, Turkey Baskent University School of Medicine, Department of Pedodontics, Bahcelievler, Ankara, Turkey
A R T I C L E I N F O
A B S T R A C T
Article history: Received 5 February 2011 Accepted 24 June 2011 Available online 8 September 2011
Objective: The purpose of this study is to establish a relation between poor oral hygiene and laryngeal dysfunction. Methods: 43 adult patients were divided into two groups according to caries activity and oral hygiene. 18 patients with oral hygiene index score (OHI-S) 0-1 were grouped as the control group (good oral hygiene). 25 patients with OHI-S 2-3 were grouped as the study group (poor oral hygiene). Larygostroboscopic examination, aerodynamic measures by defining maximum phonation time (MPT) and s/z ratio and the pitch level measurements were done. Patients with gastroesophageal reflux disease (GERD), laryngopharyngeal reflux (LPR), previously confirmed laryngeal diseases or pathologies, systemic other diseases, or smokers were excluded from this study. Results: The average MPT values of the study group were found to be statistically very significantly lower than those of the control group (p < 0.01). In the stroboscopic findings, the proportion of normal closure levels were meaningfully higher in the control group than in the study group (p < 0.05). The supraglottic involvement was found statistically meaningfully higher in the study group than in the control group (p < 0.05). The proportion of normal closure phase incidences were meaningfully higher in the control group than in the study group (p < 0.05). Conclusion: So, our findings of high glottic closure impairment, supraglottic involvement and low MPT scores in the poor oral hygiene group correlate with LPR findings such as muscle tension dysphonia. Poor oral hygiene may aggravate potential LPR in people. ß 2011 Published by Elsevier Ireland Ltd.
Keywords: Poor oral hygiene Laryngopharyngeal reflux Stroboscopy Voice disorders
1. Introduction Dental caries is deformation of the tooth enamel whereas periodontal disease is the damage in the tissues surrounding and supporting the teeth. Streptococcus Mutans is the most effective bacteria in formation of these caries and Lactobacillus plays a very important role in continuation of the caries. Anaerobes and some spirochetes also contribute to periodontal disease. Even if the teeth had recently been brushed, millions of bacteria happen to be on the dental plaque. The effects of stomach acids in the esophagus and the larynx has been a very popular topic recently. Apart from gastroesophageal reflux disease (GERD), where 40% of the patients have H. pylori infection, laryngopharyngeal reflux (LPR) produces respiratory and laryngeal manifestations [1]. In GERD, the
§
This study was approved by the Baskent University Institutional Review board (project no: KA 10/56) and supported by the Baskent University Research Fund. * Corresponding author. Baskent Universitesi Istanbul Saglik Uygulama ve Arastirrma Merkezi Hastanesi KBB Hastaliklari A.D., Mahir Iz cad., No. 43, 34662, Altunizade, Istanbul, Turkey. Tel.: +90 5322418222; fax: +90 2166513882. E-mail address: [email protected] (B.O. Ilhan). 0385-8146/$ – see front matter ß 2011 Published by Elsevier Ireland Ltd. doi:10.1016/j.anl.2011.06.003
esophagus has certain mechanisms for protection against mucosal damage (bicarbonate production, mucosal barrier, peristalsis) but the larynx and the pharynx do not. As generally known, muscle tension dysphonia (MTD, granulomas, nodules, Reinke’s edema, pseudosulcus, paroxysmal laryngospasm, laryngeal stenosis, and even cancer, may be seen as a result of LPR [1]. Dental erosion is a common finding in patients with LRP, GRP [2]. In addition to all the above factors affecting laryngeal mucosa, we think that poor oral hygiene may be a factor by itself. For this reason, in this study we explored the larynxes of patients with poor oral hygiene by stroboscopic findings, aerodynamic and acoustic measures, and discussed the results. 2. Materials and methods 43 adults who consulted with the Dentistry and Ear Nose & Throat (ENT) clinics between January and September 2010 at Baskent University Istanbul Hospital were included in this study. The low oral hygiene index score group of 18 (17 female, 1 male) patients was designated as the control group. The high oral hygiene index score group of 25 (20 female, 5 male) patients was
E. Eryaman, B.O. Ilhan / Auris Nasus Larynx 39 (2012) 284–287
designated as the study group. Patients with previously confirmed GERD, LPR, laryngeal diseases or pathologies, vocal hygiene problems including hydration, pulmonary diseases and systemic other diseases, or smokers and previous smokers were excluded from this study [3]. The clinical consultations with respiratory diseases clinic were carried out for each patients and the ones requiring lung function tests were excluded from the study. Reflux Symptom Index (RSI) scores greater than 10 and Voice Handicap Index-10 score greater than 4 were not included to the study [4,5]. The oral health status was determined by assessing caries status and oral hygiene status by a single examiner. For data analysis of dental caries, teeth were examined under proper light and with dental mirror according to WHO (World Health Organization) criteria DMFT index for permanent teeth (D = decayed, M = missing due to caries, F = filled, T = teeth). The DMFT score for any individual may range from 0 to 32 in whole numbers [6]. The oral hygiene status was determined by using the Simplified Oral Hygiene Index of Greene and Vermillion [7]. The six surfaces were stained with basic fuchsin and subsequently examined from four posterior and two anterior teeth. In the posterior region, the first fully erupted tooth, usually the first molar, no. 16, was examined. The buccal surfaces of the selected upper molars and the lingual surfaces of the selected lower molars were inspected. In the anterior region of the mouth, the labial surfaces of the upper right, no 11, and the lower left, no. 31, central incisors were scored. The oral hygiene index scores (OHI-S) range from 0 to 3 as follows [6,7]: OHI-S 0 = No debris or stain present OHI-S 1 = Soft debris covering not more than one third of the tooth surface or presence of extrinsic stains without other debris regardless of surface area covered OHI-S 2 = Soft debris covering more than one third but not more than two thirds of the exposed tooth surface. OHI-S 3 = Soft debris covering more than two thirds of the exposed tooth surface After the scores for debris were recorded, the index values were calculated. For each individual, the debris scores were totalled and divided by the number of surfaces scored. The patients were divided into two groups according to caries activity and oral hygiene. Patients with OHI-S 0-1 were grouped as the control group (good oral hygiene). Patients with OHI-S 2-3 were grouped as the study group (poor oral hygiene). Larynx was examined with Richard Wolf magnifying laryngoscope 70 degrees. Assessment of vibratory behavior was performed by Richard Wolf stroboscope, ‘‘Strobe View 5570’’. The results were marked on the ‘‘stroboscopic assessment form’’ [8]. Closure level, vocal fold edge, supraglottic involvement, amplitude, mucosal wave, non-vibrating portion and closure phase were observed and marked. Aerodynamic measures of voice was defined by Maximum phonation time (MPT) and s/z ratio. MPT was measured by a stopwatch through maximum prolongation of single vowel/a/in one breath. The s/z ratio was calculated by measuring the MPTs of single consonants/s/and/z/in two separate breaths. The acoustic analysis was made by measuring the pitch levels by the Strobe View 5570. The habitual pitch level was determined using the strobe unit as the patients read the words ‘‘gidiyorum Adanayaaaaa’’ and prolonged the final vowel/a/[9]. Finally, the results of the control and the study groups were compared through calculating statistical values. NCSS (Number Cruncher Statistical System) 2007&PASS 2008 Statistical Software (Utah, USA) program was used for statistical analyses for evaluating the study findings. Student’s t-test was used for comparative evaluations of quantitative data in evaluating the study data, in addition to definitive statistical methods (Mean,
285
Table 1 Evaluation of acoustic and aerodynamic analysis results by groups.
MPT Habitual pitch s/z <1 1 a b c
Low OHI
High OHI
Mean SD
Mean SD
20.50 6.31 202.28 27.28 n (%) 10 (55.6%) 8 (44.4%)
14.28 4.63 187.16 44.39 n (%) 11 (44.0%) 14 (56.0%)
a
p
0.001c 0.208 b p 0.455
Student’s t-test. Chi-Square test. p < 0.01.
Standard deviation, frequency). Chi-square test and Fisher’s exact Chi-square test were used for comparative analyses of qualitative data. Meaningfulness level was evaluated as p < 0.05. 3. Results This study was made with 43 subjects, 37 (86%) of whom were female and 6 (14%) were male. The age of the subjects ranged from 19 to 77 with average age 36.77 13.79. The subjects were divided into two groups, as ‘‘Low OHI’’ (n = 18) and ‘‘High OHI’’ (n = 25). The Low OHI group’s age average was 29.4 7.0, the High OHI group’s age average was 42.0 15.1. The average MPT values of the High OHI group were statistically very significantly lower than those of the Low OHI group (p < 0.01). There was no statistically significant difference between the mean habitual pitch levels of the Low OHI and the High OHI groups (p > 0.05). There was no statistically significant difference between the s/z value distributions of the Low OHI and the High OHI groups (p > 0.05) (Table 1). The closure level distributions showed statistically significant difference between the Low OHI and the High OHI groups (p < 0.05). The proportion of normal closure levels were meaningfully higher in the Low OHI group than in the High OHI group. The incidences of hourglass and bowing in the High OHI group were meaningfully higher than those of the Low OHI group. There was no statistically meaningful difference between the incidence of vocal edge fold between the two OHI groups (p > 0.05). There was a statistically meaningful difference between the incidences of supraglottic involvement between the two OHI groups (p < 0.05). The incidence of normal supraglottic involvement was meaningfully higher in the Low OHI group than in the High OHI group. The supraglottic involvement with false vocal cord compression was meaningfully higher in the High OHI group than in the Low OHI group. The amplitude distributions of the two OHI groups were not meaningfully different although they were close to being so (p > 0.05). It is noteworthy that, despite there being no meaningful difference in amplitude distributions, the incidence of normal amplitude was higher in the Low OHI group and the incidences of moderate and slight amplitude decreases were higher in the High OHI group. There was no statistically meaningful difference between mucosal wave incidence between the two OHI groups (p > 0.05). The closure phase distributions of the two OHI groups showed a statistically meaningful difference (p < 0.05). The proportion of normal closure phase incidences were meaningfully higher in the Low OHI group than in the High OHI group. The proportion of 2 closure phase values were meaningfully higher in the High OHI group than in the Low OHI group (Table 2). 4. Discussion Objective measurements of laryngeal function and phonation is made by aerodynamic and acoustic measures, and stroboscopic imaging.
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286 Table 2 Evaluation of stroboscopic results by groups.
Low OHI
High OHI
n (%)
n (%)
(66.7%) (11.1%) (22.2%) (0%) (0%)
8 4 4 4 5
(32.0%) (16.0%) (16.0%) (16.0%) (20.0%)
0.048*
Closure level
Normal Minimally incomplete Posterior chink Hourglass Bowing
12 2 4 0 0
Vocal fold edge
Normal Smooth irregular
18 (100%) 0 (0%)
23 (92.0%) 2 (8.0%)
Normal False vocal cord compression
18 (%100) 0 (0%)
18 (%72,0) 7 (28.0%)
Amplitude
Normal Moderate decrease Slight decrease
17 (94.4%) 1 (5.6%) 0 (0%)
16 (64.0%) 5 (20.0%) 4 (16.0%)
0.058
Mucosal wave
Normal Moderate decrease Slight decrease
17 (94.4%) 1 (5.6%) 0 (0%)
17 (68.0%) 3 (12.0%) 5 (20.0%)
0.082
Closure phase
Normal 1 2 3
12 6 0 0
0.502 0.030*
Supraglottic involvement
(66.7%) (33.3%) (0%) (0%)
8 6 9 2
(32.0%) (24.0%) (36.0%) (8.0%)
0.012*
Chi-square and ve Fisher’s exact test were utilised. * p < 0.05. ** p < 0.01.
The degree of glottal efficiency is measured by MPT, 15–20 s for adults. The s/z ratio measures respiration and phonation efficiency. s represents the duration of respiration, z represents the duration of phonation during exhalation. If z time is shorter, the problem is related to poor laryngeal control or lesions that increase mass. Actually, MPT and s/z ratios assess the patient’s glottal efficiency and the interaction between respiratory and laryngeal function [9]. Habitual pitch is the regular and consistent tone of voice used automatically for speaking but it may not necessarily be the best vocal quality. In our results, the average MPT values of the High OHI group were statistically very lower than those of the Low OHI group (p < 0.01). Since the impairment in closure levels are high in the High OHI group, the prolongation in MPT was considered as normal. The parameters evaluated during the course of the stroboscopic examination are very important for diagnosing voice disorders [6]. In our study, our analysis were based on closure level, vocal fold edge, supraglottic involvement, amplitude, mucosal wave, and closure phase. Glottic closure is the closure pattern of the musculomembranous portion of the vocal folds during the vibratory cycle. In our results, the closure phase degrees and closure levels in the High OHI group were found to be statistically meaningfully different from the Low OHI group. The supraglottic involvement was also statistically meaningfully higher in the High OHI group. It was our crucial observation that incidences of both MTD type 1; the failure of glottic closure and posterior chink due to simultaneous contraction of the posterior cricothyroid muscle, and type 2; the supraglottic involvement, were significantly higher in the High OHI group than in the Low OHI group. Incidences of minimally incomplete closure, hourglass and bowing ratios were also higher in the High OHI group. The High OHI group contained three eldest patients with ages 77, 70 and 60; the rest were younger than 50. Bowing which may be influenced from age was not seen in stroboscopic results of these three elder patients, instead consecutively; hourglass, incomplete and complete closure levels were remarked. Posterior chink was observed in 22% of the Low OHI group and in 16% of the High OHI group. In a study, LPR has been shown to be present in 70% of the patients with MTD [10]. The stroboscopic findings of hourglass and smooth irregular vocal folds edges showed local edema of vocal cords, which again may be due to asymptomatic
LPR. Also in other precious study, 64% of the subjects presenting bowing have been demonstrated to have at least one incidence of LPR [11]. As we mentioned before, MTD, granulomas, nodules, Reinke’s edema, pseudosulcus, paroxysmal laryngospasm, laryngeal stenosis, and even cancer, may be seen as a result of LPR [1]. So, poor oral hygiene may provoke LPR or the coexisting asymptomatic LPR. Poor oral hygiene may cause this through malfunction of the chewing process of food. The relationship between oral hygiene and infectious diseases has been observed in many studies. It has been suggested that dental plaque may act as a reservoir of respiratory pathogens, especially in patients with periodontal disease. Scannapieco has found that the subjects having the median OHI value were 1.3 times more likely to have a chronic respiratory disease relative to those with OHI value of 0 [12]. It has been proposed that poor oral hygiene and periodontal disease promote oropharyngeal colonization by potential respiratory pathogens, including Enterobacteriaceae, Pseudomonas aeruginosa, and Staphylococcus aureus [13]. Paju also supports that oral bacteria, poor oral hygiene, and periodontitis seem to influence the incidence of pulmonary infections, especially nosocomial pneumonia episodes in high-risk subjects [14]. Associations between oral health and cancer has been examined for a number of specific cancers, like oral, upper gastrointestinal, lung, and pancreatic. These associations persisted after adjustment for major risk factors, including cigarette smoking and socioeconomic status [14–16]. Chronic inflammation is induced by periodontal pathogens, which cause breakdowns in normal cell growth in already initiated cells, inducing carcinogenesis. Also in poor oral hygiene and periodontal diseases, endogenous carcinogenic nitrosamines are produced by nitrate reducing bacteria [16]. Conversely, the effects GERD on oral hygiene have been observed. In a study by Ersin, the prevalence of dental erosion and the salivary yeast and salivary Mutans streptococci colonization in GERD children was found to be significantly higher than in healthy subjects [17]. The damage of laryngeal mucosa by gastric acids and pepsin has been the subject of several experimental and clinic studies [18,19]. Having taken all the above discussions into
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consideration, we hypothesized that oral hygiene may also influence laryngeal function and phonation. The various studies cited in above discussions all conclude that varying degrees of associations exist between laryngeal dysfunction and anomalies of the esophagus and of the stomach, including gastric secretions. The fundamental reason why these studies studied such relationships is the natural proximity of the larynx with the esophagus and the stomach. The parallel proximity of the larynx and the mouth led us to think that similar associations exist between laryngeal dysfunction and oral hygiene. We could not find any published analyses of such an association. Accordingly, we decided to make a study, which focused on the influence of oral hygiene on laryngeal dysfunction. Our thoughts were that poor oral hygiene would have effects on the laryngeal mucosa, impeding laryngeal function. Our aim was to put poor oral hygiene firmly in the list of etiological factors to check for in patients with laryngeal disorders. Our findings of high glottic closure impairment, supraglottic involvement and low MPT scores in the High OHI group correlate with LPR findings such as MTD. Although we chose our subjects to be without diagnosed and symptomatic LPR, our stroboscopic and aerodynamic results showed important similarity with LPR findings. So, poor oral hygiene may provoke LPR or the coexisting asymptomatic LPR. 5. Conclusion Our findings of high glottic closure impairment, supraglottic involvement and low MPT scores in the poor oral hygiene group correlate with LPR findings such as muscle tension dysphonia. Poor oral hygiene may aggravate potential LPR in people. This relationship deserves further detailed work including objective measures of LPR in asymptomatic people with poor oral hygiene. Thinking in parallel, some dysfunctions or diseases of the larynx may be avoided by simply preventing poor oral hygiene through dental consultations. Conflict of interest None.
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