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Structural changes for speech improvement in complete upper denture fabrication
Structural changes for speech improvement in complete upper denture fabrication John M. Palmer, Ph.D.* University
of Washington,
Seattle,
Wash.
A
s clinical consultant and adjunct professor in speech pathology to the Department of Prosthodontics and clinics of the University of Washington Dental School, it has been part of my responsibility to assess and advise in situations where patients seem to develop speech problems associated with dentures. The gap between theory and practice has become evident in this activity, for there are few practical guidelines to follow in assisting such patients. Several authors have written about speech-articulation problems thought to be associated with denture wearof the ing.’ -?’ A few point to careful construction denture to include speech or phonetic considerations, but there is little information to help resolve speech problems when they do occur in the denture patient.4. ‘. i
THE PROBLEMS Denture patients (both new and replacement) may complain of speech problems. Even though such problems might have pre-existed, the distortion of the speech itself is reported variously by the patient. It can range from such expressions as “making my speech difficult to understand,” or generally “imprecise.” or “mushy,” to such complaints as a “slushy St sound” or other sounds that are “S-like.” Dentists, too, vary considerably in their manner of describing speech problems,’ not being familiar with the terminology and classifications of the speech pathologist. The severity of the speech problem is in part dependent upon the reaction of the patient to the speech sound distortion. Some patients do not notice difficulties themselves, when to a listener, speech
*Professor, Departments of Speech and Hearing Sciences and Prosthodontics. t&pita1 English alphabet letters represent the speech sounds used as illustrations and examples, rather than the mire accurate international Phonetic Alphabet symbols in general used by xpeech pathologists.
0022-3913/79/050507
+ 04f00.4010
0 1979 The
C. V. Mosby
Co
problems might be clearly evident. Other patients complain vigorously and bitterly about what a listener might hear as a minimal difficulty if any at all. In general however, patients who do complain often have a mild to moderate problem and react according to their own standards of perfection and their need to speak socially and vocationally. In short, a considerable variety of reactions to speech sound differences can be expected. It seems obvious that complaints about speech should be verified. Each patient who is having complete dentures made should have a pretreatment speech evaluation if only to identify and record any pre-existing speech differences. Should only postinsertion problems exist, the dentist might seek another opinion of the speech complaint. The nature of the problems themselves may also vary, depending on how the patient describes them. A perceptive patient with an exceptional vocabulary might be accurate while another might use general terms to describe his problem. The patient’s own feelings as to the seriousness of the problem have a great deal to do with how he describes it. The clinician should identify the precise speech problem to which the patient refers. When identification and solving the problem are difficult or unsuccessful, consultation by a speech pathologist should be considered. The problems of a patient who has difficulty with S might easily be understood if he is observed protruding the apex of his tongue through the teeth. A frontal lisp or an approximation of n ‘I‘H sound might occur. Another example might be the patient whose S sound seems to splay out over the sides of the tongue or perhaps only over one: side (a lateral lisp). Not only might the S sound be a problem., but also the Z and perhaps the SH and ZH, and even the TSH and DZH. The unvoiced sounds, e.g., the S and SH and TSH, are more likely toi be in error than are the voiced Z. ZH, and DZH sounds.
THE
JOURNAL
OF PROSTHETIC
DEN’IISTRY
507
PHYSIOLOGIC ACOUSTICS Chierici and Lawson,” Palmer,8 and Troffer and Beder” have described the principles behind the speech problems as well as some descriptions of the types found in this population. Of importance in understanding that denture changes can improve speech function is the concept of air turbulence.* The sibilant sounds are produced by turbulent air across speech articulators. The flow of air through the respiratory tract is directed by the tongue in such a way that there is an air pressure drop across static structures such as teeth. The tongue first assumes a posture for creating the sound. It probably is elevated, at least apically, and locates itself by tactile cues to some anatomic landmark. The exhaled air stream courses through the lingual groove, “nozzled” toward some object (e.g., teeth) that will act as the articulator, the source of the air turbulence. The rationale for clinical management of patients having speech sound problems demands examination of all these factors. Certainly the tongue must have some facility in both postural changes and contour adjustments, i.e., it must be able to lift itself and move about in the mouth at the same time that it is forming the necessary air-flow channels for the speech sound.
POTENTIAL PROBLEMS The distortion of speech sounds in patients may be due to a problem with the static speech articulators, with the dynamic articulators, or with some combinations of these. The static structures are the nonmobile structures. These include the teeth, the alveolar ridges, and the bony palate. Deficits can occur because of the change from predenture to denture status. It is important to consider any pre-existing edentulous state, especially of long duration. To adjust from lack of articulators, demanding considerable compensatory physiologic maneuvering, to denture-formed articulators might be a difficult task, even though the new anatomy is “more normal.” Moving of teeth in their relationships from predenture to denture status also can be responsible for speech sound production changes. The patient’s ability to adjust to new tongue positions, new occlusal relationships, and new tooth orientation might prove difficult. The size and angulation of teeth are factors in the accommodation for the patient. In addition to changes in the static articulators, changes in the alveolar ridge are etiologic factors for speech problems. Loss of the incisive papilla, if it
occurs, as well as loss of the palatal rugae when covered by the denture base, have been suspected as being related to articulatory inefficiency. These changes in anatomic landmarks could be unimportant, but the loss of a source of air-flow turbulence from these protruding objects is a possible factor. Also, the loss of these landmarks could cause the tongue to lose an important tactile guidepost as it seeks the proper articulatory positioning for the speech sound production. In the nondenture person there is tactile feedback from the tongue and the mucosa of the alveolar ridge and palate. In the denture patient, one of these contributors to the feedback is covered by the denture base. The denture base further contributes to the problem when it is finely polished and made nearly frictionless and sensation-free bv the saliva. A predenture injury resulting in impairment of the musculature or cicatricial formation or interference with easy, facile maneuvering of the tongue might be associated with speech problems. The dentist should consider possible neurogenic aspects involving the tongue. Tremor conditions, such as Parkinson’s disease or peripheral neuropathologies such as XII nerve damage, are possibilities of underlying pre-existing conditions. Such a predisposing condition might well become prominent when the denture precipitates new oral physiology. Neuromotor problems, probably pre-existing the denture, might well be exaggerated by the insertion of dentures, or remain as they were but become more noticeable to the patient. The tongue can have some difficulty in sensory functioning, especially in the pinpoint landmark identification necessary for speech sound production. The mucosal changes that often occur over the years from smoking, injury, or the aging process possibly decrease the tactile sensitivity of the tongue in this delicate process. Lastly, tongue-thrusting must be considered. A few patients have demonstrated such extreme tongue-thrusting in speaking, resting, and swallowing that dentures have been dislodged. Dislodging is of considerable importance, but all patients who tongue-thrust might not show that severe an effect; instead, they might demonstrate speech sound distortions that concern them. For example, such patients might produce a speech sound similar to the TH sound when they intend to utter an S-like sound. This is lisping of a type and can cause any of several different reactions in the denture wearer. A speech pathologist might assist in identifying the problem
MAY
1979
VOLUME
41
NUMBER
5
STRUCTURAL
CHANCES
FOR SPEECH IMPROVEMENT
and suggesting remediation approaches, including minimal structural changes in the denture. To summarize these potential etiologic factors, there is the loss of tactile sensitivity because of the presence of the denture base and the possible neuromotor weaknessess from either central or peripheral breakdowns. Tooth size and position are important, as the feedback breakdown from changes in the is an obvious lingual mucosa. Tongue-thrusting difficulty. Combinations of these potential factors are likely and make it difficult to identify a single causative factor in speech sound production problems. RELATED
PROBLEMS
Inasmuch as a large percentage of denture wearers are in the geriatric group, one would expect to find other sequelae of the aging process that might affect speech. Presbycusis, loss of hearing, which occurs frequently, is a common example. The patient who has lost auditory self-monitoring has lost an important feedback pathway to control speech. The S and Z and the SH and ZH sounds, among other utterances, may be imprecise and unclear in many deaf people. Some differentiation between hearing loss and denture-caused problems should be made, especially at the initial examination. Behavioral problems associated with senescence, as well as accompanying physiologic changes, might include attitudes and understandings as well as changes in diet and even rest patterns. The emotional changes that can occur with aging affect the patient’s ability to objectively rate the severity of a problem. Life-style changes, when they occur, can cause confusion or over-concern and affect the way in which the patient presents his speech problem to the dentist. PROBLEM RESOLUTION Evaluation and identification
procedures
Based upon the previous rationale, an analysis of the speech sound problems as well as the physiologic system generating those problems should be made. The acoustic events themselves, the S and the SH sounds among others, should be isolated. The patient should be directed to produce these sounds alone, in words, and in phrases, and his conversational speech should be examined. Having determined that there is a problem, the next step is to examine the physiologic system. Oral examination for speech purposes is both static and dynamic. The activity of the lips, the
THE JOURNAL
OF PROSTHETIC
DENTISTRY
extent and symmetry of mandibular movement and of tongue movement in both extraoral and :ntraorai maneuvers, and the examination of the, icznpue surface for obvious tissue differences should ile madr. Such examination should take place both with and without new dentures in place and should be compared with any previous dcnturcs. Note the presence of asymmetrical tonpae placcment for speech sound production, e.g.. the F or I. as well as the S sounds. Also, tongue-thrjistmg of significance should be recognized, whethe! 01’ not it is part of any speech problem. At the same time, the stability of the tongue as it seats itself brietiv .igainst the denture for speech sound production should he noted. Inconsistencies in tongue piacemenr or a sliding-slipping tongue apex indicate diffi!-ulties In locating a regular position for the speech +ound. Is the aberrant tongue movement a funcl!on of the tongue, of the denture, or of both? Keml)ving the denture and having the patient repeat [he action might discriminate between intrinsic- ttmqur’ problems and those affected by thr denttire DENTURE
CHANGES
Denture factors such as proper tooth position, dimension of occlusion, alld correct vertical adequate tongue space must be considered first. If it is determined that the tongue is :I possible source of the speech problem, a structural change in the denture should be considered. .4 nonanatomic papilla placed on the oral surface of the denture somewhat posterior to the incisive papilla location (at about the location of the incisive carlal) could serve as both a source of turbulence and fox tactile locating purposes. This tiny papilla, tried out first in wax, is conical, about 3 to 4 mm in diameter at its base, but perhaps only’ 1 to 3 mm in height. Some patients with a tongue that grooves with difficult) should have a papilla more transversely elongated into almost rugae-like structu rcs.* Tiip papilla should conform to the structure and the [‘unction of the lingual apex as it elevates to the anterior denturr region for the production of spetch sounds. If it is determined that the tongue sari elevate easily but cannot seat itself, even rnomenrarily, for speech sound production, a fricTinn are:>. or tactile
*Earlier authorities (Bloomer’ and I.uchsinper ans~ .Gnoid’i, in suggesting nearlv exact replica&m of the natural anatomy into the denture base, have supported the notion of duplicating the palatal rugae. This has not been verified, nor’ !~a\ ii beconte general practice for speech purposes.
509
PALMER
cue mark might be placed on the denture base. Usually this is best placed at the oral (polished) surface of the denture posterior to the incisive papilla area. This can be wax, later changed to acrylic resin, or it could be a surface change in the denture base. The latter is sometimes done with a dental bur OI other abrasive to roughen a region 4 to 6 mm in diameter, sufficient for the patient to identify with his tongue tip. In some instances a deeper pit or even a hole provides an even more distinctive tactile cue mark. However, such action is usually extreme. No polishing of the changed area should take place. The tongue finds it easier to identify the somewhat irregular and rough region rather than a slippery and smooth area. The patients generally do not complain of discomfort. These procedures have also proved useful for the tongue-thrusting patient. Such individuals sometimes need a device to assist in developing a new neuromotor pattern involving the tongue in talking, resting, and swallowing. The papilla can remain permanently, be enlarged or diminished, or be moved from point to point with some ease. A speech clinician can offer help in finding the optimal placement region, but often time and practice are the best guides for these problems.
SUMMARY In the absence of any clearly identifiable pathologic condition, the prosthodontic patient demonstrating speech problems after insertion of complete dentures is having difficulty with loss of turbulence, because of the diminution of tactile location skills in speaking, or both. Potential aids to speech improvement are a nonanatomic papilla placed on the oral surface of the denture just posterior to the location of the incisive papilla, a transversely elongated rugae-
INFORMATION
like papilla at about region at that spot, the patient’s tongue effectiveness of such ned and judged with speech pathologist.
the same location, or an indentation to identify. The structural changes the cooperation
a roughened sufficient. for location and can be planof a qualified
The clinical experiences underlying this writing, the guidance and technical information, the encouragements and the support available came through the good graces of the faculty of the Department of Prosthodontics at the University of Washington. The editorial and content analyses and suggestions made hv Dr. Dale Smith are especially acknowledged.
REFERENCES 1. Van Than, J.: The Relationship Between Faults of Dentition and Defects of Speech. Cambridge, 1936, Cambridge Publishing, pp 254-257. 2. Kessler, H. E.: Speech as related to dentistry. Dent Radio Photog 28:41, 57, 1955. 3. Bloomer, H. H.: Speech as related to dentistry. Mich St Dent J 40:11, 1958. 4. Saizar, P.: Phonetique et prostheses. Actualites Odont 12:561 (cited in dsh Abstracts, 1, 1960). 5. TrofFer. C., and Beder, 0. E.: Immediate dentures and speech deficiencies. Dent Prog 1:264, 1961. 6. Bloomer. H. H.: Speech Defects Associated with Dental Malocclusions and Related Abnormalities. h Travis. L. E.: Handbook of Speech Pathology and Audiology. New York, 1971, Appleton-Century-Crofts, chap 28, p 739. 7. Luchsinger, R., and Arnold, G. E.: Voice-Speech-Language. Belmont, Calif., 1965, Wadsworth Publishing Co., p 650. 8. Palmer, J. M.: Analysis of speech in prosthodontic practice.J PROSTHET DENT 31:605, 1974. 9. Chierici, G., and Lawson, L.: Clinical speech considerations in prosthodontics: Perspectives of the prosthodontist and speech pathologist. J PROSTHET DENT 29:29. 1973. Reprint requeststo. DR. JOHN M. PALMER UNIVERSITY OF WASHINGTON DEPARTMENT OF SPEECH AND HEARING SCIENCES SEATTI k, W/\SH. 98195
FOR AUTHORS
Most of the provisions of the Copyright Act of 1976 became effective on January 1, 1978. Therefore, all manuscripts must be accompanied by the following written statement, signed by one author: “The undersigned author transfers all copyright ownership of the manuscript (title of article) to The C. V. Mosby Company in the event the work is published. The undersigned author warrants that the article is original, is not under consideration by another journal, and has not been previously published. I sign for and accept responsibility for releasing this material on behalf of any and all co-authors.” Authors will be consulted, when possible, regarding republication of their material.
MAY
1979
VOLUME
41
NUMBER
5
of Washington,
Seattle,
Wash.
A
s clinical consultant and adjunct professor in speech pathology to the Department of Prosthodontics and clinics of the University of Washington Dental School, it has been part of my responsibility to assess and advise in situations where patients seem to develop speech problems associated with dentures. The gap between theory and practice has become evident in this activity, for there are few practical guidelines to follow in assisting such patients. Several authors have written about speech-articulation problems thought to be associated with denture wearof the ing.’ -?’ A few point to careful construction denture to include speech or phonetic considerations, but there is little information to help resolve speech problems when they do occur in the denture patient.4. ‘. i
THE PROBLEMS Denture patients (both new and replacement) may complain of speech problems. Even though such problems might have pre-existed, the distortion of the speech itself is reported variously by the patient. It can range from such expressions as “making my speech difficult to understand,” or generally “imprecise.” or “mushy,” to such complaints as a “slushy St sound” or other sounds that are “S-like.” Dentists, too, vary considerably in their manner of describing speech problems,’ not being familiar with the terminology and classifications of the speech pathologist. The severity of the speech problem is in part dependent upon the reaction of the patient to the speech sound distortion. Some patients do not notice difficulties themselves, when to a listener, speech
*Professor, Departments of Speech and Hearing Sciences and Prosthodontics. t&pita1 English alphabet letters represent the speech sounds used as illustrations and examples, rather than the mire accurate international Phonetic Alphabet symbols in general used by xpeech pathologists.
0022-3913/79/050507
+ 04f00.4010
0 1979 The
C. V. Mosby
Co
problems might be clearly evident. Other patients complain vigorously and bitterly about what a listener might hear as a minimal difficulty if any at all. In general however, patients who do complain often have a mild to moderate problem and react according to their own standards of perfection and their need to speak socially and vocationally. In short, a considerable variety of reactions to speech sound differences can be expected. It seems obvious that complaints about speech should be verified. Each patient who is having complete dentures made should have a pretreatment speech evaluation if only to identify and record any pre-existing speech differences. Should only postinsertion problems exist, the dentist might seek another opinion of the speech complaint. The nature of the problems themselves may also vary, depending on how the patient describes them. A perceptive patient with an exceptional vocabulary might be accurate while another might use general terms to describe his problem. The patient’s own feelings as to the seriousness of the problem have a great deal to do with how he describes it. The clinician should identify the precise speech problem to which the patient refers. When identification and solving the problem are difficult or unsuccessful, consultation by a speech pathologist should be considered. The problems of a patient who has difficulty with S might easily be understood if he is observed protruding the apex of his tongue through the teeth. A frontal lisp or an approximation of n ‘I‘H sound might occur. Another example might be the patient whose S sound seems to splay out over the sides of the tongue or perhaps only over one: side (a lateral lisp). Not only might the S sound be a problem., but also the Z and perhaps the SH and ZH, and even the TSH and DZH. The unvoiced sounds, e.g., the S and SH and TSH, are more likely toi be in error than are the voiced Z. ZH, and DZH sounds.
THE
JOURNAL
OF PROSTHETIC
DEN’IISTRY
507
PHYSIOLOGIC ACOUSTICS Chierici and Lawson,” Palmer,8 and Troffer and Beder” have described the principles behind the speech problems as well as some descriptions of the types found in this population. Of importance in understanding that denture changes can improve speech function is the concept of air turbulence.* The sibilant sounds are produced by turbulent air across speech articulators. The flow of air through the respiratory tract is directed by the tongue in such a way that there is an air pressure drop across static structures such as teeth. The tongue first assumes a posture for creating the sound. It probably is elevated, at least apically, and locates itself by tactile cues to some anatomic landmark. The exhaled air stream courses through the lingual groove, “nozzled” toward some object (e.g., teeth) that will act as the articulator, the source of the air turbulence. The rationale for clinical management of patients having speech sound problems demands examination of all these factors. Certainly the tongue must have some facility in both postural changes and contour adjustments, i.e., it must be able to lift itself and move about in the mouth at the same time that it is forming the necessary air-flow channels for the speech sound.
POTENTIAL PROBLEMS The distortion of speech sounds in patients may be due to a problem with the static speech articulators, with the dynamic articulators, or with some combinations of these. The static structures are the nonmobile structures. These include the teeth, the alveolar ridges, and the bony palate. Deficits can occur because of the change from predenture to denture status. It is important to consider any pre-existing edentulous state, especially of long duration. To adjust from lack of articulators, demanding considerable compensatory physiologic maneuvering, to denture-formed articulators might be a difficult task, even though the new anatomy is “more normal.” Moving of teeth in their relationships from predenture to denture status also can be responsible for speech sound production changes. The patient’s ability to adjust to new tongue positions, new occlusal relationships, and new tooth orientation might prove difficult. The size and angulation of teeth are factors in the accommodation for the patient. In addition to changes in the static articulators, changes in the alveolar ridge are etiologic factors for speech problems. Loss of the incisive papilla, if it
occurs, as well as loss of the palatal rugae when covered by the denture base, have been suspected as being related to articulatory inefficiency. These changes in anatomic landmarks could be unimportant, but the loss of a source of air-flow turbulence from these protruding objects is a possible factor. Also, the loss of these landmarks could cause the tongue to lose an important tactile guidepost as it seeks the proper articulatory positioning for the speech sound production. In the nondenture person there is tactile feedback from the tongue and the mucosa of the alveolar ridge and palate. In the denture patient, one of these contributors to the feedback is covered by the denture base. The denture base further contributes to the problem when it is finely polished and made nearly frictionless and sensation-free bv the saliva. A predenture injury resulting in impairment of the musculature or cicatricial formation or interference with easy, facile maneuvering of the tongue might be associated with speech problems. The dentist should consider possible neurogenic aspects involving the tongue. Tremor conditions, such as Parkinson’s disease or peripheral neuropathologies such as XII nerve damage, are possibilities of underlying pre-existing conditions. Such a predisposing condition might well become prominent when the denture precipitates new oral physiology. Neuromotor problems, probably pre-existing the denture, might well be exaggerated by the insertion of dentures, or remain as they were but become more noticeable to the patient. The tongue can have some difficulty in sensory functioning, especially in the pinpoint landmark identification necessary for speech sound production. The mucosal changes that often occur over the years from smoking, injury, or the aging process possibly decrease the tactile sensitivity of the tongue in this delicate process. Lastly, tongue-thrusting must be considered. A few patients have demonstrated such extreme tongue-thrusting in speaking, resting, and swallowing that dentures have been dislodged. Dislodging is of considerable importance, but all patients who tongue-thrust might not show that severe an effect; instead, they might demonstrate speech sound distortions that concern them. For example, such patients might produce a speech sound similar to the TH sound when they intend to utter an S-like sound. This is lisping of a type and can cause any of several different reactions in the denture wearer. A speech pathologist might assist in identifying the problem
MAY
1979
VOLUME
41
NUMBER
5
STRUCTURAL
CHANCES
FOR SPEECH IMPROVEMENT
and suggesting remediation approaches, including minimal structural changes in the denture. To summarize these potential etiologic factors, there is the loss of tactile sensitivity because of the presence of the denture base and the possible neuromotor weaknessess from either central or peripheral breakdowns. Tooth size and position are important, as the feedback breakdown from changes in the is an obvious lingual mucosa. Tongue-thrusting difficulty. Combinations of these potential factors are likely and make it difficult to identify a single causative factor in speech sound production problems. RELATED
PROBLEMS
Inasmuch as a large percentage of denture wearers are in the geriatric group, one would expect to find other sequelae of the aging process that might affect speech. Presbycusis, loss of hearing, which occurs frequently, is a common example. The patient who has lost auditory self-monitoring has lost an important feedback pathway to control speech. The S and Z and the SH and ZH sounds, among other utterances, may be imprecise and unclear in many deaf people. Some differentiation between hearing loss and denture-caused problems should be made, especially at the initial examination. Behavioral problems associated with senescence, as well as accompanying physiologic changes, might include attitudes and understandings as well as changes in diet and even rest patterns. The emotional changes that can occur with aging affect the patient’s ability to objectively rate the severity of a problem. Life-style changes, when they occur, can cause confusion or over-concern and affect the way in which the patient presents his speech problem to the dentist. PROBLEM RESOLUTION Evaluation and identification
procedures
Based upon the previous rationale, an analysis of the speech sound problems as well as the physiologic system generating those problems should be made. The acoustic events themselves, the S and the SH sounds among others, should be isolated. The patient should be directed to produce these sounds alone, in words, and in phrases, and his conversational speech should be examined. Having determined that there is a problem, the next step is to examine the physiologic system. Oral examination for speech purposes is both static and dynamic. The activity of the lips, the
THE JOURNAL
OF PROSTHETIC
DENTISTRY
extent and symmetry of mandibular movement and of tongue movement in both extraoral and :ntraorai maneuvers, and the examination of the, icznpue surface for obvious tissue differences should ile madr. Such examination should take place both with and without new dentures in place and should be compared with any previous dcnturcs. Note the presence of asymmetrical tonpae placcment for speech sound production, e.g.. the F or I. as well as the S sounds. Also, tongue-thrjistmg of significance should be recognized, whethe! 01’ not it is part of any speech problem. At the same time, the stability of the tongue as it seats itself brietiv .igainst the denture for speech sound production should he noted. Inconsistencies in tongue piacemenr or a sliding-slipping tongue apex indicate diffi!-ulties In locating a regular position for the speech +ound. Is the aberrant tongue movement a funcl!on of the tongue, of the denture, or of both? Keml)ving the denture and having the patient repeat [he action might discriminate between intrinsic- ttmqur’ problems and those affected by thr denttire DENTURE
CHANGES
Denture factors such as proper tooth position, dimension of occlusion, alld correct vertical adequate tongue space must be considered first. If it is determined that the tongue is :I possible source of the speech problem, a structural change in the denture should be considered. .4 nonanatomic papilla placed on the oral surface of the denture somewhat posterior to the incisive papilla location (at about the location of the incisive carlal) could serve as both a source of turbulence and fox tactile locating purposes. This tiny papilla, tried out first in wax, is conical, about 3 to 4 mm in diameter at its base, but perhaps only’ 1 to 3 mm in height. Some patients with a tongue that grooves with difficult) should have a papilla more transversely elongated into almost rugae-like structu rcs.* Tiip papilla should conform to the structure and the [‘unction of the lingual apex as it elevates to the anterior denturr region for the production of spetch sounds. If it is determined that the tongue sari elevate easily but cannot seat itself, even rnomenrarily, for speech sound production, a fricTinn are:>. or tactile
*Earlier authorities (Bloomer’ and I.uchsinper ans~ .Gnoid’i, in suggesting nearlv exact replica&m of the natural anatomy into the denture base, have supported the notion of duplicating the palatal rugae. This has not been verified, nor’ !~a\ ii beconte general practice for speech purposes.
509
PALMER
cue mark might be placed on the denture base. Usually this is best placed at the oral (polished) surface of the denture posterior to the incisive papilla area. This can be wax, later changed to acrylic resin, or it could be a surface change in the denture base. The latter is sometimes done with a dental bur OI other abrasive to roughen a region 4 to 6 mm in diameter, sufficient for the patient to identify with his tongue tip. In some instances a deeper pit or even a hole provides an even more distinctive tactile cue mark. However, such action is usually extreme. No polishing of the changed area should take place. The tongue finds it easier to identify the somewhat irregular and rough region rather than a slippery and smooth area. The patients generally do not complain of discomfort. These procedures have also proved useful for the tongue-thrusting patient. Such individuals sometimes need a device to assist in developing a new neuromotor pattern involving the tongue in talking, resting, and swallowing. The papilla can remain permanently, be enlarged or diminished, or be moved from point to point with some ease. A speech clinician can offer help in finding the optimal placement region, but often time and practice are the best guides for these problems.
SUMMARY In the absence of any clearly identifiable pathologic condition, the prosthodontic patient demonstrating speech problems after insertion of complete dentures is having difficulty with loss of turbulence, because of the diminution of tactile location skills in speaking, or both. Potential aids to speech improvement are a nonanatomic papilla placed on the oral surface of the denture just posterior to the location of the incisive papilla, a transversely elongated rugae-
INFORMATION
like papilla at about region at that spot, the patient’s tongue effectiveness of such ned and judged with speech pathologist.
the same location, or an indentation to identify. The structural changes the cooperation
a roughened sufficient. for location and can be planof a qualified
The clinical experiences underlying this writing, the guidance and technical information, the encouragements and the support available came through the good graces of the faculty of the Department of Prosthodontics at the University of Washington. The editorial and content analyses and suggestions made hv Dr. Dale Smith are especially acknowledged.
REFERENCES 1. Van Than, J.: The Relationship Between Faults of Dentition and Defects of Speech. Cambridge, 1936, Cambridge Publishing, pp 254-257. 2. Kessler, H. E.: Speech as related to dentistry. Dent Radio Photog 28:41, 57, 1955. 3. Bloomer, H. H.: Speech as related to dentistry. Mich St Dent J 40:11, 1958. 4. Saizar, P.: Phonetique et prostheses. Actualites Odont 12:561 (cited in dsh Abstracts, 1, 1960). 5. TrofFer. C., and Beder, 0. E.: Immediate dentures and speech deficiencies. Dent Prog 1:264, 1961. 6. Bloomer. H. H.: Speech Defects Associated with Dental Malocclusions and Related Abnormalities. h Travis. L. E.: Handbook of Speech Pathology and Audiology. New York, 1971, Appleton-Century-Crofts, chap 28, p 739. 7. Luchsinger, R., and Arnold, G. E.: Voice-Speech-Language. Belmont, Calif., 1965, Wadsworth Publishing Co., p 650. 8. Palmer, J. M.: Analysis of speech in prosthodontic practice.J PROSTHET DENT 31:605, 1974. 9. Chierici, G., and Lawson, L.: Clinical speech considerations in prosthodontics: Perspectives of the prosthodontist and speech pathologist. J PROSTHET DENT 29:29. 1973. Reprint requeststo. DR. JOHN M. PALMER UNIVERSITY OF WASHINGTON DEPARTMENT OF SPEECH AND HEARING SCIENCES SEATTI k, W/\SH. 98195
FOR AUTHORS
Most of the provisions of the Copyright Act of 1976 became effective on January 1, 1978. Therefore, all manuscripts must be accompanied by the following written statement, signed by one author: “The undersigned author transfers all copyright ownership of the manuscript (title of article) to The C. V. Mosby Company in the event the work is published. The undersigned author warrants that the article is original, is not under consideration by another journal, and has not been previously published. I sign for and accept responsibility for releasing this material on behalf of any and all co-authors.” Authors will be consulted, when possible, regarding republication of their material.
MAY
1979
VOLUME
41
NUMBER
5