JICDRO is a UGC approved journal (Journal no. 63927)

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Year : 2021  |  Volume : 13  |  Issue : 2  |  Page : 135-138

Speech assessment and recording by orthodontist in patients with cleft lip and palate

Department of Orthodontics and Dentofacial Orthopedics, Swargiya Dadasaheb Kalmegh Smruti Dental College and Hospital, Nagpur, Maharashtra, India

Date of Submission25-Jan-2021
Date of Decision02-Apr-2021
Date of Acceptance29-Nov-2021
Date of Web Publication17-Jan-2022

Correspondence Address:
Dr. Rashmi Sunil Jawalekar
Department Of Orthodontics and Dentofacial Orthopedics, Swargiya Dadasaheb, Kalmegh Smruti Dental, College and Hospital, Nagpur, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jicdro.jicdro_7_21

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Speech is a complex motor skill that involves the co-ordination of diverse muscle groups. Gross motor movements of the muscles responsible for inspiration and expiration must be coupled with intricate the muscles of larynx; soft palate tongue and lips to produce sustained intelligible speech. A defect in structure, position, or motor control of any element involved with the mechanical production of speech alters the quality of sound produced. Complete palatopharyngeal closure is required for the production of certain sounds such as plosives, while phonemes such as vowels and nasal consonant require opening of the palatopharyngeal port in varying degrees. Hypernasal speech is the common symptom in patients with valopharangeal incompetence (VPI). The treatment option includes surgical correction, prosthetic rehabilitation, and speech therapy. The optimal result requires a multidisciplinary approach for restoration of the defects.

Keywords: Cleft lip and palate, orthodontic treatment, speech assessment, speech evaluation, speech therapy

How to cite this article:
Jawalekar RS, Jawalekar SS. Speech assessment and recording by orthodontist in patients with cleft lip and palate. J Int Clin Dent Res Organ 2021;13:135-8

How to cite this URL:
Jawalekar RS, Jawalekar SS. Speech assessment and recording by orthodontist in patients with cleft lip and palate. J Int Clin Dent Res Organ [serial online] 2021 [cited 2022 May 28];13:135-8. Available from: https://www.jicdro.org/text.asp?2021/13/2/135/335876

   Introduction Top

Cleft lip and palate (CLP) is a congenital anomaly which can affect a child from any social, educational, and economical family. Patients with CLP are rehabilitated by a multidisciplinary team approach involving specialist from pediatrics; plastic surgeons; orthodontist; genetics; social worker; nursing; ENT; speech therapy maxillofacial surgery; pediatric dentist; prosthodontist, and the psychologist. The orthodontic treatment of patients with cleft is extensive, initiating at birth and continuing into adulthood until the completion of skeletal growth. The role of orthodontist in timing and sequence of treatment is important in terms of overall team management. It is the orthodontist who is in contact with the patient for the longest period, especially the period of growth. He is in a position to collect the maximum database by the observation of patient from time to time to provide a totally factual appraisal. A variable database then can be used with wisdom for comprehensive treatment planning. Perceptual speech assessment is central to the evaluation of speech outcomes associated with cleft palate and velopharyngeal dysfunction. The need is to capture meaningfully the sound of speech based on detailed phonetics.

There are the differences in measuring speech for clinical, audit, and research activities. Blind independent analysis of speech data by specialist therapist is recommended as the gold standard methodical approach, when reporting audit and research outcomes. The requirement for on-going training in the listening skill for specialist therapist is also advocated. The clinical evaluation of speech can be conducted by an orthodontist during routine orthodontic appointments. Speech can be recorded in an acoustically treated room using a unidirectional microphone. During listening task, each sample can be rated on a score sheet rating of speech is based on speech sound (phonetic characteristics and the speech outcome meaning. The methods commonly advocated for speech assessment include Temple Street Scale, Pegoraro-Krook Scale (1988), Pittsburg Scale (Mac Williams and Philips 1979 and categorical system of articulation problems in the cleft palate (Ainoda and Okazaki 1993).

   Discussion Top

Speech is considered one of the primary outcome measures of CLP management and yet its measurement is elusive and challenging. One of the aims of 1993 International congress on CLCP was to establish the basis of international protocols of speech assessments and measurement. With increasing awareness among the patients and advancement of medical services in developed countries, it is rare to find an adult with untreated CLCP. In developing countries, resources to provide coordinated team work are difficult. Further public awareness and availability of treatment anomalies are limited. In such situations, the management of CLCP demands the changes of approach, technique, and philosophy. As the patient is in contact with orthodontist for the longest period of time during the growth period, orthodontist can keep the data record of speech analysis from time to time when the patient visits clinic for routine orthodontic visits. Single operators' record in speech analysis in areas where speech specialist care has limitations is of great importance.

Patients who are operated late are not motivated to follow-up for rehabilitation sessions regularly. The chances of such patients reporting for orthodontic care are limited. They are accepted for their appearance and their speech is understood in their immediate environment. These patients have limited demands from the life. Such cases are rehabilitated by surgery and prosthetic care. Speech therapy has limitations as the speech pattern is established.

Grunwellv et al. described the general principal of perceptual speech assessment[1] in the clinical context as:

  • Data collection
  • Recording
  • Analysis
  • Interpretation
  • The live clinical databases are excellent for recording the characteristic of population and process of care. This type of data can be usefully used to inform clinical practice within a unit.[2] However, the result should be interpreted as the local evidence of audit and should not be considered generalizable.

Collection of data

  • Speech sampling should include
  • Simulability
  • Rote speech
  • Sentence and syllable repetition
  • Sample of conversational speech.

Grunwell et al. (1993) stated that the spontaneous or conversational speech[1] sample is very important. Kuehn and Moller[3] detailed that conversational speech may provide important information about consistency or deterioration of articular proficiency and changes in resonance characteristics. Sentence sampling is not only an expedient technique but also allows for the control of phonetic content of elicited speech sample. Van Denmark reported high correlation between the task of sentence repetition and spontaneous speech.[4] It allows comparable speech samples to be routinely collected as a part of data collection on the longitudinal basis. Every language can have nationally agreed speech sample including the set of sentences. Sell et al.[5] proposed that each sentence should have one for target consonant in the different word position. Each sentence should be formulated based on phonetic with no other influencing vulnerable consonants in the sentence. It should be possible for the sentences to be represented pictorially; be meaning full and relevant containing the maximal number of each target consonant.

Lohmander and Olssons review found that evaluation was most frequently based on spontaneous speech and single word.[6] Only 9% of articles were based on sentence repetition. Hutlers[7] and Hennigsson[8] have drawn attention to the importance of having phonetically similar speech material. Consonant and vowels syllables to construct the sentence can be used to ensure that there are comparable datasets. Euro-cleft speech group (2000) advocated that cross linguistic comparison[9] should be based on common consonants in the languages. These recommendations clearly make narrow phonetic transcription mandatory.

It found that consonant production was better for repeated sentences than read sentences. Keuning et al. reported no difference between read and repeated sentence.[10] There are some advantages of repeating sentences. Repeating sentences does not interact with literacy skills. Sentence repetition can be used in as young as 4 years in contrast to reading.

The rate at which sentence elicitation takes place is under the control of adult eliciting sentences.[9] The patient can be encouraged to maintain eye contact with the listener in order that the face can be viewed during the analysis. It is advised that one approach is adopted and maintained longitudinally over time to keep dataset comparable even when literacy skills have been acquired.

Jyotsna Murthy[11] analyzed the speech outcome of primary palate repair in 131 older patients (over 10 years of age). Preoperatively, these patients showed mild, moderate, and severe articulatory errors of 14%, 48%, and 38%, compared to postoperatively 44%, 48%, and 8%.

Similarly, 64% of patients showed normal or mild resonance postoperatively as opposed to 23% preoperatively. Nasal emission showed very little improvement, probably due to habituation patterns underlying this problem. The results of the study showed 55% of the patients within the first three grades of intelligibility postoperatively as compared to only 22% preoperatively. This improvement in intelligibility is attributed to significant improvement in the articulation and resonance postoperatively. All patients showed improvement in all the parameters of speech but very few achieved normal speech.

A study on audiological problem in un-operated cleft palate patients from India showed that 76% had mild-to-moderate conductive deafness.[12] The established articulation patterns and persistent incompetent velopharyngeal port makes speech outcome less than satisfactory.

It is always possible to add additional speech task as long as core dataset is always gathered. Kuehn and Moller (2000)[3] advocated the use of standard reading passages for older patients.

Importance of recording

The importance of recording achieves needs to be stressed. Wyatt et al. 1996 stated that it is only through such data that independent assessment by speech–language pathologist therapist is possible.[9] Adequate system for the documentation of recording is of paramount importance in order that retrieval is easily undertaken. There is also a need to ensure uniformity of the amplitude of speech samples. Jhon et al. (2003) suggested that nature of speech recording medium such as analog or digital may have an impact on the analysis.[9]

Speech analysis

Earlier speech reporting systems were simplistic and inadequate and developed by professional and not speech therapist.[4],[5] A system that is still in use is the traditional error frame works of substitution; distortion: omission and gross substitution. Recent approaches to speech measurement focus on speech symptoms associated with the velopharyngeal function. These are:

  • Pittsburgh Scale (Mac Williams and Philips 1979)
  • The categorical system of articulation (problems in cleft palate by Ainoda and Okazaki (1993)
  • Temple Street Scale (Sweeney 2001)

The Eurocleft speech group (1999, 2000)[5] developed a cross linguistic detailed speech analysis for children beyond speech plans. The Gos Speech Assessment frameworks for speech assessment were developed as a comprehensive and standardized approach to assessing speech in the clinical setting in the UK cleft center. Closely aligned to Gos Speech Assessment with a common set of sentence elicitation material, − the Cleft Audit Protocol for Speech − CAPS was developed for the audit purpose.

Rating scales

With this background in mind, the speech assessment at clinical practice has the following protocol:

Rapport is established with the patient in the first few visits to reduce the anxiety and consciousness on part of patient and parents. Conversation on topics which are common and requires little extraunderstanding even if speech is affected such as names of his parents and common words; name of school, city are brought up in conversation. When the patient is accustomed to the environment of clinic and he is made to understand the importance of speech therapy.

He/she is made to read the local “Barakhadi” that is the Ka; Kha; Gha Chart. Barakhadi almost cover all the consonants, vowels, and fricatives. It is observed that some words are common in all languages and well suited for speech performance.

The fricative “S” is especially sensitive to morphological changes. Speaking slowly; repeating the words and sentences is recorded.

  • Misarticulation are noted pronounced as “Ta”
  • Bilabials such as pa; ba; ma
  • Dental words Ta; The; Ma
  • Blends are then tried screw; brush; rubber, etc.

Clusters are then tried. Tra; Dra; Bhra; usually Sanskrit have blends and clusters. The elderly person in the family usually co-operate in the learning process of Shlokas and with slow training most of the patients show improvement in speech. Recording both with clinician and parents are assessed after parents' reports improvement in legibility and difficult misarticulations for patients are handed later.

Speech intelligibility

Speech Intelligibility Scale (Pegoraro-Krook 1995)[13] as per the understanding of speech sound (phonetic characteristics and the speech outcome meaning) is used to assess speech. It is graded as follows:

  • Normal speech
  • Mild: Mild intelligibility is mildly impaired speech yet speech sound and meaning can be understood
  • Mild to moderate: speech sounds can be partially understood and meaning can be full understood
  • Moderate: some difficulty in understanding speech sound with some impaired understanding of meaning
  • Moderate to severe: Great difficulty in understanding speech sound and understanding of meaning of is very Impaired
  • Severe: Speech sound and meaning cannot be understood.

Speech samples and listing levels can be adjusted. Speech improvement after placing a prosthesis was seen by most of the patients. Most patients (70.4% presented with improved speech intelligibility. According to Bzoch (2004), nasal air emission when not audible does not interfere with speech perception.

   Conclusion Top

Speech is a complex motor skill that involves the coordination of diverse muscle groups. Gross motor movements of the muscles responsible for inspiration and expiration must be coupled with intricate the muscles of the larynx; soft palate tongue and lips to produce sustained intelligible speech. A defect in structure, position, or motor control of any element involved with the mechanical production of speech alters the quality of sound produced.

Complete palatopharangeal closure is required for the production of certain sound such as plosives, while phonemes such as vowels and nasal consonant require opening of the palate-pharangeal port in varying degrees. Hypernasal speech is the common symptom in patients with valopharangeal incompetence treatment option includes surgical correction, prosthetic rehab, and speech therapy.

The optimal result requires a multidisciplinary approach for the restoration of the defects. A thorough speech assessment protocol must be followed to make sure that knowledge transfer is seamless to facilitate an efficient treatment plan.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Grunwellv P. Processes of phonological change in developmental speech disorders. Clin Linguist Phon 1992;6:101-22.  Back to cited text no. 1
Pereira VJ, Sell D, Tuomainen J. Effect of maxillary osteotomy on speech in cleft lip and palate: Perceptual outcomes of velopharyngeal function. Int J Lang Commun Disord 2013;48:640-50.  Back to cited text no. 2
Kuehn DP, Moller KT. Speech and language issues in the cleft palate population: The state of the art. Cleft Palate Craniofac J 2000;37:1-35.  Back to cited text no. 3
Sell D, John A, Harding-Bell A, Sweeney T, Hegarty F, Freeman J. Cleft Audit Protocol for Speech (CAPS-A): A comprehensive training package for speech analysis. Int J Lang Commun Disord 2009;44:529-48.  Back to cited text no. 4
Grunwell P, Brondsted K, Henningsson G, Jansonius K, Karling J, Meijer M, et al. A six-centre international study of the outcome of treatment in patients with clefts of the lip and palate: The results of a cross-linguistic investigation of cleft palate speech. Scand J Plast Reconstr Surg Hand Surg 2000;34:219-29.  Back to cited text no. 5
Lohmander A, Olsson M. Methodology for perceptual assessment of speech in patients with cleft palate: A critical review of the literature. Cleft Palate Craniofac J 2004;41:64-70.  Back to cited text no. 6
Hutters B, Bau A, Brøndsted K. A longitudinal group study of speech development in Danish children born with and without cleft lip and palate. Int J Lang Commun Disord 2001;36:447-70.  Back to cited text no. 7
Henningsson G, Isberg A. Influence of palatal fistulae on speech and resonance. Folia Phoniatr (Basel) 1987;39:183-91.  Back to cited text no. 8
Sell D, Grunwell P, Mildinhall S, Murphy T, Cornish TA, Bearn D, et al. Cleft lip and palate care in the United Kingdom – The Clinical Standards Advisory Group (CSAG) Study. Part 3: Speech outcomes. Cleft Palate Craniofac J 2001;38:30-7.  Back to cited text no. 9
Keuning KH, Wieneke GH, Dejonckere PH. The intrajudge reliability of the perceptual rating of cleft palate speech before and after pharyngeal flap surgery: The effect of judges and speech samples. Cleft Palate Craniofac J 1999;36:328-33.  Back to cited text no. 10
Murthy J. Management of cleft lip and palate in adults. Indian J Plast Surg 2009;42 Suppl:S116-22.  Back to cited text no. 11
Ramana YV, Nanda V, Biswas G, Chittoria R, Ghosh S, Sharma RK. Audiological profile in older children and adolescents with unrepaired cleft palate. Cleft Palate Craniofac J 2005;42:570-3.  Back to cited text no. 12
de Carvalho-Teles V, Pegoraro-Krook MI, Lauris JR. Speech evaluation with and without palatal obturator in patients submitted to maxillectomy. J Appl Oral Sci 2006;14:421-6.  Back to cited text no. 13


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