Predictive factors for masticatory performance in Duchenne muscular dystrophy

Evaluation of the bioelectrical activity of the masticatory muscles in patients with narrowed maxillary transverse dimension compared to the occlusal norm

OBJECTIVE

The aim of the study was to determine how the electrical activity of the temporalis, masseter and sternocleidomastoid muscles differs in children with reduced transverse jaw dimension compared to children with normal occlusion.

DESIGN

It was a experimental study. Thirty-seven patients were included in the study. 18 in the study group received orthodontic treatment with removable appliances and 19 subjects were classified as normal occlusion subjects in the control group. A panoramic X-ray and digital intraoral scan were taken, followed by an surface electromyography of three muscle pairs (temporalis muscles, masseter muscles, sternocleidomastoid muscles) in resting position, while clenching and clenching on cotton rollers.

RESULTS

There was significantly greater activity in the experimental group than in the control group comparing muscles: temporalis muscles and masseter muscles in the resting position. Additionally, significantly greater activity of muscles in the control group was found during clenching. However, the asymmetry index of muscles indicates that there is significantly greater asymmetry of muscles activity in the experimental group. Compared to children with normal occlusion, children with a narrowed transverse dimension of the jaw have statistically significant differences in the bioelectrical activity of the temporalis, masseter and sternocleidomastoid muscles, as well as greater asymmetry in the bioelectrical voltage of the masseter muscles.

CONCLUSIONS

Patients with reduced transverse dimension of the jaw are characterized by increased resting activity of the masticatory muscles and reduced functional activity of the masticatory muscles. These patients have increased asymmetry in the bioelectrical tension of the masticatory muscles.

Muscle ultrasound in hereditary muscle disease

In this review we summarise the key techniques of muscle ultrasound as they apply to hereditary muscle disease. We review the diagnostic utility of muscle ultrasound including its role in guiding electromyography and muscle biopsy sampling. We summarize the different patterns of sonographic muscle involvement in the major categories of genetic muscle disorders and discuss the limitations of the technique. We hope to encourage others to adopt ultrasound in their care for patients with hereditary muscle diseases.

Congenital or Early Developing Neuromuscular Diseases Affecting Feeding, Swallowing and Speech – A Review of the Literature from January 1998 to August 2021

Background:

The knowledge about the impact of oral motor impairment in neuromuscular diseases (NMDs) is limited but increasing.

Objective:

The aim of this review was to collect and compile knowledge on how muscle weakness in congenital or early developing NMDs directly or indirectly affects feeding, swallowing, speech and saliva control.

Methods:

A literature search was performed in PubMed from January 1, 1998, to August 31, 2021. The keywords “feeding”, “dysphagia”, “swallowing”, “dysarthria”, “speech”, “drooling” and “sialorrhea” were used in combination with “paediatric neuromuscular disease” or specific diagnoses.

Results:

Sixty-five studies were selected for the review, 33 focused on feeding and swallowing, 11 on speech, four on a combination of feeding, swallowing, saliva control or speech and 17 general descriptions. Most of the studies reported on patients with a disorder affecting muscles. These studies show that muscle weakness and impaired motility affecting the muscles innervated by the cranial nerves may influence feeding, swallowing, and speech, and that respiratory function, general health and neurodevelopmental delay also influence these functions. Feeding impairment and breathing difficulties are common in NMDs. Lifesaving interventions such as tube feeding and ventilatory support are common in severe cases.

Conclusions:

Feeding impairment, dysphagia and dysarthria are prevalent in NMDs with congenital or early age of onset. Feeding and swallowing has been studied more than speech and saliva control. More children with NMD survive thanks to new treatment options and it is therefore urgent to follow up how these therapies may impact the development of feeding, swallowing, and speech.

Occurrence of symptoms in different stages of Duchenne muscular dystrophy and their impact on social participation

Introduction/Aims

As life expectancy improves for patients with Duchenne muscular dystrophy (DMD), new symptoms are likely to arise. This aims of this study are: (1) to explore the prevalence of a broad variety of symptoms in the various stages of DMD (with and without steroid use); (2) to explore the prevalence of common secondary diagnoses; and (3) to evaluate the social participation level of patients with DMD older than 16 y of age; and to explore correlations between social participation and symptoms.

Methods

A cross‐sectional self‐report questionnaire, including questions on functional level and health status, as well as a standardized participation scale was distributed among Dutch patients with DMD.

Results

Eighty‐four male patients with a mean age of 22.0 (SD = 10.0) y were enrolled. The most prevalent and limiting symptoms were difficulty coughing (58%), coldness of hands (57%), contractures (51%), stiffness (49%), fatigue (40%), myalgia (38%), and low speech volume (33%). Prevalent secondary diagnoses included cardiac disease (14%), neurobehavioral diagnosis (13%), low blood pressure (13%), and arthrosis (5%). Social participation correlated negatively with coldness of hands (r = − .29; P < .03), decreased intelligibility (r = − .40; P < .003), and chewing problems (r = − .33; P < .02).

Discussion

The prevalence of a broad spectrum of symptoms and secondary diagnoses is high in patients with DMD, and some of these symptoms are correlated with social participation. Growing awareness of new symptoms and secondary diagnoses among patients, caregivers, and professionals can enhance their recognition, possibly facilitating prevention and early treatment.

Dysphagia in adult myopathies

Dysphagia (impaired swallowing) is not a rare problem in various neuromuscular disorders, both in the pediatric and the adult patient population. On many occasions such patients are first presented to other medical specialists or health professionals. Disorders of deglutition are probably underrecognized in patients with a neuromuscular disease as a result of patient's and doctor's delay. This review will focus on dysphagia in adults suffering from a myopathy. Dysphagia in myopathies usually affects the oropharyngeal phases which rely mostly on voluntary muscle activity of the mouth, pharynx and upper esophageal sphincter. Dysphagia is known to contribute to a reduction of quality of life and may also lead to increased morbidity and mortality. The review includes an overview on symptomatology and tools of assessments, and elaborates on dysphagia in specific hereditary and acquired myopathies.

Management of the dentoalveolar effects of tongue hypertrophy in patients with Duchenne muscular dystrophy: A pilot study

Subjects affected by Duchenne muscular dystrophy (DMD) develop severe malocclusions with the progression of the disease, due to changes in orofacial musculature and function, including tongue hypertrophy. We aimed to evaluate the benefits of maintaining mandibular interarch width with the help of a simple fixed orthodontic appliance. Three adolescent DMD boys were selected consecutively to receive a passive rigid mandibular lingual arch, and followed for 4-5 years. An untreated age-matched control group was chosen and followed for a similar period. Study casts were obtained at baseline and after follow-up. Outcomes measured were overjet, overbite, maxillary and mandibular intermolar widths, mandibular arch depth, molar relationships, and the presence of lateral crossbites and anterior or lateral openbites. Changes in measurements obtained between the two time points were compared in each age-matched pair. There was a clinically important increase in the mandibular intermolar width in the non-treated children ranging from 2.5 mm to 9 mm, but not in those treated. Malocclusions generally deteriorated in untreated children while they remained stable in treated children. The use of a rigid mandibular lingual arch in boys with DMD can help slow down the rapid deterioration of the developing malocclusions that accompanies the progression of the disease.

Dying for a Meal: An Integrative Review of Characteristics of Choking Incidents and Recommendations to Prevent Fatal and Nonfatal Choking Across Populations

Purpose The purpose of this study was to conduct an integrative review of original research, across adult populations relating to fatal or nonfatal choking on food, to understand ways to respond to and prevent choking incidents. Method Four scientific databases (CINAHL, Medline, Web of Science, and EMBASE) were searched for original peer-reviewed research relating to fatal or nonfatal choking on foods. Data were extracted on study characteristics; factors leading up to, events at the time of, and actions taken after the choking incident; and impacts of choking incidents. An integrative review of the findings across studies identified several risk factors and recommendations to reduce the risk of choking. Results In total, 52 studies met the criteria for inclusion in this review, of which 31 were quantitative, 17 were qualitative, and 4 were of a mixed methods design. Studies reported the observations and narratives of bystanders or researchers, or else were large-scale autopsy studies, and included both the general public and people at risk of dysphagia. A range of food types were involved, and several actions were reported in response to food choking. Strategies to reduce the risk of choking were identified in the studies and are presented in 5 main categories. Conclusions Factors leading up to choking incidents extend well beyond the individual to the environment for mealtimes; the provision of appropriate mealtime assistance and oral care; and regular monitoring of general health, oral health, and medications. Bystanders' increased awareness and knowledge of how to respond to choking are vital. The results of this review could be used to inform service policy and training, for individuals at risk of choking, the people who support them, and the general public. Further research is needed to explore choking prevention and airway protection in individuals with dysphagia. Supplemental Material https://doi.org/10.23641/asha.8121131.

Growing patients with Duchenne muscular dystrophy: longitudinal changes in their dentofacial morphology and orofacial functional capacities

Aim

The aim of this study was to describe the longitudinal changes in facial morphology, dental arch alterations and oral functional capacities that occur in growing patients with Duchenne muscular dystrophy (DMD) in order to identify the effects of the progression of the disease.

Subjects and Methods

Twelve DMD patients (6.5-17.5 years of age) and 12 matched controls were screened on two different occasions (T1 and T2), 2 years apart. Dental casts, lateral cephalometric radiographs, maximal posterior bite force and labial force were measured to determine changes in their functional capacities and dentofacial morphology. Furthermore, the thickness and echogenicity of the masseter muscle were measured during clenching.

Statistical evaluation

Unpaired t-tests were performed to evaluate the differences between the DMD patients and their healthy matched controls; paired t-tests were used to assess the changes that occurred within each group between T1 and T2.

Results

Between T1 and T2 the following changes were observed: widening of the lower dental arch for the DMD patients of 2.6mm (±0.9mm) compared to a slight reduction of -0.1mm (±0.8mm) for the control group (P = 0.001). We found a statistically significant reduction of the sagittal skeletal intermaxillary relationship (ANB-angle) of 2.0° (±2.0°) in the DMD group (P = 0.012). In T1 and T2, the maximal posterior bite force and the labial force were lower for the DMD patients compared to the control group (P = 0.001), who showed an increase during this period.

Conclusion

The results indicate that DMD influences the facial morphology, dental arch dimensions and oral functional capacities. The longitudinal perspective of this study revealed that the worsening of most of the measured parameters is associated with the progression of the disease. Besides the expected deterioration of the functional measurements, we found in all patients, a marked transverse increase of the posterior part of the dental arches, more in the lower than in the upper, resulting in posterior crossbites, as well as a tendency towards a skeletal Class III relationship.

Duchenne and Becker muscular dystrophy in adolescents: current perspectives

Duchenne muscular dystrophy (DMD) and Becker muscular dystrophy (BMD) are life-limiting and progressive neuromuscular conditions with significant comorbidities, many of which manifest during adolescence. BMD is a milder presentation of the condition and much less prevalent than DMD, making it less represented in the literature, or more severely affected individuals with BMD may be subsumed into the DMD population using clinical cutoffs. Numerous consensus documents have been published on the clinical management of DMD, the most recent of which was released in 2010. The advent of these clinical management consensus papers, particularly respiratory care, has significantly increased the life span for these individuals, and the adolescent years are now a point of transition into adult lives, rather than a period of end of life. This review outlines the literature on DMD and BMD during adolescence, focusing on clinical presentation during adolescence, impact of living with a chronic illness on adolescents, and the effect that adolescents have on their chronic illness. In addition, we describe the role that palliative-care specialists could have in improving outcomes for these individuals. The increasing proportion of individuals with DMD and BMD living into adulthood underscores the need for more research into interventions and intracacies of adolescence that can improve the social aspects of their lives.

Dystrophic changes in masticatory muscles related chewing problems and malocclusions in Duchenne muscular dystrophy

Dysphagia in Duchenne muscular dystrophy (DMD) worsens with age, with increasingly effortful mastication. The aims of this study were to describe mastication problems in consecutive stages in a group of patients with DMD and to determine related pathophysiological aspects of masticatory muscle structure, tongue thickness, bite force and dental characteristics. Data from 72 patients with DMD (4.3 to 28.0 years), divided into four clinical stages, were collected in a cross sectional study. Problems with mastication and the need for food adaptations, in combination with increased echogenicity of the masseter muscle, were already found in the early stages of the disease. A high percentage of open bites and cross bites were found, especially in the later stages. Tongue hypertrophy also increased over time. Increased dysfunction, reflected by increasingly abnormal echogenicity, of the masseter muscle and reduced occlusal contacts (anterior and posterior open bites) were mainly responsible for the hampered chewing. In all, this study shows the increasing involvement of various elements of the masticatory system in progressive Duchenne muscular dystrophy. To prevent choking and also nutritional deficiency, early detection of chewing problems by asking about feeding and mastication problems, as well as asking about food adaptations made, is essential and can lead to timely intervention.

Constipation in Duchenne Muscular Dystrophy: Prevalence, Diagnosis, and Treatment

OBJECTIVES

To determine the prevalence and clinical characteristics of constipation among patients with Duchenne muscular dystrophy (DMD).

STUDY DESIGN

This cross-sectional prospective study included 120 patients (age range 5-30 years old) with an established diagnosis of DMD. Participants filled out the constipation section of a validated Questionnaire on Pediatric Gastrointestinal Symptoms based on Rome-III Criteria (QPGS-RIII) for the diagnosis of functional constipation as part of a routine clinic visit. We evaluated several potential screening methods for constipation: the Bristol stool form scale, routine physical examination, and fecal load on abdominal radiograph. These methods were compared with the QPGS-RIII in diagnosing functional constipation. Risk factors for the development of functional constipation were determined.

RESULTS

Based on the QPGS-RIII, 46.7% of patients with DMD in this cohort were diagnosed with functional constipation. Prevalence was not affected by age or functional status. None of the screening methods tested were sensitive enough to diagnose functional constipation. Among patients with constipation, only 43.6% received specific treatment for constipation and only one-half of these treated patients reported resolution of constipation.

CONCLUSIONS

This study systematically examined constipation among patients with DMD and provides evidence that constipation among patients with DMD is highly prevalent, underdiagnosed, and undertreated. QPGS-RIII is easy to administer and is an efficient tool to diagnose functional constipation in patients with DMD in a clinic setting.

Fighting Against Disuse of the Masticatory System in Duchenne Muscular Dystrophy: A Pilot Study Using Chewing Gum

Duchenne muscular dystrophy patients report masticatory problems. The aim was to determine the efficacy of mastication training in Duchenne muscular dystrophy using chewing gum for 4 weeks. In all, 17 patients and 17 healthy age-matched males participated. The masticatory performance was assessed using a mixing ability test and measuring anterior bite force before, shortly after and 1 month after the training. In the patient group the masticatory performance improved and remained after 1-month follow-up, no significant changes in anterior maximum bite force was observed after mastication training. In the healthy subject the bite force increased and remained at the 1-month follow-up; no significant differences in masticatory performance were observed. Mastication training by using sugar-free chewing gum in Duchenne muscular dystrophy patients improved their masticatory performance. Since bite force did not improve, the working mechanism of the improvement in chewing may relate to changes of the neuromuscular function and coordination, resulting in improvement of skills in performing mastication.