Effects of using the stimulating palatal plate in combination with orofacial stimulation on the habitual tongue and lip posture in children with trisomy 21: an integrative literature review

Furlan, Renata Maria Moreira Moraes; Almeida, Tahyna Duda Deps; Pretti, Henrique

doi:10.1590/1982-0216/20222427021

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REVIEW ARTICLES • Rev. CEFAC 24 (2) • 2022 • https://doi.org/10.1590/1982-0216/20222427021 copy

Effects of using the stimulating palatal plate in combination with orofacial stimulation on the habitual tongue and lip posture in children with trisomy 21: an integrative literature review

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Purpose:

to verify, in the literature, the effects of using the stimulating palatal plate on lip and tongue posture in children with trisomy 21.

Methods:

a search was conducted in Medline, LILACS, CINAHL, EMBASE, Scopus, Web of Science, and Cochrane. Original articles designed as clinical trials, longitudinal studies, or case-control studies, approaching stimulating palatal plate in the treatment of children with trisomy 21 and assessing habitual lip and tongue posture as an outcome, were included.

Literature Review:

a total of 376 studies were found, of which 10 met the selection criteria. They were published between 1996 and 2007 and carried out mostly in Europe, with small samples. The age when they began wearing the plate ranged from 1 month to 5 years, and intervention lasted from 4 to 58 months; in most cases, it was combined with orofacial muscle stimulation. Use frequency ranged from two to four times a day, each period lasting from 30 minutes to 2 hours. The children’s tongue and lip posture improved in most pieces of research.

Conclusion:

studies suggest that using the stimulating palatal plate in combination with orofacial muscle stimulation brings benefits to tongue and lip posture in children presented with trisomy 21.

Keywords:
Down Syndrome; Rehabilitation; Stomatognathic System; Speech, Language and Hearing Sciences; Dentistry

Source	Strategy
PubMed	("Down Syndrome"[MeSH Terms] OR "trisomy 21" OR mongolism OR "meiotic nondisjunction" OR "mitotic nondisjunction" OR "partial trisomy 21") AND ("orthotic devices"[MeSH Terms] OR "palatal plate" OR "Orofacial regulation therapy" OR "Castillo-Morales" OR "stimulating plate" OR "Functional appliances" OR "Palatal plates" OR "Modified Palatal Plate" OR "Orofacial Stimulation" OR "Castillo-Morales stimulating plate" OR "Castillo-Morales plate" OR "Palatal plate therapy" OR "Castillo-Morales concept" OR "Stimulating palatal plate")
CINAHL	(("Down Syndrome" OR "trisomy 21" OR mongolism OR "meiotic nondisjunction" OR "mitotic nondisjunction" OR "partial trisomy 21") AND ("orthotic devices" OR "palatal plate" OR "Orofacial regulation therapy" OR "Castillo-Morales" OR "stimulating plate" OR "Functional appliances" OR "Palatal plates" OR "Modified Palatal Plate" OR "Orofacial Stimulation" OR "Castillo-Morales stimulating plate" OR "Castillo-Morales plate" OR "Palatal plate therapy" OR "Castillo-Morales concept" OR "Stimulating palatal plate"))
Scopus	(ALL("Down Syndrome") OR ALL ("trisomy 21") OR ALL (mongolism) OR ALL ("meiotic nondisjunction") OR ALL ("mitotic nondisjunction") OR ALL ("partial trisomy 21")) AND (ALL ("orthotic devices") OR ALL ("palatal plate") OR ALL ("Orofacial regulation therapy") OR ALL ("Castillo-Morales") OR ALL ("stimulating plate") OR ALL ("Functional appliances") OR ALL ("Palatal plates") OR ALL ("Modified Palatal Plate") OR ALL ("Orofacial Stimulation") OR ALL("Castillo-Morales stimulating plate") OR ALL ("Castillo-Morales plate") OR ALL ("Palatal plate therapy") OR ALL ("Castillo-Morales concept") OR ALL ("Stimulating palatal plate"))
EMBASE	("Down Syndrome" OR "trisomy 21" OR "partial trisomy 21") AND ("orthotic devices")
Web of Science	ALL=(("Down Syndrome" OR "trisomy 21" OR mongolism OR "meiotic nondisjunction" OR "mitotic nondisjunction" OR "partial trisomy 21") AND ("orthotic devices" OR "palatal plate" OR "Orofacial regulation therapy" OR "Castillo-Morales" OR "stimulating plate" OR "Functional appliances" OR "Palatal plates" OR "Modified Palatal Plate" OR "Orofacial Stimulation" OR "Castillo-Morales stimulating plate" OR "Castillo-Morales plate" OR "Palatal plate therapy" OR "Castillo-Morales concept" OR "Stimulating palatal plate"))
Cochrane Library	(("Down Syndrome" OR "trisomy 21" OR mongolism OR "meiotic nondisjunction" OR "mitotic nondisjunction" OR "partial trisomy 21") AND ("orthotic devices" OR "palatal plate" OR "Orofacial regulation therapy" OR "Castillo-Morales" OR "stimulating plate" OR "Functional appliances" OR "Palatal plates" OR "Modified Palatal Plate" OR "Orofacial Stimulation" OR "Castillo-Morales stimulating plate" OR "Castillo-Morales plate" OR "Palatal plate therapy" OR "Castillo-Morales concept" OR "Stimulating palatal plate")) in Title Abstract Keyword - (Word variations have been searched)
LILACS	("Down Syndrome" OR "trisomy 21" OR mongolism OR "meiotic nondisjunction" OR "mitotic nondisjunction" OR "partial trisomy 21") and ("orthotic devices" OR "palatal plate" OR "Orofacial regulation therapy" OR "Castillo-Morales" OR "stimulating plate" OR "Functional appliances" OR "Palatal plates" OR "Modified Palatal Plate" OR "Orofacial Stimulation" OR "Castillo-Morales stimulating plate" OR "Castillo-Morales plate" OR "Palatal plate therapy" OR "Castillo-Morales concept" OR "Stimulating palatal plate")

Author (year of publication) Country - Design	Sample	Age when the plate started being worn	Intervention duration	Frequency of plate use	Combined orofacial stimulation?	Data collection method
Carlstedt et al. (1996)²⁴ Sweden - Experimental study	- SG: 14 children with T21 (used SPP) - CG: 15 children with T21 (did not use SPP)	From 3 months to 5 years, a mean of 24±6 months	12 months	30 minutes to 1 hour, 2x a day	Yes	Analysis of 10-minute video recording without SPP
Hohoff, Ehmer (1997)²⁵ Germany - Retrospective longitudinal observational study	- SG: 20 children with T21 (used SPP) - CG: 18 children with T21 (used SPP for a maximum of 1 month)	4.8 months on average	10.8 months on average	2 hours, 2x a day	Yes	Clinical observation and parental questionnaire
Hohoff, Ehmer (1999)²⁶ Germany - Retrospective longitudinal observational study	- Group 1: 38 children with T21 (used SPP for 4 months on average) - Group 2: 18 children with T21 (used SPP for 9.9 months on average)	6.5 months on average	- Group 1: 4 months on average - Grupo 2: 9.9 months on average	1 hour, 4x a day	Yes	Clinical observation and parental questionnaire
Carlstedt et al. (2001)²⁷ Sweden - Experimental study	- SG: 9 children with T21 (used SPP) - CG: 11 children with T21 (did not use SPP)	From 3 to 33 months	48 months	1 hour, 2 to 3x a day (minimum 2hr a day)	Yes	Clinical observation, videos, and parental interview
Schuster, Giese, (2001)²⁸ Germany - Retrospective longitudinal observational study	- SG: 20 children with T21, lack of lip closure, and habitual protruded tongue posture (used SPP), with a mean of 8.8±2.3 years. - CG: 13 children with T21, slightly changed tongue and lip posture (did not use SPP), with a mean of 8.9±3.0 years.	8±5 months	2 years	30 minutes, 4x a day	Yes	Clinical observation, photos, and parental questionnaire
Rincón et al. (2003)²⁹ Colombia - Quasi-experimental study	- SG: 31 children with T21 (used SPP) with a mean of 6 months (1-11 months) - CG: 13 children with T21 (did not use SPP) with a mean of 5 months (1-12 months)	From 1 to 11 months	6 months	4 hours a day	Not reported	Analysis of 10-minute video and parental questionnaire
Carlstedt et al. (2003)³⁰ Sweden - Experimental study	- SG: 9 children with T21 (used SPP) - CG: 11 children with T21 (did not use SPP)	From 3 to 33 months	48 months	1 hour, 2x a day	Yes	Clinical observation, videos, speech recording, and parental questionnaire
Zavaglia et al. (2003)³¹ Italy - Retrospective longitudinal observational study	- SG: 38 children with T21 (used SPP) - CG: 30 children with T21 (did not use SPP)	15 months on average	Minimum of 3 years; maximum duration not reported	Initially, 1 hour a day, increasing to 1 hour, 3x a day	Yes	Clinical observation
Backman et al. (2007)³² Sweden - Retrospective longitudinal observational study	- SG: 37 children with T21 (used SPP) with a mean age of 50.6 months (44-57) - CG: 31 children with T21 (did not use SPP) with a mean age of 49.8 months (42-56) - CG: 36 children without T21 (did not use SPP) with a mean age of 49.3 months (42-55)	< 6 months	42 months	5 to 30 minutes, 2 to 3x a day	Yes	Clinical observation, videos, and parental interview
Carlstedt et al. (2007)³³ Sweden - Experimental study	- SG: 9 children with T21 (used SPP) - CG: 11 children with T21 (did not use SPP) Mean age at the end of treatment: 5.6±11.5 years	From 3 to 33 months, a mean of 24 months	49 to 58 months	1 hour, 2x a day	Yes	Clinical observation, videos, and parental questionnaire

Author (year)	Assessment method for habitual tongue posture	Assessment method for habitual lip posture	Results
Carlstedt et al. (1996)²⁴	Duration of the following postures in the video: - Visible tip of the tongue - Active (moving) protruded tongue - Inactive (still) protruded tongue	Duration of the following postures in the video : - Mouth closed (lips fully touching each other) - Mouth open (lips not touching each other, and tongue inside the mouth)	- After 9 months of treatment, the mouth was closed for longer (P < 0.01), and the tongue was inactively protruded for less time (P < 0.01) in SG, in comparison with CG. - After 12 months, the mouth was closed for longer (p < 0.001), and the tongue was inactively protruded (p<0.001) and actively protruded for less time (p < 0.05) in SG, in comparison with CG.
Hohoff, Ehmer (1997)²⁵	Parental opinion on improved or worsened tongue posture on average 39.5 months after treatment.	Parental opinion on improved or worsened lip posture on average 39.5 months after treatment.	- In SG, 80% of the patients improve tongue and lip posture (parental opinion).
Hohoff, Ehmer (1999)²⁶	Parental opinion on tongue posture. Clinical assessment: - Tongue much protruded in relation to the lips - Tongue slightly protruded in relation to the lips - Tongue inside the oral cavity Group 1: data collected soon after the treatment. Group 2 - data was collected 53 months after the treatment.	Parental opinion on lip posture. Clinical assessment: - Mouth wide open - Mouth partly open - Mouth closed	- Group 1: 65.8% of the children improved lip and tongue posture, according to parental report. - Group 2: 88.9% improved lip posture, and 77.7% improved tongue posture, according to parental report. - In clinical assessment, most cases improved tongue and lip posture. - The analysis was qualitative, without comparison between the groups.
Carlstedt et al. (2001)²⁷	Clinical assessment: - Tongue on the lower lip, mouth closed - Inactive protruded tongue, mouth open - Active protruded tongue	Clinical assessment: - Lips fully closed - Lips partly closed - Inactive open mouth - Active open mouth	- CG had more periods with inactive lips and tongue (p < 0.05) when interacting. - No difference in tongue posture and lip closure between the groups.
Schuster, Giese (2001)²⁸	Clinical assessment: - Inside the oral cavity - On the alveolar ridge - On the lower lip - Eversion - Slightly protruded over the lower lip - Much protruded over the lower lip	Clinical assessment: - Mouth closed - Mouth open	- Tongue posture and lip closure improved in both groups - greater improvement in SG. - Better results were obtained in cases of greater adherence. - Positive parental feedback on tongue posture and decreased sialorrhea. The analysis was only descriptive.
Rincón et al. (2003)²⁹	Clinical assessment of tongue posture	Clinical assessment of lip posture	100% of SG children improved tongue posture, and 13 children progressed to lip closure. The analysis was qualitative, without comparison between the groups.
Carlstedt et al. (2003)³⁰	Duration of the following postures in the video: - Inside the oral cavity - Intermittently visible - Constantly visible	Duration of the following postures in the video: - Mouth closed - Mouth open less than half the time - Mouth open more than half the time	- Better lip closure and tongue posture (p < 0.05) in SG, in comparison with CG (p < 0.05).
Zavaglia et al. (2003)³¹	Clinical assessment: - Tongue occasionally protruded, passing the lower lip - Tongue slightly protruded, but continuously passing the lower lip - Tongue significantly protruded, passing the lower lip	Not reported	- Improved tongue posture and lip closure in most SG cases. No comparison was made between the groups.
Backman et al. (2007)³²	Clinical assessment: - Retracted - Visible - Out of the mouth	Clinical assessment: - Mouth closed - Mouth partly open - Mouth open	- Better facial expressions in children with T21 in SG than in CG. In SG with T21, 66.7% of the children had active facial expressions, in contrast with only 34.5% in CG with T21. The study does not specify in what terms the muscles were considered active or inactive; however, it mentions lip closure and tongue posture as parameters used in this classification.
Carlstedt et al. (2007)³³	Duration of the following postures in the video : - Tip of the tongue visible, and tongue over the lower lip - Inactive protruded tongue (still tongue, outside the oral cavity) - Active protruded tongue (moving tongue, outside the oral cavity).	Duration of the following postures in the video: - Mouth closed (total or partial lip closure) - Mouth open (active or inactive when open > 15 to 20 mm).	- SG had lip closure for longer (p < 0.05) and the tongue was inactively protruded for less time, in comparison with CG (p < 0.05).

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[1] Corresponding address: Renata Maria Moreira Moraes Furlan, Universidade Federal de Minas Gerais - Faculdade de Medicina - Departamento de Fonoaudiologia, Avenida Alfredo Balena, 190, Santa Efigênia, CEP: 30.130-100 - Belo Horizonte, Minas Gerais, Brazil, E-mail: renatamfurlan@gmail.com