(1)
Faculdade de Ciências Médicas da
Santa Casa de São Paulo, São Paulo,
SP, Brasil.
Conict of interest: non-existent
Speech disorders related to alterations of the lingual frenulum
in schoolchildren
Alterações de fala relacionadas às alterações
do frênulo lingual em escolares
Dhyanna Domingues Suzart
(1)
Adriana Rahal Rebouças de Carvalho
(1)
Received on: December 23, 2015
Accepted on: September 16, 2016
Mailing address:
Domingues Suzart
Rua Macunaíma, 47 – Aldeia do Sol –
Polvilho – Cajamar/SP
CEP: 07792-045
E-mail: dhyanna.suzart@gmail.com
ABSTRACT
Purpose: to characterize and compare speech alterations related to the lingual frenulum alterations in
schoolchildren from 8;6 to 10;11 years old among the control and research group.
Methods: 52 school children were evaluated (8;6 to 10;11 years old) both genders, regularly enrolled in
private institutes divided into two groups: control group (without lingual frenulum alterations) and research
group (with lingual frenulum alterations). These children were initially evaluated through the Assessment
in Orofacial Motricity Protocol MBGR in a school clinic, through pictures used in this assessment. The
tests used for the statistical analysis were “Fisher Test”, “Qui Square” and “Anova”, as signicant level
5% (p<0.05).
Results: from the 52 children, 26 (50%) presented lingual frenulum alteration. From these 26 children, 21
(80.8%) presented diminished lingual tonus, 20 (76.9%) presented low tongue in the oral cavity and 16
(61.5%) presented articulation alteration. Regarding the other evaluated items, there were no statistically
signicant differences among the groups.
Conclusion: the short frenulum prevailed over the other lingual frenulum alterations classications. The
research group presented statistically signicant alterations when compared with the group control, in the
following items: tongue tonus, low tongue posture in the oral cavity and articulation. In the other items,
although there is no statistically signicant difference among the groups, there was a tendency of major
alteration in the research group. It was not possible to determine if alterations in phonetics speech are the
same regarding the different lingual frenulum alterations.
Keywords: Tongue; Muscle Tonus; Lingual Frenulum; Child
RESUMO.
Objetivo: caracterizar e comparar as alterações de fala relacionadas às alterações do frênulo lingual em
escolares, dos 8;6 anos aos 10;11 anos entre grupo controle e pesquisa.
Métodos: avaliou-se 52 crianças em idade escolar (8;6 anos a 10;11 anos), de ambos os gêneros,
regularmente matriculadas em Instituto privado, divididas em: grupo controle (sem alteração do frênulo
lingual) e grupo pesquisa (com alteração do frênulo lingual). As crianças foram avaliadas por meio do
Protocolo de Avaliação em Motricidade Orofacial utilizado em uma Clínica Escola e por meio das guras
utilizadas no Protocolo de Avaliação em Motricidade Orofacial, MBGR. Os testes utilizados para a análise
estatística foram “Teste de Fisher”, “Qui Quadrado” e “Anova”, adotando-se como nível de signicância
5% (p<0,05).
Resultados: das 52 crianças avaliadas, 26 (50%) apresentaram alteração do frênulo lingual. Destas, 21
(80,8%) apresentaram tônus de língua diminuído, 20 (76,9%) apresentaram língua baixa na cavidade oral
e 16 (61,5%) apresentaram problemas de articulação. Quanto aos demais itens avaliados, não foram
observadas diferenças estatisticamente signicantes entre os grupos.
Conclusão: o frênulo curto prevaleceu sobre as demais classicações da alteração do frênulo de língua.
O grupo pesquisa apresentou alterações estatisticamente signicantes quando comparado ao controle,
nos seguintes itens: tônus lingual, postura de língua baixa na cavidade oral e articulação. Nos demais
itens, apesar de não haver diferença estatisticamente signicante entre os grupos, houve uma tendência
de alteração maior no grupo pesquisa. Não foi possível determinar se as alterações de fala fonética são
iguais para as diferentes alterações do frênulo lingual.
Descritores: Língua; Tônus; Frênulo; Criança
Original articles
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Rev. CEFAC. 2016 Nov-Dez; 18(6):1332-1339 doi: 10.1590/1982-0216201618621715
Rev. CEFAC. 2016 Nov-Dez; 18(6):1332-1339
Lingual frenulum and speech disorders |
1333
INTRODUCTION
Speech is the motor act performed by the organs of
the stomatognathic system that express language, i.e.
the motor representation of language
1-3
.
In order for speech to be properly produced, it is
essential that there exist an anatomical balance of the
stomatognathic system allowing the articulators to
perform the movements required for its production
4
.
Furthermore, the individual must learn the physical
aspects to it, which correspond to the phonetics and
organizational or structural aspects of a language’s
system of sounds and are part of its phonology
5
.
The lingual frenulum is a fold of mucosa connecting
the tongue to the oor of the mouth.Its attachment
is closely related to the performance of tongue
movements and consequently the functions performed
by this organ
6-10
.
In order for the lingual frenulum attachment to be
classied as normal, it needs to extend from halfway on
the sublingual face down to the oor of the mouth
10-12
.
When its attachment is otherwise modied, the
lingual frenulum is then said to be altered.It is thus
classied either as short (correct attachment, albeit with
a smaller than usual size), as having an anteriorized
attachment (normal size, but attached to a point located
on the front half of the sublingual face, or even near
the apex), or short having an anteriorized attachment
(corresponding to a combination of the two previous
types)
13
.
The evaluation of the frenulum is indispensable
when the lingual mobility and orofacial functions are
abnormal. The speech therapist assesses the frenu-
lum’s condition by means of visual inspection, checking
the tongue’s mobility and usual position, as well as the
articulatory production of speech
8,10,14
.
Consequently, due to the alteration in the lingual
frenulum, the tongue may be prevented from normally
articulating with other stomatognathic structures, which
may, therefore, result in a phonetic speech disorder,
since this, according to the literature, is the orofacial
disorder most frequently found in the presence of an
altered frenulum
7,15,16
.
A study by Cuestas et al. in 2014 reported that in
preschool and school age, alterations in the lingual
frenulum manifest as difculties in articulating
phonemes for which the apex of the tongue must come
in contact with the incisive papilla and/or palate (/l/, /n/,
/r/, /t/, /d/, /s/, /z/)
17
.
Speech disorders, in general, have a negative impact
on the children’s social and school life, inuencing
their relationship with the environment and even their
self-image. They may suffer discrimination for not
speaking correctly.These reasons can jeopardize the
child’s health and quality of life.It is therefore essential
that the etiological agent(s) causing such changes be
diagnosed early so that their negative interference in
the individual’s life can be eliminated and/or reduced
by means of a precise intervention, which can reduce
or eliminate even minor changes, such as those of a
psychological nature, for instance
5,17
.
Therefore, the objective of this study was to charac-
terize and compare speech disorders related to altera-
tions of the lingual frenulum in schoolchildren, from
8;6 to 10;11 years of age, between the control and
the study groups.In addition, the specic objectives
of the study were:to phonetically characterize the
speech of schoolchildren; to identify whether there is
a relationship between the phonetic speech disorders
and altered lingual frenulum, and whether the phonetic
speech disorders are the same for the different altera-
tions in the lingual frenulum.
METHODS
This is a prospective, cross-sectional, qualitative
and quantitative study conducted at the José de Paiva
Netto Educational Institute (IEJPN), approved by the
institution’s Research Ethics Committee from Medical
Sciences College of the Santa Casa of São Paulo
(CEP-FCMSCSP) (number 771, 481/2014).
We conducted preliminary assessments in all
children with ages between 8;6 and 10;11 years, in
order to determine those who had lingual frenulum
alterations. Therefore, besides photographing the
cardinal points on the tongues of schoolchildren and
their lingual frenulum, the maximal mouth opening and
the opening with the apex of the tongue against the
incisive papilla were measured (a relation between the
two measurements, when <50% suggests alterations
in the lingual frenulum).
Out of a total of 89 children evaluated, 26 showed
alterations in their lingual frenulum, whereas a total
of 26 children had no alteration.Thus, the sample
consisted of 52 schoolchildren (aged from 8;6 to 10;11
years), of both genders, and divided into two groups:
• Study Group (SG)consisting of 26 children with
alterations in the lingual frenulum;
• Control Group (CG):consisting of 26 children with no
alteration in the lingual frenulum;
Inclusion criteria for both groups were: to be a
school-age child (aged between 8;6 and 10;11 years),
Suzart DD, Carvalho ARR Lingual frenulum and speech disorders
Rev. CEFAC. 2016 Nov-Dez; 18(6):1332-1339
1334
| Suzart DD, Carvalho ARR
and show no sign of phonological disorders. Exclusion
criteria for both groups were: to have undergone
speech therapy in the area of Orofacial Motricity; to
have performed frenectomy and/or lingual frenotomy;
to present neurological disorders or any physical or
cognitive disorder that might interfere in the speech
and audiological assessment; and to show anatomical-
functional alterations.
After the Voluntary and Informed Consent Form
(VICF) and the Voluntary and Informed Assent Form
(VIAF) were signed by the parents and/or guardians
of all children and by the children themselves, the
participants were evaluated in a private room at the
educational institution, initially by using the Orofacial
Motricity Assessment Protocol developed by the
Faculty of Medical Sciences at Santa Casa de São
Paulo (FCMSCSP). This protocol provides open- and
closed-ended questions, through which all structures,
muscles and orofacial functions are evaluated.
The items from the Adult Clinical Examination
Protocol used are as follows:
Facial measurements were taken with the aid of
a 6”, 0-150mm, digital caliper (Hardened Stainless),
manufactured in China, to check the maximum mouth
opening and opening with the apex of the tongue
against the incisive papilla and to verify whether or not
there were alterations in the lingual frenulum.
Subsequently, the following photographs of seated
subjects were taken with a digital camera SteadyShot
(Sony) xed onto a tripod: the face in the usual
posture; teeth occluded; cardinal points of the tongue
(4 photographs); with the mouth open; with the mouth
open and tongue elevated (inside the mouth/frenulum).
Three aspects of the tongue were assessed while
wearing disposable gloves and with the aid of a
disposable wooden spatula: morphology, tonus, and
mobility; and also, the type of lingual frenulum (normal;
anteriorized; short; short and anteriorized).
The palatine tonsils were evaluated by means of
clinical observation.
Speech was phonetically evaluated in order to
observe the absence or occurrence (unsystematic or
systematic) of omission, replacement and/or acoustic
distortion of the phones, locked articulation, jaw
deviation, low and anteriorized posture of the tongue on
the oor of the mouth, lips, and associated movements
of lips and cheeks, by means of shooting with the aid of
a digital Sony SteadyShot camera of the lower-third of
the face using the following questions:“Say your name
and how old you are”; “Say what you do for living (study,
work)”; “Count from 1 to 20 and say the months of the
year”; “Tell us about a trip (tour) you have taken and
enjoyed”.
Finally, the participants were asked to name the
pictures used in the Orofacial Motricity Assessment
Protocol, MGBR
18
, to complete the phonetic speech
assessment.
For a descriptive analysis, the results were tabulated
in a database, and a statistical analysis conducted,
using Fisher’s Test, Chi-Squared Test, and ANOVA,
with a signicance level of 5% (p<0.05).
Rev. CEFAC. 2016 Nov-Dez; 18(6):1332-1339
Lingual frenulum and speech disorders |
1335
Table 1. Distribution of the subjects in the group with no alteration in the lingual frenulum and in the group with alterations, according to
lingual tonus.
Lingual Tonus
Alteration In The Lingual Frenulum
p – Value
No Yes
N % N %
NORMAL 14 53.8 5 19.2 0.02
REDUCED 12 46.2 21 80.8
TOTAL 26 100 26 100
p <0.05 = statistically signicant
The statistical test used was Fisher’s Test, with a 5% (p<0.05) signicance level.
Table 2. Distribution of the subjects in the group with no alteration in the lingual frenulum and in the group with alterations, according to
a low tongue within the oral cavity.
Low Tongue Within
The Oral Cavity
Alteration In The Lingual Frenulum
p – ValueNo Yes
N % N %
NO 15 57.7 6 23.1 0.02
YES 11 42.3 20 76.9
TOTAL 26 100 26 100
p <0.05 = statistically signicant
The statistical test used was Fisher’s Test, with a 5% (p<0.05) signicance level.
Table 3. Distribution of the subjects in the group with no alteration in the lingual frenulum and in the group with alterations, according to
locked articulation.
Locked Articulation
Alteration In The Lingual Frenulum
p – ValueNo Yes
N % N %
NO 20 76.9 10 38.5 0.01
YES 6 23.1 16 61.5
TOTAL 26 100 26 100
p <0.05 = statistically signicant
The statistical test used was the Chi-Squared Test, with a 5% (p<0.05) signicance level.
RESULTS
Table 1 shows the relationship between the
presence of alterations in the lingual frenulum and
alterations in the lingual tonus.
In Table 2, the relationship between alterations in
the lingual frenulum and the low posture of the tongue
within the oral cavity is seen, during the articulatory
production.
Table 3 correlates the alterations in the lingual
frenulum to changes in the articulation, characterized
as a locked one.
Table 4 shows the relationship between phonetic
speech disorders and alterations in the lingual frenulum.
Table 5 shows the relationship between phonetic
speech disorders and alterations in the lingual frenulum.
Rev. CEFAC. 2016 Nov-Dez; 18(6):1332-1339
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| Suzart DD, Carvalho ARR
difference can be explained by the fact that, in the
current study, there are a greater number of females.
The results of this study showed a statistically
signicant difference between the groups with regard
to the tonus of the tongue, considering that 21 (80.8%)
children with alterations in the lingual frenulum
presented alterations to the lingual tonus, characterized
by a decrease in it. This is consistent with two studies
that found that the percentage of individuals with
an altered lingual tonus is higher among individuals
identied as having alterations in the lingual frenulum
and that their evaluation aids in reducing the doubts as
to the normal lingual frenulum
20,21
. A study conducted
in 2009 found that, in most of the sample with altera-
tions in the lingual frenulum, the tonus of the tongue
was also reduced
12
.
According to the literature, there may be a
relationship between alterations in the lingual frenulum
and lingual tonus
22
. When the lingual frenulum is altered,
the function of the tongue at rest will present at the oor
of the mouth due to difculties in maintaining the apex
against the incisive papilla, which may, therefore, even
result in a decreased tonus. It is noteworthy that, in this
study, out of the 26 (50%) children with alterations in the
lingual frenulum, the usual posture of the tongue (rest)
was unobservable, because, in order to determine the
DISCUSSION
Speech therapists have increasingly received
patients with complaints related to alterations in the
articulation of speech sounds. They may often be
associated with an altered lingual frenulum, which
may be either the cause or the aggravation of such
difculties
7
.
With regard to the lingual frenulum, the role of the
speech therapist entails assessing its conditions by
means of a visual inspection and verication of the
lingual movements, as well as evaluating stomato-
gnathic functions, including speech. When deemed
necessary, the speech therapist suggests the
assessment be carried out by yet another professional,
surgical intervention or speech therapy to eliminate
and/or reduce the alterations found
12
.
The subjects’ average age in this study was 9.78
years in the study group (with alterations in the lingual
frenulum) and 9.63 years in the control group (with
no alteration in the lingual frenulum). With respect to
gender, 15 (57.7%) girls were observed to have altera-
tions in the lingual frenulum, in agreement with a study
that found that 53.6% of the individuals evaluated were
females
19
. Another study
20
reports that alterations in
the lingual frenulum are more prevalent in males.This
Table 4. Distribution of the subjects in the group with no alteration in the lingual frenulum and in the group with alterations, according to
the phonetic alterations.
Phonetic Alterations
Alteration In The Lingual Frenulum
p – ValueNo Yes
N % N %
NO 25 96.2 20 76.9 0.05
YES 1 3.8 6 23.1
TOTAL 26 100 26 100
p <0.05 = statistically signicant
The statistical tests used were the Chi-Squared Test and ANOVA, with a 5% (p<0.05) signicance level.
Table 5. Relationship between speech disorders and the type of alteration in the lingual frenulum.
Lingual Frenulum
Speech Disorder
N %
SHORT 18 75.0
SHORT AND ANTERIORIZED 4 16.7
ANTERIORIZED 2 8.3
TOTAL 24 100
p <0.05 = statistically signicant
The statistical test used was the Chi-Squared Test, with a 5% (p<0.05) signicance level.