|Year : 2021 | Volume
| Issue : 2 | Page : 68-75
The effectiveness of a patakara device in improving oral function and quality of life in people with intellectual disabilities
Cheng-Hung Tsai1, Yu-Ching Chou1, Jin-Ding Lin2, Gunng-Shinng Chen3
1 School of Public Health, National Defense Medical Center, Taipei, Taiwan (R.O.C), Taiwan
2 School of Public Health, National Defense Medical Center; Institute of Long Term Care, Mackay Medical College, Taipei, Taiwan (R.O.C), Taiwan
3 Department of Dentistry, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan (R.O.C), Taiwan
|Date of Submission||24-Mar-2020|
|Date of Decision||13-Apr-2020|
|Date of Acceptance||07-Jul-2020|
|Date of Web Publication||02-Sep-2020|
Dr. Gunng-Shinng Chen
Department of Dentistry, Neihu Main Facility, Tri-Service General Hospital, National Defense Medical Center, No. 325, Sec. 2, Cheng-gong Rd., Neihu District, Taipei City 11490
Source of Support: None, Conflict of Interest: None
Background: Better labial closure strength (LCS) may improve eating, swallowing, and quality of life. Patakara is an efficient device to enhance lip strength. In this study, we analyzed differences in LCS and quality of life between before and after training with Patakara in people with intellectual disabilities. Methods: We recruited twenty participants with intellectual disabilities who had poor eating status, lower LCS, or poor oral hygiene status. These participants performed training using Patakara three times a day (3 min each time for five times/week) for 3 months. Oral examination was performed twice, and structural questionnaires and lip force measurements were performed five times. Cheek temperature was also recorded. Results: The maximum value of lip force showed a significant increase during the 3-month training period. In addition, the proportion of participants who kept food in the mouth for a long time when eating significantly reduced. Moreover, the physical functioning and mental health scores of SF-36 showed a significant increase. Conclusions: Patakara training effectively increased lip muscle strength and improved dietary function. Nevertheless, further studies with a longer training duration to investigate the long-term effects of Patakara training are needed.
Keywords: Patakara, intellectual disability, oral function, quality of life, labial closure strength
|How to cite this article:|
Tsai CH, Chou YC, Lin JD, Chen GS. The effectiveness of a patakara device in improving oral function and quality of life in people with intellectual disabilities. J Med Sci 2021;41:68-75
|How to cite this URL:|
Tsai CH, Chou YC, Lin JD, Chen GS. The effectiveness of a patakara device in improving oral function and quality of life in people with intellectual disabilities. J Med Sci [serial online] 2021 [cited 2021 Apr 16];41:68-75. Available from: https://www.jmedscindmc.com/text.asp?2021/41/2/68/294294
| Introduction|| |
According to the World Health Organization, intellectual disability is “a condition of arrested or incomplete development of the mind, which is especially characterized by impairment of skills manifested during the developmental period, which contribute to the overall level of intelligence, i.e., cognitive, language, motor, and social abilities.” People with intellectual disabilities have poor oral hygiene conditions, and the prevalence of oral diseases such as dental caries and teeth loss is higher in them than that in the general population., Except oral cancer, oral diseases are basically not fatal to humans; however, good oral condition is evidently directly correlated with a better quality of life.
Because of inadequate intelligence, people with intellectual disabilities not only have poor self-cognition, self-care, and social adaptability but also have poor ability to maintain their oral health. In addition, some such people have difficulty eating and their oral function is insufficient, which affects their diet and quality of life.
Labial closure strength (LCS) develops at the age of 18–20 years. The maximum lip strength of male and female individuals is approximately 14–16 and 10–12 N, respectively. Lip strength, however, begins to decline after 60 years of age; by the age of 80 years, it tends to be approximately equal to that of a 3-year-old child., Lip closing function is related to eating, bolus formation, swallowing, and facial expressions. Accordingly, low lip strength can cause difficulty in mouth closure and lack of saliva, and it has even been related to cerebrovascular diseases and dementia.,,
Patakara (Actwell Technology Inc., Taiwan), an oral training device made of flexible plastic, was invented in Japan in 1997, and it is a great tool to enhance lip strength. By increasing LCS, it improves blood circulation in the brain, activates facial muscles, coordinates the tongue and throat, and strengthens parasympathetic nerves., Oral exercise requires effective operation of the lips, tongue, and larynx. Patakara can train the muscles of the mouth and enhance facial expressions, and it increases lip strength to improve oral function. Patakara is mainly used to improve the closing strength of the lips and surrounding muscles. Using this device is reportedly beneficial for those who have sleep-related diseases, have undergone cerebral stroke surgery, and are undergoing rehabilitation training for cerebral hemorrhage surgery. Patakara improves the quality of sleep and stops mouth breathing and promotes nose breathing. Because using this device stretches the muscles of the cheeks and lips and fixes the hyoid, the swallowing function is also effectively improved. At present, there exist few studies that have explored the use of Patakara in people with intellectual disabilities; moreover, the relationship among LCS, oral function, and quality of life of such people warrants investigation.
In this study, our aim was to analyze differences in LCS and quality of life in people with intellectual disabilities before and after they used Patakara and explore the correlation of training using this device with their lip strength and quality of life.
| Methods|| |
This was a quasi-experimental, pre–post study, including one group of participants, conducted at an institution for people with intellectual disabilities in New Taipei City, Taiwan.
Ethical and governance approvals
This study was approved by the Institutional Review Board of Tri-Service General Hospital (TSGHIRB approval no. 1-106-05-096). Written informed consent was obtained from all participants before study initiation, and their identity was encrypted to comply with the Declaration of Helsinki so as to avoid the invasion of privacy.
Participants and data collection
We included twenty participants (13 with moderate intellectual disabilities and 7 with severe intellectual disabilities) having poor eating status and poor oral function, but excluded those who could not follow the training steps. The participants completed questionnaires as pretest before training using Patakara.
The structural questionnaire comprised three parts. The first part recorded demographic data, including age, height, weight, and blood pressure. For the second part, a dentist from the Department of Dentistry at Tri-Service General Hospital performed an oral examination for each participant and calculated the number of normal teeth and abnormal (including dental caries, missing teeth, and filling teeth) teeth, along with the amount of saliva and tongue coating. The participants were also asked to record their eating and breathing status in this part of the questionnaire. The particular section of the questionnaire assessed the oral and dietary functions of participants, with questions on dietary status, whether they could eat themselves or had to be fed, how long they took to consume each meal, whether they kept food in their mouth without chewing it when eating, whether they were incapable of putting food in their mouth when eating, whether only moving the mouth up and down when chewing, whether they always used the same part of their mouth for chewing, whether they kept food in their mouth for a long time, whether they easily choked when eating, whether they experienced mouth breathing, whether their tongue tended to become easily exposed, and whether they experienced involuntary drooling easily. Finally, the third part of the questionnaire was the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) to assess the quality of life in participants. The SF-36 is a generic well-known self-administered questionnaire, comprising of 36 items corresponding to eight quality of life domains, including physical functioning (PF), role physical (RP), body pain (BP), general health (GH), vitality (VT), social functioning (SF), role emotional (RE), and mental health (MH) [Table 1]. The SF-36 has been translated into many languages and developed around the world; it can be completed by the participant or via an interview. Moreover, it has good reliability and validity, with Cronbach's alpha ranging from 0.60 to 0.94. Each scale score for the aforementioned eight domains is summed and averaged, with the overall value ranging from 0 to 100 points; higher scores indicate a better quality of life.
In this study, 3 months of training using Patakara (three times a day, 3 min each time, five times per week) was performed in order to observe differences in the oral function and quality of life of participants. LCS was measured using a beauty health checker (BHC-V01, Musashino-city, Tokyo, Japan); in brief, a sensor was placed between the lips and gums of a participant, and the maximum and minimum LCS were recorded.
Informed consent was obtained, and the questionnaires were completed by all participants with the assistance of their instructors. Oral examination was performed by a doctor before training and at training completion (i.e., after 3 months). LCS was measured before training and after training for 15 days, 1 month, 2 months, and 3 months. Cheek temperature was measured using a forehead thermometer every time before and after training to record differences in temperature.
Categorical variables were presented as the numbers of times and percentages, and continuous variables as means and their standard deviations or minima and maxima.
We tested differences in age, height, weight, systolic blood pressure (SBP) and diastolic blood pressure (DBP), and oral examination between male and female participants using the Mann–Whitney U-test, whereas those in cheek temperature between before and after training were calculated using the Wilcoxon signed-rank test. Differences in the amount of saliva and tongue coating between male and female participants were analyzed by the Chi-square test. McNemar test was used to analyze differences in dietary functions between before and after training for half a month, 1 month, 2 months, and 3 months separately. We analyzed all repeated measurement variables, including differences among the five measurements of lip force, meal time, and SF-36 score, during the 3-month training period by using repeated-measures analysis of variance. Simple linear regression was used to analyze the relationship of LCS and oral function with SF-36 scores.
Data management was conducted by Microsoft Excel 2016, and SPSS (version 22.0; IBM) was used for statistical analyses. P < 0.05 indicated statistical significance.
| Results|| |
All the SF-36 data were coded, with some questions reverse coded, and higher scores indicated a better quality of life [Table 2]. This study included twenty participants, and their average age was 42.2 ± 16.1 years. There were no differences between men and women in terms of height, weight, and SBP and DBP (P > 0.05). Regardless of the amount of saliva or tongue coating, no statistically significant differences were present between the male and female participants (P > 0.05) [Table 3].
The maximum value for lip force showed a statistically significant increase (P = 0.028), and the average values for lip force over a period of time were 2.4, 3.1, 4.2, 4.3, and 4.8 N [Figure 1]. The average minimum value for lip force showed no statistically significant differences at each training stage (P > 0.05), but in men, the average minimum lip force demonstrated a statistically significant difference among all training stages (P = 0.038), increasing from 0.6 N before training to 1.3 N after the 3-month training.
|Figure 1: The trend of labial closure strength (N) before and after training|
Click here to view
[Table 4] shows the oral function of the participants. No statistically significant differences were present in the length of eating time during the 3-month training (P > 0.05). The proportion of participants who kept food in their mouth for a long time statistically significantly decreased after training from 4% to 1% (P = 0.031). There were 17 participants who could properly eat (8%), whereas the remaining 3 (1%) needed food to be cut into smaller pieces when eating. After training, the proportion of participants who could properly eat increased to 9%; however, this increase was statistically nonsignificant (P > 0.05). The proportion of participants who only moved the mouth up and down when chewing, always used the same part of their mouth for chewing, and easily choked when eating decreased; however, the values were statistically nonsignificant (P > 0.05). Finally, the proportion of participants who needed to be fed, those who kept food in their mouth without chewing, and those incapable of putting food in their mouth when eating did not statistically significantly change (P > 0.05).
|Table 4: Oral function and dietary status before and after Patakara training|
Click here to view
The proportion of participants who experienced mouth breathing, who involuntarily drooled easily, and whose tongue tended to become easily exposed was lower. The proportion did not show a statistically significant change over the 3-month training period [P > 0.05; [Table 4]]. Regarding cheek temperature, measured before and after each training session, we observed that the temperature statistically significantly increased (P < 0.001) [Table 5].
As presented in [Table 6], the sum of SF-36 scores decreased in the first 2 months of training but increased after 3 months of training. However, there was no statistically significant difference (P > 0.05). Regarding the eight specific domains, the PF score decreased at first and then increased from 62.3 to 62.8 (P = 0.008), whereas the MH score significantly increased from 66.8 to 71.0 over the 3-month training period (P = 0.038). No significant changes were observed in the RP, BP, GH, VT, SF, and RE scores. The PF, RP, BP, and GH scores were averaged to represent the physical component summary score, and the VT, SF, RE, and MH scores were averaged to represent the mental component summary score (MCS). The changes in physical and MCS were nonsignificant during the 3-month training period (P > 0.05).
In this study, we further analyzed lip force with SF-36 scores by using simple linear regression. [Table 7] indicates that the GH score is negatively related to LCS after training for 15 days; that is, the GH score decreased with an increase in LCS (P < 0.05).
|Table 7: Simple linear regression of labial closure strength and short-form-36 scores|
Click here to view
| Discussion|| |
Lip force starts to decline with age; premature aging in case of people with intellectual disabilities may also decrease lip force much sooner than that in the general population, which emphasizes the need for training using Patakara. Herein, the maximum lip force of participants significantly increased from 2.4 to 4.8 N after 3 months of training, and the minimum lip force of male participants significantly increased from 0.6 N before training to 1.3 N after training. These results indicated that training using Patakara can effectively strengthen the lip muscles. Although few studies have focused on Patakara use in people with intellectual disabilities, relevant research on other populations can serves as a basis for supporting the current results.
Noro et al. studied lip force distribution in the general population. Here, we studied twenty participants who had lower LCS than that observed in the general population before training. After the 3-month training with Patakara, lip force showed a statistically significant increase (P = 0.028). Although lip force of most participants (n = 17) was still lower than of the general healthy population, some (n = 3) achieved the normal lip force level. LCS in case of male participants was lower than that of female participants, attributable to the higher age of the male participants in this study.
A study by Matsumoto et al. at Okuno Hospital (Tokyo, Japan) included seven patients with speech impairment and nine with dementia, along with eight controls. All the seven patients underwent lip training using Patakara for 3 min three times a day for 37 days. As per the reported results, lip strength in the training group tended to increase, whereas that in the control group showed no difference after training. Moreover, in a study by Ishikawa et al., elderly participants (3 male and 16 female participants) at care institutions underwent training using Patakara for 24 weeks (3.5–4 min/training session), and it was found that after training, lip force statistically significantly increased from 2.6 to 4.4 N (P = 0.003). Furthermore, Ibrahim et al. enrolled 17 women aged >40 years who underwent training using Patakara; they were classified as either experiencing or not experiencing a particular condition (e.g., snoring, bad breath, mouth breathing, asthma, allergies, and bleeding gums). Thirteen women who had undergone the training (four times each day, 3 min each time, for 14 weeks) showed an increase in lip strength from 5.7 to 9.6 N (P < 0.05); in addition, 11 women who continued training for up to 24 weeks showed an increase in average lip strength from 4.9 to 12.9 N (P < 0.05).
Suzuki et al. subjected six participants with sleep disorders to training using Patakara for 6 months (5 min each time, twice a day, 4 days/week) and performed measurements by using Lip De Cum and averaged over three measurements. The results demonstrated a statistically significant increase in lip force from 8.8 to 12.9 N after training (P = 0.001). Furthermore, in a case study, Yoshimiura et al. included 40-year-old female patients with bad breath and obstructive sleep apnea syndrome and asked them to use Patakara for 2 months (5 min each time, four times a day) to improve lip force, which led to a significant increase in lip strength.
Taken together, the current results agreed to those reported in previous studies. It can thus be concluded that LCS can be effectively improved on training using Patakara.
Hsu et al. indicated that to eat most kinds of the food, having >20 natural teeth is ideal. In addition, the most important factor affecting the ability to chew is the presence of natural teeth, not age. In comparison with healthy individuals, those having more missing teeth are more likely to face difficulties in chewing. In this study, the number of normal teeth of participants in our study was close to the lower limit to maintain normal chewing ability, which may affect the chewing function. Herein, we observed that the number of participants who kept food in their mouth for a long time when eating significantly decreased, indicating that training using Patakara had positive effects on dietary functions.
Previous studies have reported that in addition to improving lip strength, training using Patakara improves breathing habits, resulting in a change from oral to nasal breathing patterns.,, Here, after 3 months of training, the proportion of participants with oral breathing patterns decreased from 40% to 30%, but the difference was not statistically significant (P > 0.05).
Overall, during the early training period, we observed that poor oral and dietary functions were associated with poor quality of life. After 3 months of training, no significant correlation was found between oral and dietary functions and quality of life, indicating that training using Patakara increased lip force and eliminated the adverse effects of poor oral and dietary functions on quality of life.
Our results indicated that after training, better lip strength was related to better quality of life, but most associations were statistically nonsignificant (P > 0.05). There was a negative relationship between the GH score and LCS, which could be attributed to the discomfort caused by the training. However, no negative effects were present after training. In addition, there was no negative relationship between the SF-36 score and LCS after training (P > 0.05). Nevertheless, additional studies with longer training durations are warranted.
This study had some limitations. Of the 20 participants, 13 had moderate and 7 had severe intellectual disabilities. We believe that the chosen participants were more likely to understand the instructions and steps involved in the process of training using Patakara. Therefore, the significant increase in lip force after training may not be extrapolated to all intellectual disabilities due to the degree of cognitive impairment. In addition, in this study, if the training time had been longer, we would have seen a higher increase in lip force. However, participants may skip training a few times due to illness or work, thereby causing a bias in the results.
| Conclusions|| |
Here, we found that the maximum lip force significantly increased from 2.4 to 4.8 N after the 3-month training using Patakara and that the training could effectively increase lip muscle strength and improve dietary function. Nevertheless, additional studies with a longer training duration to investigate the long-term effects of training using the Patakara device are warranted.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the participants have given their consents for their images and other clinical information to be reported in the journal. The participants understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Our greatest appreciation to all the volunteers participated in this study and to Actwell Technology Incorporation for providing us with technical support and training equipment during the study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
World Health Organization. The Tenth Revision of the International Classification of Diseases and Related Disorders (ICD–10). World Health Organization; 1992.
Finkelman MD, Stark PC, Tao W, Morgan JP. Relationship between duration of treatment and oral health in adults with intellectual and developmental disabilities. Spec Care Dentist 2014;34:171-5.
Wu NJ, Huang ST, Cheng YA, Hsieh ST, Hsiao SY, Chi NC, et al
. Effects of oral health education on the knowledge, attitudes, and behavior of caregivers in an institution. Chin J Dent 2007;26:226-33.
Yu H, Huang S and Chen H. Association of dietary and dental hygiene habits with the prevalence of dental caries of 6–12 year-old schoolchildren in eastern Taiwan. Taiwan J Oral Med Sci 2008;24:37-48.
Mac Giolla Phadraig C, Guerin S, Nunn J. Should we educate care staff to improve the oral health and oral hygiene of people with intellectual disability in residential care? Real world lessons from a randomized controlled trial. Spec Care Dentist 2015;35:92-8.
Kaede K, Kato T, Yamaguchi M, Nakamura N, Yamada K, Masuda Y. Effects of lip-closing training on maximum voluntary lip-closing force during lip pursing in healthy young adults. J Oral Rehabil 2016;43:169-75.
Noro A. Basic and clinical subjects of myofunctional therapy using a new oral rehabilitation apparatus part. 2 evaluation of chronological changes of” labial-closure-strength” from youth to adults. Jpn J Conserv Dent 2002; 45:817-28.
Matsumoto MR, Aoshima MC, Tsumura MK. Using Myofunctional Therapy Device (Lip Trainer Patakara®) in order to rehabilitate patients of Dementia and Dysarthria. Japan; 2003.
Tamura F, Fukui T, Kikutani T, Machida R, Yoshida M, Yoneyama T, et al
. Lip-closing function of elderly people during ingestion: Comparison with young adults. Int J Orofacial Myology 2009;35:33-43.
Yoshimiura M, Suzuki H, Tanaka H, Asakawa R, Chow C, Kawara M. Lip muscle training improves halitosis and obstructive sleep apnea syndrome: A case report. J Dent Sleep Med 2016;3:31-2.
Susuki H, Asano T, Watanabe A, Aono H, Yoshimura M, Nagata R, et al
. The effects of oral muscle strength training on sleep quality (part 1). Japan Dental Association 120th
Memorial Academic Conference. Japan; 2011.
Ishikawa M, Ishikawa S, Kamata H, Akihiro Y, Hamada U, Yonei Y. Efficacy of a health promotion program with facial mimetic muscle training in residents of a medical care facility for the elderly. Anti Aging Med 2010;7:120-8.
McKee G. Are there meaningful longitudinal changes in health related quality of life-”SF36, in cardiac rehabilitation patients? Eur J Cardiovasc Nurs 2009;8:40-7.
Ware JE Jr., Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care 1992;30:473-83.
Ibrahim F, Arifin N, Rahim ZH. Effect of orofacial myofunctional exercise using an oral rehabilitation tool on labial closure strength, tongue elevation strength and skin elasticity. J Phys Ther Sci 2013;25:11-4.
Suzuki H, Watanabe A, Akihiro Y, Takao M, Ikematsu T, Kimoto S, et al
. Pilot study to assess the potential of oral myofunctional therapy for improving respiration during sleep. J Prosthodont Res 2013;57:195-9.
Hsu KJ, Lee HE, Wu YM, Huang RD, Wu JH, Yen YY. Relationship between the remaining natural teeth status and the chewing ability of middle-aged and older adults in the Kaohsiung Area, Southwestern Taiwan. Chin J Dent 2007;26:167-75.
Arakawa I, Koide K, Takahashi M, Mizuhashi F. Effect of the tongue rotation exercise training on the oral functions in normal adults-Part 1 investigation of tongue pressure and labial closure strength. J Oral Rehabil 2015;42:407-13.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]