Swallowing assessment in obstructive sleep apnea: insights from surface electromyography Gislaine Aparecida Folha, Denny Marcos Garcia, Cláudia Maria de Felício Sleep and Breathing, 2026 Purpose To investigate the electromyographic activity (sEMG) of the suprahyoid/submental (SH) muscles during swallowing in adults with different OSA severities, controlled for body mass index (BMI), and to establish predictive factors for changes in muscle activity. Methods This cross-sectional observational study included 37 adults diagnosed with OSA (AHI > 5). The patients were divided into two groups according to the apnea-hypopnea index (AHI): Group I (AHI = 5 ≤ 30) and Group II (AHI > 30). sEMG activity was recorded during the voluntary swallowing of 10 mL and 15 mL of thin liquid (water). The sEMG peak, integral, and maximum velocity (Vmax) were calculated. Groups were compared by general multivariate analysis of covariance, with BMI as a covariate. A general multivariate linear regression model (GRM) was applied to analyze the contribution of predictors to the EMG parameters. The significance level was set at p < 0.05. Results There was a predominance of males ( n = 24, 64.9%) and obese individuals (BMI > 30, n = 25, 67.6%) in the sample. Compared with Group I, Group II presented significantly lower peak, Vmax and integral values (P ≤ 0.006). The GRM revealed that the peak and integral were explained by the AHI and BMI, whereas the tongue volume and behavior during swallowing together explained the Vmax. Conclusion Activation of the suprahyoid (SH) muscles was reduced in patients with severe OSA. In addition to disease severity, BMI and the myofunctional condition of the tongue also contribute to impaired activation. Taken together, these findings indicate that muscle weakness and deficits in motor control compromise the activation of SH muscles during swallowing.
Factors associated with orofacial myofunctional condition in patients with temporomandibular disorder and somatosensory tinnitus Gislaine Aparecida Folha, Nelma Ellen Zamberlan-Amorim, Carina Ferreira Pinheiro-Araujo, Luana Maria Ramos Mendes, Luana Denadai Oliveira Menezes, Gesseany Joice Rodrigues dos Santos, Debora Bevilaqua-Grossi Journal of Applied Oral Science, 2026 Tinnitus is frequently reported in individuals with temporomandibular disorders (TMD), especially in the somatosensory subtype, which can be modulated by afferent input from orofacial and cervical structures. While the impact of orofacial dysfunctions on tinnitus has been explored, the potential reverse relationship remains understudied. Objective To investigate the association between somatosensory tinnitus and orofacial myofunctional condition in individuals with TMD. Methodology An observational, cross-sectional study was conducted with 47 adults aged 18 to 45 years diagnosed with TMD and self-reported tinnitus. Participants were assessed in a university-based outpatient setting. The primary outcome was the orofacial myofunctional condition, measured using the Orofacial Myofunctional Evaluation with Scores (OMES) protocol. Additional variables included tinnitus intensity and frequency (via acuphenometry), tinnitus-related distress (Tinnitus Handicap Inventory – THI), cervical disability (Neck Disability Index – NDI), craniofacial pain and disability (Craniofacial Pain and Disability Inventory – CF-PDI), and psychological symptoms (Hospital Anxiety and Depression Scale – HADS). Data were analyzed using Spearman correlation and multiple linear regression, and adopted statistical significance was set at p<0.05. Results OMES scores showed negative correlations with tinnitus intensity (r=−0.353), THI, NDI, CF-PDI, and age. In the final regression model, only tinnitus intensity remained a predictor of OMES score (β =−0.356; R2=0.127, Confidence Interval −0.20 to −0.02), indicating that greater tinnitus intensity was associated with poorer orofacial myofunctional condition. Conclusion These findings suggest that somatosensory tinnitus may negatively impact orofacial motor function in patients with TMD, underscoring the need for integrated and multidisciplinary assessment approaches.
Vocal and Orofacial Myofunctional Characteristics of Individuals with Obstructive Sleep Apnea Melissa França Lima Martins, Alan Luiz Eckeli, Fernando Gustavo Stelzer, Fabiana Cardoso Pereira Valera, Gislaine Aparecida Folha Sleep Science, 2025 Obstructive sleep apnea (OSA) involves recurrent upper airway obstructions during sleep, leading to fragmentation and oxygen desaturation. Vocal complaints and orofacial myofunctional changes are common, but few studies assess both aspects in diagnosed patients. To assess vocal parameters and orofacial myofunctional conditions in adults diagnosed with OSA, comparing them to a control group at low risk for OSA. Cross-sectional study. A convenience sample (N = 63) was included: 33 with OSA confirmed by polysomnography and 30 controls at low risk for OSA (STOP-BANG < 3 and no reported snoring in Stanford Snoring Scale), aged between 18–60 years. Assessments included perceptual-auditory analysis of voice quality (GRBASI scale, Vocal Symptom Scale (VSS), maximum phonation time (MPT) for vowels and s/z ratio) and orofacial myofunctional evaluation (OMES-E protocol). Participants who had received previous treatment or medical conditions affecting OSA, voice or orofacial function were excluded. OSA group showed significantly higher scores on VSS and lower scores on OMES-E protocol. They also displayed shorter MPT, worse performance in s/z ratio, reduced pneumophonoarticulatory coordination, and higher frequency of vocal alterations. The OSA group revealed mean apnea-hypopnea index of 45.80, indicates predominance of severe cases, as well as increased desaturation index. Individuals with OSA exhibit impairments in both orofacial myofunctional and vocal parameters, with negative alterations observed in MPT speech rate, pneumophonoarticulatory coordination, and s/z ratio compared with subjects with no OSA complaints. These findings highlight the importance of evaluating vocal and orofacial aspects together in OSA.
Diagnostic Accuracy of an Orofacial Scale for the Detection of Orofacial Myofunctional Disorders in Patients With Obstructive Sleep Apnoea Gislaine Aparecida Folha, Fabiana Cardoso Pereira Valera, Cláudia Maria de Felício Journal of Oral Rehabilitation, 2025 BackgroundPatients with obstructive sleep apnoea (OSA) are known to have orofacial myofunctional disorders (OMD) compared to healthy individuals. Consequently, treatment with oropharyngeal exercises has shown promise in some OSA cases. However, this requires an adequate orofacial myofunctional evaluation.AimsTo develop a concise and reliable scale including the most relevant items for the orofacial myofunctional evaluation of individuals with OSA. The Expanded Orofacial Myofunctional Evaluation with Scores (OMES‐E) protocol was previously validated for this purpose. However, it has been criticised for its length, time‐consuming nature and omission of certain items.Materials & MethodsFifty adults diagnosed with OSA by polysomnography and 23 healthy adults were included. Based on the literature, additional items were incorporated into the OMES‐E to enhance the evaluation (OMES‐E Plus), with subsequent reliability analysis. A scale with fewer items was derived from the OMES‐E Plus based on reliability and correlation analyses. Its accuracy, sensitivity and specificity were determined in a sample of 19 subjects with OSA and 19 without OSA (Control), matched for age and sex. Statistical analyses included Cronbach's alpha, item‐total correlations and receiver operating characteristic curve analysis.ResultsThe resulting new instrument, named the Orofacial Scale for Obstructive Sleep Apnoea (OFSOSA), comprises 31 items. The OFSOSA demonstrated significant discriminatory ability, with an area under the curve of 0.987, sensitivity of 95.5% and specificity of 93.7%.ConclusionThe OFSOSA, a concise instrument for myofunctional orofacial evaluation, was developed and validated, showing excellent psychometric properties for diagnosing OMDs in OSA patients.
Letter to the Editor on Assessment of Muscular Weakness in Severe Sleep Apnea Patient Cláudia Maria de Felício, Gislaine Aparecida Folha Otolaryngology Head and Neck Surgery United States, 2025 We have read with interest the article titled “Assessment of muscular weakness in severe sleep apnea patient: A prospective study” by O'Connor-Reina et al.1 The authors reported significant differences between patients with obstructive sleep apnea (OSA)-hypopnea syndrome (OSAHS) and a healthy group in terms of tongue strength/force and the score of the orofacial myofunctional evaluation. These variables also were significant risk factors for severe OSAHS in multivariate logistic regression. Therefore, the study contributes to drawing attention to the importance of orofacial myofunctional assessment in cases of OSA. However, the results presented, especially the average for the groups, led us to think that the Expanded Protocol of Orofacial Myofunctional Evaluation With Scores (OMES-E)2 was used for the evaluation instead of the quoted OMES protocol.3 Additionally, the OMES-E protocol has been previously validated for patients with OSA,2 but not the OMES.3 Although, nothing prevents authors from using it. Therefore, as authors of both protocols of orofacial myofunctional evaluation, we would like to know which one was actually used in the aforementioned studies. It would be interesting if the authors clarified whether any modifications were made to the protocol, excluding the complementary measures using the Iowa Oral Performance Instrument and Tongue Digital Spoon. We justify that there is no reference in the paper in question, nor were we able to locate any publications about it. Cláudia Maria de Felício, writing—original draft preparation, review, and agreement to the published version of the Letter to the Editor; Gislaine Aparecida Folha, writing—original draft preparation, review, and agreement to the published version of the Letter to the Editor. None. None.
World orofacial motricity day - a decade reaffirming the role of the speech-language pathologist in the assessment and treatment of orofacial functions Lucas Ferreira, Giédre Berretin-Felix, Roberta Lopes de Castro Martinelli, Giorvan Ânderson dos Santos Alves, Viviane Veroni Degan, Gabriele Ramos de Luccas, Gislaine Aparecida Folha, Hilton Justino da Silva Codas, 2025 BACKGROUND: English is the lingua franca of science; it is the language of the two last world superpowers and the language of four out of the world's ten greatest producers of science; it is a fairly simple language and the most hybridized language in history, with Latin and French contributing 60% of the entire English lexicon. The object of this study is to determine whether the frequency of use of imported words is a function of literary genre. METHOD: Texts were randomly selected from (a) medical scientific original articles, (b) newspaper financial reports, (c) sport reportages, (d) literary texts and (e) colloquial English; for comparison a collection of similarly distributed texts were selected from Portuguese; the frequency of occurrence of Latin or Neo-Latin words was determined in the English texts as well as the occurrence of non-Latin or non-Neo-Latin words in the Portuguese texts; a oneway analysis of variance was used to determine whether significant differences occurred between genres in the two languages. RESULTS: The frequency of occurrence of Latin/French words in English text was significantly dependent on the literary genre, being maximal in medical scientific texts and minimal in colloquial English; in contrast, the frequency of occurrence of non-Latin words in Portuguese was constant throughout the same literary genres. CONCLUSION: The use of Latin/French words in English is directly proportional to the complexity of the literary genre, a phenomenon not observed in Portuguese, a typical Neo-Latin language.
Expanded Orofacial Myofunctional Evaluation Protocol with Scores (expanded-OMES) for nursling infants (6-24 Months) Andréa Monteiro Correia Medeiros, Gabriela Rodrigues Dourado Nobre, Íkaro Daniel de Carvalho Barreto, Elisdete Maria Santos de Jesus, Gislaine Aparecida Folha, Anna Luiza dos Santos Matos, Sarah Catarina Santos do Nascimento, Cláudia Maria de Felício Codas, 2021 RESUMO Objetivo Adaptar e validar conteúdo e aparência do Protocolo de Avaliação Miofuncional Orofacial com Escores Expandido (AMIOFE-E) para lactentes de 6 a 24 meses de idade. Método Estudo de validação. Os parâmetros foram baseados em literatura sobre desenvolvimento motor orofacial, experiência dos autores e painel de 10 especialistas. Os dados foram analisados por estatística descritiva, Índice de Validade de Conteúdo e concordância entre especialistas. Resultados O protocolo foi organizado em blocos funcionais após manutenção, exclusão, modificação e acréscimo de itens, adaptando-se à faixa etária. Obteve-se alto nível de concordância em 90% dos itens. Na versão final foram acrescidos: histórico de alimentação e hábitos parafuncionais orofaciais, mobilidade facial, dentição, modo oral de respiração, deglutição de pastoso e detalhamentos específicos para a faixa etária. Acrescentou-se um manual operacional e uma tabela para registro de escores. Conclusão O Protocolo AMIOFE-E Lactentes e respectivo manual operacional foram validados quanto ao conteúdo e aparência, e poderá contribuir no diagnóstico miofuncional orofacial na faixa etária de 6 a 24 meses de idade.
Validity and reliability of a protocol of orofacial myofunctional evaluation for patients with obstructive sleep apnea Gislaine A. Folha, Fabiana C. P. Valera, Cláudia M. de Felício European Journal of Oral Sciences, 2015 There is no standardized protocol for the clinical evaluation of orofacial components and functions in patients with obstructive sleep apnea. The aim of this study was to examine the validity, reliability, and psychometric properties of the Expanded Protocol of Orofacial Myofunctional Evaluation with Scores (OMES-expanded) in subjects with obstructive sleep apnea. Patients with obstructive sleep apnea and control subjects were evaluated, and the validity of OMES-expanded was tested by construct validity (i.e. the ability to discriminate orofacial status between apneic and control subjects) and criterion validity (i.e. correlation between OMES-expanded and a reference instrument). Construct validity was adequate; the apneic group showed significantly worse orofacial status than did control subjects. Criterion validity of OMES-expanded was good, as was its reliability. The OMES-expanded is valid and reliable for evaluating orofacial myofunctional disorders of patients with obstructive sleep apnea, with adequate psychometric properties. It may be useful to plan a therapeutic strategy and to determine whether the effects of therapy are related to improved muscle and orofacial functions.
Orofacial Motricity: From the Emergence of a Field to the Path Toward Global Terminology Standardization L Ferreira, RLC Martinelli, GA Folha, GR Luccas, GÂS Alves, D Grandi, ... International Journal of Orofacial Myology and Myofunctional Therapy 52 (1), 6 , 2026 2026
Swallowing assessment in obstructive sleep apnea: insights from surface electromyography GA Folha, DM Garcia, CM de Felício Sleep and Breathing 30 (2), 151 , 2026 2026
Validity and cut-off scores of the OMES protocol for orofacial myofunctional disorders across different age groups CM de Felício, MCG Ataide, LVV Trawtzki, GA Folha 2026
Cross-cultural adaptation of the Expanded Protocol of Orofacial Myofunctional Evaluation with Scores protocol for Spanish-speaking populations GA Folha, CM de Felício, C O'Connor-Reina, G Berretin-Felix, ... Acta Otorrinolaringologica (English Edition), 512336 , 2026 2026
Factors associated with orofacial myofunctional condition in patients with temporomandibular disorder and somatosensory tinnitus GA Folha, NE Zamberlan-Amorim, CF Pinheiro-Araujo, LMR Mendes, ... Journal of Applied Oral Science 34, e20250515 , 2026 2026
Surface electromyography of masticatory muscles in adults with obstructive sleep apnea GA Folha, AL Eckeli, FCP Valera, CM de Felício Sleep Medicine 138, 108217 , 2026 2026
Clinical Assessment of Patients with Sleep-Disordered Breathing and Orofacial Myofunctional Disorders CM de Felício, LV Voi Trawitzki, GA Folha Myofunctional Therapy in Snoring and Sleep Apnea: Oropharyngeal Exercises … , 2026 2026
Vocal and Orofacial Myofunctional Characteristics of Individuals with Obstructive Sleep Apnea MFL Martins, AL Eckeli, FG Stelzer, FCP Valera, GA Folha Sleep Science 18 (04), e397-e403 , 2025 2025
Dia mundial da motricidade orofacial–uma década reafirmando o papel do fonoaudiólogo na avaliação e tratamento das funções orofaciais L Ferreira, G Berretin-Felix, RLC Martinelli, GÂS Alves, VV Degan, ... CoDAS 37 (6), e20250067 , 2025 2025
Objective Assessment of Orofacial Muscle Strength: Validation of an Alternative Low-Cost Measurement Device EJ Correa, J Curtis, L Rodriguez Alcalá, JA Ibañez-Rodriguez, ... International Journal of Orofacial Myology and Myofunctional Therapy 51 (2), 9 , 2025 2025
Diagnostic accuracy of an orofacial scale for the detection of orofacial myofunctional disorders in patients with obstructive sleep Apnoea GA Folha, FCP Valera, CM de Felício Journal of Oral Rehabilitation 52 (9), 1343-1350 , 2025 2025 Citations: 5
Self-perception of voice in individuals who report snoring MFL Martins, GA Folha Revista CEFAC 27 (3), e11124 , 2025 2025 Citations: 1
Letter to the Editor on Assessment of Muscular Weakness in Severe Sleep Apnea Patient CM de Felício, GA Folha Otolaryngology–Head and Neck Surgery 172 (2), 756-757 , 2025 2025
World orofacial motricity day–a decade reaffirming the role of the speech-language pathologist in the assessment and treatment of orofacial functions L Ferreira, G Berretin-Felix, RLC Martinelli, GÂS Alves, VV Degan, ... CoDAS 37, e20250067 , 2025 2025
Autopercepção vocal em indivíduos que relatam roncar MFL Martins, GA Folha Revista CEFAC 27, e11124 , 2025 2025
Relationships between craniofacial pain and disability, neck disability, and orofacial myofunctional condition in patients with temporomandibular dysfunction GJR dos Santos, LMR Mendes, LDO Menezes, DB Grossi, GA Folha Headache Medicine, 44-44 , 2024 2024 Citations: 1
Letter to the editor on assessment of muscular weakness in severe sleep apnea patient.[Carta] CM Felício, GA Folha Otolaryngology–Head and Neck Surgery 172, 756-757 , 2024 2024
Expanded Protocol of Orofacial Myofunctional Evaluation with Scores for Nursing Infants (6-24 months)(OMES-E Infants) AMC Medeiros, GRD Nobre, ÍDC Barreto, EMS Jesus, GA Folha, ... Codas 33, e20190219 , 2021 2021 Citations: 6
Motricidade orofacial em lactentes e pré-escolares com e sem microcefalia: estudo de caso controle AMC Medeiros, GRD Nobre, CM Felicio, G Folha, S Nascimento, ... Anais Científicos , 2019 2019
MOST CITED SCHOLAR PUBLICATIONS
Expanded protocol of orofacial myofunctional evaluation with scores: validity and reliability CM de Felício, GA Folha, CLP Ferreira, APM Medeiros International journal of pediatric otorhinolaryngology 74 (11), 1230-1239 , 2010 2010 Citations: 161
Orofacial motor functions in pediatric obstructive sleep apnea and implications for myofunctional therapy CM de Felício, FV da Silva Dias, GA Folha, LA de Almeida, JF de Souza, ... International journal of pediatric otorhinolaryngology 90, 5-11 , 2016 2016 Citations: 97
Validity and reliability of a protocol of orofacial myofunctional evaluation for patients with obstructive sleep apnea GA Folha, FCP Valera, CM de Felício European journal of oral sciences 123 (3), 165-172 , 2015 2015 Citations: 74
Protocolo de avaliação miofuncional orofacial com escores informatizado: usabilidade e validade CM Felício, GA Folha, AS Gaido, MMM Dantas, PM Azevedo-Marques CoDAS 26, 322-327 , 2014 2014 Citations: 18
Relações entre idade, porcentagem de consoantes corretas e velocidade de fala GA Folha, CM Felício Pró-Fono Revista de Atualização Científica 21, 39-44 , 2009 2009 Citations: 18
Ampliação das escalas numéricas do Protocolo de Avaliação Miofuncional Orofacial (AMIOFE), validação e confiabilidade GA Folha Universidade de São Paulo , 2010 2010 Citations: 17
Computerized protocol of orofacial myofunctional evaluation with scores: usability and validity CM Felício, GA Folha, AS Gaido, MMM Dantas, PM Azevedo-Marques CoDAS 26 (4), 322-327 , 2014 2014 Citations: 10
Translation and cross-cultural adaptation of the protocol of orofacial myofunctional evaluation with scores for Italian Language CM Felício, GA Folha, CLP Ferreira, LC Paskay, C Sforza CoDAS 27, 575-583 , 2015 2015 Citations: 8
Áreas do domínio do especialista em motricidade orofacial AR Motta, AMC Medeiros, G Berretin-Felix, GA Folha, KF Genaro, ... Manual de motricidade orofacial, 128 , 2014 2014 Citations: 7
Orofacial myofunctional evaluation with scores in subjects with obstructive sleep apnea GA Folha, FCP Valera, LD Giglio, LVV Trawizki, CM De Felício Sleep Medicine 14, e51 , 2013 2013 Citations: 7
Expanded Protocol of Orofacial Myofunctional Evaluation with Scores for Nursing Infants (6-24 months)(OMES-E Infants) AMC Medeiros, GRD Nobre, ÍDC Barreto, EMS Jesus, GA Folha, ... Codas 33, e20190219 , 2021 2021 Citations: 6
Diagnostic accuracy of an orofacial scale for the detection of orofacial myofunctional disorders in patients with obstructive sleep Apnoea GA Folha, FCP Valera, CM de Felício Journal of Oral Rehabilitation 52 (9), 1343-1350 , 2025 2025 Citations: 5
Surface electromyography protocol for the assessment of human swallowing DM Garcia, A Mapelli, GA Folha, AS Gaido, FCP Valera, LVV Trawitzki, ... XXIV Brazilian Congress on Biomedical Engineering, 13-17 , 2014 2014 Citations: 3
Analysis of validity in adults of the expanded protocol of orofacial myofunctional evaluation with scores GA Folha, FCP Valera, CG Borges, CM Felício Proceedings of the 5th World Congress on Sleep Medicine , 2013 2013 Citations: 3
Self-perception of voice in individuals who report snoring MFL Martins, GA Folha Revista CEFAC 27 (3), e11124 , 2025 2025 Citations: 1
Relationships between craniofacial pain and disability, neck disability, and orofacial myofunctional condition in patients with temporomandibular dysfunction GJR dos Santos, LMR Mendes, LDO Menezes, DB Grossi, GA Folha Headache Medicine, 44-44 , 2024 2024 Citations: 1
Assessment of surface EMG supra-hyoid muscle activity in apneic patients compared to healthy subjects. A pilot study G Folha, A Mapelli, FCP Valera, LD Giglio, LVV Trawizki, CM De Felício Sleep Medicine 14, e127 , 2013 2013 Citations: 1
Orofacial Motricity: From the Emergence of a Field to the Path Toward Global Terminology Standardization L Ferreira, RLC Martinelli, GA Folha, GR Luccas, GÂS Alves, D Grandi, ... International Journal of Orofacial Myology and Myofunctional Therapy 52 (1), 6 , 2026 2026
Swallowing assessment in obstructive sleep apnea: insights from surface electromyography GA Folha, DM Garcia, CM de Felício Sleep and Breathing 30 (2), 151 , 2026 2026