Effectiveness of Chewing Technique on the Phonation

of Female Speech-Language Pathology Students:

A Pilot Study
*Iris Meerschman, *Evelien Dhaeseleer, *Elien De Cock, *Heidi Neyens, Sofie Claeys, and *Kristiane Van Lierde,
*yGent, Belgium

Summary: Objectives. The purpose of this study was to determine how use of the vocal facilitating technique,
chewing, affected the phonation of speech-language pathology (SLP) students.
Study Design. A pretest-posttest randomized control group design was used.
Methods. Twenty-seven healthy female SLP students were randomly assigned into either an experimental group or a
control group. The experimental group practiced chewing exercises across 18 weeks, whereas the control group received
no vocal facilitating techniques. Both groups completed pre- and post- objective voice assessment measures (aerodynamic measurement, acoustic analysis, voice range profile, and Dysphonia Severity Index). Differences between preand post-data were compared between the experimental and control group using an independent sample t test.
Results. Compared to the control group, chewing resulted in a significant decrease in jitter and noise-to-harmonic ratio (NHR), a significant increase in fundamental frequency (fo), a significant expansion of the voice range profile, and a
significant increase in Dysphonia Severity Index (DSI). Shimmer and maximum phonation time (MPT) were not significantly different between groups.
Conclusions. The results of this pilot study suggest that the vocal facilitating technique, chewing, may improve
objective vocal measures in healthy female SLP students.
Key Words: ChewingVoiceFacilitating techniqueEffectivenessPhonationSpeech-language pathology students
DysphoniaObjective vocal measuresPilot study.

INTRODUCTION
The vocal facilitating technique, chewing, was first described
by Froeschels1 in 1943. He based the technique on the observation that someone can chew and speak at the same time.
According to the author, chewing and speaking must be somewhat identical because both functions require the same muscles
and nerves.2 In 1956, Beebe3 confirmed Froeschels observations and described voiced chewing as an inborn and intuitive
behavior. Voiced chewing refers to the raw material used
instinctively by the aboriginal human inhabitants of the earth.2
It serves the dual purpose of supporting life (eating) and oral
communication (speech).3 Because of etiquette, the voice has
not been used in conjunction with chewing food for thousands
of years. Despite this, voicing while chewing can still be easily
accomplished by individuals.2
The most convincing support of voiced chewing as an inborn
and intuitive behavior is found in clinical experience. A natural
behavior such as chewing may facilitate improved vocal production4 through relaxation of the vocal tract5 and regulation
of the basic vocal pitch.6 According to Weiss and Beebe,7 chewing also improves coordination between respiration and phonation. Froeschels1,3 described improved vocal quality during
chewing aloud in individuals with vocal fold paresis, cyst, and
Accepted for publication June 29, 2015.
From the *Department of Speech, Language and Hearing Sciences, Ghent University,
Ghent, Belgium; and the yDepartment of Otorhinolaryngology, Ghent University, Ghent,
Belgium.
Address correspondence and reprint requests to Iris Meerschman, Department of
Speech, Language and Hearing Sciences, University Hospital, 2P1, De Pintelaan 185,
9000 Ghent, Belgium. E-mail: Iris.Meerschman@Ugent.be
Journal of Voice, Vol. -, No. -, pp. 1-5
0892-1997/$36.00
2015 The Voice Foundation
http://dx.doi.org/10.1016/j.jvoice.2015.06.016

papilloma as well as in those suffering from hypo-or

hyperfunctional voice disorders, mutational disorders, and
hearing impairment. Furthermore, Brodnitz and Froeschels8
facilitated the resolution of vocal nodules after the using of
chewing in five of the six subjects under study. Boone et al5
recommend the technique for patients with muscle tension
dysphonia who speak with tension, hard glottal attacks, and
restricted mandibular movements. According to Weiss and
Beebe,7 chewing might also be useful in treating speech disorders such as stuttering and dysarthria. However, to our knowledge, no studies confirm this finding. Weiss and Beebe7
further described the application of chewing to train the healthy
speaking and singing voice.
The use of the chewing technique in improving vocal production has mainly been supported by the results of case studies
that cannot be easily generalized. Additionally, conclusions
are based on observations and anecdotal clinical experience.
Furthermore, a detailed description of the method is lacking
and much of the published literature is outdated.18 More
recently, larger efficacy studies are available but those have
examined chewing as part of a broader therapy program,
rather than in isolation.916 Therefore, experimental studies
that specifically examine the effect of chewing on vocal
production are required.
Our pilot study aimed to make a first contribution to this
research gap. We wanted to investigate if the outdated and unproven assertions18 about the effect of chewing may be correct.
Therefore, in this first-stage investigation, we chose to focus on
chewing as a technique that could facilitate and train the healthy
voice.7
The purpose of this study was to determine how use of the
vocal facilitating technique, chewing, affected the phonation

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Journal of Voice, Vol. -, No. -, 2015

of healthy women enrolled in a speech-language pathology

(SLP) program. A positive effect on the SLP students vocal capacities was hypothesized because, according to the literature,18 chewing may facilitate a more natural vocal
production through relaxation of the vocal tract, regulation of
the basic vocal pitch, and better coordination between
respiration and phonation.
MATERIAL AND METHODS
This study was approved by the human subjects committee of
Ghent University.
Subjects
Twenty-nine female students enrolled in the first year of the
bachelor program Speech-Language Pathology at Ghent University were randomly selected to participate in this study.
Exclusion criteria included diagnoses of mental health conditions, voice disorders, nasal and ear diseases, and physicallylimiting diseases that might interfere with study completion.
Additionally, individuals who had previously participated in
voice therapy or training were excluded from participation.
To determine that participants were not currently suffering
from a voice disorder or nasal or ear disease, each subject
was assessed by an otorhinolaryngologist and audiologist performing a nasopharyngeal and laryngeal evaluation, videolaryngostroboscopy, otoscopy, and audiometry. On the basis of
these results, two students were excluded because of vocal
fold edema and vocal fold nodules.
The remaining participants included a homogeneous group
of twenty-seven healthy female students with a mean age of
18.8 years (SD, 0.8 years; range, 17.921.2 years). They were
randomly assigned into either an experimental group (n 14)
or a control group (n 13). The experimental group practiced
chewing exercises across 18 weeks, whereas the control group
received no vocal facilitating techniques. Randomization was
based on the first letter of the students last name (AM, control
group; NZ, experimental group). There were no differences
between the two groups in mean age (MannWhitney U test;
P 0.239).
Material and methods
Voice questionnaire. At the beginning of the study, each
subject filled in a questionnaire based on the voice assessment
protocol of the European Study Group on Voice Disorders17 to
describe vocal complaints and risk factors.
Objective vocal measures. Both groups completed preand post- objective voice assessment measures. Data were
collected by two SLPs (E.D.C. and H.N.) in a sound-treated
room at Ghent University Hospital.
Aerodynamic measurement. To measure the maximum phonation time (MPT), the participants were asked to sustain the
vowel /a/ at their habitual pitch and loudness in free field while
seated. The MPT was modeled by the experimenters, and the
participants received visual and verbal encouragement to
produce the longest possible sample. The length of the

sustained vowel was measured in seconds. The best trial of

three attempts was retained for further analysis.
Acoustic analysis. The fundamental frequency (fo), jitter (%),
shimmer (%), and noise-to-harmonic ratio (NHR) were
obtained by the Multi Dimensional Voice Program from the
Computerized Speech Lab (CSL, model 4300, Kay Elemetrics
Corp., Lincoln Park, NJ). The subjects were instructed to
produce the vowel /a/ at their habitual pitch and loudness. A
midvowel segment from 3 seconds registered with a sampling
rate of 50 kHz was used.
Voice range profile. The voice range assessment was performed with the CSL following the procedure outlined by
Heylen et al.18 This assessment includes determination of the
highest and lowest fundamental frequency and intensity. The
participants were instructed to produce the vowel /a/ for at
least 2 seconds using, respectively, a habitual pitch and
loudness, a minimal pitch, a minimal intensity, a maximal
pitch, and a maximal intensity. Each production was modeled
by the experimenters, and the participants received visual and
verbal encouragement.
Dysphonia Severity Index. The Dysphonia Severity Index
(DSI)19 is a multiparameter approach designed to establish
an objective and quantitative correlate of the perceived vocal
quality. The DSI is based on a weighted combination of the
following parameters: MPT (in seconds), highest frequency
(F-high, in Hz), lowest intensity (I-low, in dB), and jitter
(in %). The DSI is constructed as 0.13 MPT + 0.0053
F-high  0.26 I-low  1.18 jitter + 12.4. The index ranges
from 5 to +5 for severely dysphonic to normal voices. The
more negative the index, the worse is the vocal quality. A
DSI of 1.6 is the threshold separating normal voices from
dysphonic voices.20 The DSI can be calculated as a
percentage20 by increasing the value with five points and
then multiplying it by 10. A higher percentage indicates a
better vocal quality.
Facilitating technique chewing. The experimental group
received the facilitating technique chewing during 18 weeks.
In the first 8 weeks, the group participated in weekly 1-hour
training sessions organized by the experimenters. The experimenters provided verbal information, examples, and corrective
feedback. Incorrect posture or poor respiratory technique were
corrected. The content of the training sessions, based on the
procedure outlined by Boone et al,5 can be found in Table 1.
In addition to the exercises during training, the subjects were instructed to practice the chewing technique at home twice a day
during 10 minutes.
From week 917, the subjects repeated the technique independently at home with a frequency of two times 10 minutes
a day. Meanwhile, they had the opportunity to contact the experimenters for feedback or questions.
In week 18, an interactive rehearsal session was organized
under the guidance of the experimenters. In this session, subgroups (two or three subjects) of the experimental group presented one of the steps learned in training. The other subjects
followed their instructions.

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Iris Meerschman, et al

Effectiveness of Chewing Technique

TABLE 1.
Content of the Chewing Training Sessions Based on the Procedure Outlined by Boone et al.
Session
1

3, 4
5, 6

7, 8

Content
Education and counseling
Creating awareness of the students mandibular movements while speaking (visual
feedback: mirror)
Demonstration of the facilitating technique chewing by the experimenters
Imitation and familiarization by the subjects (visual feedback: mirror)
Open-mouth chewing without phonation
Chewing with phonation of the sound njamnjam
Chewing with phonation of nonsense words (eg, ah-la-met-erah, wan-da-pan-da)
Chewing with phonation of automatic sequences: counting, days of the week
Chewing with phonation of words: monosyllabic, polysyllabic
Chewing with phonation of phrases
Chewing with phonation of sentences
Chewing while reading texts
Phonation of sentences and texts with reduced chewing
Spontaneous speech with adequate oral openness and mandibular movements

Statistical analysis
SPSS Version 22 (SPSS Corporation, Chicago, IL) was used for
the statistical analysis of the data. All analyses were conducted
at a 0.05.
Voice questionnaire. A chi-square test of independence was
used to verify if there were differences between the experimental and control group regarding vocal complaints and risk
factors.
Objective vocal measures. The differences between preand post-data were measured for each subject. Normality of
these differences was verified using a QQ-plot and a ShapiroWilk test.21 Because all data were normally distributed, an independent sample t test was used to compare the results of
the experimental and control group.
RESULTS
Voice questionnaire
The results of the questionnaire about vocal complaints and risk
factors are presented in Table 2. Occurrence of the vocal complaints vocal fatigue, decreased vocal quality in the morning, laryngeal irritations, and decreased breath support
was not significantly different between the experimental and
control group. Significantly higher percentages of hoarseness (40.6%; c2(1) 4.464; P 0.035) and decreased vocal
range (30.8%; c2(1) 5.057; P 0.025) were found in the
control group versus the experimental group.
Occurrence of the vocal risk factors vocal abuse, nasal
airway obstructions, smoking, reflux, and allergy
was not significantly different between the experimental and
control group. A significantly higher percentage of stress
(40.6%; c2(1) 4.464; P 0.035) was found in the control
group versus the experimental group.
Objective vocal measures
Table 3 summarizes the results of the objective vocal measures
at pre- and post-condition. Compared to the control group,

chewing resulted in a significant decrease in the acoustic measures jitter (P 0.007) and NHR (P 0.048), a significant increase in the acoustic measure fo (P 0.049), a significant
expansion of the voice range profile (I-low [P 0.044],
I-high [P 0.033], F-low [P 0.048], F-high [P 0.018]),
and a significant increase in DSI score (P 0.002). No differences were found between the experimental and control group
for the aerodynamic measure MPT (P 0.791) and the acoustic
measure shimmer (P 0.202).
Figure 1 represents the changes in DSI before and after
18 weeks of chewing in the experimental group, and before
and after the same time span without facilitating techniques
in the control group. An increase of 2.3 in the experimental
group was significantly higher than the difference (0.6)
measured in the control group.

DISCUSSION
The purpose of this pilot study was to determine how use of the
vocal facilitating technique, chewing, affected the phonation of
healthy female SLP students. A positive effect on the SLP students vocal capacities was hypothesized because, according to
the literature,18 chewing may facilitate a more natural vocal
production through relaxation of the vocal tract, regulation of
the basic vocal pitch and better coordination between
respiration and phonation.
The hypothesis that vocal function would increase via the
chewing facilitating technique has been supported by the significantly decreased acoustic voice measures jitter and NHR, the
expanded voice range profile (I-low, I-high, F-low, F-high),
and the increased objective measure of vocal quality (DSI) in
the experimental group compared with the control group. The
DSI increased from 0.6 (44%) before chewing to +1.7 (67%)
after chewing, which indicates a 23% improvement as measured
by the index. Similarly, fo significantly increased in the experimental group relative to controls. A possible explanation for
this increase may be that chewing facilitated subjects to speak

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Journal of Voice, Vol. -, No. -, 2015

TABLE 2.
Percentage of Participants Having Vocal Complaints and Percentage of Participants Exposed to Vocal Risk Factors Based on
the European Study Group on Voice Disorders Voice Assessment Protocol
Vocal complaints and risk factors

Experimental Group (%)

Control Group (%)

c2

P Value

35.7 (5/14)
28.6 (4/14)
28.6 (4/14)

53.8 (7/13)
69.2 (9/13)
38.5 (5/13)

0.898
4.464
0.297

0.343
0.035*
0.586

0 (0/14)
14.3 (2/14)
14.3 (2/14)

30.8 (4/13)
46.2 (6/13)
46.2 (6/13)

5.057
3.283
3.283

0.025*
0.070
0.070

71.4 (10/14)
35.7 (5/14)
50.0 (7/14)
57.1 (8/14)
42.9 (6/14)
35.7 (5/14)
0 (0/14)
7.1 (1/14)
42.9 (6/14)
28.6 (4/14)

92.3 (12/13)
69.2 (9/13)
69.2 (9/13)
30.8 (4/13)
51.5 (8/13)
46.2 (6/13)
0 (0/14)
23.1 (3/13)
30.8 (4/13)
69.2 (9/13)

1.947
0.163
3.033
0.082
1.033
0.310
1.899
0.168
0.942
0.332
0.304
0.581
No smokers
1.356
0.244
0.422
0.516
4.464
0.035*

Vocal complaints
Vocal fatigue
Hoarseness
Decreased vocal quality in the
morning
Decreased vocal range
Laryngeal irritations
Decreased breath support
Risk factors
Vocal abuse
Shouting
Overpassing noise
Member youth organization
Throat clearing
Nasal airway obstructions
Smoking
Reflux
Allergy
Stress

Note: P is the level of significance and was set at 0.05.

* Indicates a significant difference in vocal complaint or vocal risk factor between the experimental group (chewing technique) and the control group (no facilitating techniques).

at their more natural pitch.6 However, the frequency change was

relatively small and a similar magnitude of decline, observed in
the control group, must be taken into account. Moreover, after

chewing, the fo (226.2 Hz) was situated further from the mean
norm for female adults (212 Hz; but within the normal range
of 167258 Hz).22 The assumption that chewing improves

TABLE 3.
Comparison of the Differences in Pre- and Post- Objective Vocal Measures Between the Experimental Group and the
Control Group
Experimental Group

Parameters

Control Group

Pre

Post

Difference
Pre  Post

Pre

Post

Difference
Pre  Post

Mean (SD)

Mean (SD)

Mean (SD)

Mean (SD)

Mean (SD)

Mean (SD)

0.6 (4)

22.5 (8.1)

21.5 (5.7)

Aerodynamic
MPT (s)
17.6 (5.6)
Acoustic analysis
217.8 (18.1)
fo (Hz)
Jitter (%)
2 (1.1)
Shimmer (%)
4.8 (1.2)
NHR
0.13 (0.02)
Voice range profile
I-low (dB)
63.1 (3.1)
I-high (dB)
99.7 (6.8)
F-low (Hz)
173.9 (24.9)
F-high (Hz)
661.1 (173.5)
DSI
0.6 (2.3)

17 (4.1)

1 (4.2)

P Value
0.791

226.2 (14.1)
1.2 (0.6)
4.6 (1.2)
0.12 (0.02)

+8.4 (15.3)
0.8 (0.9)
0.2 (1.7)
0.01 (0.02)

218.7 (28.4)
1.6 (0.7)
4.6 (1.1)
0.13 (0.02)

209.7 (13.1)
2 (0.9)
5.2 (1.5)
0.14 (0.02)

9 (27.4)
+0.4 (1.2)
+0.6 (1.5)
+0.01 (0.03)

0.049*
0.007*
0.202
0.048*

60.1 (2.5)
107.6 (3.9)
159.5 (24.9)
777.6 (168.5)
1.7 (1.5)

3 (3.6)
+7.9 (6.4)
14.4 (13.2)
+116.5 (145.5)
+2.3 (2.3)

60.6 (3.5)
103.4 (6.6)
173.5 (15.3)
644.5 (145.1)
1.1 (2.1)

60.3 (1.9)
106.3 (3.9)
170.9 (7.5)
638.8 (172.4)
0.5 (2)

0.3 (3)
+2.9 (5)
2.6 (16.4)
5.7 (97.3)
0.6 (2.1)

0.044*
0.033*
0.048*
0.018*
0.002*

Note: P is the level of significance and was set at 0.05.

Abbreviations: SD, standard deviation; MPT, maximum phonation time; I-low, lowest intensity; I-high, highest intensity; F-low, lowest frequency; F-high, highest frequency; fo, fundamental frequency; NHR, noise-to-harmonic ratio; DSI, Dysphonia Severity Index.
* Differences in pre- and post-data were significantly different between the experimental group (chewing technique) and the control group (no facilitating
techniques).

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Iris Meerschman, et al

Effectiveness of Chewing Technique

3
2

DSI

1
Experimental group

Control group

CONCLUSIONS
The results of this pilot study suggest that the facilitating technique chewing may improve objective vocal measures in
healthy female SLP students. The extent to which the chewing
technique may be useful in improving voice measures in the
presence of vocal pathology awaits further study.

-1
-2

REFERENCES

-3
pre

post

FIGURE 1. The changes in DSI before and after 18 weeks of chewing technique (experimental group) and before and after the same time
span without facilitating techniques (control group).

coordination between respiration and phonation7 could not be

supported because the aerodynamic measure MPT did not
improve in the experimental group. Furthermore, no improvement could be observed for the acoustic measure shimmer.
Limitations of the study design should be recognized and
taken into account for further research. A first limitation is that
subjects and experimenters were not blinded to the purpose of
the study, and no sham training was provided for the control
group. A second limitation is that, despite randomization, significant differences were found between the experimental and control group in symptoms of hoarseness and decreased vocal
range, and in the risk factor stress before the initiation of
the 18-week training period. Those differences suggest that the
study groups were too small to obtain perfectly homogeneous
groups and that larger study groups would improve future
work. Furthermore, no voice data were obtained on participants
during the 18-week time span. Follow-up assessment during
these weeks, including both the voice questionnaire and the
vocal measures, would have provided valuable information.
Follow-up assessment could also have been extended to examine
the long-term outcome of the technique. Besides, evaluation of
vocal capacities was limited to objective measures, excluding
subjective perceptual evaluations of the voice (eg, GRBASI
scale23) and a patients self-report (eg, Voice Handicap Index24).
Another shortcoming of the study is the lack of information
about whether home instructions were followed in week 917.
Hence, adherence to the practice schedule for the chewing technique cannot be ensured. Finally, other factors such as clinicianfacilitated changes in subjects posture and respiratory technique
and overlap of the production njamnjam with resonant voice
techniques might possibly have contributed to the improved
vocal capacities detected on postmeasures.
Despite the previously described limitations, this pilot study
provides useful first-stage results about the effect of an old and
understudied vocal facilitating technique and its potential ability to facilitate and train the healthy voice.7 Examining the
effect of chewing in patients with voice disorders is subject
for further research. The present study suggests that chewing
may facilitate expansion of the patients vocal range and
improvement in their vocal quality.

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