|Year : 2013 | Volume
| Issue : 2 | Page : 79-83
Dental consequences of mouth breathing in the pediatric age group
Seema Malhotra1, Vinay Gupta2, Ramesh Kumar Pandey3, Sunil Kumar Singh4, Amit Nagar5
1 Department of Pedodontics, Saraswati Dental College, Lucknow, Uttar Pradesh, India
2 Department of Public Health Dentistry, King George's Medical University (KGMU), Lucknow, Uttar Pradesh, India
3 Department of Pediatric and Preventive Dentistry, King George's Medical University (KGMU), Lucknow, Uttar Pradesh, India
4 Department of Otorhinolaryngolog, King George's Medical University (KGMU), Lucknow, Uttar Pradesh, India
5 Department of Orthodontics, King George's Medical University (KGMU), Lucknow, Uttar Pradesh, India
|Date of Web Publication||4-Jul-2014|
Department of Pedodontics, Saraswati Dental College, Lucknow, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Background: The presence of mouth breathing (MB) in pediatric patients is a relatively common fact and may result in a series of changes characteristic of occlusal features. In the presence of unbalanced muscular activity, dental inter-arch relationship is the important parameter to understand the patient's occlusion. Therefore, it is important to assess the occurrence of occlusal disorders among MB children. Aim: The present study is undertaken to verify the dental occlusal characteristics with extent of MB and nasal breathing in a pediatric patient. Materials and Methods: A cross-sectional study was performed to assess the association of changed mode of respiration with occlusal variables from dental cast. Ninety-two subjects, of whom 40 were mouth breathers and 52 were nasal breathers, of 7-11 years of age were submitted to clinical examination and dental cast analysis. Results: Mouth breathers demonstrated considerable increase in palatal height and increased overjet, and statistically significant narrowing of the upper arch at the level of the molar. Conclusion: Changed mode of respiration during critical growth periods in children has a higher tendency for increased palatal height and overjet, reduced overbite and maxillary intermolar width.
Keywords: Mouth breathing, nasal breathing, occlusal characteristics
|How to cite this article:|
Malhotra S, Gupta V, Pandey RK, Singh SK, Nagar A. Dental consequences of mouth breathing in the pediatric age group. Int J Oral Health Sci 2013;3:79-83
|How to cite this URL:|
Malhotra S, Gupta V, Pandey RK, Singh SK, Nagar A. Dental consequences of mouth breathing in the pediatric age group. Int J Oral Health Sci [serial online] 2013 [cited 2017 Apr 29];3:79-83. Available from: http://www.ijohsjournal.org/text.asp?2013/3/2/79/135977
| Introduction|| |
Breathing is a part of the neuromuscular functional system, and nasal respiration is of great significance for maintaining equilibrium of craniofacial development. The naso-respiratory function can be substituted by a compensatory oral pattern due to obstructive or habitual causes. In obstructive mouth breathing (MB), there is a mechanical interference to the airflow passage through the upper airways and in habitual MB, there is flaccidity or bad positioning of the orofacial muscles with no upper airways obstruction. Others believe that the breathing pattern depends on the interaction between genetic and environmental factors.,
The following three contacts play an important role for normal growth and development of the oral and nasal cavity: Competent lip seal, contact between tip of the tongue and lingual surfaces of the upper central incisors and the contact of soft palate with tongue base. Buccinator, orbicularis oris and superior constrictor of the pharynx support the dental arch and also contain the tongue. When the competent lip seal cannot be observed, tongue posture is on the floor of the oral cavity (depression of the tongue), lateral expansile forces of the tongue on the palate are lost and there is unopposed medial forces of the buccinators and the masseter muscles. The effect is further enhanced by a pressure differential across the hard palate in the absence of nasal airflow, leading to a narrow and high-arched hard palate Any imbalance between the buccinator mechanism and the tongue will move the teeth, leading to dental malocclusion. According to the Moss, theory of the functional matrix, bone growth dynamically responds to both function and adjoining soft tissue forces.
Based on the hypothesis that the MB mode may produce dental relationship alterations, the present study is undertaken to compare the dental pattern dimensions of the nasal-breathing (NB) children and MB children from respiratory pathology.
| Aim|| |
The aim of the present study is to verify the dental occlusal characteristics with extent of MB and NB in a pediatric patient.
| Materials and Method|| |
The present study was conducted at the Department of Pedodontics with Preventive Dentistry, KGMC, Lucknow, in collaboration with the Department of Otorhinolaryngology, KGMU, Lucknow.
The sample consisted of 92 children of both sexes selected from the Outpatient Department of Pedodontics with Preventive Dentistry and Department of Otorhinolaryngology.
Selection of cases
Children from both genders, with ages ranging from 7 to 11 years, who presented mixed dentition were included in the study. Informed written consent to the study was given by the parent/guardian.
In both groups (NB and MB), the subjects fulfilled the following criteria:
No evidence of strong hereditary predisposition to a deviant form, evidenced by striking similarity by parents. No history of any oral and maxillofacial treatment, no interproximal caries and no history of any abnormalities affecting growth and development and traumatic lesions of jaws.
Diagnosis of nasal function
Children were distributed into NB and MB groups according to diagnosis in the pedodontic clinic and the otorhinolaryngologic diagnosis.
Nasal function: Tested in the pedodontics clinic as given by Quinn. 
- Gently closing the lips together with light pressure of thumb and middle finger for 2-5 min. The patients of the experimental group started feeling short of breath, indicating deficiency in nasorespiratory function
- Without allowing the lips to be parted, the middle finger was used to close off one nostril at a time again for 2-5 min. Patients of the experimental group showed changes in expression or exaggerated movement of eyes, stomach and chest.
In the otorhinolaryngology clinic
All subjects were evaluated to confirm MB resulting from at least one of the following airway pathologies: Obstructive tonsillar hyperplasia, obstructive adenoidal hyperplasia and antrochoanal polyp.
Palatine tonsil hypertrophy were assessed by oroscopy and classified according to the criteria of Brodsky and Koch, and those classified as grade 3 and 4 were named as obstructive. Adenoids were assessed by flexible nasoendoscopy and >75% blockage of the nasopharynx was considered as obstructive.
Assessment of study cast
Maxillary and mandibular impressions were made in the alginate impression material. The study cast thus prepared was evaluated for permanent first inter-molar distance, primary intercanine distance, height of palatal vault, overjet and overbite. The measurements were made with vernier calipers corrected to 0.1 mm.
Points of reference for the measurements were:
- Intermolar distance: The distance measured between the central fossa of the right and left first maxillary and mandibular molars
- Intercanine distance: The distance measured between the cusp tips of the right and left canines of the maxillary and mandibular casts
- Palate depth: Two points on the palatal surfaces of the second upper primary molars at the cervical margin and a vertical rule in millimeters touching lightly on the palate
- Overjet: The distance between the incisor edge of the central upper incisor and the labial surface of the lower central incisor
- Overbite:The distance between how much the crowns of the central upper incisors overlap the crowns of the lower central incisors.
The sagittal relationship was classified as Class I dental relationship when the upper deciduous cuspid intercuspation was set between the lower deciduous cuspid and the first deciduous molar; class II, when the inferior molar was positioned posterior to the cuspid reference; and class III, when the inferior molar was positioned anterior to the cuspid reference as given by Barnett.
An intra-examiner reliability test was carried out (intra-class coefficient of correlation) for the inter-molar and inter-canine distance, overjet, overbite and depth measurements. The measurements were repeated with 21 children of the samples at intervals of 1 h between the examinations.
The quantitative analysis of the results was performed using means. The comparison between nasal breathers and mouth breathers was performed using an independent sample "t" test for parametric data. The significance level of P < 0.05 was chosen. For gender distribution and sagittal dental variable, the number of children with the diagnosed status (n) and its prevalence (%) are given.
| Results|| |
In the present study, there were a total of 92 subjects, of whom 40 were mouth breathers and 52 were nasal breathers. The data were obtained in the age group ranging from 7 to 11 years. The mean age of the sample was 8.9 years.
[Table 1] shows the prevalence of the studied variables by age and gender.
As shown in [Table 2], statistically significant differences in the variables-inter-molar width (P = 0.0294), palatal height (P = 0.0015), overjet (P =<0.0001) and overbite (P = 0.0059) were seen between nasal breathers and mouth breathers. Overjet and palatal height was found to be significantly higher among mouth breathers as compared with nasal breathers, whereas maxillary inter-molar width and overbite was found to be significantly higher among nasal breathers as compared with mouth breathers. Statistically, no significant differences were seen for the other variables under study.
[Table 3] shows that in the sagittal dental occlusion relationship, the class I relationship was found to be 86.54% in nasal breathers and 72.5% in mouth breathers; 11.54% nasal breathers and 22.5% mouth breathers showed class II relationship and class III relationship was seen in 1.92% of nasal breathers and 5% of mouth breathers.
|Table 2: Dental relationships from dental casts-mouth breathers and nasal breathers in the 7-11 years age group|
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|Table 3: Sagittal occlusal dental relationship with respect to mode of respiration|
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| Discussion|| |
Capability to maintain nasal respiration is of paramount importance for attaining optimal growth of the nasomaxillary complex. Prevention of undesirable growth-related changes and allowing desirable ones constitutes the general principle of orthodontic treatment in children. As individual facial genotypes following the exposure to MB show differences in type of developing malocclusion, a wide diversity of inter-arch relationships can be found. Therefore, it would be useful to know in detail the growth and development of the various occlusal patterns.
With reference to the dimensions of the maxillary cast, it has been observed that inter-molar distance was statistically smaller in MB subjects, as shown in [Table 2]. Bresolin et al.,  Berwig et al.,  Harari et al.,  Lopatiene et al.,  and Cheng et al.  observed similar result in their studies. This could be attributed to the alternation in tongue posture and perioral facial musculature activity.
Palatal depth was increased and statistically significant in mouth breathers, as shown in [Table 2]. The result corroborated with the finding of Martinez et al.,  Berwig et al.,  Cheng et al.,  De Menezes et al.,  De Freitas,  and Trask et al.  One of the theories suggest that in obstructed mouth breathers, there is an increase in pressure in the oral cavity in relation to the nasal cavity, leading to an increase in palatal depth. 
Overjet was found to be statistically significant in MB subjects, as shown in [Table 2], which was in agreement with Harari et al.,  Trask et al.,  and Behlfelt.  This may be attributed to the hypotonic and short upper lip in mouth breathers, exerting little or no influence on the upper anterior teeth and the lower lip turning outwards, resting between the upper and lower anterior teeth, causing forward pushing of the upper anterior teeth. On the other hand, Solow did not find any statistical difference in the finding related to mode of respiration. 
There was a significant difference in overbite in mouth breathers and nasal breathers, as shown in [Table 2]. This was observed in the studies of Cheng et al. and Behlfelt.  This difference may be due to the fact that there are postural changes in the mandible and tongue that is lowering of mandible and downward and frontal position of tongue in order to breathe through the mouth, causing the posterior teeth to super-erupt, leading to decrease in overbite. No open bite was observed in the present study, but De Menezes et al. found open bite in their study.
On the other hand, no difference was verified in the maxillary inter-canine distance between nasal breathers and mouth breathers, suggesting that the anterior narrowing of the hard palate is not associated with different modes of respiration. Finding of this study are in line with the studies of Berwig et al.  and Ghasempour et al.  Aznar et al. found that the maxillary inter-canine distance was less.
The inter-molar distance and inter-canine distance in the mandibular cast was lower in mouth breathers, but this was not statistical significant, as shown in [Table 2]. On the other hand, Behlfelt  and Solow et al.  found significant decrease in the mandibular inter-molar width.
The sagittal dental occlusion relationship may be altered with type of respiration, as incidence of class II and class III malocclusion was found to be twice in mouth breathers-22.5% and 5% respectively, compared with 11.54% and 1.92%, respectively, in the study with respect to nasal breathers. Similar results are observed in studies by Lopatiene et al.,  Nunes et al.,  and Bernardo et al.  Narrow and deep palate and backward rotation of the jaw leads to a more opened posture, permitting the airflow in mouth breathers. These alterations may be the factor for a high incidence of class II dental occlusion relationship in respiratory obstruction cases. A higher prevalence of the class III sagittal relationship may be attributed to the altered position of the tongue, forward and downward, in mouth breathers, which cause pushing of the mandibular anterior teeth. A high incidence of these two types of dental occlusion may be explained by the fact that if nasal obstruction is for a longer period, then genetically susceptible children will have altered craniofacial morphology.  Bresolin et al. did not find any relationship between nasal resistance and sagittal dental occlusion. 
The limitation of this study was its cross-sectional design. A methodology that can help in accurately identifying the genetic influence and along with a longitudinal study will throw light on the propensity for the presence of certain types of malocclusions.
MB, apart from causing abnormal dentofacial growth, can also case medical problems. Nasal respiration is essential for production of nitric oxide, which is crucial to the overall health and efficiency of smooth muscles such as blood vessels and the heart. ,, Mouth breathers have a lower oxygen concentration in blood, which has been associated with high blood pressure and cardiac failures. ,
All MB children should be treated by an otorhinolaryngologist regardless of the etiological factor. Specific treatment approach by pediatric dentist/orthodontist to individual characteristics would contribute immensely to a better quality of life.
| Conclusion|| |
Some of the occlusal patterns in the breathing-impaired subjects were significantly different from those in the control group. The discrepancies relate to vertical components associated with palatal height and overbite, and transversely showed significantly more narrow maxillary inter-molar width. Hence, earlier recognition of the changed mode of breathing would help in curtailing the development of muscular and dentofacial alterations. These alternations cause difficulty in restoring and providing stability to acceptable occlusion. After maximum facial growth has occurred, management of deviant dental patterns become increasingly complex and irreversible.
| References|| |
|1.||Vianna-Lara MS, Caria PH. Electromyographic analysis of the upper lip in nose and mouth breathers. Braz J Oral Sci 2006;5:1203-8. |
|2.||Frasson JM, Magnani MB, Nouer DF, de Siqueira VC, Lunardi N. Comparative cephalometric study between nasal and predominantly mouth breathers. Braz J Otorhinolaryngol 2006;72:72-81. |
|3.||Rubin RM. Mode of respiration and facial growth. Am J Orthod 1980;78:504-10. |
|4.||Bresolin D, Shapiro GG, Shapiro PA, Dassel SW, Furukawa CT, Pierson WE, et al. Facial characteristics of children who breathe through the mouth. Pediatrics1984;73:622-5. |
|5.||Principato JJ. Upper airway obstruction and craniofacial morphology. Otolaryngol Head Neck Surg 1991;104:881-90. |
|6.||Martínez Esteinou JL, Omaña Vidal E. Dental malocclusion and bony abnormalities in girls with nasopharyngeal obstruction of allergic origin. Pract Odontol 1988;9:8-12 passim. |
|7.||Garry JF: Early Iatrogenic, Orofacial Muscle, Skeletal, and TMJ Dysfunction. In Morgan D, ed. Diseases of the Temporomandibular Apparatus - A Multidisciplinary Approach, St. Louis: C.V. Mosby Co.; 1989. p .35-69. |
|8.||Moss ML, Salentijn L. The primary role of functional matrices in facial growth. Am J Orthod 1969;55:566-77. |
|9.||Moss ML. The functional matrix: Functional cranial components. In: Kraus BS, Reidel R, editors. Vistas in Orthodontics. Philadelphia: Lea and Febiger; 1962. p. 85-90. |
|10.||Quinn GW. Airway interference and its effect upon the growth and development of the face, jaws, dentition and associated parts. "The portal of life". NC Dent J 1978;61:28-31. |
|11.||Brodsky L, Koch RJ. Anatomic correlates of normal and diseased adenoids in children. Laryngoscope1992;102:1268-74. |
|12.||Pires MG, Di Francesco RC, Grumach AS, MelloJF Jr. Evaluation of inspiratory pressure in children with enlarge tonsils and adenoids. Braz J Otorhinolaryngol 2005;71:598-601. |
|13.||Cassano P, Gelardi M, Cassano M, Fiorella ML, Fiorella R. Adenoid tissue rhinopharyngeal obstruction grading based on fiberendoscopic findings: A novel approach to therapeutic management. Int J Pediatr Otorhinolaryngol 2003;67:1303-9. |
|14.||Barnett EM. Pediatric Occlusal Therapy. Saint Louis: The CVMosby Company; 1974. p. 480. |
|15.||BerwigLC, Silva AM, Côrrea EC, Moraes AB, Montenegro MM, Ritzel RA. Hard palate dimensions in nasal and mouth breathers from different etiologies. J Soc Bras Fonoaudiol 2011;23:308-14. |
|16.||Harari D, Redlich M, Miri S, Hamud T, Gross M. The effect of mouth breathing versus nasal breathing on dentofacial and craniofacial development in orthodontic patients.Laryngoscope 2010;120:2089-93. |
|17.||Lopatiene K, Babarskas A. Malocclusion and upper airway obstruction. Medicina (Kaunas) 2002;38:277-83. |
|18.||Cheng MC, Enlow DH, Papsidero M, Broadbent BH Jr, Oyen O, Sabat M. Developmental effects of impaired breathing in the face of the growing child. Angle Orthod 1988;58:309-20. |
|19.||De Menezes VA, Leal RB, Pessoa RS, Pontes RM. Prevalence and factors related to mouth breathing in school children at the Santo Amaro project-Recife, 2005. Braz J Otorhinolaryngol 2006;72:394-9. |
|20.||De Freitas FC, Bastos EP, Primo LS, De Freitas VL. Evaluation of the palate dimensions of patients with perennial allergic rhinitis. Int J Paediatr Dent 2001;11:365-71. |
|21.||Trask GM, Shapiro GG, Shapiro PA. The effects of perennial allergic rhinitis on dental and skeletal development: A comparison of sibling pairs. Am J Orthod Dentofacial Orthop 1987;92:286-93. |
|22.||Behlfelt K. Enlarged tonsils and the effect of tonsillectomy.Characteristics of the dentition and facial skeleton. Posture of the head, hyoid bone and tongue. Mode of breathing. Swed Dent J Suppl 1990;72:1-35. |
|23.||Solow B, Siersbaek-Nielsen S, Greve E. Airway adequacy, head posture, and craniofacial morphology. Am J Orthod1984;86:214-23. |
|24.||Ghasempour M, Mohammadzadeh I, Garakani S. Palatal arch diameters of patients with allergic rhinitis. Iran J Allergy Asthma Immunol 2009;8:63-4. |
|25.||Azna T, Galán AF, Marín I, Domínguez A. Dental arch diameters and relationships to oral habits. Angle Orthod 2006;76:441-5. |
|26.||Nunes WRJr, Di Francesco RC. Variation of patterns of malocclusion by site of pharyngeal obstruction in children.Arch Otolaryngol Head Neck Surg 2010;136:1116-20. |
|27.||Souki BQ, Pimenta GB, Souki MQ, Franco LP, Becker HM, Pinto JA. Prevalence of malocclusion among mouth breathing children: Do expectations meet reality? Int J Pediatr Otorhinolaryngol 2009;73:767-73. |
|28.||Trochu JN, Bouhour JB, KaleyG, Hintze TH. Role of endothelium-derived nitric oxide in the regulation of cardiac oxygen metabolism: Implications in health and disease. Circ Res 2008;87:1108-17. |
|29.||Rush JW, Denniss SG, Graham DA. Vascular nitric oxide and oxidative stress: Determinants of endothelial adaptations to cardiovascular disease and to physical activity. Can J Appl Physiol 2005;30:442-74. |
|30.||Danson EJ, Paterson DJ. Cardiac neurobiology of nitric oxide synthases. Ann N Y AcadSci 2005;1047:183-96. |
|31.||Naughton MT, Lorenzi-Filho G. Sleep in heart failure.Prog Cardiovasc Dis 2009;51:339-49. |
|32.||Andreas S, von zurMühlen F, Stevens J, Kreuzer H. Nocturnal oxygen and hypercapnic ventilator response in patients with congestive heart failure. Respir Med 1998;92:426-31. |
[Table 1], [Table 2], [Table 3]