A review - Journal of Pharmaceutical and Biomedical Sciences

JOURNAL OF PHARMACEUTICAL AND BIOMEDICAL SCIENCES

Kumar Ashok, Ahlawat Babita, Chaudhary Navdha. Mouth Breathing. J Pharm Biomed

Sci 2014; 04(02): 137-142.

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Kumar Ashok,Ahlawat Babita,Chaudhary Navdha.

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NLM Title: J Pharm Biomed Sci.

Mouth Breathing

Kumar Ashok1, Ahlawat Babita

2,*, Chaudhary Navdha

3

Affiliation:-

1Assistant Professor, Department of ENT, SHKM GMC, Nalhar, Mewat, Haryana, India 2Senior Resident, Department of Dentistry, SHKM

GMC, Nalhar, Mewat, Haryana, India 3Postgraduate Student, Department of Paedodontics and Preventive Dentistry, BRS Dental College & Hospital, Sultanpur, Panchkula, Haryana, India The name of the department(s) and institution(s) to which the work should be attributed:

1.Department of Dentistry, SHKM GMC, Nalhar, Mewat, Haryana, India 2.Department of Paedodontics and Preventive Dentistry, BRS Dental College & Hospital, Sultanpur, Panchkula, Haryana, India

*To whom it corresponds:- Dr Babita Ahlawat, Senior Resident, Department of Dentistry, SHKM GMC, Nalhar, Mewat, Haryana,India Address:- W/o Dr Ashok Kumar, Flat no. 103, C-1 Block, Doctor’s residential complex, SHKM Government Medical College, Nalhar, Mewat, Haryana,India

Contact numbers- 9728651161, 8199915555

Abstract Mouth breathing in humans is an unnatural act of necessity to get air into the lungs when the primary airway is blocked by nasal or nasopharyngeal obstruction. It may be continuous or intermittent. It is a habit in which the lower jaw is dropped. The lips are parted and the tongue is depressed from its normal position. Mouth breathing has been stated to have serious effects on the development of the facial skeleton and occlusion of teeth on account of the displacement of normal lateral, buccal, and lingual muscular forces. In mouth breathing the air is received directly into the lungs without being cleansed, warmed, and moistened and it tends to lift the palate high. Mouth Breathing should be treated during the mixed dentition period to prevent or correct its ill effects on occlusion. Treatment should be aimed at elimination of the cause, Interception of the habit and Correction of the malocclusion.

Keywords: Mouth breathing; Airway

interference syndrome.

Kumar Ashok,Ahlawat Babita,Chaudhary, Navdha. Mouth Breathing. J Pharm Biomed Sci 2014; 04(02): 137-142. Available at www.jpbms.info.

INTRODUCTION

outh Breathing Nasal breathing is the primary mode of air intake for the humans, and the mouth is only a secondary emergency orifice for

assuring an uninterrupted supply of air, and using it on a regular basis can cause many problems. Mouth breathing in humans is an unnatural act of necessity to get air into the lungs when the primary airway is blocked by nasal or nasopharyngeal obstruction. It may be continuous or intermittent1. Mouth breathing is a habit in which the lower jaw is dropped. The lips are parted and the tongue is

depressed from its normal position.2An important function of nose is to prepare and modify inspired air to a more physiologic state before it enters the lungs. The quality of the air received by the lungs may influence the health and function of the lungs themselves. When air first enters the nose, it is immediately screened for large particles by the coarse hairs in the anterior nares. Air inhaled through the nose passes over the nasal turbinates in thin layers and develops air currents that cause it to contact the moist nasal mucosa. This contact removes additional foreign particles like dust, pollen and even bacteria. The debris laden mucous

Review Article

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atop the cilia of the nasal mucosa and is carried by cilliary action to the pharynx, where it is swallowed or expectorated. The cleansed air is also warmed and moistened before it enters the lungs. By contrast, when air is inspired through the mouth it assumes a more cylindrical current and is not cleaned, warmed or moistened as it would be in the nose3. Sometimes the literature reveals as if all of mankind were divided into nasal breathers and mouth breathers. Very few people breathe solely in one manner. Normal nasal breathers, quickly change to mouth breathing during strenuous exercise or exertive running. Herein the term “nasal breather” is used to mean a person who breathes mostly through the nose except during exertion. Mouth breathers are those who breathe orally even in relaxed and restful situations4. Definitions Sassouni5: Defined mouth breathing as habitual respiration through the mouth instead of the nose. Merele5: Suggested the term oronasal breathing instead of mouth breathing. Chacker F M (1961): defined mouth breathing as the prolonged or continued exposure of the tissues of the anterior area of the mouth to the drying effects of the inspired air. Etiology Most of the children suffer from some degree of nasal insufficiency. Allergies, physical obstructions and chronic infections may cause many children to breathe through the mouth. This airways obstruction may be due to: i.Enlarged turbinates ii.Deviated septum and other nasopharyangeal deformities. iii.Allergic, rhinitis, nasal polyps. iv.Enlarged adenoids or tonsil. v.Abnormally short upper lip preventing lip seal. vi.Obstruction in the bronchial tree or larynx vii.Obstructive sleep apnea syndrome. viii.Genetically predisposed individual. Ectomorphic children having a genetic type of tapering face and nasopharynx are prone to nasal obstruction. ix.Thumb sucking or similar oral habits can be the instigating agent. Airway Interference Syndrome

1

Quinn 1983 described airway interference syndrome & gave various signs and symptoms

I.Facial Manifestations •Puffy upper eyelids. •Underdeveloped infraorbital tissues. •Hypotonia at the maxillary lip (pale and thin). •Hypertonia of the mandibular lip (red and thick). •Hypertonia of the mentalis muscle (puckering). •Anxious or unrelaxed facial expression. •Cracked, chopped, pebbled or wrinkled upper lips. •Cheilosis. •Dried saliva on the lips. II.Intraoral Manifestations •Soft tissues. •Inflammation and/or hypertrophy of gingiva (including rugae). •Hyperemia of palatal tissues. •Inflammation of anterior and posterior faucial pillars. •Inflammation of pharyngeal tissues. •Glossitis, scalloping, creasing or fissuring of the tongue. III.Hard tissues •Lingual axial inclination of alveolar process and teeth. •Rounding of posterior mandibular alveolar process. •Ribbing or prominence of roots. •Exostosis of alveolar process. •Hypertrophy of tissue at the maxillary tuberosity. IV.Occlusion •Anterior and/or posterior open bite. •Linguloaxial inclination of teeth. •Depression of teeth. V.Nasopharyngeal manifestations •Enlarged adenoid and/or tonsillar tissue. VI.Nasal Findings •Improper anterior luminal valving. •Septum deformity or deviation. •Spurs or exostoses. •Hypertrophied turbinates •Polyps or cysts, allergic and vasomotor rhinitis. •Rhinorrhea. •Foreign bodies. VII.Radiographic Findings

•Enlarged adenoid or tonsillar tissue. •Polyps and cysts. •Deformities of the septum and turbinates. •Abnormal tongue posture.


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•Anteroposterior and vertical jaw discrepancies. •Upward and outward posture of the cranium and face in relation to the cervical vertebrae. •Curvature of the cervical spine. •Asymmetries of the mandible. •Narrowing of the maxilla and nasal cavities. Review Van Bon MJ6 conducted a study to confirm the relationship pattern of habitual mouth breathing & otitis media with effusion. The results showed that there is a significant linear trend in the proportion of otitis media in 3 breathing categories i.e. nasal breathing, intermediate and mouth breathing. It was concluded that habitual mouth breathing is a risk factor of otitis media with effusion & it is estimated that about 20% of the incidence is caused by habitual mouth breathing. Juliana R C Barros et al.7 conducted a study to assess the presence of atopy among mouth breathing patients. Those with a positive result of at least one allergen were regarded as atopic. The results indicated high prevalence (44.3%) of atopy in mouth breathers. It was concluded that allergologic investigations are important, since allergy has specific treatments that may reduce morbidity in these patients. A study was conducted by Abreu RR et al.8 to investigate the etiology, main clinical findings and other concurrent findings in mouth breathing children aged 3-9 years. Clinical diagnosis was made as a combination of snoring, sleeping with mouth open, drooling of saliva on pillow and frequent nasal obstruction. It was reported that the main causes of mouthbreathing were allergic rhinitis (81.4%), enlarged tonsils (12.6%) & obstructive nasal septum (1%). The main clinical findings of mouth breathing were – sleeping with mouth open (86%), snoring (79%), itchy nose (77%), drooling on pillow (62%), nocturnal sleep problems (62%) & nasal obstruction (49%). Classification: Finn9 has classified mouth breathing into: I.Anatomic The anatomic mouth breather is the one whose short upper lip does not permit complete closure without undue effort. II.Obstructive Children who have an increased resistance to, or a complete obstruction of, the normal air flow through the nasal passages. The child is forced by sheer necessity to breathe through the mouth. III.Habitual

Habitual mouth breather is a child who continually breathes through his mouth by force of the habit, although the abnormal obstruction has been removed. Diagnosis History

The parents can be questioned whether the child adopts frequent lip apart posture. Frequent occurrence of tonsillitis, allergic rhinitis, and otitis media should also be queried Examination4 (According to Moyers) 1. Study the patient's breathing unobserved: Nasal-breathers usually show the lips touching lightly during the relaxed breathing whereas mouth-breathers must keep the lips parted. 2. Ask the patient to take a deep breath: Most respond to such a request by inspiring through the mouth, although an occasional nasal-breather will inspire through the nose with the lips lightly closed. 3. Ask the patient to close the lips and take a deep breath through the nose: Nasal breathers normally demonstrate good reflex control of the alar muscles, which control the size and shape of the external nares; therefore, they dilate the external nares on inspiration. Mouth-breathers, even though they are capable of breathing through the nose, do not change the size or shape of the external nares and occasionally actually contract the nasal orifices while inspiring. Even nasal-breathers with temporary nasal congestion will demonstrate reflex alar contraction and dilation of the nares during voluntary inspiration. Clinical tests 1. Mirror test 2. Cotton test 3. Water holding test 4. Inductive plethysography (Rhinomonometry):- This allows the percentage of nasal or oral respiration to be calculated. A minority of the long face children have less than 40% nasal breathing. 5. Cephalometrics:- To establish the amount of nasophyaryngeal space, size of adenoids and to know the skeletal patterns of the patient by taking various cephalometric angles. It is important to distinguish under which category the child with the habit belongs to; whether habitual, obstructive or anatomic. It is again important to distinguish a habitual mouth breather from a child who breaths through his


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mouth because of his short upper lip which keeps his lips apart10. Effects on dentofacial structures5 Facial form: Patient who does mouth breathing due to hypertrophied lymphoid tissue has a tendency towards more vertical growth pattern. Cephalometric analysis of such patients reveals an increased facial height and increased mandibular plane angle. Adenoid facies: It is a particular type of facial configuration frequently associated with mouth breathing characterized by a long, narrow face with an accompanying narrow nose and nasal passages, flaccid lips with the upper lip being short and dolicocephalic skeletal patterns. Often the nose is tipped superiorly in front, so as an observer can look directly into the nares. The long face is often expressionless. The buccal segments of the maxilla are collapsed, leading to ‘V’ shaped and high palatal vault. Dental effects

2:

Mouth breathing has been stated to have serious effects on the development of the facial skeleton and occlusion of teeth on account of the displacement of normal lateral, buccal, and lingual muscular forces. In mouth breathing the air is received directly into the lungs without being cleansed, warmed, and moistened and it tends to lift the palate high. •McCoy stated that the mouth is held open constantly and, as a result, the muscles which depress the mandible exert a backward muscular pull upon the mandible with each inspiration. With time this may influence the bone to modify and bring the lower teeth distal to the normal. Once this distal relationship of the molars is established, the permanent teeth assume a similar malrelation, and these mechanics of malocclusion operate constantly. •The tongue is not held in the roof of the mouth due to mandibular depression and the upper teeth are deprived of their muscular support and lateral pressure in consequence. Because of this imbalanced relationship between external and internal muscular forces in the mouth, the buccinator muscle causes a lateral pressure on the maxillary arch resulting in its narrowing. •The upper lip is so little used that it exerts very little influence on the maxillary anterior teeth and is often short. The lower lip rests between the mandibular and maxillary incisors and becomes a

factor in pushing the maxillary anterior teeth forward resulting in their proclination. •During the swallowing process the lower lip is usually forced against the mandibular incisors resulting in extrusion of mandibular incisors, exaggerating the curve of spee. Joshi found that Class II, Division 1 was more common in cases with mouth breathing. •There is increased incidence of dental caries also. Speech defects:

Abnormalities of the oral and nasal structure can seriously compromise speech performance. Nasal tone in voice is seen. Lips: These patients frequently have a lips apart posture, although this posture should not be regarded as pathognomonic for nasal obstruction. Excessive appearance of the maxillary anteriors is a sign of long face syndrome. On smiling, many of these patients reveal large amount of gingiva producing a ‘gummy smile’. Children who mouth breath have a short thick incompetent upper lip and voluminous curled over lower lip. External nares: Long-standing nasal airway obstruction can lead to a disuse atrophy of the lateral cartilage. The result is slit-like external nares with a narrow nose. Sometime after the airways obstruction is removed and a patent airway is established, the nose may collapse on inspiration, making reconstructive surgery necessary. Nasal mucosa becomes atrophied due to a disturbed ciliary action. Gingiva: Mouth breathers frequently present with problems like an inflamed and irritated gingival tissue in the anterior maxillary arch. The gingiva is hyperplastic due to continuous exposure of the tissues to air drying. Chronic gingival condition is due to a decreased salivary flow to remove the debris and bacterial overgrowth. The drying effect of moving air can also lead to heavy deposits of the plaque. Gingiva exhibits a classic rolled margin and an enlarged interdental papilla. These may occur together with a periodontal disease which may lead to an interproximal bone loss with the presence of deep pockets. Other effects: Mouth breathing may lead to otitis media. The activity of muscles differs in the nose and mouth breathers. The palatoglossus muscle is active in the case of nose breathers, whereas the levator palatini activity is lower in nose breathing as compared with mouth breathing. Sense of smell and taste also decreases.


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Treatment5 Mouth Breathing should be treated during the mixed dentition period to prevent or correct its ill effects on occlusion. Treatment depends upon: I. Age of the child As with any other habit, correction of mouth breathing could be expected to decrease as the child matures. This can be attributed to the increase in nasal passages and reduction in size of tonsils as the child grows, thereby relieving the obstruction. Mouth breathing is in many instances self-correcting after puberty. II.ENT examination An otorhinolaryngologist examination may be advised to determine whether conditions requiring treatment are present in the tonsils, adenoids or nasal septum. In some children, mouth breathing may continue even after the correction of the pathologic condition, in which case it may be habitual. Symptomatic Treatment The gingiva of the mouth breathers should be restored to normal health by coating the gingiva with petroleum jelly and by clinically correcting periodontal defect that had occurred due to the habit. Treatment should be aimed at: 1.Elimination of the cause If nasal or pharyngeal obstruction has been diagnosed as the cause of mouth breathing attempts should be made at treating the etiological factor first. Removal of nasal or pharyngeal obstruction by surgery or local medication should be sought. If a respiratory allergy is present, this should be brought under control. A marked reduction in nasal airway resistance after a rapid maxillary expansion has been reported to be achieved. 2.Interception of the habit If a habit continues even after the removal of obstruction then it should be corrected. Correction can be done by means of the following- Exercises If there is no physiologic cause the patient should be instructed for breathing and lip exercises. •Deep breathing This is done in the morning and in the night. Deep breathing exercises are done with deep inhalation

through the nose with arms raised sideways. After a short period, the arms are dropped to the sides and the air is exhaled through the mouth. •Lip exercises Hypotonicity and flaccidity of the upper lip are the most obvious characteristics. The child is instructed to extend the upper lip as far as possible to cover the vermilion border under and behind the maxillary incisors. This exercise should be done 15-30 minutes a day for a period of 4-5 months when the child has a short upper lip. If the maxillary incisors are protruded, the lower lip can be used to augment the upper lip exercise. The upper lip is first extended into the previously described position. The vermilion border of the lower lip is then placed against the outside of the extended upper lip and pressed as hard as possible against the upper lip. This type of exercise exerts a strong retraction influence on the maxillary incisors, which increases the tonicity of both the upper and lower lips. Playing a wind instrument is an interceptive orthodontic procedure. A celluloid strip or metal disk held between the lips not only necessitate their being closed, but also makes the child conscious of their opening if the object drops. Myofunctional Therapy11: To increase the tonicity of lips few myofunctional exercises are recommended. These are: During day time hold pencil between lips. During night tape the lips together with

surgical tape in habitual mouth breathing. Hold a sheet of paper between lips. Patients with hypotonic upper lip stretch upper

lip to maintain lip seal. Button pull exercise - a button is taken and

thread is passed through it. Patient is asked to place the button behind the lips and pull the thread while restricting it from being pulled out by using lip pressure.

Tug of war exercise - involves two buttons, with one placed behind the lips and other is pulled by the other person.

Maxillothorax Myotherapy

This was advocated by Macaray in 1960. These expanding exercises are used in conjunction with the Macaray activator. He constructed an activator out of aluminum with which development of the dental arches and dental base relationship could


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be corrected at the same time as encouraging nasal breathing. Oral Screen9,12,13 Although correction of the nasopharyngeal obstruction may take place through surgical intervention or physiologic shrinkage, the child may continue to breathe through his mouth from mere force of the habit. This may be especially evident when the child sleeps or is in a recumbent position. When this situation prevails the dentist may decide to intervene with an effective appliance which will cause the child to breathe through his nose. This may be done by the construction of an oral screen (oral shield) which will block the passage of air through the mouth and force the inspiration and expiration of air through the nares. 3.Correction of the malocclusion Mechanical appliances •Children with class I skeletal and dental occlusion and anterior spacing- Oral shield appliance. •Class II division 1 dentition without crowding, age 5-9 years, Monobloc activator to aid both in the correction of malocclusion and deterrence of the habit. This appliance when worn will not allow the air to be breathed through the mouth. •In Class III malocclusion interceptive methods are recommended as a chin cap. The child should be evaluated for a sufficient airway before treatment.

REFERENCES 1.Quinn G W. Airway interfernce syndrome: clinical identification and evaluation of nose breathing capabilities. Angle Orthod. 1983; 53(4):311-319.

2.Paul J L, Nanda R S. Effect of mouth breathing on dental occlusion. Angle Orthod. 1973 April: 201-206. 3.Peterson J E. Pediatric Oral Habits. In: Stewart R E, Barber T K, Troutman K C, Wei S H Y, editors. Pediatric Dentistry: Scientific foundations and clinical practice. St. Louis. The C. V. Mosby Company; 1982. p. 361-372.

4.Moyers R E. Handbook of Orthodontics. 4th

ed.

Chicago: Year Book Medical Publishers, Inc.; 1988.

5.Tandon S. Textbook of Pedodontics. 2nd

ed.

Hyderabad: Paras Medical Publishing; 2009. 6.Van Bon M J, Zielhuis G A, Rach G H, Van Den Broek P. Otitis media with effusion and habitual mouth breathing in Dutch preschool children. Int J Pediatr Otorhinolaryngol. 1989 May; 17(2):119-25. 7.Barros J R C, Becker H M G, Pinto J A. Evaluation of atopy among mouth breathing pediatric patients referred for treatment to a tertiary care center. Jornal de Pediatria 2006;82(6):458-464. 8.Abreu R R, Rocha R L, Lamounier J A, Guerra A F M. Prevalence of mouth breathing among children. Jornal de Pediatria 2008; 84(5):467-470. 9.Sim J M, Finn S B. Oral Habits in Children. In: Finn S B, editor. Clinical Pedodontics. 4th ed. Philadelphia: W. B. Saunders Company; 2003. p. 370-385. 10.Policy on Oral Habits. Oral Health Policies. American Academy of Pediatric Dentistry Reference Manual 2008-2009, Volume30. No.7. 11.http://www.identalhub.com/article_treatment-of-mouth-breathing-178.aspx

12.Rao A. Principle’s and Practice of Pedodontics. 2nd

ed. New Delhi: Jaypee Brother Medical Publishers (P) Ltd. 2008. 13.Graber T M, Rakosi T, Petrovic A G. Dentofacial Orthopedics with Functional appliance. 2nd ed. St.

Louis: Mosby; 1997.

Source of support: None

Competing interest / Conflict of interest The author(s) have no competing interests for financial support, publication of this research, patents and royalties through this collaborative research. All authors were equally involved in discussed research work. There is no financial conflict with the subject matter discussed in the manuscript. Copyright © 2014 Kumar Ashok,Ahlawat Babita,Chaudhary Navdha. This is an open access article distributed under the Creative

Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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