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Perio Reports

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Perio Reports  Vol. 24, No. 9
Perio Reports provides easy-to-read research summaries on topics of specific interest to clinicians.
Perio Reports research summaries will be included in each issue to keep you on the cutting edge
of dental hygiene science.
Mouth Breathing Reduces Exercise Capacity

Mouth breathing leads to functional, structural, postural, biomechanical, occlusal and behavioral impairments. More males suffer with mouth breathing than females. Those who mouth breathe adapt a forward head posture by bending their head forward and extending their neck to reduce airway resistance.

Researchers at the State University at Campinas School of Medical Sciences in Campinas, Brazil compared exercise capacity and respiratory muscle strength between mouth and nose breathing in children eight to 12 years of age. Of the 92 study subjects, 30 were mouth breathers and 62 were nose breathers. For the exercise section, children completed a six-minute walk test according to the American Thoracic Society recommendations.

Mouth breathing children were recruited from the Mouth Breather Clinic of the Otolaryngology Department of the State University. Nose breathers were recruited from a nearby elementar y school. Clinical and endoscopy examinations were completed on all students to evaluate the nasopharanyx and adenoids.

Inhalation and exhalation muscle function was measured prior to and during exercise. Measurements were made with a mechanical pressure gauge that was connected to a plastic mouthpiece. A 15-minute rest period was allowed between measurements taken at rest and during the walk.

Forward head posture was not a significant predictive factor for muscle function during exercise. Mouth breathing showed significantly less respiratory muscle strength compared to nose breathing.

Clinical Implications: Recognize and reverse mouth breathing in your patients as early as possible to enhance breathing biomechanics and enhance exercise inhalation and exhalation muscle strength.

Okuro, R., Morcillo, A., Ribeiro, M., Sakano, E., Conti, P., Ribeiro, J.: Mouth Breathing and Forward Head Posture: Effects on Respiratory Biomechanics and Exercise Capacity in Children. J Braz Pneumol 37(4):471-479, 2011.
Mouth Breathing Changes Facial Morphology

In the oral cavity, a balance of functions should exist between breathing, suckling, swallowing, chewing and speech. Debate still exists about the impact of mouth breathing on development of orofacial structures. Despite the fact that bone is the second hardest substance in the body, it is susceptible to small, continuous forces from muscles. Mouth breathing results in changed tongue positioning from the palate to the floor of the mouth, resulting in inferior positioning of the mandible and changes in neck and facial musculature changing dental and facial characteristics.

Researchers at the Medical University in Lucknow, India evaluated cephalometric tracings to compare landmarks in a group of 100 children ages six to 12 years. Mouth breathers accounted for 54 children in the group and nose breathers accounted for 46 subjects. Significant differences were evident between nose breathers and mouth breathers for facial development. Mouth breathers showed significant increase in facial height, mandibular plane angle and angle of the mandible. The palatal plane to mandibular plane angle was greater in mouth breathers. There was mandibular retrusion in relation to the spine in mouth breathers compared to nose breathers.

At as early as three years of age, mouth breathing and low tongue posture produce an elongation of the lower anterior facial height, which is more commonly detected after age five. Posterior rotation of the mandible in mouth breathers leads to the increased facial height. Palatal changes are also evident as the maxillary arch narrows and the height of the palate increases.

Clinical Implications: Early intervention with mouth breathers will prevent morphological changes associated with Long Face Syndrome.

Malhotra, S., Pandey, R., Nagar, A., Agarwal, S., Gupta, V.: The Effect of Mouth Breathing on Dentofacial Morphology of Growing Child. J of Indian Soc Pedod Prev Dent 30(1): 27-31, 2012.
Mouth-Breathing Kids Have Bad Breath

Mouth breathing results in many facial changes in a growing child, including changes in the dental arches, tooth position, facial bone structure, palatal development, chin positioning and lips. Those who mouth breathe complain of dry mouth, halitosis, restless sleep, snoring, drooping shoulders, daytime sleepiness, flaccid lips and protrusion of the anterior teeth.

Researchers at the Metropolitan University de Santos in Sao Paulo, Brazil evaluated bad breath in a group of 55 children between the ages of three and 14 years. Of this group, 22 were mouth breathers and 33 were nose breathers. Nose or mouth breathing was determined by clinical evaluation of the following signs: long face, drooping eyes, thin upper lip, dry lips, hypotonic lips, inverted lower lip, narrow nostrils, high-arched palate, inadequate lip seal and anterior open bite. A mirror test was used placing a flat double-sided mirror under the nostrils to see vapor formation from the nose or the mouth. A water test involved having the children hold water in the mouth without swallowing for three minutes. If unable to keep the mouth closed for three minutes, they were considered a mouth breather.

Halitosis was measured using a portable sulfite monitor. Of the 20 children with no odor, 18 were nose breathers and 2 were mouth breathers. Of the 35 with bad breath, 15 were nose breathers and 20 were mouth breathers. Mouth breathing significantly influenced bad breath.

Clinical Implications: Check to see if your child patients mouth breathe and have bad breath. Changing the mouth breathing to nose breathing may eliminate the bad breath and provide many other benefits as well.

Motta, L., Bachiega, J., Guedes, C., Laranja, L., Bussadori, S.: Association between Halitosis and Mouth Breathing in Children. Clinics (Sao Paulo) 66 (6): 939-942, 2011.
Humming Increases Nasal Nitric Oxide Production

Nitric oxide is produced and released in the nasal airways during nose breathing. It is released from nasal tissue and inhaled into the lungs. Nitric oxide is not produced or released with mouth breathing. In healthy sinuses nitric oxide levels are high. Congested airways lead to lower levels of nitric oxide and mouth breathing. Nitric oxide is important for many things including smooth muscle relaxation and vasodilation.

Researchers at the Karolinska Institute in Stockholm, Sweden hypothesized that humming would produce oscillating airflow-enhancing nasal airflow, resulting in higher release of nitric oxide in the nasal passages. Ten healthy, non-smoking subjects participated in the study measuring nitric oxide in exhaled air from both the nose and the mouth. Measurements were taken at rest with gentle breathing and again while humming.

Humming resulted in a 15-fold increase in nasal nitric oxide levels compared to relaxed breathing. During relaxed nasal breathing, nitric oxide levels were 189 nl/minute and increased to 2,818 nl/minute with humming. Nitric oxide levels with relaxed mouth breathing averaged 103 nl/minute and were 104 nl/minute for mouth breathing and humming. Air needs to pass through the nasal passages to trigger the release of nitric oxide. With mouth breathing and humming there was no increase in nitric oxide levels. Nose breathing produces more nitric oxide than mouth breathing. When humming is added to nose breathing, nitric oxide production increases significantly.

Clinical Implications: Encourage mouth breathing patients to hum with the tongue resting on the palate to ensure nose breathing. This will increase nitric oxide production while practicing lips together posture, tongue on the palate nasal breathing.

Weitzberg, E., Lundberg, J.: Humming Greatly Increases Nasal Nitric Oxide. Am J Respir Crit Care Med 166(2):144-145, 2002.
Snoring Associated with Craniofacial Development

Children who nose breathe show normal craniofacial growth. Those who mouth breathe show abnormal craniofacial development, malocclusion, narrowing and deepening of the palate, tendency toward open bite and/or cross bite, protrusion of maxillary incisors and changes in head position relative to the neck.

Researchers at the University of Sao Paulo in Brazil evaluated 27 children ages seven to 14 years to determine any relationship between cephalometry used by orthodontists and polysomnography, the gold standard when testing for obstructive sleep apnea. Fifteen of the children were mouth breathers and 12 were nose breathers. Mouth breathing was identified by parents reporting child sleeping with an open mouth, dribbling on the pillow three times or more per week or adenoid obstruction identified with nasofibroscopy. Overnight polysomnograms were performed on all the children.

All of the mouth breathers snored and only one child in the nose breathing group snored. The mouth breathers all had lower oxygen saturation levels than nose breathers. The mouth-breathing children were more likely to have a retruded mandible than nose breathers. Other measurements showed mouth breathers to have more inclined occlusal planes, steeper mandibular planes and smaller airways compared to nose breathers. Snoring was the most important variable associated with abnormal craniofacial morphology. Early detection and treatment of mouth breathing can change the child’s facial development, oxygen saturation to brain and muscles, and general quality of life.

Clinical Implications: Dentists and dental hygienists should be checking children for mouth breathing and snoring, which are signs of potential developmental and sleeping problems.

Juliano, M., Machado, M., de Carvalho, L., Zancanella, E., Santos, G., Prado, L., Prado, G.: Polysomnographic Findings are Associated with Cephlometric Measurements in Mouth- Breathing Children. J Clin Sleep Med 15(5): 554-561, 2009.
Infant Sleep Disordered Breathing Leads to Childhood Behavior Problems

Sleep disordered breathing (SDB) ranges from snoring to obstructive sleep apnea (OSA), with mouth breathing as a common clinical sign. SDB occurs in children as young as six months. SDB causes abnormal gas exchange, interferes with sleep and restorative processes, and disrupts cellular and chemical balance. Dysfunction of the prefrontal cortex impairs attention, executive function, behavioral inhibition, self-regulation of affect and arousal, and other socio-emotional behaviors. Neurological effects may be irreversible as sleep is so critical to brain development in infants and young children. Attention-deficit/hyperactivity disorder is also linked to SDB.

Three hallmark signs of SDB are snoring, mouth breathing and witnessed apnea. Researchers from Albert Einstein College of Medicine in Bronx, New York, and University of Michigan in Ann Arbor, Michigan, analyzed the data from more than 11,000 children in the Avon Longitudinal Study of Parent and Children. A total of 14,541 pregnant mothers in the county of Avon in the southwest of England entered this study between April and November of 1991. Data up to age seven was analyzed. Mothers reported on SDB symptoms and completed strengths and difficulties questionnaires at ages four and seven. The incidence of SDB in this group was identified in clusters accounting for 55 percent of the sample. The clusters reflected the onset and end or not of the SDB symptoms. Early SDB symptoms had a strong, persistent effect on subsequent behavior problems in the children.

Clinical Implications: Begin checking infants as young as six months for sleep disordered breathing, in particular mouth breathing and snoring.

Bonuck, K., Freeman, K., Chervin, R., Xu, L.: Sleep-Disordered Breathing in a Population-Based Cohort: Behavioral Outcomes at 4 and 7 years. Pediatrics 129(4): e857-e865, 2012.
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