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REVIEW ARTICLE

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MOUTH BREATHING “A HABIT OR ANOMALY”

- A REVIEW

Dr. B.N. Rangeeth, Dr. Priyaa Rangeeth*

Professor, Department of Pedodontics, Thai Moogambigai Dental College,Chennai, Tamilnadu, India

*Chief Consultant, Gums to Crowns Laser and Implant Dental Clinic, Chennai, Tamilnadu, India.

To access & cite this article

ABSTRACT

Website: jidam.idamadras.com

Mouth breathing has been discussed for quite some time

but there is a need to increase the awareness about its

effects on the dentofacial structures. The review focuses

on the systemic and local effects of Mouth Breathing

that includes the effects on psychological development

including classification based on systemic influences.

Though the dentofacial effects are discussed commonly

the article aims to summate the systemic effects such as

ADHD and sleep apnea that have an effect on the overall

development for children. Management strategies such

as nasal patches shows the importance of a parallel ENT

therapy to be incorporated for better success.

KEYWORDS : Airway Obstruction, Mouth Breathing,

Address for correspondence:

Hypoxia, Sleep Apnea Syndrome, Respiratory

insufficiency.

Dr. B.N. Rangeeth., MDS.,

Professor, Department of Pedodontics,

Thai Moogambigai Dental College

Chennai, India

E-mail: dr.rangeeth@gmail.com

Received

: 28.11.2019

Accepted

: 17.12.2019

Published

: 27.12.2019

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Rangeeth et al : Mouth breathing is a habit or anomaly

INTRODUCTION:

had a greater chance of being mouth breathers. ⁶

Human infants are sometimes considered to

EFFECTS OF MOUTH BREATHING ON

be obligate nasal breathers, may also breath through

OVERALL HEALTH:

mouth or both. “Nasal breathing at rest is most

common though the mouth is used as an additional

Effect on psychological development showed

passage during exercise or strain to increase oxygen

that children with mouth breathing had poorer

intake. Mouth Breathing (MB) is breathing through

academic achievement and cognitive skills. Studies

the mouth rather than the nose. ¹ William James (The

on Obligatory mouth breathers showed that during

Principles of Psychology,

1980) emphasized the

loud reading and exercise had negatively impacted

importance and power of human habit and proceeded

phonation threshold pressure under controlled

to draw a conclusion. It was noted that the laws of

humidity conditions. ⁷ Syntactical complexity and

habit formation are unbiased; habits are capable of

difficulty in understanding written language with

causing either good or bad actions. Once either a good

lower scores than the control group in the arithmetic

or bad habit has begun to be established, it is very

test, indicating difficulties with numerical operations

difficult to change. The repetitive nature reinforces

were noted in mouth breathers.

⁹ Symptoms

the action in the memory and control passes from

similar to those of Attention Deficit Hyperactivity

a conscious system into an automatic impulsive

disorder (ADHD) have also been seen in Mouth

system. Habit as an automaticity and frequency is a

breathers. ¹⁰ MB has been associated with asthma

more useful conceptualization because automaticity

and otitis, Atopic Dermatitis in pre-school children

explains persistence of habits and discriminates it

of more than 2 years. The increased potentially of

from frequently performed non habit actions ².

Asthma is due to increased sensitization to inhaled

allergens, which highlights the risk of mouth-bypass

MB is a more compensatory and not a learned

breathing in the ‘one airway, one disease’ concept. ¹¹,

and impulsive mechanism and it presentation as a

syndrome ³ has been considered following its effect

Hemodynamic responses in the prefrontal

on certain mental skills. Hence this review has been

cortex were found to be different in mouth and nasal

discussed with the view of depicting MB more as a

breathers by causing an increase in oxygen load

condition or anomaly rather than a habit which seems

due to increased Deoxyhemoglobin levels. Mouth

to imply that the patient is breathing though their

breathing was thus shown to result in an increasing

mouth out of their preference i.e. a learned process

oxygen load in the prefrontal cortex when compared

rather than a compensatory mechanism.

with nasal breathing. MB was thus shown to result

in an increasing oxygen load in the prefrontal cortex

REVIEW OF LITERATURE:

when compared with nasal breathing. This suggests

that mouth breathing can be associated with ADHD

ETIOLOGY:

due to its association with the pre frontal cortex due

to central fatigue. During the treatment of ADHD

A study on the etiology of MB in 3-9 year old

there is a need to evaluate MB must be considered. ¹³

children showed that it was associated in 81.4% with

Otorhinolaryngological findings that were most

allergic rhinitis,

79.2% with adenoid hypertrophy,

prevalent in MB were adenotonsillar hypertrophy,

12.6% with tonsil hypertrophy and 1% with nasal

tonsilar hypertrophy, adenoid hypertrophy

septal deviation. The study group was selected as

reveling its effect on the upper respiratory tract as

there is a peak incidence of adenoid hypertrophy in

a result of dehydration of these structures. Other

this age group. Most of the MB in this group exhibited

effects of mouth breathing on the upper respiratory

open mouth as a clinical manifestation. ⁴ The ENT

tract included increase of severity of Obstructive

specialist’s point of view suggests obstructive

Sleep Apnea

(OSA) and complicate Continuous

diseases such as tonsils, adenoid hypertrophy, nasal

Positive Nasal Airway Pressure therapy. Fiber optic

septal deviation or lower turbinate hypertrophy

nasopharyngoscopy showed that the cross sectional

to cause a significant obstruction leading to MB. ⁵

area of retro-palatal and retro-glossal region was

Children with developmental disabilities showed

reduced suggesting that knowledge of such changes

that boys and those under psychotropic medication

increases OSA affecting therapy in Mouth breathers.

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Rangeeth et al : Mouth breathing is a habit or anomaly

¹⁵ Studies on MB and OSA using 3D multi - detector

following maxillary expansion due to maxillary arch

computed tomography suggested that a more

constriction and high arch, a deformity being one

elongated and narrow upper airway during MB may

of the effects of mouth breathing. ²¹-²⁶ Effects also

aggravate the collapsibility of the upper airway and

extend to the chewing efficiency where evaluation

thus affect OSA severity. ¹⁶ A controlled, analytical

of masticatory variables a longer amount of time

cross sectional study involving children aged 8-12

is necessary to obtain higher masticatory efficiency

years on the effect of MB on respiration showed that

when breathing through the mouth. ²⁷ The soft tissue

respiratory biomechanics and exercise capability

profile in MB showed that the upper lip was more

were negatively affected leading to a forward head

protruded and the lower lip was more protruded and

position that acted as a compensatory mechanism

short. The nasolabial angle, nasal prominence and

in order to improve respiratory muscle function. ¹⁷

chin thickness were smaller.²⁸

Relationship between excursion of the diaphragm

muscle and spinal curvature in MB children showed

Cephalometric analysis showed a significant

that the subjects exhibited reduced cervical lordosis,

increase in the upper incisor and lower incisor

increased thoracic kyphosis, increased lumbar

proclination, depth of mentolabial sulcus, inter-

lordosis and the position of the pelvis was tilted

labial distance and facial convexity in MB children.

forward. The distance traveled outwards by the

Upper incisor proclination and facial convexity was

diaphragm muscles of mouth breathing children was

significantly higher in MB children with adenoids a

shorter than that traveled by the muscles of nose

causative factor for MB. The Cephalometric analysis

breathing children. ¹⁸ The effects on the lung function

also showed a more retruded mandible (SNB angle),

in MB children showed that enforced oral breathing

and a greater inclination of the mandibular plane

causes a decrease in lung function in mild asthmatics

(NS-Go Gn) and occlusal plane (NS-O Pl) with an

at rest and sometimes initiating symptoms of asthma

increase in anterior lower facial height ²⁹, ³⁰ when

since oral breathing may play a role in pathogenesis

compared to nasal breathers. A clinical significance

of acute exacerbations. ¹⁹

of the effects of MB based on a MRI study that

showed that though placement of a rubber dam had

Based on studies the effect of MB on the

no additional influence on upper airway patency

postural effect the following classes were established

shortened mean respiratory duration and decreased

based on neuronal studies

²⁰ and these postural

tidal volume suggests that rubber dam may disrupt

changes also affect pulmonary function with age.

breathing pattern therefore it may be used with

caution in patients with MB. ³¹

● Class A: mouth-breathing children with critical

postural problems needing spinal rehabilitation care

EVALUATION:

● Class B: mouth-breathing children with moderate

changes to normal posture

Glatzel mirror proves to be a reliable tool

● Class C: mouth-breathing children with posture

clinically identifying participants with and without

slightly affected

nasal obstruction ³². The use of pulse oximetry to detect

Two other classes were also proposed:

hypoxia showed that 34.6% of the cases had normal

● Class D and E: nose breathers with slightly altered

O₂ saturation. 65.4% of cases were hypoxemic with

posture

the saturation level below 95% in 42.8% and 95% in

22.6% of cases. Most of the mouth breathing patients

EFFECT ON DENTO-FACIAL

were male who were also more hypoxemic, therefore

STRUCTURES:

the pulse oximeter can be considered another simple

tool to evaluate MB though earlier studies have even

The effect of MB not only affects the general

used CO₂sensors. ³³, ³⁴ Ultrasonography as a tool

health but also the dento facial structures where the

in evaluation of muscles of mastication showed

process of respiration starts. MB is a risk factor for

that there were definite changes in muscle thickness

halitosis, periodontal disease and dental caries due to

associated with subjects who underwent exercises

increased intra-oral pH especially during. Evaluation

revealing that MB contributes to atophy of muscles.

of the mineralization of tooth and oral microbiota

³⁵ The cephalometric pattern of MB and NB children

showed that there was a significant difference in

was not similar. Cephalometric measurements of the

enamel mineralization and oral microbiota levels

MB group differed according to the etiology of upper

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JIDAM/Volume:6/Issue:4/Pages 137 - 143/October - December 2019

Rangeeth et al : Mouth breathing is a habit or anomaly

airway obstruction. The mandible was positioned in

breathing during sleep has been useful. ⁴³

an more forward and upward position in children

with palatine tonsils when compared with children

DISCUSSION:

with enlarged adenoids. ³⁶

Habit is defined as a phenomenon whereby

Electromyography

(EMG) activity of

behavior is prompted automatically by seasonal

orbicularis oris (lower fascile) and mentalis muscle

cures, as a result of learned cue behavior associations

showed that MB had increased EMG activity

and it has the potiential to activate behavour in the

of orbicularis oris during blowing, chewing and

abscement of awareness, conscious control, and

pronunciation of certain phoneme

\b\ and

\m\

cognitive effort or delibration. Habit may also be

with Mentalis showing increased EMG activity

viewed as a process by which a stimulus automatically

during chewing. ³⁷, ³⁸ Investigation into the fatigue

generates an impulse towards action, based on

of orbicularis oris muscles by EMG showed

learned stimulus-response associations. It represents

myoelectric fatigue preceding the feeling of fatigue

habit as a process by which action is cued. This also

more precociously in MB.³⁹

minimizes conceptual and logical tensions that arise

from portraying habit as behaviour, automaticity or

Non-invasive evaluation techniques such as

any other single element of the wider process.⁴⁴ A

anthropometric orofacial measurements revealed

process such as MB has never been activated or seen

that there were statistically significant difference

as ones behavior, rather with the review it can be

between the majority of the orofacial measurements

more seriously noted as an adaptation by the body in

of mouth-breathing children and the measurements

response to a stimuli such as insufficient oxygenation.

of children with no history of speech-language

The vast majority of health care professionals are

disorders showing that the possibility of comparing

unaware of the negative impact of upper airway

orofacial measurements of children with and without

obstruction on normal facial growth and physiologic

mouth-breathing behavior allows the clinician

health. Indian prevalence study on oral habits has

to determine normal and altered structures of the

detected MB in 4.6% - 6.6% of children. ^{45, 46} A

orofacial morphology. Anathropometry being non-

summary of the effect shows that the dentofacial

invasive, simple and economical with an objective

effects include long, narrow faces, narrow mouths,

analysis can be used for more advanced evaluation

high palatal vaults, dental malocclusion, gummy

of MB. ⁴⁰

smiles, and even leading to skeletal Class II or Class

III facial profiles. Sleep deprivation can affect growth

MANAGEMENT:

and academic performance, leading to diagnosis

of attention deficit disorder and hyperactivity. It

The use of Oral Screen has been seen as a

is important for the entire health care community

standard treatment protocol for MB. The knowledge

(including general and pediatric dentists) to screen

of the effect of adjunct therapies must be noted for

and diagnose for mouth breathing in adults and in

better understanding the pathogenesis as well as

children as young as 5 years of age. ¹⁰ Considering

restricting the progress of the condition. The oral

the review with the evidence of MB more as an

screen has been a suitable appliance for lip training

anomaly we have attempted to define MB according

which acts buy stretching the lip musculature,

to the dental aspect as ‘Compensatory respiration

providing a force which retroclines the proclined

through the oral cavity due to obstruction in the

incisors, and lips are strengthened simultaneously.

normal passage of respiration leading to disturbances

Surgical management alone does not convert oral

of the orofacial structures when not intervened’.

breathers to nasal breathers without intervention. ⁴¹

Speech therapy in combination with beclomethasone

Surgical

procedures

such

diproprionate inhalation had a more effective clinical

Adenotonsillectomy may not completely eliminate

and functional control of asthma, allergic rhinitis,

sleep-disordered breathing result in in progressive

and MB. ⁴² Porous Oral Patch which is a porous

worsening of abnormal breathing during sleep

skin pad consisting of three layers: silicone sheet,

requiring post-surgical intervention. ⁴⁷, Orthodontic

polyurethane foam, and polyurethane film, used to

effects on the occlusal forces were not seen in

treat obstructive sleep apnea and obstructive mouth

persistent MB , ⁴⁸ therefore the need to correct MB

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JIDAM/Volume:6/Issue:4/Pages 137 - 143/October - December 2019

Rangeeth et al : Mouth breathing is a habit or anomaly

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