ISSN: 1679-9941 (Print), 2177-5281 (Online)
Official website of the journal Adolescencia e Saude (Adolescence and Health Journal)

Vol. 2 No. 3 - Jul/Sep - 2005

The mouth breathing teenager

Nasal breathing is essential to the well-being of the body and to the harmonious development of the face. Breathing

through the mouth is a violation of this vital function and is not only a bad habit, but a disorder that brings numerous consequences, such as postural changes, upper airway infections, poor oxygenation of the brain, feeding difficulties and delayed growth and development in children and adolescents.

Harmonious craniofacial growth requires nasal breathing, good functioning of the stomatognathic system (mouth, facial muscles and bones) and perfect lip sealing.

NASAL ANATOMY

The medial wall is composed of the nasal septum, and the lateral wall comprises: a) nasal vestibule and valve (causing resistance to airflow); b) nasal conchae or turbinates (increase the mucous surface and regulate airflow by alternating vascular content); and c) meatuses: inferior – leads to the nasolacrimal duct; middle – into which the bones of the anterior sinuses (maxillary, anterior ethmoid and frontal) flow; superior – into which the bones of the posterior sinuses (posterior ethmoid and sphenoid) flow.

NASAL PHYSIOLOGY

Functions of the nose:

1. reflexogenic (vasomotor reaction);

2. drainage corridor (through mucociliary transport);

3. nasal airflow;

4. warming of inspired air;

5. humidification of inspired air;

6. air filtration (through vibrissae and mucus);

7. initiator of immune responses to inhaled antigens;

8. smell;

9. phonation (resonance of the nasal consonants M and N);

10. aesthetics (self-esteem, racial characteristics).

DEFINITION OF MOUTH BREATHER SYNDROME

Mouth breathing syndrome is characterized by an obstruction of the upper airways that leads the patient to the habit of breathing through the mouth. As a consequence, postural adaptation occurs, which is followed by changes in the dental arches and, later, in the bony skeleton of the face, in addition to infections and poor cerebral oxygenation. OBSTRUCTIVE

CAUSES

  • Hypertrophy of adenoid vegetations.
  • Chronic rhinitis: allergic, infectious, drug-induced, hormonal and idiopathic.
  • By irritants, atrophic.
  • Chronic hypertrophic tonsillitis.
  • Septal deviation.
  • Nasal masses: polyps, foreign bodies, tumors.
  • Narrow nasal passages: syndromes.
  • Macroglossia.
  • Pierre Robin syndrome (mandibular hypoplasia).

NON-OBSTRUCTIVE

  • Lip insufficiency.
  • vicious habit

SIGNS AND SYMPTOMS

  • Change: face, occlusion, posture, balance and gait; phonation, diction, hearing, smell and taste; chewing, swallowing, digestion and elimination.
  • Vices and habits.
  • Growth, development, concentration, attention, learning and sleep disorders.
  • Respiratory infections.
  • Cavities and gingivitis.
  • Physical tiredness (laziness) and fatigue.
  • Snoring, drooling, open mouth, sleep apnea, bruxism and dry mouth.
  • Change in behavior: withdrawal, prostration and defeatism.

MORPHOFUNCTIONAL CHANGES IN MOUTH BREATHER SYNDROME

CHANGES IN THE ORONASOPHARYNGEAL REGION

1. Nose: a) nostrils: lose volume and elasticity due to disuse; become narrowed and flattened; b) nasal mucosa: atrophied due to disuse; nasal voice; lost bacteriostatic action, leading to infections; impaired sense of smell (and concomitantly taste, leading to loss of appetite); and c) turbinates: engorged.

2. Nasopharynx: a) hyperplastic lymphoid tissue; b) adenoid hyperplasia leading to occlusion of the Eustachian tube, which causes decreased hearing (due to otitis media with effusion or Eustachian tube dysfunction).

3. Oral cavity: a) lips: flaccid, open; upper lip hypotonic, shortened and raised over the incisor teeth; heavy and everted lower lip, below and behind the upper incisors – the modeling action of the lips on the upper incisors is lost, causing protrusion of the upper incisors; b) gums: hypertrophied and inflamed (gingivitis); c) tongue: suspended between the arches or on the floor of the mouth (loss of the modeling action on the palate and loss of its tonicity); d) maxilla: V-shaped (due to contraction of the buccal segments and protrusion of the anterior teeth); ogival (deep) and atretic palate; e) mandible: retracted, keeping the mouth open, causing malocclusion (open bite).

POSTURAL CHANGES

1. Face: elongated and narrowed (adenoid facies); protrusion of the maxilla and retrusion of the mandible; blurred gaze, open mouth, narrowed nostrils. Dumb, distracted, absent-minded appearance.

2. Head: To breathe better, mouth breathers flex their neck forward, straightening the path of the upper airways so that air reaches the lungs more quickly.

3. Neck, thorax, abdomen and limbs:
a) neck: flexion forward; impairment of the neck and shoulder girdle muscles; straightened cervical spine;

b) thorax: elevated shoulder blades; depressed anterior region; accentuation of thoracic kyphosis; small action of the diaphragm, causing relaxation;

c) abdomen: relaxation of the rectus abdominis muscle associated with air intake causes abdominal distension; accentuation of lordosis;

d) limbs: upper limbs – arms positioned backwards; lower limbs – flat feet. To balance the body, which tends to go forward and downwards, mouth breathers make postural compensations that affect the body’s balance, causing trips and falls.

All of these changes are compensation and adaptation mechanisms, and are continuous and cumulative.

RESPIRATORY CHANGES

The air that enters through the mouth without the action of the nostrils (filtering, heating, humidification and microbicidal action) is of low quality and compromises hematosis (gas exchange).

Physical fatigue; sleep apnea; air swallowing; respiratory tract infections; poor cerebral oxygenation (with changes in the EEG tracing) are then observed, leading to difficulty with attention and concentration and leading to low academic and intellectual performance and sleep disorders.

CHANGES IN BASAL METABOLISM

Poor chewing (vertical, with loss of lateral movements) prevents the mouth breather from macerating leaves and fibers. Added to this is the reduction in taste and recurrent infections. Consequently, this patient eats poorly and little, in addition to swallowing air (swallowing and breathing at the same time), leading to impaired food absorption, flatulence and impaired expulsion of feces.

DIAGNOSIS OF MOUTH BREATHER SYNDROME

The diagnosis is made through:

1. physical examination: oral and nasal cavities (endoscopic) and ear; general physical examination;

2. assessment of respiratory function;

3. radiographic and tomographic examinations:

  • X-rays of the cavum : assess the soft profile of the face and the path of the airways;
  • X-rays of the facial bones: assess bone growth and development;
  • dental panoramic views;
  • X-rays of the spine and hand bones: assess posture and bone age;

4. photographic: compare results;

5. others: skin sensitivity test (allergy), audiometric evaluation.

TREATMENT OF MOUTH BREATHING SYNDROME

Medicine has divided the face into specializations, but the body does not respect these divisions. The face functions as a harmonious whole, therefore, for the treatment of this syndrome, integration between specialties is essential. Awareness of the interdisciplinary approach in the approach to this syndrome is the guiding paradigm for therapeutic success. The ideal is to intercept the presence of mouth breathing as soon as the process is noticed and interrupt the cycle of postural compensations and adaptations. The degree of intensity of the structural changes is directly related to the time of evolution of the syndrome and the intensity of the obstruction.

1. Otorhinolaryngological: is the treatment of the cause. It can be clinical: rhinitis; surgical: adenoid hypertrophy, polyps, septum and tumors.

2. Dental: dentistry: cavities; endodontics: root canal treatment; periodontics: gingivitis; exodontia: extractions; corrective orthodontic: through the use of fixed and/or removable appliances; oral and maxillofacial surgery: correction of bone deformities.

3. Speech therapy: consists of myofunctional rehabilitation and reeducation – respiratory and postural awareness.

4. Nutritional: consists of guiding the consumption of foods with high calorie content; changing the consistency until the preferential intake of more solid foods and avoiding cariogenic diets.

5. Others: orthopedic (deformities); physiotherapy (postural); mental health (psychological support).

The benefits of combined treatment are essential regarding body image, aesthetics, speech and growth and development of the adolescent.

PREVENTION OF MOUTH BREATHER SYNDROME

It starts at birth:

  • encouraging breastfeeding for a period longer than eight months; if using a bottle, keep the original nipple to stimulate sucking, as well as using orthodontic nipples;
  • discourage the use of pacifiers, straws, thumb sucking and any other addictive habits;
  • maintain good oral hygiene (including deciduous teeth);
  • stimulate correct chewing of food (lateralization);
  • encourage the consumption of fibrous, hard and dry foods and avoid liquefied foods to exercise the jaws;
  • encourage facial exercises (clicking the tongue, whistling and swishing your mouth).
Bibliographic References

1. Aragão W. Mouth breathing. Journal of Pediatrics. 1988;64(8):349.

2. Campos O. Textbook of otorhinolaryngology. Part III – Rhinology. São Paulo: Ed. Roca, 1994.

3. Carvalho GD. SOS mouth breathing. Ed. São Paulo: Lovise, 2003.

4. Eisenstein E, Coelho K. Pubertal growth and development. In: The health of adolescents and young people: skills and abilities. In press.

5. Maakaroun MF. Treaty of adolescence. Rio de Janeiro: Ed. Cultura Médica, 1991.

6. Messler M, Schour I. Atlas of the mouth and adjacent parts in health and disease. 3rd ed. Chicago: American Dental Association, 1948.

7. Quaglia T. Mouth breathing syndrome. In: The health of adolescents and young people: skills and abilities. In press.

8. Saffer M. The mouth-breathing child. In: II IAPO Manual of Pediatric Otorhinolaryngology, 1999.

9. Weckx LLM. Man was born to breathe through his nose. In: Mouth-breathing. São Paulo: Schering-Plough Handbook.

1. Otorhinolaryngologist at the Center for Studies on Adolescent Health of the State University of Rio de Janeiro (NESA/UERJ); coordinator of the Caras & Bocas Program – Oral Health for Adolescents (NESA/UERJ); coordinator of the Breathe Project – Rehabilitation of Mouth-Breathers (NESA/UERJ).