Oral habits part 3 mouth breathing

1. Oral Habits
By -
Sudeep Madhusudan Chaudhari
MDS 2nd Year
Dept of Paedodontics & Preventive Dentistry

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Contents
●Introduction
●Definitions
●Classification
●Prevalence of habit
1) Thumb sucking
2) Pacifier habit
3) Tongue thrusting
4) Mouth breathing
5) Bruxism

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● Nasal breathing is the primary mode of air intake for the humans, and
it is essential for supply of properly cleansed, moistened and warmed
air.
● The mouth is only a secondary emergency orifice for assuring an
uninterrupted supply of air and using it on regular basis can cause
many problems.
● The term “nasal breather” is used to mean a person who breathes
mostly through the nose except during exertion.
4)Mouth breathing :-

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●Mouth breathers are those who breathe orally even in relaxed and restful
situations.
●For normal dentofacial growth to occur there should be normal breathing.
● Mouth breathing can alter the equilibrium of pressures on the jaws and
teeth and affect both jaw growth and tooth position.

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Definitions :-
Mouth breathing can be defined as habitual breathing through
mouth instead of the nose.
- Sassouni(1971)
Merle(1980) suggested the term oronasal breathing instead of mouth
breathing.

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Mouth breathing defined as the prolonged or continued exposure
of the tissues of the anterior area of the mouth to the drying
effects of the inspired air.
- Chacker F M (1961)

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Classification
Given by Finn in 1987
● Anatomic- Short upper lip does not permit complete closure without
undue effort.
● Obstructive- Increased resistance or complete obstruction of normal
flow of air through nasal passages.
● Habitual- Breathing through mouth as a force of habit, even after the
removal of abnormal obstruction.

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Etiology
● Increased resistance to the flow of air through the nasal passage may
be considered the primary cause of mouth breathing.
● Allergies, physical obstruction and chronic infections.

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●Airway obstructions may be due to :
– Enlarged turbinates
– Deviated nasal septum
– Allergic rhinitis, nasal polyps
– Enlarged adenoids or tonsils
– Abnormally short upper lip preventing proper lip seal
– Obstructive sleep apnea syndrome
– Genetic predisposition
– Thumb sucking or similar oral habits may be instigating agents.

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Clinical features
● General effects -
– Appearance of pigeon chest.
– Low grade esophagitis.
– Blood gas constituents : Mouth breathers have 20% more carbon
dioxide and 20% less oxygen.

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● Effects on dentofacial structures -
– Facial form:
● Tendency towards more vertical growth pattern.
● Increased facial height.
● Increased mandibular plane angle.

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● Adenoid facies -
– Long narrow face.
– Narrow nose and nasal airway.
– Flaccid lips with short upper lip.
– Upturned nose exposing nares frontally.
– ‘V’ shaped and high palatal vault.
– Collapsed buccal segments of maxilla.

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● Dental effects -
– Proclined upper and lower incisors.
– Posterior cross bite.
– Tendency toward an open bite.
– Narrow palatal and cranial width(low set position of tongue).
– Constricted maxillary arch(imbalance of forces exerted by tongue
and facial musculature).

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● Speech defects:
– Nasal tone in voice.
● Lip:
– Lip apart posture.
– Excessive appearance of maxillary anteriors- long face syndrome.
– Gummy smile.
– Short thick incompetent upper lip.
– Voluminous curled over lower lip.

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● External nares:
– Disuse atrophy of the lateral nasal cartilage leading to slit like
external nares with narrow nose.
– Nasal mucosa becomes atrophied due to a disturbed ciliary action.

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● Gingiva :
– Inflamed and irritating gingival tissue in the anterior maxillary
arch.
– Hyperplastic gingiva due to continuous exposure to air drying.
– Heavy deposits of plaque due to decreases salivary cleansing
action.
– Classic rolled margin and an enlarged inter dental papilla.
– Interproximal bone loss with presence of deep pockets.
– Chronic gingival condition and periodontal disease.

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Diagnosis
● History -
● Parents should be questioned about the
– Frequent lip apart posture.
– Frequent occurrence of tonsillitis, allergic rhinitis or otitis media.

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● Examination -
– Patient’s breathing should be observed.
– Nasal breathers - lips touching lightly during relaxed breathing
whereas mouth breathers keep their lips apart.
– A mouth breather when asked to close his lips and take a forced
deep breath will not appreciably change the size and shape of the
external nares and occasionally contracts the nasal orifices while
inspiring.

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● Clinical test
1) Mirror test-
– Two-surfaced mirror is placed on the patient’s upper lip.
– If air condenses on upper side, the patient is a nasal breather and if
it condenses on lower side, the patient is mouth breather.

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2) Butterfly test/cotton test -
● Take a few fibers of cotton (in butterfly shape) and place it just
below the nasal opening.
● On exhalation if the fibers of cotton flutter downwards, the patient
is nasal breather; otherwise the patient is mouth breather.
● This can also be used to determine unilateral nasal blockage.

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3) Water holding test-
● Patient is asked to hold water in mouth for 2-3 minutes.
● A mouth breather cannot hold water for that time.

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● Cephalometrics - To establish
– Amount of nasopharyngeal space
– Size of adenoid
– Skeletal pattern of the patient

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● Inductive plethysmographry (Rhinomonometry) -
– To establish total air flow through nose and mouth respectively.

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Treatment considerations
● Age of child:
– Correction of mouth breathing could be expected to decrease as the
child matures.
– Increase in nasal passages and reduction in size of tonsils as the
child matures, thus relieving the obstruction.
● ENT Examination:
– To determine the condition requiring treatment present in tonsils,
adenoid or nasal septum.

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Correction of mouth breathing
● Elimination of cause
– Obstructive cause- treated surgically.
– Allergic cause - prevention and control.
● Interception of the habit-
– Done if the habit continues even after the removal after the cause.

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● Exercises
– Deep breathing:
● Done in morning and night .
● Deep inhalation through nose with arms raised sideways and
after a short period arms are dropped to the side and the air is
exhaled through the mouth.

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● Lip exercises:
– Child is instructed to extend the upper lip as far as possible to
cover the vermillion border under and behind the maxillary
incisors. This exercise is done for 15 to 30 mins per day for 4-5
months.
– In case of protruded maxillary incisors, 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.
– Playing a wind instrument
– Celluloid strip or metal disk held between the lips.

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To increase the tonicity of lips few myofunctional excercises are
recommended:
● Hold a sheet of paper between the lips.
●Button pull exercise- a button is taken and a
thread is passed. 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.

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● Oral screen :
– Most effective way.
–Constructed with material compatible with oral
tissues. The most commonly utilized is synthetic
resin.
– One must ascertain if the nasopharyngeal passage is sufficiently patent to allow
for exchange of air.
– If the child has no difficulty breathing through his nose and the mouth breathing is
habitual, it should be corrected by the use of oral screen.
– In the initial phase windows are made in the oral screen so as not to completely
block the airway passage.
– The appliance is worn 2-3 hours during the day and when sleeping at night.

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● It prevents lip biters from placing the lower lip lingual to the upper
incisors, tongue thrusters from forcing the tongue between the
incisors, mouth breathers from breathing through mouth and thumb
suckers from placing their fingers in the mouth.
● It, therefore, serves a multiplicity of purposes.