Keywords mouth breathing - quality of life - snore - pharyngeal tonsil - palatine tonsil
Palavras-chave respiração bucal - qualidade de vida - ronco - tonsila faríngea - tonsila palatina
Introduction
The World Health Organization (WHO), since 1947, defines health as physical well being,
psychic, social and not only the disease absence[1 ].
Among the changes with potential influence in patient́s quality of lifeis found in
oral breathing.The oral breathing occurs when nasal breathing is substituted by a
breathing pattern is supplemented by oral breathing[1 ]
[2 ]
[3 ]
[4 ]
[5 ], during a period longer than six months[1 ]. Generally, the exclusive oral breathing is rare, having in most of the times a
mixed pattern of breathing, oral and nasal, in patients in this condition[1 ].
The oral breathing can be caused by several factorsamong them adenoid hypertrophy,
tonsils and turbinates[3 ]
[6 ], deviated septum (if therés nasal obstruction)[2 ]
[3 ]
[6 ], allergic rhinitis[6 ]
[7 ], nasal deformities and facials, and,more rarely, foreign body[4 ]. The obstruction of upper airways, in its diverse locations[2 ]
[7 ], constitute the main causes of oral breathing, varying its prevalence according
to the individual age.The obstruction of upper airways does not be absolute, since
the resistance to the airflow is inversely proportional to fourth potency of the diameter
through to air passes[8 ]
[9 ].
Besides being involved in the pathophysiology of obstructive forms of oral breathers,
the irreducible hypertrophy of adenoidsand/ or tonsils is considered the primary form
of breathing disorders related to sleep, which compromise childreńs physical and
cognitivedevelopment[2 ].
In infants and preschoolers, the acquired conditions, such as adenotonsillar hyperplasia
and cronical inflammatory, are the obstructive causes observed with greater frequency[1 ], being the adenotonsillar hypertrophyirreducible is considered the primary form
of breathing disorders related to sleep, which compromises children's physical and
cognitive development[2 ]. The allergicrhinitis has great importance as oral breathing cause in schooler and
teenagers[1 ]
[2 ].
The diagnosis of oral breather patient is essentially clinic, being performed complementary
examination to evaluate the lever of airways obstruction and for differential diagnosis,
directing the therapeutic approach. The diagnosis and precocious approach of this
clinical condition are fundamental to minimize the consequences.
Depending on the duration, the oral breathing can cause functional alterations, structural,
pathological, postural, occlusive and behavioral[1 ]
[2 ]
[4 ]
[10 ]
[11 ]. The age in the beginning of symptoms, the time of permanence of these till its
normalization and the obstruction intensity which influence the installation of the
manifestations resulting from mouth[1 ].
The most common complaints from oral breathers are: nocturnal dyspnea and apnea, to
tire easily during physical activities, pain in the back and neck,olfactory and/or
gustatory disturbs[2 ], halitosis[1 ]
[10 ], dried mouth, to wake up choking during the night, sleeping badly, daytime sleepiness,
sneezing, abundant salivation when talking[10 ], hearing loss and lacrimation[1 ], among others.
According to the severity of permanence time of this breathing pattern, systemical
repercussions can occur, leading to negative consequences in quality of life of these
individuals due to the personal impact, physical, psychological and social[1 ]
[3 ]. The oral breathers can present a delay in weight and stature; cardiological changes
like hypertension , pulmonary hypertension and ”cor pulmonale”; lower respiratory
disorders with greater cough frequency, obstructive dyspnea and apnea; neuropsychiatric
disorders like behavioral alterations (such as, for example, hyperactivity, restless
sleep, irritability, difficulty of concentration, reduction on scholar performance,
despite of normal intelligence, nocturnal enuresis)[2 ]
[3 ]
[4 ]
[10 ], headache, and a tendency to higher frequency of infections[1 ].
The approach of oral breather must be alwaysmultidisciplinarywhen possible[1 ]
[10 ]. It become necessary to the professionals of health area to recognize the oral breather
in the beginning of the development of condition, in order to act precociously in
a way to minimize the cronical repercussion and improve overall quality of life of
these patients.
The oral breather patient presents several changesdue to oral breathing, being children
more affected by interference in their growth, development and quality of life. This
way, this work was proposedto evaluate the quality of life of oral breather, comparing
to non oral breathers.
Method
It was performed a descriptive transversal study through a questionnaire evaluating
the quality of life in oral breather patients.The questionnaire was addressed to patient
or to his accompanying person when he was unable to answer the proposed questionnaire.
It was included in this study patients with age between 4 and 17 years-old attended
in otorhinolaringological offices diagnosed of Oral Breather Syndrome which would
be submitted to surgery of tonsillectomy, adenoidectomy or adenotonsillectom, at city
of Tubarao/SC, in the period of 2010 March to 2010 June.
The Project of this study was approved by the Research and Ethics Committee of University
of South of Santa Catarina - UNISUL under protocol 09.693.4.01.III.
The data were collected on its own sheet and tabulated in statistical softwareEpidata
3.1 and for analysis the software SPSS (Statistical Package for Social science) version
16.0.
The data were analyzed by percentage in qualitative variables and measures of central
tendency and dispersion in quantitative variables. The qualitative variables were
compared, using the chi square test of Pearson, and the differences of mean score
differences of dominium of quality oflife questionnaire were tested through test t-Student,
in confidence level of 95%.
From the sample of 71 patients, from these: 39 were oral breathers and 32 were of
control group (children and teenager without oral breather diagnosis).
The quality of life of oral breather patients were evaluated by a questionnaire constituted
of structured questions, in which were created seven fields from dividing the questions
adapted from Ribeiro
[1 ]. The fields indentified were: nasal problems, Odontology, sleep, eating disorders,
education, communication and atopy. It was associated an ordinal value to the sequential
answer scale of 1 for “no/never”, 2 for “almost never”, 3 for “once in a time”, 4
for “almost always”, 5 for “always”, being the higher score referred to a worst quality
of life. The questions number 1of field sleep quality, 1-3 of nutrition, 3-5 of Odontology,
5,7,8 of educationand 1,2 of communication had its scored reversed in order to keep
coherency in sum of the final score.
The quality of life scale creation from the questionnaire was done in the following
way:
Field of nasal problem (P) was structured by sum of questions P1 to P8 of questionnaire
with score varying from 8-40;
Field of trouble sleeping (S), it had reversed scoring forS1 and sum of the questions
S1to S10 varying its score from 10-50;
Filed of nutrition (AL) it was performed reversed scoring for AL1 to AL3, with the
sum of the questions AL1 to AL7 with scoring varying from 7 to 35;
Field of Odontology (O) occurred the sum of the questions O3 to 06 , with reversed
scoring for O3 to O5 and the variable O6 when answered as yes = 5 scoresand no= 1
score, with scores varying between 4 and 20;
Field of education (E), occurred the sum of questions E5 to E8 the questions O5-O8
had its score reversed, the scoring varied from 4 to 20;
Field of communication (C), was structured by the sumo f questions C1 to C3, with
reversed scoring in C1 and C2 and scoring varying from 3 to 15.
Atopy field (AT), occurred to the sumof questions AT1, AT3-AT7, the question AT3 received
05 scores to answer yes and 1score for answer no, with scoring varying from 5 to 25.
The total scoring varied from 41 to 205, being the highest scoring the worst quality
of life, according to the proposed scale of questionnaire ([Table 1 ]).
Table 1.
Sociodemographic characteristicsevaluated between the cases (oral breathers) and the
controls (non oral breathers).
Variable
case n (%)
control n (%)
p
Gender:
15 (38,5%)
13 (40,6%)
1
Masculine
24 (61,5%)
19 (59,4%)
Feminine
Age (average + DP)
average= 7,05 (+-3,67)
average = 8,84 (+-3,45)
0,039
Nasal problem
35 (89,7%)
5 (15,6%)
< 0,0001
Sleeping trouble
36 (92,3%)
3 (9,4%)
< 0,0001
Eating problem
19 (48,7%)
5 (15,6%)
0,005
Odontology:
30 (76,9%)
30 (93,8%)
0,096
Have you ever been to dentist?
19 (48,7%)
14 (43,8%)
0,805
Have you ever had caries?
15 (38,5%)
8 (25%)
0,289
Would you like to use braces?
Education:
36 (92,3%)
32 (100%)
0,277
Have you ever been at school?
8 (20,5%)
2 (6,2%)
0,269
In which grade are you?
2nd period
3rd period
9 (23,1%)
6 (18,8%)
1st grade at fundamental
3 (7,7%)
2 (6,2%)
2nd grade
2 (5,1%)
3 (9,4%)
3rd grade
3 (7,7%)
2 (6,2%)
4th grade
2 (5,1%)
5 (15,6%)
5th grade
6 (15,4%)
5 (15,6%)
6th grade
0 (0,0%)
2 (6,2%)
>7th grade
3 (7,7%)
5 (15,6%)
Shift:
18 (46,2%)
13 (40,6%)
0,025
Morning
Afternoon
13 (33,3%)
19 (59,4%)
Scholar problems?
6 (15,4%)
3 (9,4%)
0,186
Practice sport?
16 (41,0 %)
21 (65,6%)
0,059
Atopy:
18 (46,2%)
14 (43,8%)
0,129
Itchy eyes?
Have you ever wheezed?
19 (48,7%)
8 (25%)
0,066
Still wheeze?
7 (17,9%)
0 (0%)
0,008
Results
The sample was composed of 39 cases (oral breathers) and 32 controls (non oral breathers),
at age of between 4 and 17 years-old.There were no differences statistically significativeamong
the cases and controls according to gender, access to Odontology and negative perception
of dental appearance, education and scholar troubles. The controls were, in average,
1,8 year oldest than the cases.
The oral breathers presented significantly nasal problems, sleeping troubles, eating
troubles, practiced fewer sports and presented asthma with greater frequency (wheezing).
In field of nasal problems, the average score was significantly higher in the oral
breather (average = 27,21), comparing to controls (average = 14,63), as can be seen
on [Table 2 ].
Table 2.
Field scores and pattern deviation in groups case (oral breathers) and control (non
oral breathers).
Field
Cases
Control
p
Nasal problem
27,21 (+-5,09)
14,63 (+- 5,80)
< 0,0001
Sleep
30,13 (+- 7,008)
17,09 (+- 6,244)
< 0,0001
Eating
18,49 (+-4,471)
14,16 (+- 3,903)
< 0,0001
Odontology
7,66 (+-3,290)
7,22 (+- 3,925)
0,612
Education
7,42 (+-2,941)
6,91 (+- 3,796)
0,535
Communication
5,92 (+-2,329)
4,31 (+- 1,991)
0,003
Atopy
15,36 (+-5,807)
10,59 (+- 3,680)
< 0,0001
Total
113,35 (+-18,627)
74,91 (+-20,04)
< 0,0001
In Odontology field (p = 0,612) and education (p = 0,535), it was not found significantly
differences between cases and controls ([Table 2 ]).
In sleeping trouble field, the average scoring was significantly greater in oral breathers
(average =30,13), comparing to controls (average = 17,09). In the same way, in the
field of nutrition disturb the average score was significantly greater in the group
of oral breather (average =18,49), comparing to controls (average = 14,16) ([Table 2 ]).
In field of communication characteristics,the average scoring was significantly greater
in oral breathers (average =5,92), comparing to controls (average =4,31). In field
related to atopy, it was found greater scoring in oral breathers (average =15,36),
when compared to control group (average =10,59) ([Table 2 ]).
By the frequency in answer scale the oral breathers presented greater average scoring
in snoring at night (p < 0,0001), sleeping with mouth opened, choking during when
having meal and feel breathless. The prevalence of nocturnal snoring in patients oral
breather was of 87,2%, setting up a risk 27 times greater of snoring when compared
to the controls (RP = 27,89; IC95%: 4,03 - 192,74; p < 0,0001).
It was observed an average scoring in total of fields of 113,35 to oral breathers
and 74,91 for control group,characterizing worst quality of life in oral breather
group ([Table 2 ]).
Discussion
From seven fields evaluated, it was observed that the trouble sleeping field and nasal
problem were the fields with greater scoring, suggesting that these fields can bring
greater negative repercussion in quality of life during evaluation of oral breather
patients[12 ]
[13 ]
[14 ]
[15 ]
[16 ]
[17 ]
[18 ]
[19 ]
[20 ]
[21 ]
[22 ]
[23 ], and nasal problems during evaluation of oral breather[24 ]
[25 ]. In this present study, the prevalence of troubles with sleep in oral breather were
almost three times greater, when compared to the study of Ribeiro (37,7%) in a sample of 75 oral breathers[1 ].
The third field with greater scoring was related to eating. The group of oral breathers
presented a prevalence of problems with nutrition three times greater than the control
group while, in study of Ribeiro
[1 ] this prevalence in oral breatherswas of 42,5%. Studies show an existing relation
between oral breather and presence of change in deglutition and mastication pattern.
This way, Junqueira et al[26 ] described a frequency of 88,5% to changes in masticatory function andof78,1% to
changes in deglutition pattern; Coelho
[27 ] found a frequency of 40% to masticatory change and of 80% to change in deglutition
pattern, in patients with adenotonsillar hypertrophy.
Some articles[22 ]
[28 ]
[29 ] demonstrated that allergic rhinitis is evidenced as the etiologic main factor of
oral breathing[22 ]
[28 ]
[29 ], agreeing with this present study in field of nasal problems presented a higher
scoring of repercussion in quality of life of oral breather adding the presence of
atopy (fourth greater score), field in which is included allergic rhinitis as important
etiologic factor.
In oral breathers, the chance in finding an asthmatic individual was almost eight
times greater than in control group (OR = 7,72; IC 95%: 0,85 - 177,31; pFisher= 0,056).
This increased prevalence of asthma in oral breathers was already described in literature[1 ]
[4 ]. This may be due to the fact of that there is a contiguous relation between upper
and lower respiratory tract, beyond a higher prevalence of atopy in oral breathers.
This way,the oral breathing allows the allergens or the irritant agents reach the
lower airways, causing bronchial hyperresponsiveness and asthma induced by exercise.
The asthma association and allergic rhinitis are of such importance that some authors
prefer to use term “united airways disease”[30 ]. Other studies had already described association between snoring and asthma, and
oral breathing fits in this environment of pathophysiological chain, once that the
first is one of the most predictive signs to diagnosis based on anamnesis, and the
second is strongly associated to Oral Breather Syndrome. In present study, the oral
breather patients presented prevalence of nocturnal snoring in 87,2%, setting a risk
27 times greater of snores when compared to controls. Lu
[31 ] studying the prevalence of snore in preschoolers showed that this was of 10,5% to
both genders and that snore is significantly associated to nocturnal cough and asthma.
Aydanur
[32 ] also observed relation between respiratory disturbs in sleep and symptoms related
to asthma in his study involving adults, in Turkey, once more, the close relationship
between upper and lower airways[33 ].
Related to the Odontology Field, the scoring were lower, showing that these factors
seem not leading to greater repercussion in quality of life of this group or maybe
occur in lower perception of orthodontic changes, taking regard to low age average
of this sample, despite of finding important orthodontic changes and craniofacial
changes in oral breathers. The literature shows that there is no direct relation between
signs and symptoms of these disorders and its repercussions over Quality of Life[24 ]
[34 ]
[35 ].
This way, the Educational Field also presented low scores, which disagree with data
found in literature, where it was found an association between the presence of oral
breather Syndrome with bad educational performance[21 ]
[36 ].
Evaluating quality of life in children presented as a challenge, by the fact, in some
situations, third parties answered to the questionnaire,which leads to decrease the
precision of the answers. However, the literature indicates that the evaluation of
quality of life related to the health of child must include information from the perspective
of patients and their caregivers, who despite of being different are equally important[34 ] and complement each other.
Conclusion
With this study, we can conclude that the Oral Breather Syndrome seem to be related
to an impact in quality of life, especially in which it refers to nasal problems,
sleep and eating. Although, future studies, applying the same questionnaire will become
necessary in order to it become an instrument capable to evaluate the quality of life
of oral breather patients.
