Abstract
Objective:
To investigate the respiratory and postural adaptations associated with mouth and nasal breathing and to evaluate the associations of such adaptations in mouth breathers' self-perceived quality of life.
Method:
Cross-sectional study with mouth breathers (initial n=116 and final n=48) and nasal breathers (initial n=131 and final n=24) from elementary school, aged between 7 and 14 years. Chest expansion, using cirtometry, the breathing pattern and the use of accessory muscles, by means of clinical evaluations and photogrammetry, and flexibility tests were evaluated in both groups. Subsequently, the mouth breathers were asked to complete the quality of life questionnaire. Statistical tests: Chi-square, odds ratio, Mann-Whitney, and binomial tests were first applied followed by logistic regressions.
Results:
Thoracic breathing (p=0.04), using of accessory muscles (p=0.03) and reductions in flexibility (p=0.001) increased the chances of an individual being a mouth breather when compared to nasal breathers. Subsequently, using of accessory muscles decreased the chances of snoring among mouth breathers (p=0.03); the presence of shoulder asymmetry reduced the chances of experiencing quiet sleep (p=0.05) and increased the chances of coughing or being tired when playing or running (p=0.008). Finally, forward head position reduced the chances of waking up at night (p=0.04) and experiencing shortness of breath (p=0.05).
Conclusions:
Respiratory and postural adaptations increased the chances of individuals persisting with mouth breathing. Additionally, these adaptations could be associated with mouth breathers' self-perceived quality of life.
preschool; mouth breathing; postural adaptations; self-perceived; quality of life; physical therapy
Introduction
During mouth breathing (MB), accessory muscle overuse leads to a predominance of
chest wall motion during inspiration11 Ribeiro EC, Marchiori SC, Silva AM. Electromyographic analysis of
trapezius and sternocleidomastoideus muscles during nasal and oral inspiration
in nasal- and mouth-breathing children. J Electromyogr Kinesiol.
2002;12(4):305-16. http://dx.doi.org/10.1016/S1050-6411(02)00025-1.
PMid:12121687
http://dx.doi.org/10.1016/S1050-6411(02)...
,
22 Hruska RJ Jr. Influences of dysfunctional respiratory mechanics on
orofacial pain. Dent Clin North Am. 1997;41(2):211-27. PMid:9142480
., and forward head posture (FHP) is the most
commonly adopted postural compensation among MB individuals33 Cuccia AM, Lotti M, Caradonna D. Oral breathing and head posture.
Angle Orthod. 2008;78(1):77-82. http://dx.doi.org/10.2319/011507-18.1.
PMid:18193952
http://dx.doi.org/10.2319/011507-18.1...
. Okuro et al.44 Okuro RT, Morcillo AM, Ribeiro M, Sakano E, Conti PBM, Ribeiro JD.
Respiração bucal e anteriorização da cabeça: efeitos na biomecânica respiratória
e na capacidade de exercício em crianças. J Bras Pneumol. 2011;37(4):471-9.
http://dx.doi.org/10.1590/S1806-37132011000400009.
PMid:21881737
http://dx.doi.org/10.1590/S1806-37132011...
identified a correlation between FHP and the functional respiratory demand in MB
individuals to facilitate air intake. One of the possible causes of FHP appears to
be related to the overuse of accessory inspiratory muscles55 Ribeiro EC, Marchiori SC, Silva AMT. Eletromiografia dos músculos
esternocleidomastóideo e trapézio em crianças respiradoras bucais e nasais
durante correção postural. Arq Int Otorrinolaringol.
2003;7(1):13-9.. Persistent FHP can affect the entire body's posture due to
the synergistic action of the head and neck muscles66 Yi LC, Jardim JR, Inoue DP, Pignatari SS. The relationship between
excursion of the diaphragm and curvatures of the spinal column in mouth
breathing children. J Pediatr (Rio J). 2008;84(2):171-7. PMid:18372937
.
,
77 Peolsson A, Marstein E, McNamara T, Nolan D, Sjaaberg E, Peolsson M,
et al. Does posture of the cervical spine influence dorsal neck muscle activity
when lifting? Man Ther. 2014;19(1):32-6.
http://dx.doi.org/10.1016/j.math.2013.06.003. PMid:23880061
http://dx.doi.org/10.1016/j.math.2013.06...
. Some studies have reported that head, neck
and shoulder girdle muscle overuse can trigger secondary muscle weakness and promote
shoulder asymmetry, which are signs of changes in the curvatures of the vertebral
column66 Yi LC, Jardim JR, Inoue DP, Pignatari SS. The relationship between
excursion of the diaphragm and curvatures of the spinal column in mouth
breathing children. J Pediatr (Rio J). 2008;84(2):171-7. PMid:18372937
.
,
88 de Arruda Falcão D, Grinfeld S, Grinfeld A, de Melo MVR.
Respiradores bucais diagnosticados clinicamente e por autodiagnóstico.
Consequências na postura corporal. Int J Dent. 2003;2(2):259-6.. Furthermore, such weakness could be due to
changes in the myofascial meridians, which, together, are responsible for
maintaining stability and discriminating how myofascial tension is distributed
throughout the body during movement99 Myers TW. Trilhos anatômicos: meridianos miofasciais para terapeutas
manuais e do movimento. 2ª ed. Rio de Janeiro: Elsevier; 2010.. Thus,
changes in posture, imbalance and muscle shortening influence the flexibility of
certain muscle groups1010 Dezan VH, Sarraf TA, Rodacki ALF. Alterações posturais,
desequilíbrios musculares e lombalgias em atletas de luta olímpica. Rev Bras
Ciênc Mov. 2004;12(1):35-8..
Depending on its duration, MB can cause functional, structural, pathological,
postural, occlusive and behavioral changes. Most studies on MB have focused on
clinical aspects11 Ribeiro EC, Marchiori SC, Silva AM. Electromyographic analysis of
trapezius and sternocleidomastoideus muscles during nasal and oral inspiration
in nasal- and mouth-breathing children. J Electromyogr Kinesiol.
2002;12(4):305-16. http://dx.doi.org/10.1016/S1050-6411(02)00025-1.
PMid:12121687
http://dx.doi.org/10.1016/S1050-6411(02)...
,
44 Okuro RT, Morcillo AM, Ribeiro M, Sakano E, Conti PBM, Ribeiro JD.
Respiração bucal e anteriorização da cabeça: efeitos na biomecânica respiratória
e na capacidade de exercício em crianças. J Bras Pneumol. 2011;37(4):471-9.
http://dx.doi.org/10.1590/S1806-37132011000400009.
PMid:21881737
http://dx.doi.org/10.1590/S1806-37132011...
,
66 Yi LC, Jardim JR, Inoue DP, Pignatari SS. The relationship between
excursion of the diaphragm and curvatures of the spinal column in mouth
breathing children. J Pediatr (Rio J). 2008;84(2):171-7. PMid:18372937
.
,
88 de Arruda Falcão D, Grinfeld S, Grinfeld A, de Melo MVR.
Respiradores bucais diagnosticados clinicamente e por autodiagnóstico.
Consequências na postura corporal. Int J Dent. 2003;2(2):259-6.. Only in recent decades have behavioral
aspects, such as hyperactivity, nonrestorative sleep, nocturnal enuresis,
irritability, headache, and difficulties in concentrating and learning, been
investigated as factors that impact the quality of life of MB individuals1111 Di Francesco RC, Passerotii G, Paulucci B, Miniti A. Mouth breathing
in children: different repercussions according to the diagnosis. Rev Bras
Otorrinolaringol (Engl Ed). 2004;70(5):665-70.
http://dx.doi.org/10.1590/S0034-72992004000500014 .
http://dx.doi.org/10.1590/S0034-72992004...
12 Abreu RR, Rocha RL, Lamounier JA, Guerra AFM. Etiologia,
manifestações clínicas e alterações presentes nas crianças respiradoras orais. J
Pediatr. 2008;84(6):529-35. http://dx.doi.org/10.1590/S0021-75572008000700010.
PMid:19060979
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13 Vera CF, Conde GE, Wajnsztejn R, Nemr K. Learning disabilities and
mouth breathing in subjects with attention deficit hyperactivity disorder
diagnosis. Rev CEFAC. 2006;8:441-55.
-
1414 Fensterseifer GS, Carpes O, Weckx LL, Martha VF. Mouth breathing in
children with learning disorders. Braz J Otorhinolaryngol. 2013;79(5):620-4.
http://dx.doi.org/10.5935/1808-8694.20130111. PMid:24141679
http://dx.doi.org/10.5935/1808-8694.2013...
. Most studies evaluate these behavioral
changes by means of various questionnaires1313 Vera CF, Conde GE, Wajnsztejn R, Nemr K. Learning disabilities and
mouth breathing in subjects with attention deficit hyperactivity disorder
diagnosis. Rev CEFAC. 2006;8:441-55.
,
1414 Fensterseifer GS, Carpes O, Weckx LL, Martha VF. Mouth breathing in
children with learning disorders. Braz J Otorhinolaryngol. 2013;79(5):620-4.
http://dx.doi.org/10.5935/1808-8694.20130111. PMid:24141679
http://dx.doi.org/10.5935/1808-8694.2013...
, including those related to quality of
life1515 Eiser C, Morse R. The measurement of quality of life in children:
past and future perspectives. J Dev Behav Pediatr. 2001;22(4):248-56.
http://dx.doi.org/10.1097/00004703-200108000-00007.
PMid:11530898
http://dx.doi.org/10.1097/00004703-20010...
,
1616 Popoaski C, Marcelino TF, Sakae TM, Schmitz LM, Correa LHL.
Avaliação da qualidade de vida em pacientes respiradores orais. Arq Int
Otorrinolaringolog. 2012;16(1):74-81.
http://dx.doi.org/10.7162/S1809-48722012000100011 .
http://dx.doi.org/10.7162/S1809-48722012...
. Popoaski et al.1616 Popoaski C, Marcelino TF, Sakae TM, Schmitz LM, Correa LHL.
Avaliação da qualidade de vida em pacientes respiradores orais. Arq Int
Otorrinolaringolog. 2012;16(1):74-81.
http://dx.doi.org/10.7162/S1809-48722012000100011 .
http://dx.doi.org/10.7162/S1809-48722012...
developed a quality of life questionnaire exclusively for MB
individuals and demonstrated that MB had a negative impact on the quality of life,
especially with respect to behavioral aspects and respiratory disorders.
However, few studies have associated clinical evaluations and the quality of life of MB students, especially regarding their self-perception. Thus, the present study aimed to evaluate possible respiratory and postural adaptations of predominantly MB students compared to their predominantly nasal breathing (NB) peers and to subsequently associate the results obtained for the MB group with aspects regarding their self-perceived quality of life. The study was divided into two stages. The first stage assessed the prevalence and chances of respiratory and postural adaptations in MB students compared to their NB peers. The second stage evaluated the chances of respiratory and postural adaptations being risk or protective factors for the self-perceived quality of life of MB students, specifically regarding sleep, school performance, atopy and nasal problems.
Method
This study was a clinical cross-sectional study approved by the Ethics Committee of the Universidade Federal do Espírito Santo (UFES), Vitória, ES, Brazil (Protocol nr. 162/2009) that was authorized by the Municipality Government of Vitória, Municipal Secretariat of Education, Vitória, ES, Brazil (Protocol nr. 281/2010). Ten elementary schools were randomly selected, and the inclusion criteria were as follows: students aged 7 to 14 years, previously screened and classified as mouth breathers by physicians and dentists (n=116), providing they also exhibited four or more of the ten craniofacial changes (described in the flowchart - Figure 1), including persistent MB, or classified as nose breathers (n=131) if they exhibited less than four or none of the above changes. Exclusion criteria were as follows: students whose parents did not sign the informed consent form prior to or during the study and students older than 12 years who did not sign the informed consent form at the beginning of the study; and students with craniofacial malformations, musculoskeletal, respiratory or neurological disorders. In the course of the study, the initial sample size was reduced in both groups, the causes of which are specified in the flowchart (Figure 1). The final sample size was of 24 males and 24 females (n=48) in the MB group and 11 males and 13 females (n=24) in the NB group.
To avoid a bias in the assessments and in the application of the questionnaire, the
examiners were trained by the most experienced examiner of the team of physical
therapists, who was considered the gold-standard examiner. The obtained Cohen's
kappa was above 0.9, which may be considered as an optimal agreement among the
examiners of the present study1717 Council for International Organizations of Medical Siences - CIOMS,
World Health Organization - WHO. International Ethical Guidelines for Biomedical
Research Involving Human Subjects. Geneva: CIOMS; 2002. Available from:
http://www.cioms.ch/frame_guidelines_nov_2002.htm
http://www.cioms.ch/frame_guidelines_nov...
.
In the first stage of the study, the instrument used for respiratory and postural
data collection was adapted from the study of Godoy et al.1818 Godoy P, Niitsuma LEMN, Caromano FA. Functional evaluation of the
buccal breather -physical therapy aspects. Arq Ciênc Saúde Unipar.
2000;4(2):111-20.. Each one of these tests was performed by physical
therapists, who performed them in a blinded fashion. At each school selected, the
students were randomly taken out of their classrooms by their supervisors and they
underwent the same respiratory and postural evaluations in locations provided by the
school. For the respiratory tests consisted of upper and lower chest expansibility,
classification of the breathing pattern and identification of the use of accessory
muscles. Chest expansibility was evaluated by dynamic cirtometry, using a
SECA®anthropometric tape measure. The variation of maximal
inspiration and expiration was measured as the circumference at the axillary and
xiphoid regions. Variations between 3.0 and 7.5 cm were considered as normal1919 Magee DJ. Avaliação musculoesquelética. 5ª ed. Barueri: Manole;
2010.. The breathing pattern and the use of
accessory muscles were subjectively evaluated by visual and manual examination of
the thorax. Subsequently, students were referred to a private room, in which body
weight and height were assessed on a digital scale (GLASS200-G-TECH(r))
and by means of an anthropometric tape measure (SECA(r)), respectively,
to calculate the body mass index (BMI). Flexibility was assessed by means of the
fingertip-to-floor (FTF) test, during which the participant was asked to bend
forward in an attempt to reach the floor with the middle finger while keeping the
knees straight1818 Godoy P, Niitsuma LEMN, Caromano FA. Functional evaluation of the
buccal breather -physical therapy aspects. Arq Ciênc Saúde Unipar.
2000;4(2):111-20.
,
2020 Carregaro RL, Silva LCCB, Gil Coury HJC. Comparison between two
clinical tests for the evaluation of posterior thigh muscles flexibility. Rev
Bras Fisioter. 2007;11(2):139-45.
http://dx.doi.org/10.1590/S1413-35552007000200009.
http://dx.doi.org/10.1590/S1413-35552007...
. For postural evaluation, a digital camera
(Sony CyberShot 7.2 megapixels) was placed at a distance of 3.10 m
from the wall on a 1.2-m-high tripod2121 Back CMZ, Lima IAX. Fisioterapia na escola: avaliação postural.
Fisioter Bras. 2009;10(2):72-7.
,
2222 Milanesi JM, Borin G, Corrêa EC, da Silva AM, Bortoluzzi DC, Souza
JA. Impact of the mouth breathing occurred during childhood in the adult age:
biophotogrammetric postural analysis. Int J Pediatr Otorhinolaryngol.
2011;75(8):999-1004. http://dx.doi.org/10.1016/j.ijporl.2011.04.018.
PMid:21632123
http://dx.doi.org/10.1016/j.ijporl.2011....
. Students, were photographed in an
orthostatic position, while standing barefoot near a 1-m-long plumb line to their
left side, on a carpet labeled with the position for their feet, which were parallel
to each other. Prior to photography, anatomical landmarks were identified by the
examiners using colored markers affixed with double-faced adhesive tape to the right
and left acromia, the anterior superior iliac spines (ASIS) and posterior superior
iliac spines (PSIS), the right and left tragus, and the 7th cervical vertebra (C7)
(Figure 2). Photographs were analyzed by
physical therapists using the postural analysis software (SAPO®, version
0.67)2323 Duarte M, Maldonado EP, Freitas AZ, Ferreira EA, Prado J, Pasqual
AP, et al. Software para avaliação postural. São Paulo: Universidade de São
Paulo; 2006 [cited 2013 Jul 30]. Available from:.
http://sapo.incubadora.fapesp.br.
http://sapo.incubadora.fapesp.br...
,in the following order: the
photograph was opened, zoomed to 40%, the photograph image was calibrated from the
plumb line and the marked anatomical landmarks to the right and left acromia, the
ASIS, the PSIS and right and left tragus, and the C766 Yi LC, Jardim JR, Inoue DP, Pignatari SS. The relationship between
excursion of the diaphragm and curvatures of the spinal column in mouth
breathing children. J Pediatr (Rio J). 2008;84(2):171-7. PMid:18372937
.
,
2424 Conti PBM, Sakano E, Ribeiro MA, Schivinski CIS, Ribeiro JD.
Assessment of the body posture of mouth-breathing children and adolescents. J
Pediatr. 2011;87(4):357-63. http://dx.doi.org/10.2223/JPED.2102.
PMid:21769416
http://dx.doi.org/10.2223/JPED.2102...
. In the frontal view, the lines plotted
between the acromia (acromion-acromion) and between the ASISs (ASIS-ASIS) were
analyzed to determine deviations of shoulders and pelvis, respectively. In the side
view, the angle formed between spinous process of C7 with respect to the horizontal
line to the chin and another until the tragus (C7-HOR-TRAGUS) and the line plotted
between ASIS and PSIS (ASIS-PSIS) were analyzed to determine cervical
lordosis/retification and deviations of pelvis, respectively (Figure 2). In the second stage of the study, still at school,
only the MB group was studied. The instrument used was adapted from the quality of
life questionnaire used in the study of Popoaski et al.1616 Popoaski C, Marcelino TF, Sakae TM, Schmitz LM, Correa LHL.
Avaliação da qualidade de vida em pacientes respiradores orais. Arq Int
Otorrinolaringolog. 2012;16(1):74-81.
http://dx.doi.org/10.7162/S1809-48722012000100011 .
http://dx.doi.org/10.7162/S1809-48722012...
. Among the seven areas described in the study (nasal
problem, sleep, eating problems, dentistry, school performance, communication and
atopy), questions regarding nasal and sleep problems, atopy and school performance
were applied by the physical therapists to each MB student, individually. This
choice was based on the negative impacts these aspects had on behavior and on the
breathing disorders in the individuals evaluated in their study1616 Popoaski C, Marcelino TF, Sakae TM, Schmitz LM, Correa LHL.
Avaliação da qualidade de vida em pacientes respiradores orais. Arq Int
Otorrinolaringolog. 2012;16(1):74-81.
http://dx.doi.org/10.7162/S1809-48722012000100011 .
http://dx.doi.org/10.7162/S1809-48722012...
. The answers given by the MB students regarding the
self-perceived quality of life questionnaire that corresponded to a scale ranging
from "sometimes" to "always" were grouped and considered as YES, whereas answers
within the range of "never" to "almost never" were grouped and considered as NO.
Photogrammetry. A) Front view: angles between the acromia and between the anterior superior iliac spines. B) Side view: angle between C7 with respect to a horizontal line and the tragus and the angle between the anterior superior iliac spine and the posterior superior iliac spine.
Statistical analysis
In the first stage of the study, Pearson's chi-squared test and the odds ratio (OR) were calculated to evaluate the association between MB and NB groups. The Mann-Whitney U test was used to assess the difference between quantitative independent variables of MB and NB students. The binomial and Mann-Whitney U tests were used to select the variables that would be used in the logistic regression model. Specifically, the binomial test selected the variables with prevalence values equal to 0.43 or above, regardless of their statistical significance. The Mann-Whitney U test selected the variables by comparing the median of each continuous variable versus the general median of MB and NB individuals. After selecting these variables, logistic regressions were performed to verify whether the variables selected by the binomial test (i.e. sex, breathing pattern, use of accessory muscles, cirtometry, acromion-acromion, ASIS-ASIS, C7-HOR-TRAGUS, ASIS-PSIS measurements) and by the Mann-Whitney U test (i.e. age, height and FTF distance measurements) were risk or protective factors when related to the selected questions of the adapted instrument of the quality of life questionnaire in the MB group. The best regression model was chosen by means of the backward method of the Wald test, which removes the variables that do not influence the model. The level of significance was set at 5% and the confidence interval at 95%. Analyses were performed using the Statistical Package for Social Sciences Software (SPSS19, IBM Company, Armonk, New York, USA).
Results
The results from the first stage revealed a statistically significant association between the MB and NB groups only with respect to respiratory variables regarding the breathing pattern and the use of accessory muscles (Table 1). Thoracic breathing increased the chances of the student being a mouth breather 3.8-fold compared to students without this pattern (NB) (p=0.041). The use of altered accessory muscles increased the chances of being classified as a MB 4.2-fold compared to NB (p=0.031). Table 2 shows that the medians of MB students significantly differed from those of their NB peers with respect to anthropometric variables (i.e. body weight and height), age and FTF distance measurements (flexibility) (p<0.05). However, the BMI exhibited no statistically significant difference between the groups (p=0.27).
In the second stage, some of the self-perceived aspects of the MB group, specifically regarding school performance, atopy, sleep and nose problems, exhibited 50% or higher prevalence rates, namely: "Do you usually have a stuffed nose?" (79.2%); "Do you usually have a runny nose?" (50.0%); "Do you usually wake up at night?" (60.4%); "Are you usually sleepy during the day?" (52.1%); "Is your sleep usually quiet?" (87.5%); "Do you usually wake up with a headache?" (58.3%); "Do you usually wake up with a dry mouth?" (77%); "Do you usually cough when you lie down?" (56.3%); "Do you usually cough or get tired when you play/run?" (79.2%); "Do you usually feel shortness of breath?" (62.5%); "Do you usually have good memory?" (87.5%); and "Do you keep up with your class mates in school?" (83.3%). Further, Table 3 shows whether respiratory and postural variables of the MB group were risk or protective factors when associated with variables regarding the above-described aspects of self-perceived quality of life. Specifically, the use of accessory muscles decreased the chances of snoring at night among MB students (p=0.03). Additionally, shoulder asymmetry reduced the chances of quiet sleep among MB students (p=0.05) and increased their chances of coughing or feeling tired while playing or running (p=0.008). However, FHP reduced the chances of waking up at night (p=0.04) and having shortness of breath (p=0.05) among MB children. Sex was also considered a risk factor when related to the self-perception of MB students, as being female increased the chances of waking up at night (p=0.02) and experiencing shortness of breath (p=0.03).
Discussion
The results of the first stage of this study showed that individuals classified as
mouth breathers exhibited significantly increased chances of thoracic breathing and
the use of accessory muscles related to the persistence of MB compared to NB
individuals. Previous studies suggested the presence of increased nasal resistance
in MB, which could lead to increased respiratory effort11 Ribeiro EC, Marchiori SC, Silva AM. Electromyographic analysis of
trapezius and sternocleidomastoideus muscles during nasal and oral inspiration
in nasal- and mouth-breathing children. J Electromyogr Kinesiol.
2002;12(4):305-16. http://dx.doi.org/10.1016/S1050-6411(02)00025-1.
PMid:12121687
http://dx.doi.org/10.1016/S1050-6411(02)...
,
55 Ribeiro EC, Marchiori SC, Silva AMT. Eletromiografia dos músculos
esternocleidomastóideo e trapézio em crianças respiradoras bucais e nasais
durante correção postural. Arq Int Otorrinolaringol.
2003;7(1):13-9.. This causes the accessory inspiratory
muscles to be needed, thus leading to a predominantly upper thoracic inspiratory
motion11 Ribeiro EC, Marchiori SC, Silva AM. Electromyographic analysis of
trapezius and sternocleidomastoideus muscles during nasal and oral inspiration
in nasal- and mouth-breathing children. J Electromyogr Kinesiol.
2002;12(4):305-16. http://dx.doi.org/10.1016/S1050-6411(02)00025-1.
PMid:12121687
http://dx.doi.org/10.1016/S1050-6411(02)...
,
55 Ribeiro EC, Marchiori SC, Silva AMT. Eletromiografia dos músculos
esternocleidomastóideo e trapézio em crianças respiradoras bucais e nasais
durante correção postural. Arq Int Otorrinolaringol.
2003;7(1):13-9.
,
2424 Conti PBM, Sakano E, Ribeiro MA, Schivinski CIS, Ribeiro JD.
Assessment of the body posture of mouth-breathing children and adolescents. J
Pediatr. 2011;87(4):357-63. http://dx.doi.org/10.2223/JPED.2102.
PMid:21769416
http://dx.doi.org/10.2223/JPED.2102...
. According to Conti et al.2424 Conti PBM, Sakano E, Ribeiro MA, Schivinski CIS, Ribeiro JD.
Assessment of the body posture of mouth-breathing children and adolescents. J
Pediatr. 2011;87(4):357-63. http://dx.doi.org/10.2223/JPED.2102.
PMid:21769416
http://dx.doi.org/10.2223/JPED.2102...
, there was a 42.21% prevalence of thoracic
breathing in MB individuals, whereas nasal breathers exhibited a 44.35% prevalence
of abdominal breathing. Additionally, Yi et al.66 Yi LC, Jardim JR, Inoue DP, Pignatari SS. The relationship between
excursion of the diaphragm and curvatures of the spinal column in mouth
breathing children. J Pediatr (Rio J). 2008;84(2):171-7. PMid:18372937
.have shown that MB individuals exhibited lower diaphragmatic excursion,
which further required the use of the accessory muscles. Other anatomical or
functional changes resulting from MB are associated with FHP and head extension77 Peolsson A, Marstein E, McNamara T, Nolan D, Sjaaberg E, Peolsson M,
et al. Does posture of the cervical spine influence dorsal neck muscle activity
when lifting? Man Ther. 2014;19(1):32-6.
http://dx.doi.org/10.1016/j.math.2013.06.003. PMid:23880061
http://dx.doi.org/10.1016/j.math.2013.06...
,
2727 Okuro RT, Morcillo AM, Sakano E, Schivinski CIS, Ribeiro MAGO,
Ribeiro JD. Exercise capacity, respiratory mechanics and posture in mouth
breathers. Braz J Otorhinolaryngol. 2011;77(5):656-62.
http://dx.doi.org/10.1590/S1808-86942011000500020.
PMid:22030977
http://dx.doi.org/10.1590/S1808-86942011...
. Electromyogram studies of the cervical
muscles, such as those of Ribeiro et al.55 Ribeiro EC, Marchiori SC, Silva AMT. Eletromiografia dos músculos
esternocleidomastóideo e trapézio em crianças respiradoras bucais e nasais
durante correção postural. Arq Int Otorrinolaringol.
2003;7(1):13-9.,
have shown that the upper fibers of the sternocleidomastoid and upper trapezius
muscles exhibit higher activity to obtain head posture control in MB individuals
compared to nasal breathers during both resting and active situations. However, the
postural imbalance of mouth breathers that begins in the head could be responsible
for the more general involvement of the body posture due to the disorganization of
the myofascial structures of the cervical and thoracic regions66 Yi LC, Jardim JR, Inoue DP, Pignatari SS. The relationship between
excursion of the diaphragm and curvatures of the spinal column in mouth
breathing children. J Pediatr (Rio J). 2008;84(2):171-7. PMid:18372937
.
,
77 Peolsson A, Marstein E, McNamara T, Nolan D, Sjaaberg E, Peolsson M,
et al. Does posture of the cervical spine influence dorsal neck muscle activity
when lifting? Man Ther. 2014;19(1):32-6.
http://dx.doi.org/10.1016/j.math.2013.06.003. PMid:23880061
http://dx.doi.org/10.1016/j.math.2013.06...
,
99 Myers TW. Trilhos anatômicos: meridianos miofasciais para terapeutas
manuais e do movimento. 2ª ed. Rio de Janeiro: Elsevier; 2010.. Krakauer and Guilherme2828 Krakauer LH, Guilherme A. Relationship between mouth breathing and
postural alterations of children: a descriptive analysis. Int J Orofacial
Myology. 2000;26:13-23. PMid:11307345 . have shown that these postural changes
become predominant in 8-year-old MB students when compared to their respective NB
peers. The above authors showed that these postural imbalances were initially
triggered as an adaptation to balance the action of gravity. On the other hand,
Peolsson et al.77 Peolsson A, Marstein E, McNamara T, Nolan D, Sjaaberg E, Peolsson M,
et al. Does posture of the cervical spine influence dorsal neck muscle activity
when lifting? Man Ther. 2014;19(1):32-6.
http://dx.doi.org/10.1016/j.math.2013.06.003. PMid:23880061
http://dx.doi.org/10.1016/j.math.2013.06...
, have shown that FHP could
favor other types of musculoskeletal adaptations such as increased extensor muscle
activity2929 Edmondston SJ, Sharp M, Symes A, Alhabib N, Allison GT. Changes in
mechanical load and extensor muscle activity in the cervico-thoracici spine
induced by sitting posture modification. Ergonomics. 2011;54(2):179-86.
http://dx.doi.org/10.1080/00140139.2010.544765. PMid:21294015
http://dx.doi.org/10.1080/00140139.2010....
, which, in turn, could
increase gravitational load to some cervical and thoracic motion segments66 Yi LC, Jardim JR, Inoue DP, Pignatari SS. The relationship between
excursion of the diaphragm and curvatures of the spinal column in mouth
breathing children. J Pediatr (Rio J). 2008;84(2):171-7. PMid:18372937
.
,
77 Peolsson A, Marstein E, McNamara T, Nolan D, Sjaaberg E, Peolsson M,
et al. Does posture of the cervical spine influence dorsal neck muscle activity
when lifting? Man Ther. 2014;19(1):32-6.
http://dx.doi.org/10.1016/j.math.2013.06.003. PMid:23880061
http://dx.doi.org/10.1016/j.math.2013.06...
,
2222 Milanesi JM, Borin G, Corrêa EC, da Silva AM, Bortoluzzi DC, Souza
JA. Impact of the mouth breathing occurred during childhood in the adult age:
biophotogrammetric postural analysis. Int J Pediatr Otorhinolaryngol.
2011;75(8):999-1004. http://dx.doi.org/10.1016/j.ijporl.2011.04.018.
PMid:21632123
http://dx.doi.org/10.1016/j.ijporl.2011....
,
2828 Krakauer LH, Guilherme A. Relationship between mouth breathing and
postural alterations of children: a descriptive analysis. Int J Orofacial
Myology. 2000;26:13-23. PMid:11307345 .
,
3030 Harms-Ringdahl K, Ekholm J, Schüldt K, Németh G, Arborelius UP. Load
moments and myoelectric activity when the cervical spine is held in full flexion
and extension. Ergonomics. 1986;29(12):1539-52.
http://dx.doi.org/10.1080/00140138608967267. PMid:3816747
http://dx.doi.org/10.1080/00140138608967...
. In view of this information, overuse of
the accessory muscles observed in MB students could cause an increase in muscle
tension in the cervical segment promoting tensioning and fixings of myofascial
lines99 Myers TW. Trilhos anatômicos: meridianos miofasciais para terapeutas
manuais e do movimento. 2ª ed. Rio de Janeiro: Elsevier; 2010., which then leads to FHP. The
persistence of the muscle tension along the other myofascial lines99 Myers TW. Trilhos anatômicos: meridianos miofasciais para terapeutas
manuais e do movimento. 2ª ed. Rio de Janeiro: Elsevier; 2010.could reach other myofascial structures in the
trunk and extremities, eventually triggering shoulder and pelvic asymmetry, which
could, in turn, negatively affect flexibility among these individuals. The results
of the present study showed that the flexibility of MB students was significantly
reduced compared to their NB peers. Assuming that, in MB, the static muscles have
evolved to hypertonicity and that this alteration leads to muscle shortening, this
set of changes could entail loss of flexibility, especially of those muscles that do
not reach the resting position during effort55 Ribeiro EC, Marchiori SC, Silva AMT. Eletromiografia dos músculos
esternocleidomastóideo e trapézio em crianças respiradoras bucais e nasais
durante correção postural. Arq Int Otorrinolaringol.
2003;7(1):13-9..
The persistency of respiratory and postural adaptations in MB individuals can have a
negative impact on the quality of life. In view of this observation, the second
stage of this study showed the chances of these respiratory and postural adaptations
in influencing the quality of life of MB students, specifically regarding their
self-perceived sleep, school performance, atopy and nasal problems. The use of
accessory muscles increased the chances of MB individuals experiencing a stuffed
nose. Interestingly, allergic rhinitis is one of the main causes of airway
obstruction in students and adolescents3131 Barros JR, Becker HM, Pinto JA. Evaluation of atopy among
mouth-breathing pediatric patients referred for treatment to a tertiary care
center. J Pediatr. 2006;82(6):458-64. PMid:17171205,
suggesting that the chronic edema caused by the inflammatory process could cause a
persistently stuffed nose, and due to the inflammation, the use of the accessory
muscles might be a compensating adaptation that eases air intake. Given that the
muscles are organized into myofascial chains3232 Vig PS, Showfety KJ, Phillips C. Experimental manipulation of head
posture. Am J Orthod. 1980;77(3):258-68.
http://dx.doi.org/10.1016/0002-9416(80)90081-0. PMid:6928735
http://dx.doi.org/10.1016/0002-9416(80)9...
, constant physical effort of the accessory muscles might compromise
other postural segments. Therefore, the other significant relationship shown in the
present study was shoulder asymmetry. Specifically, this asymmetry was related to
25-fold higher chances of coughing or feeling tired during physical effort in MB
students. The secondary involvement of neck and shoulder girdle muscles, influenced
by accessory muscle overuse during inspiration, might be the most probable cause of
shoulder asymmetry. This disorganization between cervical and thoracic posture is
also known to impair pulmonary ventilation2727 Okuro RT, Morcillo AM, Sakano E, Schivinski CIS, Ribeiro MAGO,
Ribeiro JD. Exercise capacity, respiratory mechanics and posture in mouth
breathers. Braz J Otorhinolaryngol. 2011;77(5):656-62.
http://dx.doi.org/10.1590/S1808-86942011000500020.
PMid:22030977
http://dx.doi.org/10.1590/S1808-86942011...
.
Ribeiro and Soares3333 Ribeiro EC, Soares LM. Avaliação espirométrica de crianças
portadoras de respiração bucal antes e após intervenção fisioterapêutica.
Fisioter Bras. 2003;4:163-7., have shown a reduced
pulmonary volume in MB individuals, in which spirometric values were below the
predicted levels, with a predominance of airway obstruction. In view of these
findings, the increased chances of MB individuals reporting coughing or being tired
during physical activity are thought to be due to increased physical effort.
Even though the items regarding sleep were not significant in the present study, it
is important to note that the use of accessory muscles in MB individuals increased
the chances of daytime sleepiness, and there was a significant decrease of their
self-perception of having a quiet sleep by 88.5% for each 1% increase in shoulder
asymmetry, evaluated by the lines plotted between the acromia (acromion-acromion).
Studies3434 Katz ES, D'Ambrosio CM. Pathophysiology of pediatric obstructive
sleep apnea. Proc Am Thorac Soc. 2008;5(2):253-62.
http://dx.doi.org/10.1513/pats.200707-111MG. PMid:18250219
http://dx.doi.org/10.1513/pats.200707-11...
,
3535 Abou-Khadra MK. Sleep of children living in institutional care
facilities. Sleep Breath. 2012;16(3):887-94.
http://dx.doi.org/10.1007/s11325-011-0592-z. PMid:21915643
http://dx.doi.org/10.1007/s11325-011-059...
showed that there were intercostal and
upper airway dilating, muscle hypotony during sleep and, during the slow-wave sleep
phase, there was reduction or even abolition of the activation reflex of the
genioglossus and tensor palatine muscles. Consequently, the caliber of the upper
airways was reduced, and their resistance to airflow increased3434 Katz ES, D'Ambrosio CM. Pathophysiology of pediatric obstructive
sleep apnea. Proc Am Thorac Soc. 2008;5(2):253-62.
http://dx.doi.org/10.1513/pats.200707-111MG. PMid:18250219
http://dx.doi.org/10.1513/pats.200707-11...
. These functional changes might promote sleep fragmentation,
which is one of the causal factors of daytime sleepiness, and, thus, might recruit
the accessory inspiratory muscles, as was observed in the present study.
Although studies have shown that MB is more prevalent among males2727 Okuro RT, Morcillo AM, Sakano E, Schivinski CIS, Ribeiro MAGO,
Ribeiro JD. Exercise capacity, respiratory mechanics and posture in mouth
breathers. Braz J Otorhinolaryngol. 2011;77(5):656-62.
http://dx.doi.org/10.1590/S1808-86942011000500020.
PMid:22030977
http://dx.doi.org/10.1590/S1808-86942011...
,
3131 Barros JR, Becker HM, Pinto JA. Evaluation of atopy among
mouth-breathing pediatric patients referred for treatment to a tertiary care
center. J Pediatr. 2006;82(6):458-64. PMid:17171205
,
3636 Brant T, Parreira V, Mancini M, Becker H, Reis A, Britto R.
Breathing pattern and thoracoabdominal motion in mouth-breathing children. Rev
Bras Fisioter. 2008;12(6):495-501.
http://dx.doi.org/10.1590/S1413-35552008005000010 .
http://dx.doi.org/10.1590/S1413-35552008...
, the results of the present study show
that female MB students exhibited significant relationships with MB effects,
including a 5.2-fold increase in the chances of waking up at night, a 4.1-fold
greater chance of the feeling of having shortness of breath, and a tendency to
daytime sleepiness, with respect to male students. It is worth mentioning that these
results are in disagreement with the literature, since it is known that male
individuals are more prone to MB due to the smaller size of their airways and the
higher prevalence of allergic rhinitis3131 Barros JR, Becker HM, Pinto JA. Evaluation of atopy among
mouth-breathing pediatric patients referred for treatment to a tertiary care
center. J Pediatr. 2006;82(6):458-64. PMid:17171205.
Furthermore, school failure might be related to MB and sleep disordered breathing
during childhood1313 Vera CF, Conde GE, Wajnsztejn R, Nemr K. Learning disabilities and
mouth breathing in subjects with attention deficit hyperactivity disorder
diagnosis. Rev CEFAC. 2006;8:441-55.
,
1414 Fensterseifer GS, Carpes O, Weckx LL, Martha VF. Mouth breathing in
children with learning disorders. Braz J Otorhinolaryngol. 2013;79(5):620-4.
http://dx.doi.org/10.5935/1808-8694.20130111. PMid:24141679
http://dx.doi.org/10.5935/1808-8694.2013...
. Allergic or infectious processes, along
with processes of mechanic airway obstruction, are the major causes of the above
respiratory problems. Allergic rhinitis is one of the main causes of MB1212 Abreu RR, Rocha RL, Lamounier JA, Guerra AFM. Etiologia,
manifestações clínicas e alterações presentes nas crianças respiradoras orais. J
Pediatr. 2008;84(6):529-35. http://dx.doi.org/10.1590/S0021-75572008000700010.
PMid:19060979
http://dx.doi.org/10.1590/S0021-75572008...
and can entail several compensatory postural
adaptations. Recently, Hitos et al.3737 Hitos SF, Arakaki R, Solé D, Weckx LL. Respiração oral e alteração
de fala em crianças. J Pediatr. 2013;89:361-5.
http://dx.doi.org/10.1016/j.jped.2012.12.007. PMid:23809686
http://dx.doi.org/10.1016/j.jped.2012.12...
have
shown that allergic processes, which are associated with postural complications, can
lead to malformation of the eustachian tube, thus decisively interfering with the
loss of speech sound perception and leading to difficulties in learning to read and
write. These findings are in agreement with the relationships between risk or
protective factors observed in the present study, which showed that MB students with
shoulder asymmetry had reduced chances for exhibiting good memory. Similarly, the MB
students with pelvic asymmetry had reduced chances of keeping up with classmates in
school.
This study has some limitations. The reduced final sample size was a limiting factor
for statistical power, especially with respect to logistic regression. Some of the
evaluations were more subjective because the study was exclusively performed in
public schools. Although the literature suggests that the evaluation of a child's
health-related quality of life must include information regarding both the patients'
and their caregivers' perspective1212 Abreu RR, Rocha RL, Lamounier JA, Guerra AFM. Etiologia,
manifestações clínicas e alterações presentes nas crianças respiradoras orais. J
Pediatr. 2008;84(6):529-35. http://dx.doi.org/10.1590/S0021-75572008000700010.
PMid:19060979
http://dx.doi.org/10.1590/S0021-75572008...
,
1818 Godoy P, Niitsuma LEMN, Caromano FA. Functional evaluation of the
buccal breather -physical therapy aspects. Arq Ciênc Saúde Unipar.
2000;4(2):111-20., the self-perceived quality of life
questionnaire of this study was only administered to the MB group. Specifically, the
original idea of including the parents and/or legal guardians as a parameter for
comparison was hampered, in part due to the lack of the involvement and adherence of
the parents and/or legal guardians, who gave inaccurate answers that did not
correspond with those given by their children.
Conclusion
In this study, respiratory and postural adaptations were associated with the self-perceived quality of life of MB students with respect to the variables of sleep, signs of atopy, respiratory changes and learning deficits.
The obtained results suggest that respiratory and postural adaptations, which were observed in MB individuals, increased the chances of persistent MB. From another point of view, this study suggests that the association of these adaptations with the self-perception of these individuals might be related to their quality of life.
These results demonstrate that greater attention must be given to the evaluation of the MB children's point of view about their quality of life, since, in most evaluations of quality of life, the impressions of third-party individuals (i.e., parents and legal guardians) did not represent the real impact on the quality of life of these individuals.
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» http://dx.doi.org/10.1080/00140139.2010.544765 -
30Harms-Ringdahl K, Ekholm J, Schüldt K, Németh G, Arborelius UP. Load moments and myoelectric activity when the cervical spine is held in full flexion and extension. Ergonomics. 1986;29(12):1539-52. http://dx.doi.org/10.1080/00140138608967267. PMid:3816747
» http://dx.doi.org/10.1080/00140138608967267 -
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-
32Vig PS, Showfety KJ, Phillips C. Experimental manipulation of head posture. Am J Orthod. 1980;77(3):258-68. http://dx.doi.org/10.1016/0002-9416(80)90081-0. PMid:6928735
» http://dx.doi.org/10.1016/0002-9416(80)90081-0 -
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34Katz ES, D'Ambrosio CM. Pathophysiology of pediatric obstructive sleep apnea. Proc Am Thorac Soc. 2008;5(2):253-62. http://dx.doi.org/10.1513/pats.200707-111MG. PMid:18250219
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36Brant T, Parreira V, Mancini M, Becker H, Reis A, Britto R. Breathing pattern and thoracoabdominal motion in mouth-breathing children. Rev Bras Fisioter. 2008;12(6):495-501. http://dx.doi.org/10.1590/S1413-35552008005000010 .
» http://dx.doi.org/10.1590/S1413-35552008005000010 -
37Hitos SF, Arakaki R, Solé D, Weckx LL. Respiração oral e alteração de fala em crianças. J Pediatr. 2013;89:361-5. http://dx.doi.org/10.1016/j.jped.2012.12.007. PMid:23809686
» http://dx.doi.org/10.1016/j.jped.2012.12.007
Publication Dates
-
Publication in this collection
12 June 2015 -
Date of issue
May-Jun 2015
History
-
Received
28 May 2014 -
Reviewed
03 Sept 2014 -
Accepted
08 Dec 2014