Occurrence of rhinitis , mouth breathing and orofacial alterations in adolescents with asthma

Purpose: to determine the occurrence of rhinitis, mouth breathing and orofacial alterations in adolescents with asthma. Method: cross-sectional study was conducted with 155 adolescents with asthma from 12 to 15 years old and both sexes, treated at the Institute Professor Fernando Figueira. The survey consisted of two phases: the first to review patients’ records and carrying out two tests for further evaluation of respiratory function, being one with the help of the Glatzel mirror and the other with the counting of time of water in the mouth; the second through identification of clinical examination for orofacial alterations. Results: the frequency of allergic rhinitis was high (80.6%), with no significant difference between female (80.9%) and male (80.5%). Regarding the pattern of breathing, 32.9% of the patients presented oral breathing. The most common facial changes for males were dark circles (93.1%), high palate (82.8%), dry lips (70.1%), inadequate lip sealing (77.0%), droopy eyes (62.1%) and elongated face (57.5%). Females had the highest frequency for the following characteristics: dark circles (91.2%), high palate (85.3%), inadequate lip sealing (67.6%), dry lips (63.2%) elongated face (66.2%) and narrow upper lip (57.4%). Conclusion: in adolescents with asthma, the frequency of allergic rhinitis was high, as well as the occurrence of oral breathing and facial changes.

symptom of individuals who have oral breathing mode 7,8 .
TEST 2: Water proof, we asked the adolescents themselves to keep a sip of water in the mouth, keeping their lips sealed, without swallowing, for 3 minutes, watching through the labial cleft, if there was any effort during the time.
The inter-examiners calibration consisted of a clinical activity in which participation was a "gold standard."Individual tests were performed (Test 1 and Test 2) in 15 adolescents.Regarding the observation of orofacial alterations it was used 17 photographs of teens that contained these features or not.To ensure data reliability Kappa test was applied, the value of intra-examiner agreement was 0.84 and 0.73 for inter-examiner.
Those responsible for the subjects involved in this study have authorized their participation by signing the consent form.This study was approved by the Ethics in Research Committee from iMIP under protocol number 1176/08.
For data analysis we used methods of descriptive and inferential statistics.In the descriptive analysis it was obtained absolute distributions and univariate and bivariate percentage and statistical measures.In inferential analysis tests were used: Student t test for independent samples with equal or unequal variances and Pearson's chi-square test.To verify the hypothesis of equality of variances between two independent groups, the F test will be held.The margin of error used in the decision of the statistical tests was 5.0%.

RESULTS
Table 1 highlights mainly the presence of a significant association with age to the level of considered significance (5.0%), it was observed with each of the variables: allergic rhinitis, type of respirator and crossbite.
In Table 2, it stands out that the largest percentage differences between gender were the variables: hypotonic lips, which was 17.3% higher in female than male, mouth breathing, 14.8% higher in females and droopy eyes with value 12.1% higher in males, however, the only significant association was recorded for the type of respirator (p <0,05).
the patients have associated allergic rhinitis, while allergic rhinitis is found in 20% of the population.It is noteworthy that asthma coexists in 13% to 38% of patients with allergic rhinitis, whereas the proportion in the general population varies from 5% to 15%.Other studies have shown a prevalence of up to 98.9% of rhinitis in asthmatic patients with atopy and up to 78.4% in patients with asthma without atopy 3,4 .
Individuals with allergic rhinitis may have enlarged adenoids, tonsils, the tissue coating the nasal concha and deviated septum, leading to changes in the breathing pattern for a predominantly mouth breathing.This, depending on its duration, can cause functional, structural, pathological, occlusal and behavior alterations 5,6 .
Within this context, the aim of this study is to determine the occurrence of allergic rhinitis, oral or oronasal breathing and orofacial alterations in asthmatics.

METHOD
The transversal study in question, which is part of the research entitled "Prevalência de cárie dentária e fatores associados em adolescentes asmáticos" ("Prevalence of dental caries and associated factors in adolescents with asthma") was held at the Institute of Maternal and Child Health Professor Fernando Figueira (Instituto Materno Infantil Professor Fernando Figueira -iMIP), located in the metropolitan area of Recife, in the state of Pernambuco.The sample consisted of 155 adolescents.
The study included adolescents aged from 12 to 15 years old and those presenting during childhood/adolescence characteristic episodes of asthma (chest tightness, coughing, wheezing and shortness of breath), diagnosed by the responsible physician.The registration of respiratory function and the presence of allergic rhinitis were obtained by analyzing the records.Exclusion criteria were adolescents with systemic diseases and psychiatric disorders, as well as neurological disabilities.
As additional evaluation parameters of respiratory function were performed two tests: TEST 1: Glatzel mirror to assess nasal patency due to obstruction of the upper airways, common  Table 3 presents the study of the association between the occurrence of allergic rhinitis with the results of the type of respirator and each of the facial changes.This table highlights that the largest percentage differences between those who had allergic rhinitis or not occurred for those with long face, with a value of 23.2% higher among the group of those without allergic rhinitis and those classified as nasal -oral , according to the mirror test, 20.7% higher among those who had allergic rhinitis, these being the only two variables in which it proves significant association with the occurrence of allergic rhinitis (p <0.05 and OR intervals that exclude 1,00 value).It is observed in Table 4 the results of facial changes according to the type of respirator.Here, it is emphasized that: the greatest differences in the percentage classified as mouth breathing occurred among those who had and those who had not: narrow nose, inadequate lip seal, narrow upper lip, dark circles under their eyes and droopy eyes.Except for the dark circles there is a significant association between the type of breathing with each of the other variables mentioned (p <0.05 and OR intervals that exclude the value 1,00).

DISCUSSION
The main limitation of this study relates to the fact that it is composed of a population of convenience.Therefore, the results should be interpreted cautiously, observing this particularity.Thus, one should take into account the fact that the research was developed in a reference center for the treatment of asthma, causing patients to have access to appropriate treatment and monitoring, leading to better control of asthma, rhinitis and changes caused by these pathologies.
External validity corresponds to the ability to generalize the results of a particular study, applying them to the population from which the sample was taken, or to other populations 9 .Therefore, in this study the results cannot be generalized to all adolescents with asthma because it is a specific population, making it necessary that further studies are conducted to ensure external validity.Although the study was performed when adolescents consulted a health service, the iMIP is a state reference for adolescents with asthma, thus justifying the choice of this place for the research.
As for the analysis of the association between the occurrence of allergic rhinitis with the results of the type of respirator and each facial changes, it stands out in this study that the largest percentage differences between those who had allergic rhinitis or not occurred to those who had dry lips (67.2%), narrow upper lip (58.4%), anterior open bite (36.8%) and palate (84.8%) (Table 3).It was not found in the literature, studies that have observed this same result, but Júnior, Ezequiel and Gazêta (2006) 25 found values around 62.50% for the deepening of the palate.
As for the facial changes that affect individuals with mouth breathing, in a study conducted in the city of Recife by Menezes et al., (2006)  6 , the highest percentages were observed for anterior open bite (60%), incomplete lip closure (58.8%) and palate (38.8%).These data are similar to those of the present study in which the highest percentages occurred for elongated face (66.3%), dark circles (65.7%), anterior open bite (67.3%), dry lips (65.4%) and ogival palate (65.4%) (Table 4).When comparing the two studies, evidently, there are some differences in the percentage values, however, it was not found in the literature similar searches.
The impact of asthma, allergic rhinitis and mouth breathing affect the quality of life of individuals not only for the breathing disorder, but also for causing behavioral, functional and physical problems, highlighting, mainly orofacial alterations in these patients in order to provide them greater social integration and improved quality of life.Given this context, we see the need for a correct diagnosis, treatment and multidisciplinary (teams consisting of physicians, dental surgeons and phonoaudiologists) for this population [26][27][28] .

CONCLUSION
The frequency of allergic in the study population was high, resulting in considerable values to the occurrence of mouth breathing and facial changes.and multiple diseases [10][11][12] .Thus, the exploration of this issue by relating the occurrence of rhinitis and oral breathing in asthmatic adolescents contributes to the development of health policies directed to this group of society, seeking, diagnosis, monitoring and appropriate multidisciplinary treatment.
So it was included in this study, the following variables: gender, age, type of breathing, presence or absence of allergic rhinitis and the presence or absence of facial changes (elongated face, droopy eyes, narrow nostrils, inadequate lip seal, hypotonic lips, parched lips, narrow upper lip, anterior open bite, cross bite and ogival palate).
The literature shows that the relationship between allergic rhinitis and asthma is not completely established: These conditions may represent two distinct entities or a disease involving both airways.Allergic rhinitis is a risk factor for the development of asthma 3,[13][14][15][16] , it is concluded, therefore, that the majority of patients with asthma have rhinitis.
The literature has shown that allergic rhinitis is a highly prevalent disease.The International Study of Asthma and Allergies in Childhood (ISAAC) at the end of the 90s showed that the co-morbidity of asthma and allergic rhinitis can achieve up to 80% 17 .The data obtained in this study corroborate the ISAAC, proving that 80.6% of adolescents with asthma (Table 1) had allergic rhinitis.Similar results were obtained in a survey conducted in the city of Belo Horizonte, which showed that among 560 children and adolescents with asthma, allergic rhinitis diagnosis was confirmed in 65% 3 , as well as the findings of Imbaud et al. (2006)  18 , who found 69.1%, when evaluating 136 asthmatic patients from seven to 15 years old, thus representing epidemiologically significant values.
Allergic rhinitis is an important etiological factor of mouth breathing 10,19,20 .Papers related to the prevalence of mouth breathing are few in the literature and present percentages ranging around 58-75% 6 .As for the breathing mode, expressed in Table 1, we obtained a higher prevalence of nasal breathing (67.1%) compared to oral (32.9%).These data come in disagreement with those obtained in the study of Lemos et al. (2007) 21 which found in the group of teenagers, a percentage of approximately 60% for the oral standard, however, the distinction of the populations involved in both studies justifies the difference in values .We also emphasize the fact that there are few studies in the literature relating to the prevalence of oral breathing in adolescents with concomitant asthma and allergic rhinitis, which makes comparisons difficult.

Table 2 -Evaluation of allergic rhinitis, type of respirator and face changes according to gender
(*):Significant difference at 5.0%.

Table 3 -Evaluation of facial changes according to the occurrence of allergic rhinitis
(*):Significant difference at 5.0%.(**):It was not possible to determine due to the very low frequency of occurrence.1): According to Pearson's Chi-square test.