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Surface electromyography in orofacial and cervical musculature in mouth breathing children: an integrative literature review

ABSTRACT

Purpose:

to review, in an integrative manner, studies using surface electromyography in the orofacial and cervical musculature in mouth breathing children aged from three to 11 years and 11 months old.

Methods:

the survey was conducted in national and international databases, from 1998 to 2018, in Portuguese, English and Spanish. Review articles, dissertations, book chapters, case studies and editorials were excluded.

Results:

86 articles were found, 14 of which met the inclusion criteria. Most of these studies used surface electromyography to assess and describe the muscle condition of the mouth breathing population. Only one study addressed the influence of myofunctional speech therapy and two studies included physical therapy treatment, using electromyographic evaluation before and after the intervention. Given the main categories of analysis, the discussion was based on the year, state of publication and journal, sample size, scientific methodology, muscles assessed, assessment protocols used and the results of the publications.

Conclusions:

surface electromyography has been used mainly in the initial assessment of orofacial and postural myofunctional changes caused by mouth breathing and not as a therapeutic biofeedback, thus, it is important to conduct longitudinal studies using this instrument in mouth breathers.

Keywords:
Surface Electromyography; Mouth Breathing; Children; Preschool

RESUMO

Objetivo:

revisar, de maneira integrativa, estudos que utilizaram a eletromiografia de superfície (EMGs) em musculatura orofacial e cervical de crianças respiradoras orais da faixa etária dos três aos 11 anos e 11 meses de idade.

Métodos:

a busca foi realizada em bases de dados nacionais e internacionais, entre 1998 a 2018, nos três idiomas português, inglês e espanhol. Foram excluídos os artigos de revisão, as dissertações, os capítulos de livros, os estudos de caso e os editoriais.

Resultados:

foram encontrados 86 artigos, e desses, 14 atendiam aos critérios de inclusão. A maioria desses estudos utilizaram a EMGs para avaliação e descrição da condição muscular da população de respiração oral. Apenas um estudo abordou a influência da terapia fonoaudiológica miofuncional e dois realizaram o tratamento fisioterápico utilizando a avaliação eletromiográfica antes e após a intervenção. A discussão foi construída em torno do ano, estado de publicação e periódico, tamanho da amostra, metodologia científica, músculos avaliados, protocolos de avaliação utilizados e os resultados contidos nas publicações, considerando que estas são as principais categorias de análise.

Conclusões:

constata-se que a EMGs tem sido utilizada, principalmente, na avaliação inicial das alterações miofuncionais orofaciais e posturais causadas pela respiração oral e não como biofeedback terapêutico, sendo importante a condução de estudos longitudinais utilizando tal instrumento em respiradores orais.

Descritores:
Eletromiografia de Superfície; Respiração Bucal; Criança, Pré Escolar

Introduction

Nasal breathing plays an important role in the quality of life of humans, as it promotes the filtration, heating and humidification of inspired air in order to reach the lungs in an optimum temperature11. Yi LC, Jardim JR, Inoue DP, Pignatari SSN. The relationship between excursion of the diaphragm and curvatures of the spinal column in mouth breathing children. J Pediatr. 2008;84(2):171-7.. This type of breathing also favors the craniofacial growth as well as the development of the individual and the proper functioning of stomatognathic functions22. Lessa FCR, Enoki C, Feres MFN, Valera CP, Lima WTA, Matsumoto MAN et al. Influência do padrão respiratório na morfologia craniofacial. Rev Bras Otorrinolaringol. 2005;71(2):156-60..

The literature indicates that any factor that leads to an upper airway (UA) obstruction, such as septum deviation, pharyngeal or palatine tonsil hypertrophy (adenoids and/or tonsils)33. Hermens HJ, Freriks B, Disselhorst-Klug C, Rau G. Development of recommendations for SEMG sensors and sensor placement procedures. J. Electromyogr. and Kinesiol. 2000;10(5):361-74., or even due to sagging on speech organs and simple parafunctional habits, causes nasal breathing to be replaced by mouth breathing44. Barros JRC, Becker HMG, Pinto JA. Avaliação de atopia em crianças respiradoras bucais atendidas em centro de referência. J Pediatr. 2006;82(6):458-64..

Mouth breathing has been studied since the 20th century with publications focused on Dentistry due to the occlusal consequences55. Hartsook JT. Mouth breathing as a primary etiologic factor in the production of malocclusion. J Dent Child. 1946;13(4):91-4.. However, as a public health problem, it has generated greater scientific interest in recent years in other health areas due to the multidisciplinary aspects involved66. Veron HL, Antunes AG, Milanesi JM, Correa ECR. Implications of mouth breathing on the pulmonary function and respiratory muscles. Rev. CEFAC. 2016;18(1):242-51.. Areas such as otorhinolaryngology, dentistry and speech-language pathology associate mouth breathing with nasal, dental and orofacial motricity aspects77. Trevisan ME, Boufleur J, Soares JC, Haygert CJP, Ries LGK, Correa ECR. Diaphragmatic amplitude and accessory inspiratory muscle activity in nasal and mouth-breathing adults: a cross-sectional study. J Electromyogr Kinesiol. 2015;25(3):463-8.. Most studies address mouth breathing in childhood66. Veron HL, Antunes AG, Milanesi JM, Correa ECR. Implications of mouth breathing on the pulmonary function and respiratory muscles. Rev. CEFAC. 2016;18(1):242-51., since the child's craniofacial growth and development occur at this stage and inadequate breathing, depending on its duration, may cause structural, functional, postural and behavioral changes that impact negatively on the individual's quality of life88. Silva HJ, Tessitore A, Motta AR, Cunha DA, Felix-Berretin G, Marchesan IQ (orgs). Tratado de Motricidade Orofacial. 1st ed. Pulso; 2019..

As for the aspects of orofacial motricity, the main characteristics of the mouth breather are the lack of lip sealing, arched or high palate, Angle's Class II occlusion, unilateral or bilateral crossbite, open bite, sleep apnea, everted lower lip, retracted upper lip, generalized facial hypotonia, changes in stomatognathic functions, postural changes99. Cattoni DM, Fernandes FDM, Di Francesco RC, Latorre MRDO. Quantitative evaluation of the orofacial morphology: anthropometric measurements in healthy and mouth-breathing children. Int J Orofacial Myology. 2009;35:44-54.,1010. Posnick JC, Agnihotri N. Consequences and management of nasal airway obstruction in the dentofacial deformity patient. Curr Opin Otolaryngol Head Neck Surg. 2010;18(4):323-31., among others. These postural changes include shoulders rotated forward, head projected forward from the body, forward displacement of the hip, and body weight resting on the belly1111. Castro Martinelli RLd, Fornaro EF, Oliveira CJMd, Ferreira LMDB, Rehder MIBC. Correlações entre alterações de fala, respiração oral, dentição e oclusão. Rev. CEFAC. 2011;13(1):17-26..

The literature also describes the main signs and symptoms in mouth breathers, such as sleeping with an open mouth, snoring, scratching the nose, difficulty breathing at night or restless sleep, irritability, as well as daytime sleepiness, frequent tiredness, learning issues, learning deficit and behavioral problems1212. Abreu RR, Rocha RL, Lamounier JA, Guerra AFM. Etiology, clinical manifestations and concurrent findings in mouth-breathing children. J Pediatr. 2008;84(6):529-35.. Due to the wide changes found in mouth breathing children, it is important to emphasize the relevance of a multidisciplinary team, composed by otorhinolaryngologist, orthodontist, speech-language pathologist and physiotherapist1313. Bednarz C, Czlusniak GR, Bagarollo MF, Costa CC, Alencar BLF. Perfil orofacial de crianças respiradoras orais pré adenoidectomia e/ou amidalectomia. Distúrb. Comun. 2017;29(3):558-69..

In order to assist in the early assessment and diagnosis of children with respiratory disorders, advances and scientific studies have enabled additional clinical evaluation through instrumental tests, such as the surface electromyography (sEMG)1414. Hennig TR, Toniolo da Silva AM, Busanelo AR, Almeida FL, Berwig LC, Boton LM. Deglutição de respiradores orais e nasais: avaliação clínica fonoaudiológica e eletromiográfica. Rev. CEFAC. 2009;11(4):618-23..

The sEMG has been studied for some years in speech-language pathology research as an opportunity to analyze the muscle electrical activity in a quantitative manner, and may help in understanding the patterns of electrical activity of facial and masticatory muscles, leading professionals to an early diagnosis and a more effective intervention in Oral Motricity1515. Ferla A, Silva AM, Corrêa EC. Atividade eletromiográfica dos músculos temporal anterior e masseter em crianças respiradoras bucais e em respiradoras nasais. Rev Bras Otorrinolaringol. 2008;74(4):588-95..

Thus, this article aimed to review, in an integrative manner, studies using surface electromyography in mouth breathing children aged from three to 11 years and 11 months old, in order to understand the purpose of using this instrument and its contribution to the therapeutic intervention and evaluation.

Methods

An integrative review study was conducted in order to analyze the available scientific evidence, both in the speech-language pathology literature as in other health areas, on the use of sEMG in mouth breathing children upon the following questions: “What is the purpose of using surface electromyography in orofacial and cervical muscles in mouth breathing children?”. “What surface electromyography can provide to the assessment and intervention of these children?”. The researchers conducted a survey of studies in Portuguese, English and Spanish published in the US National Library of Medicine National Institutes Health (PubMed), Scientific Electronic Library Online (SciELO), Medical Literature Analysis and Retrieval System Online (MEDLINE) and Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS) databases from 1998 to 2018. The descriptors found in the DeCS and MeSH that were used to find the studies in the three languages were: Electromyography OR Electromiografia OR Eletromiografia; Mouth Breathing OR Respiración por la Boca OR Respiração Bucal AND Child, Preschool OR Preescolar OR Pré-Escolar OR Child OR Niño OR Criança. The search was conducted by the association of at least two of the descriptors.

Exclusion criteria were: studies not published in journals indexed in PubMed, SciELO, MEDLINE and LILACS databases; studies not published from 1998 to 2018; studies that did not included surface electromyography in mouth breathing children; studies with a sample population with an age range different of three to 11 years and 11 months of age; literature review, dissertations, book chapters, case studies and editorials, as well as those that did not have the subject addressed in this review in its title, abstract or text. The study included original research articles published in journals of speech-language pathology and other health areas, such as physical therapy and dentistry.

The selection stages of the articles were: first, a reading of the title of the studies found and the exclusion of those that did not fit the purpose of this study; then, a reading of its abstracts including the use of surface electromyography in the mouth breathing children population and the exclusion of those that did not fit the inclusion criteria.

The search and selection of articles were conducted as follows: 1) initial search for references in databases; 2) selection of references based on inclusion criteria by reading title and abstract; 3) duplicate deletion; 4) exclusion of studies according to the exclusion criteria, by reading the abstract and the methodology. All stages of the study were performed by the researcher student and the professor adviser.

Figure 1 shows the search and selection process of studies until the final design of the database for the analysis process.

Figure 1:
Organization chart of the literature search and selection process

Literature Review

Eighty-six references were found from the search descriptors. Out of these, 26 were found in PubMed, 8 in SciELO, 17 in LILACS and 35 in MEDLINE. 35 studies were excluded in the third stage due to duplicate databases and 37 studies were excluded when applying the exclusion criteria, resulting in the 14 articles remaining in this study. Although the descriptors were used in the three languages (Portuguese, English and Spanish) in the databases, the final result included only articles published in Brazil. As shown in Figure 2, the studies were initially described by their main characteristics and then characterized in three items, for descriptive statistics of the frequency of each characteristic: scientific production (year of publication, journal of publication and the state in which the study was conducted); population (number of sample subjects, gender and age group) and assessed muscles, according to Tables 1, 2 and 3, respectively.

Figure 2:
Main findings in the literature on the use of surface electromyography in mouth breathing children

Figure 3:
Main findings in the literature on the use of surface electromyography in mouth breathing children

Table 1:
Frequency of scientific production characteristics of surface electromyography in mouth breathers
Table 2:
Frequency of sample population characteristics
Table 3:
Frequency of muscles assessed

The year of publication ranged from 1998 to 2015, that is, it can be noticed that the articles found were published in the last 17 years, and no study of the current year met the inclusion criteria. It can also be noted that most studies were published annually from 1998 to 2011. It may be related to the emergence of new devices that makes it easier to perform electromyography and to the training of professionals for the electromyographic technique after the creation of the standardized protocol suggested by the Surface ElectroMyoGraphy for the Non-Invasive Assessment of Muscles (SENIAN) during the International Society of Electrophysiology and Kinesioly (ISEK), in 20021616. Berzin F, Nagae M. Eletromiografia de superfície: do sinal bruto à digitalização. In: Rahal A, Oncins MC (orgs). Eletromiografia de superfície na terapia miofuncional. 1.ed. São José dos Campos, SP: Pulso Editorial; 2014. p. 42-53.. Subsequently, the next study is from 2015, which is also the last publication found in the survey.

There was a higher number of publications in the Rio Grande do Sul state with 8 (57.1%) studies published from 2002 to 2015, which is believed to be due to the study group led by the speech-language pathologist Ana Maria Toniolo da Silva with a team of students and colleagues at the Universidade Federal de Santa Maria, RS, Brazil, following a line of research associated with orofacial motricity, mouth breathers and electromyography.

As for publication journals, there is a wide variety of journals. Among the 14 studies, one that stands out was found in the “Journal of Electromyography and Kinesiology”1717. 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., which is the main source of outstanding original articles on the study of muscle contraction and human movement, focused on publishing the best studies in all areas related to electromyography and kinesiology. Two studies were published in the Revista CEFAC, which addresses only articles from the Speech-Language Pathology-related areas1414. Hennig TR, Toniolo da Silva AM, Busanelo AR, Almeida FL, Berwig LC, Boton LM. Deglutição de respiradores orais e nasais: avaliação clínica fonoaudiológica e eletromiográfica. Rev. CEFAC. 2009;11(4):618-23.,1818. Boton LM, Toniolo AM, Bolzan GP, Corrêa ECR, Busanello AR. Estudo eletromiográfico dos músculos faciais de respiradores nasais, respiradores orais viciosos e obstrutivos. Rev. CEFAC. 2011;13(1):27-34.. Two other studies in the area of Dentistry and Orthodontics were published in the Revista Dental Press de Ortodontia e OrtopediaFacial1919. Tomé MC, Marchiori SC. Estudo eletromiográfico dos músculos orbiculares superior e inferior da boca em crianças respiradoras nasais e bucais durante o repouso com e sem contato labial. J Bras Ortodon Ortop Facial. 1998;3(15):59-66.,2020. Fronza F, Kowalski RV, Shimizu RH, Michelon D, Tanaka OM. Estudo morfofuncional do segmento medial, porção superior, do músculo orbicular da boca em crianças com má oclusão de Classe II, divisão 1 de Angle e com modos respiratórios predominantemente nasal ou bucal. Rev. Dent. Press Ortod. Ortop. Facial. 2004;9(1):88-102. and, finally, two studies in the area of Otorhinolaryngology were published in the Revista de Otorrinolaringologia Pediátrica2121. Corrêa ECR, Bérzin F. Efficacy of physical therapy on cervical muscle activity and on body posture in school-age mouth breathing children. Int J Pediatr Otorhinolaryngol. 2007;71(10):1527-35.,2222. Corrêa ECR, Bérzin F. Mouth Breathing Syndrome: cervical muscles recruitment during nasal inspiration before and after respiratory and postural exercises on Swiss Ball. Int J Pediatr Otorhinolaryngol. 2008;72(9):1335-43..

The sample ranged from 13 to 88 individuals, including children of both genders from 4-12 years old, and the largest age group studied was from 6-12 years old. Even in studies with smaller samples1414. Hennig TR, Toniolo da Silva AM, Busanelo AR, Almeida FL, Berwig LC, Boton LM. Deglutição de respiradores orais e nasais: avaliação clínica fonoaudiológica e eletromiográfica. Rev. CEFAC. 2009;11(4):618-23.,2121. Corrêa ECR, Bérzin F. Efficacy of physical therapy on cervical muscle activity and on body posture in school-age mouth breathing children. Int J Pediatr Otorhinolaryngol. 2007;71(10):1527-35.

22. Corrêa ECR, Bérzin F. Mouth Breathing Syndrome: cervical muscles recruitment during nasal inspiration before and after respiratory and postural exercises on Swiss Ball. Int J Pediatr Otorhinolaryngol. 2008;72(9):1335-43.
-2323. Schievano D, Rontani RM, Bérzin F. Influence of myofunctional therapy on the perioral muscles. Clinical and electromyographic evaluations. J Oral Rehabil. 1999;26(7):564-9., the authors reported an electromyographic evidence of both for the improvement of the muscles evaluated after speech-language pathology therapy2323. Schievano D, Rontani RM, Bérzin F. Influence of myofunctional therapy on the perioral muscles. Clinical and electromyographic evaluations. J Oral Rehabil. 1999;26(7):564-9. and physical therapy2121. Corrêa ECR, Bérzin F. Efficacy of physical therapy on cervical muscle activity and on body posture in school-age mouth breathing children. Int J Pediatr Otorhinolaryngol. 2007;71(10):1527-35.,2222. Corrêa ECR, Bérzin F. Mouth Breathing Syndrome: cervical muscles recruitment during nasal inspiration before and after respiratory and postural exercises on Swiss Ball. Int J Pediatr Otorhinolaryngol. 2008;72(9):1335-43., as for the electrical activity of the upper orbicularis muscle in mouth breathers1414. Hennig TR, Toniolo da Silva AM, Busanelo AR, Almeida FL, Berwig LC, Boton LM. Deglutição de respiradores orais e nasais: avaliação clínica fonoaudiológica e eletromiográfica. Rev. CEFAC. 2009;11(4):618-23.. No article indicates that a restricted number of subjects may have been a factor that influenced the results.

As for the methodology of the studies, it was found that most studies divided the sample into two groups (mouth and nasal breathers)1414. Hennig TR, Toniolo da Silva AM, Busanelo AR, Almeida FL, Berwig LC, Boton LM. Deglutição de respiradores orais e nasais: avaliação clínica fonoaudiológica e eletromiográfica. Rev. CEFAC. 2009;11(4):618-23.,1515. Ferla A, Silva AM, Corrêa EC. Atividade eletromiográfica dos músculos temporal anterior e masseter em crianças respiradoras bucais e em respiradoras nasais. Rev Bras Otorrinolaringol. 2008;74(4):588-95.,1717. 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.,1919. Tomé MC, Marchiori SC. Estudo eletromiográfico dos músculos orbiculares superior e inferior da boca em crianças respiradoras nasais e bucais durante o repouso com e sem contato labial. J Bras Ortodon Ortop Facial. 1998;3(15):59-66.,2121. Corrêa ECR, Bérzin F. Efficacy of physical therapy on cervical muscle activity and on body posture in school-age mouth breathing children. Int J Pediatr Otorhinolaryngol. 2007;71(10):1527-35.

22. Corrêa ECR, Bérzin F. Mouth Breathing Syndrome: cervical muscles recruitment during nasal inspiration before and after respiratory and postural exercises on Swiss Ball. Int J Pediatr Otorhinolaryngol. 2008;72(9):1335-43.

23. Schievano D, Rontani RM, Bérzin F. Influence of myofunctional therapy on the perioral muscles. Clinical and electromyographic evaluations. J Oral Rehabil. 1999;26(7):564-9.

24. Tomé MC, Marchiori SC. Análise eletromiográfica dos músculos orbiculares superior e inferior da boca em crianças respiradoras nasais e bucais durante a emissão de sílabas. Pro-Fono R. Atual. Cientif. 1999;11(1):1-7.

25. Ribeiro EC, Marchiori SC, da Silva AM. Electromyographic muscle EMG activity in mouth and nasal breathing children. Cranio. 2004;22(2):145-50.
-2626. Busanello-Stella AR, Blanco-Dutra AP, Corrêa EC, Silva AM. Electromyographic fatigue of orbicular oris muscles during exercises in mouth and nasal breathing children. CoDAS. 2015;27(1):80-8. doi: 10.1590/2317-1782/20152014078.
https://doi.org/10.1590/2317-1782/201520...
with subgroups1818. Boton LM, Toniolo AM, Bolzan GP, Corrêa ECR, Busanello AR. Estudo eletromiográfico dos músculos faciais de respiradores nasais, respiradores orais viciosos e obstrutivos. Rev. CEFAC. 2011;13(1):27-34.,2727. Povh GZ, Essenfelder LR, Shimizu RH, Maruo H, Tanaka O. Estudo eletromiográfico do músculo orbicular da boca, segmento superior (região medial) em crianças com má oclusão Classe I e modo respiratório bucal. Rev. dent. press ortodon. ortop. maxilar. 2003;8(5):59-67.,2828. Vieira SW, Tanaka OM, Maruo H, Essenfelder LRC, Vieira S. Estudo da função muscular peribucal, do grau de inclinação vestíbulo-lingual e da discrepância de modelo dos incisivos inferiores permanentes em crianças respiradoras nasais e bucais com oclusão normal e má oclusão de Classe I. R Dental Press Ortodon Ortop Facial. 2005;10(1):108-16. to compare the electromyographic findings of the muscles studied in the two populations. A single study addressed the impact of myofunctional therapy by performing an electromyographic assessment before and after a speech-language pathology therapy2323. Schievano D, Rontani RM, Bérzin F. Influence of myofunctional therapy on the perioral muscles. Clinical and electromyographic evaluations. J Oral Rehabil. 1999;26(7):564-9., and two other studies assessed muscle electrical activity after months of physical therapy sessions2121. Corrêa ECR, Bérzin F. Efficacy of physical therapy on cervical muscle activity and on body posture in school-age mouth breathing children. Int J Pediatr Otorhinolaryngol. 2007;71(10):1527-35.,2222. Corrêa ECR, Bérzin F. Mouth Breathing Syndrome: cervical muscles recruitment during nasal inspiration before and after respiratory and postural exercises on Swiss Ball. Int J Pediatr Otorhinolaryngol. 2008;72(9):1335-43., while the other studies used the electromyography to complement the initial clinical assessment, detect the muscle activity pattern1414. Hennig TR, Toniolo da Silva AM, Busanelo AR, Almeida FL, Berwig LC, Boton LM. Deglutição de respiradores orais e nasais: avaliação clínica fonoaudiológica e eletromiográfica. Rev. CEFAC. 2009;11(4):618-23.,1515. Ferla A, Silva AM, Corrêa EC. Atividade eletromiográfica dos músculos temporal anterior e masseter em crianças respiradoras bucais e em respiradoras nasais. Rev Bras Otorrinolaringol. 2008;74(4):588-95.,1717. 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.,1818. Boton LM, Toniolo AM, Bolzan GP, Corrêa ECR, Busanello AR. Estudo eletromiográfico dos músculos faciais de respiradores nasais, respiradores orais viciosos e obstrutivos. Rev. CEFAC. 2011;13(1):27-34.,2020. Fronza F, Kowalski RV, Shimizu RH, Michelon D, Tanaka OM. Estudo morfofuncional do segmento medial, porção superior, do músculo orbicular da boca em crianças com má oclusão de Classe II, divisão 1 de Angle e com modos respiratórios predominantemente nasal ou bucal. Rev. Dent. Press Ortod. Ortop. Facial. 2004;9(1):88-102.,2424. Tomé MC, Marchiori SC. Análise eletromiográfica dos músculos orbiculares superior e inferior da boca em crianças respiradoras nasais e bucais durante a emissão de sílabas. Pro-Fono R. Atual. Cientif. 1999;11(1):1-7.,2525. Ribeiro EC, Marchiori SC, da Silva AM. Electromyographic muscle EMG activity in mouth and nasal breathing children. Cranio. 2004;22(2):145-50.,2727. Povh GZ, Essenfelder LR, Shimizu RH, Maruo H, Tanaka O. Estudo eletromiográfico do músculo orbicular da boca, segmento superior (região medial) em crianças com má oclusão Classe I e modo respiratório bucal. Rev. dent. press ortodon. ortop. maxilar. 2003;8(5):59-67.,2828. Vieira SW, Tanaka OM, Maruo H, Essenfelder LRC, Vieira S. Estudo da função muscular peribucal, do grau de inclinação vestíbulo-lingual e da discrepância de modelo dos incisivos inferiores permanentes em crianças respiradoras nasais e bucais com oclusão normal e má oclusão de Classe I. R Dental Press Ortodon Ortop Facial. 2005;10(1):108-16. and to assist in the diagnosis2626. Busanello-Stella AR, Blanco-Dutra AP, Corrêa EC, Silva AM. Electromyographic fatigue of orbicular oris muscles during exercises in mouth and nasal breathing children. CoDAS. 2015;27(1):80-8. doi: 10.1590/2317-1782/20152014078.
https://doi.org/10.1590/2317-1782/201520...
. The literature in the speech-language pathology area understands the sEMG as a reliable tool for a reliable assessment, diagnosis and treatment related to speech-language pathology2424. Tomé MC, Marchiori SC. Análise eletromiográfica dos músculos orbiculares superior e inferior da boca em crianças respiradoras nasais e bucais durante a emissão de sílabas. Pro-Fono R. Atual. Cientif. 1999;11(1):1-7.,2626. Busanello-Stella AR, Blanco-Dutra AP, Corrêa EC, Silva AM. Electromyographic fatigue of orbicular oris muscles during exercises in mouth and nasal breathing children. CoDAS. 2015;27(1):80-8. doi: 10.1590/2317-1782/20152014078.
https://doi.org/10.1590/2317-1782/201520...
.

Only three of the 14 studies include the etiology of mouth breathing undergoing nasopharyngoscopy and oroscopy to confirm the diagnosis of upper airway obstruction2121. Corrêa ECR, Bérzin F. Efficacy of physical therapy on cervical muscle activity and on body posture in school-age mouth breathing children. Int J Pediatr Otorhinolaryngol. 2007;71(10):1527-35.,2222. Corrêa ECR, Bérzin F. Mouth Breathing Syndrome: cervical muscles recruitment during nasal inspiration before and after respiratory and postural exercises on Swiss Ball. Int J Pediatr Otorhinolaryngol. 2008;72(9):1335-43. and there are reports that few studies classified mouth breathers according to the etiology as obstructive and vicious, making it difficult to discuss its results1818. Boton LM, Toniolo AM, Bolzan GP, Corrêa ECR, Busanello AR. Estudo eletromiográfico dos músculos faciais de respiradores nasais, respiradores orais viciosos e obstrutivos. Rev. CEFAC. 2011;13(1):27-34.. In this study, the authors show the importance of knowing the etiology of mouth breathing in order to assist in therapeutic management, as they believe that children with mouth breathing caused by nasal obstruction are more likely to develop more severe muscle changes than children with vicious mouth breathing1818. Boton LM, Toniolo AM, Bolzan GP, Corrêa ECR, Busanello AR. Estudo eletromiográfico dos músculos faciais de respiradores nasais, respiradores orais viciosos e obstrutivos. Rev. CEFAC. 2011;13(1):27-34..

The literature reports that children who have chronic mouth breathing may show significant changes in the craniofacial development, with changes in both bone and muscle tissues, that is, several structural changes of the speech organs, such as: hypotonia of the jaw elevators (masseter muscles) , tongue hypotonia, changes in the tongue resting posture, as well as in the orbicularis oris (the short upper and everted lower lip)2929. Silva AMT. Eletromiografia: avaliação dos músculos orbiculares orais da boa em crianças respiradoras bucais, pré e pós mioterapia [tese]. São Paulo (SP): Universidade Federal de São Paulo; 2000. and mentalis muscles, all of which impair the stomatognathic functions, such as speech, swallowing and chewing in addition to vocal changes2929. Silva AMT. Eletromiografia: avaliação dos músculos orbiculares orais da boa em crianças respiradoras bucais, pré e pós mioterapia [tese]. São Paulo (SP): Universidade Federal de São Paulo; 2000.

30. Cattoni DM, Fernandes FD, Di Francesco RC, Latorre MDO. Características do sistema estomatognático de crianças respiradoras orais: enfoque antroposcópico. Pró-Fono R. Atual. Cient. 2007;19(4):347-51.

31. Dutra EH, Maruo H, Vianna-Lara MS. Electromyographic activity evaluation and comparison of the orbicularis oris (lower fascicle) and mentalis muscles in predominantly nose- or mouth-breathing subjects. Am J Orthod Dentofacial Orthop. 2006;129(6):722.e1-722.e9.

32. Trask G, Shapiro P. The effects of perennial rhinitis on dental and skeletal development: a comparison of sibling pairs. Am J Orthod Dentof Orthop 1987;92(4):286-93.
-3333. Bresolin D, Shapiro PA, Shapiro GG, Chapko MK, Dassel S. Mouth breathing in allergic children: Its relationship to dentofacial development. Am J Orthod. 1983;83(4):334-40.. As shown in Table 3, the assessment of the orbicularis oris muscles was included in 9 studies (64.2%)1515. Ferla A, Silva AM, Corrêa EC. Atividade eletromiográfica dos músculos temporal anterior e masseter em crianças respiradoras bucais e em respiradoras nasais. Rev Bras Otorrinolaringol. 2008;74(4):588-95.,1717. 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.,2020. Fronza F, Kowalski RV, Shimizu RH, Michelon D, Tanaka OM. Estudo morfofuncional do segmento medial, porção superior, do músculo orbicular da boca em crianças com má oclusão de Classe II, divisão 1 de Angle e com modos respiratórios predominantemente nasal ou bucal. Rev. Dent. Press Ortod. Ortop. Facial. 2004;9(1):88-102.,2121. Corrêa ECR, Bérzin F. Efficacy of physical therapy on cervical muscle activity and on body posture in school-age mouth breathing children. Int J Pediatr Otorhinolaryngol. 2007;71(10):1527-35.,2323. Schievano D, Rontani RM, Bérzin F. Influence of myofunctional therapy on the perioral muscles. Clinical and electromyographic evaluations. J Oral Rehabil. 1999;26(7):564-9.

24. Tomé MC, Marchiori SC. Análise eletromiográfica dos músculos orbiculares superior e inferior da boca em crianças respiradoras nasais e bucais durante a emissão de sílabas. Pro-Fono R. Atual. Cientif. 1999;11(1):1-7.
-2525. Ribeiro EC, Marchiori SC, da Silva AM. Electromyographic muscle EMG activity in mouth and nasal breathing children. Cranio. 2004;22(2):145-50.,2828. Vieira SW, Tanaka OM, Maruo H, Essenfelder LRC, Vieira S. Estudo da função muscular peribucal, do grau de inclinação vestíbulo-lingual e da discrepância de modelo dos incisivos inferiores permanentes em crianças respiradoras nasais e bucais com oclusão normal e má oclusão de Classe I. R Dental Press Ortodon Ortop Facial. 2005;10(1):108-16.,3030. Cattoni DM, Fernandes FD, Di Francesco RC, Latorre MDO. Características do sistema estomatognático de crianças respiradoras orais: enfoque antroposcópico. Pró-Fono R. Atual. Cient. 2007;19(4):347-51. and this is due to the fact that the perioral muscles, including the orbicularis oris and mentalis muscles1717. 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.,2121. Corrêa ECR, Bérzin F. Efficacy of physical therapy on cervical muscle activity and on body posture in school-age mouth breathing children. Int J Pediatr Otorhinolaryngol. 2007;71(10):1527-35., will act more actively in order to restore the lip sealing required to adequate breathing3434. Lemos CM, Junqueira PAS, Goffi-Gomez MVS, Faria MEJ, Basso SC. Estudo da relação entre a oclusão dentária e a deglutição no respirador oral. Arq Int Otorrinolaringol. 2006;10(2):114-8.,3535. Nagae MH. Estudo eletromiográfico da correlação entre os músculos bucinador e masseter, durante a mastigação, em sujeitos Classe I e Classe III de Angle. [Dissertação] Piracicaba (SP): Universidade Estadual de Campinas, Faculdade de Odontologia de Piracicaba; 2005., which arouses the interest of researchers to evaluate both subjectively and quantitatively with electromyographic results, correlating with swallowing1414. Hennig TR, Toniolo da Silva AM, Busanelo AR, Almeida FL, Berwig LC, Boton LM. Deglutição de respiradores orais e nasais: avaliação clínica fonoaudiológica e eletromiográfica. Rev. CEFAC. 2009;11(4):618-23., chewing1515. Ferla A, Silva AM, Corrêa EC. Atividade eletromiográfica dos músculos temporal anterior e masseter em crianças respiradoras bucais e em respiradoras nasais. Rev Bras Otorrinolaringol. 2008;74(4):588-95.,1818. Boton LM, Toniolo AM, Bolzan GP, Corrêa ECR, Busanello AR. Estudo eletromiográfico dos músculos faciais de respiradores nasais, respiradores orais viciosos e obstrutivos. Rev. CEFAC. 2011;13(1):27-34. and speech2424. Tomé MC, Marchiori SC. Análise eletromiográfica dos músculos orbiculares superior e inferior da boca em crianças respiradoras nasais e bucais durante a emissão de sílabas. Pro-Fono R. Atual. Cientif. 1999;11(1):1-7. functions.

There are studies that claim that the compensatory participation of perioral muscles in mouth breathers during the swallowing function, for example, is an adaptation of the stomatognathic system as the chewing muscles do not perform the muscle activity that is required for this function3636. Coelho MF, Terra VHTC. Implicações clínicas em pacientes respiradores bucais. Rev Bras Patol Oral. 2004;3(1):17-9.,3737. Cattoni DM. Alterações da mastigação e deglutição. In: Ferreira LP, Befi-Lopes DM, Limongi SCO (orgs). Tratado de fonoaudiologia. São Paulo: Roca; 2004. p. 277-91.. Therefore, two studies among the results of this integrative review evaluated not only the orbicularis oris muscles, but also the temporal and masseter muscles1515. Ferla A, Silva AM, Corrêa EC. Atividade eletromiográfica dos músculos temporal anterior e masseter em crianças respiradoras bucais e em respiradoras nasais. Rev Bras Otorrinolaringol. 2008;74(4):588-95.,1818. Boton LM, Toniolo AM, Bolzan GP, Corrêa ECR, Busanello AR. Estudo eletromiográfico dos músculos faciais de respiradores nasais, respiradores orais viciosos e obstrutivos. Rev. CEFAC. 2011;13(1):27-34. in mouth breathers comparing them to the group of mouth breathers. It is believed that the interest of these scholars towards these masticatory muscles in this specific population is due to the fact that the discussions are restricted to chewing development in mouth breathers, and the evaluation is based only on clinical aspects, with the need for a quantitative aspect, through a device to assist in the assessment, diagnosis and a more effective intervention1313. Bednarz C, Czlusniak GR, Bagarollo MF, Costa CC, Alencar BLF. Perfil orofacial de crianças respiradoras orais pré adenoidectomia e/ou amidalectomia. Distúrb. Comun. 2017;29(3):558-69..

Other studies decided to evaluate the sternocleidomastoid (SCM) and trapezius muscles in both relaxation and maximal voluntary contraction2525. Ribeiro EC, Marchiori SC, da Silva AM. Electromyographic muscle EMG activity in mouth and nasal breathing children. Cranio. 2004;22(2):145-50. and during oral and nasal inspiration1818. Boton LM, Toniolo AM, Bolzan GP, Corrêa ECR, Busanello AR. Estudo eletromiográfico dos músculos faciais de respiradores nasais, respiradores orais viciosos e obstrutivos. Rev. CEFAC. 2011;13(1):27-34. in order to understand the level of muscle activity since, as mentioned, mouth breathing children change the position of the head and neck1111. Castro Martinelli RLd, Fornaro EF, Oliveira CJMd, Ferreira LMDB, Rehder MIBC. Correlações entre alterações de fala, respiração oral, dentição e oclusão. Rev. CEFAC. 2011;13(1):17-26. to reduce the narrowing of the airways2525. Ribeiro EC, Marchiori SC, da Silva AM. Electromyographic muscle EMG activity in mouth and nasal breathing children. Cranio. 2004;22(2):145-50., and the SCM muscle is considered a tool for inspiratory movement. These authors found greater SCM muscle activity in mouth breathing children during nasal inspiration, attributing this increased activity to the effort to increase lung volumes1818. Boton LM, Toniolo AM, Bolzan GP, Corrêa ECR, Busanello AR. Estudo eletromiográfico dos músculos faciais de respiradores nasais, respiradores orais viciosos e obstrutivos. Rev. CEFAC. 2011;13(1):27-34.. Regarding this action of accessory muscles during nasal breathing in mouth breathers, some authors1717. 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. concluded that the therapy aimed at this population should not be performed only for orofacial changes, as there are also changes in the cervical muscles. Thus, other studies2121. Corrêa ECR, Bérzin F. Efficacy of physical therapy on cervical muscle activity and on body posture in school-age mouth breathing children. Int J Pediatr Otorhinolaryngol. 2007;71(10):1527-35.,2222. Corrêa ECR, Bérzin F. Mouth Breathing Syndrome: cervical muscles recruitment during nasal inspiration before and after respiratory and postural exercises on Swiss Ball. Int J Pediatr Otorhinolaryngol. 2008;72(9):1335-43. using sEMG on cervical muscles (sternocleidomastoid, subocciptal and upper trapezius) were also found to verify the effectiveness of physical therapy sessions after a period of treatment. However, there is a consensus that there are few publications involving these muscles, and the authors suggest the development of further studies to verify the level of cervical muscle activity after postural and respiratory care.

The following category of analysis refers to the evaluation protocols used for both the evaluation, especially of the stomatognathic system, as for the use of the surface electromyography. None of the 14 studies mentioned any of the various types of surface electromyography protocols created by the Professor Hilton Justino da Silva3838. Silvia HJ. Protocolos de Eletromiografia de Superfície em Fonoaudiologia. Barueri: PróFono, 2013. and other authors of the book “Protocolos de Eletromiografia de Superfície em Fonoaudiologia”, published by Pró Fono3838. Silvia HJ. Protocolos de Eletromiografia de Superfície em Fonoaudiologia. Barueri: PróFono, 2013. This book has electromyographic assessment protocols in phonation, an electromyographic assessment protocol for cervical muscles, among others, that could and should be present in studies using surface electromyography as a complementary tool for evaluation, diagnosis and clinical intervention. Only one speech-language pathology study3030. Cattoni DM, Fernandes FD, Di Francesco RC, Latorre MDO. Características do sistema estomatognático de crianças respiradoras orais: enfoque antroposcópico. Pró-Fono R. Atual. Cient. 2007;19(4):347-51. reported the use of the MBGR protocol (Protocol of Orofacial Myofunctional evaluation with scores)3939. Felício CM, Ferreira CL. Protocol of orofacial myofunctional evaluation with scores. Int J Pediatr Otorhinolaryngol. 2008;72(3):367-75. that addresses general aspects of the stomatognathic system, as well as breathing, chewing and swallowing functions, for the clinical evaluation of the study population.

Referring to the results analyzed in the studies included in this integrative review, it was found that there were data showing the increased electrical activity of the orbicularis oris muscles with and without lip contact in mouth breathers when compared to nasal breathers, with a statistically significant difference1919. Tomé MC, Marchiori SC. Estudo eletromiográfico dos músculos orbiculares superior e inferior da boca em crianças respiradoras nasais e bucais durante o repouso com e sem contato labial. J Bras Ortodon Ortop Facial. 1998;3(15):59-66. in line with the findings of another study2929. Silva AMT. Eletromiografia: avaliação dos músculos orbiculares orais da boa em crianças respiradoras bucais, pré e pós mioterapia [tese]. São Paulo (SP): Universidade Federal de São Paulo; 2000.. However, the electromyographic activity was lower2424. Tomé MC, Marchiori SC. Análise eletromiográfica dos músculos orbiculares superior e inferior da boca em crianças respiradoras nasais e bucais durante a emissão de sílabas. Pro-Fono R. Atual. Cientif. 1999;11(1):1-7. during the speech test (production of syllables with bilabial and labiodental phonemes) in the same muscles evaluated, and it is believed that this is due to the hypotonia of the speech organs. Two of the studies assessed only the upper orbicularis oris muscle and found that there was no statistically significant difference between the subgroups2727. Povh GZ, Essenfelder LR, Shimizu RH, Maruo H, Tanaka O. Estudo eletromiográfico do músculo orbicular da boca, segmento superior (região medial) em crianças com má oclusão Classe I e modo respiratório bucal. Rev. dent. press ortodon. ortop. maxilar. 2003;8(5):59-67. evaluated, as well as for the shape of the upper lip in relation to function2020. Fronza F, Kowalski RV, Shimizu RH, Michelon D, Tanaka OM. Estudo morfofuncional do segmento medial, porção superior, do músculo orbicular da boca em crianças com má oclusão de Classe II, divisão 1 de Angle e com modos respiratórios predominantemente nasal ou bucal. Rev. Dent. Press Ortod. Ortop. Facial. 2004;9(1):88-102.. On the other hand, the literature shows an increase in the activity of the lower orbicularis oris muscle due to the joint action of the mentalis muscle, in order to compensate the hypofunctionality observed in mouth breathers4040. Tulley WJ. Methods of recording patterns of behavior of the orofacial muscles using the electromyography. Dental Record. 1953;73:741-8.. This activation of the lower orbicularis oris muscle seen in the literature is in line with the results reported also in the study that composes this integrative review, in which when evaluating the vicious mouth breathing (VMB) and the obstructive mouth breathing (OBM) at rest, the authors found that the lower orbicularis oris muscle in OBMs were electrically more active than in nasal breathers1818. Boton LM, Toniolo AM, Bolzan GP, Corrêa ECR, Busanello AR. Estudo eletromiográfico dos músculos faciais de respiradores nasais, respiradores orais viciosos e obstrutivos. Rev. CEFAC. 2011;13(1):27-34..

Finally, regarding the electromyographic findings of the temporal muscles evaluated, there was also an increased electrical activity of the left temporal muscle in OMBs during masticatory isometry1818. Boton LM, Toniolo AM, Bolzan GP, Corrêa ECR, Busanello AR. Estudo eletromiográfico dos músculos faciais de respiradores nasais, respiradores orais viciosos e obstrutivos. Rev. CEFAC. 2011;13(1):27-34., similar result was found in another study1414. Hennig TR, Toniolo da Silva AM, Busanelo AR, Almeida FL, Berwig LC, Boton LM. Deglutição de respiradores orais e nasais: avaliação clínica fonoaudiológica e eletromiográfica. Rev. CEFAC. 2009;11(4):618-23. that evaluated the maximum intercuspidal position and during habitual chewing1818. Boton LM, Toniolo AM, Bolzan GP, Corrêa ECR, Busanello AR. Estudo eletromiográfico dos músculos faciais de respiradores nasais, respiradores orais viciosos e obstrutivos. Rev. CEFAC. 2011;13(1):27-34.)(1414. Hennig TR, Toniolo da Silva AM, Busanelo AR, Almeida FL, Berwig LC, Boton LM. Deglutição de respiradores orais e nasais: avaliação clínica fonoaudiológica e eletromiográfica. Rev. CEFAC. 2009;11(4):618-23. In this regard, the literature explains that due to the anterior head posture in mouth breathers, which occurs in order to facilitate the air flow through the oropharynx, the temporal muscles have increased electrical activity in an attempt to compensate the lower activity of the masseter muscles. In addition, the greater activity of the left temporal muscle in relation to the right one may be related to the chewing lateral preference pattern1818. Boton LM, Toniolo AM, Bolzan GP, Corrêa ECR, Busanello AR. Estudo eletromiográfico dos músculos faciais de respiradores nasais, respiradores orais viciosos e obstrutivos. Rev. CEFAC. 2011;13(1):27-34.. As for the SCM, subocciptal and trapezius muscles, the studies found a significant reduction in the electrical activity of the muscles evaluated during the relaxed position, aligned posture2121. Corrêa ECR, Bérzin F. Efficacy of physical therapy on cervical muscle activity and on body posture in school-age mouth breathing children. Int J Pediatr Otorhinolaryngol. 2007;71(10):1527-35. and nasal breathing2222. Corrêa ECR, Bérzin F. Mouth Breathing Syndrome: cervical muscles recruitment during nasal inspiration before and after respiratory and postural exercises on Swiss Ball. Int J Pediatr Otorhinolaryngol. 2008;72(9):1335-43. of mouth breathers after physical therapy treatment

Final Considerations

Given all of the above, the study contributes to the area of Orofacial Motricity as well as other areas of health, such as physical therapy, since only a few studies have been published in the last 20 years including the use of surface electromyography to complement the clinical evaluation, assist in the diagnosis and, mainly, in the therapeutic intervention of mouth breathing children within the age group of the inclusion criteria. Specifically in the field of speech-language pathology, only one study focused on using sEMG in orofacial muscles, in order to demonstrate the therapeutic efficacy. Similarly, only two papers, among the physical therapy studies, included the use of sEMG in cervical muscles in the study population, after postural exercise sessions, suggesting that the main purpose of the instrument would be the initial assessment of myofunctional and postural changes caused by mouth breathing, and not as a therapeutic biofeedback.

Therefore, the researchers recommend the publication of further longitudinal studies including the use of sEMG, in order to understand the electrical activity of various muscle groups a given time after the surgical and/or therapeutic intervention, in mouth breathers, that may assist professionals in the therapeutic planning.

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Publication Dates

  • Publication in this collection
    10 Jan 2020
  • Date of issue
    2020

History

  • Received
    22 Feb 2019
  • Accepted
    29 Oct 2019
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