Mouth breathing habit pathophysiology and treament.pptx

MOUTH BREATHING
Dr Nikhil Shrivastava
Junior Resident
Dept of Pediatric & Preventive Dentisrty

INTRODUCTION
• A mouth breather is every individual who breaths through the mouth as a result of a
pathological adaptation, whether in the presence of nasal and/or pharyngeal obstruction.
• Mouth breathing is the concern of all who deal with the health of the child— the
rhinologist, the pediatrician, the orthodontist and the pedodontist
Morais-Almeida M, Wandalsen GF, Solé D. Growth and mouth breathers. Jornal de pediatria. 2019;95:S66-71.

• The primary function of the nose is to bring the inhaled air to the lungs under ideal conditions
for hematosis, i.e., heated, humidified, and free of microorganisms and pollutants present in
room air.
• In oral respiration the air enters the larynx at a temperature somewhat lower than is given it by
a passage through the nasal chambers; this cold air excites inflammatory action, producing
soreness, cough, hoarseness and other symptoms of pharyngeal, laryngeal, and bronchial
irritation.
Gordon N. Mouth breathing and its treatment. Journal of the American Medical Association. 1887 Apr 23;8(17):458-9.

• Owing to the dryness of the atmosphere in our dwellings, the mucus membrane of the
mouth and throat, in its efforts to furnish the required additional moisture, becomes
very dry and parched.
• In children, nasal breathing is more important than in adults. At birth, nasal breathing
is a mandatory condition due to the high position of the larynx in comparison with the
oral cavity, which allows the newborn to be breastfed and breathe.
Gordon N. Mouth breathing and its treatment. Journal of the American Medical Association. 1887 Apr 23;8(17):458-9.

Anatomical differences between adult and pediatric upper airways
Due to the higher location of the larynx, the tip of the epiglottis almost reaches the soft palate: this anatomical
conformation allows the infant to breathe and suckle simultaneously without aspirating
Di Cicco M, Kantar A, Masini B, Nuzzi G, Ragazzo V, Peroni D. Structural and functional development in airways throughout
childhood: Children are not small adults. Pediatric Pulmonology. 2021 Jan;56(1):240-51.

• The high location of the epiglottis, in this case, makes it difficult for air to enter the
lower airways when the flow comes from the mouth, causing an intense respiratory
discomfort in the presence of bilateral nasal obstruction.
Morais-Almeida M, Wandalsen GF, Solé D. Growth and mouth breathers. Jornal de pediatria. 2019;95:S66-71.

The most frequent are –
• hypertrophy of pharyngeal (adenoids) and/or palatine tonsils (amygdala) and
• untreated (and, therefore, uncontrolled) allergic rhinitis.
• unilateral or bilateral choanal atresia,
• anatomical variations of the nasal conchae,
• nasal foreign body, septal deformities or nasal masses, and
• even rarer entities that can cause nasal congestion such as as cystic fibrosis, primary
ciliary dyskinesia.
Morais-Almeida M, Wandalsen GF, Solé D. Growth and mouth breathers. Jornal de pediatria.
2019;95:S66-71

Vig KW. Nasal obstruction and facial growth: the strength of evidence for clinical assumptions. American journal
of orthodontics and dentofacial orthopedics. 1998 Jun 1;113(6):603-11.
Hypertrophied adenoids in 10-year-old
child who was a “mouth breather.” She
demonstrated none of the characteristic
features of the “adenoidal facies.

Both of these images indicate that the patient has a
deviated nasal septum and an enlarged left inferior turbinate.
Images of a patient with chronic oral breathing.
Preston B. Upper airway and cranial morphology. Graber T.M Orthodontics Current principles and techniques.5th
edition; 2011. Elsevier

Neskey D, Eloy JA, Casiano RR. Nasal, septal, and turbinate anatomy and
embryology. Otolaryngologic Clinics of North America. 2009 Apr
1;42(2):193-205.
Bilateral hypertrophy of the soft tissue component of
the inferior turbinate (Chronic rhinitis)
Axial CT-
Bilateral choanal
atresia (arrows).

The characteristic openbite, increase in anterior lower face height, retrogenia and associated decreased posterior face
height, and sagittal mandibular deficiency. Both nasal and postlingual airways are compromised, and the patient had
a tracheotomy.
Lateral cephalogram of child with
posterior choanal atresia associated
with Treacher Collins syndrome
Vig KW. Nasal obstruction and facial growth: the strength of evidence for clinical assumptions. American journal

CLASSIFICATION
Sim and Finn (1987) classified mouth breathers into the following three categories according
to the etiology as-
• Obstructive
• Habitual
• Anatomic

HABITUAL OR OBSTRUCTIVE
A habitual mouth breather often is unaware of his habit and may deny it if he is challenged
directly. Habitual mouth breathing often is performed only at night (nocturnal mouth
breathing) when the patient is unaware of it.
Obstructive mouth breathing rarely is denied; in fact, it is usually the patient’s primary
complaint
Massler M, Zwemer JD. Mouth breathing. II. Diagnosis and treatment. The Journal of the American
Dental Association. 1953 Jun 1;46(6):658-71

• It is important to determine the type and character of the mouth breathing, since such
information will greatly influence the treatment.
• Thus, mouth breathing on an obstructive basis should be treated by the rhinologist;
whereas, habitual mouth breathing is best corrected by the pedodontist or orthodontist
incidental to the treatment of the oral effects

• The typical features that are considered characteristic of persons who have difficulty
breathing through their nose and therefore may be diagnosed as having nasal
obstruction, is exemplified by the long-face syndrome.
• The pediatrician often refers this as adenoid facies. The prototype of this condition is
considered to include an increase in lower facial height, lip apart posture, narrow alar
base, and frequently self reported “mouthbreathing.”
• Cases with chronic mouth breathing have been associated with narrow Vshaped upper
jaws, high palatal vaults, proclined Upper incisors and Class II occlusal relationships.
Vig KW. Nasal obstruction and facial growth: the strength of evidence for clinical assumptions. American journal of
orthodontics and dentofacial orthopedics. 1998 Jun 1;113(6):603-11

Typical features –
Vig KW. Nasal obstruction and facial growth: the strength of evidence for clinical
assumptions. American journal of orthodontics and dentofacial orthopedics. 1998
Jun 1;113(6):603-11
A 16 year-old boy with an
increase in lower face height, lip
apart posture, and narrow alar
base.
Anterior open bite, bilateral
posterior crossbite associated
with transverse maxillary
deficiency

EFFECT ON DENTITION AND
CRANIOFACIAL MORPHOLOGY

• Forty two animals, of which four were females, ranged in age from 2 to 6 years.
• At the onset, metal bone markers were placed in the jaws and skull as previously described.
• The nasal airway was blocked in the experimental animals. The control animals were not subjected to
any special procedures except record taking.

• Soft, hollow, cone-shaped silicon plugs, approximately 1 cm. long and cast to fit the
individual nares, were used. The plugs were held in position by a silk ligature through
the septum. The plugs obstructed inspiration but allowed some air to escape during
expiration.
• Records were taken at 3-month intervals during the experiment and every 6 months
after the nose was reopened.

Normal postural positions of lips.
Three years of oral respiration caused a notch
in the upper lip and an open mouth.
All mouth breathers showed a tendency to develop a
notch in the upper lip.

Tongue became thinner, usually creating an open passage to the pharynx
Became long and narrow

Conclusions –
• The primates in these experiments developed an oral airway in response to nasal
obstruction. The response was not uniform among the animals.
• However, some traits were common: increased face height, steeper mandibular plane, and
larger gonial angle. Various animals recruit different muscle combinations for rhythmic
movements or for changing position of the lips, tongue, and mandible.
• The morphologic changes in the orofacial region, facial skeleton, and dental occlusion did
vary accordingly.

• It is unlikely that a correlation can be established between oral respiration and a
particular type of dental malocclusion.
• On the other hand, it can be postulated that increased tonic activity in certain muscles
and a specific change in jaw positioning may cause corresponding bone remodeling,
which should be predictable.

Linder Aronson carried out comprehensive clinical study of effects of
removal of nasal obstructions.
• He followed 41 children who had undergone adenoidectomies for a
period of 5 years postoperatively.
• 34 children who had switched post operatively from oral breathing to
nasal breathing were compared to 54 normal children.
British Journal of Orthodontics; Vol 6/1979/59-71 Printed in Great Britain©

• The mean age for the operated children was initially 7·5 years and for the control children 7·9 years.
• The significant group mean differences found initially between dentitions and facial skeletons of
operated and control children showed marked change over postoperative years.
• Greatest change occurred in the dentition and in sagittal depth of the nasopharynx during 1st
postoperative year.
• It was noted at beginning that mouth breathers had more retroclined upper and lower incisors than did
the nose breathers.
Linder-Aronson S. Effects of adenoidectomy on the dentition and facial skeleton over a period of five years. InTransactions
of the third international orthodontic congress 1975 (pp. 85-100). The CV Mosby Company St. Louis.

• The greatest change for the children who altered their mode of breathing following
adenoidectomy was seen during the first year postoperatively.
• During the subsequent 4 years no significant difference could be found between the
adenoidectomy and control children
• As a result of adenoidectomy an increase in the nasal airflow and a change from mouth
to nose breathing occurs. This allows the tongue position to. be raised, the lips are held
together and the arch Width increases.

• The classic work of Harvold was based on total obstruction of the nasal airway in
monkeys; this resulted in a cause and effect relationship.
• However, human studies have indicated that total nasal obstruction is rare, and the most
common respiratory mode is a simultaneous oral and nasal airflow
Vig KW. Nasal obstruction and facial growth: the strength of evidence for clinical assumptions.
American journal of orthodontics and dentofacial orthopedics. 1998 Jun 1;113(6):603-11

Factors contributing to the alteration in the posture of the mandible

DIAGNOSIS
History – from family/parents ● Clinical features: as above ● Assessment of mode of respiration

The open-mouth habit should not be confused with actual mouth
breathing.
An open-mouth habit does not necessarily prove mouth breathing.
Many children habitually keep their lips apart, especially those with a
characteristic familial short upper lip.
Most of these children breathe normally through their nose. On the other
hand, a closed mouth at the time of inspection does not exclude the
"possibility of intermittent mouth breathing, particularly during sleep.
Clarice S. Law, ... Samuel J. Christensen, in Pediatric Dentistry (Sixth Edition), 2019

• If the lip is anatomically short, there usually is no loss of lip tonus and there is not
necessarily any protrusion of the upper incisors. The lip merely is short— probably a
familial trait.
• A short upper lip may be anatomically normal but appear to be short because of
protruded incisors. Orthodontic correction and proper muscle exercises quickly restore
the normal appearance of the lip.

TESTING
• The ordinary involuntary type of breathing which is quiet and rather
shallow should be distinguished from the voluntary, forceful breathing
which the child performs on demand.
• This should be done on a relaxed patient who is uninformed of the
purpose of the test, whose eyes are closed and whose respirations are of
the normal, shallow type
• The test for the excursion of air is performed with a thin, long strip of
tissue paper about 3/8 by 1.5 inches. (A thin wisp of cotton, or a chilled
mirror also may be used.)

• .
If mouth breathing is
demonstrable during quiet
respiration, the dentist must test
further in order to determine
whether this is on an
obstructive basis or is habitual
The child is now instructed to “
Breathe through your nose
If the child is unable to breathe
through his nose, or can do so
only with difficulty, it is
presumptive evidence of nasal
obstruction and the child
should be referred to the
rhinologist

• Water holding test – Patient is asked to hold water in his mouth. Inability to keep the mouth
closed for more than 2 minutes confirms nasal obstructions and therefore mouth breathing
habit.
• Mirror condensation test. A two-surface mirror is placed under the nose. If the upper
surface condenses, then breathing is through the nose, but if the condensation occurs on the
lower surface then the breathing is through the mouth.
• Cotton wisp test. A small wisp of cotton (butterfly shaped) is placed below the nostrils in a
butterfly shape. If the upper fibres are displaced then the breathing is through the nose. If the
lower fibres are displaced then it is mouth breathing habit.
Kharbanda O.P .Orthodontics: Diagnosis and Management of Malocclusion and Dentofacial
Deformities. 3rd ed, 2019 Elsevier India;

• The aim of this paper is to propose and test guidelines for
clinical recognition of MB and some predisposing factors
for SDB in children.
• Semi-structured interviews were conducted with 110
orthodontists regarding their procedures for clinical
evaluation of MB and their knowledge about SDB
during childhood.

• Thereafter, based on their answers,
guidelines were developed and tested in 687
children aged between 6 and 12 years old
and attending elementary schools.
• Results: There was no standardization for
clinical recognition of MB among
orthodontists.
• The most common procedures performed
were inefficient to recognize differences
between MB by habit or obstruction.

Marking the steam halo on the graded mirror test.

Conclusion –
To achieve clinical recognition of mouth breathing (MB), it is important to integrate results yielded by visual assessment,
questions, and at least two types of breathing tests. It is essential to ask questions that help identify predisposing factors for sleep-
disordered breathing in children.
The guidelines proposed herein facilitate clinical recognition of MB, help clinicians to differentiate between habit and obstruction,
suggest the most appropriate treatment for each case, and avoid maintenance of mouth breathing patterns during adulthood.

Posterior nasal airway region with adenoidal encroachment in the Shulhof “airway space.
The McNamara linear measurement of the minimum distance from soft palate to adenoidal shadow on lateral
ceph.
Cephalometric findings-
Vig KW. Nasal obstruction and facial growth: the strength of evidence for clinical assumptions. American journal of
orthodontics and dentofacial orthopedics. 1998 Jun 1;113(6):603-11

Morais-Almeida M, Wandalsen GF, Solé D. Growth and mouth breathers. Jornal de pediatria. 2019;95:S66-71
At cephalometric evaluation, an increased Y-axis
is observed

• Objective – To elucidate, through a systematic review and meta-analysis, the changes in facial skeletal
development and malocclusion in mouthbreathing children.
• Method – An electronic search in PubMed, the Cochrane Library, Medline, Web of Science, EMBASE and
Sigle through February 23rd, 2020, was conducted.

Inclusion Criteria:
(1) Population: children under the age of 18 with mouth breathing habits;
(2) Exposure: mouth breathing due to several causes, including but not limited to tonsil and
adenoid hypertrophy, polyps, allergies, recurrent infections and nasal deformities ;
(3) Control: patients without mouth breathing;
(4) Outcome: defects in development in facial bone or dental, which can be embodied in the
cephalometric indicators, overbite, and overjet; and
(5) Study design: Clinical controlled trials, randomized controlled trials, and cohort studies.

Quality assessment:
The risk of bias in nonrandomized studies of interventions (ROBINS-I) tool was used for
controlled clinical trials (CCTs). The Grading of Recommendation, Assessment,
Development and Evaluation (GRADE) approach was used to evaluate the quality of
evidence in four domains: strong, moderate, low, and very low

Results – A total of 1358 subjects; 643 children with mouth breathing were included
experimental group and 715 children with normal nasal breathing were included in the
control group.
• Four articles had low risk and six articles had medium risk
• 10 studies were included in the final quantitative synthesis.

Primary outcome measures –
• Sagittal direction
• Vertical direction
• Airway
• Airway data of children in the mouth breathing group were lower than those in the control group. SPAS, PAS ,
C3-H were statistically significant.
• The following indexes were higher in
mouth-breathing individuals than in
nasal-breathing individuals: SN-PP,
SN-OP, SN-GoGn
• Parameters showed higher values in
children with mouth breathing: ANB,
1-NA, 1-NB

Conclusion:
• It showed that the mandible and maxilla rotated backward and downward, and the
occlusal plane was steep in mouth breathing children.
• In addition, mouth breathing presented a tendency of labial inclination of the upper
anterior teeth.
• Airway stenosis was common in mouth-breathing children.

• It is generally stated in periodontal literature and confirmed by clinical observation
that mouth breathing constitutes an aggravating factor in the development of marginal
gingivitis, especially in upper anterior region.
• Some authors suggest intermittent drying of gingiva produces either a lowered
resistance to bacterial irritation or inflammatory reaction caused directly by the drying
process itself. (Warwics and Hastings 1933, Austr Dent J)
Effect on gingival health

• It is also claimed that loss of continuous salivary flow over the marginal tissues and the
teeth in mouth breathers would reduce the salivary cleansing of this area. This might
cause either an increased plaque accumulation or altered plaque composition with
stronger pathogenic potential. (Warwics and Hastings 1933, Austr Dent J)
• Fifty five 6-12 yr old children compared with forty healthy children of same age to
establish a corelation of mouth breathing and gingival inflammation. Mouth breathers
found to have higher GI scores. The most significant difference was found in maxillary
anterior region. No statistical difference in Plaque scores existed between two groups.
Jacobson L. Mouthbreathing and gingivitis: 1. Gingival conditions in children iowith epipharyngeal adenoids.
Journal of periodontal research. 1973 Oct;8(5):269-77.

MANAGEMENT
• Treatment should be preceded by an appraisal of the total child by a pediatrician.
• Expert rhinologic examination of the nasopharyngeal airway always should be made before
any form of treatment is instituted.
• Actual treatment can be divided into three parts:
.
 Removal of nasal or pharyngeal obstructions by the rhinologist,
 Interception of the habit by the pedodontist and
 Correction of the dental effects by the orthodontist and pedodontist

SELF CORRECTION OF MOUTH BREATHING
• In many instances, the mouth breathing habit is self-corrected after puberty.
• A number of factors contribute to the self-correction of mouth breathing after adolescence,
even if the condition is not treated.
• First, the hypertrophied pharyngeal and palatine lymphoid masses (tonsils and adenoids)
atrophy rapidly after puberty.
• The nasal and pharyngeal passages increase in size during the period of rapid growth of
the child in adolescence.
Massler M, Zwemer JD. Mouth breathing. II. Diagnosis and treatment. The Journal of the
American Dental Association. 1953 Jun 1;46(6):658-71

• Finally, the oral sphincter becomes less flaccid and
more mature and tonic as the child grows up.
• Self consciousness, particularly in the girl,
encourages the adolescent to lift the lower lip
habitually over the protruding upper incisors in
order to hide the teeth and to close her lips.
Massler M, Zwemer JD. Mouth breathing. II. Diagnosis and treatment. The
Journal of the American Dental Association. 1953 Jun 1;46(6):658-71.

R E M O V A L O F N A S A L OR P H A R Y N G E A L
O B S T R U C T IO N S
Insure adequate nasal function by removing all obstructions. It is always wise to consult the
rhinologist prior to any dental treatment, since he is most competent in direct examination
of the nasopharyngeal passages.
Only after the rhinologist has removed all pharyngeal obstructions and has insured a patent
nasal airway by means of vasoconstricting nose drops, may the dentist interfere with oral
breathing. The danger of anoxia by shutting off the oral passage must not be taken lightly
Dental Association. 1953 Jun 1;46(6):658-71.

IN T E R C E P T IO N O F T H E H A B IT
• Frequently, however, mouth breathing will persist during sleep even after the
obstruction has been removed, especially in persons with narrow airway.
• Removal of the lymphoid tissue and reduction of engorged turbinates is evidence
only that mouth breathing is not obstructive. It may still be habitual.

• First introduced by Newell et al in 1912.
• The oral screen is an easily constructed myofunctional appliance which has been used for the
correction of upper anterior protrusions resulting from prolonged mouth-breathing.
• Works on principle of both force application and force elimination. The source of the force is
the pressure of the labial musculature transmitted to the teeth.
• The appliance may be passive to prevent, mouth-breathing only, or it may be made active to
cause a retrusion of protruded upper incisors.
Toepfer AK, Massler M, Brown WB. Effectiveness of the oral screen in the treatment of upper incisor
protrusions. American Journal of Orthodontics. 1959 Oct 1;45(10):759-67.
Oral screen

Oral screen in place. Note pressure
areas on teeth in active screen and
peripheral pressure area in passive
screen
Massler M, Zwemer JD. Mouth breathing. II. Diagnosis and treatment. The Journal of the American Dental
Association. 1953 Jun 1;46(6):658-71.

• The exact adaptation of the oral screen to the cast depends entirely on the
purpose of the screen.
• The periphery of the baseplate is trimmed so that the edge reaches the
mucobuccal fold in the closed-mouth position.
• Under-extension of the periphery will allow it to slip out of the mouth
during sleep, especially in children with vigorous tongue-thrusting habits.
• A deep notch is cut for the upper and lower labial frena in the central
incisor and cuspid areas.
• The posterior border is carried to about the first molar area and all edges
are rounded

• Instructions to the Patient
The patient is instructed to wear the oral screen for three
successive nights.
He is advised that it undoubtedly will be uncomfortable the first
night and he should be told to come in for an immediate
adjustment if sore spots develop.
If there is no difficulty, the patient should return in three days for a
check-up and for minor adjustment of the appliance

Lip training with the oral screen.

Das U M, Beena J P. Effectiveness of circumoral muscle exercises in the developing dentofacial morphology in adenotonsillectomized
children: An ultrasonographic evaluation. J Indian Soc Pedod Prev Dent 2009;

The effectiveness of the oral screen in correcting protrusions of the maxillary anterior teeth was
evaluated in 146 cases.
• The percentage was considerably higher in cases with spacing of the incisors before
treatment than in those with no spacing.
• Almost all cases in which incisor alignment became worse after treatment were those in
which there was no spacing or even crowding of the upper incisors before treatment.
• Lack of spacing is therefore considered to be a contraindication
• The oral screen was also much more successful in cases with normal molar relations than in
those with Class II molar relations.
Toepfer AK, Massler M, Brown WB. Effectiveness of the oral screen in the treatment of upper incisor
protrusions. American Journal of Orthodontics. 1959 Oct 1;45(10):759-67.

Contraindications –
• The oral screen should never be used until the child has been tested for adequacy of
nasal function by the dentist or the rhinologist. Consultation with the latter is desirable
in all cases.
• The oral screen is not indicated at any age if for any reason it is not wanted by the child,
for the efficacy of this appliance rests largely on the acceptance by the patient as well as
on his active cooperation.

• RME was first described by Angell in 1860 and it is a well-established and widely
accepted procedure. One of the procedures mostly indicated for correction of posterior
crossbite is rapid maxillary expansion (RME).
• Although forces arising from RME are primarily directed to result in the opening of the
mid-palatal suture, adjacent facial sutures are also affected.
• Most studies have frequently demonstrated significant increase in the cross-sectional
dimensions of the nasal cavity, as well as volumetric increase and reduction in nasal
resistance.
Rapid Maxillary expansion

• Objective: To assess short-term tomographic changes in the upper airway dimensions and quality of life of
mouth breathers after rapid maxillary expansion (RME).
• Methods: A total of 25 mouth breathers with maxillary atresia and a mean age of 10.5 years old were
assessed by means of cone-beam computed tomography (CBCT) and a standardized quality of life
questionnaire answered by patients’ parents/legal guardians before and immediately after rapid maxillary
expansion.
Dental Press J Orthod. 2015 May-June;20(3)

• Inclusion criteria: Children should have presented maxillary atresia and posterior
crossbite, as revealed by clinical examination performed by a single experienced
orthodontist.
• Firstly, parents or legal guardians were requested to answer a standardized questionnaire
originally designed to measure the impact of adenotonsillectomy on the quality of life of
patients with sleep breathing disorders.
• Physical suffering, sleep disturbance, speech or swallowing problems, emotional distress,
activity limitation, and degree of parents/legal guardians’ concern about their own child’s
snoring.

• There was statistically significant increase in ANF, PNF and VNN after treatment. The
magnitude of VO, however, showed no statistically significant difference when compared to
the volume observed before RME.
• The questionnaire total score obtained after RME was statistically lower than that obtained
before RME.
CONCLUSION:
Short-term RME promotes significant increase in airway volume of the nasopharynx and nasal
cavities as well in anterior and posterior widths of the nasal floor. Additionally, it significantly
improves the quality of life of mouth-breathing patients with maxillary atresia.

• The purpose of this study was to assess how type of cleft affects nasal cross-sectional area and mode of
breathing.
• This study involved 60 children with cleft lip and/or palate. Their ages ranged from 6 to 15 years.
• A group of 95 normal children was analyzed for comparison.

• The data demonstrate that nasal size decreased among cleft types as follows: children
with bilateral cleft lip and palate had largest airway, followed by unilateral cleft lip, cleft
of the hard and soft palate, cleft of the soft palate, and unilateral cleft lip and palate.
•
• The data also indicated that most subjects with cleft were mouth breathers.
• Results of otolaryngologic examinations suggest that septal deformities affecting nasal
valve function are responsible for much of the impairment, especially in the group with
unilateral cleft lip and palate.

• Pediatric OSA is a disorder of breathing characterized by prolonged, partial upper airway obstruction
and or intermittent/ complete obstruction (obstructive apnea) that disrupts normal ventilation during
sleep and normal sleep patterns.
• Symptoms of OSA include: • excessive daytime sleepiness. • loud snoring three or more nights per
week. • episodes of breathing cessation witnessed by another person. • abrupt awakenings accompanied
by shortness of breath. • awakening with dry mouth or sore throat. • morning headache. • difficulty
staying asleep. • attention problems. • mouth breathing. • sweating. • restlessness. • waking up a lot

• Patients with certain anatomic anomalies, craniofacial anomalies, neuromuscular diseases, or
Down syndrome are at increased risk for development of obstructive sleep apnea.
• Anatomic anomalies may include hypertrophic tonsils and adenoids, choanal atresia, respiratory
tissue thickening (e.g., caused by disease such as polysaccharidosis, achondroplasia), or obesity.
• Midface deficiency, with or without micrognathia, may predispose some children with craniofacial
abnormalities to development of OSA.

• Pediatric dentists are in a unique position to be able to identify patients at greatest risk.
Adenotonsillar hypertrophy and obesity are major risk factors for OSA in otherwise
healthy children.
• Assessment of tonsillar hypertrophy and percentage of airway obstruction by the
Friedman Tongue Classification system may be done as part of the routine intraoral
examination

• Oral appliances commonly used for treatment of sleep-related breathing: mandibular
advancing devices, tongue retaining devices, and rapid maxillary expansion
• It is advised that the dentist work with the physician to determine if adjunctive
options (e.g., RPE, orthodontic treatment) are advised as part of a multidisciplinary
treatment effort
• Pediatric dentists who perform sedation and surgical procedures in patients with
OSA should be aware that these patients are more likely to experience perioperative
and postoperative breathing complications.

AAPD encourages health care professionals to:
Screen patients for snoring and sleep-related breathing disorders.
• assess the tonsillar pillar area for hypertrophy.
• assess tongue positioning as it may contribute to obstruction.
• recognize obesity may contribute to OSA.
• refer to an appropriate medical provider (e.g., otolaryngologist, sleep medicine physician,
pulmonologist) for diagnosis and treatment of any patient suspected of having OSA.
• consider non-surgical intraoral appliances only after a complete orthodontic/craniofacial
assessment of the patient’s growth and development as part of a multi-disciplinary approach

REFERENCES
• Vig KW. Nasal obstruction and facial growth: the strength of evidence for clinical assumptions. American journal
• MC NAMARA JR JA. Influence of respiratory pattern on craniofacial growth. The Angle Orthodontist. 1981
Oct;51(4):269-300.
• Massler M, Zwemer JD. Mouth breathing. II. Diagnosis and treatment. The Journal of the American Dental
Association. 1953 Jun 1;46(6):658-71.
• Harvold EP, Tomer BS, Vargervik K, Chierici G. Primate experiments on oral respiration. American journal of
orthodontics. 1981 Apr 1;79(4):359-7.
• Morais-Almeida M, Wandalsen GF, Solé D. Growth and mouth breathers. Jornal de pediatria. 2019;95:S66-71.
• Toepfer AK, Massler M, Brown WB. Effectiveness of the oral screen in the treatment of upper incisor protrusions. American
Journal of Orthodontics. 1959 Oct 1;45(10):759-67
• GORDON N. MOUTH BREATHING AND ITS TREATMENT. Journal of the American Medical Association. 1887
Apr 23;8(17):458-9.

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