Changes in Breathing Mode, Sensory Profile andMalocclusions in Infant Patients

Respiratory problems have been a major challenge toglobal public health due to its high incidence and opportunityto impact the quality of life of affected individuals. Rising Earthsurface temperatures, which often increase air pollution, bringthe possibility of reduced lung function and the aggravation ofbreathing disorders. In addition, climate change leads to increasedproduction of airborne allergens with increased asthmatic episodes,particularly among children and adolescents [1,2]. Regardingthe influence of breathing on craniofacial morphology, thereare several publications in the literature that have highlighted arelationship between nasal breathing mode and the normal patternof craniofacial growth and development of teeth and occlusion. Theresearchers pointed out that, in the opposite condition, probableimpairments would also occur in the body posture and in thesensory and cognitive performance of patients with mouth or oralbreathing [3-5].

Children chronically breathing through the mouth maydevelop speech disorders, inadequate body posture, changes in therespiratory system, deformities of the face, and poor positioning ofthe teeth, leading to structural changes in the face, including lips,tongue, palate, and jaw, which will adapt to new breathing pattern.With this there is a buccolingual imbalance and consequently in thefacial muscles, generating an important functional deficiency [6].Despite evidence in the literature about the possible associationbetween breathing mode and malocclusions, there is no furtherinformation on the frequency of respiratory problems amongchildren attending dental school clinics, as well as the impact thiscondition in the oral processing of the individual concerned. The objective of the present study covers this investigation, highlightingwhether there is a relationship between what is reported duringthe anamnesis, by those responsible, and what is found functionally.

Cross-sectional study with descriptive and inferential dataanalysis. The study area included the Pediatric Outpatient Clinic ofthe University Hospital, Federal University of Pernambuco (UFPE)in Recife, the dental school-clinic of the same Higher EducationInstitution, the universe comprised all children assisted at thedental school clinic, in the first semester of 2019. As inclusioncriteria, the sample included children from six to nine yearsold, with the history or record of some type of respiratory modealteration in the anamnesis and in the mixed dentition phase,whose records included evaluations of Speech Therapy, Dentistryand Occupational Therapy. There was the exclusion of children,under speech therapy, otorhinolaryngology therapy or with the useof functional orthodontic or orthopedic appliances of the jaws. Also,those that presented some organic or neurological condition thatmade the communication or the functional assessment tests of therespiratory mode unfeasible.

The following study variables were age, gender, maternallevel of education, presence and type of respiratory disorder,sleep problems, diagnosis of oral breathing, sensory profile,presence and classification of malocclusion. The assessment of thebreathing mode was performed by otorhinolaryngology and speechpathology professionals, adopting the Protocol of Identificationof Signs and Symptoms of Oral Breathing (PISSRO), according tothe supplementary material, prepared by the PathophysiologyResearch Group of the Stomatognathic System - GPPSE / UFPE, withinformation on breathing mode (with related signs and symptomsand nosologically diagnosis).

In the protocol cited above, the percentage distribution forfunctional diagnosis adds up to a total of responses and observations:less than 40% - no changes in breathing mode; 41% to 60%-mildoral breathing mode; from 61% to 80%-moderate breathing; above80%-severe oral breathing. For the analysis of sensory processing,performed by an occupational therapist, the Sensory Profile Test 2was used. This instrument captures information regarding sensoryprocessing (auditory, visual, vestibular, tactile, multisensory andoral sensory), sensory modulation (tolerance and tone, relatedto body position and movement, movement modulation affectingalert level, sensory modulation affecting emotional responses,modulation of visual stimulus affecting emotional response andactivity level) and emotional and behavioral responses (behavioraland emotional responses, behavioral results of sensory processing,items indicating response thresholds). The data from this analysisincluded the participation of mothers in the responses.

The record of the presence and types of sleep and respiratoryalterations, as well as the presence and type of malocclusion existedfrom the data in each patient’s chart, establishing a new intraoralphysical examination of these patients for occlusal evaluation [7].This research respected the universal principles of bioethics andhuman rights. It was previously approved by the UFPE EthicsCommittee. For data analysis, the Statistical Package for SocialSciences Software (SPSS - version 18) and Excel 2010 were used. Theresults are presented in table form, with their respective absoluteand relative frequencies. To verify the existence of an associationbetween oral breathing and the presence of malocclusion, Fisher’sExact Test was adopted. The 95% confidence interval was adoptedand only p values <0.05 were considered statistically significant.

There was a survey of 208 medical records referring to childpatients from six to nine years old, in attendance in the first halfof 2019, for the dental school clinic in question. These includedrespiratory changes for 33 children, according to the inclusion andexclusion criteria; 17 were male (51.5%) and had a mean age of 8 (±1.39) years. The average age of the mothers was 34 (± 8.92) yearsand complete high school education (75.8%).

Respiratory abnormalities were allergic in 14 children(42.4% with allergic rhinitis) and asthma in 12 (36.4%). Amongthe 33 patients in whom the type of respiratory disorder wasdiscriminated, two (6.1% reported asthma and allergy). For sevenchildren (21.2%) there was no specific cause. Regarding theclassification of the child’s breathing mode as oral breathing, sevenwere in this perspective (21.2%). Six children had sleep problems(18.2%) and 12 (36.4%) had malocclusions. There was no record ofsensory processing disorder.

The distribution of malocclusions was as follows, consideringthe Angle classification: five Class I, three Class II division 1 andone Class III. For the remaining four the type was not specified.Considering the registration of the other malocclusions: from theunilateral posterior crossbite records, two for the anterior open biteand two for the anterior crossbite. There was a record for bilateralposterior crossbite. Five children did not find the classificationof malocclusion. Comparing the data obtained from the medicalrecords with the respiratory mode assessments and the intraoralphysical examinations of the patients, there were statisticallysignificant differences p<0.05 in relation to the patients with oralbreathing (all patients registered with respiratory alterations hadthis type of mode, either in the functional evaluation or in theevaluation made by the otolaryngologist).

Concerning the presence of malocclusions; these were found in27 (81.8%) of the children assisted at the dental school in questionafter the intraoral physical examination, especially for Class I,Class II division 1, Class II, division II malocclusions and Class III.Also, for other types of malocclusions such as anterior open biteand unilateral posterior crossbite (Table 1). Although not includedin the table, eight (24.4%) of the evaluated children had primarycrowding in the region of the lower permanent incisors. Therewas a significant difference between medical records and datafrom intraoral physical examination (p <0.05). Among the childrenevaluated, 16 (48.5%) had sleep problems (Table 1).

Table 1: Distribution of malocclusions evaluated after intraoral physicalexamination of children assisted at a dental clinic.

Table 2 presents the distribution of children according to thepresence and type of sensory alteration. According to their analysis,32 (97%) of the children with RO had some kind of alteration inthe sensory profile, the most frequent being oral sensitivity andchanges in the child’s auditory processing and movement. Whencomparing patients’ oral sensitivity to other sensory changes,there was a significant association between exploration, sensitivity,observation, socio-emotional and attention (Table 2).

Table 2: Distribution of malocclusions evaluated after intraoral physicalexamination of children assisted at a dental clinic.

One of the biggest challenges of the present study was thegathering of information in the dental records of the consideredclinical school, due to information gaps. Clinical and functionalexaminations took place in only 33 assisted children. However,considering the differences observed between the recorded dataand the clinical and functional exams, possibly changes in breathingmode may compromise a higher percentage of assisted children.

Dentistry students recognize the importance of completing thecomplete medical record8. However, during this research, someflaws in this sense were observed; especially after a new clinicaland functional evaluation.

The dental record is a very important document for recordingdata of variables that guide the diagnosis and treatment plan. It hasadministrative, ethical, legal and legal aspects. Higher EducationInstitutions have a primary role in raising awareness of the needfor complete and well-prepared dental documentation, withreinforcement in the training of future professionals [8].

Most orthodontists and functional orthopedists of the jawsform the diagnosis of breathing in the anamnesis phase, when oneobserves and/or questions about the harmful habits associated witha possibly altered breathing mode [9]. The early observation of thecharacteristics of the oral breathing mode performed by the dentistallows a diagnosis of sensory system disorders and malocclusionsand also signals about possible behaviors or attitudes of the childwhen in the dental environment, which, it is usually full of stimulifor the human senses. The considered ideal breathing patterncan be replaced by the oral one, this functional adaptation canoccur for organic and nonorganic causes (considered vicious). Inorganic breathing, there is nasal cavity obstruction due to chronicinflammation of the nasal mucosa, deviated septum, pharyngealand / or palatine tonsil hypertrophy, polyps, tumors and others.Allergic rhinitis and increased adenoids and decreased or absentbreastfeeding are still considered [3,10,11].

Among the studies consulted in the literature, most authorsagree that the most common implications of RO are changes inthe craniofacial and dental systems, the phono articulatory, body,behavioral and oral functions. [2-4,11]. However, it was alsomentioned that the methods to verify this relationship are notyet satisfactory. The lack of sample representativeness, followupover time and protocols validated for this purpose representa challenge to be overcome [12,13]. In the present study, it wasfound that almost all children with oral breathing had somekind of sensory processing disorder, which can have a number ofimplications for the development of the individual, particularly inthis very unique phase. The presence of frequent tiredness, daytimesleepiness, prostration, nocturnal enuresis, reduced appetite,nutritional alterations, poor cerebral oxygenation, learning deficitand impairments in some sensory systems, such as olfactory, tasteand hearing, may cause speech and developmental difficulties. arelisted during the literature reviews on changes in breathing mode[10,12,14].

These changes in the Stomatognathic System (SS) and sensoryintegration could occur due to the organism adapting to the changesoccurred by the new non-physiological breathing format, whetherassociated with organic, functional or neurological variables[7,10,14]. The oral breather patient does not respond correctly toexternal stimuli, with diminished or increased responses. Sensoryprocessing plays an important role for the executive functions ofthe individual. Sensory integration is the neurological processthat organizes the sensations of one’s own body and environment;modulates the information received by the senses (taste, smell, sight, hearing, touch, movement, gravity and body position). Whenthere is a disorder in this processing, it begins to generate analtered, diminished, or increased response to any stimulus, with amajor impact on the performance of executive functions (skills thatcontrol our thoughts, emotions, and actions), on the performanceof everyday activities, consequently on the quality of life [10,14].

Among the types of alterations found in oral breathing children,in the current study, there was a higher frequency of changes in theprocessing of oral sensitivity, auditory perception and movementare closely related to the child’s behavior and the conduct of thedentist, during the dental appointment. The response of oralbreather in manipulating the face, specifically its oral cavity, willdepend on how the dental surgeon will approach the individual inorder to familiarize him not only with the environment but also withthe treatment itself and together with other professional, giving thenecessary support and seeking understanding of the whole contextin which the oral breather is inserted, from a morpho functionalproblem to the psychosocial impact on the life of this individual.The most frequent orofacial and postural characteristics in the oralbreather include: elongated face, narrow nostrils, inadequate lipseal, lack of facial muscle tone, slanted or slanted eyes, dark circles,shoulder closure, spinal imbalance, small nose, hypotonic lips , dry,everted, narrow and deep palate, open mouth, atresic upper arch,Class II, malocclusions (facial asymmetry, open bite and posteriorcross) and alterations in swallowing, suction and phonation[2,3,11-15].

Changes in sleep and malocclusions were considered here,and according to the data obtained for the latter, about one thirdof the children assisted had Angle Class II, anterior open bite andunilateral posterior crossbite. This result is similar to that of thestudy consulted for Angle Class II division 1; but without significantassociation with breathing mode or facial type [16]. Subsequentintervention with functional orthodontic and orthopedic featuresof the jaws was performed to treat installed malocclusions. Theneed for prevention and early (interceptive) treatment of oralbreathing is reinforced to avoid the development of malocclusionsor increased complexity, with the worsening of the conditions thatare present from the perspective of a multidisciplinary approach[17]. This research emphasizes the importance of the integratedperformance of Dentistry, with professionals of Speech Therapy,Occupational Medicine and Therapy, besides the approach ofPsychology, in the search for comprehensive and humanizedassistance to children with RO, reducing negative repercussions,not only in the orofacial complex, but in the approach to the globaldevelopment of these individuals.

There was a small record of respiratory changes in therecords of children assisted by dentistry; however, most of thesehad malocclusions and disorders in sensory processing withimplications for oral sensitivity.

Of the twelve domains evaluated for the relationship betweensensory alterations and oral processing, the exploration, sensitivity,observation, socio-emotional and attention domains present amore significant association with patients who have oral breathing,suggesting a relationship between oral breathing and sensoryprocessing disorders of these individuals.

None.

No conflicts of interest.

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