Authored by Luciana BC Fontes*
Abstract
Objective: To verify the frequency of respiratory mode changes among children assisted at a dental school, as well as the impact of this condition on the oral processing of the individual in question, comparing data recorded in medical records and those obtained in clinical and functional examination.
Method: Cross-sectional study with descriptive and inferential treatment of data, developed with children undergoing dental treatment at the Federal University of Pernambuco, Recife, northeast of Brazil and their mothers, during the first semester of 2019. These are in the age group of six to nine years. and in the mixed dentition phase, according to the defined inclusion and exclusion criteria. The project was approved by the UFPE Ethics Committee. For the statistical analysis a margin of error of 5% and the Fisher’s exact teste were adopted. Medical records and clinical and functional evaluations were considered regarding breathing mode, sensory profile and malocclusions.
Results: For a universe of 208 medical records, 33 (15.9%) had the record of respiratory alterations, with allergic rhinitis and asthma being the registered conditions. Among the children with respiratory alterations, 21.2% had mouth breathing, 18.2% had sleep alterations and 36.4% had malocclusions, with no reports of changes in sensory processing. After clinical examination and functional evaluation for the 33 children with respiratory disorders, 48.5% had sleep disorders, 97.0% had some sensory processing disorder and 81.8% had malocclusions, with significant differences between the records and the data obtained after the evaluations. The most frequent malocclusions were Angle Class I, open bite and unilateral crossbite.
Conclusion: There was a small record of respiratory changes in the records of children assisted by dentistry; however, most of these had malocclusions and disorders in sensory processing with implications for oral sensitivity.
Keywords: Malocclusion; Mouth breathing; Children; Sensation
Introduction
Respiratory problems have been a major challenge to global public health due to its high incidence and opportunity to impact the quality of life of affected individuals. Rising Earth surface temperatures, which often increase air pollution, bring the possibility of reduced lung function and the aggravation of breathing disorders. In addition, climate change leads to increased production of airborne allergens with increased asthmatic episodes, particularly among children and adolescents [1,2]. Regarding the influence of breathing on craniofacial morphology, there are several publications in the literature that have highlighted a relationship between nasal breathing mode and the normal pattern of craniofacial growth and development of teeth and occlusion. The researchers pointed out that, in the opposite condition, probable impairments would also occur in the body posture and in the sensory and cognitive performance of patients with mouth or oral breathing [3-5].
Children chronically breathing through the mouth may develop speech disorders, inadequate body posture, changes in the respiratory system, deformities of the face, and poor positioning of the 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 the facial muscles, generating an important functional deficiency [6]. Despite evidence in the literature about the possible association between breathing mode and malocclusions, there is no further information on the frequency of respiratory problems among children attending dental school clinics, as well as the impact this condition in the oral processing of the individual concerned. The objective of the present study covers this investigation, highlighting whether there is a relationship between what is reported during the anamnesis, by those responsible, and what is found functionally.
Material and Methods
Cross-sectional study with descriptive and inferential data analysis. The study area included the Pediatric Outpatient Clinic of the University Hospital, Federal University of Pernambuco (UFPE) in Recife, the dental school-clinic of the same Higher Education Institution, the universe comprised all children assisted at the dental school clinic, in the first semester of 2019. As inclusion criteria, the sample included children from six to nine years old, with the history or record of some type of respiratory mode alteration in the anamnesis and in the mixed dentition phase, whose records included evaluations of Speech Therapy, Dentistry and Occupational Therapy. There was the exclusion of children, under speech therapy, otorhinolaryngology therapy or with the use of functional orthodontic or orthopedic appliances of the jaws. Also, those that presented some organic or neurological condition that made the communication or the functional assessment tests of the respiratory mode unfeasible.
The following study variables were age, gender, maternal level of education, presence and type of respiratory disorder, sleep problems, diagnosis of oral breathing, sensory profile, presence and classification of malocclusion. The assessment of the breathing mode was performed by otorhinolaryngology and speech pathology professionals, adopting the Protocol of Identification of Signs and Symptoms of Oral Breathing (PISSRO), according to the supplementary material, prepared by the Pathophysiology Research Group of the Stomatognathic System - GPPSE / UFPE, with information on breathing mode (with related signs and symptoms and nosologically diagnosis).
In the protocol cited above, the percentage distribution for functional diagnosis adds up to a total of responses and observations: less than 40% - no changes in breathing mode; 41% to 60%-mild oral breathing mode; from 61% to 80%-moderate breathing; above 80%-severe oral breathing. For the analysis of sensory processing, performed by an occupational therapist, the Sensory Profile Test 2 was used. This instrument captures information regarding sensory processing (auditory, visual, vestibular, tactile, multisensory and oral sensory), sensory modulation (tolerance and tone, related to body position and movement, movement modulation affecting alert level, sensory modulation affecting emotional responses, modulation of visual stimulus affecting emotional response and activity level) and emotional and behavioral responses (behavioral and emotional responses, behavioral results of sensory processing, items indicating response thresholds). The data from this analysis included the participation of mothers in the responses.
The record of the presence and types of sleep and respiratory alterations, as well as the presence and type of malocclusion existed from the data in each patient’s chart, establishing a new intraoral physical examination of these patients for occlusal evaluation [7]. This research respected the universal principles of bioethics and human rights. It was previously approved by the UFPE Ethics Committee. For data analysis, the Statistical Package for Social Sciences Software (SPSS - version 18) and Excel 2010 were used. The results are presented in table form, with their respective absolute and relative frequencies. To verify the existence of an association between oral breathing and the presence of malocclusion, Fisher’s Exact Test was adopted. The 95% confidence interval was adopted and only p values <0.05 were considered statistically significant.
Results
There was a survey of 208 medical records referring to child patients from six to nine years old, in attendance in the first half of 2019, for the dental school clinic in question. These included respiratory changes for 33 children, according to the inclusion and exclusion 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) years and complete high school education (75.8%).
Respiratory abnormalities were allergic in 14 children (42.4% with allergic rhinitis) and asthma in 12 (36.4%). Among the 33 patients in whom the type of respiratory disorder was discriminated, two (6.1% reported asthma and allergy). For seven children (21.2%) there was no specific cause. Regarding the classification of the child’s breathing mode as oral breathing, seven were in this perspective (21.2%). Six children had sleep problems (18.2%) and 12 (36.4%) had malocclusions. There was no record of sensory processing disorder.
The distribution of malocclusions was as follows, considering the Angle classification: five Class I, three Class II division 1 and one Class III. For the remaining four the type was not specified. Considering the registration of the other malocclusions: from the unilateral posterior crossbite records, two for the anterior open bite and two for the anterior crossbite. There was a record for bilateral posterior crossbite. Five children did not find the classification of malocclusion. Comparing the data obtained from the medical records with the respiratory mode assessments and the intraoral physical examinations of the patients, there were statistically significant differences p<0.05 in relation to the patients with oral breathing (all patients registered with respiratory alterations had this type of mode, either in the functional evaluation or in the evaluation made by the otolaryngologist).
Concerning the presence of malocclusions; these were found in 27 (81.8%) of the children assisted at the dental school in question after 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 bite and unilateral posterior crossbite (Table 1). Although not included in the table, eight (24.4%) of the evaluated children had primary crowding in the region of the lower permanent incisors. There was a significant difference between medical records and data from intraoral physical examination (p <0.05). Among the children evaluated, 16 (48.5%) had sleep problems (Table 1).
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