Comparison of dental occlusion in children with mouth breathing and different types of pharyngeal lymphoid tissue obstruction

Tanzeem Ahmed; Samsuddin Ahmed; Nikhil Kaushal

doi:10.4103/ijds.ijds_124_21

ORIGINAL ARTICLE

Year : 2022 | Volume : 14 | Issue : 4 | Page : 198-201

Comparison of dental occlusion in children with mouth breathing and different types of pharyngeal lymphoid tissue obstruction

Tanzeem Ahmed¹, Samsuddin Ahmed², Nikhil Kaushal³
¹ Department of Pediatric Dentistry, Tooth Buddy Children's Dental Care, Guwahati, Assam, India
² Department of ENT, Akanksha Hospital, Guwahati, Assam, India
³ Department of Oral and Maxillofacial Surgery, Kaushal Dental Care, New Delhi, India

Date of Submission	24-Sep-2021
Date of Decision	08-Mar-2022
Date of Acceptance	29-Mar-2022
Date of Web Publication	15-Nov-2022

Correspondence Address:
Tanzeem Ahmed
Tooth Buddy Children's Dental Care, Prag Plaza, Bhangagarh, GS Road, Guwahati - 781 005, Assam
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/ijds.ijds_124_21

Abstract

Background: The relationship between malocclusion and respiration has been debated for decades. Aim: The aim of this study is to assess dental occlusion in relation to mouth breathing and different types of pharyngeal lymphoid tissue obstruction in children. Settings and Design: This was a cross-sectional study of 200 children aged between 6 and 12 years who were clinically examined and divided into two groups: mouth breathers and nasal breathers. Materials and Methods: The children were subjected to otorhinolaryngologic examination to identify the type of pharyngeal obstruction. Dental interarch relationship and pharyngeal tissue obstruction were diagnosed and appropriate cross tabulations were done. Statistical Analysis Used: The data collected were statistically analyzed using the SPSS version 15.0 software. Results: Statistically significant association was found between type of breathing and pharyngeal lymphoid tissue obstruction (P = 0.001), dental occlusion and type of breathing (P = 0.001), and pharyngeal lymphoid tissue obstruction and dental occlusion (P = 0.001). Higher prevalence of crossbite, deep bite, and Class II malocclusion was seen in children with adenotonsillar hypertrophy as well as mouth breathing habit. Conclusion: Obstructive tonsils and adenoids are risk factors for the development of malocclusion. Early detection and correction of airway obstruction can help in proper growth of the dentofacial region.

Keywords: Lymphoid tissue obstruction, mouth breathing, occlusion

How to cite this article:
Ahmed T, Ahmed S, Kaushal N. Comparison of dental occlusion in children with mouth breathing and different types of pharyngeal lymphoid tissue obstruction. Indian J Dent Sci 2022;14:198-201

How to cite this URL:
Ahmed T, Ahmed S, Kaushal N. Comparison of dental occlusion in children with mouth breathing and different types of pharyngeal lymphoid tissue obstruction. Indian J Dent Sci [serial online] 2022 [cited 2023 Nov 28];14:198-201. Available from: http://www.ijds.in/text.asp?2022/14/4/198/361194

Introduction

The normal development of the craniofacial structures and the dentofacial complex has been largely attributed to normal respiratory activity. The mode of breathing and the functions of the stomatognathic apparatus influence the craniofacial and occlusal development. Chronic nasal obstruction may lead to mouth breathing to compensate for the reduced nasal airflow and facilitate respiration. Mouth breathing causes reduced tonicity of the orofacial muscles, anterior and lower position of the tongue, and lower position of the mandible.^[1],[2],[3] This results in changes in the growth and development of the orofacial structures leading to malocclusion. Mouth breathing can occur as a result of anatomical obstruction such as pharyngeal lymphoid tissue enlargement, allergic rhinitis, nasal septum deviation, nasal polyps, and nasal turbinate hypertrophy. One of the main causes cited for nasal obstruction among children is adenoid hypertrophy.^[4],[5] However, the relationship between palatine tonsil hypertrophy, mouth breathing, and malocclusion is still controversial. Therefore, the objective of this study was to compare the dental occlusion in children with mouth breathing and two types of pharyngeal lymphoid tissue obstruction, i.e., adenoid and palatine tonsil hypertrophy.

Materials and Methods

Ethics

The approval for the study was obtained from the institutional ethics committee.

Study design

The study was conducted among 200 children aged 6–12 years who reported to the dental hospital with the chief complaint of malocclusion. Children between the ages of 6 and 12 years with complete dental development were included in the study. The children with any previous history of orthodontic therapy, oral or nasal surgical treatment, abnormal habits, muscular dystrophy, bone deformity, birth injuries, and absence of first permanent molars were excluded from the study. The children were divided into two groups. Group A consisted of 100 children with mouth breathing habit and Group B consisted of 100 children with nasal breathing. Nasal breathing was evaluated on the basis of the ability of the child to breathe through the nose for 1 min while holding water in his/her mouth. Mouth breathing was evaluated by checking for fogging on the lower side of a double-sided mirror which was placed just beneath the nose. The children were also referred to the ENT department where a detailed physical and clinical examination was done. The children were subjected to dental and otorhinolaryngologic examination. During dental examination, interarch dental occlusion was recorded based on the criteria of Barnett.^[6] The transverse dental relationship was categorized into normal and crossbite. Any tooth with inverted or edge relationship was considered to be in crossbite. The sagittal dental relationship was determined using Angle's classification which was based on the relationship of the first permanent molars. In the primary and mixed dentition stages, Class I dental relationship was considered when the maxillary primary canine intercuspation was set between the mandibular primary canine and first primary molar; Class II dental relationship was when the mandibular molar was placed posterior to the cuspid reference and Class III when the mandibular molar was placed anterior to the cuspid reference. An open bite was recorded when there was a lack of overbite. A deep bite was recorded when the incisal edges of the maxillary incisors overlapped more than half of the mandibular incisors. During otorhinolaryngologic examination, the palatine tonsil hypertrophy was recorded and classified according to the Brodsky and Koch criteria:^[7] Grade 0: tonsils limited to the tonsillar fossa, Grade 1: tonsils occupying up to 25% of the space between the anterior pillars in the oropharynx, Grade 2: tonsils occupying 25%–50% of the space between the anterior pillars, Grade 3: tonsils occupying 50%–75% of the space between the anterior pillars, and Grade 4: tonsils occupying 75%–100% of the space between the anterior pillars. Grades 3 and 4 were recorded as obstructive tonsil enlargement.^[7]

The adenoids were assessed by flexible nasal endoscopy and “soft-tissue X-ray” of the lateral view of the nasopharynx for adenoids. They were categorized as obstructive and nonobstructive depending on the narrowing of the air passage of the nasopharynx. When the adenoids obstructed more than 70% of the choana, it was considered to be obstructive adenoid enlargement.^[7]

Statistics

The data collected were statistically analyzed using the SPSS version 15.0 software. Chi-square test was employed to find out the association between type of breathing and pharyngeal lymphoid tissue obstruction and association between type of breathing and sagittal and vertical dental relationship, whereas Fisher's exact test was employed to find out the association between type of breathing and transverse dental relationship, association between pharyngeal lymphoid tissue obstruction and transverse dental relationship, and association between pharyngeal lymphoid tissue obstruction and sagittal and vertical dental relationship.

Results

Two hundred children between the ages of 6 and 12 years underwent dental and otorhinolaryngologic examination, out of which hundred children were mouth breathers (Group A) and the other hundred were nasal breathers (Group B). In Group A, 64% suffered from obstructive enlargement of tonsils as well as adenoids, 22% suffered from obstructive adenoids only, whereas 8% suffered from obstructive tonsils only. Six percent of the children in Group A had nonobstructive tonsils and adenoids. In Group B, all the children had nonobstructive tonsils and adenoids. The association between the type of breathing and pharyngeal lymphoid tissue obstruction was found to be statistically significant (P = 0.001) [Table 1].

Table 1: Association between the type of breathing and pharyngeal lymphoid tissue obstruction

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In Group A, crossbite was detected in 36% of the children, and in Group B, it was seen in 16%. Statistically significant association (P = 0.001) was seen between the type of breathing and transverse dental relationship [Table 2].

Table 2: Association between the type of breathing and transverse dental relationship

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While comparing sagittal dental relationship to the type of breathing, it was found that in Group A, Class I dental relationship was seen in 52%, Class II relationship was seen in 38%, and Class III was seen in 10%. In Group B, Class I dental relationship was found in 84%, Class II relationship was found in 12%, and Class III was found in 4% of the children. The association between type of breathing and sagittal dental relationship was found to be statistically significant (P = 0.001). The association between the type of breathing and vertical dental relationship was also found to be statistically significant (P = 0.001) with higher cases of deep bite (34%) and open bite (22%) seen in Group A as compared to Group B [Table 3].

Table 3: Association between the type of breathing and sagittal and vertical dental relationship

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A higher prevalence of crossbite was seen in children with combined obstructive adenoid and tonsil enlargement (34.4%) as well as children with isolated obstructive adenoid enlargement (45.5%). The association between the pharyngeal lymphoid tissue obstruction and the transverse dental relationship was found to be statistically significant [Table 4].

Table 4: Association between pharyngeal lymphoid tissue obstruction and transverse dental relationship

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Statistically significant association (P = 0.001) was found between the pharyngeal lymphoid tissue obstruction and the sagittal dental relationship with the highest number of Class II dental relationship (43.8%) and Class III dental relationship (9.4%) cases found in children with obstructive enlargement of both tonsils and adenoids. Higher prevalence of deep bite cases (37.5%) and open bite cases (25%) was found in children with combined obstructive tonsils and adenoids. The association between pharyngeal lymphoid tissue obstruction and vertical dental relationship was found to be statistically significant (P = 0.001) [Table 5].

Table 5: Association between pharyngeal lymphoid tissue obstruction and sagittal and vertical dental relationship

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Discussion

Nasal obstruction and mouth breathing leading to malocclusion is a controversial subject. Several authors such as Behlfelt et al. and Fields et al. suggested mouth breathing to be the primary factor for malocclusion, whereas authors such as Miller et al., Solow et al., and Cheng et al. considered mouth breathing as an unbalancing neuromuscular factor that secondarily causes or aggravates malocclusion.^{[8],[9],[10],[11],[12]} One of the etiologies stated in the literature for mouth breathing is pharyngeal airway obstruction. In the present study, a significantly higher prevalence of mouth breathing was seen in children having combined tonsil and adenoid enlargement. Malocclusion in relation to the interarch dental relationship in all the three planes of space was also found to be significantly higher in mouth breathing patients as compared to patients who breathe through their nose. In the present study, it was seen that patients with adenotonsillar hypertrophy had a higher prevalence of posterior crossbite as compared to isolated tonsil or adenoid enlargement. The presence of crossbite can cause alteration in the growth pattern of the jaws. Unilateral crossbite can lead to facial asymmetries, whereas bilateral crossbite can restrict the growth of the maxilla, thereby reducing the volume of the upper airway.^[13]

In the case of sagittal dental relationship, the prevalence of Class II malocclusion was 38% in mouth breathing children as compared to 12% in nasal breathing children. In mouth breathing children, the tongue occupies a lower position in the mouth causing the tendency to rotate the jaw backward.^[14] The prevalence of Class III dental relationship was also found to be higher in mouth breathing patients that could be due to tonsil enlargement causing forward position of the tongue and subsequent forward pushing of the lower anterior teeth.

The association between the vertical dental relationship and tonsil and adenoid hypertrophy was found to be statistically significant. It suggests that treating and maintaining a normal nasal airflow in children may help prevent or treat malocclusions. Obstruction in the upper respiratory airway may lead to changes in the balance between the muscles of the tongue, buccinators, and orbicularis oris causing changes in the growth pattern of the jaws and malocclusion.^[3] A physiological mechanism in which obstruction in the upper respiratory airway causes changes in the neuromuscular system was described by McNamara. The changes in the neuromuscular system encourage the alteration in the dental and craniofacial structures.^[15] The present study shows that enlarged tonsil and adenoids are related to mouth breathing and they have an adverse effect on dental occlusion. The findings of this study suggest that all the children suffering from malocclusion should be screened for the habit of mouth breathing and all the mouth breathing children must be screened for pharyngeal lymphoid tissue enlargement. Detection and management of enlarged adenoid and tonsil can not only reduce the severity of developing malocclusion but also prevent malocclusion from developing if done at an early stage.

Limitations and future research

Longitudinal studies with larger sample size are needed to evaluate the long-term effects of pharyngeal tissue obstruction on malocclusion.

Conclusion

A statistically significant association was found between mouth breathing and malocclusion in all the three planes of space in children aged 6–12 years. A significant association of adenoid and tonsil enlargement with malocclusion was also seen along with a higher prevalence of crossbite, Class II relationship, and deep bite among children having adenotonsillar hypertrophy. An interdisciplinary approach is advocated to restrict the detrimental effects of mouth breathing and treat malocclusion.

Ethical clearance

Ethical Clearance was obtained form the Institutional ethics committee of Army College of Dental Sciences, Secunderabad.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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