Hindawi

BioMed Research International

Volume 2021, Article ID 5550267, 13 pages
https://doi.org/10.1155/2021/5550267

Research Article
Comparative Evaluation of the Effects of Adenotonsillar
Hypertrophy on Oral Health in Children

Nilsu İnönü-Sakallı,1 Cemal Sakallı,2 Özgür Tosun,3 and Damla Akşit-Bıçak 1

1
Department of Pediatric Dentistry, Near East University Faculty of Dentistry, Nicosia/ TRNC, 99138 Mersin 10, Turkey
2
Department of Otorhinolaryngology, Near East University Training and Research Hospital, Nicosia/ TRNC,
99138 Mersin 10, Turkey
3
Department of Biostatistics, Near East University Faculty of Medicine, Near East University, Nicosia/ TRNC,
99138 Mersin 10, Turkey

Correspondence should be addressed to Damla Akşit-Bıçak; damla.aksitbicak@neu.edu.tr

Received 6 January 2021; Revised 23 March 2021; Accepted 29 March 2021; Published 5 April 2021

Academic Editor: Bing Wang

Copyright © 2021 Nilsu İnönü-Sakallı et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is
properly cited.

We aimed to investigate the oral health of children in terms of the presence of dental caries, periodontal health, halitosis, and
dentofacial changes in patients who had adenotonsillar hypertrophy related to mouth breathing and compared these findings
with nasal breathing healthy and adenotonsillectomy-operated children. The patient group comprised 40 mouth-breathing
children who were diagnosed with adenotonsillar hypertrophy, while the control group consisted of 40 nasal breathing children
who had no adenotonsillar hypertrophy. Forty children who had undergone an adenotonsillectomy operation at least 1 year
prior to the study were included in the treatment group. Oral examinations of all children were conducted, and the parents were
asked about medical and dental anamnesis, demographic parameters, toothbrushing and nutrition habits, oral health-related
quality of life (OHRQoL), and symptoms of their children. Demographic parameters, toothbrushing and nutrition habits, and
the presence of bad oral habits did not differ between groups (p > 0:05). Adenotonsillectomy is associated with a remarkable
improvement in symptoms; however, some symptoms persist in a small number of children. The salivary flow rate, dmft/s,
DMFT/S index, plaque, and gingival index scores did not differ between groups (p > 0:05). The patient group showed higher
rates of halitosis when compared with the treatment and control groups (p < 0:001). Mouth breathing due to adenotonsillar
hypertrophy caused various dentofacial changes and an increase in Class II division 1 malocclusion (p < 0:001). It was shown
that adenotonsillar hypertrophy does not negatively affect OHRQoL, it could be a risk factor for dental caries, periodontal
diseases, and halitosis, but by ensuring adequate oral health care, it is possible to maintain oral health in children with
adenotonsillar hypertrophy. Also, it is recommended that orthodontic treatment should start as soon as possible if it is required.
In this context, otorhinolaryngologists, pedodontists, and orthodontists should work as a team in the treatment of children with
adenotonsillar hypertrophy.

1. Introduction antigenic substances [1, 2]. Adenoid and tonsil tissues begin
to grow in the first years of life with gradual growth up to
The Waldeyer’s ring is known as the lymphoid tissue sur- the age of five and have the feature of regressing and dimin-
rounding the opening of the oral and nasal cavities to the ishing in size from childhood to adolescence [2]. Hence, ade-
pharynx and consists of the palatine, pharyngeal (adenoids), notonsillar hypertrophy is defined as the condition in which
lingual, and tubal tonsils together with lymphatic tissue scat- adenotonsillar tissue enlarges in dimension and accordingly
tered along the mucosal lining of the pharynx. It serves as the invades a larger space in the nasopharynx wall, which can
first-line defence mechanism against microorganisms and lead to the development of serious problems such as snoring,
2 BioMed Research International

abnormal and sleep-disordered breathing, obstructive sleep formed the control group of this study. Also, 40 children
apnoea, speaking, smelling, tasting, swallowing difficulties, who had undergone an adenotonsillectomy operation at the
mouth breathing, and orofacial problems [3–7]. Near East University Hospital Otorhinolaryngology Clinic
A compensatory mouth breathing habit among young at least 1 year prior to the study were included in the treat-
children is widely accepted as one of the primary outcomes ment group. Treatment group patients were contacted by
of the mechanical obstruction of the airflow passage because phone using their contact details from the patient records
of adenotonsillar hypertrophy together with untreated aller- and were requested to visit the Near East University, Faculty
gic rhinitis [8, 9]. Mouth breathing due to adenotonsillar of Dentistry, Paediatric Dentistry Department for oral
hypertrophy has been shown to cause the majority of dento- examination.
facial changes such as V-shaped narrowing in the maxillary G∗ Power (Version 3.1.9.4) for Mac software was used
arch, opening of the lips and positioning of the tongue below for sample size calculation. Based on similar studies [16,
its normal position, retrognathic mandible, increased overjet, 17] in the literature and as a result of the statistical evaluation
anterior and posterior crossbite, and anterior open bite. All with 80% statistical power and 5% margin of error, it was
these changes affecting the dentofacial development are found that 35 patients should be included in each group.
described as “Adenoid face” [8, 10–12]. In order to treat Considering the possible errors that might occur during the
chronic upper airway obstruction in the presence of adeno- study resulting in patient or data loss, the decision was made
tonsillar hypertrophy, adenoidectomy or adenotonsillectomy to incorporate 40 patients in each group. Thus, a total of 120
surgeries are generally conducted on children and it has been children were enrolled in the study. This study was con-
reported that most dentofacial anomalies are reversible ducted between February 2020 and November 2020.
within the first year after adenoidectomy [13, 14]. Further-
more, mouth breathing due to adenotonsillar hypertrophy 2.2. Ethical Approval. Ethical approval was obtained from
has been shown to induce the formation of dental caries, hal- Near East University Clinical Research Ethics Committee
itosis, and periodontal problems because of the decrease in (NEU/2019/71-882). Parents of all 120 children who
the cleaning effect of saliva and the open positioning of the accepted to participate in this study read and signed written
lips [11, 12, 15]. However, conflicting results can be found informed consent forms about the study.
in the literature on this topic, and the effect of adenotonsil-
2.3. Inclusion Criteria. The patient group included children
lectomy treatment on the improvement of halitosis, peri-
with adenotonsillar hypertrophy and mouth breathing,
odontal problems, dental caries formation, and oral health-
between the ages of 3-14, no chronic or systemic disease, no
related quality of life (OHRQoL) has not been sufficiently
immune system deficiency, and the presence of adenotonsil-
clarified. Thus, according to the above information, the pur-
lar hypertrophy with surgical indications for adenotonsillect-
pose of this study was to evaluate the oral health of children
omy together with mouth breathing. The control group
in terms of the presence of dental caries, periodontal health,
included children without adenotonsillar hypertrophy and
halitosis, and malocclusions in children who have adenoton-
nasal breathing, between the ages of 3-14, no chronic or sys-
sillar hypertrophy related mouth breathing and to compare
temic disease, no immune system deficiency, no history of
these findings with healthy children with nasal breathing
adenotonsillar hypertrophy or previous adenotonsillectomy
and children who have undergone adenotonsillectomy treat-
surgery, and no history of mouth breathing and children with
ment. Our study is based on the hypothesis that mouth
nasal breathing. The treatment group included children who
breathing due to adenotonsillar hypertrophy may negatively
had undergone adenotonsillectomy surgery between the ages
affect OHRQoL and cause an increase in malocclusion, hali-
of 3-14, no chronic or systemic disease, no immune system
tosis, dental caries, and periodontal diseases in children when
deficiency, and children who had undergone adenotonsillect-
compared with healthy controls and adenotonsillectomy
omy surgery at least 1 year prior to the study.
operated children. Evaluating the oral health status of chil-
dren who have undergone adenotonsillectomy operations 2.4. Exclusion Criteria. For all groups, exclusion criteria
provided us with the opportunity to examine the benefits of included previous facial surgery, dysmorphic or craniofacial
adenotonsillectomy surgery on oral health and thus enabling syndromes, septum deviation, chronic disease, upper respira-
us to make a significant contribution to this field, which tory tract obstruction other than adenoid vegetation, acute
needs support in the literature. upper respiratory tract infection period, finger sucking
habits, previous orthodontic treatment, and ongoing ortho-
2. Materials and Methods dontic treatment [18].

2.1. Patient Recruitment. Eighty children aged 3-14 who pre- 2.5. Medical and Dental Anamnesis. The demographic infor-
sented to the Near East University Hospital Otorhinolaryn- mation together with dental and medical anamnesis of a total
gology Clinic due to ear, nose, and throat (ENT) of 120 children were obtained in detail and recorded in
complaints and consented to participate in the study consti- anamnesis forms. Questions about the parents’ income level,
tuted the patient and control groups. After adenoid and ton- education level, children’s previous dental treatment experi-
sil evaluation, 40 children who were diagnosed with ence, presence of snoring, open mouth during sleep, daytime
adenotonsillar hypertrophy together with mouth breathing somnolence, restless sleep, salivate on the pillow during
represented the patient group and 40 children who had no sleeping, thirsty awakening at nights, dry mouth, bedwetting,
adenotonsillar hypertrophy together with nasal breathing headache, aggression, lack of attention, hyperactivity, abnormal
BioMed Research International 3

breathing, difficulty in swallowing, smelling, tasting and speak- and deep bite. Transversal relationship was categorized as
ing difficulties, negative effect on school performance, and the normal and posterior crossbite. Sagittal relationship was cat-
presence of allergies were asked to the parents, and their egorized as normal occlusion, Class I malocclusion, Class II
responses were recorded on the anamnesis forms. In addition, Division 1 malocclusion, Class II Division 2 malocclusion,
parents were asked about the frequency of their child’s tooth- and Class III malocclusion [21].
brushing, their participation in toothbrushing, nutrition habits
of the child, fluoride concentration of the child’s toothpaste, 2.8. Oral Health-Related Quality of Life (OHRQoL)
the presence of bad oral habits such as bruxism, nail biting, lip Assessment. The Turkish version of the Early Childhood Oral
biting, tongue-thrusting, lip sucking, and if they detected bad Health Impact Scale (ECOHIS) was used to assess the OHR-
breath in their child or themselves. QoL of children who participated in this study, which was
shown to have acceptable validity and reliability by Peker
2.6. Ear Nose Throat Examination. Eighty children who pre- et al. [27]. Parents of all children rated 13 questions in total.
sented to the Near East University Hospital Otorhinolaryn- The first part is the child impact section and includes 4
gology clinic underwent examination by the same domains, namely, child symptoms, functions, psychology,
otolaryngologist. Flexible fiberoptic nasopharyngolaryngo- self-image, and social interaction. The second part is the par-
scopy (FNFL) was used for direct visualization of the adenoid ent impact section and includes two domains, namely, paren-
and tonsils [18, 19]. Palatine tonsil hypertrophy was deter- tal distress and family function. A five-point Likert scale was
mined according to the Brodsky and Koch criteria [20]. used for rating each item (0 = never; 1 = hardly ever; 2 =
Patients with adenoid hypertrophy were evaluated with occasionally; 3 = often; 4 = very often; and 5 = do not know).
FNFL in two categories according to the degree of nasopha- Higher scores indicated more problems and/or greater
ryngeal obstruction (<75% and ≥75%) [21]. Children with impacts [27].
Grade 4 and ≥75 obstruction of the airway were included in
the study as the patient group. Children without adenotonsil- 2.9. Statistical Analysis. For all study variables, descriptive
lar hypertrophy were included in the study as the control statistics were calculated. Qualitative variables were
group. described with frequency and percentage, while arithmetic
mean, standard deviation (SD), and standard error of the
2.7. Oral Examination. The oral examinations of all 120 chil- mean (SE) were calculated for quantitative variables. Pearson
dren were performed by one examiner at the Near East Uni- Chi-Square test, Fisher’s Exact test, and trend test for ordinal
versity, Faculty of Dentistry, Paediatric Dentistry variables were used to compare the distribution differences of
Department. Patients were requested to sit in a dental chair. qualitative variables between study groups. Following the
Under dental chair light, the surfaces of the teeth were inves- Shapiro-Wilk test of normality, the nonparametric Kruskal
tigated by using a dental mirror and dental explorer after dry- Wallis test was applied to compare the three study groups
ing with air. The dentition period for each child was recorded with respect to the quantitative variables. The level of signif-
as primary, permanent, and mixed dentition. In addition, the icance was accepted as 0.05. All calculations and statistical
DMFT/S values for permanent teeth and dmft/s values for analyses were carried out with Jamovi (Version 1.2.27.0 for
primary teeth (D,d: decayed, M,m: missing, F,f: filled, and Mac) software.
T,t: total) were detected consistent with World Health Orga-
nization standards [22]. Plaque index and gingival index 3. Results
values of children were evaluated according to Silness and
Löe [23] and Löe and Silness [24], respectively. Unstimulated A total of 120 children participated in this study. The mean
salivary flow rates were assessed by asking the children to spit ages of the groups were 7:35 ± 3:55 for the patient group,
into a 15 ml falcon tube placed in a funnel for 5 minutes and 8:08 ± 2:89 for the treatment group, and 8:08 ± 2:89 for the
were calculated as millilitres per minute (ml/min). Children control group. No statistically significant difference was
were instructed not to swallow during saliva collection [25]. found in the mean ages of the study groups (p = 0:284). Of
In the evaluation of halitosis, the organoleptic measurement the children participating in the study, 53 (44.2%) were girls
technique was used. Children were asked to hold a plastic and 67 (55.8%) were boys, and no difference was found
tube in their mouth and told to slowly exhalate into the tube. between the groups in terms of gender distribution
During exhalation, the examiner evaluated the odor from the (p = 0:9671). The children included in this study were
other side of the tube. The organoleptic measurement of odor selected in such a manner that there was an equal distribu-
was classified as stated in a recent study [26]. tion between the groups in terms of age, gender, and denti-
In the evaluation of malocclusion, the presence of a V- tion period. Family income (p = 0:262) and parental
shaped narrowing in the maxillary arch, adenoid face, teeth education level (p = 0:098) also did not differ between
crowding, macroglossia, open mouth posture, anterior and groups. It was detected that 57.5% of children in the patient
lower tongue position, mandibula (normal, prognathic, and group had never visited a dentist, but 82.5% of children in
retrognathic), position of the maxillary and mandibular ante- the control group had visited a dentist before (Table 1).
rior teeth, and presence of dry, chapped lips were assessed. In Table 2 displays the symptoms of the patient and treat-
addition, vertical, transversal, and sagittal interarch dental ment groups. No statistically significant differences were
occlusion were evaluated [21]. Vertical relationship was cat- found in terms of tasting (p = 0:077), smelling (p = 0:288),
egorized as normal, posterior open bite, anterior open bite, speaking (p = 0:251) difficulties, hyperactivity (p = 0:822),
4 BioMed Research International

Table 1: Demographic parameters.

Patient group Treatment group Control group

p value
(N = 40) (N = 40) (N = 40)
Girl 17 (42.5%) 18 (45.0%) 18 (45.0%)
Gender (n-%) 0.9671
Boy 23 (57.5%) 22 (55.0%) 22 (55.0%)
Mean 7.35 8.075 8.075
Age SD 3.5486 2.8946 2.8946 0.2842
SE 0.56108 0.45768 0.45768
3.000–6.000 ₺ 10 (25.0%) 3 (7.5%) 7 (17.5%)
Family income (n-%) 6.000–9.000 ₺ 15 (37.5%) 15 (37.5%) 13 (32.5%) 0.2621
≥10.000 ₺ 15 (37.5%) 22 (55.0%) 20 (50.0%)
Primary school 2 (5.0%) 1 (2.5%) 0 (0.0%)
Middle school 4 (10.0%) 1 (2.5%) 3 (7.5%)
High school 12 (30.0%) 6 (15.0%) 10 (25.0%)
Parental education level (n-%) 0.0983
University 17 (42.5%) 26 (65.0%) 20 (50.0%)
Master degree 5 (12.5%) 5 (12.5%) 5 (12.5%)
Doctorate degree 0 (0.0%) 1 (2.5%) 2 (5.0%)
Yes 17 (42.5%) 25 (62.5%) 33 (82.5%)
Previous dental visit (n-%) 0.0011
No 23 (57.5%) 15 (37.5%) 7 (17.5%)
1
Pearson’s Chi-squared test, 2Kruskal Wallis Test, and 3Trend test for ordinal variables.

Table 2: Symptoms of patient and treatment groups.

Patient group (N = 40) Treatment group (N = 40) p value

Tasting difficulty 3 (7.5%) 0 (0.0%) 0.077
Smelling difficulty 6 (15.0%) 3 (7.5%) 0.288
Speaking difficulty 18 (45.0%) 13 (32.5%) 0.251
Difficulty in swallowing 21 (52.5%) 4 (10.0%) <0.001
Abnormal breathing 33 (82.5%) 2 (5.0%) <0.001
Hyperactivity 23 (57.5%) 22 (55.0%) 0.822
Lack of attention 22 (55.0%) 18 (45.0%) 0.371
Aggression 19 (47.5%) 15 (37.5%) 0.366
Headache 5 (12.5%) 3 (7.5%) 0.456
Bedwetting 2 (5.0%) 0 (0.0%) 0.152
Dry mouth 36 (90.0%) 9 (22.5%) <0.001
Thirsty awakening at nights 36 (90.0%) 5 (12.5%) <0.001
Salivate on the pillow during sleeping 35 (87.5%) 7 (17.5%) <0.001
Negative affection of school performance 5 (12.5%) 2 (5.0%) 0.235
Restless sleep 30 (75.0%) 3 (7.5%) <0.001
Daytime somnolence 15 (37.5%) 2 (5.0%) <0.001
Open mouth during sleeping 37 (92.5%) 15 (37.5%) <0.001
Snoring 40 (100.0%) 4 (10.0%) <0.001
Mouth breathing 40 (100.0%) 3 (7.5%) <0.001
Pearson’s Chi-squared test.

lack of attention (p = 0:371), aggression (p = 0:366), head- at nights, 35 (87.5%) had salivate on the pillow during
ache (p = 0:456), bedwetting (p = 0:152), and negative sleeping, 30 (75.0%) had restless sleep, 15 (37.5%) had
affection of school performance (p = 0:235) among the daytime somnolence, and 37 (92.5%) had open mouth
patient and treatment groups. It was found that in the during sleeping. All children in the patient group had
patient group, 21 (52.5%) children had difficulty in swal- snoring and mouth breathing. These findings were found
lowing, 33 (82.5%) children had abnormal breathing, 36 to be significantly higher when compared with the findings
(90.0%) had dry mouth, 36 (90.0%) had thirsty awakening of the treatment group (p < 0:001).
BioMed Research International 5

Table 3: Toothbrushing and nutrition habits.

Patient group Treatment group Control group

p value
(N = 40) (N = 40) (N = 40)
At least once a day 36.0 (90.0%) 32.0 (80.0%) 33.0 (82.5%)
Toothbrushing frequency 0.444
Several times a week or never 4.0 (10.0%) 8.0 (20.0%) 7.0 (17.5%)
Generally 13.0 (32.5%) 11.0 (27.5%) 19.0 (47.5%)
Supervised toothbrushing 0.152
Occasionally or never 27.0 (67.5%) 29.0 (72.5%) 21.0 (52.5%)
Nonfluoridated 1.0 (2.5%) 2.0 (5.0%) 5.0 (12.5%)
Used toothpaste 0.175
Fluoridated 39.0 (97.5%) 38.0 (95.0%) 35.0 (87.5%)
Milk and milk products
Less than once a week 4.0 (10.0%) 4.0 (10.0%) 7.0 (17.5%)
0.504
At least once a day 36.0 (90.0%) 36.0 (90.0%) 33.0 (82.5%)
Fruits and vegetables
Less than once a week 1.0 (2.5%) 5.0 (12.5%) 1.0 (2.5%)
0.088
At least once a day 39.0 (97.5%) 35.0 (87.5%) 39.0 (97.5%)
Carbonated beverages
Less than once a week 26.0 (65.0%) 30.0 (75.0%) 32.0 (80.0%)
0.303
At least once a day 14.0 (35.0%) 10.0 (25.0%) 8.0 (20.0%)
Nutrition habits
Chocolate and biscuits
Less than once a week 7.0 (17.5%) 7.0 (17.5%) 8.0 (20.0%)
0.946
At least once a day 33.0 (82.5%) 33.0 (82.5%) 32.0 (80.0%)
Chips and snacks
Less than once a week 18.0 (45.0%) 24.0 (60.0%) 26.0 (65.0%)
0.171
At least once a day 22.0 (55.0%) 16.0 (40.0%) 14.0 (35.0%)
Candy and lollipops
Less than once a week 18.0 (45.0%) 31.0 (77.5%) 26.0 (65.0%)
0.010
At least once a day 22.0 (55.0%) 9.0 (22.5%) 14.0 (35.0%)
Pearson’s Chi-squared test.

Table 3 illustrates the toothbrushing and nutrition habits 24 in the control group (60%) had no or barely noticeable
of all children in this study. Most of the children performed odor (p < 0:001). In addition, the parents of 39 (97.5%) chil-
toothbrushing at least once a day and used fluoridated tooth- dren in the patient group perceived odor, whereas 19 (47.5%)
paste; however, it was detected that parents did not brush and 14 (35.0%) parents detected such odors in the treatment
their child’s teeth and performed supervised toothbrushing. and control groups, respectively.
No statistically significant differences were detected in the The presence of bad oral habits did not differ between
nutrition habits of children when the different groups were patient, treatment, and control groups (p > 0:05) (Table 6).
compared. Only candy and lollipop consumption frequency It was determined that 32 (26.7%) children were in pri-
differed as 31 (77.5%) children in the treatment group con- mary, 68 (56.7%) children were in mixed, and 20
sumed candy and lollipops less than once a week, followed (16.7%) children were in permanent dentition. The pres-
by 26 (65%) children in the control and 18 (45%) children ence of teeth crowding did not differ between groups
in the patient group (p = 0:010). (p = 0:051). It was detected that 38 (95%) children in the
The salivary flow rate, dmft/s, DMFT/S index, and plaque patient group, 38 (95.0%) children in the treatment group,
and gingival index scores did not differ between the patient, and none of the children in the control group showed V-
treatment, and control groups (p > 0:05) (Table 4). A total shaped narrowing in their maxillary arch (p < 0:001). Ade-
of 33 children in the treatment group (82.5%), 24 children noid face was detected in 38 (95%) children in the patient
in the patient group (60%), and 24 in the control group group, 30 (75%) children in the treatment group, and
(60%) had dental plaque on the buccal surface of the anterior none of the children in the control group (p < 0:001).
teeth, and a statistically significant difference was found Macroglossia was detected in 27 (67.5%) children in the
between groups (p = 0:046). treatment group, 26 (65.0%) children in the patient group,
Table 5 displays the statistically significant difference in and 5 (12.5%) children in the control group (p < 0:001).
the organoleptic assessment of halitosis among the study Open mouth posture was found in 33 (82.5%), 27
groups (p < 0:001). Twenty-seven (67.5%) children demon- (67.5%), and 4 (10.0%) children in the patient, treatment,
strated weak but clearly noticeable odor, and 13 (32.5%) chil- and control groups, respectively. It was found that 26
dren had moderate or strong odor in the patient group. (65%) children in the patient group, 25 (62.5%) children
However, 21 children in the treatment group (52.5%) and in the treatment group, and none of the children in the
6 BioMed Research International

Table 4: Assessment of caries index, plaque index, and gingival index.

Group N Mean SD SE p
Patient 40 0.73 0.5441 0.08602
Salivary flow rate Treatment 40 0.6325 0.4548 0.07191 0.377
Control 40 0.7725 0.5435 0.08593
Patient 33 2.51515 2.9593 0.51515
dmft Treatment 35 2.62857 2.8808 0.48695 0.288
Control 34 3.58824 3.1249 0.53591
Patient 33 3.69697 4.74 0.82513
dmfs Treatment 35 3.45714 4.154 0.70215 0.338
Control 34 4.91176 4.6343 0.79478
Patient 23 1.73913 2.4162 0.50381
DMFT Treatment 29 0.82759 1.3646 0.2534 0.124
Control 32 0.4375 0.9483 0.16763
Patient 23 2.26087 3.2783 0.68357
DMFS Treatment 29 1 1.5584 0.28939 0.145
Control 32 0.625 1.4756 0.26085
Patient 40 0.145 0.2025 0.03202
Plaque index Treatment 40 0.14185 0.1616 0.02555 0.176
Control 40 0.0868 0.0984 0.01555
Patient 40 0.00432 0.0162 0.00256
Gingival index Treatment 40 0.02732 0.069 0.01091 0.134
Control 40 0.02113 0.05 0.00791
Kruskal Wallis Test.

Table 5: Assessment of halitosis.

Patient group (N = 40) Treatment group (N = 40) Control group (N = 40) p value
Organoleptic measurement
No or barely noticeable odor 0.0 (0.0%) 21.0 (52.5%) 24.0 (60.0%)
Weak but clearly noticeable odor 27.0 (67.5%) 8.0 (20.0%) 8.0 (20.0%) <0.001
Moderate or strong odor 13.0 (32.5%) 11.0 (27.5%) 8.0 (20.0%)
Parental perception of odor in the child
Yes 39.0 (97.5%) 19.0 (47.5%) 14.0 (35.0%)
<0.001
No 1.0 (2.5%) 21.0 (52.5%) 26.0 (65.0%)
Pearson’s Chi-squared test.

control group had anterior or lower tongue positions.

Table 6: Assessment of oral bad habits. Thirty-seven (92.5%) children had dry, chapped lips in
Patient Control the patient group; however, this finding was detected in
Treatment p only 7 (17.5%) children in the treatment group and 1
group group
group (N = 40) value (2.5%) child in the control group (Table 7).
(N = 40) (N = 40)
Tongue
Mandibula position was mainly (92.5%) retrognathic
3.0 (7.5%) 0.0 (0.0%) 0.0 (0.0%) 0.0461 among the patient group followed by children in the treat-
thrusting
ment group (75.0%). However, in the control group, it was
Lip
sucking
3.0 (7.5%) 1.0 (2.5%) 1.0 (2.5%) 0.4341 found that the mandibular position was predominantly
(87.5%) normal. Prominent position of the maxillary anterior
Lip biting 2.0 (5.0%) 1.0 (2.5%) 0.0 (0.0%) 0.3591
teeth was detected in 15 (37.5%), 18 (45%), and 3 (7.5%) chil-
Nail dren in the patient, treatment, and control groups, respec-
5.0 (12.5%) 2.0 (5.0%) 2.0 (5.0%) 0.3391
biting tively. Also, retrognathic position of the mandibular
Bruxism 9.0 (22.5%) 5.0 (12.5%) 2.0 (5.0%) 0.0691 anterior teeth was detected in 20 (50.0%) children in the
Pearson’s Chi-squared test. patient group, 10 (25.0%) children in the treatment group,
and 1 (2.5%) child in the control group (Table 7).
BioMed Research International 7

Table 7: Assessment of dentofacial findings.

Patient group (N = 40) Treatment group (N = 40) Control group (N = 40) p value
V-shaped narrowing in the maxillary arch 38.0 (95.0%) 38.0 (95.0%) 0.0 (0.0%) <0.001
Adenoid face 38.0 (95.0%) 30.0 (75.0%) 0.0 (0.0%) <0.001
Teeth crowding 12.0 (30.0%) 17.0 (42.5%) 7.0 (17.5%) 0.051
Macroglossia 26.0 (65.0%) 27.0 (67.5%) 5.0 (12.5%) <0.001
Open mouth posture 33.0 (82.5%) 27.0 (67.5%) 4.0 (10.0%) <0.001
Anterior and lower tongue position 26.0 (65.0%) 25.0 (62.5%) 0.0 (0.0%) <0.001
Dry, chapped lips 37.0 (92.5%) 7.0 (17.5%) 1.0 (2.5%) <0.001
Position of mandibula
Normal 0.0 (0.0%) 9.0 (22.5%) 35.0 (87.5%)
Prognatic 3.0 (7.5%) 1.0 (2.5%) 4.0 (10.0%) <0.001
Retrognatic 37.0 (92.5%) 30.0 (75.0%) 1.0 (2.5%)
Position of maxillary anterior teeth
Normal 25.0 (62.5%) 22.0 (55.0%) 37.0 (92.5%)
<0.001
Prominent 15.0 (37.5%) 18.0 (45.0%) 3.0 (7.5%)
Position of mandibular anterior teeth
Normal 20.0 (50.0%) 30.0 (75.0%) 39.0 (97.5%)
<0.001
Retrognatic 20.0 (50.0%) 10.0 (25.0%) 1.0 (2.5%)
Dentition period
Primary dentition 16.0 (40.0%) 10.0 (25.0%) 6.0 (15.0%)
Mixed dentition 17.0 (42.5%) 23.0 (57.5%) 28.0 (70.0%) 0.111
Permanent dentition 7.0 (17.5%) 7.0 (17.5%) 6.0 (15.0%)
Pearson’s Chi-squared test.

Table 8: Assessment of interarch dental occlusal relationship.

Patient group (N = 40) Treatment group (N = 40) Control group (N = 40) p value
Sagittal relationship
Normal occlusion 6.0 (21.4%) 9.0 (30.0%) 20.0 (58.8%)
Class I malocclusion 4.0 (14.3%) 6.0 (20.0%) 10.0 (29.4%) <0.001
Class II division 1 malocclusion 18.0 (64.3%) 15.0 (50.0%) 4.0 (11.8%)
Transversal relationship
Posterior crossbite 9.0 (22.5%) 10.0 (25.0%) 5.0 (12.5%)
0.335
Normal, no crossbite 31.0 (77.5%) 30.0 (75.0%) 35.0 (87.5%)
Vertical relationship
Normal overbite 20.0 (50.0%) 18.0 (45.0%) 23.0 (57.5%)
Anterior open bite 8.0 (20.0%) 11.0 (27.5%) 3.0 (7.5%) 0.244
Deep bite 12.0 (30.0%) 11.0 (27.5%) 14.0 (35.0%)
Pearson’s Chi-squared test.

Table 8 displays the results of the interarch dental occlu- children in the patient group (p < 0:001). No statistically sig-
sal assessment of the study participants. Class II Division 1 nificant differences were detected in the frequency of the
malocclusion was detected in 18 (64.3%) children in the presence of posterior crossbite (p = 0:335), anterior open
patient group, 15 (50.0%) children in the treatment group, bite, and deep bite (p = 0:244) between groups.
and in only 4 (11.8%) children in the control group. A statis- Table 9 shows the OHRQoL of all children who partici-
tically significant difference was found among the study pated in the study. When the ECOHIS scores were com-
groups (p < 0:001). Class I malocclusion was detected in 4 pared between the groups, difference was only found
(14.3%), 6 (20.0%), and 10 (29.4%) children in the patient, between the children’s self-image and social interaction
treatment, and control groups, respectively. Normal occlu- scores (p = 0:049). This difference was between the patient
sion was detected in 20 (58.8%) children in the control group, and control groups (p = 0:012). No difference was found in
9 (30%) children in the treatment group, and only 6 (21.4%) terms of the self-image and social interaction scores of the
8 BioMed Research International

Table 9: Assessment of OHRQoL-ECOHIS scale.

Group Mean SD SE p
Child impact section
Patient 0.95 1.319 0.209
Treatment 1.03 1.387 0.219
Child symptoms 0.984
Control 1.05 1.518 0.240
Total 1.01 1.399 0.128
Patient 2.15 3.363 0.532
Treatment 2.65 3.634 0.575
Child function 0.816
Control 2.45 3.404 0.538
Total 2.42 3.446 0.315
Patient 0.48 1.261 0.199
Treatment 0.60 1.516 0.240
Child psychology 0.936
Control 0.53 1.519 0.240
Total 0.53 1.426 0.130
Patient 1.90 1.809 0.286
Treatment 1.48 2 0.316
Child self-image and social interaction 0.049∗
Control 0.98 1.459 0.231
Total 1.45 1.796 0.164
Patient 5.48 6.869 1.086
Treatment 5.75 7.2 1.138
Total child score 0.519
Control 5 6.887 1.089
Total 5.41 6.935 0.633
Family impact section
Patient 0.65 1.494 0.236
Treatment 1.23 2.270 0.359
Parental distress 0.494
Control 1.13 2.09 0.330
Total 1 1.979 0.181
Patient 0.30 0.883 0.140
Treatment 0.55 1.154 0.182
Family function 0.255
Control 0.73 1.502 0.237
Total 0.53 1.209 0.110
Patient 0.95 2.309 0.365
Treatment 1.78 3.363 0.532
Total parent score 0.402
Control 1.85 3.446 0.545
Total 1.53 3.084 0.282
Patient 6.43 8.918 1.410
Treatment 7.53 10.163 1.607
Total ECOHIS score 0.690
Control 6.85 9.991 1.580
Total 6.93 9.635 0.880
Kruskal Wallis Test.

children between the patient and treatment groups [8, 10, 30]. Symptoms that were detected in higher rates in
(p = 0:170). the patient group when compared with children in the treat-
ment group were mouth breathing, followed by snoring,
4. Discussion open mouth during sleep, dry mouth, thirsty awakening at
nights, salivate on the pillow during sleeping, abnormal
Adenotonsillar hypertrophy (AH) is regarded as a prevalent breathing, and restless sleep. The lower rates of symptoms
disease among children and one of the primary causes of detected in the treatment group showed that adenotonsillect-
upper respiratory obstruction [28, 29]. In this study, it was omy surgery has a positive effect on relieving such symptoms.
found that children with adenotonsillar hypertrophy experi- Elsherif and Kareemullah [30] conducted a study involving
enced various symptoms that were reported in the literature 76 children aged between 3 and 12 with large adenoids and
BioMed Research International 9

tonsils who had surgery in order to improve upper airway among the nasal and mouth breathing patients. Also, they
obstruction. The researchers reported that after surgery, did not find any difference between the DMFT scores in the
nearly all patients demonstrated recovery of all symptoms two groups. Koga-Ito et al. [15] conducted a study among
such as snoring, mouth breathing, sleep apnoea, and daytime 30 mouth-breathing and healthy children and found no dif-
somnolence. In accordance with this study, Elsherif and Kar- ference in terms of salivary flow rate among the study and
eemullah [30] reported that children who had adenotonsillar control groups. The findings of the present study were found
hypertrophy showed significant improvement after adeno- to be in accordance with the findings of Yıldırım and Aktören
tonsillectomy surgery. Orji and Ezeanolue [13] conducted a [32], Mummalo et al. [33], Alqutami et al. [34], Weiler et al.
study on 59 children with chronic upper airway obstruction [35], and Koga-Ito et al. [15]. Dental caries is a multifactorial
and examined their improvements in breathing difficulties disease, and various factors play a role in the formation and
and sleep disturbances following adenotonsillectomy sur- progression of dental caries such as biological factors, the
gery. The researchers reported that the most improved symp- presence of cariogenic microorganisms, dietary habits, oral
tom was snoring, and the least was daytime somnolence. In hygiene practices, parental education, and socioeconomic
our study, the symptom with the most significant improve- status [36]. Thus, in this study, these factors were also inves-
ment was mouth breathing followed by snoring, and the least tigated. No statistically significant difference was found in the
improvement was observed in hyperactivity. Orji and Ezea- family income and parental education status among study
nolue [13] reported that although they found significant groups, and both family income and education status were
recovery in obstructive symptoms in most of the children found to be high and satisfactory among the parents of all
after adenotonsillectomy, some children continued mouth children. Furthermore, toothbrushing frequency, supervised
breathing and snoring as with our findings. Several children toothbrushing, usage of fluoridated toothpaste, and nutri-
in the treatment group continued snoring and mouth breath- tional habits did not differ among the study groups apart
ing along with other symptoms in this study. According to from the higher frequency of candy and lollipop consump-
our findings, we concluded that although adenotonsillectomy tion among the patient group compared with the treatment
is associated with remarkable improvement in the symptoms and control groups. Most of the children in all study groups
of children with adenotonsillar hypertrophy, some symp- said they brushed their teeth at least once a day and used
toms persist in a small number of children. fluoridated toothpaste. The similar results obtained with
Patients with adenotonsillar hypertrophy mainly breath respect to those factors among the study groups could be
through the mouth [8, 9]. In mouth breathing patients, there the reason for the lack of difference in terms of dental caries
may be a decrease in the amount of saliva through evapora- formation. According to our findings, we could not demon-
tion. Saliva has many important functions in maintaining strate a relationship between adenotonsillar hypertrophy
oral health. These include self-cleaning of the oral cavity, and dental caries formation. Furthermore, when the ECOHIS
buffering of the acids, antimicrobial properties, and reminer- scores were compared between groups, there were no statisti-
alization of demineralized enamel. A reduction in resting sal- cally significant differences found between groups in terms of
ivary flow is related to increased numbers of candida and child symptoms, function, psychology, family distress, and
lactobacilli species, decreased plaque pH, and a higher risk function. Therefore, it was shown that adenotonsillar hyper-
of caries [31]. Ahmed [17] reported that children with trophy did not contribute negatively to the OHRQoL of the
chronic tonsillitis had higher mean values of dental caries children; it might be a risk factor for dental caries, but by
when compared to children with intact tonsils. The ensuring adequate oral health care, it is possible to prevent
researchers stated that dental caries and peritonsillar infec- the formation of dental caries in children with adenotonsillar
tions possess the same microbial pathogens. Ballıkaya et al. hypertrophy.
[11] reported that mouth breathing might be related to the Mouth breathing is also regarded as one of the factors
severity of dental caries. The results of the studies by Ahmet that contribute to the initiation and progression of periodon-
[17] and Ballıkaya et al. [11] contradict our findings because tal diseases. Chronic mouth breathing-related anterior open
no significant relationship was found in the salivary flow rate, bite is linked with a high incidence of periodontal problems.
dmft/s, DMFT/S index scores between the patient, treatment, Possible causes include the lack of cleansing effect of saliva,
and control groups of this study. Yıldırım and Aktören [32] reduced epithelial defence to dental plaque, and dehydration
conducted a study among 75 mouth-breathing children and of the gingival surface [31, 37]. Yıldırım and Aktören [32]
25 nasal breathing children aged between 5 and 12 years, found no significant differences in terms of marginal gingivi-
and no statistically significant difference was found between tis between nose and mouth breathing children. In addition,
the df, dfs, DMF, DMFS values of the mouth and nasal plaque indices were found to be higher in nose breathing
breathing children. Mummolo et al. [33] also reported that children compared to mouth breathing children. Alqutami
salivary flow rates did not differ between 20 mouth- et al. [34] also failed to demonstrate a relationship between
breathing patients and the same number of nasal breathing the mouth breathing habit and the prevalence of gingivitis
patients. Alqutami et al. [34] investigated the effect of mouth based on the examination of mandibular left central incisor
breathing on the prevalence of dental caries but they were and maxillary right central incisor. The plaque and gingival
unable to show such a relationship. Weiler et al. [35] con- index evaluation findings of this study were in line with the
ducted a study among 61 adolescents aged 10-19 years, where findings of Yıldırım and Aktören [32] and Alqutami et al.
30 were mouth breathers and 31 were nose breathers. The [34]. On the other hand, the results of this study were not
researchers reported no difference in salivary flow rates in agreement with those of Gulati et al. [38], Mummolo
10 BioMed Research International

et al. [33], Demir et al. [16], and Nascimento Filho et al. [37]. between the patient, treatment, and control groups. Although
Gulati et al. [38] reported that because of insufficient lip the prevalence of children with nail biting and bruxism was
height in mouth breathing patients, plaque accumulation is slightly higher in the patient group, no statistically significant
high in the anterior region, so gingival index values are differences were found.
higher. Mummolo et al. [33] reported that plaque index Mouth breathing due to adenotonsillar hypertrophy has
values were higher in 20 mouth-breathing patients when been shown to cause most dentofacial changes [2, 8, 10–12,
compared with the same number of nasal breathing patients. 45], and it has been reported that the majority of dentofacial
Demir et al. [16] investigated 20 patients with adenotonsillar anomalies are reversible within the first year after an adenoi-
hypertrophy and 15 children without adenotonsillar hyper- dectomy [13, 14]. In our study, in accordance with the liter-
trophy and concluded that adenotonsillar hypertrophy leads ature [2, 8, 10–12, 45], we found that adenotonsillar
to the occurrence of gingival disease and plaque accumula- hypertrophy caused dentofacial changes. A V-shaped nar-
tion and improves gingival health after surgery. In our study, rowing in the maxillary arch and the presence of adenoid face
plaque and gingival index scores did not differ between were found to be statistically high in the patient group when
patient, treatment, and control groups. However, the inci- compared with the control group, which concurs with the
dence of dental plaque on the buccal surface of the anterior findings of Yıldırım and Aktoren [32]. Open mouth posture
teeth was found to be higher than the posterior teeth among was observed in nearly 80% percent of children in the patient
all study participants. The reason for this result might be group in line with the findings of Yıldırım and Aktören [32],
because even though open mouth posture was detected in Lopatienė and Bbarskars [45], and Osiatuma et al. [46]. The
higher rates among patient and treatment groups when com- statistically significant higher prevalence of anterior and
pared with the control group, the salivary flow rates did not lower tongue position detected in the patient group was sim-
differ between groups, most of the children perform mechan- ilar to the findings of Osiatuma et al. [46], but the higher
ical plaque removal at least once a day, and only few children prevalence of anterior and lower tongue position and retro-
exhibited anterior open bite. gnathic position of the mandibula was detected in the patient
Pathogenesis of adenoid hypertrophy is one of the possi- group when compared with the control group not in line with
ble causes of halitosis [39]. In the formation of halitosis, the findings of Yıldırım and Aktören [32]. Furthermore, a
mouth breathing is also important in addition to plaque prominent position of the maxillary anterior teeth was found
accumulation, presence of dental caries, and tooth brushing in nearly 38% of children in the patient group, but only 8%
habits [40]. The organoleptic test is accepted as the gold stan- percent of children in the control group. This finding was
dard in oral malodor diagnosis, which can detect the strength in accordance with Lopetiene and Bbarskars [45] and Bassh-
of smell exhalated through the mouth or the nose [39]. Thus, eer et al. [47]. Statistically significant higher rates of Class II
in this study, the organoleptic measurement technique was Div 1 malocclusion were detected in the patient group when
used in the evaluation of halitosis. Dinc et al. [41] reported compared with the control group. Similar observations were
a statistically significant relationship between halitosis and reported by Grippadue et al. [48], Lopatiene and Bbarskars
adenoid hypertrophy and valuable recovery in halitosis after [45], and Osiatuma et al. [46]. The presence of posterior
adenoidectomy surgery. Aw et al. [42] reported that adeno- crossbite among the patient group was slightly higher when
tonsillar hypertrophy and tonsillitis are the main throat dis- compared with the control group. This finding was not found
orders that cause halitosis. Motta et al. [43] and Alqutami statistically significant, which is in line with Yıldırım and
et al. [34] also demonstrated a statistically significant rela- Aktören [32] and Melink et al. [49] but contradicts the find-
tionship between mouth breathing and halitosis. Yıldırım ings of Grippaduo et al. [48] and Osiatuma et al. [46]. Fur-
and Aktören [32] found halitosis in 58.7% of mouth breath- thermore, the prevalence of anterior open bite among the
ing children and 64% of children with normal breathing, but patient group was slightly higher in the patient group when
they could not show a difference in terms of halitosis between compared with the control group, but the difference was
the studied groups. In this study, the patient group showed not statistically significant. Thus, this finding was not in
higher rates of halitosis when compared with the treatment accordance with Grippaudo et al. [48], Yıldırım and Aktören
and control groups. The findings of the present study were [32], and De Lira et al. [8]. In addition, high and very similar
found to be accordance with Dinc et al. [41], Aw et al. [42], rates of dentofacial changes were detected in the treatment
Motta et al. [43], and Alqutami et al. [34], but not in accor- group and patient groups. Thus, the high and very similar
dance with Yıldırım and Aktören [32]. Adenoid hypertrophy detection rates of V-shaped narrowing in the maxillary arch,
can occur because of infectious and noninfectious etiologies adenoid face, macroglossia, open mouth posture, anterior
[44]. Tonsillitis is one of the reasons for oral malodor in and lower tongue position, retrognathic position of mandi-
healthy individuals [26]. Parapharyngeal infections and nasal bula, prominent position of maxillary anterior teeth, retro-
secretions might be the reasons for the higher rates of halito- gnathic position of mandibular anterior teeth, and Class II
sis detected in the patient group when compared with the division 1 malocclusion in the patient and treatment group
treatment and control groups of this study. compared to the control group indicated that adequate
Morais-Almeida et al. [9] reported that mouth breathing recovery could not be achieved on these findings after adeno-
is frequently associated with bad oral habits; however, the tonsillectomy surgery. Higher self-image and social interac-
results obtained in the present study failed to demonstrate tion scores in the assessment of OHRQoL could originate
such a relationship as the presence of nail biting, lip biting, from the dentofacial changes and halitosis among the patient
lip sucking, tongue thrusting, and bruxism did not differ group when compared with the control group. The lack of
BioMed Research International 11

difference between the patient and treatment groups in terms [2] N. Viveros, “Adenoid and tonsil hypertrophy in children and
of self-image might be because of the previously mentioned facial malformations,” Journal of Otolaryngology-ENT
fact that adequate recovery of dentofacial changes was not Research, vol. 4, no. 1, article 00086, 2016.
achieved after adenotonsillectomy surgery. In accordance [3] F. B. D. Andrade-Balieiro, R. Azevedo, and B. M. Chiari,
with our findings, Pereira et al. [50] reported that adenoton- “Aspects of stomatognathic system before and after adenoton-
sillar hypertrophy is associated with mouth breathing and sillectomy,” Codas., vol. 25, no. 3, pp. 229–235, 2013.
can cause facial changes, while adenotonsillectomy is not suf- [4] M. Capua, N. Ahmadi, and C. Shapiro, “Overview of obstruc-
ficient for improvement and recommended facial orthodontic tive sleep apnea in children: exploring the role of dentists in
treatments in order to achieve functional and morphological diagnosis and treatment,” Journal of the Canadian Dental
healing. William and Mahony [51] reported that by the age Association, vol. 75, no. 4, pp. 285–289, 2009.
of 12, 80%-90% of craniofacial growth is complete, and the [5] V. Padmanabhan, P. R. Kavitha, and A. Hegde, “Sleep disor-
early prevention and management of young patients with dered breathing in children-a review and the role of a pediatric
increased nasal airway resistance have vital importance. dentist,” The Journal of Clinical Pediatric Dentistry, vol. 35,
no. 1, pp. 15–21, 2010.
5. Conclusion [6] J. Ngiam and P. A. Cistulli, “Dental treatment for paediatric
obstructive sleep apnea,” Paediatric Respiratory Reviews,
In conclusion, this study demonstrated that mouth breathing vol. 16, no. 3, pp. 174–181, 2015.
due to adenotonsillar hypertrophy may cause various dento- [7] F. C. Valera, L. V. Travitzki, S. E. Mattar, M. A. Matsumoto,
facial changes and an increase in Class II division 1 malocclu- A. M. Elias, and W. T. Anselmo-Lima, “Muscular, functional
sion and halitosis. However, we could not demonstrate such a and orthodontic changes in pre school children with enlarged
relationship with dental caries and periodontal diseases. It adenoids and tonsils,” International Journal of Pediatric Oto-
rhinolaryngology, vol. 67, no. 7, pp. 761–770, 2003.
was detected that adequate recovery could not be achieved
on dentofacial changes after adenotonsillectomy surgery. In [8] A. D. L. S. De Lira, A. De Moraes Izquierdo, S. Prado, M. M. G.
order to improve the dentofacial changes after surgery, it is Souza, and S. R. Torres, “Adenoid hypertrophy and open bite,”
Brazilian Journal of Oral Sciences, vol. 10, no. 1, pp. 17–21, 2011.
recommended that orthodontic treatment should start as
soon as possible if indicated. Furthermore, it is also extremely [9] M. Morais-Almeida, G. F. Wandalsen, and D. Solé, “Cresci-
important to consult with a paediatric dentist in order to per- mento e respiradores orais,” Jornal de Pediatria, vol. 95,
no. 1, pp. 66–71, 2019.
form oral rehabilitation, determine risk factors, educate and
support the child and family about oral health, and prevent [10] L. Agarwal, R. Tandon, R. Kulshrestha, and A. Gupta, “Ade-
the formation of new carious lesions by applying preventive noid facies and its management: an orthodontic perspective,”
Indıan Journal of Orthodontics and Dentofacial Research.,
measures and remineralisation agents. It was shown that ade-
vol. 2, no. 2, pp. 50–55, 2016.
notonsillar hypertrophy does not negatively affect OHRQoL,
but it could be a risk factor for dental caries, periodontal dis- [11] E. Ballikaya, B. G. Dogan, O. Onay, and M. U. Tekcicek, “Oral
health status of children with mouth breathing due to adeno-
eases, and halitosis; however, by ensuring adequate oral
tonsillar hypertrophy,” International Journal of Pediatric Oto-
health care, it is possible to maintain oral health in children rhinolaryngology, vol. 113, pp. 11–15, 2018.
with adenotonsillar hypertrophy. In this context, otorhino-
[12] L. Kaskova and L. Ulasevych, “Oral hygienic state and pH
laryngologists, pedodontists, and orthodontists should work
value in children with adenoid hypertrophy,” Ukrainian Den-
as a team in the treatment of children with adenotonsillar tal Almanac., vol. 2, pp. 64–66, 2016.
hypertrophy.
[13] F. T. Orji and B. C. Ezeanolue, “Outcome of adenotonsillect-
omy for sleep and breathing difficulties in Nigerian children
Data Availability with obstructive adenotonsillar enlargement,” Indian Journal
of Otolaryngology and Head & Neck Surgery, vol. 64, no. 2,
The data used to support the findings of this study are avail- pp. 131–136, 2012.
able from the corresponding author is upon request.
[14] L. Zettergren-Wijk, C. M. Forsberg, and S. Linder-Aronson,
“Changes in dentofacial morphology after adeno-/tonsillec-
Conflicts of Interest tomy in young children with obstructive sleep apnoea- a 5-
year follow-up study,” The European Journal of Orthodontics.,
The authors declare that there is no conflict of interest vol. 28, no. 4, pp. 319–326, 2006.
regarding the publication of this paper.
[15] C. Y. Koga-Ito, C. S. Unterkircher, H. Watanabe, C. A. D. P.
Martins, V. Vidotto, and A. O. C. Jorge, “Caries risk tests
Acknowledgments and salivary levels of immunoglobulins to Streptococcus
mutans and Candida albicans in mouth breathing syndrome
We thank all the children and parents for their contributions patients,” Caries Research, vol. 37, no. 1, pp. 38–43, 2003.
to this study.
[16] U. L. Demir, B. Cetinkaya, S. Karaca, and D. Sigirli, “The
impacts of adenotonsillar hypertrophy on periodontal health
References in children: a prospective controlled pilot study,” American
Journal of Otolaryngology, vol. 34, no. 5, pp. 501–504, 2013.
[1] A. L. Jácomo, F. E. Akamatsu, M. Andrade, and N. F. Margar-
ido, “Pharyngeal lymphatic ring: anatomical review,” Morpho- [17] Z. S. H. Ahmed, “The relationship between severity of dental
logical Sciences, vol. 27, no. 1, pp. 47–49, 2010. caries and chronic tonsillitis among Iraqı children,” Journal of
12 BioMed Research International

the Faculty of Medicine Baghdad, vol. 58, no. 2, pp. 149–153, [34] J. Alqutami, W. Elger, N. Grafe, A. Hiemisch, W. Kiess, and
2016. C. Hirsch, “Dental health, halitosis and mouth breathing in
[18] C. F. Koca, T. Erdem, and T. Bayındır, “The effect of adenoid 10-to-15 year old children: a potential connection,” European
hypertrophy on maxillofacial development: an objective pho- Journal of Paediatric Dentistry, vol. 20, no. 4, pp. 274–279,
tographic analysis,” Journal of Otolaryngology - Head & Neck 2019.
Surgery, vol. 45, no. 1, pp. 1–8, 2016. [35] R. M. Weiler, M. Fisberg, A. S. Barroso, J. Nicolau, R. Simi, and
[19] L. E. Miller, A. Buzi, A. Williams et al., “Reliability and accu- W. L. Siqueira Jr., “A study of the influence of mouth-
racy of remote fiberoptic nasopharyngolaryngoscopy in the breathing in some parameters of unstimulated and stimulated
pediatric population,” Ear, Nose, & Throat Journal, Article whole saliva of adolescents,” International Journal of Pediatric
ID 145561320919109, 2020. Otorhinolaryngology, vol. 70, no. 5, pp. 799–805, 2006.
[20] L. Brodsky and R. J. Koch, “Anatomic correlates of normal and [36] Z. Hatipoğlu and D. Akşit-Bıçak, “Maternal anxiety, social sta-
diseased adenoids in children,” The Laryngoscope., vol. 102, tus, and dental caries formation in children: a cross-sectional
no. 11, pp. 1268–1274, 1992. study,” The Journal of International Medical Research,
[21] B. Q. Souki, G. B. Pimenta, M. Q. Souki, L. P. Franco, H. M. vol. 47, no. 12, pp. 6206–6214, 2019.
Becker, and J. A. Pinto, “Prevalence of malocclusion among [37] E. NascimentoFilho, M. P. A. Mayer, P. Pontes, A. C. C. Pigna-
mouth breathing children: do expectations meet reality?,” tari, and L. L. M. Weckx, “Caries prevalence, levels of mutans
International Journal of Pediatric Otorhinolaryngology, streptococci, and gingival and plaque indices in 3.0- to 5.0-
vol. 73, no. 5, pp. 767–773, 2009. year-old mouth breathing children,” Caries Research, vol. 38,
[22] World Health Organization, Oral Health Survey Basic no. 6, pp. 572–575, 2004.
Methods, WHO, Geneva, 4th edition, 1997. [38] M. S. Gulati, N. Grewal, and A. Kaur, “A comparative study of
[23] J. Silness and H. Löe, “Periodontal disease in pregnancy II. Cor- effects of mouth breathing and normal breathing on gingival
relation between oral hygiene and periodontal condition,” Acta health in children,” Journal of the Indian Society of Pedodontics
Odontologica Scandinavica, vol. 22, no. 1, pp. 121–135, 1964. and Preventive Dentistry, vol. 16, no. 3, pp. 72–83, 1998.
[24] H. Löe and J. Silness, “Periodontal disease in pregnancy I. [39] M. Sikorska-Żuk and M. Bochnia, “Halitosis in children with
Prevalence and severity,” Acta Odontologica Scandinavica, adenoid hypertrophy,” Journal of Breath Research, vol. 12,
vol. 21, no. 6, pp. 533–551, 1963. no. 2, article 026011, 2018.
[25] F. A. Sawair, S. Ryalat, M. Shayyab, and T. Saku, “The unsti- [40] T. Kanehira, J. Takehara, D. Takahashi, O. Honda, and
mulated salivary flow rate in a Jordanian healthy adult popula- M. Morita, “Prevalence of oral malodor and the relationship
tion,” Journal of Clinical Medical Research, vol. 1, no. 4, with habitual mouth breathing in children,” The Journal of
pp. 219–225, 2009. Clinical Pediatric Dentistry, vol. 28, no. 4, pp. 285–288, 2004.
[26] D. Aksit-Bicak, “A current approach to halitosis and oral mal- [41] M. E. Dinc, A. Altundag, D. Dizdar et al., “An objective assess-
odor- a mini review,” The Open Dentistry Journal., vol. 12, ment of halitosis in children with adenoid vegetation during
no. 1, pp. 322–330, 2018. pre- and post-operative period,” International Journal of Pedi-
atric Otorhinolaryngology, vol. 88, pp. 47–51, 2016.
[27] K. Peker, Ö. Uysal, and G. Bermek, “Cross - cultural adapta-
tion and preliminary validation of the Turkish version of the [42] A. Aw, T. G. Olajıde, A. G. Olusola, F. Olatoke, and C. C. Nwa-
early childhood oral health impact scale among 5-6-year-old wolo, “Paediatric otorhinolaryngological presentation of hali-
children,” Health and Quality of Life Outcomes, vol. 9, no. 1, tosis in a developing country,” Journal of the West Afrıcan
p. 118, 2011. College of Surgeons., vol. 7, no. 4, pp. 34–51, 2017.
[28] S. M. H. Jazi, B. Barati, and A. Kheradmand, “Treatment of [43] L. J. Motta, J. C. Bachiega, C. C. Guedes, L. T. Laranja, and S. K.
adenotonsillar hypertrophy: a prospective randomized trial Bussadori, “Association between halitosis and mouth breath-
comparing azithromycin vs. fluticasone,” Journal of Research ing in children,” Clinics, vol. 66, no. 6, pp. 939–942, 2011.
in Medical Sciences, vol. 16, no. 12, pp. 1590–1597, 2011. [44] M. R. Rout, D. Mohanty, Y. Vijaylaxmi, K. Bobba, and
[29] R. R. Abreu, R. L. Rocha, J. A. Lamounier, and Â. F. M. Guerra, C. Metta, “Adenoid hypertrophy in adults: a case series,”
“Etiology, clinical manifestations and concurrent findings in Indian Journal of Otolaryngology and Head & Neck Surgery,
mouth-breathing children,” Jornal de Pediatria, vol. 84, no. 6, vol. 65, no. 3, pp. 269–274, 2013.
pp. 529–535, 2008. [45] K. Lopatienė and A. Babarskars, “Malocclusion and upper air-
[30] I. Elsherif and C. Kareemullah, “Tonsil and adenoid surgery way obstruction,” Medicina, vol. 38, no. 3, pp. 277–283, 2002.
for upper airway obstruction in children,” Ear, Nose, & Throat [46] V. I. Osiatuma, O. D. Otuyemi, K. A. Kolawole, B. O. Ogun-
Journal, vol. 78, no. 8, pp. 617–620, 1999. banjo, and Y. B. Amusa, “Occlusal characteristics of children
[31] B. E. G. Triana, A. H. Ali, and I. G. León, “Mouth breathing with hypertrophied adenoids in Nigeria,” International Ortho-
and its relationship to some oral and medical conditions: phys- dontics, vol. 13, no. 1, pp. 26–42, 2015.
iopathological mechanisms involved,” Revista Habanera de [47] B. Basheer, K. S. Hegde, S. S. Bhat, D. Umar, and K. Baroudi,
Ciencias Médica, vol. 15, no. 2, pp. 200–212, 2016. “Influence of mouth breathing on the dentofacial growth of
[32] M. Yıldırım and O. Aktören, “Evaluation of the effects of children: a cephalometric study,” Journal of International Oral
mouthbreathing on orodental health and surrounding tissues Health., vol. 6, no. 6, pp. 50–55, 2014.
in children,” Journal of Istanbul University Faculty of Den- [48] C. Grippaudo, E. G. Paolantonio, G. Antonini, R. Saulle, G. la
tistry, vol. 41, no. 3, pp. 65–74, 2012. Torre, and R. Deli, “Association between oral habits, mouth
[33] S. Mummolo, V. Quinzi, A. Dedola, F. Albani, G. Marzo, and breathing and malocclusion,” Acta Otorhinolaryngologica Ita-
V. Campanella, “Oral microbiota in mouth-breathing lica, vol. 36, no. 5, pp. 386–394, 2016.
patients,” Journal of Oral Hygiene & Health, vol. 8, no. 2, arti- [49] S. Melink, M. V. Vagner, I. Hocevar-Boltezar, and M. Ovsenik,
cle 1000259, 2020. “Posterior crossbite in the deciduous dentition period, its
BioMed Research International 13

relation with sucking habits, irregular orofacial functions, and

otolaryngological findings,” American Journal of Orthodontics
and Dentofacial Orthopedics, vol. 138, no. 1, pp. 32–40, 2010.
[50] S. R. A. Pereira, L. L. M. Weckx, C. L. F. Ortolani, and S. F.
Bakor, “Estudo das alterações craniofaciais e da importância
da expansão rápida da maxila após adenotonsilectomia,” Bra-
zilian Journal of Otorhinolaryngology, vol. 78, no. 2, pp. 111–
117, 2012.
[51] K. William and D. Mahony, “The effects of enlarged adenoids
on a developing malocclusion,” Journal of Pediatric Dental
Care, vol. 13, no. 3, 2007.