ORIGINAL ARTICLE

Clinical recognition of mouth breathers

Introduction: A routine diagnosis of a patient's breathing status performed by an orthodontist normally includes
visual assessment, medical history, clinical examination of habitual lip posture, size and shape of the nostrils,
reflex control of the alar muscle and respiratory tests, and the dental mirror test. The objective of this study
was to test the recognition of mouth breathers in young persons by an orthodontist and agreement with an oto-
laryngologist's reference diagnosis when routine assessments were carried out. Methods: Three independent
and blind evaluations were conducted on the same day by 2 orthodontists independently (anamnesis and
breathing tests, respectively) and an otolaryngologist (rhinoscopy, nasal endoscopy, and visual assessment).
The weighted kappa coefficient was used to test intraexaminer and interexaminer agreement. The frequencies
of answers and findings were reported for each breathing status. Results: Fifty-five volunteers composed the
sample of this study; 20 participants were nasal breathers, and 35 participants were classified as mouth
breathers (and subdivided into mouth breathers with airway obstruction and mouth breathers by habit) by the
otolaryngologist. The weighted kappa coefficient showed poor interrater agreement for most comparisons.
Conclusions: Recognition of mouth breathing in young persons by orthodontists is poor. (Am J Orthod
Dentofacial Orthop 2017;152:646-53)

N
asal breathing promotes proper growth and frequency, and duration, might lead to persistent mouth
development of the craniofacial and dentofacial breathing and, consequently, deform the dental arch
complexes in accordance with the theory of the and alter facial harmony.7,8 The most common cause
functional matrix of Moss and Salentijn.1 This theory of mouth breathing is nasal obstruction, specifically
is based on the principle that normal nasal respiratory adenoid hypertrophy, in the pediatric population.9
activity influences and favors harmonious growth and Children with mouth breathing have a higher ten-
development by adequately interacting with mastication dency for clockwise rotation of the growing mandible,
and swallowing and other functions of the head and with a disproportionate decrease in posterior facial height
neck region.1 and an increase in anterior lower face height. The latter is
Mouth breathing has a multifactorial etiology that often associated with a retrognathic mandible and an
may vary from an anatomic obstruction, such as palatine open bite.10 However, Harvold et al11 showed in a study
and pharyngeal tonsil hypertrophy, septal deviation, with young growing rhesus monkeys that when a nasal
nasal polyps, nasal turbinate hypertrophy,2 allergic obstruction or tonsil-like obstruction was almost
rhinitis,2,3 overweight,4 oral habits,5 and neuromuscular completely blocking, a few dentofacial changes could
diseases,6 or indirectly from deleterious oral habits. In be observed; this means that moderate obstructions do
particular, allergic rhinitis, depending on its intensity, not necessarily lead to craniofacial alterations. Orthodon-
tic treatment seeks to solve dentofacial and craniofacial
a
Department of Orthodontics, Universidade Federal Fluminense, Niter
oi, Rio de alterations, and a multidisciplinary approach may be
Janeiro, Brazil.
b
necessary, with participation of pediatric surgeons,
Private practice otolaryngologist, Rio de Janeiro, Brazil.
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
otolaryngologists, allergists, and speech therapists.12,13
tential Conflicts of Interest, and none were reported. The orthodontist may be the first health care profes-
Address correspondence to: Adriana de Alcantara Cury-Saramago, Universidade sional to monitor the craniofacial growth and develop-
Federal Fluminense, Rua M
ario Santos Braga, 30, 2 andar, sala 214, Campos
Valoguinho, Centro, Niter
oi, RJ CEP 24020-140, Brazil; e-mail, adricury@
ment time of childhood. Young patients should be
gmail.com. referred to an otolaryngologist when signs or symptoms
Submitted, May 2016; revised and accepted, March 2017. of mouth breathing are identified to improve their qual-
0889-5406/$36.00
Ó 2017 by the American Association of Orthodontists. All rights reserved.
ity of life and prevent any adaptive dental and facial
http://dx.doi.org/10.1016/j.ajodo.2017.03.025 changes.14,15
646
Costa et al 647

Alternative methods of airway evaluation associated about health problems, incidence of sinusitis or tonsil-
with a multidisciplinary approach have been used, litis, use of medications, speech therapy, allergies,
including nasal resistance tests or rhinomanometry, rhinos- breathing problems, open mouth breathing, stuffy
copy,16 fluoroscopy,17 magnetic resonance imaging,18,19 nose, sneezing frequency, snoring, dry mouth on awak-
nasal endoscopy,20-23 lateral cephalograms,21,24-26 and ening, suffocation or breathlessness, water drinking dur-
computed tomography scans.22,27-30 ing the night, daytime sleepiness, use of nasal spray,
Nasal endoscopy is the reference standard for assess- physical activities, and deleterious habits (Appendix
ing the nasopharynx by an otolaryngologist with a stan- 1).12,14,33,34
dardized grading system for the evaluation of airway Another orthodontist, responsible for the clinical ex-
obstruction.20 However, nasal findings may be restricted amination, who had more than 10 years of clinical prac-
by septal deviation, size of adenoids and nasal turbinates tice, assessed (Appendix 2) the participant in the sitting
hypertrophy, and nasal polyps and tumors, since the position, with straight head and breathing normally.
endoscope fiber optic may be blocked by these anatomic Two breathing tests were conducted: the first was an
structures.31 observation of nasal movement while the participant
The diagnostic routine of the breathing status was breathing,35 and subsequently, the clinical mirror
accomplished by an orthodontist normally includes vi- test was performed in which a mirror is positioned under
sual assessment (97.2%), clinical medical history each nostril for 30 seconds to observe fogging or
(87.2%), and clinical examination of habitual lip condensation.36
posture, size and shape of the nostrils, reflex control of According to the evaluations, after the participants
the alar muscle, and respiratory tests (59%)14 such as were assessed, they were classified as mouth breathers
the dental mirror test.32 Moreover, orthodontists' ability or nasal breathers by each orthodontist independently
to recognize a patient's breathing status confirmed by to isolate findings obtained from the anamnesis and
an otolaryngologist's diagnostic analysis has not been clinical examinations and to check whether one of
adequately documented. them contributed more to an ascertained recognition.
The objective of this study was to compare the recog- Each orthodontist reached this definition for each pa-
nition of mouth breathers in young persons by the tient based on his or her personal experience and on
routine orthodontic assessment with an otolaryngolo- literature recommendations (in the case of clinical exam-
gist using a clinical diagnostic assessment. ination).
The otolaryngologist, who had more than 25 years
MATERIAL AND METHODS of clinical practice, then examined the participants
This cross-sectional blind comparative clinical study clinically, in the upright rest position without exercise.
was approved by the research ethics committee of Uni- Initially they were examined with rhinoscopy to diag-
versidade Federal Fluminense in Niter
oi, Rio de Janeiro, nose obstructions or alterations in the nasal cavity
Brazil. Initially, this study involved 125 consecutive space, such as septum deviation and nasal turbinates
young patients from the Department of Orthodontics. hypertrophy. The tonsils were observed with and
Before the study started, participants and their parents without a tongue depressor. A topical decongestant
or guardians were informed and signed a written con- spray (0.05% xymetazoline) was administered to
sent form to participate in the research and to allow each participant; immediately after that, a topical
the use of their orthodontic records. anesthetic spray (2% xylocaine) was applied into
Eligibility criteria included (1) age from 10 to 25 years, each nostril. The participants were oriented to aspire
(2) no recent surgery (in the prior 6 months), (3) no in- solutions to improve absorption and achieve greater
fections or inflammatory diseases in the airways at the comfort during nasal endoscopy. The nasal endoscopy
time of examination, (4) no confirmed syndromes, (5) was performed using a rigid fiberoptic 30 endoscope,
no neurologic disorders, (6) no facial anomalies, and and digital images of the nasal cavity and its adjacent
(7) no previous orthodontic therapy. The participants structures up to the cavum were captured and re-
were instructed to not use nasal spray on the day they corded during the examination. Immediately after
were examined. the examination, clinical records were completed
Three independent evaluations were conducted on (Appendix 3), and some characteristics were included,
the same day by 2 orthodontists (J.G.C., A.A.C-S.) and such as the amplitude of the adenoids, nasal turbi-
1 otolaryngologist (G.S.C.). The orthodontist responsible nates and palatine tonsils, the classification of Mal-
for anamnesis, who had more than 20 years of clinical lampati et al,37 nasal septum position, and Cottle's
practice, administered a questionnaire to each partici- classification.38 Each participant's body mass index
pant and the parents or guardians (when necessary) was calculated and registered.

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648 Costa et al

After the nasal endoscopy, alterations of nasal turbi- combination of the examinations previously described;
nates were evaluated once again under the effect of the however, no quantitative index was used for that pur-
topical decongestant and the anesthetic to verify the pose. Nasal breathing corresponded to the physiologic
behavior of these tissues. When there was a decrease pattern and did not have obstructive respiratory char-
of nasal turbinates, it indicated that the obstructions acteristics. MBAO were characterized by any airway ob-
were temporary due to a mucous-vascular component structions observed on clinical evaluation by the
of resistance, such as turbinates hypertrophy,39 and it otolaryngologist as previously described. MBH were
was probably a consequence of unknown allergic pro- characterized by the ability to breathe through the
cesses. nose—ie, without permanent obstacles in the airway;
The severity of adenoid obstruction was evaluated however, they persisted in breathing through the
through nasal endoscopy in the following way: grade mouth. This diagnosis was considered the reference
1, less than 25% obstruction; grade 2, 25% to 50% against which the examinations performed by the or-
obstruction; grade 3, 50% to 75% obstruction; and thodontists were compared.
grade 4, more than 75% obstruction.20 The data collected from the 3 records were tabulated
The classification of Mallampati et al37 correlates and analyzed by a blind researcher.
tongue size to pharyngeal size in the following way:
Class I means visualization of the soft palate, larynx,
uvula, and anterior and posterior pillars of the tonsils; Statistical analysis
Class II means visualization of the soft palate, larynx, All assessments of breathing status from the ques-
and uvula; Class III means visualization of the soft palate tionnaires were repeated by the orthodontist responsible
and the base of uvula; and Class IV means only the hard for anamnesis and also analyzed by the orthodontist
palate is visible. responsible for the clinical examination 1 month later,
According to Cottle's classification, the septal defor- blinded and independently, only through the answers
mities were classified by area: 1 area means the nasal in the records. No patient was recalled for reexamina-
vestibule; 2 area of the nasal valve means the region cor- tion. The latter orthodontist considered the answers
responding to the borderline between the upper and and his own clinical experience to establish his recogni-
lower lateral cartilage, soft tissue adjacent to the piri- tion of each patient. The level of agreement among the
form aperture, and floor of the nasal cavity and nasal evaluators was statistically analyzed using the weighted
septum; 3 attical area means the region behind and kappa test. The agreement between the original recogni-
above the nasal valve in the nasal bones; 4 anterior tion from the questionnaires by the orthodontist respon-
turbinate area means the region corresponding to the sible for anamnesis and its repetition, and the same
cartilaginous and bony septum, opposite the turbinates; analysis from the other orthodontist was statistically
and 5 posterior turbinate area means the region adjacent checked using the weighted kappa test, indirectly assess-
to the choana.38 ing the error of the method.
During nasal endoscopy when the obstruction or nar- Descriptive analyses were used to provide frequencies
rowing in the nasopharynx made it impossible to further of answers from the anamnesis, according to the otolar-
introduce the nasal endoscopy fiberoptic into the yngologist's diagnostic breathing status, and the Pear-
cavum, the computed tomography examinations son chi-square test or the Fisher exact test was used to
routinely included in the patients’ clinical records were test differences. Descriptive statistics and the Pearson
available and accessed by the otolaryngologist to verify chi-square test were also used to assess the frequency
the size of the adenoids. of findings in the otolaryngologist's examination ac-
During the otolaryngologist's clinical evaluation, cording to her diagnosis. Odds ratios associated with
many signs were observed, such as the distance between the presence or absence of characteristics were also
the septum and turbinates, retro tongue freeway space, calculated. For these descriptive statistics, the findings
narrow alar base, dry mouth, labial competence, labial (adenoid hypertrophy, nasal turbinates hypertrophy,
posture, tooth positions, chin, facial height, dark circles tonsil hypertrophy, and septum deviation) were charac-
under the eyes, and self-reported mouth breathing.40 terized as none to mild obstruction or moderate to se-
Ultimately, the participants were diagnosed by the vere obstruction.
otolaryngologist as nasal breathers or mouth breathers, The sensitivity and specificity of the orthodontists in
and the latter were further classified as mouth detecting mouth breathers were also calculated.
breathers with airway obstruction (MBAO) or mouth The significance level was set at 5%. Data were
breathers by habit (MBH). This classification was per- analyzed with the Statistical Package for the Social Sci-
formed by the otolaryngologist, by considering a ences software (version 17; SPSS, Chicago, Ill).

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Costa et al 649

Table I. Agreement between methods of assessment Table II. Agreement between methods of assessment
of clinical recognition of nasal and mouth breathers of clinical recognition of breathing status (orthodon-
tested by the weighed kappa coefficient (n 5 55) tist x OL) in participants diagnosed as mouth breathers
(OL) when considering nasal breathers (by the
Clinical examination
(orthodontist) orthodontist) 5 mouth breathers by habit (by the OL)
Weighted
Nasal Mouth kappa Otolaryngologist examination
breather breather Total (P value) Weighted kappa
MBAO MBH Total (P value)
Anamnesis (orthodontist)
Nasal 38 3 41 0.174 (0.144) Anamnesis (orthodontist)
breather MBAO 7 4 11 0.276 (0.093)
Nasal 8 16 24 SE 0.161
Mouth 11 3 14 SE 0.140
breather Total 15 20 35 CI, –0.039 to 0.592
Total 49 6 55 CI, –0.101 to Clinical examination (orthodontist)
0.449 MBAO 3 3 6 0.054 (0.698)
Nasal 12 17 29 SE 0.141
Otolaryngologist examination Total 15 20 35 CI, –0.222 to 0.331
Anamnesis (orthodontist)
OL, Otolaryngologist; MBAO, mouth breathers with airway obstruc-
Nasal 17 24 41 0.134 (0.178)
tion; MBH, mouth breathers by habit; CI, confidence interval.
breather
Mouth 3 11 14 SE 0.094
breather
Total 20 35 55 CI, –0.050 to and 0.39) for anamnesis and poor (below 0.2) for clinical
0.318 examination, as shown in Table II.41
Otolaryngologist examination The weighted kappa coefficient used to assess incon-
Clinical examination (orthodontist) sistency in the diagnosis and that measured agreement
Nasal 20 29 49 0.131 (0.050) between the original recognition from the anamnesis
breather and its repetition was 0.371 (P \0.0001), and the coef-
Mouth 0 6 6 SE 0.055 ficient between the 2 orthodontists based on the ques-
breather
tionnaire was 0.305 (P 5 0.004).
Total 20 35 55 CI, 0.023 to
0.238 Frequencies of characteristics collected during the
anamnesis according to the reference diagnostic by the
CI, Confidence interval.
otolaryngologist (nasal and mouth breathers) are shown
in Table III. The main issues for mouth breathers were
breathing problems, open-mouth breathing, snoring,
dry mouth on awakening, drinking water during the
RESULTS night, daytime sleepiness, and use of nasal spray. No sta-
The body mass index values of the participants indi- tistically significant difference was observed. The condi-
cated that 76.3% of them were considered to be at a tions that both nasal and mouth breathers mentioned
healthy weight or underweight, and 23.7% were over- were health problems, allergies, stuffy nose, sneezing
weight or obese. frequency, suffocation or breathlessness, physical activ-
The sample included 55 volunteers who were ities, and deleterious habits.
receiving treatment at the orthodontic clinics of Univer- Mouth breathers, of whom 15 participants were
sidade Federal Fluminense. Twenty participants were MBAO and 20 were MBH, demonstrated that frequencies
considered by the otolaryngologist to be nasal breathers of characteristics collected during the anamnesis accord-
(12 female, 8 male; age range, 10-23 years; mean age, ing to the reference diagnosis by the otolaryngologist
15.3 6 3.64 years), whereas 35 participants were classi- (MBAO and MBH) are shown in Table III. The MBAO
fied as mouth breathers (22 female; 13 male; age range, had the following issues that were reported more
10-23 years; mean age, 15.9 6 2.94 years). frequently than among the MBH: health problems, inci-
The weighted kappa coefficient showed poor (below dence of sinusitis or tonsillitis, medical treatment, med-
0.2) interrater agreement for most comparisons (Table I). ications, speech therapy, surgeries (tonsillectomy or
When only mouth breathers (diagnosed by the otolaryn- adenoidectomy), breathing problems, open mouth,
gologist) were considered and the participants recog- stuffy nose, snoring, and dry mouth on awakening. A
nized as nasal breathers by each orthodontist were statistically significant difference was observed
tested for agreement with those diagnosed by the otolar- regarding speech therapy, which was significantly more
yngologist as MBH, the agreement was fair (between 0.2 frequently reported by MBAO.

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650 Costa et al

Table III. Frequency of record answers (orthodontic Table IV. Frequency of airway findings by otolaryn-
anamnesis) from nasal and mouth breathers (classified gologist examination
by the otolaryngologist) and from mouth breathers
NB MBAO MBH Total P
subdivided into mouth breather with airway obstruc- (n 5 20) (n 5 15) (n 5 20) (n 5 55) value
tion (MBAO) and mouth breathers by habit (MBH) Adenoids
Moderate/ 2 (10%) 7 (47%) 4 (20%) 13 (24%) 0.037
Nasal Mouth
severe
breathers breathers MBAO MBH
Characteristic (n 5 20) (n 5 35) (n 5 15) (n 5 20) None/mild 18 (90%) 8 (53%) 16 (80%) 42 (76%)
Nasal turbinates
Tonsillitis or 9 (45%) 10 (28.6%) 6 (40%) 4 (20%)
Moderate/ 9 (45%) 14 (93%) 18 (90%) 41 (74%) 0.001
sinusitis
severe
Medical 20 (50%) 9 (25.7%) 6 (40%) 3 (15%)
None/mild 11 (55%) 1 (7%) 2 (10%) 14 (26%)
treatment
Tonsils
Speech 10 (50%) 11 (31.4%) 8 (53.3%) 3 (15%)
Moderate/ 2 (10%) 3 (20%) 1 (5%) 6 (11%) 0.366
therapy
severe
Allergies 12 (60%) 18 (51.4%) 7 (46.7%) 11 (55%)
None/mild 18 (90%) 12 (80%) 19 (95%) 49 (89%)
Breathing 6 (30%) 14 (40%) 7 (46.7%) 7 (35%)
Septum
problems
Moderate/ 1 (5%) 5 (33%) 5 (25%) 11 (20%) 0.091
Open mouth 10 (50%) 22 (62.9%) 12 (80%) 10 (50%)
severe
Stuffy nose 11 (55%) 18 (51.4%) 10 (66.7%) 8 (40%)
None/mild 19 (95%) 10 (67%) 15 (75%) 44 (80%)
Sneezing 8 (40%) 13 (37.1%) 6 (40%) 7 (35%)
frequency NB, Nasal breather; MBAO, mouth breather with airway obstruc-
Snoring 4 (20%) 13 (37.1%) 8 (53.3%) 5 (25%) tion; MBH, mouth breather by habit.
Dry mouth on 10 (50%) 23 (65.7%) 11 (73.3%) 12 (60%)
awakening
Daytime 6 (30%) 16 (45.7%) 7 (46.7%) 9 (45%)
We performed this study because of the lack of an ac-
sleepiness
Nasal spray 2 (10%) 10 (28.6%) 5 (33.3%) 5 (25%) curate description, and the subjectivity of the concept of
Deleterious 10 (50%) 17 (48.6%) 6 (40%) 11 (55%) a mouth breather is 1 major problem in an orthodontist's
habits diagnosis of mouth breathing.10,30 Few studies18-20,42 in
orthodontics have included patients diagnosed
according to airway obstruction or breathing status by
Statistically significant differences in the frequency an otolaryngologist in their comparisons or used
of findings by the otolaryngologist's examinations otolaryngology tools such as airflow monitoring.43 Pre-
(Table IV) were observed in 2 situations: moderate to se- vious studies, including 2 systematic reviews, concluded
vere adenoid hypertrophy was more frequent in MBAO that no ideal tool exists for dentists to screen adenoid
(47%), and moderate to severe nasal turbinate hypertro- hypertrophy, which is a major cause of airway obstruc-
phy was less frequent in nasal breathers (45%). tion in young patients, and the evidence suggests the
When the findings of the otolaryngologist's exami- use of lateral cephalograms as a screening tool before
nation were compared 2 by 2 considering patients with an otolaryngologist's follow-up.17,19,20,22
the same breathing status, the only significant result The age range used in this study was selected to
was that most MBH (80%) did not have either tonsil or include growing young people and to avoid the peak
adenoid hypertrophy that was considered moderate to size of adenoids during childhood, which is around
severe. 7 years old.43
The sensitivity of orthodontists in recognizing mouth Our anamnesis records included several aspects re-
breathers—ie, the proportion of mouth breathers ported by different authors as possible indicators or con-
correctly identified—ranged from 17.1% (orthodontic tributors to breathing status recognition.28,30-32
clinical examination) to 31.4% (orthodontic anamnesis). Our results showed that previous medical treatment
Specifically, the proportion of nasal breathers correctly and speech therapy were more frequently reported by
identified ranged from 85% (orthodontic anamnesis) the nasal breathers, different from the results of Felcar
to 100% (orthodontic clinical examination). et al.34 Nasal breathers also had a greater reported fre-
quency of sinusitis or tonsillitis, use of medications,
DISCUSSION and surgeries (tonsillectomy and adenoidectomy). This
The aim of this study was to evaluate the recognition could indicate that these patients searched for treatment
of mouth breathing by the orthodontists and agreement more often and may have accomplished a nasal breath-
with the otolaryngologist's diagnosis. ing status.

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Costa et al 651

Regular allergic episodes are noteworthy and should diagnoses; this was the main object of this study. The
be considered, -since repeated obstruction of the up-per orthodontists could identify correctly most nasal
airway, even if temporary, can create the habit of breath- breathers (85% in anamnesis and 100% in clinical ex-
ing through the mouth.28 In this study, the frequency of amination) but were less able to recognize mouth
nasal problems reported including allergies, stuffy nose, breathers (31% in anamnesis and 17% in clinical exam-
and sneezing frequency was similar between nasal and ination). When patients diagnosed as MBH by the
mouth breathers and higher than reported by mouth otolaryngologist were matched with the orthodontists'
breathers in a similar study.28 classification as nasal breathers (since they were poten-
Sleep-related problems have been reported to be tially able to breathe through the nose), the recognition
associated with mouth breathing.28,32,44,45 In our increased greatly (80% in anamnesis and 85% in clin-
study, the problems that appeared more often in ical examination). However, the match between the
mouth breathers than in nasal breathers’ answers were otolaryngologist's diagnosis of MBAO and the ortho-
snoring, with a frequency greater than found by dontists' classification as mouth breathers was still
Pacheco et al14 (18.6%), Huynh et al33 (18.9%), and low, although it was increased (46% in anamnesis
Petry et al46 (27.6%); dry mouth on awakening, greater and 20% in clinical examination). These results may
than reported by Huynh et al (53.1%); drinking water indicate that orthodontists are partly able to identify
during the night and daytime sleepiness, greater than re- MBAO through the anamnesis. Our clinical examina-
ported by Huynh et al (8.6%) and Pacheco et al (34%). tion may be limited to recognize those patients. This
Although Felcar et al34 did not report specific fre- may be partly explained by other authors' reports that
quencies, they found that snoring and poor sleep may breathing tests used by orthodontists are not standard-
predict mouth breathing. ized and are described with divergent information in
In the study of Villa et al,47 the majority of patients different publications.30
(88.1%) with snoring had a positive sleep clinical record; An interesting finding of our study was that when the
according to the authors, children with a positive sleep orthodontists classified the participants as nasal or
clinical record score had an approximately 8-fold mouth breathers only considering the answers from
increased risk for an important obstructive apnea- the anamnesis—ie, without the influence of each partic-
hypopnea index. In our study, mouth breathers had an ipant's visual appearance—the agreement was very good.
increased frequency of snoring (37.1%) compared with That may indicate a great deal of subjectivity in the or-
nasal breathers (20%), especially the ones with airway thodontists' evaluation of a subject.
obstruction (53.3%). A powerful point of this research was the homoge-
When comparing the answers of MBAO and MBH to neous sample with the standardization of the body
anamnesis, MBAO more frequently revealed health mass index, considering that anthropometric data might
problems, medical treatment, speech therapy, nasal correlate with airway obstruction.48
problems such as stuffy nose and sneezing frequently One limitation of this study was that the otolaryngol-
(except allergies), and sleep-related problems (snoring ogist's determination of mouth breathers could not be
and dry mouth on awakening). MBH showed a greater based on a specific index or a pure objective evaluation.
frequency of drinking water during the night and dele- A systematic review that assessed subjective and objec-
terious habits. These results may indicate that MBH tive evaluations of the nasopharynx and tried to identify
may be less aware of their health problems in general whether conclusions can be drawn based on more than
since they are used to their respiratory condition and an “expert opinion” showed discrepancies between
probably rarely seek treatment. objective measurements and patients' reports.49 Since
When the answers to anamnesis were considered, 2 the gold standard for breathing status evaluation has
aspects were noteworthy. First, subjects who had an ad- not yet been determined, subjective assessment is
enoidectomy did not necessarily observe an immediate important,50 and evaluations with different tools, such
establishment of nasal breathing, especially when other as anatomic, physiologic, and subjective nasal measures,
allergic factors were not investigated. Second, most pa- may reflect the multidimensional feeling of nasal
tients do not recognize their allergic condition, although obstruction and provide complementary informa-
they observed other symptoms such as stuffy nose and tion.50,51
sneezing frequency. The allergy diagnosis should be ob- Another limitation was that questionnaire answers by
tained after an immunologic test.3 third parties may lead to decreased precision of the
The agreement was rather poor between recognition acknowledgment. However, the literature indicates
of mouth breathers after anamnesis or clinical exami- that the health evaluation of a child must include infor-
nation by the orthodontists' and the otolaryngologist's mation from the patients and their parents or guardians,

American Journal of Orthodontics and Dentofacial Orthopedics November 2017  Vol 152  Issue 5
652 Costa et al

who despite of being different are equally important and dontistas da cidade do Recife. Dental Press J Orthod 2011;16:
complement each other.52 84-92.
13. McNamara JA. Influence of respiratory pattern on craniofacial
New studies should be performed considering the
growth. Angle Orthod 1981;51:269-300.
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Avaliaç~ao da qualidade de vida em pacientes respiradores orais.
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17. Ysunza A, Pamplona MC, Ortega JM, Prado H. Video fluoroscopy
The orthodontists could identify correctly most nasal for evaluating adenoid hypertrophy in children. Int J Pediatr Oto-
breathers (85% in anamnesis and 100% in clinical exam- rhinolaryngol 2008;72:1159-65.
ination). Recognition of mouth breathing in young per- 18. Ehman RL, McNamara MT, Pallack M, Hricak H, Higgins CB. Mag-
sons by the orthodontists was poor (17.1% to 31.4%). netic resonance imaging with respiratory gating: techniques and
advantages. AJR Am J Roentgenol 1984;143:1175-82.
Subjects should be referred to an otolaryngologist
19. Kao DS, Soltysik DA, Hyde JS, Gosain AK. Magnetic resonance im-
when any disturbing sign or symptom of airway obstruc- aging as an aid in the dynamic assessment of the velopharyngeal
tion or mouth breathing is identified or reported. mechanism in children. Plast Reconstr Surg 2008;122:572-7.
20. Parikh SR, Coronel M, Lee JJ, Brown SM. Validation of a new
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