Clinical Assessment and Recognition of Mouth Breathing in Children

This prospective cross-sectional study was approved by Universidade Federal do Espírito
Santo Institutional Review Board under protocol #162/09. All participants signed an
informed consent form before data collection. All procedures were performed by trained
and calibrated researchers.
The study was carried out with two distinct populations: orthodontists and children. A
sample of 110 orthodontists answered a semi-structured questionnaire about clinical
evaluation of respiratory patterns during childhood and their knowledge about SDB in
children. Data collection was tabulated and analyzed. Lack of standardization of the
procedures employed by orthodontists as well as of diagnostic information in the
literature led us to prepare basic guidelines to clinically recognize MB in children
(Table 1), based on the most cited
procedures.
Table 1.

CLINICAL RECOGNITION OF MOUTH BREATHING
These guidelines can be used to examine children and aid recognition of mouth breathing
1. Visual assessment
The dentist should assess at least the presence of the following characteristics:
With the patient standing:
» Lack of lip seal	( ) YES ( ) NO
» Posture changes	( ) YES ( ) NO
» Dark eye circles	( ) YES ( ) NO
» Long face	( ) YES ( ) NO
With the patient sited:
» Anterior open bite	( ) YES ( ) NO
» High narrow palate	( ) YES ( ) NO
» Gingivitis in maxillary incisors	( ) YES ( ) NO
2. Questions
Questions should be directed to the child or parents
Do you:
» Sleep with your mouth open?	( ) YES ( ) NO
» Keep your mouth open when you are distracted?	( ) YES ( ) NO
» Snore?	( ) YES ( ) NO
» Drool on your pillow?	( ) YES ( ) NO
» Experience excessive daytime sleepiness?	( ) YES ( ) NO
» Wake up with a headache?	( ) YES ( ) NO
» Get tired easily?	( ) YES ( ) NO
» Often have allergies?	( ) YES ( ) NO
» Often have a stuffy nose and/or runny nose?	( ) YES ( ) NO
» Have difficulty in school?	( ) YES ( ) NO
» Have difficulty concentrating?	( ) YES ( ) NO
3. Breathing tests
The child must be sitting. At least two tests should be performed.
a. Graded mirror test
After the second output of air on the mirror, mark the halo area with a marker (Fig 1).
(Low nasal flow: up to 30 mm; Average nasal flow: 30-60 mm; High nasal flow: above 60 mm)
b. Water retention test
Place water in the patient’s mouth (approximately 15 ml) and ask him/her to hold it for 3 minutes.
c. Lip seal test
Seal the patient’s mouth completely with a tape for 3 minutes.
4. Training to eliminate the habit of mouth breathing
Training should be performed at home on a daily basis until the child is able to return to nasal breathing.
Lip seal test
Seal the child’s mouth with masking tape when he/she is distracted or focusing his/her attention on another activity. Progressively increase the time each day until the child is able to breathe only through the nose for, at least, two consecutive hours.

Guidelines presented in Table 1 were applied to
687 children aged 6-12 years old and attending elementary schools. Only healthy children
whose parents gave permission to participate were included.
Children were clinically assessed and received diagnostic impressions as mouth breathers
or nose breathers according to their clinical characteristics. Subsequently, they were
subjected to three breathing tests selected to assist MB recognition: the mirror test,
the water retention test and the lip seal test. All tests were performed with the child
sitting with his/her head straight, keeping his/her lips closed, and breathing
normally.