Archives of Oral Biology 92 (2018) 57–61

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Archives of Oral Biology

journal homepage: www.elsevier.com/locate/archoralbio

An exploratory study of the factors related to mouth breathing syndrome in T

primary school children
⁎
Issei Saitoha, , Emi Inadab, Yasutaka Kaiharac, Yukiko Nogamia, Daisuke Murakamib,
Naoko Kubotab, Kaoru Sakuraic, Yoshito Shirazawab, Tadashi Sawamia, Miyuki Gotod,
Maki Nosoue, Katsuyuki Kozaic, Haruaki Hayasakia, Youichi Yamasakib
a
Division of Pediatric Dentistry, Graduate School of Medical and Dental Science, Niigata University, 2-5274 Gakkocho-dori, Chuo-ku, Niigata 951-8514, Japan
b
Department of Pediatric Dentistry, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima 890-8544, Japan
c
Department of Pediatric Dentistry, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8553, Japan
d
Shinonome Elementary School attached to Hiroshima University, 3-1-33 Shinonome, Minami-ku, Hiroshima 734-0022, Japan
e
Department of Public Oral Health Integrated Health Sciences Hiroshima University Institute of Biomedical & Health Sciences, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-
8553, Japan

A R T I C LE I N FO A B S T R A C T

Keywords: Objective: Mouth breathing syndrome (MBS) is defined as a set of signs and symptoms that may be completely or
Mouth breathing syndrome incompletely present in subjects who, for various reasons, replace the correct pattern of nasal breathing with an
Incompetent lip seal oral or mixed pattern. It is important to identify the relevant factors affecting MBS in order to diagnose its cause
Nose and throat since breathing obstructions can result from multiple factors. The purpose of this study is to clarify the relevant
Oral environment
factors and the interrelationships between factors affecting MBS among children.
Factor analysis
Design: We surveyed 380 elementary school children from 6 to 12 years in age. The questionnaire consisted of 44
questions regarding their daily health conditions and lifestyle habits and was completed by the children’s
guardians. A factor analysis was performed to classify closely related questions into their respective factors and
to examine the strength of the correlation between the newly revealed factors.
Results: Twenty-six out of the 44 questions were selected, and they were classified into seven factors. Factors 1–7
were defined as “Incompetent lip seal”, “Diseases of the nose and throat”, “Eating and drinking habits”, “Bad
breath”, “Problems with swallowing and chewing”, “Condition of teeth and gums”, and “Dry lips”, respectively.
There were also correlations between these factors themselves.
Conclusion: MBS was categorized according to 7 major factors. Because Factor 1 was defined as “Incompetent lip
seal”, which was representative of the physical appearance of mouth breathers and correlated with other factors,
we suggested that MBS should consist of 7 factors in total.

1. Introduction (Jakobsone, Urtane, & Terauds, 2006; Mizuno, Yamada, Murakami,

Respiration is one of the body’s vital functions and under normal
physiological conditions, breathing takes place through the nose
(Basheer, Hegde, Bhat, Umar, & Baroudi, 2014). When a child has
mixed breathing i. e., the nose is supplemented by the mouth, this
breathing pattern is referred to as mouth breathing. Lip pressure is a
weak but continuous passive force that operates all day (Nishiura et al.,
2015; Sabashi et al., 2011). Because lips function actively in feeding,
chewing, swallowing, speech and facial expression, they can also pro-
duce tooth movement and inclination change. Measuring lip-closing
strength is one method of evaluating lip pressure (Fukami et al., 2010),
and the relevance of incompetent lip seal to mouth breathing
Kaede, & Masuda, 2014). However, the relationship between in-
competent lip seal and mouth breathing is unclear.
On the other hand, there has been great interest in mouth breathing
among children because of its harmful effects, which include local in-
flammation, allergies, postural problems, facial changes and oral states.
(Campanha, Fontes, Camargos, & Freire, 2010; Okuro et al., 2011). And
a set of signs and symptoms that may be completely or incompletely
present in subjects who, for various reasons, replace the correct pattern
of nasal breathing with an oral or mixed pattern is defined as Mouth
breathing syndrome (MBS) (Conti, Sakano, Ribeiro, Schivinski, &
Ribeiro, 2011). In the field of dentistry, it is also well known that
continuous mouth breathing during growing period is detrimental to

⁎
Corresponding author.
E-mail address: isaito@dent.niigata-u.ac.jp (I. Saitoh).

https://doi.org/10.1016/j.archoralbio.2018.03.012
Received 23 August 2017; Received in revised form 17 March 2018; Accepted 23 March 2018
0003-9969/ © 2018 Elsevier Ltd. All rights reserved.
I. Saitoh et al. Archives of Oral Biology 92 (2018) 57–61

oral function, oral environment, and craniofacial morphology (Gulati, Table 1

Grewal, & Kaur, 1998; Nascimento Filho, Mayer, Pontes, Pignatari, & Questionnaire on conditions which might be linked to Mouth Breathing
Weckx, 2004). Choi et al. compared the intraoral pH and temperature Syndrome.
of individuals who were mouth breathing during sleep and those who Question item
were not (Choi, Waddell, Lyons, & Kieser, 2016). They concluded that
mouth breathing during sleep was related to a decrease in intraoral pH 1. Do you get tired easily?
2. Are you good riser?
compared with nasal breathing during sleep, suggesting that it could be
3. Are you good at exercising?
a causal factor for dental erosion and caries. Moreover, several studies 4. Are you a restless sleeper?
showed that there were significant differences in the growth of the 5. Do you have round shoulders?
dental arch and craniofacial morphology between mouth breathers and 6. Does your nose become stuffed easily during the day?
7. Does your nose become stuffed easily while sleeping?
nasal breathers (Juliano et al., 2009; Lofstrand-Tidestrom, Thilander,
8. Do you sneeze often?
Ahlqvist-Rastad, Jakobsson, & Hultcrantz, 1999). 9. Do you often have a runny nose?
Additionally, physical problems affected by mouth breathing among 10. Do you often have a nosebleed?
children have appeared in some literature (Chaves et al., 2010). Boas 11. Do you often have a sore throat?
et al. compared the physical performance of mouth-breathing and 12. Do you have swollen tonsils?
13. Do you often fail to listen?
nasal-breathing children in a six-minute walking test. They concluded
14. Are you a habitual snorer?
that the physical performance of mouth breathers was poorer than that 15. Is your mouth often dry?
of nasal breathers because there was a statistical difference between the 16. Do people tell you that you have bad breath in the morning?
two groups in respiratory rate, oxygen saturation and distance walked 17. Do people tell you that you have bad breath during day?
18. Is your mouth often open during the day?
in six minutes (Boas et al., 2013). Conti et al. investigated the body
19. Do you sleep with your mouth open?
posture classifications and clinical variables of mouth-breathing chil- 20. Can you keep your mouth closed for about 1 min?
dren, and reported that mouth breathers exhibited a higher incidence 21. Do you have an over bite?
rate of thoracic respiratory patterns and unfavorable postural classifi- 22. Do you have an under bite?
cations (Conti et al., 2011). To prevent these clinical problems, the 23. Do you have an anterior open bite?
24. Can you talk clearly?
proper diagnosis and treatment of MBS is important.
25. Are your lips often chapped?
It is considered that mouth breathing may occur due to many 26. Are your lips thick?
causes, as indicated by the aforementioned symptoms. The purpose of 27. Is your upper lip turned upward?
this study is to clarify the relevant factors and interrelationship between 28. Are your teeth visible between your upper and lower lips?
factors affecting MBS among children. 29. Are your lips droopy?
30. Are your lips often cracked?
31. Are your gums often swollen?
2. Materials & methods 32. Are your gums easily stained?
33. Are your teeth easily stained?
2.1. Human subjects and questionnaire 34. Do you often have canker sores?
35. Do you have tartar build-up?
36. Do your meals consist of small servings?
We surveyed 380 elementary school children (187 boys and 193 37. Do you prefer soft food?
girls) from 6 to 12 years in age. These subjects had no serious dental 38. Do you drink water during meals?
caries and no known lip dysfunction or trouble with occlusion or 39. Do you eat fast?
mandibular function. The questionnaire consisted of 44 questions re- 40. Are you a picky eater?
41. Do you chew food well?
garding their daily health conditions and lifestyle habits which might 42. Are you a noisy eater?
be linked to MBS (Table 1) and was completed by the subjects’ guar- 43. Do you keep your mouth closed when you eat?
dians. Questionnaires were prepared by referring to a 47-item survey 44. Do you have food left in your mouth for a long time?
conducted by Kogue et al., which included 24 items that were judged to
have a significant difference between mouth breathing children and
nose breathing children. (Kogue et al., 2003). We also referred to a exploratory factor analysis (maximum-likelihood method and promax
questionnaire, developed by Yamaguchi et al., that had been used in a rotation).
survey on the relationship between mouth breathing and present and The number of factors was determined based on the Kaiser-Guttman
past diseases of children. (Yamaguchi et al., 2015). Forty and 7 items rule (eigenvalue of 1 or more) and a scree plot. Statistical analyses were
were taken from the questionnaires of Kogue et al. and Yamaguchi performed using IBM SPSS Statistics for Windows (version 20; SPSS,
et al., respectively; some items from the two questionnaires were du- Inc., Tokyo, Japan), and statistical significance was set at P < 0.05.
plicate. This study was approved by the Epidemiological Ethics Com-
mittee of Kagoshima University Graduate School of Medical and Dental 3. Results
Sciences (No. 378), and informed consent was obtained from the sub-
jects or their parents prior to their entering the study. Table 2 shows the factor analysis. Twenty-six out of the 44 questions
were selected and classified into seven factors. The Kaiser-Meyer-Olkin
2.2. Statistical analysis measure was 0.819 and Bartlett’s test of sphericity yielded P < 0.001,
showing the validity of the factor analysis. The cumulative contribution
When there are a large number of questions in a questionnaire, the ratio was 50.5%.
answers to some of the questions may be strongly correlated. For ex- We defined Factor 1 as “Incompetent lip seal”, based on the ques-
ample, those who often leave their mouths open and respond in the tions “Are your lips droopy?” and “Is your mouth often open during the
affirmative to the question “Is your mouth often open during the day?” day?” Factor 2 was defined as “Diseases of the nose and throat” based
may also responded “yes” to the question, “Are your lips droopy?” In on the strong factor loading of “Does your nose become stuffed easily
other words, grouping together multiple questions that are highly (during the day, while sleeping)?” and “Do you often have a sore
correlated may reveal common factors between them. throat?” Similarly, based on the factor loading and content of the other
Therefore, in order to 1) classify questions which were closely re- questions, Factors 3, 4, 5, 6, and 7 were defined as “Eating and drinking
lated into their respective factors, and 2) examine the strength of the habits”, “Bad breath”, “Problems with swallowing and chewing”,
correlations between the newly revealed factors, we performed an “Condition of teeth and gums”, and “Dry lips”, respectively.

58
I. Saitoh et al. Archives of Oral Biology 92 (2018) 57–61

Table 2
Pattern matrix of the factor analysis.

Table 3
Factor correlation matrix.
Factor 1 Factor 2 Factor 3 Factor 4 Factor 5 Factor 6 Factor 7
Incompetent lip seal Diseases of the nose and Eating and drinking Bad breath Problems with swallowing and Condition of teeth and Dry lips
throat habits chewing gums

*** *** *** *** *** ***

Factor 1 1 0.378 0.215 0.397 0.506 0.489 0.480
*** *** *** *** ***
Factor 2 1 0.010 0.416 0.256 0.280 0.374
*** *** *** ***
Factor 3 1 0.208 0.264 0.306 0.184
*** *** ***
Factor 4 1 0.326 0.374 0.294
*** ***
Factor 5 1 0.292 0.256
***
Factor 6 1 0.314
Factor 7 1

All estimates are significant at 0.1% (Tests for no correlation).***: P < 0.001.

Table 3 shows the factor correlation matrix. In our study, the cor-
relation coefficient between the male participants was used as re-
ference; a correlation coefficient of 0.5 or higher was interpreted as a
strong correlation; a correlation coefficient of 0.2 or higher but less
than 0.5 was interpreted as a moderately strong correlation; and a
correlation coefficient less than 0.2 was interpreted as a weak corre-
lation.
The Factor 5 had the strongest correlation with the Factor 1. With
regard to the other factors, their correlation with the Factor 1 is as
follows, in the descending order of correlation strength: Factor 6, 7, 4, 2
and 3. A strong correlation was found between the Factor 1 and Factor
5, and a moderate strong correlation was found between the Factor 1
and other factors. As regards the correlation between the factors other
than the Factor 1, the findings showed that the correlation between the
Factor 2 and Factor 3 was the weakest, with a correlation coefficient of
0.010. On the other hand, a moderately strong correlation was found
between the Factor 3, 4, 5 and 6.
4. Discussion
Factor 1, which was defined as “Incompetent lip seal” was identified
as a relevant factor for MBS. Lip closing strength is the force of the
orbicularis oris muscle. The orbicularis oris muscle functions to close
the lips and can press the lips against the anterior teeth, maintaining the
balance between the inner and the outer forces on the teeth in the rest
position (Frohlich, Thuer, & Ingervall, 1991; Trotman, McNamara,
Dibbets, & van der Weele, 1997). Oral habits such as finger-sucking,
tongue thrust, lip biting, and nail biting can cause various malocclu-
sions by disrupting this balance (Kasparaviciene et al., 2014; Reyes
Romagosa et al., 2014), and mouth breathing is possibly as important as
those oral habits.
Cabrera et al. reported that the overjet and upper and lower incisor
angles of mouth breathers were greater than those of nasal breathers
(Cabrera L de, Retamoso, Mei, & Tanaka, 2013). Harari et al. reported
that mouth breathing during critical growth periods in children had a
higher tendency for the clockwise rotation of the growing mandible,
with a disproportionate increase in anterior lower vertical face height
and decreased posterior facial height (Harari, Redlich, Miri, Hamud, &
Gross, 2010). Thus, mouth breathing affects on not only the tooth axis
but also maxillofacial morphological growth. Saccomanno et al. ad-
vocated the importance of the combination of orthodontic treatment
and myofunctional treatment, which is the muscle condition approach,
in order to obtain the balance needed for the stability of orthodontic
treatment in patients with oral habits (Saccomanno et al., 2012). Since
this study suggests that “Incompetent lip seal” is a relevant factor af-
fecting MBS, the maintenance and improvement of lip-closing strength
should be considered crucial to the prevention and improvement of
MBS.

59
I. Saitoh et al.
Factor 2, which was defined as “Diseases of the nose and throat” was
also identified as a relevant factor for MBS. Furthermore, Factor 2
moderately correlated with Factor 1. Relevant items regarding rhinitis,
such as “Does your nose become stuffed easily (during the day, while
sleeping)?” were included in Factor 2. There is a medical consensus
about the relationship between mouth breathing and allergic rhinitis
(Stensson et al., 2010), and these insights have been documented in the
Allergic Rhinitis and its Impact on Asthma guidelines, which led to the
evidence-based management algorithms (Georgalas, Terreehorst, &
Fokkens, 2010). Moreover, it has been proposed that treating in-
flammation of the upper and lower airway and mouth breathing are
important considerations for the improvement of allergic rhinitis. Thus,
medical professionals and researchers are interested in the relationship
between allergosis and mouth breathing. Our results suggested that
MBS might relate to allergosis during growth periods.
Examination of the correlation between the factors revealed that
Factor 1 correlated with factors 4 to 7. This suggests that incompetent
lip seal or MBS was associated with the bad breath, swallowing habits
and chewing, as well as the condition of the teeth and gums. Motta et al.
examined the relationship between bad breath and mouth breathing in
children, and concluded that the occurrence of bad breath was sig-
nificantly associated with mouth breathing (Motta, Bachiega, Guedes,
Laranja, & Bussadori, 2011). Regarding the issue of oral environment,
Gulati et al. reported that the gingival index in mouth breathers with
incompetent lip seal was higher than that of normal nasal breathers,
and that mouth breathers showed a prevalence of bleeding gingivitis
(Gulati et al., 1998). Additionally, Hsu and Yamaguchi reported that
the number of chewing strokes and the chewing cycles in mouth
breathers were significantly lower in comparison with nasal breathers,
and the variance of chewing cycles among mouth breathers was sig-
nificantly greater than in nasal breather (Hsu & Yamaguchi, 2012).
Thus, it was reported that mouth breathing might be associated with
oral environment and oral function. Our results not only agree with past
reports, but could provide statistical proof to support their findings.
Our findings indicated that MBS was categorized by major 7 factors
which were defined as “Incompetent lip seal”, “Diseases of the nose and
throat”, “Eating and drinking habits”, “Bad breath”, “Problems with
swallowing and chewing”, “Condition of teeth and gums”, and “Dry
lips”. There were also correlations between these factors themselves.
Especially, “Incompetent lip seal” was correlated with the others.
In the future, we plan to increase the number of survey subjects and
analyze the rate of mouth breathing due to medical factors, such as nose
disease, separately from habitual mouth breathing. Alternatively, a
multi-faceted examination should be performed in order to analyze
whether there are any differences in correlation between factors based
on subject age.
5. Conclusion
To clarify the relevant factors affecting MBS in children and to ex-
amine the hypothesis that incompetent lip seal is related to mouth
breathing, we grouped closely related questions about daily health
conditions and lifestyle habits into their respective factors. The results
of the examination of the correlations between the newly revealed
factors support the following:
1. The questions were classified into seven categories. Factors 1–7
were defined as “Incompetent lip seal”, “Diseases of the nose and
throat”, “Eating and drinking habits”, “Bad breath”, “Problems with
swallowing and chewing”, “Condition of teeth and gums”, and “Dry
lips”, respectively.
2. Factor 1, defined as “Incompetent lip seal,” was representative of the
physical appearance of a mouth breather, and it correlated with
other factors. There were also correlations between the 7 factors
themselves.
3. Factor 2, which was defined as “Diseases of the nose and throat,”
60
Archives of Oral Biology 92 (2018) 57–61
moderately correlated with “Incompetent lip seal”.
4. As a result, we suggest that MBS might consist of 7 factors.
Funding
This study was supported by a Grant-in-Aid for Scientific Research
(grant no. 16K11809) from the Ministry of Education, Science, Sports,
Culture, and Technology of Japan.
Ethical approval
This study was approved by the Epidemiological Ethics Committee
of Kagoshima University Graduate School of Medical and Dental
Sciences (No. 378), and informed consent was obtained from the sub-
jects or their parents prior to their entering the study.
Conflict of interests
Nothing particular.
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