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Journal of Dentistry Indonesia 2016, Vol. 23, No.2, 28-32
doi:10.14693/jdi.v23i2.981
ORIGINAL ARTICLE
Distribution of Gingival Inflammation in Mouth Breathing Patients: An
Observational Pilot Study
Rajinder Kumar Sharma, Anu Bhatia, Shikha Tewari, Satish Chandar Narula
Pandit Bhagwat Dayal Sharma University of Health Sciences, Rohtak, Haryana 124000, India
Correspondence e-mail to: bhatiaanu01@gmail.com
ABST R ACT
Mouth breathing has been reported to affect gingival health in children. However, studies on the effect of mouth
breathing in adult patients are scarce. Objective: To examine the relationship between mouth breathing and gingival
condition and to evaluate the distribution of gingival inammation in young adult mouth breathing patients.
Methods: Study groups comprised of participants with mouth breathing (test group) and nose breathing (control
group) patients with gingivitis. Both the groups underwent periodontal examination. PI, GI and BOP % sites were
recorded and analyzed statistically for the differences in mean values. Results: Mouth breathing patients showed
higher full mouth GI and BOP scores. Upper anterior segment in mouth breathing patients showed highest GI and
BOP followed by lower anterior segment, lower posterior and upper posterior region. Conclusion: Within the limits
of present study, our ndings suggest that relative to control group participants, test group i.e. patients with mouth
breathing had higher gingival inammation and bleeding sites in upper anterior region.
Keywords: gingivitis, mouth breathing, young adult
INTRODUCTION
Mout h bre ath i ng may be rega rde d as ben ign, harmless,
self-effacing and unsuspecting way of breathing.
Mouth breathing syndrome is a term used when mouth
supplements the nose for breathing.1 Oral breathing
patterns exclusively are rare or non-existent.1 For ma ny,
it hardly matters whether breathing is done through
mouth or nose. Consequently, the debilitating effects
of mouth breathing may be disregarded and thus, are
failed to be noticed even by dental professionals.
Primary etiological factor for chronic gingivitis is dental
plaque; however, anything that favors plaque formation,
accumulation and retention will perpetually aggravate
existing gingivitis. Results of epidemiological studies
in dic ate that mout h bre ath i ng may cause an incre ase in
susceptibility of gingival inammation.2,3 Although the
denite mechanism of the damaging effects of mouth
breathing on gingiva is still unknown; irritation from
surface dehydration, reduced resistance of epithelium
to plaque, and the absence of cleansing effects of
saliva have been suggested as some of the reasons for
increased gingivitis prevalence in mouth breathers.3,4
Evidence regarding the relationship between mouth-
breathing and gingivitis has contradictory positions.
While Sutcliffe et al reported a total lack of correlation
between mouth breathing and gingivitis, others like
Alexander et al proposed a partial association asserting
that mouth breathing in itself is of no consequence
except in the presence of crowding and calculus.5,6
However, previous studies observed a definite
association between mouth breathing and chronic
gingivitis.2, 3,7
In light of the paucity of denite research information
concerning the effect of mouth breathing on gingival
inammation, the current pilot study was conducted
with an aim to nd out the distribution of gingival
inammation within the oral cavity in mouth breathers
and to explore any association between mouth
breathing, plaque level and gingivitis.
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Journal of Dentistry Indonesia 2016, Vol. 23, No.2, 28-32
METHODS
Study design and sample
The study population consisted of patients who
attended the outpatient section of the Department of
Periodontics and Oral Implantology, Post Graduate
Institute of Dental Sciences, Rohtak, India. Study was
conducted in agreement with the ethical principles
embodied in Helsinki Declaration of 1975, as revised
in 2008, and was approved by the institutional review
board (PGIDS/2013/IEC/94, 2013). The study was
conducted between April 2013 and August 2014. The
study consisted of two groups: test group comprising
of 30 mouth breathing patients with incompetent lip
seal, with an age ra nge of 20 -35 yea r s and age matched
control group of 34 nose breathing participants.
Diagnosis of mouth breathing
Diagnosis of mouth breathing was made on the basis
of history and clinical examination of the patients.
Patients were enquired if in their opinion, they were
mouth breathers or not, whether they sleep with their
mouth open and also whether on waking they had
dryness of mouth. Clinical examination included
several diagnostic tests for mouth breathing. Firstly, the
subjects were asked to breathe while closing one of the
nostrils with lips sealed. Nose breathers demonstrated
good control of alar muscle which was absent in mouth
breathers. Secondly, mirror test. Double sided mirror
was held horizontally below the nostrils of patients who
were instructed to breathe normally. Fogging on lower
side of mirror suggested mouth breathing.8 Third ly,
Buttery test. Buttery shaped piece of cotton was
placed below the nostrils on upper lip. Fluttering of
cotton wisp indicated breathing pattern. If the upper
bres were displaced then the breathing was considered
through the nose and if lower fibres quivered, it
suggested mouth breathing.9 Forthly, Water holding
te st. Parti cipants were aske d to l l the mou th wi th water
and hold it for three to ve minutes. Mouth breathers
suffered difculty completing this task whereas nasal
breathers did it with relative ease.8
For fullling the criteria of mouth breathing, subjects
were required to give a positive history along with
minimum of two clinical tests suggestive of mouth
breathing habit.The inclusion criteria for the study were
presence of > 20 teeth; systemically healthy patients
with gingivitis in the age group of 20-35 years; and
no periodontal treatment within past 6 months prior
to inclusion into the study. The exclusion criteria
included presence of clinical signs or symptoms of
any acute infection in the oral cavity; use of systemic
antibiotics or anti-inammatory therapy in the last
3 months before start of study; any known systemic
(e.g. hepatic, renal, haematological or cardiovascular)
disease; pregnancy and lactation; systemic conditions
with gingival manifestations and non-plaque induced
gingival inammation; xerostomia and drugs reported
to cause it; and current or former smokers.
Periodontal measurements
The full-mouth periodontal examination of all
individuals was done by measurement of Loe and
Silness gingival index (GI) and Silness and Loe plaque
index (PI) on all teeth except third molars. These
indices were recorded on four sites (mesiobuccal,
midbuccal, distobuccal and palatal aspects) around each
tooth with University of North Carolina-15 (UNC-15)
periodontal probe. Bleeding sites were registered on
six sites per tooth in a dichotomous way, and scores
were expressed as the percentage of positive sites per
patient (BOP %).
In order to ensure investigator blinding as well as to
preclude inter examiner variability, oral examination
was carried out by one investigator (AB). Investigator
was masked to the study group to which the patient
belongs. Examiner reproducibility was determined by
ca r r y i ng out double clin ical periodo nta l data recordin g
on ten patients. Operator calibration for GI was based
on >85% intra-examiner exact reproducibility.
Statistical analysis
Post hoc power analysis was done using statistical
software (G power 3.1.9.2). With a sample size of 64
and signicance level of two-sided α = 0.05, xed-
effect size was calculated taking upper anterior GI as
primary outcome variable. With these measurements,
statistical power exceeded 95%, with allocation ratio
of 1:1 between two groups. Results are reported
as mean ± standard deviation. The normality of
distribution of data was examined using Shapiro-Wilk
test. Data was found to be non-normally distributed.
All the measurements were subjected to intergroup
comparisons and analyzed by Mann-Whitney U test.
Al l stat ist ica l analys es were car rie d out usi ng st atis tic al
software (SPSS V. 19) with a two-tailed p value of 0.05
used as a threshold for signicance.
RESULTS
Study group comprised 64 adult patients. Table 1
illustrates the demographic and clinical parameters
among the mouth breathing and nose breathing groups.
Average age of patients in test group was 24.6 years
and average age of control group was 25.0 years.
Full mouth plaque score between two groups did not
differ significantly. Patients with mouth breathing
demonstrated signicantly higher full mouth GI and
BOP (%) (p<0.05) than nose breathing group. The
dentition was analyzed after being divided into four
segments - two anterior segments – each comprising
of either upper or lower anterior teeth and two lateral
zones- upper and lower, comprising of remaining teeth.
Table 2 showed comparison of segment wise periodontal
parameters between two groups. Control group showed
higher plaque scores as well as gingival index in lower
posterior area followed by lower anterior regions.
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Journal of Dentistry Indonesia 2016, Vol. 23, No.2, 28-32
Upper posterior segment still showed higher values
of PI and GI than upper anterior region in control
group. In test group, highest plaque score was found
in lower anterior region followed by upper anterior,
lower posterior and upper posterior segments. GI value,
however, was highest in upper anterior region as was
BOP % sit es in te st group. Also, lower ante r ior seg ment
showed GI higher score as compared to lower posterior
area. Upper posterior region in mouth breathing group
exhibited lowest score of GI and BOP% sites.
In mouth breathing patients, facial surfaces of upper
anterior teeth showed greater PI, GI and BOP% as
compared to palatal surfaces (Table 3). Also, inter-
dental sites of facial surfaces had higher scores than
mid-facial regions in test group.
DISCUSSION
Although a correlation between mouth breathing and
oral conditions in children has been reported, there are
few such studies in young adults. Also, there are only
a few reports dealing with the regional distribution
of gingival inammation in the oral cavity. The aim
of this study was thus to examine the relationship
between mouth breathing and gingival condition in
young patients and to assess the distribution pattern
of inammation in such patients.
Mouth breathing habit is widely reported among
school going children.10 If left untreated, it can lead
to morphological alterations in the facial growth and
various adverse effects on physiological, social and
mental health.11 Compared with the previous studies
where mouth breathing patients were recruited from
younger age groups (less than 14 years), participants
in our study were older and thus, ndings of this study
may be applicable to a broader range of population with
similar characteristics. The age and gender distribution
was rea son ably wel l bal anc ed in both the gro ups. The re
were more females in mouth breathing group. Study
population belonged to same ethnic background and
was recruited from middle class families.
Results of our study showed higher plaque score
in lower dentition as compared to upper dentition
in control group. Lower posterior areas showed
greatest accumulation of plaque followed by lower
anterior region. Upper posterior region harbored
more plaque compared to upper anterior area. In nose
breathing patients, pattern of distribution of gingival
inammation and BOP % sites closely followed the
areas of plaque accumulation. Thus, upper anterior
area showed least gingival inammation and bleeding
sites in nose breathing patients. These observations
were similar to the results of previous studies that
demonstrated higher levels of plaque on molar, lingual
and posterior surfaces than on anterior teeth.12,13
Contrary to above observation, in mouth breathing
group, upper anterior area showed greatest GI score and
BOP % sites. This observation of our study is consistent
with results of previous studies that demonstrated
maxillary anterior area as most susceptible to gingival
inflammation in mouth breathing subjects.2 ,7,14 In
lower arch, lower anter ior segment showed greater
Tab le 1. Comparison of demog raphic and clinical per iodontal
parameters among nose breathing and mouth breathing
group.
Parameters Group
Nose breathing
(n=34)
Mean±SD
Mouth breathing
(n=3 0)
Mean±SD
Age (years) 25.02 ± 3.78 24.67 ± 3.51
Male : Female 1.31 : 1 1.66 : 1
Full Mouth PI 1.47 ± 0.50 1.48 ± 0.62
Full Mou th GI 1.71 ± 0.37 1.93 ± 0.31*
Fu l l M o u t h
BOP%
74.10 ± 20. 20 83.50 ± 18.91*
* p<0.05
Table 2. Comparison of seg ment wise periodontal parameters
among nose breathing and mouth breathing group
Segment Parameters Group
Nose
breathing
Mean±SD
Mouth
breathing
Mean±SD
Upper anterior PI 1.34 ± 0.48 1.52 ± 0.62
GI 1.58 ± 0.37 2.09 ± 0.28*
BOP (%) 67.21 ± 24.13 91.88 ± 8.01*
Upper posterior PI 1.44 ± 0.56 1.33 ± 0.61
GI 1.65 ± 0.45 1.68 ± 0.35
BOP (%) 73.93 ± 22.84 77.75 ± 24.85
Lower anterior PI 1.52 ± 0.58 1.54 ± 0.70
GI 1.77 ± 0.44 1.99 ± 0.46*
BOP (%) 77.09 ± 22.46 85.60 ± 21.57*
Lower posterior PI 1.54 ± 0.53 1.40 ± 0.61
GI 1.80 ± 0.47 1.70 ± 0.40
BOP (%) 76.30 ± 21.91 78.20 ± 24.98
Table 3. Comparison of periodontal parameter in upper
anterior region in mouth breathing group
Parameter Facial surface
Mean±SD
Palatal surface
Mean±SD
PI 1.57 ± 0.65 1.46 ± 0.59
GI 2.17 ± 0.27 2.00 ± 0.33*
BOP(%) 95.11 ± 9.80 88.10 ± 16.14*
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Journal of Dentistry Indonesia 2016, Vol. 23, No.2, 28-32
gingival in ammation and bleeding as compared to
corresponding posterior segment. Noticeably, the result
of our study als o showed th at th e upper po ste r ior area in
mouth breathing patients had least amount of gingival
in ammation. Plaque scores in this segment was also
least as compared to rest of the areas.
The importance of normal hydration state of peri-
odontium in the maintenance of periodontal health is
underscored by the increase in gingival in ammation
that inevitably follows the chronic mouth breathing
habit. Also, in a recent study mizutani et al has ob-
served that xerostomia was related to gingival disease
activity and % BOP through the accumulation of dental
plaque.15 The great propensity for gingival in amma-
tion in mouth breathers probably stems from dryness of
affected area causing the loss of the protective powers
of saliva. Saliva has an essential role in protecting the
tissues against dessication. Alteration of homeostatis of
hydration state of gingiva can be caused by continuous
exposure to the dry air of tissues of oral cavity. Without
the shielding effects of adequate salivary ow, peri-
odontal tissues might become prone to disease. Patients
with chronic mouth breathing habit might suffer from
dry mouth which could eventually create a predisposi-
tion to oral infection and progressive gingivitis.15 Simi-
la r observation wa s made in Al- awa di et al’s study who
noticed increase in PI and GI in mouth breathing group
as compared to nose breathing group and attributed this
to reduced salivary ow rate in mouth breathers.16 Since
gingivitis is a disease of microbial origin, the mouth
breathing related (increase in) gingival in ammation
could be an expression of increased or altered microbial
population dynamics in the oral cavity.
Previous studies by Wagaiyu et al and Gulati et al7
have assessed the effects of mouth breathing, lip
competency and upper lip coverage of maxillary incisor
teeth simultaneously on gingival health.2-7 Both these
studies revealed that mouth breathing patients with
incompetent lip seal and wide exposure of maxillary
labial gingiva had more gingival in ammation. Our
study population composed of test group including
mouth breathers with incompetent lip seal and gingival
exposure in order to create homogeneity of test group
sampled and also to lessen the inf luence of other
confounding factors.
Though the distribution of gingival units bearing
in ammation as well as severity of in ammation in
these units was uniform to a large extent in mouth
breathing patients, there was no characteristic clinical
picture depicting inflammatory changes in the
marginal tissues of this population. Clinical picture in
mouth breathing patients demonstrated that marked
gingival inflammation was confined to anterior
Figure 1. Mou th br eat hing pat ient a) Lip po si tio n at rest ; b) Ant erior regi on showing sever e ging iv al in am m at ion ; c) Max ill ary
palatal aspect; d) Left lateral region showing in ammation upto premolar; e) Right lateral region showing in ammation upto
premolar
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Journal of Dentistry Indonesia 2016, Vol. 23, No.2, 28-32
regions of maxilla. Interdental papilla and marginal
gingiva belonging to areas exposed to the drying
effects of inspired air also exhibited marked gingival
inammation in mouth breathing patients. Incidence
and severity of ginigival inammation was signicantly
lower in the areas not supposed to be in the pathway of
inspired air during mouth breathing.
When upper anterior area is investigated in mouth
breathers, facial surface showed higher GI score
and BOP% sites than the palatal surface. On further
analyses of the facial surface, inter-dental sites had
higher score than mid-facial sites in mouth breathers.
Thus, upper anterior area in mouth breathing patients
demands attention and can be regarded as a seat for
early detection or screening of gingival inammation.
Dental plaque formation and gingival inammation
are the earliest and most common indicators of
periodontal disease in children and adolescents.
Not only are individuals with mouth breathing
susceptible to gingival inammation, but also such
changes start manifesting at quite young age in life.
Therefore, controlling oral health behaviour and
evaluating mouth breathing would effectively prevent
periodontal disease at an early stage in young people.
The stringent inclusion and exclusion criteria, study
population derived from the same ethnic background,
and exclusion of smokers were some of the strengths
of present study. The results of this study should be
interpreted cautiously in light of its limitations. As
this study was cross-sectional, it remains uncertain
as to whether mouth breathing is the cause of gingival
inf lammation. Prospective cohort studies may be
required to fully elucidate the mechanism involved.
CONCLUSION
In conclusion, the results of present study indicate
that the mouth breathing patients with incompetent
lip seal had higher scores of gingival inammation in
adults, especially in upper anterior segment. Also, the
distribution of gingival inammation in such patients
differs when compared to nasal breathers. Thus,
clinician should be more vigilant while screening such
individuals as mouth breathing could be one of the risk
factors in gingivitis.
CONFLICT OF INTEREST
There are no potential conf licts of interest or any
nancial or personal relationships with other people
or organizations that could inappropriately bias the
conduct and ndings of this study.
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(Received February 2, 2016; Accepted June 24, 2016)
