Mouth Breathing and Speech Disorders: A Multidisciplinary Evaluation Based on The Etiology.

Objective: The objective of the study was to determine the most common speech impairments among mouth breathing (MB) children and to assess the relationship between them in terms of etiology, gender, clinical symptoms, clinical findings, and dental traits. Materials and
Methods: A total of 498 mouth-breathers, both male and female, aged 9-17 years, were screened for allergic rhinitis (AR), adenoid hypertrophy (AH), and/or functional mouth breathing (FM). The subjects were assessed by a team that included an otorhinolaryngologist, an allergologist, an orthodontist, and a speech pathologist.
Results: MB was associated with AR, AH, FM, and orofacial myofunctional disorders (OMD). AR was the most common etiology, followed by FM. Further, 81.7% of the children had speech disorders such as speech sound problems, fluency disorders, and voice disorders. A statistically significant association was found between etiology, OMD, and speech alterations. Males had a statistically highly significant frequency of speech abnormalities than females. Frontal lisp was found in 36.1%, followed by stuttering (19.2%). In 10.6% of the children, two or more speech impediments occurred simultaneously. There was also a statistically significant association between various speech abnormalities and malocclusion.
Conclusion: The findings of the study suggested that articulation disorders were frequently associated with MB children. It emphasizes the necessity of monitoring MB children through a multidisciplinary approach to prevent the adverse effects of MB and improve the overall development of individuals. Copyright:

INTRODUCTION

Mouth breathing (MB) is a pathological disorder characterized by varying degrees of upper airway blockage and can affect orofacial development, speech, nutrition, and body posture.[12] Nasal obstruction is caused by enlargement of the adenoids, a deviated nasal septum, and rhinitis, which can occur alone or in combination.[3] In Saudi Arabia, a study done by Baidas et al.[4] reported a prevalence of sleep-disordered breathing (SDB) to be 21%. Another study done among 285 children and adolescents aged 5–18 years old who were undergoing orthodontic treatment reported that 47.7% of them had high risk of developing SDB.[5] MB syndrome is a term used to describe the symptoms of mouth breathers, including fatigue, daytime sleepiness, failure to thrive, restless sleep, nocturnal enuresis, immature auditory processing, inadequate oxygenation of the brain, and learning impairments.[678] Due to its wide range of comorbidities, MB has long been a concern for healthcare providers.

One of the most common causes of chronic MB in children is allergic rhinitis (AR), which disrupts the normal growth of the facial skeleton and impairs overall mental wellbeing.[36] Additionally, adenoid hypertrophy (AH) and nasal septum deviation can cause blockage of the nasal airway. When MB is caused by long-term oral habits, muscular changes, or a transient inflammation of the nasal mucosa, it is referred to as functional MB.[9] MB-induced dysgnathia leads to the development of “adenoidal facies” or “long face syndrome.”[10]

The different forms of speech disturbances, such as articulation and voice disorders, are among the characteristics of MB that pose the most concern.[16] Speech of the mouth breathers is influenced by a multitude of factors, notably inappropriate tongue posture, malocclusion, and/or impairments in facial growth and development, which lead to structural anomalies in the oral cavity and flaccid facial muscles. They experience difficulties with bilabial (/p/,/b/,/m/) and fricative (/f/,/v/,/s/,/z/) phonemes. Due to the pull on the lingual frenum, an individual with tongue-tie generally finds it difficult to deliver a rapid, clear speech because the movements of the tongue, such as extending out to the upper teeth and forward horizontally, are arduous.[8]

A range of speech impairments hinders the ability of the child to converse to varying degrees and, in turn, negatively impact the emotional, social, and functional wellbeing.[11] Epidemiological evidence shows that speech and communication disorders are reported as the second most common type of disability among children in Saudi Arabia.[12] For accurate speech assessment, children with speech difficulties frequently require a multidisciplinary approach in the Department of Otorhinolaryngology.

The objective of this study was to determine the most common speech impairments among MB children and the relationship between them in terms of etiology, gender, clinical manifestations, clinical findings, and dental traits.

MATERIALS AND METHODS

This cross-sectional study included 498 children, 177 females and 321 males, aged 9–17 years, who had a history of MB for at least 6 months and attended the Department of Otorhinolaryngology, Maternity and Children Hospital Buraydah. Children were excluded from the study if they had exacerbated rhinitis, had been on antihistaminic or oral/topical steroid therapy in the past 1 month, had a history of prior orthodontic treatment, physiotherapy, or speech therapy, had reconstructive facial surgery or trauma, or had orofacial malformation; had obvious signs of neurological disease or genetic diseases, or had any other comorbidities that could affect the research results, and/or had mental retardation. The institutional ethics committee approved the study protocol, and all subjects gave informed assent and/or proxy consent.

Evaluation of otorhinolaryngologist

The diagnosis of MB was validated by the evaluation of an otorhinolaryngologist, taking into account the patient history, clinical criteria, and physical examination for detecting MB children, as indicated in Table 1. Mouth breathers were defined as children who had two major signs or one major sign with two or more minor signs at the time of the examination. The Nasal Obstruction Symptom Evaluation (NOSE) scale and the Peak Nasal Inspiratory Flow (PNIF) were used to assess nasal patency. Nasofibroscopy was used to examine the adenoids, and AH was diagnosed when the aerial column of the nasal cavity was blocked by more than 80%. Those who show no indications of AR or nasal blockage were said to be functional mouth breathers.

Table 1

Patient history and physical examination protocol for screening of mouth breathing children

	Patient history	Physical examination
Major signs	Complains of blocked nose very frequently, snores, sleeps with mouth open, drools on the pillow	Adenoid facies, high-arched palate, open bite, hypertrophy of nasal conchae, deviated nasal septum, adenoid hypertrophy
Minor signs	Itchy nose, disturbed sleep at night, feeling sleepy or irritable during the day, difficulty in swallowing,	Nasal voice, abnormal chest and posture, hyperemia, perforation/thickening of the tympanic membrane, and speech disorders

Evaluation of allergologist

Their clinical history included signs and symptoms of AR, and a standard volar forearm skin test was performed under the supervision of an otorhinolaryngologist.

Evaluation of orthodontist

Based on the MBGR criteria,[13] a dental evaluation was performed by an experienced orthodontist. Inter-arch occlusal traits such as sagittal, transverse, and vertical relationships were documented.

Evaluation of speech therapist

A speech therapist examined the entire stomatognathic system by using the MBGR protocol, evaluating the habitual posture of the lips and/or tongue, muscle tonus, and speech mechanisms.[13] Subjects were classified as having abnormalities in orofacial myology with speech sound, voice, and/or fluency disorder based on clinical examination. They were termed normal when no defects in orofacial myofunctional areas or speech areas were found.

Assessing speech sound production

The most common source of pronunciation errors was determined by evaluating whether the child correctly misspells the numbers 6, 16, 7, and 17. The patient was asked to count from 1 to 20 during the speech and sound screening assessment. The orthodontist kept track of the numbers that were incorrectly pronounced. Later, the children participated in a quick discussion, concentrating on the sounds that were identified as defects during the screening test, which could provide further insight into the nature of the anomaly pattern. If the pronunciation flaws persisted in rapid conversation, professional speech therapy was suggested.

SPSS version 25.0 was used for statistical analysis, and the Chi-square test was applied, with findings considered significant at P < 0.05.

RESULTS

There were 498 participants in the study, ranging in age from 9 to 17 years. The average age of the study participants was 14.56 ± 1.14 years, with 177 (35.5%) females and 321 (64.5%) males. It was found that the clinical manifestations and clinical findings protocol were statistically insignificant in both males and females [Table 2]. The most prevalent clinical signs of MB, according to the patient history, were sleeping with the mouth open (40.6%), followed by snoring (14.7%), frequent nasal blockage (14.1%), drooling on the pillow (12.4%), and itching nose (11.2%). About 7% of the sample had more than one manifestation.

Table 2

Frequency distribution of clinical manifestations and clinical findings among mouth breathing children in the study sample

	Males n (%)	Females n (%)	Total n (%)	Chi-Square test	P
Clinical manifestations (n=498)
Snores	42 (8.4)	31 (6.2)	73 (14.7)	7.72	0.17
Sleeps with open mouth	129 (25.9)	73 (14.7)	202 (40.6)
Drools on pillow	45 (9)	17 (3.4)	62 (12.4)
Itchy nose	42 (8.4)	14 (2.8)	56 (11.2)
Frequent nasal blockage	40 (8)	30 (6)	70 (14.1)
More than one manifestation	23 (4.6)	12 (2.4)	35 (7)
Total	321 (64.5)	177 (35.5)	498 (100)
Clinical findings (n=498)
High-arched palate	42 (8.4)	73 (14.7)	115 (23.1)	11.94	0.10
Tongue-tie	13 (2.6)	18 (3.6)	31 (6.2)
Adenoid facies	39 (7.8)	83 (16.7)	122 (24.5)
Hypertrophy of nasal conchae	13 (2.6)	37 (7.4)	50 (10)
Deviated nasal septum	10 (2)	35 (7)	45 (9)
Abnormal chest and posture	15 (3)	16 (3.2)	31 (6.2)
Abnormalities of the tympanic membrane	17 (3.4)	25 (5)	42 (8.4)
More than one findings	28 (5.6)	34 (6.8)	62 (12.4)
Total	321 (64.5)	177 (35.5)	498 (100)

Adenoid facies was observed in 24.5% of the entire sample, and narrow-arched palate was found in 23.1% of the children. Nasal endoscopy revealed that 50 of the children (10%) had hypertrophy of nasal conchae, and 45 children (9%) had deviated nasal septum. Tongue-tie (6.2%), abnormalities of the tympanic membrane (8.4%), and abnormal chest posture (6.2%) were also observed. Further, 12.4% of children exhibited concomitant clinical findings [Table 2].

There was a statistically significant association between the etiology of MB and the occurrence of any changes, such as OMD or speech problems (P < 0.05). The participants were divided into groups based on the cause of MB. Functional MB (53.2%) was the most common etiology, followed by AR, which was observed in 84 (16.9%) of the children. Further, 14.3% were identified with AH. Concomitant occurrence of AR and AH were found in 15.7% of children. The subjects were then divided into normal, oromyofunctional disorder (OMD), and OMD in combination with any speech impairments. The presence of OMD with speech abnormalities was found in 407 (81.7%) individuals, which was the most common finding [Table 3].

Table 3

Association between speech disorders and various etiologies of mouth breathing

Speech disorders	AR n (%)	AH n (%)	AR + AH n (%)	FM n (%)	Total n (%)	Chi-Square test	P
Normal	10 (2)	11 (2.2)	10 (2)	10 (2)	41 (8.2)	17.77	<0.001**
OMD	10 (2)	8 (1.6)	9 (1.8)	23 (4.6)	50 (10)
OMD + speech alteration	64 (12.9)	52 (10.4)	59 (11.8)	232 (46.6)	407 (81.7)
Total	84 (16.9)	71 (14.3)	78 (15.7)	265 (53.2)	498 (100)

**highly significant; AR - Allergic Rhinitis; AH - Adenoidal Hypertrophy; FM - Functional Mouth Breathing; OMD - Orofacial Myofunctional Disorder

This group of 407 children comprising 123 (30.2%) females and 284 (69.8%) males with a speech impediment was categorized into speech sound disorders or misarticulation, fluency disorders, and voice disorders (dysphonia). Frontal lisp, an articulation issue, was the most commonly observed speech disorder in 36.1% of children, followed by stuttering (19.2%) and lateral lisp (17.2%). Gender disparities in these speech impairments were found to be statistically significant. Voice disorders affected 10.6% of children, whereas fluency issues affected 25.6%. In this study, the male to female ratio of speech problems was determined to be 2.31:1 Table 4. Moreover, males were observed to have several concomitant speech impediments than females.

Table 4

Gender distribution of various speech disorders among children in the study sample

Speech disorders	Females n (%)	Males n (%)	Total n (%)	Chi-Square test	P
I. Speech sound disorder (Articulation disorder)				11.68	0.040*
Frontal lisp	40 (9.8)	107 (26.3)	147 (36.1)
Lateral lisp	30 (7.3)	40 (9.8)	70 (17.2)
II. Fluency disorder
Stuttering	15 (7.3)	63 (15.5)	78 (19.2)
Cluttering	10 (2.5)	16 (3.9)	26 (6.4)
III. Voice disorder	15 (3.7)	28 (6.9)	43 (10.6)
More than one disorder	13 (3.2)	30 (7.3)	43 (10.6)
Total	123 (30.2)	284 (69.8)	407 (100)

*significant

The prevalence of class I, class II, and class III sagittal relationships were found in 12.9%, 57.6%, and 29.5% of the sample, respectively. Because of the established physiologic differences that occur during the developing period, the vertical inter-arch relation must be examined during the developmental stage of dentition. Regardless of the dental stage of development, 86.2% of this sample had a vertical disharmony, which was indicated by an open bite and/or a deep bite. About 71.1% of the children had a posterior crossbite in the transversal study. The comparison of gender difference and dental traits were statistically insignificant (P > 0.05). Hence, further association analysis of the dental traits and speech alterations was conducted on the entire sample as a single entity [Table 5].

Table 5

Dental characteristics of mouth breathing children in the study sample

Malocclusion	Males n (%)	Females n (%)	Total n (%)	Chi-Square test	P
Sagittal relationship (n=498)
Class I	41 (8.2)	23 (4.6)	64 (12.9)	0.45	0.80
Class II	182 (36.5)	105 (21.1)	287 (57.6)
Class III	98 (19.7)	49 (9.8)	147 (29.5)
Vertical relationship (n=498)
Open bite	195 (39.2)	98 (19.7)	293 (58.9)	5.51	0.06
Deep bite	77 (15.5)	59 (11.8)	136 (27.3)
Normal	49 (9.8)	20 (4)	69 (13.9)
Transverse relationship (n=498)
Posterior cross bite	229 (46)	125 (25.1)	354 (71.1)	0.03	0.87
Normal	92 (18.5)	52 (10.4)	144 (28.9)

We observed a statistically significant association between various speech abnormalities and malocclusion (P < 0.05). Speech alterations were frequently observed in children with class II malocclusion (48.4%), followed by class III subjects (36.6%). About 56% and 77.9% of children with speech alterations among MB children had an open bite and posterior crossbite, respectively [Table 6].

Table 6

Comparison of dental findings among mouth breathing children with various speech disorders in the study sample

Malocclusion	Frontal lisp	Lateral lisp	Stuttering	Cluttering	Voice disorder	>1 disorder	Total	Chi-square test	P
Sagittal relationship (n=407)
Class I	10 (2.5)	10 (2.5)	12 (2.9)	8 (2)	11 (2.7)	10 (2.5)	61 (15)	27.79	0.001**
Class II	90 (22.1)	33 (8.1)	30 (7.4)	9 (2.2)	17 (4.2)	18 (4.4)	197 (48.4)
Class III	47 (11.5)	27 (6.6)	36 (8.8)	9 (2.2)	15 (3.7)	15 (3.7)	149 (36.6)
Vertical relationship (n=407)
Openbite	92 (22.6)	38 (9.3)	51 (12.5)	13 (3.2)	19 (4.7)	15 (3.7)	228 (56)	38.42	0.000**
Deepbite	10 (2.5)	10 (2.5)	16 (4)	8 (2)	14 (3.4)	14 (3.4)	72 (17.7)
Normal	45 (11.1)	22 (5.4)	11 (2.7)	5 (1.2)	10 (2.5)	14 (3.4)	107 (26.3)
Transverse relationship (n=407)
Posterior crossbite	118 (29)	55 (13.5)	68 (16.7)	16 (3.9)	30 (7.4)	30 (7.4)	317 (77.9)	11.74	0.04*
Normal	29 (7.1)	15 (3.7)	10 (2.5)	10 (2.5)	13 (3.2)	13 (3.2)	90 (22.1)

*significant; **highly significant

DISCUSSION

Despite the fact that various studies have shown that mouth breathers may have speech difficulties, the absence of more detailed evidence describing the possible association in the Indian population prompted this investigation. In terms of clinical manifestations and clinical examinations, Abreu et al.[3] identified an overall higher prevalence in a study of 2927 children aged 3–9 years in Brazil, which was considerably different from the prevalence rate found herein. Among all of the factors considered, it is worth noting that the children aged 9–17 years were chosen because the craniofacial symptoms of MB become more visible during this time.[14] Furthermore, it has been documented in the literature that children beyond the age of 8 years are predominantly nasal breathers, and the milestones of speech development are nearly complete by this age.[810] As a result, the persistence of MB after the age of 8 years is detrimental and alarming.

According to the multidisciplinary assessment, 53.2% of the 498 MB were classified as functional MB without obstructive reasons, which was not consistent with the previous study by Junqueira et al.[6] In contrast with the previous reports, individuals with MB had a lower rate of OMD (10%) and a greater incidence of combined OMD and speech impairments (81.7%) than those who were diagnosed as mouth breathers in earlier investigations.[6] This study also revealed that 10.6% of the participants had multiple concomitant speech impediments, which were inconsistent with the reports of Hitos et al.[1]

The results of this study demonstrated a male predisposition to speech impairments, which was consistent with previous research.[111] Psychosocial factors such as shyness and a sense of social isolation by females may be accountable for under-reported female incidences. Community-based or gender-specific rehabilitative programs that address this issue can help to alleviate the problem.[15] On the contrary, a study conducted by Youssef et al.[16] in Dubai indicated that the highest percentage of voice disorders (62.3%) occurred among females with the mean age of 41 years. The divergence of gender-related distribution may be either due to sampling bias or the varying etiological factors of speech disorders among different populations.[17]

The prevalence of stuttering was determined to be 19.2% in our study, which was consistent with the findings of Dave et al.[18] Swain et al.[11] found that stuttering is the most common speech disturbance. However, misarticulation (53.3%) was the most frequent finding in the current study, which was concurrent with Dey et al.[15] but inconsistent with Dave et al.[18] Frontal lisp, the most prevalent speech concern in mouth breathers (36.1%), occurs when the tongue protrudes anteriorly during the generation of lingual dental phonemes, resulting in ambiguities in labial and fricative phonemes.[11]

Comparison of the findings of the study conducted among 7881 primary school children in Iran by Karbasi et al.[19] disclosed a lower prevalence than that of the present study. Concerning the divergence elicited between the prevalence, figures could be due to different age groups of the selected sample and data collection methods such as questionnaire survey (reports from parents or teachers), which discloses lower or underreporting of the prevalence rates. Discrepancies in the prevalence rate of stuttering in different age groups are also well documented in the literature and found to be decreasing with age.[19]

The prevalence of malocclusion among MB children with speech challenges is critical. The basic clinical parameters in understanding dental traits are the sagittal, vertical, and transverse relationships.[17] The present study indicated an association between malocclusion and several speech abnormalities among MB children, which includes class II malocclusion (48.4%), open bite (56%), and posterior crossbite (77.9%), which was consistent with prior studies.[142021]

The tip of the tongue should indeed contact the palate when pronouncing “/t/,/d/,/n/,” and certain words such as “/l/,/s/,/z/,” require the tip to be directed upward. Words incorporating “/r/” are the usually affected sounds in subjects with tongue-tie. The frequency of tongue-tie (2.9%) was lower than that reported by Swain et al.[11] Because of their limited tongue mobility, most children with tongue-tie were able to pronounce the aforementioned sounds by adjusting their oral movements to some amount, but they eventually fail as they are generally obtrusive or ineffectual.[8]

Despite the fact that speech sound problems account for 70% of all pediatric speech pathology, the diagnostic standards for speech disorders provide a clinical issue due to the diversified symptomatology, inadequate research arena, and poor long-term results. As a result, the effects of the childhood disorder are carried over into adulthood, resulting in a negative psychological impact on normal speech development, which is in good consensus with similar studies reported.[2223]

CONCLUSION

The findings of the study suggest that articulation disorders were frequently associated with MB children. It emphasizes the necessity of monitoring mouth-breathing children through a multidisciplinary approach to prevent the adverse effects of MB and improve the overall development of individuals.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.