Relationship between inflammation and the severity of Recurrent Respiratory Papillomatosis.

OBJECTIVE: To characterize inflammatory cells in Recurrent Respiratory Papillomatosis (RRP) and to correlate it with severity using the Derkay laryngoscopic scale. MATERIALS AND METHODS: The data and biopsies from 36 patients with Juvenile (JRRP) and 56 patients with Adult (ARRP) were collected and analyzed under light microscopy. The patients were separated into groups according to the Derkay index: ≥20 for the most severe and < 20 for the less severe cases. Immunohistochemical analysis using CD3, CD4, CD8, CD15, CD20, CD68, FoxP3 and MUM-1 antibodies was performed, and the inflammatory cells were quantified. All the clinicopathological characteristics and the results of the immunohistochemical analysis were compared among the groups proposed using the Chi-Square test and correlated through the Spearman correlation test. RESULTS: The ARRP showed significantly higher quantities of CD3+, CD8+ and MUM1+ cells (p < .05) than the JRRP samples. The presence of CD15+ cells showed positive correlation with the Derkay index (p < .05), while the MUM-1+ cells showed an inverse correlation (p = .01). CONCLUSION: There are differences between the inflammatory cells population in the juvenile and adult groups and it can be related to disease severity.

Cephalometric evaluation of adenoids: an analysis of current methods and a proposal of a new assessment tool.

INTRODUCTION: Although the scientific literature recognizes that lateral cephalometric radiographs might be clinically useful, there is no consensus in relation to the best parameter available. Therefore, this research was aimed at evaluating current radiographic assessment methods designed to investigate adenoid hypertrophy and nasopharyngeal obstruction. METHODS: Children from 4 to 14 years old with nasal obstruction or oral breathing complaints, suspected to be caused by adenoid hypertrophy, received cephalometric examinations. One hundred twenty radiographic records were evaluated according to several current methods, and data were compared with respective gold-standard videonasopharyngoscopic examinations, in relation to the percentage of choanal obstruction. RESULTS: Groups derived from a grading system had significantly different percentages of choanal obstruction. However, this parameter showed low sensitivity. Significant but moderate correlations were observed between most of the quantitative radiographic parameters and the percentage of choanal obstruction. Alternatively, a regression model was introduced; it demonstrated satisfactory ability to predict choanal obstruction percentage. Despite limitations, this model could also distinguish patients who might benefit from referral to otolaryngologic care. CONCLUSIONS: Current adenoid assessment methods have significant limitations. A novel assessment method introduced here might be clinically useful.

3D technology to measure dental arches and create a template for lingual brackets technique.

OBJECTIVE: This study aims at identifying anatomical dimensions of dental arches, based on landmarks currently used in the lingual orthodontic technique, and create an archwire form template to be used in orthodontic clinics. METHODS: Maxillary and mandibular dental casts of 140 Caucasian individuals with natural and normal occlusion were digitized (3D), and the images were analyzed with Delcam Power ShapeTM 2010 software. The dental arch shapes and sizes were obtained from 14 landmarks selected on the lingual surface of the teeth. Points and segments defined by the software were used to create an archwire form template. RESULTS: Various dental arch patterns were found for both maxilla and mandible. The smallest sizes were found in females, and the largest were found in male subjects. Six categories were defined for each gender, three for the maxilla and three for the mandible (Small, Medium and Large). A template was created with eighteen anatomic lingual archwire designs, nine for the maxilla and nine for the mandible, for both genders. CONCLUSIONS: Landmarks evaluated in this study showed dental arch differences between genders. This information enables making orthodontic lingual archwires that are more compatible with the anatomical forms and sizes of the maxilla and mandible. The findings also allowed the creation of a template for an anatomic lingual metallic archwire form to be used in the lingual technique.

Role of epstein-barr virus in the severity of recurrent respiratory papillomatosis.

OBJECTIVE: The objective was to investigate the prevalence of the Epstein-Barr virus (EBV) and its association with human papilloma virus (HPV) detection, clinicopathological features, and the severity of recurrent respiratory papillomatosis (RRP). METHODS: Cases of juvenile recurrent respiratory papillomatosis (JRRP) (n = 36) and adult recurrent respiratory papillomatosis (ARRP) (n = 44) were collected retrospectively and subdivided into low- and high-risk severity groups based on the Derkay score. We performed HPV detection and genotyping using a reverse hybridization protocol and investigated the presence of EBV by polymerase chain reaction (PCR) and in situ hybridization. CD21 levels were accessed by immunohistochemistry. RESULTS: All samples were HPV-positive, including 49 cases of HPV 6, 26 cases of HPV 11, four cases of HPV 6 and 11 coinfections, and one case of HPV 16. EBV-DNA was detected in nine samples by PCR, although none of the cases were positive by means of in situ hybridization. CD21 immunoexpression was not statistically associated with any of the variables analyzed. HPV 6 detection was significantly higher in ARRP cases (P = 0.03), whereas HPV 11 was more prevalent in JRRP cases (P = 0.02) and was even more prevalent in JRRP cases of greater severity (Derkay laryngoscopic scale ≥20) (P = 0.04). CONCLUSION: The presence of EBV does not seem to play an important role in the progression/severity of RRP. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:E611-E618, 2020.

Histopathological features of juvenile-onset laryngeal papillomatosis related to severity.

BACKGROUND: Laryngeal papillomatosis (LP) is a disease that presents in both juvenile (JLP) and adult patients (ALP). This study correlated papillomatosis characteristics with the Derkay score. METHODS: Retrospective data and biopsies of 36 patients with JLP and 56 with ALP were collected and separated into groups according to their scores. RESULTS: The mean of the Derkay score, in the JLP group was 10.97 and in Group ALP was 8.26. The JLP group presented a more aggressive result than in the adult group (P = .02). In the JLP group, the respiratory difficulty (P = .01) and tracheostomy were correlated to a higher Derkay score (P < .05). Microscopically, the JLP samples presented a higher incidence of atypical mitosis and mitosis above the basal cells layer of the epithelium (P < .05) and these characteristics were correlated with a higher Derkay index (P = .03). CONCLUSION: Findings suggest that ALP and JLP can present different clinical courses and histopathological features. There was a higher degree of LP severity in JLP.

How to avoid the inappropriate use of antibiotics in upper respiratory tract infections? A position statement from an expert panel.

INTRODUCTION: Bacterial resistance burden has increased in the past years, mainly due to inappropriate antibiotic use. Recently it has become an urgent public health concern due to its impact on the prolongation of hospitalization, an increase of total cost of treatment and mortality associated with infectious disease. Almost half of the antimicrobial prescriptions in outpatient care visits are prescribed for acute upper respiratory infections, especially rhinosinusitis, otitis media, and pharyngotonsillitis. In this context, otorhinolaryngologists play an important role in orienting patients and non-specialists in the utilization of antibiotics rationally and properly in these infections. OBJECTIVES: To review the most recent recommendations and guidelines for the use of antibiotics in acute otitis media, acute rhinosinusitis, and pharyngotonsillitis, adapted to our national reality. METHODS: A literature review on PubMed database including the medical management in acute otitis media, acute rhinosinusitis, and pharyngotonsillitis, followed by a discussion with a panel of specialists. RESULTS: Antibiotics must be judiciously prescribed in uncomplicated acute upper respiratory tract infections. The severity of clinical presentation and the potential risks for evolution to suppurative and non-suppurative complications must be taken into 'consideration'. CONCLUSIONS: Periodic revisions on guidelines and recommendations for treatment of the main acute infections are necessary to orient rationale and appropriate use of antibiotics. Continuous medical education and changes in physicians' and patients' behavior are required to modify the paradigm that all upper respiratory infection needs antibiotic therapy, minimizing the consequences of its inadequate and inappropriate use.

Histological analysis of palatopharyngeal muscle from children with snoring and obstructive sleep apnea syndrome.

Obstructive sleep apnea syndrome (OSAS) is an upper airway obstruction that occurs during the sleep. One of the suggested mechanisms involved in this process is a neuromuscular abnormality of the palatal muscles. Whether children with OSAS develop into OSAS adults, or children and adult OSAS are two distinct disorders occurring at different ages are questions to be answered. Here, we made the histological analysis of palatophryngeal muscle in 34 oral-breathing children of both genders, aged 5-12 years old, with hypertrophic tonsils and adenoids. According to the polysomnographic study the participants were divided into children without sleeping disorders (group I) and children with primary snoring (group II) or apnea (group III). The main histological findings were fiber size variability in 70% cases from groups II and III and in 71% from group I; perimysial connective tissue infiltration in 48% children from groups II and III and in 71% from group I; intracytoplasmatic mitochondrial proliferation in 63% cases from groups II and III and in 57% cases from group I. Muscle necrosis was only observed in one case, in association with subglandular inflammation. Others findings observed in all groups included fibers with internal architecture alteration, such as moth-eaten and lobulated fibers, type 2 fiber predominance, and small areas of fiber type grouping. The presence of similar histological findings in the palatopharyngeal muscle in children with primary snoring or apnea but also in children without sleeping disorders indicate that such changes could be a normal histological feature of this muscle rather than a neurogenic or myopathic pathology.

Gastroesophageal reflux in patients with recurrent laryngeal papillomatosis.

UNLABELLED: Evidence of a relation between gastroesophaeal reflux and pediatric respiratory disorders increases every year. Many respiratory symptoms and clinical conditions such as stridor, chronic cough, and recurrent pneumonia and bronchitis appear to be related to gastroesophageal reflux. Some studies have also suggested that gastroesophageal reflux may be associated with recurrent laryngeal papillomatosis, contributing to its recurrence and severity. AIM: the aim of this study was to verify the frequency and intensity of gastroesophageal reflux in children with recurrent laryngeal papillomatosis. MATERIAL AND METHODS: ten children of both genders, aged between 3 and 12 years, presenting laryngeal papillomatosis, were included in this study. The children underwent 24-hour double-probe pH-metry. RESULTS: fifty percent of the patients had evidence of gastroesophageal reflux at the distal sphincter; 90% presented reflux at the proximal sphincter. CONCLUSION: the frequency of proximal gastroesophageal reflux is significantly increased in patients with recurrent laryngeal papillomatosis.

Impact of rapid maxillary expansion on nasomaxillary complex volume in mouth-breathers.

OBJECTIVE:: To assess the volumetric changes that occur in the nasomaxillary complex of mouth-breathing patients with transverse maxillary deficiency subjected to rapid maxillary expansion (RME). METHODS:: This was a controlled, prospective intervention study involving 38 mouth-breathing patients presenting with transverse maxillary deficiency, regardless of malocclusion type or race. Twenty-three of them comprised the experimental group, which was composed of 11 (47.8%) boys, and 12 (52.2%) girls, with a mean age of 9.6 years, ranging from 6.4 to 14.2 years and standard deviation of 2.3 years; and 15 of them comprised the control group, composed of 9 (60%) boys and 6 (40%) girls with an mean age of 10.5 years, ranging from 8.0 to 13.6 years, and standard deviation of 1.9 years. All patients were scanned (CT) according to a standard protocol: Initial CT (T1), and CT three months thereafter (T2), and the patients in the experimental group were treated with RME using a Hyrax expander for the correction of maxillary deficiency during the T1-T2 interval. The CT scans were manipulated using Dolphin® Imaging version 11.7 software for total and partial volumetric assessment of the nasomaxillary complex. RESULTS:: The results revealed that in the experimental group there was a significant increase in the size of the structures of interest compared to the control group, both in general aspect and in specific regions. CONCLUSIONS:: Rapid maxillary expansion (RME) provided a significant expansion in all the structures of the nasomaxillary complex (nasal cavity, oropharynx, right and left maxillary sinuses).

Skeletal effects of RME in the transverse and vertical dimensions of the nasal cavity in mouth-breathing growing children.

INTRODUCTION:: Maxillary constriction is a dentoskeletal deformity characterized by discrepancy in maxilla/mandible relationship in the transverse plane, which may be associated with respiratory dysfunction. OBJECTIVE:: The objective of this study was to evaluate the skeletal effects of RME on maxillary and nasal transverse dimensions and compare the differences between males and females. METHODS:: Sixty-one mouth-breathers patients with skeletal maxillary constriction (35 males and 26 females, mean age 9.6 years) were included in the study. Posteroanterior (PA) radiographs were taken before expansion (T1) and 3 months after expansion (T2). Data obtained from the evaluation of T1 and T2 cephalograms were tested for normality with the Kolmogorov-Smirnov method. The Student's t-test was performed for each measurement to determine sex differences. RESULTS:: RME produced a significant increase in all linear measurements of maxillary and nasal transverse dimensions. CONCLUSIONS:: No significant differences were associated regarding sex. The RME produced significant width increases in the maxilla and nasal cavity, which are important for treatment stability, improving respiratory function and craniofacial development.

Position statement of the Brazilian Academy of Rhinology on the use of antihistamines, antileukotrienes, and oral corticosteroids in the treatment of inflammatory sinonasal diseases.

INTRODUCTION: Inflammatory conditions of the nose and paranasal sinuses are very prevalent in the general population, resulting in marked loss of quality of life in affected patients, as well as significant work, leisure, and social activity losses. These patients require specific and specialized treatment. A wide range of oral medications are available. OBJECTIVE: The present document is aimed to clarify, for professionals treating patients with inflammatory sinonasal diseases, both specialists and general practitioners, specific oral therapies in noninfectious nasal inflammatory conditions. METHODS: The methodology used to create this article included the search for the key words: oral corticosteroids, antihistamines, antileukotrienes, rhinitis, rhinosinusitis in the MEDLINE and EMBASE databases in the last 5 years. Since no relevant article was found for the text on the subject of interest in the last 5 years, the search was extended for another 5 years, and so on, according to the authors' needs. RESULTS: Relevant literature was found regarding the use of antihistamines, antileukotrienes and oral corticosteroids in these conditions. The Brazilian Academy of Rhinology emphasizes, after extensive discussion by the collegiate, key points in the treatment with these drugs. CONCLUSION: There is support in the literature for the use of these drugs; however, final considerations about the role of each of them have been made.

Behavioral evaluation in children with obstructive sleep disorders.

AIM: The purpose of this study was to evaluate the behavior in children with obstructive sleep disorder. STUDY DESIGN: Prospective study. MATERIAL AND METHOD: Children's parents (4 to 18 years old) completed the CBCL4/18 (Child Behavior Checklist) in the period of January to July 2005. RESULTS: In the group, 12 (60%) were males and 8 (40%) females; the total problem score was abnormal in 5 children (25%); introversion was affected in 2 children (10%); extroversion in 5 children (25%). The scales of individual syndromes were abnormal in between 0 and 20% of patients. The individual scales most frequently affected were: total competency (20%), somatic complaints (10%), social problems (10%) and aggressive behavior (10%). DISCUSSION: This study demonstrates high prevalence (25%) of abnormal behavior. Although widely reported as a common complication of pediatric OSAS, behavioral and neurocognitive disorders have mostly been inferred in several cases and studies. There are few recent studies using standardized assessment to evaluate these alterations. Our study presents preliminary results of the behavior of children with obstructive sleep disorders.

Efficacy and safety of Sultamicillin (Ampicillin/Sulbactan) and Amoxicillin/Clavulanic acid in the treatment of upper respiratory tract infections in adults--an open-label, multicentric, randomized trial.

UNLABELLED: Upper respiratory tract infections are the most common causes of medical visits in children and adults, demanding massive use of antibiotics. Bacterial resistance caused by beta-lactamase is one of the most serious problems in this matter. Sultamicillin, a double pro-drug of Ampicillin/Sulbactan, is a potent beta-lactamase inhibitor which can face this challenge. AIM: Evaluate efficacy, safety and tolerability of Ampicillin/Sulbactan compared to Amoxicillin/Clavulanate in upper respiratory tract infections in adults. METHODS: 102 patients were enrolled and randomized to receive Ampicillin/Sulbactan or Amoxicillin/Clavulanate during 10 days. They were evaluated 10 and 30 days after treatment to learn about the therapeutic response. RESULTS: There were no differences between the two groups respecting cure at the end of treatment (visit 2) or at the end of the study (visit 3). Cure ratio was 61.7% and 93.2% (visits 2 and 3) in the Amoxicillin/Clavulanate group compared to 64.4% and 97.4%, respectively, in Ampicillin/Sulbactan group. The adverse events ratio for the two groups was the same (p=0.940). The number of patients with diarrhea was greater in the group of patients receiving Amoxicillin/Clavulanate (70.6%) than in the group receiving Ampicillin/Sulbactan (29.4%) (p=0.0164). CONCLUSIONS: Ampicillin/Sulbactan is as safe and efficient as Amoxicillin/Clavulanate in the empiric treatment of upper respiratory infections in adults. The low occurrence of diarrhea in the group receiving Ampicillin/Sulbactan needs confirmation in other studies.

Impact of adenotonsillectomy on vocal emission in children.

INTRODUCTION: Adenotonsillectomy is the most common surgery performed by otolaryngologists in pediatric age, and one of the most frequently asked questions about the postoperative period is whether there is a potential for change in vocal pattern of these children. OBJECTIVE: To evaluate the impact of adenotonsillectomy in the voice emission pattern of children with hypertrophy of palatine and pharyngeal tonsils. METHODS: This is a prospective study in which we carried out perceptual auditory assessments and acoustic analysis of 26 children with adenotonsillar hypertrophy at three time points: before surgery, one month and three months after surgery. The following acoustic parameters were estimated using the Praat software: fundamental frequency, jitter, shimmer, and harmonic-noise ratio. RESULTS: A statistically significant change was found between shimmer and harmonic-noise ratio during vowel /u/ production between the preoperative and 1st month postoperative time points. No significant differences were detected for acoustic parameters between preoperative analysis and that of the 3rd month post-operation. CONCLUSION: Transient changes in acoustic parameters occur in children with adenotonsillar hypertrophy submitted to adenotonsillectomy, progressing to normalization in the 3rd postoperative month.

3D technology to measure dental arches and create a template for lingual brackets technique

ABSTRACT Objective: This study aims at identifying anatomical dimensions of dental arches, based on landmarks currently used in the lingual orthodontic technique, and create an archwire form template to be used in orthodontic clinics. Methods: Maxillary and mandibular dental casts of 140 Caucasian individuals with natural and normal occlusion were digitized (3D), and the images were analyzed with Delcam Power ShapeTM 2010 software. The dental arch shapes and sizes were obtained from 14 landmarks selected on the lingual surface of the teeth. Points and segments defined by the software were used to create an archwire form template. Results: Various dental arch patterns were found for both maxilla and mandible. The smallest sizes were found in females, and the largest were found in male subjects. Six categories were defined for each gender, three for the maxilla and three for the mandible (Small, Medium and Large). A template was created with eighteen anatomic lingual archwire designs, nine for the maxilla and nine for the mandible, for both genders. Conclusions: Landmarks evaluated in this study showed dental arch differences between genders. This information enables making orthodontic lingual archwires that are more compatible with the anatomical forms and sizes of the maxilla and mandible. The findings also allowed the creation of a template for an anatomic lingual metallic archwire form to be used in the lingual technique.

RESUMO Objetivo: O presente estudo tem como objetivo encontrar as formas anatômicas e dimensões das arcadas dentárias com base em pontos de referência utilizados na técnica ortodôntica lingual, e criar um diagrama com um maior número de arcos metálicos para serem utilizados na clínica ortodôntica. Métodos: 140 modelos de indivíduos caucasianos com oclusão normal e natural foram digitalizados (3D) e as imagens, analisadas com o software Delcam Power ShapeTM 2010. A determinação das formas e tamanhos das arcadas dentárias foi obtida a partir de 14 pontos selecionados na superfície lingual dos dentes. Outros pontos e segmentos foram utilizados, com o auxílio do software, para definir um diagrama. Resultados: Foram encontrados diferentes tamanhos de arcadas dentárias linguais, tanto para a maxila quanto para a mandíbula. Os menores tamanhos foram os femininos, e os maiores, os masculinos. Definiram-se seis tamanhos para cada sexo, sendo três para a maxila e três para a mandíbula, nomeados como P, M e G. Foi criado um diagrama com dezoito desenhos de arcos linguais anatômicos, nove para a maxila e nove para a mandíbula, para ambos os sexos. Conclusões: A posição dos pontos de referência nesse estudo evidenciou diferenças entre os sexos, o que permitiu a criação de arcos mais compatíveis com as formas e dimensões anatômicas da maxila e mandíbula. A diferença entre os tamanhos das arcadas dentárias linguais possibilitou a criação de um diagrama com formas de arcos metálicos linguais anatômicos para serem utilizados na técnica lingual, para auxiliar o profissional a criar os seus próprios arcos.

The impact of laronidase treatment in otolaryngological manifestations of patients with mucopolysaccharidosis.

INTRODUCTION: Mucopolysaccharidosis (MPS) is a lysosomal storage disease caused by deficiency of α-l-iduronidase. The otolaryngological findings include hearing loss, otorrhea, recurrent otitis, hypertrophy of tonsils and adenoid, recurrent rhinosinusitis, speech disorders, snoring, oral breathing and nasal obstruction. OBJECTIVE: To evaluate the impact of enzymatic replacement therapy with laronidase (Aldurazyme(®)) in patients with mucopolysaccharidosis (MPS I), regarding sleep and hearing disorders, and clinical manifestations in the upper respiratory tract (URT). METHODS: Nine patients with MPS I (8 Hurler-Scheie, and 1 Scheie phenotypes) of both sexes, ages ranging between 3 and 20 years, were included in this study. Patients were evaluated between seven and 11 months before the treatment and between 16 and 22 months after the onset of the enzymatic replacement. They were all submitted to a clinical and otolaryngological evaluation, including nasofibroscopical, polysomnographic and audiologic exams. RESULTS: The results' data showed decreasing of the frequency of ear, nose and throat infections, with improvement of the rhinorrhea and respiratory quality. No remarkable changes were observed regarding macroglossia and tonsil and adenoid hypertrophy. Audiometric and polysomnographic evaluations did not show statistical significance. CONCLUSION: Enzymatic replacement therapy in patients with mucopolysaccharidosis I provides control of recurrent URT infections, rhinorrhea and respiratory quality, however it is does not seem to improve audiologic and polisomnographic parameters, with no effect on adenoid and tonsils hypertrophy and macroglossia.

Immediate impact of rapid maxillary expansion on upper airway dimensions and on the quality of life of mouth breathers.

OBJECTIVE: To assess short-term tomographic changes in the upper airway dimensions and quality of life of mouth breathers after rapid maxillary expansion (RME). METHODS: A total of 25 mouth breathers with maxillary atresia and a mean age of 10.5 years old were assessed by means of cone-beam computed tomography (CBCT) and a standardized quality of life questionnaire answered by patients' parents/legal guardians before and immediately after rapid maxillary expansion. RESULTS: Rapid maxillary expansion resulted in similar and significant expansion in the width of anterior (2.8 mm, p < 0.001) and posterior nasal floor (2.8 mm, p < 0.001). Although nasopharynx and nasal cavities airway volumes significantly increased (+1646.1 mm3, p < 0.001), oropharynx volume increase was not statistically significant (+1450.6 mm3, p = 0.066). The results of the quality of life questionnaire indicated that soon after rapid maxillary expansion, patients' respiratory symptoms significantly decreased in relation to their initial respiratory conditions. CONCLUSIONS: It is suggested that RME produces significant dimensional increase in the nasal cavity and nasopharynx. Additionally, it also positively impacts the quality of life of mouth-breathing patients with maxillary atresia.

Dentofacial characteristics of oral breathers in different ages: a retrospective case-control study.

BACKGROUND: This study aimed to investigate the dental and skeletal variables associated with disturbances of craniofacial development in oral-breathing (OB) individuals and the probability that these variables are related to this condition. METHODS: This is an observational retrospective case-control study of 1596 patients divided into three groups of age n1 5-12, n2 13-18, and n3 19-57 years. Radiographic, clinical, and models data were analyzed. The control group was consisted of nasal breathing (NB) individuals. Statistical analyses of the qualitative data were performed with x (2) test to identify associations, and odds ratio (OR) tests were performed for the variables that the chi-square test (x (2)) identified an association. RESULTS: In the descriptive analysis of the data, we observed that the class II malocclusion was the most frequent in the total sample, but when divided by age group and mode of breathing, there is a random division of these variables. In n1 group, class II, (OR = 2.02) short and retruded mandible (SM and RM) (OR = 1.65 and1.89) were associated with OB and it was considered a risk factor. In n2 group, class II (OR = 1.73), SM (OR = 1.87) and increased lower anterior height (ILAFH) (OR = 1.84) seemed to be associated and to be risk factors for OB. In the n1 group, decreased lower anterior facial height (DLAFH) and brachycephalic facial pattern (BP) seemed to be associated with NB and a protective factor against oral breathing. CONCLUSIONS: This study showed that dental and skeletal factors are associated with OB in children, and it seems that it becomes more severe until adolescence. But adults showed no associations between OB and skeletal factors, only in dental variables, indicating that there is no cause-effect relationship between the dental and skeletal factors and OB. The treatment of nose breathing patient should be multidisciplinary, since OB remains even when dental and skeletal factors slow down.