Association between severe asthma and changes in the stomatognathic system
Identifieur interne : 003029 ( Pmc/Corpus ); précédent : 003028; suivant : 003030Association between severe asthma and changes in the stomatognathic system
Auteurs : Mayra Carvalho-Oliveira ; Cristina Salles ; Regina Terse ; Argemiro D'OliveiraSource :
- Jornal Brasileiro de Pneumologia [ 1806-3713 ] ; 2016.
Abstract
To describe orofacial muscle function in patients with severe asthma.
This was a descriptive study comparing patients with severe controlled asthma (SCA) and severe uncontrolled asthma (SUA). We selected 160 patients, who completed a sociodemographic questionnaire and the 6-item Asthma Control Questionnaire (ACQ-6), as well as undergoing evaluation of orofacial muscle function.
Of the 160 patients evaluated, 126 (78.8%) and 34 (21.2%) presented with SCA and SUA, respectively, as defined by the Global Initiative for Asthma criteria. Regardless of the level of asthma control, the most frequent changes found after evaluation of muscle function were difficulty in chewing, oronasal breathing pattern, below-average or poor dental arch condition, and difficulty in swallowing. When the sample was stratified by FEV1 (% of predicted), was significantly higher proportions of SUA group patients, compared with SCA group patients, showed habitual open-mouth chewing (24.8% vs. 7.7%; p < 0.02), difficulty in swallowing water (33.7% vs. 17.3%; p < 0.04), and voice problems (81.2% vs. 51.9%; p < 0.01). When the sample was stratified by ACQ-6 score, the proportion of patients showing difficulty in swallowing bread was significantly higher in the SUA group than in the SCA group (66.6% vs. 26.6%; p < 0.01).
The prevalence of changes in the stomatognathic system appears to be high among adults with severe asthma, regardless of the level of asthma control. We found that some such changes were significantly more common in patients with SUA than in those with SCA.
Url:
DOI: 10.1590/S1806-37562015000600006
PubMed: 28117472
PubMed Central: 5344090
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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Association between severe asthma and changes in the stomatognathic system</title><author><name sortKey="Carvalho Oliveira, Mayra" sort="Carvalho Oliveira, Mayra" uniqKey="Carvalho Oliveira M" first="Mayra" last="Carvalho-Oliveira">Mayra Carvalho-Oliveira</name><affiliation><nlm:aff id="aff1">. Programa de Controle da Asma e Rinite Alérgica da Bahia - ProAR - Salvador (BA) Brasil.</nlm:aff></affiliation><affiliation><nlm:aff id="aff2">. Programa de Pós-Graduação em Ciências da Saúde, Universidade Federal da Bahia, Salvador (BA) Brasil.</nlm:aff></affiliation></author><author><name sortKey="Salles, Cristina" sort="Salles, Cristina" uniqKey="Salles C" first="Cristina" last="Salles">Cristina Salles</name><affiliation><nlm:aff id="aff3">. Escola Bahiana de Medicina e Saúde Pública, Salvador (BA) Brasil.</nlm:aff></affiliation></author><author><name sortKey="Terse, Regina" sort="Terse, Regina" uniqKey="Terse R" first="Regina" last="Terse">Regina Terse</name><affiliation><nlm:aff id="aff4">. Departamento de Pediatria, Faculdade de Medicina, Universidade Federal da Bahia, Salvador (BA) Brasil.</nlm:aff></affiliation></author><author><name sortKey="D Oliveira, Argemiro" sort="D Oliveira, Argemiro" uniqKey="D Oliveira A" first="Argemiro" last="D'Oliveira">Argemiro D'Oliveira</name><affiliation><nlm:aff id="aff2">. Programa de Pós-Graduação em Ciências da Saúde, Universidade Federal da Bahia, Salvador (BA) Brasil.</nlm:aff></affiliation><affiliation><nlm:aff id="aff5">. Programa de Pós-Graduação em Medicina e Saúde, Universidade Federal da Bahia, Salvador (BA) Brasil.</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">28117472</idno><idno type="pmc">5344090</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5344090</idno><idno type="RBID">PMC:5344090</idno><idno type="doi">10.1590/S1806-37562015000600006</idno><date when="2016">2016</date><idno type="wicri:Area/Pmc/Corpus">003029</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">003029</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Association between severe asthma and changes in the stomatognathic system</title><author><name sortKey="Carvalho Oliveira, Mayra" sort="Carvalho Oliveira, Mayra" uniqKey="Carvalho Oliveira M" first="Mayra" last="Carvalho-Oliveira">Mayra Carvalho-Oliveira</name><affiliation><nlm:aff id="aff1">. Programa de Controle da Asma e Rinite Alérgica da Bahia - ProAR - Salvador (BA) Brasil.</nlm:aff></affiliation><affiliation><nlm:aff id="aff2">. Programa de Pós-Graduação em Ciências da Saúde, Universidade Federal da Bahia, Salvador (BA) Brasil.</nlm:aff></affiliation></author><author><name sortKey="Salles, Cristina" sort="Salles, Cristina" uniqKey="Salles C" first="Cristina" last="Salles">Cristina Salles</name><affiliation><nlm:aff id="aff3">. Escola Bahiana de Medicina e Saúde Pública, Salvador (BA) Brasil.</nlm:aff></affiliation></author><author><name sortKey="Terse, Regina" sort="Terse, Regina" uniqKey="Terse R" first="Regina" last="Terse">Regina Terse</name><affiliation><nlm:aff id="aff4">. Departamento de Pediatria, Faculdade de Medicina, Universidade Federal da Bahia, Salvador (BA) Brasil.</nlm:aff></affiliation></author><author><name sortKey="D Oliveira, Argemiro" sort="D Oliveira, Argemiro" uniqKey="D Oliveira A" first="Argemiro" last="D'Oliveira">Argemiro D'Oliveira</name><affiliation><nlm:aff id="aff2">. Programa de Pós-Graduação em Ciências da Saúde, Universidade Federal da Bahia, Salvador (BA) Brasil.</nlm:aff></affiliation><affiliation><nlm:aff id="aff5">. Programa de Pós-Graduação em Medicina e Saúde, Universidade Federal da Bahia, Salvador (BA) Brasil.</nlm:aff></affiliation></author></analytic><series><title level="j">Jornal Brasileiro de Pneumologia</title><idno type="ISSN">1806-3713</idno><idno type="eISSN">1806-3756</idno><imprint><date when="2016">2016</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><title>ABSTRACT</title><sec><title>Objective:</title><p>To describe orofacial muscle function in patients with severe asthma. </p></sec><sec><title>Methods:</title><p>This was a descriptive study comparing patients with severe controlled asthma (SCA) and severe uncontrolled asthma (SUA). We selected 160 patients, who completed a sociodemographic questionnaire and the 6-item Asthma Control Questionnaire (ACQ-6), as well as undergoing evaluation of orofacial muscle function. </p></sec><sec><title>Results:</title><p>Of the 160 patients evaluated, 126 (78.8%) and 34 (21.2%) presented with SCA and SUA, respectively, as defined by the Global Initiative for Asthma criteria. Regardless of the level of asthma control, the most frequent changes found after evaluation of muscle function were difficulty in chewing, oronasal breathing pattern, below-average or poor dental arch condition, and difficulty in swallowing. When the sample was stratified by FEV<sub>1</sub> (% of predicted), was significantly higher proportions of SUA group patients, compared with SCA group patients, showed habitual open-mouth chewing (24.8% vs. 7.7%; p < 0.02), difficulty in swallowing water (33.7% vs. 17.3%; p < 0.04), and voice problems (81.2% vs. 51.9%; p < 0.01). When the sample was stratified by ACQ-6 score, the proportion of patients showing difficulty in swallowing bread was significantly higher in the SUA group than in the SCA group (66.6% vs. 26.6%; p < 0.01). </p></sec><sec><title>Conclusions:</title><p>The prevalence of changes in the stomatognathic system appears to be high among adults with severe asthma, regardless of the level of asthma control. We found that some such changes were significantly more common in patients with SUA than in those with SCA.</p></sec></div></front><back><div1 type="bibliography"><listBibl><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Salles, C" uniqKey="Salles C">C Salles</name></author><author><name sortKey="Cruz, Aa" uniqKey="Cruz A">AA Cruz</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Kairaitis, K" uniqKey="Kairaitis K">K Kairaitis</name></author><author><name sortKey="Garlick, Sr" uniqKey="Garlick S">SR Garlick</name></author><author><name sortKey="Wheatley, Jr" uniqKey="Wheatley J">JR Wheatley</name></author><author><name sortKey="Amis, Tc" uniqKey="Amis T">TC Amis</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="De Felicio, Cm" uniqKey="De Felicio C">CM de Felicio</name></author><author><name sortKey="De Oliveira, Mm" uniqKey="De Oliveira M">MM de Oliveira</name></author><author><name sortKey="Da 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uniqKey="Wenzel S">SE Wenzel</name></author><author><name sortKey="Brozek, Jl" uniqKey="Brozek J">JL Brozek</name></author><author><name sortKey="Bush, A" uniqKey="Bush A">A Bush</name></author><author><name sortKey="Castro, M" uniqKey="Castro M">M Castro</name></author><author><name sortKey="Sterk, Pj" uniqKey="Sterk P">PJ Sterk</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Stanton, Ae" uniqKey="Stanton A">AE Stanton</name></author><author><name sortKey="Sellars, C" uniqKey="Sellars C">C Sellars</name></author><author><name sortKey="Mackenzie, K" uniqKey="Mackenzie K">K Mackenzie</name></author><author><name sortKey="Mcconnachie, A" uniqKey="Mcconnachie A">A McConnachie</name></author><author><name sortKey="Bucknall, Ce" uniqKey="Bucknall C">CE Bucknall</name></author></analytic></biblStruct><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Leite, M" uniqKey="Leite M">M Leite</name></author><author><name sortKey="Ponte, Ev" 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<front><journal-meta><journal-id journal-id-type="nlm-ta">J Bras Pneumol</journal-id><journal-id journal-id-type="iso-abbrev">J Bras Pneumol</journal-id><journal-id journal-id-type="publisher-id">jbpneu</journal-id><journal-title-group><journal-title>Jornal Brasileiro de Pneumologia</journal-title></journal-title-group><issn pub-type="ppub">1806-3713</issn><issn pub-type="epub">1806-3756</issn><publisher><publisher-name>Sociedade Brasileira de Pneumologia e Tisiologia</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">28117472</article-id><article-id pub-id-type="pmc">5344090</article-id><article-id pub-id-type="doi">10.1590/S1806-37562015000600006</article-id><article-categories><subj-group subj-group-type="heading"><subject>Original Article</subject></subj-group></article-categories><title-group><article-title>Association between severe asthma and changes in the stomatognathic system</article-title><trans-title-group xml:lang="pt"><trans-title>Associação entre asma grave e alterações do sistema estomatognático</trans-title></trans-title-group></title-group><contrib-group><contrib contrib-type="author"><name><surname>Carvalho-Oliveira</surname><given-names>Mayra</given-names></name><xref ref-type="aff" rid="aff1"><sup>1</sup></xref><xref ref-type="aff" rid="aff2"><sup>2</sup></xref></contrib><contrib contrib-type="author"><name><surname>Salles</surname><given-names>Cristina</given-names></name><xref ref-type="aff" rid="aff3"><sup>3</sup></xref></contrib><contrib contrib-type="author"><name><surname>Terse</surname><given-names>Regina</given-names></name><xref ref-type="aff" rid="aff4"><sup>4</sup></xref></contrib><contrib contrib-type="author"><name><surname>D'Oliveira</surname><given-names>Argemiro</given-names><suffix>Júnior</suffix></name><xref ref-type="aff" rid="aff2"><sup>2</sup></xref><xref ref-type="aff" rid="aff5"><sup>5</sup></xref></contrib></contrib-group><aff id="aff1"><label>1</label>. Programa de Controle da Asma e Rinite Alérgica da Bahia - ProAR - Salvador (BA) Brasil.</aff><aff id="aff2"><label>2</label>. Programa de Pós-Graduação em Ciências da Saúde, Universidade Federal da Bahia, Salvador (BA) Brasil.</aff><aff id="aff3"><label>3</label>. Escola Bahiana de Medicina e Saúde Pública, Salvador (BA) Brasil.</aff><aff id="aff4"><label>4</label>. Departamento de Pediatria, Faculdade de Medicina, Universidade Federal da Bahia, Salvador (BA) Brasil.</aff><aff id="aff5"><label>5</label>. Programa de Pós-Graduação em Medicina e Saúde, Universidade Federal da Bahia, Salvador (BA) Brasil.</aff><author-notes><corresp id="c1">Correspondence to: Mayra Carvalho-Oliveira. Centro Médico Hospital da Bahia, Clinica CEVEM, Avenida Professor Magalhães Neto, 1541, Sala 2010, Pituba, CEP 41810-011, Salvador, BA, Brasil. Tel./Fax: 55 71 2109-2210. E-mail: <email>mayrafono@hotmail.com</email></corresp></author-notes><pub-date pub-type="epub-ppub"><season>Nov-Dec</season><year>2016</year></pub-date><pmc-comment>Fake ppub date generated by PMC from publisher
pub-date/@pub-type='epub-ppub' </pmc-comment>
<pub-date pub-type="ppub"><season>Nov-Dec</season><year>2016</year></pub-date><volume>42</volume><issue>6</issue><fpage>423</fpage><lpage>428</lpage><history><date date-type="received"><day>03</day><month>5</month><year>2015</year></date><date date-type="accepted"><day>31</day><month>5</month><year>2016</year></date></history><permissions><license license-type="open-access" xlink:href="http://creativecommons.org/licenses/by-nc/4.0/"><license-p>This is an open-access article distributed under the terms of the Creative Commons Attribution License</license-p></license></permissions><abstract><title>ABSTRACT</title><sec><title>Objective:</title><p>To describe orofacial muscle function in patients with severe asthma. </p></sec><sec><title>Methods:</title><p>This was a descriptive study comparing patients with severe controlled asthma (SCA) and severe uncontrolled asthma (SUA). We selected 160 patients, who completed a sociodemographic questionnaire and the 6-item Asthma Control Questionnaire (ACQ-6), as well as undergoing evaluation of orofacial muscle function. </p></sec><sec><title>Results:</title><p>Of the 160 patients evaluated, 126 (78.8%) and 34 (21.2%) presented with SCA and SUA, respectively, as defined by the Global Initiative for Asthma criteria. Regardless of the level of asthma control, the most frequent changes found after evaluation of muscle function were difficulty in chewing, oronasal breathing pattern, below-average or poor dental arch condition, and difficulty in swallowing. When the sample was stratified by FEV<sub>1</sub> (% of predicted), was significantly higher proportions of SUA group patients, compared with SCA group patients, showed habitual open-mouth chewing (24.8% vs. 7.7%; p < 0.02), difficulty in swallowing water (33.7% vs. 17.3%; p < 0.04), and voice problems (81.2% vs. 51.9%; p < 0.01). When the sample was stratified by ACQ-6 score, the proportion of patients showing difficulty in swallowing bread was significantly higher in the SUA group than in the SCA group (66.6% vs. 26.6%; p < 0.01). </p></sec><sec><title>Conclusions:</title><p>The prevalence of changes in the stomatognathic system appears to be high among adults with severe asthma, regardless of the level of asthma control. We found that some such changes were significantly more common in patients with SUA than in those with SCA.</p></sec></abstract><trans-abstract xml:lang="pt"><title>RESUMO</title><sec><title>Objetivo:</title><p>Descrever os achados da avaliação miofuncional orofacial em pacientes com asma grave. </p></sec><sec><title>Métodos:</title><p>Estudo descritivo comparando pacientes com asma grave controlada (AGC) e asma grave não controlada (AGNC). Foram selecionados 160 participantes, que responderam a um questionário sociodemográfico e o Asthma Control Questionnaire com seis questões (ACQ-6) e realizaram avaliação miofuncional orofacial. </p></sec><sec><title>Resultados:</title><p>Na amostra estudada, 126 (78,8%) e 34 (21,2%) pacientes, respectivamente, apresentavam AGC e AGNC segundo os critérios da Global Initiative for Asthma. Independentemente do nível de controle da asma grave, as alterações mais frequentes observadas na avaliação miofuncional foram problemas de mastigação, padrão de respiração oronasal, estado de conservação da arcada dentária médio ou ruim e problemas na deglutição. Quando a amostra foi estratificada pelo VEF<sub>1</sub> (% do previsto), os resultados foram significativamente maiores no grupo AGNC que no grupo AGC quanto a mastigação habitual com boca aberta (24,8% vs. 7,7%; p < 0,02), deglutição de água com dificuldade (33,7% vs. 17,3%; p < 0,04) e problemas de voz (81,2% vs. 51,9%; p < 0,01). Quando estratificada pelo ACQ-6, os resultados do grupo AGNC foram significativamente maiores que no grupo AGC quanto à deglutição de pão com dificuldade (66,6% vs. 26,6%; p < 0,01). </p></sec><sec><title>Conclusões:</title><p>A prevalência de alterações do sistema estomatognático parece ser alta em adultos com asma grave independentemente do nível de controle da doença. No grupo AGNC, algumas dessas alterações foram significativamente mais frequentes que no grupo AGC.</p></sec></trans-abstract><kwd-group><title>Keywords:</title><kwd>Speech/physiology</kwd><kwd>Stomatognathic system/physiopathology</kwd><kwd>Asthma/complications</kwd><kwd>Deglutition disorders</kwd><kwd>Mastication/physiology</kwd></kwd-group><counts><fig-count count="6"></fig-count><table-count count="6"></table-count><equation-count count="0"></equation-count><ref-count count="20"></ref-count><page-count count="6"></page-count></counts></article-meta></front><body><sec sec-type="intro"><title>INTRODUCTION</title><p>The 2015 update of the Global Initiative for Asthma (GINA) guidelines<xref rid="B1" ref-type="bibr"><sup>1</sup></xref> indicates that, in 10-40% of patients with (allergic or non-allergic) asthma, the disease may be associated with rhinitis. However, a study conducted at a referral center in the city of Salvador, Brazil, found a 100 percent association between asthma and allergic rhinitis. <xref rid="B2" ref-type="bibr"><sup>2</sup></xref> Allergic rhinitis, in turn, can cause nasal obstruction, with consequent oral breathing at rest, even when individuals with severe asthma are experiencing stable periods.<xref rid="B3" ref-type="bibr"><sup>3</sup></xref> Oral breathing can change the functions of the stomatognathic system (breathing, sucking, chewing, swallowing, and speech), functions that affect vital and social aspects.<xref rid="B4" ref-type="bibr"><sup>4</sup></xref></p><p>The literature has demonstrated that oral breathing in children and adults with severe asthma can cause changes in the structures and functions of the stomatognathic system, which are represented, for example, by maxillary atresia and a high-arched palate; protrusion of the tongue between or against the dental arches; open bite and crossbite; hypotonic lips and lip occlusion with muscle tension; and inappropriate patterns of breathing, chewing, and swallowing.<xref rid="B5" ref-type="bibr"><sup>5</sup></xref><sup>-</sup><xref rid="B8" ref-type="bibr"><sup>8</sup></xref></p><p>The static and mobile structures of the stomatognathic system act jointly and synchronously to perform the functions of breathing, sucking, chewing, swallowing, and speech. One can hypothesize that a change in an upper airway structure may change its corresponding function, such an example being that missing dental units will affect chewing. When a structure or function is changed, the other structures and functions may play their roles in a way befitting that new condition, one such example being that of hypotonia of the tongue leading to changes in executing swallowing movements.</p><p>Severe asthma can be identified by difficulty in controlling the disease or achieving treatment response, as well as by the presence of at least one of the following indicators: poor symptom control, as indicated by an Asthma Control Questionnaire (ACQ) score > 1.5 or an Asthma Control Test score < 20; frequent exacerbations requiring two or more doses of systemic corticosteroids (> 3 times a day) in the previous year; severe exacerbations in the previous year, with at least one requiring hospitalization or mechanical ventilation; airflow limitation after bronchodilator use, with an FEV<sub>1</sub> < 80% of predicted; and frequent symptoms of nocturnal asthma and limitation in physical activities.<xref rid="B9" ref-type="bibr"><sup>9</sup></xref><sup>-</sup><xref rid="B11" ref-type="bibr"><sup>11</sup></xref> Patients with severe asthma tend to show a high rate of allergic rhinitis, one of the clinical symptoms of which is nasal obstruction, and consequently have predominantly oral breathing. In such cases, the phonoarticulatory organs are positioned improperly and can lead to impairment of the functions of sucking, chewing, swallowing, and speech. Therefore, the objective of the present study was to describe orofacial muscle function in patients with severe asthma.</p></sec><sec sec-type="methods"><title>METHODS</title><p>This was a cross-sectional study of a consecutive sample selected in an asthma referral center-<italic>Programa de Controle da Asma e da Rinite Alérgica da Bahia</italic> (ProAR, Bahia State Program for the Control of Asthma and Allergic Rhinitis)-in the city of Salvador, Brazil. The inclusion criteria were as follows: having been diagnosed with severe asthma in accordance with the Global Initiative for Asthma criteria<xref rid="B12" ref-type="bibr"><sup>12</sup></xref>; and being 18 to 85 years of age. The exclusion criteria were as follows: having a neurological disorder, a genetic syndrome, a heart disease, a debilitating disease, facial trauma, cognitive deficit, or difficulty in understanding and performing the requested movements; having a history of head and neck surgery; and being pregnant.</p><p>Of the 160 subjects invited to participate in the study, all completed a sociodemographic questionnaire and the 6-item ACQ (ACQ-6), with the cut-off point for control being 1.5.<xref rid="B13" ref-type="bibr"><sup>13</sup></xref> The evaluation of muscle function consisted of observation of the face and oral function, following a validated protocol.<xref rid="B8" ref-type="bibr"><sup>8</sup></xref> The data for FEV<sub>1</sub> were obtained from medical records, which had to have been completed within twelve months previously.</p><p>To calculate the sample size required to estimate the frequency of myofunctional dysfunction in patients with severe asthma, we used the PEPI-Sample software (Sagebush Press, Salt Lake City, UT, USA) and the following parameters: a confidence level of 95%; an estimated prevalence of myofunctional changes in the general population of 30-40%; population from which the sample was drawn: approximately 2,000 severe asthma patients enrolled in the ProAR; and a difference in prevalence of 10% as being acceptable. To achieve the study objective, the required sample size was estimated at 145 patients. Allowing for a loss to follow-up rate of 10%, a sample of 160 patients was determined.</p><p>Data were tabulated and analyzed with the IBM SPSS Statistics software package, version 20.0 (IBM Corporation, Armonk, NY, USA). Quantitative variables were expressed as mean ± standard deviation or as median (interquartile range). Qualitative variables were expressed as absolute and relative frequencies. Proportions were compared with the chi-square test. Two means were compared with the Student's t-test for independent samples. Values of p < 0.05 were considered statistically significant.</p><p>The present study was approved by the Research Ethics Committee of the Federal University of Bahia (Protocol No. 088/2010; Additional Resolution No. 41/2013). Written informed consent was given by the patients at the time they agreed to participate in the study.</p></sec><sec sec-type="results"><title>RESULTS</title><p>A total of 160 adult patients (age ≥ 18 years) were invited to participate in the evaluation of orofacial muscle function in patients with severe asthma. On the basis of the GINA criteria for classification of asthma,<xref rid="B12" ref-type="bibr"><sup>12</sup></xref> 126 patients (79%) had controlled asthma and 34 (21%) had uncontrolled asthma. <xref ref-type="table" rid="t1">Table 1</xref> shows the sociodemographic aspects of the severe asthma patients enrolled in the ProAR, providing data on gender, skin color, level of education, family income, age, BMI, spirometry, and ACQ-6 scores.</p><p><table-wrap id="t1" orientation="portrait" position="float"><label>Table 1</label><caption><title>Sociodemographic aspects, as well as clinical and spirometric characteristics, of the patients with severe asthma included in the study (N = 160).<sup>a</sup></title></caption><table frame="hsides" rules="groups"><colgroup span="1"><col span="1"></col><col span="1"></col></colgroup><thead><tr><th align="center" rowspan="1" colspan="1">Variable</th><th align="center" rowspan="1" colspan="1">Patients</th></tr></thead><tbody><tr><td align="left" rowspan="1" colspan="1">Gender (female)</td><td align="center" rowspan="1" colspan="1">123 (76.9)</td></tr><tr><td align="left" rowspan="1" colspan="1">Skin color (brown)</td><td align="center" rowspan="1" colspan="1">100 (62.7)</td></tr><tr><td align="left" rowspan="1" colspan="1">Level of education (< 9 years of schooling)</td><td align="center" rowspan="1" colspan="1">80 (50.0)</td></tr><tr><td align="left" rowspan="1" colspan="1">Family income (one time the national minimum wage)</td><td align="center" rowspan="1" colspan="1">80 (50.0)</td></tr><tr><td align="left" rowspan="1" colspan="1">Age, years</td><td align="center" rowspan="1" colspan="1">51.5 ± 12.6</td></tr><tr><td align="left" rowspan="1" colspan="1">BMI, kg/m<sup>2</sup></td><td align="center" rowspan="1" colspan="1">29.0 ± 5.2</td></tr><tr><td align="left" rowspan="1" colspan="1">Pre-bronchodilator FEV<sub>1</sub>, % of predicted</td><td align="center" rowspan="1" colspan="1">63.7 (49.6-76.0)</td></tr><tr><td align="left" rowspan="1" colspan="1">Post-bronchodilator FEV<sub>1</sub>, % of predicted</td><td align="center" rowspan="1" colspan="1">69.5 (57.5-82.0)</td></tr><tr><td align="left" rowspan="1" colspan="1">ACQ-6 score</td><td align="center" rowspan="1" colspan="1">0.66 (0.50-1.33)</td></tr></tbody></table><table-wrap-foot><fn id="TFN1"><p>ACQ-6: 6-item Asthma Control Questionnaire<italic>.</italic><sup>a</sup>Values expressed as mean ± SD or as median (interquartile range).</p></fn></table-wrap-foot></table-wrap></p><p>At the time of the evaluation of muscle function, 4 of the 160 invited patients (3 with severe controlled asthma and 1 with severe uncontrolled asthma) were excluded because they were unable to perform the requested movements. <xref ref-type="fig" rid="f1">Figure 1</xref> shows, by level of asthma control, the results for dental arch condition and presence/absence of fixed or removable dental prostheses in the severe asthma patients enrolled in the ProAR.</p><p><fig id="f1" orientation="portrait" position="float"><label>Figure 1</label><caption><title>Comparison of dental arch characteristics in patients with severe asthma, by level of asthma control. Chi-square test; p < 0.05.</title></caption><graphic xlink:href="1806-3713-jbpneu-42-06-00423-gf1"></graphic></fig></p><p><xref ref-type="fig" rid="f2">Figure 2</xref> shows, by level of asthma control, the results of the evaluation of masticatory function (solid food: milk bread) in the severe asthma patients enrolled in the ProAR.</p><p><fig id="f2" orientation="portrait" position="float"><label>Figure 2</label><caption><title>Comparison of masticatory function (solid food) in patients with severe asthma, by level of asthma control. Chi-square test; p < 0.05.</title></caption><graphic xlink:href="1806-3713-jbpneu-42-06-00423-gf2"></graphic></fig></p><p><xref ref-type="fig" rid="f3">Figure 3</xref> shows, by level of asthma control, the results for swallowing function (solid food and liquids) in the severe asthma patients enrolled in the ProAR.</p><p><fig id="f3" orientation="portrait" position="float"><label>Figure 3</label><caption><title>Comparison of swallowing function in patients with severe asthma, by level of asthma control. Chi-square test; p < 0.05.</title></caption><graphic xlink:href="1806-3713-jbpneu-42-06-00423-gf3"></graphic></fig></p><p>The evaluation of orofacial muscle function, the responses on the ACQ-6, and the spirometric data revealed changes in breathing, voice, tongue mobility, masticatory function, and swallowing function. To gain a better understanding of these changes in asthma patients, the variables were analyzed by comparing these results on the basis of the two asthma control measures used. <xref ref-type="table" rid="t2">Table 2</xref> shows, by FEV<sub>1</sub> in % of predicted after bronchodilator use, the results of the statistical analysis (chi-square test) for tongue mobility, masticatory function, swallowing function, and voice complaints.</p><p><table-wrap id="t2" orientation="portrait" position="float"><label>Table 2</label><caption><title>Data from the evaluation of orofacial muscle function in adults with asthma, by FEV<sub>1</sub> in % of predicted after bronchodilator use.<sup>a</sup></title></caption><table frame="hsides" rules="groups"><colgroup span="1"><col span="1"></col><col span="1"></col><col span="1"></col><col span="1"></col></colgroup><thead><tr><th align="center" rowspan="2" colspan="1">Variable</th><th align="center" rowspan="1" colspan="1">FEV<sub>1</sub> ≥ 80%</th><th align="center" rowspan="1" colspan="1">FEV<sub>1</sub> < 80%</th><th align="center" rowspan="2" colspan="1">p*</th></tr><tr><th align="center" rowspan="1" colspan="1">(n = 52)</th><th align="center" rowspan="1" colspan="1">(n = 101)</th></tr></thead><tbody><tr><td align="left" rowspan="1" colspan="1">Tongue, flaccid tone</td><td align="center" rowspan="1" colspan="1">19 (35.8)</td><td align="center" rowspan="1" colspan="1">54 (51.9)</td><td align="center" rowspan="1" colspan="1">0.06</td></tr><tr><td align="left" rowspan="1" colspan="1">Tongue, asymmetric sucking</td><td align="center" rowspan="1" colspan="1">14 (26.4)</td><td align="center" rowspan="1" colspan="1">34 (32.7)</td><td align="center" rowspan="1" colspan="1">0.47</td></tr><tr><td align="left" rowspan="1" colspan="1">Tongue, changes in the 4 cardinal points</td><td align="center" rowspan="1" colspan="1">3 (5.8)</td><td align="center" rowspan="1" colspan="1">14 (13.9)</td><td align="center" rowspan="1" colspan="1">0.18</td></tr><tr><td align="left" rowspan="1" colspan="1">Habitual open-mouth chewing</td><td align="center" rowspan="1" colspan="1">4 (7.7)</td><td align="center" rowspan="1" colspan="1">25 (24.8)</td><td align="center" rowspan="1" colspan="1">0.02</td></tr><tr><td align="left" rowspan="1" colspan="1">Habitual chewing more on one side</td><td align="center" rowspan="1" colspan="1">46 (88.5)</td><td align="center" rowspan="1" colspan="1">92 (91.1)</td><td align="center" rowspan="1" colspan="1">0.58</td></tr><tr><td align="left" rowspan="1" colspan="1">Difficulty in swallowing bread</td><td align="center" rowspan="1" colspan="1">15 (28.8)</td><td align="center" rowspan="1" colspan="1">38 (37.6)</td><td align="center" rowspan="1" colspan="1">0.37</td></tr><tr><td align="left" rowspan="1" colspan="1">Mentalis muscle contraction during water swallowing</td><td align="center" rowspan="1" colspan="1">51 (98.1)</td><td align="center" rowspan="1" colspan="1">100 (99.0)</td><td align="center" rowspan="1" colspan="1">1.00</td></tr><tr><td align="left" rowspan="1" colspan="1">Difficulty in swallowing water</td><td align="center" rowspan="1" colspan="1">9 (17.3)</td><td align="center" rowspan="1" colspan="1">34 (33.7)</td><td align="center" rowspan="1" colspan="1">0.04</td></tr><tr><td align="left" rowspan="1" colspan="1">Chocking during water swallowing</td><td align="center" rowspan="1" colspan="1">13 (25.0)</td><td align="center" rowspan="1" colspan="1">37 (36.6)</td><td align="center" rowspan="1" colspan="1">0.20</td></tr><tr><td align="left" rowspan="1" colspan="1">Voice problems</td><td align="center" rowspan="1" colspan="1">27 (51.9)</td><td align="center" rowspan="1" colspan="1">82 (81.2)</td><td align="center" rowspan="1" colspan="1">0.01</td></tr></tbody></table><table-wrap-foot><fn id="TFN2"><label>a</label><p>Values expressed as n (%). *Chi-square test or Fisher's exact test.</p></fn></table-wrap-foot></table-wrap></p><p><xref ref-type="table" rid="t3">Table 3</xref> shows, by level of asthma control as determined by the ACQ-6, the results of the statistical analysis (chi-square test) for tongue mobility, masticatory function, swallowing function, and voice complaints.</p><p><table-wrap id="t3" orientation="portrait" position="float"><label>Table 3</label><caption><title>Data from the evaluation of orofacial muscle function in adults with severe controlled asthma or severe uncontrolled asthma, as determined by the 6-item Asthma Control Questionnaire (ACQ-6).<sup>a</sup></title></caption><table frame="hsides" rules="groups"><colgroup span="1"><col span="1"></col><col span="2"></col><col span="1"></col></colgroup><thead><tr><th align="center" rowspan="3" colspan="1">Variable</th><th align="center" colspan="2" rowspan="1">Patients<sup>b</sup></th><th align="center" rowspan="3" colspan="1">p*</th></tr><tr><th align="center" rowspan="1" colspan="1">Controlled asthma</th><th align="center" rowspan="1" colspan="1">Uncontrolled asthma</th></tr><tr><th align="center" rowspan="1" colspan="1">(n = 123)</th><th align="center" rowspan="1" colspan="1">(n = 33)</th></tr></thead><tbody><tr><td align="left" rowspan="1" colspan="1">Tongue, flaccid tone</td><td align="center" rowspan="1" colspan="1">55 (43.7)</td><td align="center" rowspan="1" colspan="1">19 (56.0)</td><td align="center" rowspan="1" colspan="1">0.25</td></tr><tr><td align="left" rowspan="1" colspan="1">Tongue, asymmetric sucking</td><td align="center" rowspan="1" colspan="1">36 (28.6)</td><td align="center" rowspan="1" colspan="1">13 (38.2)</td><td align="center" rowspan="1" colspan="1">0.30</td></tr><tr><td align="left" rowspan="1" colspan="1">Tongue, changes in the 4 cardinal points</td><td align="center" rowspan="1" colspan="1">11 (9.0)</td><td align="center" rowspan="1" colspan="1">6 (18.1)</td><td align="center" rowspan="1" colspan="1">0.12</td></tr><tr><td align="left" rowspan="1" colspan="1">Habitual open-mouth chewing</td><td align="center" rowspan="1" colspan="1">21 (17.0)</td><td align="center" rowspan="1" colspan="1">9 (27.3)</td><td align="center" rowspan="1" colspan="1">0.14</td></tr><tr><td align="left" rowspan="1" colspan="1">Habitual chewing more on one side</td><td align="center" rowspan="1" colspan="1">111 (90.2)</td><td align="center" rowspan="1" colspan="1">30 (91.0)</td><td align="center" rowspan="1" colspan="1">0.65</td></tr><tr><td align="left" rowspan="1" colspan="1">Difficulty in swallowing bread</td><td align="center" rowspan="1" colspan="1">32 (26.0)</td><td align="center" rowspan="1" colspan="1">22 (66.6)</td><td align="center" rowspan="1" colspan="1">0.01</td></tr><tr><td align="left" rowspan="1" colspan="1">Mentalis muscle contraction during water swallowing</td><td align="center" rowspan="1" colspan="1">121 (98.4)</td><td align="center" rowspan="1" colspan="1">33 (100.0)</td><td align="center" rowspan="1" colspan="1">0.62</td></tr><tr><td align="left" rowspan="1" colspan="1">Difficulty in swallowing water</td><td align="center" rowspan="1" colspan="1">31 (25.2)</td><td align="center" rowspan="1" colspan="1">14 (42.4)</td><td align="center" rowspan="1" colspan="1">0.05</td></tr><tr><td align="left" rowspan="1" colspan="1">Chocking during water swallowing</td><td align="center" rowspan="1" colspan="1">39 (31.7)</td><td align="center" rowspan="1" colspan="1">13 (38.2)</td><td align="center" rowspan="1" colspan="1">0.26</td></tr><tr><td align="left" rowspan="1" colspan="1">Voice problems</td><td align="center" rowspan="1" colspan="1">87 (71.0)</td><td align="center" rowspan="1" colspan="1">25 (76.0)</td><td align="center" rowspan="1" colspan="1">0.66</td></tr></tbody></table><table-wrap-foot><fn id="TFN3"><label>a</label><p>Values expressed as n (%). <sup>b</sup>Controlled asthma: ACQ-6 scores ≥ 1.5; and uncontrolled asthma: ACQ-6 scores < 1.5. *Chi-square test or Fisher's exact test.</p></fn></table-wrap-foot></table-wrap></p></sec><sec sec-type="discussion"><title>DISCUSSION</title><p>Our study results revealed that the frequency of changes in the stomatognathic system was high in patients with severe controlled asthma as well as in those with severe uncontrolled asthma. Two references were used as parameters for assessing asthma control: an objective one and a subjective one. Spirometry is an objective test and provides pre- and post-bronchodilator FEV<sub>1</sub> values. The ACQ is a subjective questionnaire for assessing asthma control that uses patients' memories and perceptions of their health status in the last seven days. The two parameters were associated with the variables studied.</p><p>In the present study, the results for the muscles and functions of the stomatognathic system were associated with asthma severity both with the use of FEV<sub>1</sub> and ACQ-6 score. Campanha et al. also observed associations between changes in the stomatognathic system and FEV<sub>1</sub> in patients with uncontrolled asthma. <xref rid="B14" ref-type="bibr"><sup>14</sup></xref> In contrast, when asthma patients undergo speech therapy to restore a nasal breathing pattern, it can be seen that the clinical and functional improvement relative to an oronasal breathing pattern is evidenced by the increase in PEF and FEV<sub>1</sub> percentage values, indicating the superiority of nasal breathing.<xref rid="B15" ref-type="bibr"><sup>15</sup></xref></p><p>In the present study, voice changes (<xref ref-type="table" rid="t2">Tables 2</xref> and 3) were common in the asthma patients and can be described as hoarseness, throat clearing, scratchy voice, dry throat, burning sensation when talking, and faulty or difficult voice. The literature shows that asthma treatment can affect patients' voices. The findings of the present study corroborate those of Stanton et al., who concluded that impaired voice quality is common in patients with asthma and that the Grade-Roughness-Breathiness-Asthenicity-Strain system (GRBAS), which is a voice assessment scale, should be included in ear, nose, and throat assessment and in speech pathology assessment in asthma patients.<xref rid="B11" ref-type="bibr"><sup>11</sup></xref></p><p>Regarding the posture of the articulators, the findings of the present study were as follows: a habitual anterior tongue posture; a low tongue tip posture (on the floor of the mouth); a lowered posture of the tongue dorsum; a broad and tall maxilla; use of dental prostheses; and an elongated, edematous uvula. Corroborating these results, Berlese et al. found several orofacial changes in oral breathers, such as dry, open lips; a short, hypofunctioning upper lip; a full, everted lower lip; a lowered, hypotonic tongue; maxillary atresia and a high-arched palate; open bite and crossbite; hypotonic orofacial muscles; a flat nose with small nostrils; and protruding upper teeth.<xref rid="B7" ref-type="bibr"><sup>7</sup></xref></p><p>We found that 18.3% of our study participants were totally edentulous. As for dental arch condition, it was possible to observe caries and diastemas in the teeth, regardless of their position; poor overall condition; unhealthy gums; and use of fixed or removable dental prostheses. In a study of children with asthma conducted in 2007, Shashikiran et al. found an association between bronchodilator use, causing local effects such as a decrease in salivary pH, and changes in salivary secretion levels and composition, which explains the increased incidence of caries and periodontal disease and draws attention to need for more effective hygiene as a means of preventing caries.<xref rid="B16" ref-type="bibr"><sup>16</sup></xref> Another study, which found asthma to be associated with orthodontic changes, facial symmetry, and Angle's classification of dental occlusion, observed the presence of crossbite, overbite, and diastemas,<xref rid="B17" ref-type="bibr"><sup>17</sup></xref> corroborating the findings of the present study.</p><p>Changes in masticatory function include crushing food with the tongue and chewing rapidly and insufficiently. Da Cunha et al. suggested that chewing duration tends to be decreased in asthma patients. Breathing difficulties and incoordination of breathing may be associated with decreased chewing duration, since asthma patients have difficulty in maintaining the balance required for breathing during feeding.<xref rid="B18" ref-type="bibr"><sup>18</sup></xref> Using the tongue to help chewing, promoting food crushing, is consistent with the result of Lemos et al., who show that chewing is a learned function and may undergo changes.<xref rid="B6" ref-type="bibr"><sup>6</sup></xref> The patients in the present study made a lot of random chewing sounds. This result may be associated with the high frequency of oral breathers in the study population. Oliveira et al. define masticatory performance as a measure of the ability to grind food. <xref rid="B19" ref-type="bibr"><sup>19</sup></xref> They believe that nasal obstruction produces sounds and changes in the posture of the tongue, lips, and jaw. Therefore, oral breathers, as well as asthma patients, do not eat well, undermining their craniomaxillary and orofacial development.</p><p>Studies of the functions of the stomatognathic system draw attention to the fact that the age at which an individual develops a mature swallowing pattern is controversial, ranging from 18 months to 6 years of age. Lemos et al., in 2009, pointed out that there is a relationship between oral breathing and the presence of changes in the swallowing pattern.<xref rid="B6" ref-type="bibr"><sup>6</sup></xref> Drozdz et al. reported that the act of swallowing depends on a complex and dynamic process using structures in common with the act of breathing, and, therefore, respiratory problems can cause swallowing difficulties.<xref rid="B20" ref-type="bibr"><sup>20</sup></xref> Berlese et al. agreed on the fact that oral breathing causes functional changes, such as adaptive swallowing, which can be characterized by the association of lip action, mentalis muscle action, and tongue protrusion, which occurs because of decreased tongue tone and a lowered tongue posture.<xref rid="B7" ref-type="bibr"><sup>7</sup></xref> In an attempt to correct these changes, the perioral muscles, including the orbicularis oris and the mentalis muscle, act more actively to reestablish the lip seal required for proper breathing.<xref rid="B7" ref-type="bibr"><sup>7</sup></xref></p><p>We emphasize the importance of the originality of the present study, which involved adults with severe asthma. The limitations of the present study are considered to be the lack of a control group, the fact that the study's convenience sample was drawn consecutively, the probability that the subjective responses on the ACQ-6 negatively affected the correct perception of asthma control, and the lack of an otolaryngologist to diagnose and quantify the presence of allergic rhinitis. However, this loss of information is in line with the literature.</p><p>Our study results revealed that the frequency of changes in the stomatognathic system affecting muscles and structures was higher in patients with severe uncontrolled asthma than in those with severe controlled asthma; that the frequency of oronasal breathing, dental arch changes, and voice changes was high in patients with severe asthma, regardless of the level of asthma control; and that the frequency of changes in the stomatognathic system affecting the functions of breathing, chewing, and swallowing was higher in patients with severe uncontrolled asthma than in those with severe controlled asthma.</p></sec></body><back><ack><title>ACKNOWLEDGMENTS</title><p>We would like to thank the ProAR team for their genuine willingness and cooperation at the times of data collection. We would also like to thank the severe asthma patients enrolled in the ProAR for being so available, cheerful, interested, and cooperative at all times in the present study.</p></ack><fn-group><fn fn-type="other" id="fn1"><label>1</label><p>Study carried out under the auspices of the Programa de Controle da Asma e Rinite Alérgica da Bahia - ProAR - Salvador (BA) Brasil.</p></fn><fn fn-type="supported-by" id="fn2"><p><bold>Financial support:</bold> This study received financial support from the Fundação de Amparo à Pesquisa do Estado da Bahia (FAPESB, Foundation for the Support of Research in the State of Bahia).</p></fn></fn-group><ref-list><title>REFERENCES</title><ref id="B1"><label>1</label><element-citation publication-type="book"><person-group person-group-type="author"><collab>Global Initiative for Asthma</collab></person-group><publisher-loc>Bethesda</publisher-loc><publisher-name>Global Initiative for Asthma</publisher-name><source>Pocket Guide for Health Professionals</source><year>2015</year><ext-link ext-link-type="uri" xlink:href="http://ginasthma.org/wp-content/uploads/2016/01/GINA_Pocket_2015.pdf">http://ginasthma.org/wp-content/uploads/2016/01/GINA_Pocket_2015.pdf</ext-link></element-citation></ref><ref id="B2"><label>2</label><element-citation publication-type="book"><person-group person-group-type="author"><name><surname>Salles</surname><given-names>C</given-names></name><name><surname>Cruz</surname><given-names>AA</given-names></name></person-group><source>Vias Aéreas Unidas. 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