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Correlation between otitis media and dental malocclusion in children.


Acute otitis media (AOM) is a middle ear infection, usually caused by bacteria or viruses, that affects both children and adults. Next to the common cold, ear infections are the most common childhood diseases [Coker et al., 2010]. The infection occurs with acute onset in the eardrum, behind the tympanic membrane, with presence of middle ear effusion, obstruction of the eustachian tubes and signs of middle ear inflammation [Hoberman and Paradise, 2000]. AOM often occurs as a complication of a viral upper respiratory infection and frequent recurrences are very common, especially in the presence of predisposing factors such as cleft palate, presence of adenoids or gastro-oesophageal reflux. Furthermore, the incidence of AOM is higher in males than in females.

Symptoms may include: ear pain, decreased hearing, fever and drainage from the ear [Glasziou et al., 2011]. Recurrent acute otitis media is defined as three episodes within 6 months or four or more episodes within 12 months. Risk factors associated with recurrent acute otitis media include: primary treatment failure, a first episode of AOM early in life, passive smoking, winter season, craniofacial abnormalities such as Down's syndrome and cleft palate and inner ear abnormalities [Morris and Leach, 2009].

Eustachian tube function is assumed to play an important role in the aetiology of this disease. Under physiological conditions the Eustachian tube equalises air pressure in the middle ear to the outside air pressure and allows for drainage of mucus from the middle ear into the throat [Corbeel, 2007].

Instead, when otitis media occurs, tube dysfunction, secondary to constriction around its pharyngeal end, leads to increased negative pressure in the middle ear and improper ventilation [Fireman, 1997]. Several studies in the literature investigated the association between otologic symptoms and maxillary anatomical alterations and evaluated possible correlations between tubal dysfunction and the stomatognathic system [McDonnell et al., 2001; Di Francesco et al., 2008; Giuca et al., 2009].

The association between malocclusion and otitis media in children has long been discussed; some authors showed a significant correlation between deep bite and otitis media [McDonnell et al., 2001; Azadani et al., 2007], while in other studies no significant association could be found [Nery Cde et al., 2010]. The aim of this study was to determine if there is a correlation between otitis media and dental malocclusion in children.

Materials and methods

Selection criteria of patients and controls The sample consisted of 50 subjects (26 males and 24 females; mean age: 7.8 [+ or -] 1 years) who were referred from the Department of Otolaryngology. There were 25 patients (13 males and 12 females; mean age: 7.7 [+ or -] 0.9 years) with diagnoses of otitis media who formed the study group, while 25 healthy subjects (13 males and 12 females; mean age: 7.9 [+ or -] 1.1 years) formed the control group.

Inclusion criteria included a mixed dentition, after the eruption of maxillary and mandibular permanent first molars, and maxillary and mandibular dental casts available. Exclusion criteria included previous orthodontic and cranio-facial surgical treatment, cranio-facial anomalies and chronic medical conditions. Medical information was obtained from the medical records and included: anamnestic information and oral habits (thumb-sucking, atypical swallowing and mouth breathing).

Methods concerning the ear-nose-throat evaluation The diagnosis of otitis media was established, by the same operator (SN), with otoscopy, tympanometry and audiogram. Otoscopy was performed with an otoscope to evaluate the path to the eardrum and the presence of perforations. Tympanometry was used in order to measure an ear's responses to the sound and different pressures, by using a special probe inside the ear canal. The instrument, changing the pressure in the ear, generates a pure tone, and measures the eardrum responses.

Pure tone audiometric air conduction testing was performed by presenting a pure tone to the ear through an earphone and measuring the lowest intensity in decibels at which this tone was perceived 50% of the time.

The study group suffered recurrent otitis media (here defined as three or more episodes in 6 months, or four or more in 12 months) [Coker et al., 2010]. Patients in the control group had normal tympanogram and audiogram values and did not present any previous episode of otitis. During the otolaryngological examination the presence of hypertrophic adenoids and tonsils were evaluated [Di Francesco et al., 2008]. Posterior rhinoscopy with a rhinoscope was performed in all the subjects.

Methods concerning the oral examination Dental occlusion was analysed on the dental models in order to evaluate vertical, sagittal and transversal problems. The investigator (MG) was blinded as to control and study group models during model analysis. Overbite, overjet, and Angle Class relationship, based on maxillary and mandibular first molars were considered. Furthermore, presence of unilateral or bilateral cross-bite was investigated.

Statistical analysis To calculate the measurement error, each dental model was remeasured one week after the first measurement and the method error was calculated as recommended by Dahlberg [Dahlberg, 1940]. The Dahlberg error was 0.32 mm for dental cast measurements. Statistical analysis of the data was performed using the SPSS statistical package (version 15.0 for Windows; SPSS Inc. Chicago, Illinois, USA). Pearson's Chi square and Fisher test were utilised for the comparison between the two groups. Significance for all statistical tests was pre-determined at p<0.05.


Vertical planes With regards to the vertical relationship, five patients from the study group and three from the control group exhibited a deep bite (overbite < 0 mm). Moreover, an open bite (overbite > 4 mm) was found in only two patients of the control group. Comparing the two groups, no correlation between otitis media and overbite was found (p>0.05).

Sagittal planes Of the study group, 19 children exhibited a Class I relationship and six patients exhibited a Class II relationship. Of the control group, 17 subjects showed a Class I relationship, five patients exhibited a Class II relationship, and three subjects exhibited a Class III relationship (Table 3). All the patients with a Class II relationship also showed an overjet > 4 mm. Comparing the two groups, no significant correlation between otitis media and overjet or Angle Class relationship was found (p>0.05)

Transverse planes In the strudy group 19 patients presented a unilateral (eight subjects) or bilateral (11 subjects) posterior cross-bite. In the control group, four subjects exhibited a bilateral posterior cross bite. The difference between the study group and the control group was statistically significant (p<0.05).

Oral habits In the study group, 13 patients presented hypertrophic adenoids and 11 patients presented enlargement of tonsils. In the control group only three subjects showed enlarged adenoids and two subjects enlarged tonsils (Table 1). When comparing the two groups, a significant difference (p<0.05) was found in relation to hypertrophic adenoids and tonsils. Furthermore, it was found that seven children of the study group and six children of the control group exhibited atypical swallowing (Table 2). The difference between the two groups was not statistically significant.

Regarding to frequent thumb sucking, two subjects of the study group and two subjects of the control group were found to have this habit. However, no significant difference could be found between the two groups.

Mouth breathing was observed in 11 and 8 patients of the study and control groups respectively. No significant difference between the groups could be found, according to this parameter.


AOM has a multifactor aetiology; both exogenous and endogenous factors have been shown to be correlated with the onset of this disease [Gunasekera et al., 2009]. Bacterial and viral infection of the middle ear, upper respiratory infection and nasal inflammation are acknowledged contributing factors. Moreover, among the endogenous factors, auditory tube dysfunction is assumed to play a major role [Cozza et al., 2007]. In fact, AOM is believed to be more prevalent in childhood, because of the differences in the anatomy of the auditory tube, that is more horizontal and shorter in children than in adults [Gould and Matz, 2010]. Anatomical development of the Eustachian tube depends on cranio-facial growth and body development [Di Francesco et al., 2008].

Transverse, sagittal and vertical planes Regarding dental malocclusion, in the present study we found a significant correlation between otitis media and posterior cross-bite. Maxillary constriction combined with malfunction of the auditory tubes may cause a negative middle-ear pressure. Some authors have shown that rapid maxillary expansion can be considered a valid procedure for preventing recurrent otitis media in children affected by maxillary anatomical alterations; furthermore, the orthopaedic effect of the rapid maxillary expansion may also improve the hearing loss secondary to otitis media [Enoki et al., 2006; Cozza et al., 2007]. No other significant association was seen between dental malocclusion and otitis media.

It was reported that children with deep dental overbites were at a significantly increased risk for developing eustachian tube dysfunction [McDonnell et al., 2001; Azadani et al., 2007]. In the present study the degree of overbite was slightly higher in the patients with otitis in comparison to the controls. However, no significant correlation was found between otitis media and deep bite.

Oral habits In the present study we found a significant correlation between otitis media and enlargement of adenoids and tonsils. Adenoids and tonsils are thought to assist the body, in the first year of life, in its defence against incoming bacteria and viruses by helping the body form antibodies. Hypertrophic tonsils and adenoids, however, may lead to infection of the air passages around the nose and may affect the auditory tube, causing ear infections. Furthermore, these enlargements may lead to chronic mouth-breathing [Pelton and Leibovitz, 2009; Wiertsema and Leach, 2009].

Tonsils, ademoids and mouth breathing Several methods can be used to assess the size of the tonsils and adenoids such as endoscopy, lateral radiographs of the neck, acoustic rhinometry and digital palpation. Nasal endoscopy and radiology are the most accepted procedures of diagnosis [Mostafa, 1997; Saedi et al., 2011]. In the present study, all the patients exhibiting hypertrophic adenoids and tonsils were also mouth breathers.

However, the difference between study and control groups, concerning mouth breathing, was not significant, probably because of the high number of mouth breathing children in the healthy group. These results corroborate the findings of other studies, that did not find a correlation between inadequate oral habits, such as atypical deglutition and thumb sucking and otitis media [Watase et al., 1998]


The data of this study demonstrated a significant correlation between otitis media and posterior cross-bite in children. Moreover, hypertrophic adenoids and tonsils were associated with otitis media. Instead, no significant correlation was found in relation to thumb-sucking, atypical swallowing and mouth breathing. Further studies in this field should be carried out with an increased number of patients involved in the surveys.


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M.R, Giuca *, E. Caputo *, S. Nastassio **, M. Passini

Deps of * Surgery, Unit of Paediatric Dentistry, ** Paediatrics University of Pisa, Pisa, Italy.

Postal address: M.R. Giuca, Via Roma 67, Pisa (PI) 56100, Italy.

Table 1 Evaluation of of hypertrophic
adenoids and tonsils in study and
control groups.

OTOLARYNGOLOGY EXAMINATION     Study     Control   p value
                               group      group

Enlarged adenoids             13 (52%)   3 (12%)   0.039 *

Enlarged tonsils              11 (44%)   2 (8%)    0.041 *

* p< 0.05; N.S.: not statistically significant

Table 2 Prevalence of thumb-sucking, atypical
swallowing and mouth breathing in study and
control groups.

ORAL HABITS           Study group   Control group    p value

Thumb-sucking           2 (8%)         2 (8%)         1 N.S.

Atypical swallowing     7 (28%)        6 (24%)      0.881 N.S.

Mouth-breathing        11 (44%)        8 (32%)      0.411 N.S.

* p< 0.05; N.S.: not statistically significant

Table 3 Dental casts examination in children
with otitis media and healthy subjects.

DENTAL OCCLUSION        Study     Control     p value
                        group      group

Bilateral posterior    11 (44%)   4 (16%)     0.046 *

Unilateral posterior   8 (32%)     0 (0%)     0.026 *

Deep bite              5 (20%)    3 (12%)    0.536 N.S.

Open bite               0 (0%)     2 (8%)    0.404 N.S.

Angle Class I          19 (76%)   17 (68%)   0.694 N.S.

Angle Class II         6 (24%)    5 (20%)    0.872 N.S.

Angle Class III         0 (0%)    3 (12%)    0.255 N.S.

* p< 0.05; N.S.: not statistically significant
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Article Details
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Author:Giuca, M.R.; Caputo, E.; Nastassio, S.; Passini, M.
Publication:European Archives of Paediatric Dentistry
Article Type:Clinical report
Geographic Code:4EUIT
Date:Oct 1, 2011
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