Association between Mouth Breathing, Gingival Enlargement and Anxiety Symptoms in Adults.

Abstract

Background: Mouth breathing alters the oral environment and is linked to gingival inflammation in children, but evidence in adults is scarce and its relationship with psychological symptoms is poorly characterised, particularly in Pakistan. Objective: To determine the association of mouth breathing with gingival enlargement and anxiety symptoms in adults, and to examine whether gingival enlargement is independently related to anxiety. Methods: This cross-sectional study included 320 adults aged 18–65 years attending the Dental Outpatient Department (OPD), Sir Syed College of Medical Sciences, Karachi, Pakistan, over a one-year period from 1 July 2025 to 31 June 2026. Mouth breathing, gingival enlargement (grades 0–3), plaque and gingival indices, bleeding on probing, probing depth and anxiety (Generalized Anxiety Disorder-7, GAD-7) were recorded. Group comparisons and multivariable regression were used. Results: One hundred and five participants (32.8%) were mouth breathers. Gingival enlargement was present in 41.0% of mouth breathers and 15.8% of nasal breathers (p < 0.001). Mouth breathers had higher plaque (1.53 vs 1.18) and gingival indices (1.89 vs 1.34) and more bleeding on probing (37.1% vs 26.4%; all p < 0.001). After adjustment for age, sex, tobacco use, brushing frequency, diabetes, gingival-enlarging medication and plaque, mouth breathing remained associated with gingival enlargement (adjusted OR 2.91; 95% CI 1.59–5.32). Mean GAD-7 scores were 8.06 ± 3.71 in mouth breathers and 5.33 ± 3.58 in nasal breathers; moderate-to-severe anxiety (GAD-7 ≥ 10) occurred in 39.0% and 11.6%, respectively (adjusted OR 5.31; 95% CI 2.86–9.86). Gingival enlargement was not independently associated with anxiety (adjusted β = 0.11; p = 0.81). Conclusion: Mouth breathing was strongly associated with both gingival enlargement and anxiety symptoms, whereas the apparent link between enlargement and anxiety was explained by mouth breathing. Adults with mouth breathing may merit combined periodontal and psychological screening.