The Role of the Dentist in Pediatric Sleep Apnea

Symptoms

Snoring is not the only tell-tale sign of a child who has OSA. It is not always present, particularly if the airway turbulence happens in the lower section of the upper airway behind or below the tongue. Children with OSA have noisy breathing, restlessness during sleep, and pauses in breathing, which results in fragmented sleep. Other signs and comorbidities can develop as a result including bedwetting, sleepwalking, growth impairment, hormonal abnormalities, type 2 diabetes, obesity, and metabolic problems.

Joseph Yousefian, DMD, MS, DABO, DABDSM, says dental providers play a key role in early intervention by understanding how pharyngorofacial disorders can also lead to sleep-disordered breathing in children. “Clinicians need to evaluate the physiological capability of the upper airway and breathing patterns,” says Yousefian, who practices at Yousefian Orthodontics. “Once a risk is determined, they need to make a referral for proper diagnosis.” In the past, he adds, dentists have been perceived to be responsible for the health of just the teeth and gums in patients, but a growing number are also screening for potential airways issues.

Stacy Ochoa, DDS, DABDSM, a general dentist at Precision Dental Care, says, “I’d like to see more pediatric patients discussed as part of our conversations about OSA because early intervention is so critical in the development of children.” Seeing firsthand how her father and her children struggled with OSA and their adherence to CPAP therapy, Ochoa addresses the awareness gap via a membership-only study club for dentists who are interested in pediatric dental sleep medicine.

Echoing Ochoa’s concerns, Yousefian highlights that untreated sleep apnea can become a massive threat to a child’s development. “What we’re really worried about is the neurological impact of the upper airway and sleep-related issues,” he says.

Screening

Emily Varsanik, DDS, owner of Davison Dental, says it’s important for dentists to understand that OSA isn’t just an anatomic disease caused by a narrow upper airway. Instead, she looks for multiple factors such as enlarged tonsils, obesity, and genetic conditions that make some groups of children more susceptible than others. “We not only look at the child’s jaw development and behavior in the office [whether they display signs of excessive daytime sleepiness] but also ask the parents a series of questions that can clue us in on what’s going on when the child is asleep—this is how screening questionnaires are helpful,” Varsanik says.

A meta-analysis found the Pediatric Sleep Questionnaire (PSQ) to have the best diagnostic accuracy in identifying sleep-disordered breathing in children,² so the PSQ can be a good first step for dental practices to incorporate. What’s more, screening isn’t limited to questionnaires and clinical predictive tools. For instance, dentists can look for abnormalities in the anatomy and neuromuscular function of the upper airway such as underdeveloped (hypoplastic) maxilla and mandible, which are also commonly found in patients with OSA. If a child is deemed high risk for sleep-disordered breathing, the next step is to refer to a physician for a definitive diagnosis. And when physicians refer pediatric patients to dentists for treatment, dentists are in a unique position to provide certain therapies.

Therapy

Although the standard treatment for OSA has been CPAP therapy, appliance therapy has emerged as a viable treatment option for patients who either have mild OSA or have trouble tolerating or refuse CPAP. The American Association of Orthodontists (AAO) states, “Possible negative craniofacial consequences of longitudinal usage of PAP on the developing facial structures should be considered.”³ Adenotonsillectomy is frequently leveraged as a surgical treatment option for children whose tonsils obstruct their airway, but some develop a recurrence during adolescence,⁴ which illustrates how dynamic the condition can be in growing children.

Oral appliances for children have characteristics different from those that treat adult patients. “Unlike adult oral appliances, pediatric appliances take into account that the child is still growing and are designed to move or make [the mandible] develop forward [for patients with mandibular retrusion],” Varsanik says.

The AAO states, “The use of mandibular advancing devices may be prescribed by the physician, and this prescription is not predicated solely on Angle’s classification of occlusion. In this instance, treatment with an oral device is directed primarily toward airway maintenance and less so with dentofacial orthopedic management. Careful monitoring of facial growth and development is important during this time.”³

According to Yousefian, ensuring that the appliance isn’t creating what’s called the “headgear effect” is key. Headgears have been used to correct a misaligned bite by controlling jaw growth. But this control can have a broader impact in the child’s mouth and distort the growth pattern of bones and muscles beyond the upper jaw. As a result, these underdeveloped jaws and dental arches can narrow a child’s facial structure, which in turn overcrowd the tongue and soft tissues in the mouth and can increase the child’s risk of OSA. “The good news is that the headgear effect is reversible; instead we’re shifting to an approach that expands the upper arches, nasal cavities, and the lower jaw to support the upper airway for the treatment of OSA, known as teledontics,” says Yousefian.

Yousefian says teledontics can be started as a treatment modality for children as young as 3-years-old. Teledontics also can complement telegnathics for sleep apnea. Although the AAO cautions, “Orthognathic surgery usually is not indicated until craniofacial growth is completed….After considering the potential benefits and risks involved (including the need for later surgical revision), orthognathic or telegnathic surgery could be considered.”³

Summary

In a world with millions of undiagnosed sleep apnea patients, progress in treatment and early interventions can be both promising and daunting, Yousefian says. “I’ve suffered through this issue when my child was suffering in school and dying right in front of my eyes,” Yousefian says. “To help him, I tried to understand the science of sleep medicine and combine it with the science of orthodontics and that’s how I got to where I am today.”

REFERENCES

1. Honaker SM, Meltzer LJ. Sleep in pediatric primary care: A review of the literature. Sleep Med Rev. 2016 Feb;25:31-9.
2. De Luca Canto G, Singh V, Major MP, et al. Diagnostic capability of questionnaires and clinical examinations to assess sleep-disordered breathing in children: a systematic review and meta-analysis. J Am Dent Assoc. 2014 Feb;145(2):165-78.
3. American Association of Orthodontists. White paper: Obstructive sleep apnea and orthodontics. 2019 March 15. Available at www1.aaoinfo.org/wp-content/uploads/2019/03/sleep-apnea-white-paper-amended-March-2019.pdf
4. Guilleminault C, Partinen M, Praud JP, et al. Morphometric facial changes and obstructive sleep apnea in adolescents. J Pediatr. 1989 Jun;114(6):997-9.
5. Yousefian J, Brown M. Teledontics and telegnathic surgery for treatment of obstructive sleep apnea syndrome utilizing surgically assisted mandibular expansion (SAME). EC Dental Science. 2017;14.1:31-9.
6. Dentists Make a Difference in Pediatric Sleep Apnea Cases. Sleep Review. Retrieved on 4/6/2021 from https://www.sleepreviewmag.com/sleep-disorders/breathing-disorders/obstructive-sleep-apnea/dentists-pediatric-sleep-apnea/?campaign_type=newsletter&_hsmi=120494872&_hsenc=p2ANqtz-8XRA_P4-b-VLO7DCP4eUTnj3W1uhkPjngRizczc0OlgpoOuMGIU8zAJ9GfRahtBOGvFlKUeh1qtsaDKxEFQzTrn5eBgQ.