Breathe, breathe in the air: Don’t be afraid to care. A blog series on Sleep disordered breathing and orthodontic treatment: Part 1.
This post is the first of a series in which I will address the role of breathing in the aetiology of malocclusion and whether there is a role for orthodontic treatment to help reduce childhood sleep-disordered breathing (SDB).
This has recently become controversial because orthodontists and general dental practitioners are carrying out orthodontic treatment to “cure” sleep-disordered breathing and I am unsure of the evidence base of this treatment.
Orthodontic opinion is currently split on this issue. Some feel that they are providing an essential service as part of the holistic treatment of a young person. Alternatively, there are those who think that this is a newly invented “disease” that requires treatment and which can be done by orthodontists or general dental practitioners. This, of course, could be considered quackery and I have discussed this concept before in orthodontics.
Those of you who are “children of the 70s” will recognise the line from Dark Side of the Moon by Pink Floyd, and this is relevant to this series of posts. This is because practitioners who are providing orthodontic treatment for SDB feel that they are “caring” for patients in a holistic way and those who do not support this treatment suggest they are “caring” because they are not providing this treatment because of the low evidence base. So, if I move on from my adolescent and current taste in music and get on with the blog. I will start by considering “what is childhood disordered breathing and how should it be treated”? I have been joined in this blog by my colleague Professor Iain Bruce who is a Paediatric Otolaryngologist at the Royal Manchester Children’s Hospital, Manchester, North of England.
Childhood Sleep Disordered Breathing
We gathered information from several sources. This is by no means a formal systematic review, but we have used some systematic reviews as source documents.
Sleep-disordered breathing (SDB) is a general term for breathing difficulties during sleep. This may range from loud snoring to obstructive sleep apnoea (OSA), in which the airway becomes partially or completely blocked. In most cases, the “blockage” is caused by adenotonsillar hypertrophy. Airway collapse can affect the ability of the respiratory system to effectively exchange oxygen and carbon dioxide between inhaled air and the bloodstream. Subsequent fall in blood oxygen saturation and/or blood carbon dioxide rises, can be associated with changes in heart rate, blood pressure increase, arousals and sleep disturbance.
Sleep Disordered Breathing may be considered to be a spectrum from primary snoring, which is unlikely to have any potential physiological consequences, through to severe OSA with more potential significant implications (e.g. pulmonary hypertension and cor pulmonale). If a child does not get good quality sleep, they may become irritable, sleepy during the day, or have difficulty concentrating at school, with the potential for noticeable deterioration in school performance. Sleep-disordered breathing is a common condition with an estimated prevalence of primary snoring in children ranging from 8 to 27% and obstructive sleep apnoea from 1 to 5%.
How is sleep-disordered breathing diagnosed?
The diagnosis of SDB is mainly clinical and based on a history of snoring with disturbed sleep, apneas and arousals. There are 2 main investigations commonly used in clinical practice, namely, overnight pulse oximetry and polysomnography (PSG). Both tests have drawbacks, not least because we do not have age-specific normative data, or absolute parameter changes defining ‘abnormal’ sleep, to help with interpretation. PSG may not be readily available in all hospitals and may be best reserved for children with co-morbidities, where significant diagnostic doubt exists, or apparent failure of initial treatment. Unfortunately, the correlation between clinical examination, quality-of-life scores and polysomnography are not high. ‘Positive’ overnight pulse oximetry is highly suggestive of SDB, but ‘negative’ results do not necessarily preclude the diagnosis.
As a result, current diagnostic practice tends to be based around a clinical history and examination, with possible supplementation with overnight pulse oximetry or PSG.
The diagnosis of SDB should be made by an Otolaryngologist or Paediatric Respiratory Physician. I cannot help feeling that this is outside the scope of practice of an orthodontist/general dentist.
How is sleep-disordered breathing treated?
The most common cause of SDB due to airway obstruction is hypertrophy of the tonsils and adenoids. As a result, removing them solves the problem. Other treatments are positive airway pressure and lifestyle changes to help an obese child lose weight.
There has been a Cochrane systematic review that investigated the benefits and harms of tonsillectomy with and without adenoidectomy compared with nonsurgical management. They looked at the following PICO
- Participants: children aged 2 to 16 years with obstructive sleep-disordered breathing
- Intervention: Adenotonsillectomy
- Comparator: nonsurgical management, for example, lifestyle interventions. Medical treatment, positive airway pressure and watchful waiting.
- Outcomes: disease-specific quality-of-life
This was the usual, well carried out, Cochrane systematic review and they concluded:
“Moderate quality evidence is available that in otherwise healthy children (5-9 years old), without a syndrome, who have been diagnosed with mild-to-moderate obstructive sleep apnoea by PSG, there is moderate quality evidence that adenotonsillectomy in terms of quality of life, symptoms and behaviour and high-quality evidence in terms of overnight sleep study findings”.
They also pointed out that polysomnographic recordings of almost half of the children managed non-surgically had normalised by 7 months after the start of the studies. This is a condition that may spontaneously resolve over time. I will return to this later when we discuss treatment.
“If a child has SDB and has a clinical examination consistent with adenotonsillar hypertrophy, and there are no contraindications to surgery, then the clinician should recommend adenotonsillectomy as the first line of treatment”.
The simple “take home” messages from this post are:
- Sleep disorder breathing in children is a spectrum from primary snoring to obstructive sleep apnoea.
- It is a severe problem for some children
- The diagnosis of SDB should be made by an Otolaryngologist or Paediatric Respiratory Physician, not a dentist in isolation.
- The most common cause of SDB due to airway obstruction is hypertrophy of the tonsils and adenoids. As a result, removing them solves the problem most of the time.
We hope that post provides good initial information on Sleep Disordered Breathing. But does orthodontic treatment have a role in the treatment of sleep-disordered breathing? I will start to address this in the next part of this series when I discuss the evidence behind the effect of sleep-disordered breathing on craniofacial growth.
Emeritus Professor of Orthodontics, University of Manchester, UK.