Breathe, breathe in the air: Part 3 Does orthodontic treatment cure childhood breathing problems?
Breathe, breathe in the air: Does orthodontic treatment cure childhood breathing problems?
This is the third and final part of my series on childhood sleep-disordered breathing and orthodontics and is about the effects of orthodontic treatment.
In the first post of this series, we concluded that the first line of treatment for children with disordered sleep breathing was tonsillectomy and adenoidectomy. Positive airway pressure could also be considered, but there are co-operation difficulties with this treatment. However, some practitioners suggest that orthodontic treatment has a role to play. As a result, I decided to investigate this issue. I think that this a controversial post!
I started by carrying out a standard computerised literature search. Unfortunately, I did not find any studies that had sufficient sample sizes or clearly defined questions to help me. Then I came across two systematic reviews, which I hoped would be able to provide me with a high level of evidence. I am basing this post on my interpretation of these reviews. Finally, I will try to draw some conclusions about childhood sleep-disordered breathing and orthodontic treatment.
Sleep Medicine Reviews published this systematic review;
Huynh et al
Sleep Medicine Reviews 25 (2016) 84e94
The authors aimed to investigate the efficacy of orthopaedic mandibular advancement and/or rapid maxillary expansion for treating pediatric obstructive sleep apnea.
They carried out a standard systematic review of the literature and included randomised trials and non-randomised studies. They found one RCT and one non-randomised trial that had evaluated the effect of advancement appliances. When they looked at RME, they found 2 RCTs and 3 non-randomised trials.
Whenever I read a systematic review, I have a close look at the papers that are selected. I found it very disappointing that when I read the randomised controlled trials, one was not an RCT (it was a retrospective cohort study) one was a small-scale feasibility study, and one was full of bias, lack of blinding, selective reporting and absence of essential data. So, I moved on to look at the other systematic review, which was in the Cochrane Library.
Cochrane Database of Systematic Reviews 2014, Issue 9.
This was a Cochrane review, as I have described before, these are very rigorous reviews and only include high-quality trials. They aimed to evaluate the effect of orthodontic treatment on anterior open bite and determine if there was an association between AOB, its treatment and sleep-disordered breathing. They found three RCTs that evaluated
- The effect of the Frankel 4 appliance and lip exercises vs control
- Repelling magnets vs bite blocks
- Removable appliance with high pull headgear vs control
They found that all three studies had significant problems with and were at high risk of bias concerning randomisation, concealment, blinding and they did not take sucking habits into account.
They concluded that recommendations on treatment could not be made from these studies.
So, the mainstream literature could not really help me answer the question on the effectiveness of orthodontic treatment on childhood breathing problems.
I then went to look at any evidence I could find about other methods of treatment, for example, myofunctional appliances, orthotropic and other methods. All I could see was simple poorly presented case reports in journals and websites……..I have discussed this previously.
I can only conclude that there is no or minimal research evidence that supports the use of orthodontic treatment as part of the treatment of sleep disordered breathing in children. I may have missed something here, perhaps someone can point me in the right direction and let me know if I missed something?
So what can I conclude?
When I started on this series of posts, I was optimistic that I would have found something positive to say about the role of facial growth and orthodontics and treating childhood breathing problems. I am very disappointed to come to these conclusions.
- Sleep-disordered breathing appears to be a significant problem for a proportion of children.
- The first line of treatment appears is the removal of enlarged adenoids and tonsils.
- There is very weak evidence that mode of breathing influences facial growth and skeletal pattern.
- There is very weak evidence that orthodontic treatment has a role in treating sleep disordered breathing.
However, this is a growth area in orthodontics, with active promotion of orthodontic treatment in treating SDB. Indeed, since I started this series, I have been exposed to degrees of patronising abuse on web pages, had posts removed and generally been made to feel uncomfortable for even trying to address this subject. This has been an interesting experience, and I suppose that I have been around long enough to make these suggestions.
- This area should be researched with randomised trials of interventions
- These studies will attract grant income because this is an important area
- If I were a young aspiring academic orthodontist, I would make this a primary focus of my work
- Can someone please do these studies?
If you are promoting orthodontic treatment to treat SDB, it would be great if you could
- Provide your patients, and the whole orthodontic community, with evidence on the effectiveness of the treatment that you provide. This is your ethical responsibility.
- If you are convinced that your own particular treatment is effective, engage with the research community and try to do some studies.
- Do not merely dismiss people, who ask questions, as being out of touch.
- Learn to critically appraise the literature and realise that a series of pictures on a website is not sufficient evidence to justify treatment.
Does this influence my practice?
Finally, since I did my speciality training, I always believed that mouth breathing influenced facial growth in severe cases and that I could help with breathing problems by expanding palates with RME etc. But the research that I have carried out to do this blog makes me very uncertain that this approach is supported by scientific evidence.
I work as an orthodontist in a Children’s Hospital and see children who have sleep-disordered breathing referred from my ENT colleagues. So what do I do the next time I see a drowsy looking child with a long face and bags under their eyes? I will modify my approach towards consent and explain that my treatment will be directed at correcting their malocclusion and if we get an improvement in breathing this will be a bonus. I certainly will not be informing them that I am carrying out treatment to improve their breathing. I can still sleep at night.
So that is breathing and orthodontics……just tumbleweed blowing down empty streets…
Comments are always welcome on my posts, so please make them!
Emeritus Professor of Orthodontics, University of Manchester, UK.