October 24, 2016

Can we ethically provide orthodontic treatment for children with obstructive sleep apnoea?

Can we ethically provide orthodontic treatment for children with obstructive sleep apnoea?

Earlier this year I published several posts on breathing and orthodontics. This new post is a follow-up that has been prompted by an updated Cochrane review on the treatment of obstructive sleep apnoea in children. I will discuss the review and then the ethics of providing this type of treatment.

Sleep disordered breathing is a common childhood disorder. The most common treatment is adeno-tonsillectomy, but this carries surgical risks. Furthermore, this treatment is not always successful. It has been suggested that children with OSA have a narrow airspace and poorly developed maxilla and mandible.

This has led to claims that orthodontic treatment with specially designed appliances can help ‘cure’ OSA in children. Indeed, there are orthodontists and general dental practitioners who specialise in childhood breathing issues and promote this form of orthodontic treatment. This updated systematic review gives us new information on this area of work.

Oral appliances and functional orthopaedic appliances for obstructive sleep apnoea in children


Fernando R Carvalho et al

Cochrane Database of Systematic Reviews 2016, Issue 10. Art. No.: CD005520.

DOI: 10.1002/14651858.CD005520.pub3.

As this was a Cochrane review, it was well carried out and written. I thought that the introduction was an excellent summary of the current situation. They did the review to answer this simple question;

“What are the effects of oral or functional appliances for obstructive sleep apnoea for children”?

What did they do?

They carried out a classic systematic review and looked at;

Participants: Children and adolescents less than 15 years old diagnosed with OSA

Intervention: Any oral appliance designed to treat OSA.

Outcomes: Reduction to less than one episode of apnoea per hour.

They carried out an extensive search of the literature and used the Cochrane risk of bias tool to assess bias in any of the studies that they found.

What did they find?

They initially found 686 potentially useful studies. At the end of their filtering of the papers they only included one study.

This was a quasi-randomised study. When they looked at the study closely they found that randomisation, concealment, and blinding were poor. There was also considerable loss to follow-up.

They concluded that the available information from this one study with very low quality evidence was not sufficient to answer their study question.

The final conclusion was:

“There is insufficient evidence to support or refute the effectiveness of all functional appliances in the treatment of OS they in children”.

In other words we do not know whether this treatment works!

What did I think?

They carried out a Cochrane review that provides us with useful information. Importantly, this is a situation in which there is clearly “absence of evidence”. We need to consider that this does not mean that the appliances “do not work” but there is simply no evidence on their effectiveness.  As a result, I can only conclude that we do not know if this treatment is effective.

While some readers may think that, yet again, we have a systematic review that does not help. I disagree. I think that we need to consider this finding in relation to information that we must give to our patients as part of informed consent. This means that if we want to use an appliance to treat OSA in children, we should let our patients know that we are proposing a treatment that we do not know if it works!

This is in complete contrast to information provided by the websites of practitioners promoting these techniques. If you would like to see examples of this, just cut and paste “sleep apnoea, myofunctional orthodontics and/orthotropics” into your favourite search engine.

Finally, this brings me to the question that I raised at the start of this post. I feel that as we do not know if this treatment works, it is not ethical to inform patients that we can treat childhood OSA with orthodontic appliances. I know that this may open up a “Pandora’s box”. What do you think?





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Have your say!

  1. Dear Kevin,

    Your blog raises 2 important issues which I feel often puts frontline Clinicians in conflict with Academics, sadly.

    Absence of definitive RCTs in the literature to prove a particular hypothesis, is NOT the same as saying no Evidence-Base to support a particular hypothesis in selected cases, or even that it equals ‘Evidence of Absence’, because if it did either of those, we would ALL have to down our Restorative and Orthodontic tools for 95% of dental cases, as according to your slant, it would be ‘unethical’ in the absence of a Cochrane report to ‘prove’ the hypothesis is applicable to all cases regardless etc.

    That is clearly nonsense and as you know, modern Evidence-Based-Medicine concepts recognise this, as do Clinicians who see clinical successes in their hands for particular clinical cases, when the ‘published RCTs’ don’t support such success or options, are inconclusive or simply not sufficiently designed well enough to reflect reality 😮

    I put it to you that it is unethical to imply to any patient, that a lack of the highest level of published RCTs, means they are being denied any choice or the benefit of the individual’s Clinical experience after a bespoke examination – otherwise again MOST restorative or orthodontics would be denied to the population !!!

    Yours proportionately,


    • Hi Tony, thanks for the post. You have made good points. In my post I highlighted that we are faced with the “absence of evidence” that this treatment cured OSA. However, I did not say that this treatment should not be done, I felt that it was necessary for anyone wanting to provide this treatment to let their patients know that there was no scientific evidence that suggested the treatment would be successful. I think that this covers most of your comments and I certainly do this when I am consenting patients to some of the orthodontic treatments for which I do no have much evidence. Interestingly, in the “real world” of full time orthodontic practice these are very few.

      The real problem arises when people make claims for treatment that are not supported by any evidence and do not inform their patients that this is the case.

      I hope that this has answered your points

      best wishes: Kevin

      • Hi Kevin,

        I must say I do like your approaches when you describe what you actually do and say when face to face with patients on clinic.

        My concern is equating the phrase ‘no evidence’ when what one REALLY means is ‘No multi-centred double blknd and randomised trials that have passed the Cochrane stringent research criteria!’

        However one then needs to put that ‘No Cochrane’s Conclusion’ in persoective and state that neither does the vast majority of Restorative or Orthodontic treatments we do every day, maybe 95% of all routine care?

        So it MAY come down to just some case studies, the Clinician’s experience and the patient’s wishes is the BEST evidence available for a particular clinical option AFTER a bespoke examination!

        So from your reply Kevin can I assume we agree up to this point, let’s call it point A.

        My point B is that it would be entirely wrong to state there was NO EVIDENCE for a particular intervention, if there’s no Cochrane review confirming AND my point C is that it would be quite wrong to state there was NO EVIDENCE if all one could muster was a few case studies done elsewhere and one’s own Clinical experiences, coupled with say the Patient’s wishes after a bespoke examination!

        Of course if there were some case studies, reports or even moderately scientific publications that showed something caused harm or made an existing treatment worse or introduced more risks, then OVERALL that may influence a particular choice, the OPTIMUM evidence-based choice for that particular patient, if you like.

        So that is my point D Kevin, sometimes the overall evidence as sparse as it often is, pushes our considerations in another direction, because evidence is growing that standard X approach isn’t Optimum, so although Y and Z options aren’t X and aren’t backed up by Cocherane reviews, they are nevertheless preferable to the negatives being associated more with some Traditional X approaches……

        I don’t like to assume, but I would like to know if you agree or disagree with points A, B, C or D, in principle.

        Of course in an ideal world everything would have the highest level of Cochrane review approval, but as nearly everything DOESN’T have this in Dentistry in 2016, we have to take a stiff dose of reality IMHO.

        Yours reflectively,


        • There is always a role for professional opinion. Nothing at all is wrong with “buy this product from me because I like it and can use it more effectively than other products and I think you may prefer it”

          However, general claims about a product should be described in terms of the evidence available to back them up.

          I think those members of the public (and indeed the dental profession) who are inadequately versed in critical appraisal would have a difficult time in telling low quality evidence (which can yield misleading findings due to high levels of bias) from high quality evidence.

          Thankfully, when a company or individual makes claims that are not backed up by sufficient evidence in order to sell a given medical intervention in the UK, the Advertising Standards Authority are on hand to provide a (fully independent) stiff dose of reality.

          • Dear Nicky,

            Most research is very poor or even at the ‘highest’ level of Cochrane reviews, is inconclusive for maybe 95% of Dentistry ie: the vast majority.

            There is therefore a range of ‘Evidences’ and ultimately where Clinical Experience has found clinical successes, this must then take priority in decision-making with the patient, because it is based upon ‘real’ practice-level results, not theory!

            Yes some are using the ASA to bash others inappropriately because the ASA only/mainly judge by the published evidence alone at the higher levels and REFUSE to take into account Patient wishes or Clinical Experience or Case-based results, no matter how compelling.

            Thus they do not comply with best Evidence-Based-Medicine approaches in the public interest, by default.

            It is thus not truly and appropriate body to judge ‘clinical options after a full examination’ possibilities, independently and are thus being used inappropriately to block or hamper true public informed choice of ALL the options available, by some.

            I appreciate some have such strong ‘belief’ systems they feel this is Right or Ethical, but it is not IMHO.

            Indeed if one applied the ASA judgement standards to Traditional orthodontics, there would be many clinical claims that would have to be withdrawn publicly, because there is no Highest level of published Evidence to support them – again that would be nonesense because it is NOT following EBM highest standards to consider all 3 aspects of EBM after a clinical examination.

            I agree any claims made SHOULD also be accompanied by evidence as far as it exists, as well as Clinical Experience/s as well as Case studies and as well as Patient Choice/Options being fully informed too.

            Perhaps with a caveat of ‘subject to a clinical examination’ as not everyone is suitable or favourable for a particular therapy or TP.

            To just stay/wait for Cochrane reviews to say ‘You can Do this Now’ for patients or even ‘You can tell patients about these other Options now’ would simply grind any progress or choice to a halt – indeed we’d have to stop 95% of routine restorative and orthodontic treatments we do NOW every day, because the published evidence is so poor or non-existant already !

            We cannot wait for the very slow research to be done, then await publication for 18 months then maybe after 5 years, still await further work to be conclusive enough to CHANGE current practise or support current progress!

            Yours proportionately,


          • I’m not convinced by an arguement that dentists shouldn’t hold themselves up to as high a standard as (looking at this weeks ASA rulings) shower gel manufacturers, bookmakers, car salesmen or the makers of alcopops. Neither, given recent fitness to practice cases, are the GDC.

            We should wait for high quality research before we tell patients that product x will make them fitter, happier and more productive.

            “Mr Kilcoyne likes product x because…” or “Mr Kilcoyne’s patients say this…” is fine. Personal opinion or previous patient experience is fine and perfectly reasonable to tell/advertise to patients.

            Presenting “facts” that are derived from poor quality research is not.

            Any drug company would be called to task for that kind of thing, and rightly so. There’s no reason any other dental company should be treated differently.

        • Hi Tony, thanks, I think that we agree on point A.
          Point B. The best way to think of this is to consider that there maybe no evidence that suggests a particular intervention has an effect. This, of course, may also mean that we have not found the evidence and this is where we need to consider the strength of evidence and its role in reducing uncertainty. If the studies are only case reports etc then this would signify that there is still high levels of uncertainty about whether the intervention “works” or the claims that are being made stand up to scrutiny.
          Point C. This is the most important part of evidence based care, with it being three components of clinical experience, evidence and patient opinion. However, these are not equal. If there is a high level of uncertainty, treatment may be driven by clinical experience, however, the patient needs to be informed about this. Conversely, if there is evidence that reduces the uncertainty, then again this should outweigh clinical experience, but the patient should still be informed. This is pretty straightforward.
          Point D: it does not always need a Cochrane review and we should be able to interpret the evidence and this is where the problem lies. I am not sure how many people are able to interpret the evidence or are simply blinded by the advertising and the statements of gurus and key opinion leaders who all have a financial interest in the selling their treatment.
          Finally, this is not really an academic argument. It is a real world clinical situation that we all face every day. I hope that this clarifies the situation?
          Best wishes: Kevin

          • Thanks Kevin,

            So point C is probably the most contentious then – when faced with the 3 factors, Patient Opinion/wishes, the Clinician’s experience and a range of ‘Evidences’ right up to a full Cochrane revue at the top or right down to ‘nobody really knows’ at the bottom, so to speak.

            The problem with ‘Evidences’ is that more often than not, the currently regarded highest level of Evidences, a Cochrane review, concludes that ‘nobody really knows’ so more research is needed etc.

            Thus very quickly, except for maybe 5% of the population, this aspect of Evidence Based Medicine (and dentistry) falls by the wayside, leaving MAINLY Clinical Experience + Patient wishes.

            Now practically, if we don’t have Patient motivation, Consent and a ‘wish’ to cooperate and complete a treatment option, then frankly nothing will help or improve anyway, so this is perhaps THE most important of the three aspects. Then second is Clinical Experiences in a particular option, then third the published ‘Evidences’ which in the main are inconclusive or inadequate to be ‘sure’ of anything, anyway 🙁

            I suspect those in Academia would perhaps prioritise those 3 aspects in the reverse that I have and maybe some others have a different opinion again ?

            What might surprise some is that in each case, those different opinions are actually equally VALID, ETHICALLY, providing such a process of evaluation has been undertaken with each patient AFTER a full clinical examination.

            Just in case anyone else reading this mistakes what I am saying as anything randomly is OK, that is NOT what I mean – equality doesn’t have to mean identical, thus that old adage of ask 3 dentists for an opinion and get 4 treatment plans in return – this reflects variability of experiences, successes and failures and assertive patient priorities over relatively poor research library available today.

            Yours reflectively,


          • Thanks, I agree with some of your points, however, I do not agree with you that the evidence is not there for most of treatment. There is plenty of evidence that we can use in orthodontic treatment, its just that it is buried in the journals and the only people who read the specialist orthodontic journals tend to be specialists. I will reiterate, when the evidence is available we need to share this with our patients, importantly, when the evidence is not there, we also need to inform our patients that the treatment is not underpinned by evidence. But this does not mean that the treatment will not work, it is just there is no evidence to suggest that it will.

      • Dear Dr. O’Brien
        To your, ‘….let their patients know that there was no scientific evidence that suggested the treatment would be successful.’, I respectfully disagree with your premise….please see references that do indeed contain scientific evidence to ‘suggest’ certain treatments will decrease airway obstruction.


        1. Liang Li et al, (2014). CBCT Evaluation of the Upper Airway Morphological Changes in Growing Patients of Class II Division 1 Malocclusion with Mandibular Retrusion Using Twin Block Appliance: A Comparative Research. PLoS ONE 8(4): e94378.

        2. Xueling Chen et al, (2015). Three-Dimensional Evaluation of the Upper Airway Morphological Changes in Growing Patients with Skeletal Class III Malocclusion Treated by Protraction Headgear and Rapid Palatal Expansion: A Comparative Research. PLoS ONE 10(8): e0135273.

        3. Tomonori Iwasaki et al, (2013). Tongue posture improvement and pharyngeal airway enlargement as secondary effects of rapid maxillary expansion: A cone-beam computed tomography study. Am JO/DO 143:235-45.

        4. Kirsi Pirilä-Parkkinen et al, (2010). Cephalometric evaluation of children with nocturnal sleep-disordered breathing.
        Eur J Orthod 32:662–671.

        5. Sayinsu K et al, (2006). Sagittal airway dimensions following maxillary protraction: a pilot study. Eur J Orthod 28(2):184.

        6. Emine Kaygısız et al, (2009). Effects of Maxillary Protraction and Fixed Appliance Therapy on the Pharyngeal Airway. Angle Orthod. 79:660–667.

        • Thanks, I am not sure that these references actually suggest that there is an effect. For example, I have looked closely at the first one and all this suggests to me is that as children get older their tissues grow. Have you looked at these references critically, in terms of scientific method. I think that this would be a good idea?

  2. Thanks Kevin for putting things in perspective. I personally feel that these kind of claims about treating OSA and other problems by self proclaimed leaders are part of a growing trend in the orthodontic field are as unethical as it can get.
    In the absence of any regulators in our field we have only ourselves to blame if we let these cowboys loose to do as they choose by fear mongering and last chance saloon deals.
    I hope those who are less experienced/beginners are able to look at practical studies to see for themselves to judge the efficacy or not of the very tall claims made by such unscrupulous practitioners.

  3. In the absence of Science, the Salesman prevails.

  4. From a historical perspective, we have been through this before. “Functional Orthodontics” was touted in the ’80s as the cure all for all orthodontic problems and “traditional” Orthodontic treatment regimens were blamed for every headache or TMD issue the previously treated patient experienced. Many lawsuits ensued and that forced our profession to apply valid scientific method to unmuddy the waters. While this period was contentious to say the least, it also encouraged orthodontists to look outside their own treatment “box” and allowed for professional acceptance of new treatment modalities that proved scientifically efficacious.
    Annecdotally we have all had experiences where our treatment had a positive side effect from a breathing perspective for our patients. At the same time, it is unprofessional at best to make some of the claims of treatment success made today about the ability to cure all breathing problems with their appliance therapy. Hopefully the Scienctific effort sheds light more quickly than last time.

  5. Thank you for sharing these information prof.

  6. I have read many systematic reviews and am more and more doubtful of their use in clinical practice. The conclusion is usually: no conclusion or more research is needed. If this methodology of research does not contribute significantly to what we know, why bother. The only systematic reviews i read that made sense wer related to hard data.
    Thanks for the review

  7. Hi Kevin:

    This is an interesting topic of debate. IMHO, I feel that the question you raise “Can we ethically treat childhood OSA with orthodontic appliances?” is non sequitur (“it does not follow”) . What I mean is orthodontic treatment targets dento-alveolar correction predominantly and does not aim for craniofacial correction of TMJ or upper airway issues per se. I believe that “orthodontic treatment” is downstream from craniofacial correction. In that respect, I believe we now need a new dental specialty of Dental Sleep Medicine that will target the upper airway, sleep and breathing as the focus of correction – in collaboration with our medical colleagues. Orthodontic correction will naturally follow once the child (or adult) is able to breath and sleep soundly with an adequate upper airway. We are currently working on this concept with medical specialists as other childhood issues, including nocturnal enuresis, obesity, allergies and ADHD often accompany oral issues such as bruxism and malocclusion in pediatric cases.

  8. Dear Prof O’Brien

    So good that you are again encouraging discourse on an important, albeit controversial, area of orthodontics and airway health/morphology. Per your mentioning, ‘….if we want to use an appliance to treat OSA in children, we should let our patients know that we are proposing a treatment that we do not know if it works!’, agreed, but perhaps you might also mention at some point something about the evidence (see truncated (six) list of references below) behind precisely why a clinician might, as you state ‘want to use an appliance’ not so much for ‘treating’ OSA, but to offer specific orthodontic/dentofacial orthopedic Tx options (e.g., Twinblock, Orthotropics, etc.) when there are pre-Tx airway concerns that might be favorably impacted by altering craniofacial-respiratory morphology. In 2003 yourself and others published a paper (Am JO/DO 2003;124:488) that reported on the effectiveness and psychosocial effect of Twin Block appliance therapy; and you concluded,’ The results of this study suggest that early orthodontic treatment for Class II Division 1 malocclusion with a Twin-block appliance results in higher self- concept scores and fewer negative social experiences. The patients also reported treatment benefits that might be related to improved self-esteem.’ Interestingly, amongst the variables listed in your paper as possible determinants of self-esteem and adequacy of social experience were: ‘…..To help me with my schoolwork, To help my breathing, To help me speak more clearly, To make me healthier, etc.’. Dr. O’Brien, might it be possible that improved nasal breathing during wakefulness and/or sleep, as a Tx effect of the Twin Block regimen in your trial could’ve accounted for some of the positive outcomes on which you concluded? Amongst the references listed below giving support to the hypothesis that posterior pharyngeal airway corridor volumes can indeed be enhanced with certain appropriately-applied and timed orthodontic/dentofacial orthopedic regimens, there is a paper that also reports on effectiveness of Twin Block in cohort (N=30) similar in age to your 2003 study patients, but this 2014 paper was focused mainly on Twin Block Tx-effect upon posterior airway morphology. Their conclusion, ‘Compared to the untreated Class II patients, the upper airway of growing patients with Class II division 1 malocclusion and mandibular retrusion showed a significant enlargement in the oropharynx and hypopharynx as well as a more elliptic transverse shape in the oropharynx, and the hyoid bone moved to an anterior position after Twin Block treatment.’ I’m curious Dr. O’Brien if possibly your 2003 Twin Block patients also maybe showed 2-D cephalometric evidence of airway morphology enlargement?


    1. Liang Li et al, (2014). CBCT Evaluation of the Upper Airway Morphological Changes in Growing Patients of Class II Division 1 Malocclusion with Mandibular Retrusion Using Twin Block Appliance: A Comparative Research. PLoS ONE 8(4): e94378.

    2. Xueling Chen et al, (2015). Three-Dimensional Evaluation of the Upper Airway Morphological Changes in Growing Patients with Skeletal Class III Malocclusion Treated by Protraction Headgear and Rapid Palatal Expansion: A Comparative Research. PLoS ONE 10(8): e0135273.

    3. Tomonori Iwasaki et al, (2013). Tongue posture improvement and pharyngeal airway enlargement as secondary effects of rapid maxillary expansion: A cone-beam computed tomography study. Am JO/DO 143:235-45.

    4. Kirsi Pirilä-Parkkinen et al, (2010). Cephalometric evaluation of children with nocturnal sleep-disordered breathing.
    Eur J Orthod 32:662–671.

    5. Sayinsu K et al, (2006). Sagittal airway dimensions following maxillary protraction: a pilot study. Eur J Orthod 28(2):184.

    6. Emine Kaygısız et al, (2009). Effects of Maxillary Protraction and Fixed Appliance Therapy on the Pharyngeal Airway. Angle Orthod. 79:660–667.

  9. “Eppur si muove” , and yet it moves…Galileo’s response that the earth moves around the sun.
    Helpful References
    1. Pediatr Pulmonol. 2008 Sep;43(9):837-43.
    Obstructive sleep disordered breathing in children: beyond adenotonsillectomy.
    Praud JP, Dorion D. Source
    Respiratory Medicine Division, Department of Pediatrics, Université de Sherbrooke, Québec, Canada. [email protected]
    Traditionally, adenotonsillectomy (AT) has long been the treatment of choice for obstructive sleep disordered breathing (SDB) in children. AT is usually considered a safe procedure, which cures 80% of children with SDB. Accumulated data have however challenged this overly simplistic view. Indeed, AT is invariably associated with significant morbidity, post-operative pain, and a mortality rate which, though low, cannot be ignored. In addition, aside from a recurrence of SDB at adolescence in an unknown percentage of cases, some recent results suggest that complete SDB cure is not achieved in as much as 75% of cases after AT. Interestingly, several treatment options have been recently proposed for replacing or complementing AT. Continuous positive airway pressure (CPAP) is now suggested in children with remaining SDB after AT; however, compliance and suitability of equipment remain important hurdles, especially in small children and infants. Anti-inflammatory treatments, including nasal glucocorticoids and/or the anti-leukotriene montelukast, appear to hold great promise. Finally, orthodontic treatments are an appealing option, with recent results in children suggesting that it is possible to improve or perhaps even cure SDB in a durable manner by enlarging the nasal passages and/or the oropharyngeal airspace. In conclusion, while we are currently in the midst of an exciting time with several new treatments being developed for childhood SDB, randomized controlled trials are urgently needed to delineate their indications. In the meantime, it appears that systematic detection of orthodontic anomalies and better collaboration with maxillofacial specialists, including orthodontists and/or dentists, is needed for deciding the best treatment options for childhood SDB.
    2. Sleep. 2004 Jun 15;27(4):761-6.
    Rapid maxillary expansion in children with obstructive sleep apnea syndrome.
    Pirelli P, Saponara M, Guilleminault C. Source
    Department of Odontological Sciences, University Tor Vergata, Rome Italy.
    To evaluate the effect of rapid maxillary expansion on children with nasal breathing and obstructive sleep apnea syndrome.

    Recruitment of children with maxillary contraction, without adenoid hypertrophy, with a body mass index < 24 kg/m2, with obstructive sleep apnea syndrome demonstrated by polysomnography, and whose parents signed informed consent. Otolaryngologic and orthognathic-odontologic evaluation with clinical evaluation, anterior rhinometry and nasal fibroscopy, panoramic radiographs, anteroposterior and laterolateral telecephalometry were performed at entry and follow-up. Intervention: Rapid maxillary expansion (ie, active phase of treatment) was performed for 10 to 20 days; maintenance of device (for consolidation) and orthodontic treatment on teeth lasted 6 to 12 months.
    31 children (19 boys), mean age 8.7 years, participated in the study. The mean apnea- hypopnea index was 12.2 events per hour. At the 4-month follow-up, the anterior rhinometry was normal, and all children had an apnea-hypopnea index < 1 event per hour. The mean cross-sectional expansion of the maxilla was 4.32 +/- 0.7 mm. There was a mean increase of the pyriform opening of 1.3 +/- 0.3 mm.
    Rapid maxillary expansion may be a useful approach in dealing with abnormal breathing during sleep.
    3. Angle Orthod. 1990 Fall;60(3):229-33; discussion 234.
    Rapid maxillary expansion in the treatment of nocturnal enuresis.
    Timms DJ. Source
    Oral Surgery Department, Royal Preston Hospital, United Kingdom.
    There is growing consensus that upper airway obstruction is a causative factor in nocturnal enuresis. This phenomenon has an unhappy history, although some surgeons in the past have touched on its treatment through the relief of upper airway obstruction. Only recently have sleep laboratory investigations presented a clearer, though still incomplete, picture of the etiology of nocturnal enuresis through disturbed sleep patterns. The obstruction is usually an adenoidal hypertrophy or, less commonly, an anterior nasal stenosis. While the otolaryngologist can readily cope with the former, surgical difficulties make treating the latter problematic. In many cases, the constriction can be reduced by rapid maxillary expansion. In the ten cases examined in this study, nocturnal enuresis ceased within a few months of maxillary expansion.
    4. http://www.einstein.yu.edu/news/releases/771/kids-abnormal-breathing-during-sleep- linked-to-increased-risk-for-behavioral-difficulties/
    Kid’s Snoring Linked to Hyperactivity
    5. http://abcnews.go.com/WNT/video/snoring-babies-sign-trouble-15853888

    6. http://www.med.umich.edu/opm/newspage/2006/sleep.htm
    April 3, 2006
    Kids behave and sleep better after tonsillectomy, University of Michigan study finds
    Hyperactivity, attention deficit, sleepiness, and ADHD often improved – whether or not sleep studies showed sleep apnea before surgery
    7.Sleep Breath. 2012 Mar;16(1):23-9. Epub 2011 Jan 16.
    Primary snoring in school children: prevalence and neurocognitive impairments.
    Brockmann PE, Urschitz MS, Schlaud M, Poets CF. Source
    Working Group on Paediatric Sleep Medicine, Department of Neonatology, University Children's Hospital, University of Tuebingen, Tuebingen, Germany.
    We aimed to investigate the prevalence of primary snoring (PS) and its association with neurocognitive impairments.
    Data from a community-based study in 1,114 primary school children were used to identify children who never (N = 410) or habitually snored (N = 114). In order to separate children with PS from those with upper airway resistance syndrome (UARS) or obstructive sleep apnoea (OSA), home polysomnography was conducted in all habitually snoring children. Neurocognitive impairments and poor school performance were compared between children who never snored, PS, and UARS/OSA.
    Polysomnography was successfully conducted in 92 habitual snorers. Of these, 69 and 23 had PS and UARS/OSA, respectively. Prevalence [95% confidence interval (95% CI)] of PS was 6.1% (4.5-7.7). Compared to children who had never snored, children with PS had more hyperactive (39% vs. 20%) and inattentive behaviour (33% vs. 11%), as well as poor school performance in mathematics (29% vs. 16%), science (23% vs. 12%), and spelling (33% vs. 20%; all P values <0.05). PS was a significant risk factor (odds ratio; 95% CI) for hyperactive behaviour (2.8; 1.6-4.8), inattentive behaviour (4.4; 2.4-8.1), as well as daytime sleepiness (10.7; 4.0-28.4). PS was also an independent risk factor for poor school performance in mathematics (2.6; 1.2-5.8), science (3.3; 1.2-8.8), and spelling (2.5; 1.1-5.5). Odds ratios throughout were similar to the UARS/ OSA group.
    Children with non-hypoxic, non-apnoeic PS may exhibit significant neurocognitive impairments. Consequences may be similar to those associated with UARS or OSA. If

    confirmed, PS is not "benign" and may require treatment. Children with non-hypoxic, non-apnoeic PS may exhibit significant neurocognitive impairments. Consequences may be similar to those associated with UARS or OSA. If confirmed, PS is not "benign" and may require treatment.
    8. http://www.bristol.ac.uk/alspac/
    9. Kid’s Snoring Linked to Hyperactivity http://www.einstein.yu.edu/news/releases/771/ kids-abnormal-breathing-during-sleep-linked-to-increased-risk-for-behavioral- difficulties/
    10. How Children’s Sleep Affects their Health and Well being http://www.psychologytoday.com/em/4594
    11. Snoring, mouth breathing, or apnea early in life may predict later behavioral and emotional problems, researchers found. http://www.medpagetoday.com/Pediatrics/ GeneralPediatrics/31477 and the link to the abstract http:// pediatrics.aappublications.org/content/early/2012/02/29/peds.2011-1402

    While you are are waiting for more proof, I will continue treating and will add, In spite of the Cochrane findings, " and yet they get better…" Sincerely, Karen O'Rourke, DDS

  10. I’m loving and learning a lot from the considerations of all. Congratulations Kevin for instigating us to think and debate.

  11. I think you need to look for studies that demonstrate a vaulted palate, class II malocclusion, and obstructed nasal breathing all contribute to OSA and therefore correcting these issues in order to promote a patent Airway is the only ethical thing to do.

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