July 16, 2018

How many orthodontic patient have sleep disordered breathing?

Sleep disordered breathing (SDB) is a serious problem for children. This new paper provides us with information on the potential prevalence of SDB in a population of orthodontic patients.

The role of SDB in the aetiology of malocclusion is far from clear. However, there is little doubt that SDB can cause severe problems for children. For example, SDB leads to hyperactivity and this may be misdiagnosed as attention deficit disorder.  As  orthodontists mostly see children for treatment it is important that we identify those potential patients who have SDB.  We can then refer them for appropriate treatment. The AJO-DDO published this paper and a team from Cleveland, Ohio did this study.

Ashok K. Rohra, et al

AJO-DDO Am J Orthod Dentofacial Orthop 2018;154:65-71  https://doi.org/10.1016/j.ajodo.2017.11.027

 

 

They set out to ask the following question

“What is the prevalence of SDB in children who present for orthodontic treatment”?

What did they do?

They did a screening study of 303 children who attended a dental school orthodontic clinic between January 2014 and March 2016. They included all children who had not had orthodontic treatment previously. Each patient completed the Paediatric Sleep Questionnaire (PSQ), which is a validated instrument that other investigators have used.  Importantly, this questionnaire has reasonable accuracy when compared to polysomnography.  They used the PSQ to identify patients who are likely to have SDB.  This was a simple straightforward method of data collection.

What did they find?

They set a cut off point for SDB as 33% of yes responses to the questions.  They found that 44% of the children had no SDB positive responses, but 7% were identified as being at clear risk of SDB.

Their overall conclusion was that SDB was a potential problem for a proportion of patients referred for orthodontic treatment. When they considered other data, other studies have suggested a prevalence of 0.7-13% of children have SDB. However, some of this variation may be due to different methods of measurement.

They also suggested that the average orthodontic practice in the USA may see 2-3 children with SDB per day.

Finally, they concluded that if orthodontists routinely screened their patients for SDB and referred those with SDB for treatment, they would provide a more comprehensive health care service.

What did I think?

I have often thought that the simplest studies are potentially the most useful because they ask a simple question using simple methods. This is one of those studies. The authors used a simple validated questionnaire and gave it to their patients. The findings are relevant to an orthodontic population. However, we need to consider that the population in a dental school clinic may be different from those referred to a private practice.  But this is not a major shortcoming.

I was also pleased that the authors felt that the children at risk should be referred for relevant treatment.  Importantly, they did not use this small sample to “go off” on a long diatribe about the benefits of orthodontic treatment for SDB.

Finally, it was nice to see a well written and simple study that has clinically relevant findings. I wonder if we should routinely use this method to screen our patients for SDB?  Lets have a discussion.

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Have your say!

  1. Avatar

    It is indeed good to have more studies that quantify potential SDB among patients seeking orthodontic treatment. But we need to be careful with the implications. Because the positive predictive value (PPV) of SDB is quiet low. If we apply the PPV formula and use 3% as the real prevalence of fully diagnosed SDB, a PSQ sensitivity of 0.81 and specificity of 0.83 (PMID: 24487608 DOI: 10.14219/jada.2013.26) then only around 43% of those children with a positive PSQ will actually have SDB confirmed by full diagnosis. In simple terms only 2 of every 5 positive PSQ will really mean the patient has SDB. This implies that in this sample chances are the real prevalence of SDB is closer to 2.8%. Where PSQ is really good as a screening tool is when is negative as 99.9% of the times that negative suggestion is conformed by proper diagnosis. We should be using the PSQ consistently but always keep in mind when we discuss findings that it is a screening not a diagnosis tool.

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      And also, to be fair, it’s 2.8% of a sample that has inherent selective bias. I suppose that the real answer is that all children are screened at dental recall appointments. What age should this be started at?

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    Dear Kevin
    Given your high profile and the degree of respect earned by you over the decades from your students and peers within the global Orthodontic community, I think this particular posting will very likely lead to a much greater awareness concerning the often comorbid relationship between certain phenotypes of malocclusion and increased SDB/OSA risk susceptibility; which in turn will very likely lead to greater numbers of young children being helped…..for this Kevin I commend you and wish to express my sincere gratitude.

    We have been utilizing the validated Chervin (behavioral) PSQ as an integral component of our intake protocol for ALL patients in our Chicago Pediatric Dental practice since 2007; over that timespan we have identified hundreds of children, most of whom were between the ages of 2-8, who were either later diagnosed with SDB/OSA (based upon data from referred overnight PSG-overnight sleep study), or deemed at significant risk for later sleep-respiratory problems. In addition to adenotonsillar hypertrophy, for which ENT referral was made, nearly all of the aforementioned children also displayed some degree of comorbid transverse and/or sagittal and/or vertical skeletal discrepancies. We are now in the process of analyzing these data for eventual publication.

    The PSQ will be discussed next month by myself and others, at the American Dental Association’s first annual Pediatric Airway Symposium to be held at the ADA headquarters in Chicago. It would be great if you and some of your readership could attend.
    Thanks again.

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      Nice comment ——we in E.Canada have little impact on paediatric ENT,s as they don’t seem to be interested in co-operating in this area or really recognize the interrelation between dental and skeletal malocclusion and OSA . I am a huge supporter of socialised medicine here BUT the downside is that is sometimes difficult to move and motivate folks to push themselves out of their routine /rut.
      You are fortunate .

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    The AAO has commissioned a task force to take a very deep dive into this subject and attempt to articulate something of meaning for the specialty. I serve on that TF and can tell you that there is a tremendous body of quality research out there on the subject. We’ve read and analyzed most of it!

    The Sleep Apnea TF will be writing a white paper which will be released at the Winter Conference in early 2019. For those interested in this subject, I recommend attending that conference as the TF has assembled an impressive group of speakers from many disciplines.

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    Dear Kevin

    I am a retter ortho from Germany.
    I love your Blogs!
    Is it OK if I send them – of course with your name- to other ortho in Germany??
    Thank you so much for your time! cordially
    Hans

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    I like your power calculation, Carlos – but a recent study published in the AJODO noted that kids who had conventional orthodontic treatment (with or without premolar extractions) has an SDB prevalence of about 10%, which is x2 to x10 greater that what might be expected in an untreated pediatric population, based on the current study. So I guess my question is: If we follow this particular cohort with a follow-up PSQ after conventional orthodontic treatment, I wonder what the risk of SDB might be?

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    Excellence evaluation and research. Dr. Ashok Rohra

  7. Avatar

    Dave, good point that you raised. If indeed patients with certain malocclusions have a higher risk of SDB then the prevalence in orthodontic practices would be larger. In sleep medicine clinics it would been even higher. So that the numbers I provided apply to general paediatric populations. The more specialized the service the more likely SDB and hence better performance of PSQ. At certain point there is no need to apply PSQ patients should get full diagnostic assessment. I wanted to make the point that we need to be careful not to imply to the parents of our patients that PSQ is closely equivalent to a proper medical diagnosis. We certainly can play a huge role in referring patients that otherwise will stay undiagnosed.
    In regards to the second question my understanding is that there is increasing data that some orthodontic interventions temporarily reduce SDB symptoms. Some of the long term studies imply that a significant relapse occurs. So orthodontic treatment should be an adjunct for a multidisciplinary approach. Maybe in those cases the stability is larger; although medical colleagues refer that relapse is not so uncommon.

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    This is a nice way to detract from the core of the issue: the role of the tongue, the dentition, the profile of palate and forward growth of jaw. How can you expect to screen and refer SDB cases while simultaneously elongating faces, extracting teeth and placing functional appliances ( large objects) inside children’s mouths escapes all measure of sanity. But that is course because we all know most adolescent cases of SDB are caused by enlarged adenoids…so what’s causing that? Could it be the same thing causing the occlusal issues? Im sorry but there’s just too many shortfallings in this study alone for this to be taken seriously, you must see this yourself, so this is a joke? And why the blog post is title ‘ how many patients’ but deliberately refers only to children at the time of first tx….come on this is so deliberately misleading, it’s almost like falsifying tx outcomes by ignoring long term efficacy or follow ups. Once a patient always a patient, and especially orthodontics. So where’s the long term studies and where’s the actual testing , not a questionnaire!

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    So, another conspiracy theory? Hmmm….quite a pattern here. So what does “elongating faces, extracting teeth or functional appliances have to do with SDB”? Is this the new theory that these cause SDB? These comments seem very delusional….quite typical for the fringe.

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