What is better RME or watchful waiting for paediatric OSA?
There is a debate among orthodontists regarding the relationship between orthodontics and breathing. Some orthodontists claim that orthodontic treatment with Rapid Maxillary Expansion (RME) can cure breathing problems in children, but their argument is based on low-quality research. The studies that support this claim are typically uncontrolled and do not consider the role of average growth. For instance, the reduction in tonsillar size with growth could lead to improved breathing rather than orthodontic treatment. In fact, one study even asserts that orthodontic treatment reduces tonsil size.
Although there is no conclusive evidence, a growing number of orthodontists are becoming vocal about the issue, which is gaining importance. To delve deeper into this matter, I analyzed a research paper that compared Rapid Maxillary Expansion (RME) with watchful waiting as potential treatments for pediatric OSA.
A team from Vitoria-Gasteiz, Spain this study. Sleep medicine reviews published the paper. This paper is open-access.
Fernandez-Barriales et al.
Sleep Medicine Reviews 62 (2022) 101609. https://doi.org/10.1016/j.smrv.2022.101609
What did they ask?
They did this systematic review to ask.
“In children less than 18 years old with OSA, does RME improve sleep outcomes as compared to watchful waiting or alternative treatment”?
This quote from a paper they highlighted in their literature review particularly struck me.
‘American guidelines warn that data is insufficient to recommend maxillary expansion for OSA due to the absence of controls in published case series”.
What did they do?
The team conducted a systematic review and followed the classic stages of literature search identification of papers, assessment of the risk of bias, data extraction and relevant statistical analysis if possible.
The PICO was
Participants: Children diagnosed with OSA using PSG or HSAT
Intervention: Orthodontic maxillary expansion using an intra-oral device
Comparison: Watchful waiting or alternative treatment
Outcome: Difference between pre and post-treatment Apnea Hypoxic Index as measured in a sleep study; polysomnography (PSG) or Home Sleep Apnea Test (HSAT).
What did they find?
During the process of paper selection, they found five articles. These included one parallel-sided RCT, one cross-over RCT and three non-randomised longitudinal studies.
These studies included data on 213 participants, of which 129 had RME treatment. No article reported on race, socioeconomic status or pre-term birth.
All patients who underwent rapid maxillary expansion (RME) had a medical diagnosis of pediatric obstructive sleep apnea (OSA). In four of the studies, the alternative treatment was the surgical removal of tonsils and adenoids. The randomized controlled trial (RCT) did not describe any intervention in the control group; instead, they opted for a watchful waiting approach.
It was not possible to conduct a meta-analysis due to significant heterogeneity amongst the studies. The differences in follow-up duration, type of sleep study, scoring criteria, and incomplete data on outcomes contributed to this heterogeneity. Additionally, the authors concluded that the overall risk of bias was noteworthy.
They highlighted the data from the randomised trial and reported that over five months, the AHI dropped from 2.5 to 1.79 (28% drop) with RME and from 2.67 to 1.8 (33% drop) with watchful waiting. This study concludes that RME would not be better than watchful waiting.
The team also reported the following problems with the included papers
- The sample sizes were low
- Reproducibility was low because of unclear definitions of the participants’ dentofacial features.
- The investigators used multiple outcomes for sleep studies.
- They could only find one RCT
Their conclusion was
“In this systematic review, we could not find convincing evidence of a significant benefit of RME treatment over watchful waiting in patients with paediatric OSA”.
‘RME should not be recommended for the treatment of paediatric OSA”.
What did I think?
The team followed the standard steps for conducting a systematic review and executed it well. However, they faced a common challenge encountered in systematic reviews – the studies they analyzed were too diverse to combine their data. Consequently, they concluded that additional research in this area is required.
However, they differed from other orthodontic reviews by concentrating on the lack of evidence. In effect, they took the stance that if the evidence had been published, they would have found it. This meant that they could come to relatively firm conclusions. If I quote directly from their discussion.
“Given the ability of paediatric OSA for spontaneous resolution, treatment alternatives should include watchful waiting. Evidence that supports the use of RME comes mainly from uncontrolled, short-term, small case series”.
Importantly, this stance led to the statement that RME should not be a treatment for paediatric OSA. This is a clear conclusion.
As regular readers of this blog will know, I have highlighted the lack of research and evidence to support expanding to cure paediatric RME. As a result, I strongly support this conclusion.
When we look at the evidence base for treating paediatric breathing disorders with orthodontics, it’s unclear to me why clinicians promote this approach. It’s actually better to wait for the child’s facial growth to change the environment and resolve the issue of obstructive sleep apnea. The motivation to treat may come from a desire to help, but we should resist this temptation and monitor any changes to allow nature to solve the problem? This may sound harsh, but we should not view treatment as an opportunity to differentiate ourselves from other orthodontists by building an “airway-friendly practice” that generates work and income. If we are to practice ethically, we need to carefully consider the conclusions of this paper.
Emeritus Professor of Orthodontics, University of Manchester, UK.