February 05, 2024

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.

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. 

Final comments

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.

Have your say!

  1. We must consider, above all, the position of the tongue in the oral cavity. This is part of my studies.

  2. Is there much consensus/reporting of how much Expansion is done? It’s one thing to get rid of a crossbite, another to take into account WALA measurements and the like and it’s completely another to max out the Hyrax. What’s the target depending on the goal?

    Stephen Murray
    Swords Orthodontics

  3. Apart from the OSA Dx would some percent of the patient sample have been candidates for expansion for orthodontic reasons alone? If so then could the treatment be said to have a positive effect on nasal breathing while not being the prime desired outcome?

  4. Thank you for your synopsis of this research and where we are on this issue. What is absent in the evaluation of efficacy of expansion here is whether or not there is a clinical finding of skeletal maxillary constriction as evidenced by a significant posterior crossbite. The anatomy of OSA is multi-variant with hard and soft tissue contributions. Is skeletal maxillary construction one of those variants? Does a patient with skeletal maxillary construction show a more significant alleviation of OSA symptoms when expanded than watchful waiting? While there is not scientific support for maxillary expansion in pediatric the OSA population as a whole, does that subset of Skeletal maxillary construction OSA pediatric patients derive greater benefit from maxillary expansion than watchful waiting?
    Again, thank you for your continued efforts at keeping us appraised.

    • This is an important aspect. No one is saying: do not treat a crossbite or real maxillary restriction at the age of 7-9.
      But do not promise that the treatment will improve behaviour problems or OSA. Not beyond watchful waiting.
      Expand at the best age for orthodontic purposes, with the best outcome and the least amount of relapse.
      Small airway is not a disease. If it works well during sleep, don’t change, as you will make it worse as seen in some studies.

  5. “Numerous studies have shown that, due to a myriad of cognitive biases such as belief perseverance and confirmation bias, facts unfortunately do not change people’s minds. Propaganda, on the other hand, works very well on this front, something we see clearly from how people and groups have used it over the past century.”

  6. It might be OK for the professional to undertake ‘watchful waiting’ but one needs to be cognizant that it’s a fine line between that and ‘supervised neglect’ from the parents’ point of view as they endure a childhood/adolescence of potential:
    Loud snoring, Breathing pauses during sleep, Restless sleep, Mouth breathing, Night sweats, Difficulty waking up in the morning, Excessive daytime sleepiness or fatigue, Behavioral problems (such as irritability, aggression, hyperactivity, and difficulty concentrating), Poor academic performance (since sleep disruptions can affect cognitive function, leading to difficulties in learning), and Enuresis (bedwetting)

    Having worked in a craniofacial cleft-palate team, I believe parents can make a difference in treatment choices and outcomes

    • To put all and every signs and symptoms in one bucket is naive. Most children today suffer from the lack of sleep. Not sleep disordered breathing!
      Snoring alone is not a disease. And to scare parents on outcomes such as poor school outcomes, without any data is unethical.
      Parents decide on the evidence you give, being it true or false.

      • Over 11 thousand children studied…snoring/mouthbreathing. 6 months old to 7 years old. Snoring/mouthbreathing IS a health problem and not a “scare tactic”.

        Logo of pediatrics
        Pediatrics. 2012 Apr; 129(4): e857–e865.
        doi: 10.1542/peds.2011-1402
        PMCID: PMC3313633
        PMID: 22392181
        Sleep-Disordered Breathing in a Population-Based Cohort: Behavioral Outcomes at 4 and 7 Years
        Karen Bonuck, PhD,corresponding authora Katherine Freeman, DrPH,b Ronald D. Chervin, MD, MS,c and Linzhi Xu, PhDa
        Author information Article notes Copyright and License information PMC Disclaimer
        Associated Data
        Supplementary Materials
        Go to:
        Abstract
        OBJECTIVES:
        Examine statistical effects of sleep-disordered breathing (SDB) symptom trajectories from 6 months to 7 years on subsequent behavior.

        METHODS:
        Parents in the Avon Longitudinal Study of Parents and Children reported on children’s snoring, mouth breathing, and witnessed apnea at ≥2 surveys at 6, 18, 30, 42, 57, and 69 months, and completed the Strengths and Difficulties Questionnaire at 4 (n = 9140) and 7 (n = 8098) years. Cluster analysis produced 5 “Early” (6–42 months) and “Later” (6–69 months) symptom trajectories (“clusters”). Adverse behavioral outcomes were defined by top 10th percentiles on Strengths and Difficulties Questionnaire total and subscales, at 4 and 7 years, in multivariable logistic regression models.

        RESULTS:
        The SDB clusters predicted ≈20% to 100% increased odds of problematic behavior, controlling for 15 potential confounders. Early trajectories predicted problematic behavior at 7 years equally well as at 4 years. In Later trajectories, the “Worst Case” cluster, with peak symptoms at 30 months that abated thereafter, nonetheless at 7 years predicted hyperactivity (1.85 [1.30–2.63]), and conduct (1.60 [1.18–2.16]) and peer difficulties (1.37 [1.04–1.80]), whereas a “Later Symptom” cluster predicted emotional difficulties (1.65 [1.21–2.07]) and hyperactivity (1.88 [1.42–2.49]) . The 2 clusters with peak symptoms before 18 months that resolve thereafter still predicted 40% to 50% increased odds of behavior problems at 7 years.

        CONCLUSIONS:
        In this large, population-based, longitudinal study, early-life SDB symptoms had strong, persistent statistical effects on subsequent behavior in childhood. Findings suggest that SDB symptoms may require attention as early as the first year of life.

        • GREAT RESPONSE!!!! Well said!!
          Sory but 20 years of doing expansion in littles seeing amazing outcomes: orthodontically , cosmetically, cognitively, and systematically I am not going to change my practice philosophy based on one flawed study.

        • Thank you for your response. It seems that there is growing evidence that sleep-disordered breathing (SDB) is a significant concern. However, it is uncertain how effective orthodontics is in treating SDB, as discussed in the research paper I shared earlier.

      • enjoyed your response

  7. “Watchful waiting”……Isn’t this the MO for traditional orthodontists? I believe that it is really rich for an orthodontist to accuse anyone of “generating work” when the literature shows a 22% success rate with traditional orthodontic therapy. Orthodontics completed solely for straight teeth and done so after the age of 12 is strictly a cosmetic procedure…nothing else. You claim evidence based but don’t follow your own evidence! Look at Little’s study on success rates completed at the U of Washington’s Orthodontic Department. That was a 40 year study and the results are abysmal yet Orthodontist keep doing the same things and hope for a different outcome. The very definition of insanity. As for this study, how can AHI be the sole indicator in adults much less children. AHI is a very poor statistic and that fact is recognized by anyone who treats patients for sleep apnea. There are so many other things to measure than just AHI.

  8. I applaud the summary. There is an important aspect, No one is saying: do not treat a crossbite or real maxillary restriction at the age of 7-9.
    But do not promise that the treatment will improve behaviour problems or OSA. Not beyond watchful waiting.
    Expand at the best age for orthodontic purposes, with the best outcome and the least amount of relapse.
    Small airway is not a disease. If it works well during sleep, don’t change, as you will make it worse as seen in some studies.

  9. I wonder how many orthodontists out there would “watch and wait” their own child if they had OSA and maxillary constriction.

  10. I wonder how many orthodontists out there would “watch and wait” their own child who had OSA and maxillary constriction.

  11. I agree with Dr. Almeida’s wise caution to those who might foolishly promise that the (orthodontist-determined) need for RME Tx(indications from the review article,…“narrow maxilla associated with a high and narrow hard palate, as determined by an orthodontist” [43], high-arched palate and/or malocclusions, and dysgnathia, according to the orthodontist’s evaluation [45], clinical signs of maxillary transverse deficiency, malocclusion (high, narrow palate associated with deep bite, retrusive bite, or cross-bite”) will improve behaviour problems or OSA.

    Although RME in ‘early childhood’ (the age of Tx’d individuals within 4 of the 5 selected studies) might indeed in some cases coincide with improved QOL, neurocognitive/neurobehavioral problems and also naso-respiratory incompetency indicators, it should always/only be recommended for correction of the specific malocclusion phenotype classified as maxillary transverse deficiency (with or without a posterior dental crossbite).

  12. I would be interested in hearing from anyone here who might think that specific ‘maxillary skeletal transverse deficiency phenotypes, such as those listed in the review article as being ‘orthodontist identified’ (“narrow maxilla associated with a high and narrow hard palate, high-arched palate and/or malocclusions, and dysgnathia, clinical signs of maxillary transverse deficiency, malocclusion (high, narrow palate associated with deep bite, retrusive bite, or cross-bite”), might ever self-resolve (i.e., without appropriate O/DO intervention) after their initial detection during ‘early childhood’ (deciduous/early mixed dentitions).

  13. The study does nothing more than to highlight there is an absence of quality research comparing RME to watchful waiting, which I can completely agree with.

    The data they included was very limited and narrowly focused on PSG variables only. It is well known that there is no correlation between AHI and symptoms and developmental risks, and that in fact even “primary snoring” is linked to comparable risks in children.

    In the real world, parents are concerned when their child snores, and presents with difficulties with emotional regulation, deficits in attention and concentration, hyperactivity, tiredness, and more. I know this because I see parents at breaking point all the time in my practice.

    Does anyone really think it is reasonable to suggest that parents wait for a child’s facial growth to resolve OSA? Where is the evidence that the risk factor of constricted palate will normalise with time? And what is happening to that child and for the family in the meantime? Is it in their best interests to withhold treatment for exhausted and despairing parents, when we know there are multiple systematic reviews and meta-analysis supporting RME may help? Parents should be given all info, and limitations to make their own decision.

    The systematic review highlighted reminds me of these other studies that demonstrate whilst AHI may resolve with watchful waiting, those who have intervention can experience significantly greater improvements in symptoms, and quality of life. Should we be discounting these other benefits?

    Effectiveness of Adenotonsillectomy vs Watchful Waiting in Young Children With Mild to Moderate Obstructive Sleep Apnea A Randomized Clinical Trial

    https://pubmed.ncbi.nlm.nih.gov/32463430/

    A Randomized Trial of Adenotonsillectomy for Childhood Sleep Apnea

    https://www.nejm.org/doi/full/10.1056/nejmoa1215881

    Furthermore – if we want to practice more precisely – perhaps we need to look more closely at mouth breathing, because ten years after the publication of the initial study suggesting watchful waiting for mild OSA could be an alternative to early adenotonsillectomy, this study of the same data set, suggests doing nothing could be detrimental as mouth breathing tends not to resolve during a critical period of facial development.

    Ineffectiveness of watchful waiting on mouth breathing in children with obstructive sleep apnea

    https://www.tandfonline.com/doi/full/10.1080/08869634.2023.2180984?scroll=top&needAccess=true

    Whilst it can be daunting to discuss publicly online – I did take the opportunity to share my perspectives further with Dr Mike DeLuke earlier this year. This is an important area to keep discussing and debating for the benefit of patients. Here is the link for those with a genuine interest to keep exploring this topic and one practitioner’s practical application of evidence in this area. It is my perception that exchanging clinical observations, and listening to parents is just as important as debating the literature when it comes to solving real-life problems and advancing children’s sleep and airway health.
    https://youtu.be/RiP_gvkKSkk

    • Thanks for the thoughtful comment. I will look at the papers that you have suggested and do another blog post and hopefully this will lead to further discussion.

  14. Logically and eloquently proposed Dr. Lim…. Thanks.

    And your to your questions, “Where is the evidence that the risk factor of constricted palate will normalise with time? And what is happening to that child and for the family in the meantime? “,
    I am hopeful that Prof O’Brien, and/or maybe some of the elite orthodontist contributors here, such as Michael DeLuke, dual-trained Pediatric Dentist-ABO Orthodontist Gerry Samson et al, will offer their own inputs regarding skeletal malocclusion’s persistence from early childhood and potential respiratory-related disease co-morbidities.

  15. For some reason, it’s not giving me the option to reply to Kevin O’Brien’s last comment in our thread. Therefore, I am posting my response in a new thread:

    That’s disappointing, but I’m not surprised. It’s too bad as I think it would have helped shed a lot of light on this very important and controversial topic.

    In response to your claim that a debate will lead to more misunderstanding, I strongly disagree. Instead, it is an opportunity for us to go point/counterpoint on the entire topic of airway and orthodontics, as well as take questions from colleagues. That provides honesty and transparency and only increases understanding. Everyone knows that is a much more effective means of communication than our own prepared 500-word statements on a specific article.

    Further, it’s a bit presumptuous, and quite arrogant, to claim that your blog has a greater reach than my website, as you have no idea how many docs (not just orthos) my platform reaches. In addition, I’d be willing to post a recording of the debate on all the major social media pages, including this one. I’d even post it on my podcast (The DOC Podcast), which is on Apple, Spotify, and YouTube and has a substantial following around the world. For that matter, you could even post a link to it on your blog so you’d still reach your audience! 🙂

    You clearly don’t want to have an honest debate with me on the topic of airway and orthodontics, so you’re making excuses. I’m not going to continue to go back and forth as to why we should or shouldn’t debate. I made the offer, and you refused.

    That being said, you have my email, and my offer stands should you ever change your mind.

  16. It’s an unnecessary discussion.

    Imagine having to compare whether CPAP is efficient in a child or wait for a controlled group.

    It would be a waste of time and extremely unethical, because it is already known that apnea does not self-regress in young children.

    Autoregression will only happen after adenoid reduction, which happens around the age of 9.

    Therefore, discussing this is unprofitable and typical of those who have nothing to add, in addition to being unethical.

  17. Kevin, This discussion proves why this blog is so valuable to our profession. (That is a thanks for keeping this going) This research was confined to a pretty simple question frame in a way (I believe) to keep this extraneous emotion out of the answer, and yet, people can not quite keep the emotion in check and just absorb this small bit of information on this topic with out getting bent out of shape. I appreciate you staying on the high road of written discourse which is how thoughtful and serious people share share thoughtful and serious ideas.. Anyone who can not put together 500 words to support their point of view is, (in my opinion) probably not worth listening to.

  18. First of all I want to thank you, that you had mentioned this point..
    I think this topic must be evaluated with nose,throat,ear department..
    This department’s kids must reffered to the orthodontic department suffered from oral breathing. Unfortunatelly these kids havle to use many medicaments due to narrow maxilla..
    Unfortunatelly, doctors do not care these situation they give only antibiotics..
    RME have significant affect on improving nasal breathing..
    But to see this results we need to work medical departments..

  19. Thank you for providing evidence backed research as opposed to anecdotal opinions presented by some here in the comments Dr. O’Brien. As a lay person wanting to understand this issue, it appears that some orthodontists are overstepping ENTs in order to enrich themselves. I look at it logically…why wouldn’t orthodontists want to make more money if research proved that expansion could solve many of their younger patients’ medical issues? It’s simple, the ethical doctors won’t push such treatment until there is scientific data supporting it.

    I also appreciate your respectful responses to that guy trying to bully you into debating on his website. I would rather READ a point/counterpoint piece on your blog than listen to that guy yelling over you.

    • Dear Emma

      That specific deciduous skeletal malocclusion traits, such as: excessive vertical growth sensitivity (aka, ‘adenoid facies’), maxillary transverse deficiency (with or without a posterior dental crossbite) possibly manifesting with high/narrow palatal vault and/or incisor crowding, etc. and distal step primary molars, might each/all self-correct without appropriate and timely early intervention, is a long-cherished hypothesis, but without scientific support; however, the converse does indeed have scientific support, but not with data derived from prospective and blinded RCT’s.

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