Obstructive sleep apnea (OSA) is a condition caused by respiratory disturbances at night with sleep fragmentation, which can lead to hypoxia and inflammation. The effects of OSA can be particularly harmful for the pediatric population, leading to potential issues in neurobehavioral development, obesity, growth failure, bed-wetting and tooth wear. While less prevalent than OSA in adults, pediatric obstructive sleep apnea (POSA) affects approximately 1%–6% of children.¹ These children will continue into adulthood with the potential consequences of OSA, such as cardiovascular disease, hypertension and metabolic disorders. Typically, the first-line medical therapy is adenotonsillectomy. Craniofacial abnormalities are frequently overlooked, yet anatomical deficiencies of the upper airway place the child at risk of OSA, and that risk progresses throughout life. As members of the healthcare team, dentists can change patient lives by screening for and, in some cases, treating POSA by altering the developing craniofacial structure. 

What Is POSA? 

Sleep-disordered breathing represents a spectrum in severity of upper airway obstruction, from effort-related arousals of the upper airway resistance syndrome (UARS) to full collapse of the airway with severe POSA (see Figure 1). Snoring is a sign of airway obstruction and should always be considered abnormal in a child, thus warranting further assessment. The severity of POSA has been categorized based on the frequency of abnormal respiratory events, referred to as the apnea hypopnea index (AHI). The AHI represents the number of partial (hypopnea) or complete (apnea) blockage of airflow events per hour of sleep. The threshold in children is different than that of adults, such that an AHI of 1–5 represents mild POSA — for adults, it would be considered normal. An AHI of 5–10 represents moderate POSA, and greater than 10 represents severe POSA. 

During sleep, the physiology of breathing changes; reduced muscle tone results in a narrowing of the airway. This narrowing is enhanced when factors such as large tonsils/soft palate or a small mandible are present. This narrowing of the airway leads to increased resistance of airflow, otherwise referred to as airway obstruction. To overcome the airway resistance, a greater degree of respiratory effort is required for the individual to maintain the same amount of ventilation. Increased effort will generate a larger degree of negative pressure in the airway. As the degree of effort increases to maintain respiration, a point is reached in which an arousal of the brain occurs. With this arousal, the airway opens, and the obstruction is reduced. Brain (cortical) arousals are measured using electroencephalography, which tracks changes in signal as the cortex of the brain becomes activated and disrupts the continuity of sleep. Repetitive arousals from sleep cause sleep fragmentation and can be thought of as a form of sleep deprivation, with consequences that include hyperactivity, excessive daytime sleepiness, poor daytime concentration and learning/behavioral issues. With more severe degrees of OSA, the oxygen level decreases, causing a cascade of detrimental events that are thought to hinder normal development in a child and enhance systemic inflammation.^2–4 

Anatomical Considerations 

Although the causes of OSA are heterogeneous, the anatomy of the patient is the most critical element that can predispose patients to a collapsible airway.⁵ The anatomy of the craniofacial complex influences the function of breathing, and 80% of craniofacial development occurs in the first five to six years of life.⁶ Craniofacial features of retrognathia, retrusive chin, steep mandibular plane and increased vertical direction of growth, among other factors, are associated with increased likelihood of POSA.⁷ Kevin Boyd, MD, has further investigated the causation of POSA through anthropomorphic changes of underdeveloped upper airway structures. His research suggests that a societal reduction of breastfeeding and a shift to softer diets has reduced physical challenges to oral structures that are necessary for normal growth and development. This has resulted in increased predisposing factors that lead to OSA.⁸ His research, through comparing the skulls of humans from hundreds of years ago to those of today, concludes that there is a higher occurrence of OSA in our current generation when compared with hundreds of years ago. 

Screening in the Dental Office 

How can we assess if a child in our dental office has sleep apnea? There are multiple risk factors that a dental office can look for. These factors, in combination, help determine low versus high risk for POSA. In general, using information collected from a clinical examination of the head and neck, in addition to symptoms, can provide a reliable method to screen for POSA. Improved methods for screening are currently in development. However, existing questionnaires such as the Pediatric Sleep Questionnaire (PSQ)⁹ or the Sleep Disorders Inventory for School (SDIS) can be used to assess POSA risk. Recent reviews have assessed the multiple screening tools available.¹⁰ The American Dental Association is also currently working on additional screening approaches. Symptoms that are frequently assessed include snoring, nighttime mouth breathing, daytime sleepiness, hyperactivity, bed wetting and obesity. Habitual snoring (snoring for three nights or more per week) is a particularly relevant screening question. The clinical examination for POSA risk likely includes factors that are already being assessed as part of the routine dental examination. Some clinical features that are associated with higher POSA risk are high Mallampati score, high Friedman tongue classification, high Brodsky score, tonsillar hypertrophy, adenoid facies, micrognathia, retrognathia, a high-arched palate, obesity and genetic diseases affecting the upper airway (i.e., Treacher Collins, Apert and Down syndromes).¹¹ 

If the patient presents with a high risk for POSA, the next step might be referral to a medical colleague. While it is currently not in the dental scope of practice to diagnose sleep apnea, a qualified referral to the medical provider — a physician boarded in sleep medicine, if there is one in close proximity — can offer the best care for the patient. An ultimate diagnosis for sleep apnea will typically be completed with an in-lab sleep study (using polysomnography, or PSG) or a home sleep apnea test (HSAT). These are typically ordered by a physician but can vary based on state laws. One consideration prior to a pediatric referral to a physician is to ensure the medical center/ office accepts pediatric patients and at which age. There are a limited number of pediatric labs that are able to test this population, and testing can be inconvenient and costly to the patient.^12,13 

Nondental Treatments 

A number of methods exist to treat POSA. Some treatments that might be beneficial based on the clinical and subjective presentations of the individual patient are: 

• Weight loss. 
• Nasal corticosteroids. 
• Montelukast. 
• Adenotonsillectomy (AT). 
• Rapid maxillary expansion (RME). 
• Continuous positive airway pressure (CPAP), bilevel positive airway pressure (BiPAP), or noninvasive positive pressure ventilation (NPPV). 
• Craniofacial surgery. 
• Mandibular advancement (MA) and other orthodontic devices. 
• Myofunctional therapy. 
• Supplemental oxygen. 
• Tracheostomy. 

AT surgery is the first-line therapy for patients with enlarged tissue and without contraindications to surgery. Of important note is that POSA can remain after AT surgery, and long-term efficacy of this treatment is lacking.¹⁴ Pharmacological interventions such as nasal corticosteroids and montelukast can reduce inflammation and are recommended for those with mild POSA.¹² Positive airway pressure therapies in pediatric patients should be considered as a temporizing measure while working toward a long-term solution by enhancing the structure of the upper airway. There are also concerns that having the mask strapped on nightly could cause retrusive forces to the maxilla that may have detrimental effects on facial development.¹⁵ 

Dental Treatments 

Nonsurgical dental treatments include RME, MA and myofunctional therapy. RME is a fixed appliance that expands the maxillary arch by opening the midpalatal suture. The primary increase in transverse width is in the nasal cavity and hard palate. Through increasing the transverse skeletal relationship, the airway volume can be increased, and treatment is particularly effective in younger patients with a high, narrow palate and presence of crossbite.¹⁴ MA is used to redirect early growth of the mandible in a more forward position. These appliances are functional and can be used in combination with myofunctional therapy. Some examples of MA devices are Herbst, Twin bloc, Bionator and Frankel. One systematic review and meta-analysis found that RME and MA devices may be effective in managing POSA, but that more studies with larger sample sizes are needed to help establish guidelines for orthodontic treatment of POSA.¹⁶ 

Myofunctional therapy involves oral complex-strengthening exercises typically performed by a myofunctional therapist (i.e., speech language pathologist, hygienist, dentist or physician). Treatments focus on improving tone and function of the muscles of the tongue, lip, soft palate and lateral pharyngeal wall. This realm of therapy stemmed from reports that strengthening oral complex muscles in patients who played the didgeridoo (a musical instrument used by several of the Aboriginal peoples of northern Australia) reduced the severity of OSA. Subsequent studies have demonstrated that myofunctional therapy reduces the severity of POSA if continued performance of exercises is maintained.¹⁷

Craniofacial surgery can be an option for treating severe POSA affecting quality of life and for those with genetic craniofacial syndromes in order to avoid tracheostomy. Surgeries can involve hyoid expansion, skeletal expansion or modified maxillomandibular advancement.¹⁸ 

The Dentist’s Role 

As a member of the healthcare team with extensive knowledge of the craniofacial complex, dentists are well poised to screen and potentially treat POSA. The American Academy of Pediatric Dentistry recommends a dental home prior to one year of age.¹⁹ Early recognition and treatment of POSA has the potential to reduce long-term consequences and improve the cognitive potential of the child. Treatment of POSA in children as young as 6 months had significant effects on behavior later in life, which suggests that we should examine children within the first year of life for craniofacial and behavioral POSA risk factors.²⁰ In addition, dentists are able to alter the craniofacial morphology to a certain degree early in life. 

Multidisciplinary Care 

Ultimately, patients benefit from a team-based approach. The American Academy of Sleep Medicine recognizes the serious consequences and broad prevalence of OSA and the limited number of trained physicians, thus recommending collaboration to address these issues.²¹ Personalized treatment tailored to the individual can be most effective. Some examples of healthcare professionals that can aid in comprehensive POSA care are: 

• Dentist (general and pediatric dentist, oral surgeon and orthodontist). 
• Physician (otolaryngologist, neurologist, pulmonologist and pediatrician). 
• Lactation consultant/feeding specialist. 
• Dietician. 
• Myofunctional therapist. 
• Weight-loss specialist. 
• Pharmacist. 
• Chiropractor. 
• Genetic counselor.

It is important to recognize that if you don’t look, you will not see. Screening for POSA in your practice is the first step. With prevalence rates up to about 6%, all dentists have these patients in their practice. Simple steps to identify airway issues tomorrow can be to start screening, modify intake forms, and ask the patient or caregiver about breathing and sleep behaviors. Recognize other healthcare providers in your community to whom you can reach out for assistance when you find a child about whom you are concerned. These early steps can positively change the trajectories of your young patients’ lives. 

Aaron Glick, DDS, is a clinical assistant professor, and Karen Wuertz, DDS, is a clinical associate professor, both in the Department of General Practice & Dental Public Health at the University of Texas Health Science Center at Houston School of Dentistry. Jerald Simmons, MD, is in private practice at Comprehensive Sleep Medicine Associates in Houston, Texas, and founding director of the Sleep Education Consortium. To comment on this article, email impact@agd.org. 

References 
1. Brockbank, Justin C. “Update on pathophysiology and treatment of childhood obstructive sleep apnea syndrome.” Paediatric Respiratory Reviews, vol. 24, Sept. 2017, pp. 21-23. 
2. Gozal, David. “Obstructive sleep apnea in children: implications for the developing central nervous system.” Seminars in Pediatric Neurology, vol. 15, no. 2, 2008, pp. 100-106. 
3. Simmons, Jerald H. “Neurology of sleep and sleep-related breathing disorders and their relationships to sleep bruxism.” Journal of the California Dental Association, vol. 40, no. 2, 2012, pp. 159-167. 
4. Guilleminault, Christian, et al. “From obstructive sleep apnea syndrome to upper airway resistance syndrome: consistency of daytime sleepiness.” Sleep, vol. 15, suppl. 6, 1992, pp. S13-S16. 
5. Eckert, Danny J., et al. “Defining phenotypic causes of obstructive sleep apnea. Identification of novel therapeutic targets.” American Journal of Respiratory and Critical Care Medicine, vol. 188, no. 8, 2013, pp. 996-1004. 
6. Guilleminault, Christian, and Farah Akhtar. “Pediatric sleep-disordered breathing: new evidence on its development.” Sleep Medicine Reviews, vol. 24, 2015, pp. 46-56. 
7. Flores-Mir, Carlos, et al. “Craniofacial morphological characteristics in children with obstructive sleep apnea syndrome: a systematic review and meta-analysis.” The Journal of the American Dental Association, vol. 144, no. 3, 2013, pp. 269-277. 
8. Boyd, Kevin, and John J. Kelly. “Prevention and Correction of Pediatric SDB/OSA and Post T&A Relapse: A Non-Surgical Orthodontic/Dentofacial Orthopedic Approach.” Sleep Apnea and Snoring, edited by Michael Friedman and Ofer Jacobowitz, Elsevier, 2020, pp. 439-444. 
9. Chervin, Ronald D., et al. “Pediatric sleep questionnaire (PSQ): validity and reliability of scales for sleep-disordered breathing, snoring, sleepiness, and behavioral problems.” Sleep Medicine, vol. 1., no. 1, 2000, pp. 21-32. 
10. Spruyt, Karen, and David Gozal. “Pediatric sleep questionnaires as diagnostic or epidemiological tools: a review of currently available instruments.” Sleep Medicine Reviews, vol. 15, no. 1, 2011, pp. 19-32. 
11. Stauffer, J., et al. “A review of pediatric obstructive sleep apnea and the role of the dentist.” Journal of Dental Sleep Medicine, vol. 5, no. 4, 2018, pp. 111-130. 
12. Marcus, Carole L., et al. “Diagnosis and management of childhood obstructive sleep apnea syndrome.” Pediatrics, vol. 130, no. 3, 2012, pp. e714-e755. 
13. Radhakrishnan, D., et al. “Geographic disparities in performance of pediatric polysomnography to diagnose obstructive sleep apnea in a universal access health care system.” International Journal of Pediatric Otorhinolaryngology, 2021, pp. 110803. 
14. Gozal, David, et al. “Treatment of obstructive sleep apnea in children: handling the unknown with precision.” Journal of Clinical Medicine, vol. 9, no. 3, 2020, pp. 888. 
15. Garg, Ravi K., et al. “Pediatric obstructive sleep apnea: consensus, controversy, and craniofacial considerations.” Plastic and Reconstructive Surgery, vol. 140, no. 5, 2017, pp. 987- 997. 
16. Huynh, Nelly T., Eve Desplats, and Fernanda R. Almeida. “Orthodontics treatments for managing obstructive sleep apnea syndrome in children: A systematic review and meta-analysis.” Sleep Medicine Reviews, vol. 25, 2016, pp. 84-94.
 17. Camacho, Macario, et al. “Myofunctional therapy to treat obstructive sleep apnea: a systematic review and meta-analysis.” Sleep, vol. 38, no. 5, 2015, pp. 669-675. 
18. Kaditis, Athanasios G., et al. “Obstructive sleep disordered breathing in 2- to 18-year-old children: diagnosis and management.” European Respiratory Journal, vol. 47, no. 1, 2016, pp. 69-94. 
19. “Definition of Dental Home.” American Academy of Pediatric Dentistry, aapd.org/research/oral-health-policies--recommendations/Dental-Home/. Accessed 12 Oct. 2021. 
20. Bonuck, Karen, et al. “Sleep-disordered breathing in a population-based cohort: behavioral outcomes at 4 and 7 years.” Pediatrics, vol. 129, no. 4, 2012, pp. e857-e865. 
21. Rosen, Ilene M., et al. “Strategies to improve patient care for obstructive sleep apnea: a report from the American Academy of Sleep Medicine Sleep-Disordered Breathing Collaboration Summit.” Journal of Clinical Sleep Medicine, vol. 16, no. 11, 2020, pp. 1933-1937.