What Dentists Need to Know About Obstructive Sleep Apnea in Children

June 17, 2022

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It’s a common misconception that snoring and sleep apnea only impact overweight, older men. However, the truth is that sleep apnea—especially the most common type of sleep apnea, obstructive sleep apnea (OSA)—can affect people of all ages. In fact, it’s estimated that as many as 1–5 percent of children have the disorder, which is most commonly found in children ages three to seven.

OSA can lead to detrimental health consequences that affect a child’s ability to develop and thrive. For example, children with OSA may experience nighttime bedwetting (enuresis), attention-deficit disorder (ADD), poor academic performance, and behavior problems.1

Dentists are in a unique position to screen for OSA in children during routine hygiene exams. However, a recent study found only 70 percent of pediatric dentists screen for OSA, and approximately 72 percent of pediatric dentists report some lack of confidence regarding their capability for OSA screening.5

Here is what dentists need to know about OSA and children.

Causes 

According to the American Academy of Pediatric Dentistry, OSA diagnosis is often delayed in children. Dentists can easily recognize the physical causes of OSA during routine hygiene exams. Orofacial variations can create upper airway narrowing and lead to reduced oxygen levels in the blood (oxyhemoglobin saturation).1

The following are a few common orofacial characteristics in children with OSA:1

  • Adenotonsillar hypertrophy
  • Midface deficiency
  • Narrow palatal arch
  • Retrognathia
  • Macroglossia
  • Long, narrow face (dolichofacial pattern)
  • Enlarged palate or uvula
  • Deviated septum

There are also a few additional reasons why a child may be dealing with OSA, including the following:

  • Infection
  • Being overweight
  • Certain syndromes or birth defects like Pierre-Robin syndrome or Down syndrome
  • A tumor or growth1

Hypertrophy of the tonsils is the most common cause of OSA, followed by obesity and craniofacial characteristics.8 However, the cause of OSA in children is typically multifactorial.8 Patients with Treacher Collins syndrome, Pierre Robin syndrome, Crouzon syndrome, or Down syndrome are more likely to experience OSA due craniofacial variations associated with each disease.8 Regardless of the cause, OSA in children can present as a multitude of symptoms.

Symptoms 

Symptoms of obstructive sleep apnea in children vary based on a child’s age. In children under the age of five, for example, snoring is the most common complaint.1 On the other hand, older children are more likely to experience bedwetting, ADD, and challenges in school.1 Children often fail to report fatigue, which is why it’s so important to be able to recognize the most tell-tale signs that a child is experiencing a sleep-breathing disorder.

Some of the most common symptoms of OSA include the following:1

  • Mouth breathing
  • Sleep bruxism
  • Loud snoring or noisy breathing as they sleep
  • Pauses in breathing (lasting for a few seconds up to a minute)
  • Hyperactivity during the day
  • Restless sleep
  • Excessive daytime sleepiness and irritability
  • Bedwetting
  • Behavioral problems
  • Learning problems

Obstructive events cause sleep fragmentation, which can cause excessive daytime sleepiness in older children and hyperactivity in younger children.1 For this reason, children with untreated OSA may be inappropriately diagnosed as having ADHD.1 Since OSA can significantly impact a child’s quality of life, early diagnosis of OSA is essential to encourage healthy development and nurture wellbeing.

Screening and Diagnosing 

A diagnosis of OSA must come from a sleep medicine physician, but dentists can help screen for OSA in children during routine hygiene exams.1,3 There are three main screening methods dentists can use to screen for OSA.4

First, a dentist can perform a physical examination focusing on the adenotonsillar tissue and jaws. Determining a patient’s Mallampati score provides an efficient way to evaluate a child’s risk of OSA. A Mallampati score of 2 and above is associated with an increased risk of OSA.8

Second, a dentist can give parents and patients a questionnaire to complete together. The Pediatric Sleep Questionnaire can be used as an adjunctive diagnostic tool, and its accuracy has been validated by multiple studies.

Third, dentists can interview parents and patients. Interviews provide more personal information and give you an opportunity to discuss how OSA can affect children.4 While these tests can help screen and facilitate a diagnosis, a polysomnogram remains the gold standard for OSA diagnosis.1

There are a variety of tests physicians and dentists can recommend to confirm OSA in a child. Tests may include one or a combination of the following:

  • Polysomnogram: Also known as an overnight sleep study, a polysomnogram uses sensors applied to the body to record oxygen levels, heart rate, muscle activity, and brain wave activity as a child sleeps.
  • At-home sleep test: Like a traditional sleep study, an at-home sleep test monitors one’s functioning throughout the night to provide important diagnostic information. For example, Vivos uses proprietary technology from SleepImage—which comes in the shape of a ring—to help diagnose OSA. Effective at-home sleep tests like SleepImage are shown to be as accurate as a polysomnogram.
  • Oximetry: This form of test monitors oxygen levels throughout the night to help make a diagnosis of OSA. However, these tests can fail to provide sufficient information to make a full diagnosis.
  • Electrocardiogram: An electrocardiogram is used to measure the impulses given off by a child’s heart. These are often used to help determine whether a child has an underlying heart condition.

Diagnosis of OSA is based on the apnea-hypopnea index (AHI), but the threshold is lower for children than in adults.1 Apnea occurs when there is breathing cessation, and hypopnea is a reduction in oxygen saturation.1 After conducting a polysomnogram, a sleep medicine doctor can make a positive diagnosis of OSA based on the presence of signs/symptoms with at least one obstructive respiratory event, mixed apnea, or hypopnea per hour of sleep.

Treatment Options 

An interdisciplinary approach is recommended when treating OSA in children. A team comprising a sleep medicine physician, otolaryngologist, pediatrician, orthodontist, and dentist is ideal. The American Academy of Pediatrics recommends a tonsillectomy as the first-line treatment for pediatric patients with adenotonsillar hypertrophy, and continuous positive airway pressure (CPAP) is recommended if a tonsillectomy can not be performed.7 Weight loss is recommended in addition to other therapy for patients who are overweight.7 Intranasal corticosteroids are an option for children with mild OSA.7

The American Association of Orthodontics recommends using rapid maxillary expansion (RME) to normalize maxillary transverse deficiencies and mandibular advancement devices (MADs) for class II malocclusion correction. Oral appliance therapy (OAT) has shown promising results for some pediatric patients, but clinical studies are still limited.8 Myofunctional therapy also has the potential to help some patients with pediatric OSA, and studies have found that myofunctional therapy reduces the severity of OSA.6 The goal for every type of treatment is to reduce or eliminate snoring, resolve the patient’s initial symptoms of OSA, normalize the AHI, and normalize the oxyhemoglobin saturation.3 Follow-up appointments and monitoring symptoms are essential after treatment.

Dentists can easily incorporate screening pediatric patients for OSA. Treating pediatric OSA patients requires a team of healthcare providers, including dentists. Additional sleep medicine training can increase your confidence and skills when screening for pediatric OSA.

To learn more about sleep medicine training opportunities for dentists, visit the Vivos Institute events page.

References
  1. American Academy of Pediatric Dentistry. Policy on obstructive sleep apnea (OSA). The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry; 2021:123-6.
  2. Al Ashry, H. S., Hilmisson, H., Ni, Y., Thomas, R. J., & APPLES Investigators. (2021). Automated apnea-hypopnea index from oximetry and spectral analysis of cardiopulmonary coupling. Annals of the American Thoracic Society, 18(5), 876–883. doi:10.1513/AnnalsATS.202005-510OC
  3. Behrents, R. G., Shelgikar, A. V., Conley, R. S., Flores-Mir, C., Hans, M., Levine, M., & Hittner, J. (2019). Obstructive sleep apnea and orthodontics: An American Association of Orthodontists White Paper. American Journal of Orthodontics and Dentofacial Orthopedics: Official Publication of the American Association of Orthodontists, Its Constituent Societies, and the American Board of Orthodontics, 156(1), 13-28.e1. doi:10.1016/j.ajodo.2019.04.009
  4. Chervin, R. D., Hedger, K., Dillon, J. E., & Pituch, K. J. (2000). Pediatric sleep questionnaire (PSQ): validity and reliability of scales for sleep-disordered breathing, snoring, sleepiness, and behavioral problems. Sleep Medicine, 1(1), 21–32. doi:10.1016/s1389-9457(99)00009-x
  5. Chiang, H. K., Reddy, N., Carrico, C., Best, A. M., & Leszczyszyn, D. J. (2017). The prevalence of pediatric dentists who screen for obstructive sleep apnea. Journal of Dental Sleep Medicine, 04(01), 5–10. doi:10.15331/jdsm.6416
  6. Aaron Glick, D. D. S. K. W. (2021, December 13). The dentist’s role in screening and treating pediatric obstructive sleep apnea. constituent. Retrieved May 24, 2022, from https://agd.org/constituent/news/2021/12/13/the-dentist-s-role-in-screening-and-treating-pediatric-obstructive-sleep-apnea 
  7. Marcus, C. L., Brooks, L. J., Draper, K. A., Gozal, D., Halbower, A. C., & Jones, J.American Academy of Pediatrics. (2012). Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics, 130(3), 576–584. doi:10.1542/peds.2012-1671
Stauffer, J., Okuji, D., Lichty, G., II, Bhattacharjee, R., Whyte, F., Miller, D., & Hussain, J. (2018). A review of pediatric obstructive sleep apnea and the role of the dentist. Journal of Dental Sleep Medicine, 5(4). doi:10.15331/jdsm.7046