Introduction
Pediatric sleep-disordered breathing (SDB) describes a spectrum of disease ranging from snoring to upper airway resistance syndrome and obstructive sleep apnea (OSA). Anatomical features assessed during orthodontic exams are often associated with symptoms of SDB in children. Hence, we need to determine the prevalence of positive risk for SDB in the pediatric orthodontic population compared with a general pediatric population and understand comorbidities associated with SDB risk among orthodontic patients.
Methods
Responses from Pediatric Sleep Questionnaires were collected from 390 patients between the ages of 5 and 16 years, seeking orthodontic treatment. Prevalence of overall SDB risk, habitual snoring, and sleepiness were determined in the orthodontic population and compared with those previously reported by identical methods in the general pediatric population. Additional health history information was used to assess comorbidities associated with SDB risk in 130 of the patients.
Results
At 10.8%, the prevalence of positive SDB risk was found to be significantly higher in the general pediatric orthodontic population than in a healthy pediatric population (5%). The prevalence of snoring and sleepiness in the orthodontic population was 13.3% and 17.9%, respectively. Among the comorbidities, nocturnal enuresis (13.6%), overweight (18.2%), and attention deficit hyperactivity disorder (31.8%) had a higher prevalence in orthodontic patients with higher SDB risk ( P < 0.05).
Conclusions
There is a higher pediatric SDB risk prevalence in the orthodontic population compared with a healthy pediatric population. Orthodontic practitioners should make SDB screening a routine part of their clinical practice.
Highlights
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The prevalence of pediatric sleep-disordered breathing (SDB) risk was 10.8% in an orthodontic population.
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Pediatric SDB risk was higher in the orthodontic population than in a healthy population.
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A subtype of SDB patients may only be seen at orthodontic clinics.
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Nocturnal enuresis, attention deficit hyperactivity disorder, and overweight were higher in patients with high SDB risk.
Pediatric sleep-disordered breathing (SDB) encompasses a broad spectrum of disease complex that includes snoring, upper airway resistance syndrome, and obstructive sleep apnea (OSA). Habitual snoring and OSA are the most noted symptoms of SDB in children and have been associated with neurocognitive and behavioral impairments, including deficits in memory, attention, social interactions, and overall cognitive performance. , The prevalence of pediatric OSA is estimated at 1%-4%, and the prevalence of SDB and habitual snoring are estimated at 4%-11% and 1.5%-14.8%, respectively. These findings are mainly because of the wide variety of methodology that different studies have used in diagnosing OSA and SDB, including overnight polysomnography (PSG), home cardiorespiratory sleep study, and various self-reported and parent-reported questionnaires. Currently, PSG is considered the gold standard for SDB diagnosis because it monitors various physiological parameters related to sleep and wakefulness. However, the time, effort, and expense of the procedure have limited many experimental and epidemiological studies from using it as a means of assessment. For clinicians, recognizing the prevalence of SDB and its associated symptoms in their target population can prompt a more regular, thorough, and individualized screening and determine the possible need for an additional diagnostic workup.
Pediatric SDB is most commonly associated with enlarged tonsil and adenoids. In addition, factors such as obesity, upper airway inflammation (such as asthma and allergic rhinitis), and altered neurological reflexes involving muscles of the upper airway (such as cerebral palsy) and neuromuscular disorders can lead to SDB symptoms. , Other risk factors reportedly associated with pediatric SDB include preterm birth, nocturnal enuresis, and African American descent. Craniofacial disharmony is also associated with pediatric SDB. Anatomical and craniofacial features that have been linked with upper airway narrowing and SDB in children include macroglossia, midface hypoplasia, mandibular and maxillary retrognathia, maxillary constriction, short cranial base length, increased total and lower anterior facial heights, and a more anterior and inferior position of the hyoid bone. , These anatomical features are clinically and radiographically assessed during a routine orthodontic exam, and in some cases, can be the target of orthodontic treatment. Thus, understanding the presence and prevalence of SDB, its associated symptoms, and potential risk factors in the orthodontic population can help practitioners make timely decisions regarding treatment options and necessary referrals.
Most studies that have examined the prevalence of SDB in the orthodontic population have mainly focused on snoring as the criteria of assessment. Snoring prevalence in the orthodontic population has been variable in the literature, with 1 article reporting that 10.8% of patients “usually snore,” and 2.9% “always snore,” with a reported prevalence of 1.8% for apneas. Other articles have reported that 17% of the orthodontic patients “often snore,” and others have reported that up to 53% of the orthodontic population snores; this was attributed to a lack of question specificity. The use of various nonvalidated questionnaires, with different definitions of “habitual snoring,” has resulted in a wide range of reported snoring prevalence in the orthodontic population, which is difficult to compare with the general pediatric population. A thesis study that looked at the overall risk of SDB in the orthodontic population reported a prevalence of 18%. However, this study only looked at 100 patients who were receiving orthodontic treatment at the University of North Carolina Orthodontic Department and was therefore subject to selection bias. Another more recent study that evaluated the prevalence of high SDB risk in an orthodontic population, reported a prevalence of 7.3% in a sample of 303 subjects selected from a single site.
The current study aimed to determine the prevalence of positive risk for SDB in the pediatric orthodontic population using a large and varied sample selected from various clinics in Alberta, Canada. A validated questionnaire for SBD using PSG was used, and the results were compared with the general pediatric population. The prevalence of specific comorbidities and environmental conditions among the high- and low-risk SDB subjects in a subpopulation of our sample was also evaluated.
Material and methods
Ethics approval was obtained from the University of Alberta’s Health Research Ethics Board. Data was collected from 390 patients who were between the ages of 5 and 16 years and were seeking orthodontic treatment at the University of Alberta clinic and 9 other private practices in Alberta ( Table I ). The age range was determined by the research team, which included 2 orthodontists, an orthodontic resident, and a pediatric sleep specialist, and was meant to be inclusive of the typical pediatric population seeking orthodontic treatment. The inclusion criteria included the patient’s age (range, 5-16 years), patients seeking orthodontic treatment, and completion of the Pediatric Sleep Questionnaires (PSQ). The patients either had already completed the PSQ as a routine part of their initial orthodontic records by their treating clinician or were asked to fill out a questionnaire during their initial records appointment. The number of patients who were recruited prospectively (n = 130) were limited by their continual recruitment over 11 months. All patients completed the appropriate consent forms and were asked to complete an additional health history questionnaire.
| University of Alberta | Private practice in Calgary (n = 1) | Private practices in Edmonton (n = 8) | |
|---|---|---|---|
| No. of patients (n = 390) | 37 | 259 | 94 |
| No. of males (n = 173) | 21 | 114 | 38 |
| No. of females (n = 217) | 16 | 145 | 56 |
| Average age (10.3 ± 2.6) | 12.5 ± 1.7 | 9.4 ± 2.4 | 11.5 ± 1.8 |
In this study, PSQ was used to assess the risk of SBD, because it is generally considered the best currently available and validated screening method for SDB. This questionnaire has been validated against overnight polysomnogram and multiple sleep latency tests for determining SBD and sleepiness in children. This 22-item questionnaire contained questions on snoring frequency, loud snoring, observed apneas, difficulty breathing, daytime sleepiness, and inattentive and hyperactive behavior. Possible responses were “yes” (1), “no” (0), and “I don’t know” (missing item). The score was calculated by determining the mean response on nonmissing items. In the development of the PSQ, the authors noted to have reduced responses to the yes/no format and scoring responses such as “applies quite a bit” and “definitely applies most of the time” as a “yes” response. In addition, epidemiological studies have used snoring for more than 3 nights per week as a positive response. In our study, when subjects had written “sometimes” (33 subjects), it was considered a positive response. The optimal cutoff score to indicate the presence of SDB has been suggested to be 0.33 (33% positive responses), with higher values indicating a positive diagnosis. Thus, for our study, any patient scoring positive on 33% or more on the questionnaire was categorized as having a high risk for SDB. Frequency of patients with habitual snoring (defined as snoring more than half the time while asleep, on the basis of the PSQ question) and excessive daytime sleepiness (defined as presence of 2 or more symptoms of the 4 sleepiness items in the PSQ) were also assessed as per Archbold et al. The treating practitioners were responsible for providing follow-up care and any necessary referrals for any patients identified as having a high risk.
An additional health history questionnaire was formulated by the research team on the basis of the known associated health and environmental factors related to pediatric SDB and was modeled after the University of Alberta’s Interdisciplinary Airway Research Clinic checklist for identifying pediatric SBD ( Supplementary Fig ). This additional questionnaire was given prospectively to 130 patients and their parents to assess the presence of additional pre-existing symptoms and conditions. These included the presence or absence of nocturnal enuresis, attention deficit hyperactivity disorder (ADHD), gastroesophageal reflux disease (GERD), asthma, environmental allergies, indoor pets, smoking environment, preterm labor and birth, family history of sleep apnea, and being overweight.
Among the 130 patients who completed the additional health questionnaire, SDB risk was separately assessed, once on the entire population and again on a subpopulation not experiencing gastrointestinal or respiratory problems (asthma, GERD, environmental allergies), to evaluate how much these conditions the prevalence of SDB in our orthodontic population.
Statistical analysis
PSQ responses were collected from 390 patients and were quantified based on total score, habitual snoring, and sleepiness. The responses were then compared with the same categorical responses collected from general pediatric clinics by Archbold et al. A subset of our sample (n = 130) were assessed for conditions based on the added health questionnaire, and the results were compared between patients in the high-risk and low-risk SDB groups. These findings were used to identify if certain conditions were significantly affected by the prevalence of high SDB risk in our orthodontic sample.
A chi-square test was used to assess significant differences between the frequency of SDB symptoms in our orthodontic sample vs the general pediatric population as reported by Archbold et al. Fisher exact test was used to compare the presence and absence of certain health and environmental conditions among the high-risk vs low-risk groups in our sample. SPSS software (version 22.0; IBM, Armonk, NY) was used to carry out all analyses. Statistical significance was set at P ≤ 0.05.
Results
Our collected sample of 390 patients was comprised of 173 (44%) male patients and 217 female patients (56%). The average age (±standard deviation) of our sample was 10.3 ± 2.6 years, with an age range of 5-16 years. In addition, the sample consisted of 74 patients in the age range of 5-7 years, 119 patients in the age range of 8-10 years, 156 patients in the age range of 11-13 years, and 41 patients in the age range of 14-16 years. Of the 390 patients, 37 were from the university setting, and the rest were from various private practices in Alberta ( Table I ).
A score suggestive of a high risk for SDB (≥0.33) was found in 22 of 130 (16.9%) patients who completed the additional health history questionnaire and in 17 of 105 (16.2%) patients when those with respiratory and/or gastrointestinal conditions were removed from the sample ( Fig 1 ). Because these conditions did not have a significant effect on the prevalence of SDB in one-third of the orthodontic population, we assumed that these conditions had little effect on our remaining sample. Among our total sample (n = 390), 42 of 390 (10.8%) patients had a PSQ score suggestive of a high risk for SDB. Habitual snoring, defined as snoring more than half the time while sleeping, was present in 52 of 390 (13.3%) of patients, and sleepiness was present in 70 of 390 (17.9%) patients. The noted prevalence and their sex and age distribution are outlined in Table II .
| Sex distribution | Age distribution | ||||||
|---|---|---|---|---|---|---|---|
| Patients (N = 390) | Males (n = 173) | Females (n = 217) | 5-7 y old (n = 74) | 8-10 y old (n = 119) | 11-13 y old (n = 156) | 14-16 y old (n = 41) | |
| PSQ (score ≥ 0.33) | 42 (10.8%) | 21 (12.1%) | 21 (9.7%) | 3 (4.1%) | 13 (10.9%) | 22 (14.1%) | 4 (9.8%) |
| Snores (more than half the time) | 52 (13.3%) | 20 (11.6%) | 32 (14.7%) | 11 (14.9%) | 18 (15.1%) | 21 (13.5%) | 2 (4.9%) |
| Sleepiness (≥2) | 70 (17.9%) | 36 (20.8%) | 34 (15.7%) | 8 (10.8%) ∗ | 14 (11.8%) | 36 (23.1%) | 12 (29.3%) ∗ |
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