Sleep-disordered breathing (SDB) encompasses a spectrum of conditions from habitual snoring to obstructive sleep apnea (OSA), each with potentially serious health consequences when left undiagnosed. Unlike the 2019 American Association of Orthodontists (AAO) white paper’s focus on OSA specifically, the updated 2026 document adopts broader terminology to reflect the full continuum of breathing disorders that orthodontists may encounter. As experts in monitoring craniofacial growth and development, orthodontists are uniquely positioned to both identify and manage patients with SDB, including OSA. , Frequent patient contact over long periods of treatment allows orthodontists to detect risk indicators that might otherwise go unnoticed, particularly during the developmental windows when SDB often emerges or evolves. Accordingly, this longitudinal relationship creates screening opportunities for appropriate patient care.
The primary role of the orthodontist in the context of SDB is screening, not diagnosis. This screening process involves reviewing medical history, performing clinical examinations of the oral cavity and pharyngeal structures, and using validated questionnaires, such as the Pediatric Sleep Questionnaire for children and the STOP-Bang questionnaire for adults. , These tools help orthodontists systematically identify patients requiring further evaluation and naturally align with routine orthodontic assessment, which includes tonsillar size, tongue position, palatal dimensions, and other craniofacial morphology. Once risk factors are identified, the next step is referral to a specialist, as the final diagnosis of OSA or other SDBs is a medical decision made by a physician. It is outside the orthodontist’s scope of practice to diagnose a medical condition based solely on dental exams or imaging, and exceeding these boundaries places practitioners at a considerable medico-legal risk. ,
As outlined in the 2026 white paper, the AAO cautions against diagnosing SDB based on cone-beam computed tomography (CBCT) or lateral cephalometric radiographs. Although CBCT and lateral cephalograms excel at visualizing hard tissue anatomy, they are not recommended for diagnosing SDB or assessing airway risk, as these imaging modalities capture static anatomy in awake, upright patients, whereas SDB results from dynamic airway collapse during sleep when muscular tone diminishes. , The airway that appears patent on daytime imaging may obstruct completely during sleep. Volume measurements and dimensional analyses, though numerically precise, fail to predict functional behavior during sleep. Thus, upper airway imaging with CBCT or lateral cephalograms has no diagnostic value for assessing SDB risk or diagnosis. Polysomnography combined with clinical symptom assessments remains the gold standard.
After a physician’s diagnosis, orthodontists can intervene with adjunctive therapy, such as rapid maxillary expansion (RME) or mandibular advancement devices. These treatments should be based on clear orthodontic indications, such as transverse maxillary deficiency, or on specific physician prescriptions to assist with airway management. , For example, a patient with maxillary transverse deficiency and diagnosed OSA presents a scenario in which RME addresses both the skeletal discrepancy and potentially improves the airway. However, current evidence does not support the use of expansion or functional appliances as prophylactic measures for SDB in patients without underlying skeletal discrepancies. Treatment decisions should rest primarily on skeletal abnormalities, with airway benefits considered secondary outcomes. Similarly, for adult patients, mandibular advancement devices prescribed by physicians require careful fabrication, titration, and monitoring, whereas orthodontists are uniquely qualified to manage the predictable occlusal changes that result from long-term use of the devices.
One important topic that is repeatedly brought up and addressed in the updated white paper is the misconception that orthodontic treatment causes SDB. Current evidence does not support that traditional orthodontic mechanics or appliances, such as extraction space closure or headgear, affect the etiology or increase the likelihood of SDB. , Large retrospective studies examining thousands of patients found no association between extraction treatment and subsequent sleep apnea diagnosis. Comparable concerns about headgear therapy compromising airways lack evidential support. Similarly, current evidence does not support ankyloglossia as a cause of SDB, and routine frenectomy is not recommended for SDB prevention or treatment. Multiple professional organizations, including the American Academy of Otolaryngology-Head and Neck Surgery and the American Academy of Pediatrics, have reached consistent conclusions. Orthodontists should provide patients with evidence-based information to counter widespread misinformation on these topics.
For pediatric patients, the most effective treatment involves interdisciplinary collaboration, meaning that orthodontists should communicate directly and responsibly with sleep physicians, otolaryngologists, and other professionals to safeguard patients’ overall health. Considering the potential for natural remission of childhood SDB during growth phases, physician involvement in determining when intervention is appropriate becomes more critical. In addition, children with SDB often present with adenotonsillar hypertrophy requiring surgical intervention before or concurrent with orthodontic treatment. The updated white paper notes that although RME combined with adenotonsillectomy shows greater apnea-hypopnea index reduction than RME alone, adenotonsillectomy produces a more significant reduction in apnea-hypopnea index than RME. These findings reinforce that orthodontic interventions support rather than replace medical treatments.
Upholding the scope of practice and providing clear patient education are crucial for ensuring that clinical practice aligns with medico-legal standards. Although orthodontists should explain the potential impact of orthodontic treatments on SDB to their patients, overstating that such treatments guarantee resolution, or initiating them without a medical diagnosis, can expose practitioners to significant legal risk under state medical and dental practice acts. , Patients must be clearly informed about the current level of evidence, expected outcomes, treatment limitations, and the absolute necessity of physician diagnosis. When orthodontic treatment improves diagnosed SDB, outcomes should be verified through physician-ordered sleep studies rather than relying solely on subjective improvement.
Orthodontists stand at the forefront of SDB screening due to their specialized knowledge and long-standing patient relationships. Successful management of SDB relies on a cohesive, interdisciplinary model facilitated by effective screening, appropriate referral, intervention, and collaboration with medical colleagues. By embracing our role as screening specialists and collaborative partners, rather than independent diagnosticians, orthodontists can make meaningful contributions to addressing the significant public health challenge posed by SDB.
Moving forward, comprehensive education on SDB should become a standard competency for all orthodontists, emphasizing both the specialty’s contributions and its limitations. By adhering to evidence-based principles and professional boundaries, the orthodontic community can meaningfully contribute to the care of patients with SDB while maintaining the highest standards of care.
The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest, and none were reported.
Given his role as Editor-in-Chief, Jae Hyun Park, DMD, MSD, MS, PhD, ABO-Board Certified, had no involvement in the peer review of this article and has no access to information regarding its peer review.
References
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