Obstructive sleep apnea and early orthodontic intervention: How early is early?

Highlights

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Obstructive sleep apnea (OSA) is a condition that has health implications for people of all ages who are undiagnosed and not receiving the appropriate and necessary treatment.
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There is growing controversy that OSA needs to be assessed and managed orthodontically in children aged 2-3 years.
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Routine expansion and/or growth modification is not an evidence-based means of improving or curing OSA in children.
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There is little to no evidence to support expansion and/or growth modification to improve a child’s OSA or prevent a child from developing OSA.

It appears that the debate regarding the role of the orthodontist in assessing and managing patients with obstructive sleep apnea (OSA) has become more controversial and contentious, especially after the recent American Association of Orthodontists (AAO) conference in Chicago in May 2023.

The controversy revolves around the key issue of early orthodontic intervention for OSA in pediatric patients. Some speakers highlighted the need for early orthopedic maxillary expansion, early myofunctional therapy, and growth modification to improve OSA signs and symptoms or to prevent their occurrence later in young patients as early as 3 years old.

In November 2017, the AAO identified that there was a need to address the growing controversy regarding the role of orthodontists with patients with OSA. As a result, a panel of dental and medical experts convened to create a document to serve as an evidence-based guide for clinicians. In May 2019, the AAO released this document as a White Paper, which today still serves as a reasonable guide for clinicians to follow around the world. A more expanded clinical perspective on this topic was later published by Kandasamy in 2019.

Despite multiple publications in our literature proposing a conservative approach, more recently, there has been increasing advocacy for early orthodontic intervention for OSA by certain groups and/or self-appointed experts. Early intervention treatments range from promoting nasal breathing, postural correction, midface advancement, slow or rapid maxillary expansion, unlocking deep overbites and growing mandibles, adenotonsillectomy, and myofunctional therapy in children as young as 2-3 years old. As a result of this latest controversy, I was asked to put into perspective the current state of OSA and early orthodontic intervention.

The consequences of OSA in any age group are real, and this definitely needs proper attention, assessment, and appropriate patient-specific management. OSA in the pediatric population has been shown to lead to cognitive and social impairment, behavioral and mood disturbances, impaired growth, and obesity. It also has been reported to cause cardiovascular complications, initially starting as increased blood pressure. When left untreated in children, OSA may progress into adulthood, increasing the risk of diabetes, coronary artery disease, congestive heart failure, myocardial infarction, hypertension, cardiac arrhythmia, and stroke. ^, The prevalence of OSA in the general pediatric population ranges from 1.2%-5.7%. While there may be health risks associated with untreated OSA in children, there is little substantiated evidence to suggest that expansion and growth modification will mitigate these risks. Accordingly, where is the benefit in recommending parents to bring their children in for treatment as early as 2-3 years of age?

The treatments that are mostly talked about are maxillary expansion and orthopedic advancement/growth of the maxilla and/or mandible to increase airway space to prevent or cure childhood OSA. Interestingly, these early treatment modalities also conveniently happen to be financially lucrative to anyone keen on embracing this newfound means of income, self-promotion, and practice growth. This is perhaps the real reason why it has become so popular today despite the lack of data to support such treatments for OSA. Have we not seen this before with self-ligating brackets, temporomandibular disorders, third molar extractions, maxillary expansion, and functional appliances, to name a few? Is it really ethical to financially benefit from the unsupported so-called benefits of expansion and growth modification for OSA while masquerading as a clinician primarily concerned about the short- and long-term mental and systemic health consequences of childhood OSA?

Some orthopedic maxillary expansion studies have shown a significant improvement in the apnea-hypopnea index scores in children with sleep apnea after rapid maxillary expansion. ^, As a result, these authors have advocated rapid maxillary expansion before adenotonsillectomy in children, as this may reduce the need for adenotonsillectomy after expansion in a large proportion of patients. According to the inclusion criteria, it would appear that maxillary expansion might have been carried out in many patients without the presence of a posterior crossbite in those studies. Instead, expansion was prescribed because of the presence of a high palatal vault and narrow maxillary arch related to the contraction of the maxilla at its base. ^, What does appearing to be narrow even mean? Narrow to the naked eye or some generic intermolar width? Furthermore, the amount of expansion varied, and little to no attention was paid to the skeletal and dental malocclusion, including the vertical facial patterns of the subjects. Thus, if there is no bilateral or unilateral posterior crossbite, any expansion will result in creating a buccal scissor bite relationship or overexpansion of the posterior maxillary teeth. This will result in unnecessary extrusion of the overexpanded maxillary posterior teeth and lingual tipping of the opposing mandibular posterior teeth in the long term, as well as all the unwanted bite opening and dentoalveolar compensations, including asymmetries. To avoid this, the clinician will need to then transversely expand the mandibular posterior teeth, which we know is limiting and unstable if not retained on the long term, to accommodate the newly overexpanded maxillary arch. How is it even justifiable or even practical from a patient management perspective to carry out all of these procedures at the age of 2-3 years and then have this expansion maintained over many years in a large cohort of children when we cannot predict which children will actually develop OSA in later years?

As a result of this controversy regarding early expansion and/or growth modification for OSA, there has been a call for better research, including randomized controlled trials, to investigate these incredible claims. Carrying out these studies will take a significant amount of time, collaboration, and financial aid. Considering the invasiveness and cost of the proposed procedures, how many children are going to be subjected to treatments that ultimately may not make any difference to their breathing and sleeping lives in the long term?

In addition, do we not already know enough about our inability to grow mandibles? Interestingly, an exceptionally small mandible associated with Pierre Robin syndrome is commonly referred to as the key example of why a small mandible obstructs the posterior airway. As a result of this extreme syndromic example, many self-recognized experts have extrapolated that all the less-than-normally-sized mandibles now need to be grown to increase the posterior airway space. Randomized controlled trials carried out almost 20 years ago have shown us that the mandible is going to grow to where it is going to grow. Despite the significant amount of information in the literature supporting not exposing children to acrylic poisoning and/or subjecting children to forward mandibular posturing early in life to grow mandibles, functional appliance therapy is still a common practice around the world. Can we not see the same thing happening here again with OSA in children? Do all people with retruded mandibles suffer from OSA? No, it is more complicated than that.

Furthermore, has anyone not seen the practicality associated with orthodontically assessing and treating a child for OSA as young as 2-3 years? Are these children coughing and gasping for air in bed every night that they need orthodontic intervention at 2-3 years of age? If these children are in such a state, no amount of orthodontic intervention is going to help or cure their OSA signs and symptoms. In fact, they will require medical attention immediately. Would it not be better, and more in line with the AAO White Paper’s guidelines, for such treatments to be carried out when these children are much older? Even if we do wait for those more appropriate age groups to receive the treatments being discussed here, we know that orthodontic intervention such as expansion and growth modification for OSA is not definitive, and there is no long-term data to support these treatment modalities as being effective for OSA. Thus, should we be subjecting very young children to any of this? Should we be using these treatment modalities like vaccinations to prevent young children from developing OSA? The answer is clearly no.

Currently, the AAO recommends that children be screened by an orthodontist around 7 years old for any dental and skeletal issues. What does this new version of early orthodontic OSA assessment and management actually require orthodontists to do? Should orthodontists now start assessing children as young as 2 years old? If so, what are they supposed to be assessing, and how? Are they meant to assess a child’s respiratory function, issues with snoring frequency, difficulty with breathing during sleep, mouth breathing, observed apneas, daytime sleepiness, and irritability? If they crudely identify any sleep issues chairside, are they expected to assume then that the presence of various anatomic phenomena such as a maxillary transverse discrepancy, a smaller than “normal” mandible, a retruded maxilla, abnormal tongue posture, chewing or swallowing, or a long face is the cause? In contrast, the literature shows that OSA occurs as a complex interplay between anatomic and nonanatomic factors. It is not appropriate to simply look at a specific craniofacial morphologic characteristic and assume someone exhibits or will later develop OSA. It is more complicated than this.

It is accepted today that orthodontists should screen for any obvious OSA signs and symptoms. This makes sense. If an orthodontist detects a problem, then making the necessary referral to the appropriate medical practitioner would be indicated. However, what if we do not? Is there a childhood OSA health crisis requiring orthodontic intervention unbeknownst to the medical specialty, such that it is now the orthodontist’s responsibility to get children in and treat them as early as 2-3 years old?

There is not enough evidence currently to even consider following this new line of thinking about early interventions. In addition, there is certainly little to no quality evidence when it comes to advocating nasal vs mouth breathing, postural correction, and myofunctional therapy routinely for OSA in children as young as 3 years old. The burden of responsibility should lie on the shoulders of those people both within and outside of our specialty, advocating a shift in our specialty’s responsibilities and this type of management. We cannot misinform the public and scare families into believing that their children will develop all these conditions from a morphologic problem that they potentially may not have. Furthermore, we do not want our patients to believe that these early treatments are capable of effectively managing these problems when the evidence clearly does not even support this.

If our colleagues want to play medical doctor, then they should consider going to medical school. If our colleagues want to carry out orthodontic treatment to treat medical problems on the basis of anecdotal claims and beliefs unsubstantiated by the evidence, such as expansion and growth modification at all costs, then this is not only unethical but grossly misleading to the public. To expect a significant paradigm shift in the way patients are to be treated requires more than hands-on experience, biased limited research, and basic rationalism. Our expectations as a specialty collectively need to be raised, and the way we interpret new information needs to be more rigorous and critical. Our specialty, our patients, and our future deserve better.

Author credit statement

Sanjivan Kandasamy contributed to conceptualization, data curation, formal analysis, investigation, validation, visualization, original draft preparation, and manuscript review and editing.

All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest, and none were reported.