Sleep apnea in pediatric and adolescent patients
Sleep apnea is often thought of as a disorder found only in adults. Research reveals that children can also suffer from sleep apnea, and if left undiagnosed, it can lead to problems with oral development. Approximately seven to nine million children suffer from pediatric obstructive sleep apnea (POSA) and suffer from sleep disordered breathing (SDB).1 Indications of obstructive sleep apnea (OSA) in children are partial and/or complete blockage of the upper airways, usually caused by adenotonsillar hypertrophy or enlarged tonsils.2
Research has shown that most cases in children and adolescents go unnoticed by parents or guardians. There is a direct correlation between POSA/SDB and the development of oral structures and speech and language outcomes in pediatric and adolescent patients. Early detection of POSA and SDB by dentists and a multidisciplinary team (physicians, orthodontists and other health care providers) can improve oral structural development in pediatric and adolescent patients who, if left untreated , could contribute to other health-related complications. The American Academy of Pediatric Dentistry lists common signs and symptoms of OSA in children as loud snoring three or more nights a week, mouth breathing, and waking up with a dry mouth or sore throat.3
Prevalence by sex and race
The highest prevalence of POSA and SDB cases is found in children aged 3 to 5 years.1 Unlike adults, both sexes are equally affected; however, after puberty POSA/SDB tends to be predominant in males. Because African American children have a steeper mandibular plane angle and steeper anterior cranial base inclination, they are at greater risk for POSA/SDB than Caucasians and Hispanics of age and mass index (BMI) similar.1
Childhood obesity is a risk factor for POSA/SDB and a growing concern. Obesity and POSA/SDB share many similar complications. Maintaining a healthy weight decreases factors that contribute to POSA/SDB. As BMI increases, the risk of POSA/SDB also increases.4 For each increase in BMI of one kg/m, the risk of POSA increases by 12%.1
Waiting to Exhale: Managing Sleep Apnea in the Pediatric Dental Patient
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Premature infants have features such as narrow arched and vaulted palates, which lead to a higher risk of POSA/SDB during childhood. About 50% to 80% of children with Down syndrome have POSA/SBD due to an enlargement of the tongue called macroglossia.1
Neurocognitive and neurobehavioral outcomes
Sleep bruxism (SB) is considered a parasomnia, which is a form of neurocognitive disorder. There has been a disparity of information linking bruxism to POSA/SDB.4 However, there is a high prevalence of patients reporting sleep bruxism when diagnosed with POSA/SDB. Studies have shown that around 14-17% of children grind their teeth while they sleep.5 Research revealed in a sleep clinical trial has shown that up to half of pediatric and adolescent patients diagnosed with POSA/SDB suffer from sleep bruxism.1
Malocclusion occurs when there is a misalignment or mismatch of the upper and lower teeth when closing the jaw. This disorder is usually detected by a dentist or dental hygienist and corrected by an orthodontist. SDB is associated with orofacial and dentofacial features related to malocclusion.6 Retrognathia is a risk factor for SDB because it obstructs the upper airways of the throat. Parents may be unaware of malocclusion and retrognathia and rarely report this disorder during primary care appointments. Routine dental appointments are necessary to detect SDB and with the goal of reducing the underdiagnosis of SDB and hopefully preventing long-term adverse effects.
Timing of diagnosis/treatment and solutions
Early detection of POSA/SDB is essential. Late diagnosis and treatment could delay verbal skills. Phonetic sounds are acquired from 3 to 6 years.seven This age range also corresponds to enlarged (enlarged) tonsils, which is a risk factor for POSA/SDB.8 The most common underlying condition for POSA/SDB is enlarged adenoids and tonsils.1 Due to the anatomy, dentists and dental hygienists are most likely to identify this abnormality and order additional testing for the diagnosis of POSA/SDB. Proper diagnosis to confirm POSA/SDB consists of a history and physical assessment of nocturnal and daytime behaviors, physical examination of the face and neck, upper airway assessment, home monitoring, and polysomnography test (PSG ).
PSG has been suggested as the gold standard for diagnosing POSA/SDB in children and adolescents.2 The POSA/SDB study is still evolving, with new treatment options emerging. Doctors continue to watch for innovative treatments that will replace invasive treatments such as tonsillectomy and adenoidectomy (TA). Since obesity is the second most common cause of POSA/SDB, weight reduction is a common nonsurgical recommendation for these patients.1 The most common non-surgical treatment options include continuous positive airway pressure (CPAP), myofunctional therapy and, if indicated, maxillary expansion, as well as other dental/orthodontic treatments.9
Although research indicates that seven to nine million pediatric and adolescent patients are affected by sleep apnea,1 it is feared that many children remain undiagnosed. Dentists and dental hygienists should familiarize themselves with the signs and symptoms of POSA/SDB to screen and clinically assess patients for referral to a specialist physician.
Editor’s note: This article appeared in the July 2022 print edition of HDR magazine. Dental hygienists in North America are eligible for a free print subscription. Register here.
- Stauffer J, Okuji DM, Lichty II GC, et al. A review of pediatric obstructive sleep apnea and the role of the dentist. J Dent Medical Sleep. 2018;5(4):111-130. org/10.15331/jdsm.7046
- Mohammed D, Park V, Bogaardt H, Docking K. The impact of childhood obstructive sleep apnea on speech and oral language development: a systematic review. Sleep Med. 2021;81(5):144-153. doi:10.1016/j.sleep.2021.02.015
- Obstructive sleep apnea policy. The reference manual of pediatric dentistry. Chicago, IL: American Academy of Pediatric Dentistry. 2021:123-126. https://www.aapd.org/media/Policies_Guidelines/P_SleepApnea.pdf
- Kuehne CA. Bruxism, obstructive sleep apnea and dentistry. J Calif Dent Assoc. 2020;48(4):195-197. https://www.cda.org/Portals/0/journal/journal_042020.pdf
- Children who grind their teeth are more likely to have problems at school, to be distant from others. American Academy of Sleep Medicine. Updated November 5, 2017. https://aasm.org/children-who-grind-their-teeth-are-more-likely-to-have-problems-in-school-be-withdrawn-from-others/
- Lyra MCA, Aguiar D, Paiva M, et al. Prevalence of sleep-disordered breathing and associations with malocclusion in children. J Clin Sleep Med. 2020;15(7):16. org/10.5664/jcsm.8370
- Speech sound development chart. Sense of the child. https://childdevelopment.com.au/resources/child-development-charts/speech-sounds-developmental-chart/
- De Castro Correa C, Cavalheiro M, Maxinino L. et al. Sleep apnea and oral language disorders. Brazilian J Otorhinolaryngol. 2017;83(2):98-104. https://www.sciencedirect.com/science/article/pii/S1808869416300659
- Cielo CM, Gungor A. Treatment options for pediatric obstructive sleep apnea. Curr Probl Pediatr Adolesc Health Care. 2016;46(1):27-33. doi:10.1016/j.cppeds.2015.10.006