Assessment of the risk of sleep-related breathing disorders in young orthodontic population (6–14 years old) in Southern Italy

Background: Sleep-Related Breathing Disorders is characterized by prolonged upper airway obstruction during sleep. The present study aimed to assess the frequency of Sleep-Related Breathing Disorders in the pediatric orthodontic cohort representative of the Southern Italy population, and to evaluate the prevalence of the type of malocclusion in subjects resulting at risk of Sleep-Related Breathing Disorders. Methods: The study sample comprised 364 children, aged 6–14 years who referred to the Department of Orthodontics and Pediatric Dentistry of the University of Catania for orthodontic treatment. Parents were requested to self-administer the Pediatric Sleep Questionnaire questionnaire (PSQ) through Quick Response (QR) code using Google Forms™ before the orthodontic consultation. Subjects who were at high risk of Sleep-Related Breathing Disorders were retrospectively screened for skeletal malocclusion and craniofacial morphologic characteristics. Data were recorded along with cephalometric parameters describing sagittal and vertical skeletal growth pattern and were statistically analyzed using chi-square tests. Results: Within the overall sample, 9.89% of the children were at high risk for Sleep-Related Breathing Disorders. Younger children (6–9 years old) were more prone than older children (11–14 years old) to the risk of developing Sleep-Related Breathing Disorders (13.74% vs. 7.76%). Boys were significantly at a higher risk for Sleep-Related Breathing Disorders than girls, in particular at younger age. There were no questions that could differentiate a child considered to be at high risk of Sleep-Related Breathing Disorders. Conclusions: The present findings would suggest the importance of conducting screenings for Sleep-Related Breathing Disorders in young orthodontic patients and to address individuals identified as high-risk to the sleep-related breathing disorders (SRBD) specialists for additional assessment and treatment.

Obstructive sleep apnoea syndrome; Paediatric sleep questionnaire; Sleep breathing disorder; OSA; OSAS

[1] DelRosso LM, Picchietti DL, Spruyt K, Bruni O, Garcia-Borreguero D, Kotagal S, et al. Restless sleep in children: a systematic review. Sleep Medicine Reviews. 2021; 56: 101406.

[2] Smith DF, Amin RS. OSA and cardiovascular risk in pediatrics. Chest. 2019; 156: 402–413.

[3] Alsubie HS, BaHammam AS. Obstructive sleep apnoea: children are not little adults. Paediatric Respiratory Reviews. 2017; 21: 72–79.

[4] Lo Bue A, Salvaggio A, Insalaco G. Obstructive sleep apnea in developmental age. A narrative review. European Journal of Pediatrics. 2020; 179: 357–365.

[5] Operto FF, Precenzano F, Bitetti I, Lanzara V, Fontana ML, Pastorino GMG, et al. Emotional intelligence in children with severe sleep-related breathing disorders. Behavioural Neurology. 2019; 2019: 6530539.

[6] Flores-Mir C, Korayem M, Heo G, Witmans M, Major MP, Major PW. Craniofacial morphological characteristics in children with obstructive sleep apnea syndrome: a systematic review and meta-analysis. The Journal of the American Dental Association. 2013; 144: 269–277.

[7] Galeotti A, Festa P, Viarani V, D’Antò V, Sitzia E, Piga S, et al. Prevalence of malocclusion in children with obstructive sleep apnoea. Orthodontics & Craniofacial Research. 2018; 21: 242–247.

[8] Karpinski AC, Scullin MH, Montgomery-Downs HE. Risk for sleep-disordered breathing and executive function in preschoolers. Sleep Medicine. 2008; 9: 418–424.

[9] Ezeugwu VE, Adamko D, van Eeden C, Dubeau A, Turvey SE, Moraes TJ, et al. Development of a predictive algorithm to identify pre-school children at risk for behavior changes associated with sleep-related breathing disorders. Sleep Medicine. 2022; 100: 472–478.

[10] Blumer S, Eli I, Kaminsky-Kurtz S, Shreiber-Fridman Y, Dolev E, Emodi-Perlman A. Sleep-related breathing disorders in children-red flags in pediatric care. Journal of Clinical Medicine. 2022; 11: 5570.

[11] Bilgin N, Ozdogan S, Kaya A, Yildirmak Y. Sleep-related breathing disorders in children with asthma: impact on asthma control. Journal of College of Physicians and Surgeons Pakistan. 2022; 32: 473–477.

[12] Gerdung CA, Castro-Codesal ML, Nettel-Aguirre A, Kam K, Hanly PJ, MacLean JE, et al. Feasibility of split night polysomnography in children to diagnose and treat sleep related breathing disorders. Sleep Medicine. 2022; 96: 107–112.

[13] Behrents RG, Shelgikar AV, Conley RS, Flores-Mir C, Hans M, Levine M, et al. Obstructive sleep apnea and orthodontics: an American association of orthodontists white paper. American Journal of Orthodontics and Dentofacial Orthopedics. 2019; 156: 13–28.e1.

[14] Paglia L. Respiratory sleep disorders in children and role of the paediatric dentist. European Journal of Paediatric Dentistry. 2019; 20: 5.

[15] Ronsivalle V, Isola G, Lo Re G, Boato M, Leonardi R, Lo Giudice A. Analysis of maxillary asymmetry before and after treatment of functional posterior cross-bite: a retrospective study using 3D imaging system and deviation analysis. Progress in Orthodontics. 2023; 24: 41.

[16] Gay PC, Selecky PA. Are sleep studies appropriately done in the home? Respiratory Care. 2010; 55: 66–75.

[17] Lo Giudice A, Ronsivalle V, Gastaldi G, Leonardi R. Assessment of the accuracy of imaging software for 3D rendering of the upper airway, usable in orthodontic and craniofacial clinical settings. Progress in Orthodontics. 2022; 23: 22.

[18] Ishman SL, Yang CJ, Cohen AP, Benke JR, Meinzen-Derr JK, Anderson RM, et al. Is the OSA-18 predictive of obstructive sleep apnea: comparison to polysomnography. The Laryngoscope. 2015; 125: 1491–1495.

[19] LeBourgeois MK, Harsh JR. Development and psychometric evaluation of the children’s sleep-wake scale. Sleep Health. 2016; 2: 198–204.

[20] Paduano S, Paduano FP, Aiello D, Barbara L, Zampogna S, Pujia R, et al. OSAS in developing age: screening of a Southern Italy population. European Journal of Paediatric Dentistry. 2019; 20: 302–305.

[21] Chervin RD, Hedger K, Dillon JE, Pituch KJ. Pediatric sleep questionnaire (PSQ): validity and reliability of scales for sleep-disordered breathing, snoring, sleepiness, and behavioral problems. Sleep Medicine. 2000; 1: 21–32.

[22] Handelman CS, Osborne G. Growth of the nasopharynx and adenoid development from one to eighteen years. The Angle Orthodontist. 1976; 46: 243–259.

[23] Papaioannou G, Kambas I, Tsaoussoglou M, Panaghiotopoulou-Gartagani P, Chrousos G, Kaditis AG. Age-dependent changes in the size of adenotonsillar tissue in childhood: implications for sleep-disordered breathing. The Journal of Pediatrics. 2013; 162: 269–274.e264.

[24] Ranieri S, Ballanti F, Cozza P. Linguistic validation of a questionnaire for the diagnosis of sleep respiratory disorders in children. Dental Cadmos. 2016; 84: 576–585. (In Italian)

[25] Nagappa M, Liao P, Wong J, Auckley D, Ramachandran SK, Memtsoudis S, et al. Validation of the stop-bang questionnaire as a screening tool for obstructive sleep apnea among different populations: a systematic review and meta-analysis. PLOS ONE. 2015; 10: e0143697.

[26] Beck SE, Marcus CL. Pediatric polysomnography. Sleep Medicine Clinics. 2009; 4: 393–406.

[27] Jafari B, Mohsenin V. Polysomnography. Clinics in Chest Medicine. 2010; 31: 287–297.

[28] Orbach H, Wexler A, Orbach A, Gross M, Shalish M. Sleep-related breathing disorders in young orthodontic patients. American Journal of Orthodontics and Dentofacial Orthopedics. 2023; 163: 95–101.

[29] Rohra AK Jr, Demko CA, Hans MG, Rosen C, Palomo JM. Sleep disordered breathing in children seeking orthodontic care. American Journal of Orthodontics and Dentofacial Orthopedics. 2018; 154: 65–71.

[30] Quintana-Gallego E, Carmona-Bernal C, Capote F, Sánchez-Armengol A, Botebol-Benhamou G, Polo-Padillo J, et al. Gender differences in obstructive sleep apnea syndrome: a clinical study of 1166 patients. Respiratory Medicine. 2004; 98: 984–989.

[31] Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S. The occurrence of sleep-disordered breathing among middle-aged adults. The New England Journal of Medicine. 1993; 328: 1230–1235.

[32] Marcus CL, Moore RH, Rosen CL, Giordani B, Garetz SL, Taylor HG, et al. A randomized trial of adenotonsillectomy for childhood sleep apnea. The New England Journal of Medicine. 2013; 368: 2366–2376.

[33] Hoxha S, Kaya-Sezginer E, Bakar-Ates F, Köktürk O, Toygar-Memikoğlu U. Effect of semi-rapid maxillary expansion in children with obstructive sleep apnea syndrome: 5-month follow-up study. Sleep and Breathing. 2018; 22: 1053–1061.

[34] Yoon A, Abdelwahab M, Bockow R, Vakili A, Lovell K, Chang I, et al. Impact of rapid palatal expansion on the size of adenoids and tonsils in children. Sleep Medicine. 2022; 92: 96–102.

[35] Bariani RCB, Bigliazzi R, Badreddine FR, Yamamoto LH, Tufik S, Moreira G, et al. A clinical trial on 3D CT scan and polysomnographyc changes after rapid maxillary expansion in children with snoring. Brazilian Journal of Otorhinolaryngology. 2022; 88: S162–S170.

[36] Pereira L, Monyror J, Almeida FT, Almeida FR, Guerra E, Flores-Mir C, et al. Prevalence of adenoid hypertrophy: a systematic review and meta-analysis. Sleep Medicine Reviews. 2018; 38: 101–112.

[37] Langer MR, Itikawa CE, Valera FC, Matsumoto MA, Anselmo-Lima WT. Does rapid maxillary expansion increase nasopharyngeal space and improve nasal airway resistance? International Journal of Pediatric Otorhinolaryngology. 2011; 75: 122–125.

[38] Wood CL, Lane LC, Cheetham T. Puberty: normal physiology (brief overview). Best Practice & Research Clinical Endocrinology & Metabolism. 2019; 33: 101265.

[39] Slobodin O, Davidovitch M. Gender differences in objective and subjective measures of ADHD among clinic-referred children. Frontiers in Human Neuroscience. 2019; 13: 441.

[40] Ohan JL, Visser TA. Why is there a gender gap in children presenting for attention deficit/hyperactivity disorder services? Journal of Clinical Child & Adolescent Psychology. 2009; 38: 650–660.

[41] Beebe DW. Neurobehavioral morbidity associated with disordered breathing during sleep in children: a comprehensive review. SLEEP. 2006; 29: 1115–1134.

[42] Lo Giudice A, Rustico L, Caprioglio A, Migliorati M, Nucera R. Evaluation of condylar cortical bone thickness in patient groups with different vertical facial dimensions using cone-beam computed tomography. Odontology. 2020; 108: 669–675.

[43] Grippaudo MM, Quinzi V, Manai A, Paolantonio EG, Valente F, La Torre G, et al. Orthodontic treatment need and timing: assessment of evolutive malocclusion conditions and associated risk factors. European Journal of Paediatric Dentistry. 2020; 21: 203–208.

[44] Leonardi R, Ronsivalle V, Lagravere MO, Barbato E, Isola G, Lo Giudice A. Three-dimensional assessment of the spheno-occipital synchondrosis and clivus after tooth-borne and bone-borne rapid maxillary expansion. The Angle Orthodontist. 2021; 91: 822–829.

[45] Lo Giudice A, Ronsivalle V, Lagravere M, Leonardi R, Martina S, Isola G. Transverse dentoalveolar response of mandibular arch after rapid maxillary expansion (RME) with tooth-borne and bone-borne appliances. The Angle Orthodontist. 2020; 90: 680–687.

[46] Leonardi R, Ronsivalle V, Barbato E, Lagravère M, Flores-Mir C, Lo Giudice A. External root resorption (ERR) and rapid maxillary expansion (RME) at post-retention stage: a comparison between tooth-borne and bone-borne RME. Progress in Orthodontics. 2022; 23: 45.

[47] Rosa M, Quinzi V, Marzo G. Paediatric orthodontics Part 1: anterior open bite in the mixed dentition. European Journal of Paediatric Dentistry. 2019; 20: 80–82.

[48] Lo Giudice A, Ronsivalle V, Santonocito S, Lucchese A, Venezia P, Marzo G, et al. Digital analysis of the occlusal changes and palatal morphology using elastodontic devices. A prospective clinical study including Class II subjects in mixed dentition. European Journal of Paediatric Dentistry. 2022; 23: 275–280.

[49] Quinzi V, Salvati SE, Pisaneschi A, Palermiti M, Marzo G. Class III malocclusions in deciduous or early mixed dentition: an early orthopaedic treatment. European Journal of Paediatric Dentistry. 2023; 24: 42–44.

[50] Lo Giudice A, Ronsivalle V, Conforte C, Marzo G, Lucchese A, Leonardi R, et al. Palatal changes after treatment of functional posterior cross-bite using elastodontic appliances: a 3D imaging study using deviation analysis and surface-to-surface matching technique. BMC Oral Health. 2023; 23: 68.