Effectiveness of Early Intervention with a Monobloc Oral Appliance in Reducing Symptoms of Breathing Disorders at Sleep in Children with Dentofacial Anomalies Ages 5-12: A Retrospective, Multicenter Analysis
Sleep Disordered Breathing (SDB) is increasingly common and defined as a group of disorders characterized by abnormal breathing patterns such as hypopneas or apneas, or inadequate ventilation during sleep that disrupts the sleep pattern leading to Obstructive Sleep Apnea (OSA) [1]. The prevalence of breathing disorders during sleep in school-aged children 5-12 years of age is between 1 and 4% with habitual snoring prevalence at about 7.45% [2]. In a retrospective analysis of data reported by parents, Lumeng, et al. [3] found similar prevalence estimations reported by parents: Parent-reported “always” snoring, 1.5 to 6%; parentreported apneic events during sleep, 0.2 to 4%; SDB by varying constellations of parent-reported symptoms on questionnaire, 4 to 11%; OSA diagnosed by varying criteria on diagnostic studies, 1 to 4%. Overall prevalence of parent-reported snoring by any definition in meta-analysis was 7.45% (95% confidence interval, 5.75-9.61) [3].
Other studies suggest OSA may be a far more common complaint, with upper airway resistance and snoring reported as high as 27% [4]. Furthermore, undiagnosed “silent” Obstructive Sleep Apnea (OSA) occurring in Dentofacial Deformities (DFD) patients with primary mandibular deficiency and short face DFDs (p<0.001 and p=0.001, respectively) [5].
Guilleminault, et al. [6], first reported the diagnosis of OSA in children 5 to 14 years of age. Theories and hypotheses explaining the connection between SDB, OSA, oral-facial growth, dentofacial anomalies, and when they occur have been debated and studied over the past decade [7-9]. Huang, et al.[10], reviewed evidence hypothesizing the connection of OSA and oral-facial growth. Their findings showed the association between pediatric sleep issues and abnormal breathing affecting facial hypotonia and concluded abnormal oral-facial anatomy that must be treated in order for the resolution of OSA [10]. Dentofacial anomalies are common craniofacial abnormalities resulting as a substantial risk for sleep deficiencies, Breathing Disorders (BD) and Obstructive Sleep Apnea (OSA) [7-10]. The developing oral-facial anatomy has an impact on the teeth and alveolar processes of the face where disease and systemic conditions manifest as soon as the embryonic phases [11]. Previous studies found a causal relationship between upper respiratory obstruction and dentofacial abnormalities related to genetic or structural issues resulting in maxillary hypoplasia, mandibular condylar hypoplasia, retrognathism, or narrow palatal arch [12]. Within the pediatric population, it has been hypothesized an oral appliance in early intervention may address OSA and dentofacial anomalies prior to more aggressive interventions; however, the durability and adherence of a tooth positioner should be considered [13,14]. It has been hypothesized Monobloc Oral Appliances (MOA) have a positive effect in reducing symptoms of breathing disorders at sleep in school-aged children. de Rutier, et al. [15], concluded the efficacy of a Sleep Position Trainer (SPT) comparable to an Oral Appliance (OAT) with a relatively high adherence [15,16]. Therapy for OSA has been discussed. Capan, et al. [8], initially found MOAs to be an effective treatment option for children with retrognathia and OSA as evidenced by a reduction in the Apnea Hypopnea Index (AHI). Another study by Capan, et al. [12], and Issaccson, et al. [17], found MOAs may also improve the behavior in children with snoring symptoms and skeletal class II malocclusions. Corrective action using a monobloc appliance shows comparable corrective action to a bibloc appliance in treating OSA; however, the monobloc device reduced the ODI at greater level than a bibloc with a lower cost of treatment after one year by 17% and with greater patient compliance [17]. Breathing disorders during sleep begin at an early age. Changes in the pediatric airway resulting in the paradigm of Sleep Disordered Breathing (SDB) increase the risk of adulthood comorbidities and disease states physically and psychologically [18]. Such comorbidities from unresolved or unimproved SDB symptoms can lead to hypertension, cor pulmonale, bronchopulmonary dysplasia, sickle cell disease, obesity, insulin resistance, failure to thrive (malnutrition), Attention-Deficit/Hyperactivity Disorder (ADHD), and major depressive disorder [18]. Furthermore, pediatric Sleep Disordered Breathing (SDB) is a continuum of symptoms ranging from snoring to Obstructive Sleep Apnea (OSA) that can differ from adult OSA symptoms [19,20]. However, research shows symptoms are a result of downstream problems in natural nasal breathing The multisymptomatic presence of SDB can occur with 2 symptoms or as many as 11, as found on various subjective, patient directed data questionnaires, including the one used in this study [21]. The role of airway dentistry assessing nasal function and for OSA symptoms has come to the forefront in order to collaborate with the medical community addressing SDB, specifically with oral devices such as an MOA. For the purposes of this study, the eleven symptoms for analysis commonly seen in pediatric OSA were snoring, snore interruption, labored breathing, mouth breathing, restlessness, teeth grinding, sleep talking, sweating, waking up, bed wetting, and daytime sleepiness.
