ada and the United States over the last 15 years, we see an increasing number
of children with obesity-related SDB. 3, 4 Mixed sleep apnea combines features
of both central and obstructive causes. The Canadian Sleep Society (css-scs.
ca) and the American Sleep and Breathing Academy (
americansleepand-breathingacademy.com) are valuable resources on this topic.
Given the added complexity of behavioral and developmental issues
that often accompany a child with SDB, our mission is to heighten the
awareness for the dental professional and in doing so, promote earlier in-
tervention. As cotherapists, it is important for us to have a clear under-
standing of our role in interdisciplinary management and to highlight various
methodologies of treatment to broaden our scope of knowledge.
Contrary to adult SDB, pediatric SDB or OSA often presents with behavioral symptoms that can have cascading effects in many areas of their life.
These may include mood changes, misbehavior, and poor school perfor-
mance. Often symptoms of SDB are confused with ADHD and treated with
medications that include stimulants, nonstimulants, and antidepressants.
Not every child with academic or behavioral issues will have SDB, but if a
child snores loudly on a regular basis and is experiencing mood, behavior,
or school performance issues, SDB should be considered.
The largest and most comprehensive study to examine the effects of
SDB symptoms on behavior from six months to seven years of age was
conducted in the United Kingdom. The study evaluated and followed more
than 11,000 children for over six years. The combined effects of snoring,
apnea, and mouth-breathing on the behavior of children enrolled in the Avon
Longitudinal Study of Parents and Children in the United Kingdom were
examined. Parents completed questionnaires about their children’s SDB
symptoms at several intervals, from 6 to 69 months of age. At approximately
ages four and seven years old, parents filled out the Strengths and Difficulties
Questionnaire (SDQ). The SDQ rated the individual for inattention/hyper-activity; emotional symptoms (anxiety and depression); peer difficulties;
behavior problems (aggressiveness and rule-breaking); prosocial behavior
(sharing, helpfulness, etc.).
The study controlled for 15 possible confounding factors (e.g., socioeconomic status, maternal smoking during the first trimester of pregnancy, low
birth weight). The study revealed children with SDB were from 40% to 100%
more likely to develop neurobehavioral problems by age seven, compared
to children without breathing problems. The largest increase was seen in
hyperactivity. There were, however, significant increases across all five behavioral measures. Children whose SDB symptoms peaked early, at six or
18 months, were 40% and 50% more likely, respectively, to have behavioral
problems at seven years of age compared with children who had normal
breathing. Children with the worst behavioral problems had SDB symptoms
that continued throughout the evaluation period and became most severe
at 30 months. 5
This shines a light on the unique opportunity for dental professionals
to be on the front line of discovery for numerous oral-systemic diseases.
Many of our patients visit the dental office more often than any other
health-care provider. Given its severity and far-reaching effects, should we
not consider screening for SDB on a routine basis? The pathway to discovery
begins with a clear understanding of the physical signs and symptoms of
• Abnormal breathing during sleep
• Frequent awakenings or restlessness
• Frequent nightmares
• Enuresis (bedwetting)
• Difficulty awakening
• Excessive daytime sleepiness
• Hyperactivity/behavior problems
• Daytime mouth breathing
• Poor or irregular sleep patterns
• Growth impairment
The screening process for the dental professional begins with general
observation of the patient. Mouth breathing and adenoidal facies (i.e., dull
expression with open mouth) should be noted. Hyponasal voice (i.e., a voice
that sounds like the nose is pinched when speaking) is a clue to nasal ob-
struction; a muffled voice suggests adenotonsillar enlargement. Secondly,
the lateral facial profile should be examined for retrognathia, micrognathia,
or midfacial hypoplasia. These can all have an effect on the nasopharyngeal
and oropharyngeal passages and are key diagnostic findings. The oral cavity
should be observed for tongue and soft palate size and appearance. A large
tongue along with or independent of a high/low-arched or elongated palate
may reveal a predisposition to SDB. 6
Note the patient’s head posture. Blocked nasal breathing and jaw joint
inflammation both result in forward head posture. Persistent forward head
posture causes muscle contraction and results 96% of the time in occipital
and forehead headaches. 7
Once you have established and documented clinical findings, asking a
series of questions contributes greatly to the screening process for SDB:
1. Does the patient snore?
2. Have you heard the patient grinding his or her teeth?
3. Does the patient appear restless and/or awaken frequently at night?
4. Does the patient have frequent nightmares?
5. Does the patient wet his or her bed?
6. Is it difficult to waken the patient in the morning?
7. Are you aware of excessive sleepiness during the day?
8. Are there any hyperactive or behavioural issues you are aware of?
9. Would you consider the patient to be a mouth breather?
In keeping with an interdisciplinary approach, it is vital to share any abnormal
clinical findings with the child’s physician as soon as possible. Children are
in such a rapid state of cognitive development that time is of the essence
to effect change. According to Halbower et al., “any alterations of health
and brain function associated with SDB could permanently alter a child’s
social and economic potential, especially if the disorder is not recognized
early in life or treated inadequately. It is imperative that healthcare workers
Given its severity and
far-reaching effects, should
we not consider screening for
sleep-disordered breathing on
a routine basis?