Paediatric Sleep‐Disordered Breathing Special Issue Introductory Editorial

This special issue covers a critical and timely topic—the role of the orthodontist in managing paediatric obstructive sleep apnea (OSA). Although our understanding of the impact of mandibular advancement devices for adult OSA is gaining increasing recognition [1, 2], the evidence of the impact of orthodontics in children with paediatric OSA is scarcer [3]. Orthodontists play a crucial role in screening for paediatric OSA, and they could also play a significant additional role by addressing craniofacial anatomical and developmental factors that contribute to airway obstruction in very selected cases [4]. It is important to remember that there are non-anatomical and anatomical contributing factors that facilitate upper airway obstruction, and - very few cases have an underlying anatomical factor as the only causative effect [5, 6]. It has been proposed that through the evaluation and treatment of craniofacial structures and dental occlusions, orthodontists can implement therapies designed to expand the upper airway, improve breathing patterns, and enhance overall sleep quality in children. However, the current evidence supporting these interventions is limited and primarily short-term [3]. While initial studies have consistently reported improvements in signs and symptoms of paediatric OSA, these do not represent a complete cure [7]. The mid- and long-term effectiveness of these approaches remains unclear, and variability in patient response is notable, from some children experiencing worsening symptoms to others showing no improvement. Therefore, caution and further research are needed to understand better the sustained impact and optimal application of orthodontic treatments in this context. Nevertheless, the expertise of orthodontists in growth and development should allow them to collaborate effectively with paediatricians, sleep specialists and otolaryngologists to create a comprehensive and individualised treatment plan, ultimately promoting better health outcomes and quality of life for paediatric patients with OSA [7]. A succinct summary and the clinical impact of the included manuscripts are noted in the following paragraphs. This issue begins with a perspective paper [8] that examines the foundational findings from rodent models of intermittent hypoxia. The central argument of this paper is the need for caution when considering the translational potential of these animal studies, highlighting both their utility and their inherent limitations for informing clinical practice. The second article [9] presents the findings of a mixed-methods study investigating the attitudes and clinical practices of orthodontists and paediatric dentists in Brazil concerning paediatric OSA. The study revealed that while these oral health professionals reported an awareness of the condition's signs and symptoms, a notable lack of confidence was observed regarding their professional role and the potential impact of orthodontic interventions. The authors highlight a greater reliance on palatal expansion and mandibular advancement appliances among orthodontists attempting to manage pediatric OSA. Although the sample is geographically representative, the paper cautions against generalising these findings to other populations, positing that such baseline data on provider perceptions and attitudes are crucial for developing targeted educational and clinical strategies. The third paper [10] presents an extensive cross-sectional study of over 3600 children who sought an orthodontic assessment and were considered to be at high risk for OSA. A polysomnography (PSG)-based diagnosis of OSA was associated with a series of facial skeletal analyses. A Class II facial profile, maxillomandibular retrusion, and increased anterior lower facial height were highly prevalent in children with severe OSA between the ages of 7 and 9. When considering these findings, it is important to note that the private practice from which these cases were drawn is known in the community for its focus on craniofacial management in paediatric OSA cases. This means the proportion of cases with both conditions is high and does not represent what is typically found in an average dental or orthodontic office. The next paper [11] presents a systematic review and meta-analysis on the utility of hyoid bone position as a radiographic screening metric for paediatric OSA. The analysis revealed that the hyoid bone is consistently located more anteriorly and inferiorly in children with OSA. Given that lateral cephalograms, a common component of orthodontic assessment, readily visualise the hyoid bone, the authors argue for its integration into routine screening protocols as an initial indicator of heightened OSA risk. In a study [12] contributing to the epidemiology of paediatric OSA, the authors administered the validated NOSE questionnaire to a sample of 431 children seeking orthodontic treatment. Their findings reported a low prevalence of severe nasal airway obstruction, with only 11.4% classified as moderate, 2.6% as severe, and 0.2% as extreme. The primary clinical takeaway is the critical distinction drawn between the significant overall prevalence of high risk of nasal obstruction (58.1%) and the much smaller subset of cases (25%) that could be deemed clinically relevant in a population of children seeking orthodontic treatment. It is important to emphasise that the utilised questionnaire is not diagnostic per se, but that it suggests a high risk of nasal airway obstruction. The acute or chronic nature of the obstruction is unknown. A paper [13] on management alternatives for paediatric OSA examined the efficacy of a nasopharyngeal airway (NPA) in infants under 1 month of age with upper airway obstruction. The study, conducted on a population of predominantly syndromic patients, reported clinically meaningful improvements across a range of breathing parameters. The primary clinical contribution of this work is its suggestion of a management modality that offers a viable solution without the adverse effect on mid-facial growth that may be associated with other interventions. The subsequent management paper [14] investigates the therapeutic effects of a combined palatal expansion and protraction protocol in children presenting with both transverse and sagittal deficiencies. The intervention produced a significant increase in nasopharyngeal and oropharyngeal airway width dimensions compared to a control group. This was accompanied by a self-reported reduction in functional limitations, including psychosocial well-being. However, the authors importantly emphasise that an increase in upper airway dimensions should not be a surrogate for demonstrating clinically meaningful improvements in sleep breathing parameters. Another included paper [15] analysed hyoid positional and pharyngeal airway changes after Class III malocclusion orthognathic surgery. The authors noted that airway constriction occurred after surgery, especially when the hyoid position was more inferior. This information is clinically relevant as it suggests that Class III orthognathic surgery should be individualised in cases with a lower hyoid position. Within an interdisciplinary management team, myofunctional therapy may play a critical role in addressing perioral muscle dysfunction. A paper [16] presents pioneering research on targeted oropharyngeal exercises. Using nasofibrolaryngoscopy, the study reveals how specific exercises may induce myo-morphological changes in paediatric patients with OSA. The key clinical contribution of this study is its potential to identify and optimise individualised oromyofunctional therapy (OMT), significantly advancing our understanding of the subject. The second last included paper [17] in this issue proposes a shift from a multidisciplinary to an interdisciplinary care model for paediatric OSA. It begins with an overview of the condition's pathophysiology, epidemiology, sequelae, and diagnostic approaches, before exploring the role of oral health providers. The manuscript concludes with a critical assessment of the strengths and weaknesses of both multidisciplinary and interdisciplinary team models. This opinion paper's key clinical contribution is its emphasis on the need for timely interdisciplinary interaction, a departure from the common, sequential model where each health professional independently assesses and addresses the problem. The concluding paper [18] addresses a critical, understudied area: the lived experiences of parents whose children are undergoing OSA management. Using an explanatory qualitative design, the authors documented the significant challenges parents face in navigating the currently prevalent multidisciplinary care model. Common themes that emerged from the data were the receipt of confusing and conflicting clinical information and a perceived detachment among practitioners. This paper provides a crucial reminder that a successful transition to an interdisciplinary framework necessitates the active inclusion of parental perspectives as a central component of the management paradigm. In summary, this collection of papers underscores the orthodontist's significant, yet evolving, potential role in the interdisciplinary management of paediatric OSA. While foundational articles provide a comprehensive overview of the condition and caution against the direct translational application of animal model findings, a series of studies explores screening and management strategies. These include a systematic review arguing for the integration of hyoid bone position as a radiographic screening metric and an epidemiological study highlighting the crucial distinction between the high prevalence of nasal obstruction and the subset of clinically significant cases. On the management front, papers present a range of interventions, from the use of NPAs in syndromic infants to combined maxillary expansion and protraction protocols. Importantly, a consistent theme is the need for caution, as an increase in airway dimensions does not automatically equate to a clinically meaningful improvement, and some procedures, such as Class III orthognathic surgery, may carry a risk of airway constriction. Ultimately, the issue presents a compelling case for a paradigm shift from the current fragmented, multidisciplinary care model to a more collaborative and interdisciplinary one, powerfully reinforced by a qualitative study that documents the challenging parental experiences and underscores the necessity of incorporating their perspectives into any new management framework. The authors declare no conflicts of interest. The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

Fetched live from OpenAlex and de-inverted. Abstracts are not stored in this database: the inverted indexes are 8.6 GB of the frame’s 9.3 GB of text, and the host has 13 GB free.