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for Young Children

SLEEP DISORDERED BREATHING

QUESTIONNAIRESfor Young Children

SLEEP DISORDERED BREATHING

By Earl O. Bergersen, DDS, MSD

QUESTIONNAIRES

Sleep Disordered Breathing(SDB) has been researched formany years for the adult,however, interest in sleep prob-

lems for children is a more recentoccurrence. Various questionnaireshave been used for adults to deter-mine the likelihood of sleep issues.These adult questionnaires such asthe Epworth Sleepiness Scale1, theSTOP-Bang Score2, the Multiple SleepLatency Test3, the Stanford SleepinessScale4, and the Snoring SeverityScale5 were specifically designed toanalyze the symptoms typical foradults suspected of having SDB.

Symptoms that are observed in chil-dren however, are different fromthose of the adult and as a result, theadult scales are not appropriate forthe analysis of a child.6

The dental professional usuallybegins seeing young patients ataround 2 to 4 years of age andtraditionally they recall them backinto the office every six months ona regular basis. This is in directcontrast to the medical professional,where a patient is usually only seenwhen a problem arises but not as aroutine. The dental professional, asa result, is well positioned to recog-

nize patients with SDB at a veryyoung pre-school age. An easy touse questionnaire(s) for the parentsof every child would be extremelybeneficial to patients that aresuspected to be suffering from sleepissues. Treating young patientsbefore they start school wouldprovide them with a great advan-tage. Treatment however, at anygiven age up to 12 years could be ofgreat advantage to any patient.

A few questionnaires are avail-able for children such as the Pedi-atric Sleep Questionnaire7, the Pedi-atric Quality of Life Inventory8, and

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the ClevelandAdolescent Sleepi-ness Questionnaire9,however, a question-naire that could bemore specific fordental use would bean advantage indiagnosing childrensuspected of havingsleep deprivation.The dental profes-sion has appliancesthat are capable ofpreventing themandible andtongue from beingposteriorly displacedwhile sleeping, andthese same appli-ances can alsoadvance the lowerjaw and tongue andas well as to increasemandibular growthin cases with aretrognathic lowerjaw. Thus it followsthat these appli-ances can be usedfor a greater advan-tage in treatingsleep problems.10

These various appli-ances can also,correct open-bites,swallowing abnor-malities, maxillarypalatal narrowing,mouth breathing,advance the maxil-lary dentition andpre-maxilla, increasenasal breathingwith, improvedpalatal tongue posi-tion, snoring,thumb and finger sucking.

All of these problems above thatcan be corrected by the dentalprofessional are typically associatedwith SDB as well as being intercon-nected with many other symptoms.These problems, when treated atearly ages are easily corrected andare usually more stable than thoseattempted to be treated at otherages such as at 12 years or older. Asa result, these corrections by thedental professional11,12 may be able

to permanently improve a youngchild’s well-being.

The SDB Questionnaire for Chil-dren is patterned after the variouschild questionnaires that arecommonly used at present. It isspecifically designed to be moreapplicable for the dental profes-sional. This Parent Questionnairefor children consists of 15 symp-toms obtained from Sahin et al’sresearch13 from a sample size of1164 children. These 15 items hadstatistical confidence levels of

P=0.001. Four items were obtainedfrom research by Urschitz et al14

while one item was used fromAttanasio and Bailey15 (dark circlesunder the eyes, that is reported tobe linked to a reduction in nasalbreathing). Symptoms #6 and #7 inthe questionnaire are based on datafrom the American Thoracic SocietyStandards.16 The section of abnor-mal speech symptoms that are asso-ciated with SDB are based onresearch by Barr et al.17 A question-naire to determine the presence of

to permanently improve a yo g P=0 001 Four items were obtainedoun

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ADHD in a child is drawn fromstandards of diagnosis of those chil-dren suspected of having ADHDfrom the American Psychiatric Asso-ciation18 and is a separate additionto the basic questionnaire.

A third questionnaire (Question-naire #3) is for the dental profes-sional. This questionnaire consistsof 12 items filled out during thegeneral patient exam and 9 itemsthat are present from a cephalomet-ric evaluation involving measuresof the antero-posterior position of

the mandible in relation to thepharynx and the width of the phar-ynx as well as the size of theadenoid tissue.

These three questionnaires covera diagnosis applicable for the dentalprofessional in order to considertreatment of these symptoms. ThePediatric Sleep Questionnaire1 wasanalyzed by Chervin et al (2007)9 inorder to see if this questionnairecould predict the presence ofobstructive sleep apnea (OSA). Itwas found to accurately predict OSA

about 74% of thetime in children asverified bypolysomnography.OSA has an inci-dence of only 1.6%in children20

however, there aremany other symp-toms that have asignificant impacton a child’s futurelife without the pres-ence of apnea.

If one examinescommon symptomsof children at vari-ous ages havingsuspected ADHD,one is impressed bythe increase in seri-ous consequences asthe affected childmatures. One is also

impressed by the great similaritybetween the symptoms of ADHDand sleep problems in children.Tables 4-8 show the advancing andincreasing detrimental effects as thechild matures.21 Of significance isthe general behavioral problems(Tables #4 and #5), however, whenthe affected child begins school, thedifficulties become considerablymore serious (Table #6). Suchsymptoms as poor school perfor-mance, 50% failing at least one

grade, being antisocial,50% developing drugand alcohol problems,having fewer friends,and often being introuble are all quitecommon. Once thechild starts highschool (Table #7) theproblems become evenmore serious since80% of hyperactivechildren retain thesesymptoms even intothe teen years. Thosewith 2 symptoms ormore are considered tobe at high risk. Fiftypercent have drug andalcohol addiction andare often in troublewith the law.19

These tables

dible in relation to the

atvpOdinhmtsolie

coosototmADHD in a child is drawn from the mand

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www.orthodontics.com Fall 2015 17

strongly indicate the need for earlyrecognition of these symptoms inthe pre-school child, or at leastbefore the child enters high school.In that these various symptoms areso similar to those of sleep-disor-dered breathing, it makes it impera-tive for the dental practitioner torecognize and treat these problemsas early as possible.

A perfect example is of an 8 yearold boy that had a sleep and speechquestionnaire which indicated 17problems (Table #9). The samechild’s questionnaire at 13 years ofage is shown in Table #10 afterwearing an appliance this patientwas voted as the most popular andthe most athletic student in his 6thgrade. When the mother filled outthe questionnaire for ADHD, theresult was predictable (Table #11).He would not sit still even for 30seconds and had severe attentiondeficit. He breathed through hismouth while sleeping and snoredevery night. When an appliance(Nite-Guide®) was given to him thatprevents the distalization of themandible and tongue while sleep-

ing, several of his telltale symptomsimmediately stopped (constantmovement in bed, sitting up andtalking, sleep walking). In additionthe patient had more energy uponwaking. School performance alsobegan to improve. Taking the sameADHD test at 13 years (Table #12)shows the improvement. This caseillustrates the changes that thedental professional is able to makein order to redirect a young person’slife. Eighty percent of early ADHDpatients maintain the problem intotheir teen years, as stated above.21

This patient makes a point ofwearing his preformed mandibularadvancement appliance to preventthe mandible from posteriorlydisplacing while sleeping before ascheduled sports competition. Heexperienced increased energy andperformance as a result. This isprobably due to the increasedoxygen restoration while sleeping.Often ADHD patients are found tobe clumsy and uncoordinated, sothis is a dramatic change for thispatient. He was captain of hishockey team and had the highest

number of goals as a 13 year old.He also ran the half mile and wasranked #3 over approximately38000 6th grade students.

This case illustrates the impor-tance of intercepting such a case ata young age to change a child’scoarse of development withoutmedication to calm the hyperactiv-ity which can dull a child’s person-ality without curing the cause ofsuch a problem.

The introduction of the dentalprofessional into the diagnosis andtreatment of sleep problems in chil-dren is a great advantage for acouple of reasons. The first of theseis that with the early monitoring ofpatients on a regular basis, startingat 2 to 4 years of age, allows thedental office the ability to interceptsleep issues at a very early age. Thesecond is that the child can becorrected prior to their enteringschool where more complicatedissues exist.

Editor’s Note: Forfull references, visit

www.orthdontics.com

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