More Treatment Options For Obstructive Sleep Apnea

Abstract

Source: Guilleminault C, Quo S, Huynh NT, Li K. Orthodontic expansion treatment and adenotonsillectomy in the treatment of obstructive sleep apnea in prepubertal children. Sleep. 2008;31(7):953–958.Researchers from Stanford University and the University of California San Francisco School of Dentistry evaluated the efficacy of sequential rapid maxillary expansion (RME) using orthodontic treatment and adenotonsillectomy (T&A) in prepubertal children with obstructive sleep apnea (OSA).Patients with polysomnogram (PSG)-proven moderate OSA and a recommendation by a multidisciplinary team that both T&A and RME were needed were enrolled.Study patients were randomized to either T&A or RME as initial treatment; the efficacy of the treatments was assessed by parental reports of symptoms and repeat PSG three and six months post-intervention. If the results of the polysomnogram were abnormal or the child was still symptomatic after initial treatment, the second stage of treatment was recommended.Over a 2.5-year period, 32 children (16 boys) with a mean age of 6.5 years (range 4.7–9) were enrolled. All patients had some degree of tonsillar enlargement and high and narrow hard palates with crowded dentition. At the completion of the initial treatment each of the 32 patients improved, but the results of follow-up PSG were not statistically significant between those in the T&A and orthodontic expansion groups. Two patients assigned to the RME group had marked improvement in symptoms and did not undergo T&A. The remaining 30 patients underwent the second procedure. This led to a resolution of symptoms with confirmatory normal PSGs in 28 of the 30 children. Final PSG results were significantly improved over both entry PSG and PSG obtained after the first stage of treatment.Although improvement was seen with one or the other type of treatment in all 32 patients, 87.5% (28/32) required both T&A and RME for complete resolution of OSA. Tonsillar size was not helpful in predicting outcome. Most patients in this select population required both surgical and orthodontic intervention, regardless of the order in which they were performed, for complete resolution of symptoms.Dr. Dubik has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.RME is a dentofacial procedure used to widen the maxilla and the maxillary dental arch and improve the nasal airway.1 The beneficial medical impact of orthodontic expansion is increasingly suggested in the sleep medicine literature2 but it is not “on the radar” in mainstream pediatrics or dentistry. Although the number of patients in this study is small and the authors do not define or grade “crowded teeth” and “high arched palate,” this article reminds us that there is more to the teeth and the jaw than cosmetics and malocclusion.Doctors and dentists often do not fully appreciate the effects of the maxilla and the mandible on the airway. Treatment with orthodontics is too often not considered in pediatric sleep medicine. And by the time it is, the growth plates may be gone and it’s too late. It would appear that for many children T&A is not enough, and that perhaps most children with OSA need both surgery and orthodontic intervention if complete resolution of symptoms is to be achieved. Indeed, some experts believe that orthodontics may have a more lasting impact on OSA in the long term.And that brings us to the insurance issue. There is no question that RME is an orthodontic procedure, but it is being performed for a medical indication and should be covered by medical insurance. This is not an elective aesthetic procedure; it is a medically indicated intervention. It seems very reasonable that if a child’s sleep-disordered breathing symptoms do not resolve with a T&A, orthodontic expansion should be considered and should be covered as a medical procedure equivalent to the preceding T&A. Considering the difficulty that children with OSA have accepting continuous positive airway pressure (CPAP) therapy, including RME as an early treatment option seems all the more reasonable. Guilleminaut, et al, are to be commended for ensuring that orthodontic expansion of the palate is considered among the therapeutic options by those who treat children with OSA or refer them for treatment.