Summary:
August 2026 Dental Pearl: Orthodontics
Obstructive Sleep Apnea and Orthodontics
The American Association of Orthodontists recently updated their 2019 white paper on obstructive sleep apnea. This is a summary of that paper, with the original attached. While the paper is addressed to orthodontists, the information provided is essential to all dental providers.
There is growing recognition of orthodontists' role in screening for obstructive sleep apnea [OSA] and contributing to its multidisciplinary management in both children and adults. Sleep-related breathing disorder [SRBD] is the term used to encapsulate multiple conditions ranging from snoring to obstructive sleep apnea. This document focuses primarily on OSA.
Obstructive sleep apnea occurs when the upper airway repeatedly collapses during sleep due to increased airway collapsibility and reduced neuromuscular tone, causing breathing interruptions, drops in oxygen levels, and frequent sleep arousals. In children, they have additional exacerbating factors like lymphoid hyperplasia and growth-related changes that can impact the upper airway. These events trigger increased heart rate, blood pressure, and cardiovascular stress, often recurring many times throughout the night. OSA has a multifactorial etiology involving craniofacial anatomy, neuromuscular function, obesity, hormonal changes, fluid shifts, and genetic factors, resulting in wide variation in disease severity and treatment needs among patients. Although obesity increasingly contributes to childhood OSA, affected children may also be underweight due to growth restriction or failure to thrive; therefore, OSA risk assessment is recommended in children regardless of weight.
OSA affects an estimated 14 of men and 5 of women, though it is likely underdiagnosed and more common in high-risk groups such as obese individuals and post-stroke patients. Risk factors include obesity, male sex, aging, menopause, genetic predisposition, and certain craniofacial or syndromic conditions. Craniofacial features such as retrognathia, long narrow faces, and a constricted palate may contribute to OSA risk, although the strength of these associations remains unclear. In children, it is harder to diagnose due to differences in criteria and changes in growth.
Symptoms
Patients with OSA commonly report snoring, gasping or choking during sleep, and witnessed breathing pauses. Parents may report unusual sleeping positions for their children such as hyperextended necks or their head hanging off the side of the bed, or a restless sleep with them frequently changing positions. Symptoms often include fragmented, nonrestorative sleep, morning headaches, excessive daytime sleepiness, impaired concentration, mood changes, and difficulty managing comorbid conditions such as hypertension, diabetes, and obesity. Children may revert to requiring daily naps, but other children may have it manifest as hyperactivity rather than sleepiness.
Diagnosis
All SDRB must be diagnosed by a physician with a sleep study. The gold standard is polysomnography. The severity of OSA is classified based on the Apnea-Hypopnea index [AHI] which includes the number of apnea or hypopnea events per hour of sleep or the respiratory disturbance index [RDI] which includes apnea/hypopnea events along with respiratory effort-related arousals per hour of sleep. In adults, scoring of obstructive apneas and hypopneas on a polysomnography are defined of at least 10 seconds duration, whereas for children and obstructive event is defined as 2 breaths.
Severity categories for OSA in adults are mild [AHI or RDI ?5 and <15], moderate [AHI or RDI ?15 and <30] and severe [AHI or RDI ?30]. In children, some studies diagnose mild OSA with as little as one AHI or RDI.
Significance
Untreated obstructive sleep apnea can have serious health and quality-of-life consequences. It often causes excessive daytime sleepiness and cognitive impairment, increasing the risk of motor vehicle accidents while negatively affecting school, work performance, and daily functioning. Long-term untreated OSA is also associated with metabolic and cardiovascular complications, including insulin resistance, hypertension, coronary artery disease, heart failure, stroke, cardiac arrhythmias, and an increased risk of sudden cardiac death. Children can have impaired growth, cardiovascular dysfunction, and neurocognitive function which in turn can affect academic performance and behavior.
Role of Orthodontics in OSA
Orthodontists should be familiar with the signs and symptoms of obstructive sleep apnea in both adults and children and incorporate OSA screening into routine patient evaluations. A thorough medical and dental history, combined with clinical examination, is essential for identifying risk factors, determining the need for referral, establishing baseline findings, and monitoring treatment outcomes. For all patients, assessment should include height, weight, and neck circumference. In adults, screening should address symptoms and risk factors such as loud snoring, witnessed apneas, choking or gasping during sleep, excessive daytime sleepiness, fatigue, morning headaches, hypertension, mouth breathing, nasal obstruction, type 2 diabetes, cognitive or mood disturbances, and factors included in the STOP-Bang questionnaire, including age, sex, body mass index, and neck size.
Pediatric evaluations should similarly focus on identifying symptoms suggestive of OSA, including loud snoring, mouth breathing during sleep, breathing difficulties, witnessed pauses in breathing, daytime sleepiness, attention or behavioral concerns, poor school performance, developmental delays, morning headaches, bedwetting, and symptoms consistent with attention deficit-hyperactivity disorder [ADHD]. The American Academy of Pediatric Sleep Physicians emphasizes that any child who snores warrants further questioning and evaluation. Because clinical signs and symptoms may vary widely among children, comprehensive history-taking and examination are critical to identifying at-risk patients and facilitating timely referral for definitive diagnosis and management.
Screening Tools
There are different screening tools for adults and children. In adults, the STOP-Bang questionnaire is a validated and efficient screening tool for identifying adults at risk for OSA. It evaluates eight factors: snoring, daytime tiredness, observed breathing pauses during sleep, high blood pressure, elevated BMI, age over 50 years, increased neck circumference, and male sex. Patients are categorized as low, intermediate, or high risk based on their score, with a score of 3 or more indicating an increased likelihood of OSA. Because of its high sensitivity for detecting moderate to severe OSA and its ease of administration, the STOP-Bang questionnaire can be quickly incorporated into an orthodontic screening workflow to help identify patients who may benefit from further medical evaluation.
The Pediatric Sleep Questionnaire [PSQ] is a validated screening tool that can be used in orthodontic practices to identify children who may be at risk for OSA. Its high negative predictive value [only 1 of patients with a negative PSQ score will be diagnosed with OSA] makes it particularly useful for ruling out OSA in patients without a prior diagnosis. Another option, the Epworth Sleepiness Scale for Children and Adolescents, can help assess excessive daytime sleepiness in patients aged 12 to 18 years, although it does not determine the underlying cause of sleepiness. Together, these questionnaires can serve as valuable adjuncts in the initial screening process and help guide referral decisions when sleep-disordered breathing is suspected.
In addition to a standard orthodontic examination, clinicians should assess factors relevant to pediatric obstructive sleep apnea, including tonsil size, tongue posture and size, obesity, and overall growth and development. Tonsillar hypertrophy can be evaluated using grading systems such as the Brodsky or Friedman scales; however, tonsil size alone does not predict OSA severity. Therefore, referral for further evaluation should be based on the patient's overall symptoms, medical history, and clinical findings rather than a specific tonsil grade.
Facial growth influences the size and shape of the upper airway in the pediatric population. During growth, airway skeletal dimensions expand while tonsil and adenoid tissue shrinks, resulting in a marked increase in upper airway size from infancy through adolescence. These growth-related airway changes are far greater than the effects that orthodontic or orthopedic treatments can have on airway size or shape. Understanding these normal developmental changes is essential for appreciating the underlying mechanisms and progression of obstructive sleep apnea in children.
Imaging can provide useful information about airway anatomy during orthodontic evaluation, but it should not be used to diagnose or screen for obstructive sleep apnea. While CBCT offers more accurate three-dimensional assessment of airway size and areas of constriction than traditional cephalometric radiographs, neither imaging modality can evaluate airway function, neuromuscular tone, or susceptibility to collapse during sleep. Furthermore, no radiographic measurements have been reliably linked to OSA severity or sleep study results. Therefore, imaging findings should be interpreted alongside clinical signs and symptoms and may be used to support treatment planning, monitoring, and evaluation of airway-related structures such as the adenoids and hyoid bone.
Treatment options
Positive airway pressure [PAP] therapy, including CPAP, BPAP, and APAP, is the gold-standard treatment for adult obstructive sleep apnea. PAP devices maintain airway patency during sleep and can significantly improve daytime sleepiness, cognitive function, and overall OSA symptoms. However, adherence can be challenging, with factors such as disease severity, pressure tolerance, mask fit, and social support influencing long-term use.
Additional treatment options may include weight management, positional therapy, management of nasal obstruction or allergies, and, in selected cases, surgical interventions involving the nasal airway, palate, jaws, tongue, tonsils, adenoids, or hyoid structures. Hypoglossal nerve stimulation is another treatment option for certain patients and works by improving upper airway muscle tone during sleep.
Oral appliances, including mandibular advancement devices and tongue-retaining appliances, are well-established treatment options for appropriately selected patients with OSA. These devices work by positioning the mandible and associated soft tissues forward, helping maintain upper airway patency during sleep. Oral appliances are commonly used for patients with mild to moderate OSA and for those with severe OSA who are unable or unwilling to use PAP therapy. A variety of oral appliance designs are available, differing in fabrication, adjustability, jaw positioning, and other features, with appliance selection based on the patient's individual needs. Although generally well tolerated, treatment success varies, with complete effectiveness reported in approximately 36 to 70 of patients.
Oral appliance therapy typically begins with the mandible positioned at approximately two-thirds of its maximum protrusion. The appliance is then gradually adjusted based on the patient's symptoms, sleep quality, and treatment response to achieve optimal results. Portable sleep monitoring devices may assist in determining the ideal mandibular position, and a follow-up sleep study is often used to confirm treatment effectiveness. If the appliance does not adequately control OSA, further titration or alternative therapies may be considered in collaboration with the treating physician. Patients treated with oral appliances require ongoing follow-up to assess symptom improvement, appliance fit, comfort, compliance, treatment effectiveness, and the development of side effects. Regular communication between the orthodontist and physician is recommended, with monitoring typically occurring every six months during the first year and annually thereafter. Treatment goals include reducing or eliminating snoring, resolving OSA-related symptoms, normalizing the apnea-hypopnea index [AHI], and improving oxygen saturation during sleep.
Improved awareness of OSA and the use and effectiveness of oral appliances for its treatment has led to an increase of patients receiving OSA/oral appliance treatment from non-orthodontists. However, these providers may be unaware of the unwanted side effects that these oral appliances can have in the long term. Changes include reduction in overbite and overjet, development of anterior crossbites and posterior open bites and changes in facial height. Because many patients wear these appliances long term, orthodontists play an important role in monitoring, preventing, and managing treatment-related malocclusions that may develop during therapy. When orthodontic correction of an oral appliance-induced malocclusion is needed, patients may be unable to wear the appliance during treatment and may require alternative OSA management, such as positive airway pressure [PAP] therapy. Close communication between the orthodontist and treating physician is essential to ensure continued control of OSA. In some cases, occlusal changes may recur if oral appliance therapy is resumed after orthodontic treatment, leading patients to consider PAP therapy or surgical treatment alternatives.
For selected patients with severe OSA who cannot tolerate PAP or oral appliance therapy and who have an underlying skeletal discrepancy, surgical options such as maxillomandibular advancement [MMA] or, in cases of maxillary transverse deficiency, surgically assisted rapid maxillary expansion [SARME] may be considered. Orthodontic treatment is often an important adjunct to these procedures, helping optimize occlusion, treatment outcomes, and postoperative stability as part of a comprehensive multidisciplinary treatment plan.
Management of pediatric OSA differs significantly from adult treatment and requires a multidisciplinary approach involving physicians, dentists, and orthodontists. Enlarged tonsils and adenoids are the most common causes of pediatric OSA, making adenotonsillectomy the typical first-line treatment. Additional therapies may include medications to reduce nasal inflammation, nasal surgery when indicated, weight management for obese children, and positive airway pressure [PAP] therapy in severe cases , with consideration of its potential effects on craniofacial development during growth.
Orthodontic interventions such as rapid maxillary expansion and mandibular advancement appliances may improve airway function in selected children with underlying skeletal deficiencies, although the evidence remains limited. These treatments should be used to correct documented orthodontic or skeletal discrepancies rather than solely to treat OSA, and there is no evidence that their preventive use reduces future OSA risk.
Because long-term outcomes of orthodontic treatment for pediatric OSA remain uncertain, treatment goals should focus on correcting dentofacial abnormalities while recognizing that improvement in OSA may be a possible secondary benefit. Ongoing collaboration among healthcare providers and careful monitoring of growth and development are essential, and orthodontists should avoid guaranteeing resolution of OSA through orthodontic treatment alone.
Fallacies about orthodontics in relation to OSA
Current evidence does not support the belief that routine orthodontic treatment causes obstructive sleep apnea [OSA]. Although concerns have been raised about premolar extractions, arch constriction, or headgear therapy reducing airway dimensions, studies have generally found no consistent relationship between these treatments and the development of OSA. Airway size alone does not determine airway function; sleep-disordered breathing is influenced by multiple factors, including neuromuscular control, craniofacial anatomy, obesity, and airway collapsibility. Large retrospective studies have found no increased prevalence of OSA in patients treated with premolar extractions compared with matched controls. Available research indicates that airway dimensions typically remain stable or increase over time in patients treated with headgear. While orthodontic treatment may influence dental and skeletal structures, there is insufficient evidence to suggest that these changes result in clinically significant impairment of airway function or predispose patients to OSA. Frenectomy remains an appropriate treatment for functional problems related to tongue-tie, such as speech, swallowing, or chewing difficulties. However, current evidence does not support frenectomy as a means of preventing or treating OSA.
Summary
Obstructive sleep apnea [OSA] is a serious medical condition that can affect both children and adults and should be considered during routine orthodontic evaluations. Orthodontists are encouraged to understand the signs and symptoms of OSA, screen patients for risk factors, and obtain a thorough history and clinical examination to identify individuals who may require referral. Patients suspected of having OSA should be referred to a physician, preferably a sleep medicine specialist, for definitive diagnosis, while pediatric and adult patients with significant nasal obstruction or adenotonsillar hypertrophy may benefit from evaluation by an otolaryngologist. Orthodontists may choose to participate in the treatment and monitoring of OSA. Responsibilities may include monitoring oral appliance therapy and managing treatment-related side effects. Importantly, current evidence does not support the claim that orthodontic treatment causes or increases the risk of OSA; rather, certain orthodontic interventions may contribute to OSA management in appropriately selected patients. Because OSA is a complex, multifactorial disorder, interdisciplinary collaboration among physicians, orthodontists, and other healthcare providers is essential to achieving optimal patient outcomes.
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