Pacific Coast Society of Orthodontists Bulletin Spring 2018 - 25

Let's Talk About That

patients, and this interest is an extension of that.
However, at times I feel that orthodontists'
excitement and interest in sleep medicine is a
bit of a double-edged sword.
PT: You mean to say there is a downside to this?
BP: Don't get me wrong: I consider the increased
awareness among orthodontists about SDB and
its related health consequences a good thing; it
will undoubtedly improve the detection and
treatment of the disease in patients. However,
I think problems can arise when we become
overzealous about the issue. As we've seen
recently with other topics such as self-ligating
brackets or vibrating mouthpieces, our profession
sometimes dives headfirst into clinical practices
well before there is evidence to support their use.
I see this with SDB today as orthodontic and dental colleagues make claims of treating or even
preventing OSA with orthodontic treatment.
When these assertions are made for the sake of
promoting what is often early or interceptive
orthodontics in the absence of evidence, we risk
losing credibility with our medical colleagues -
and more importantly, our patients. Even more
worrisome is the practice of using the risks and
negative health impacts of OSA as scare tactics
to promote particular philosophies of orthodontic treatment.
PT: Describe your experience in treating children
with OSA.
BP: Through my association with our local children's hospital, I've been fortunate to develop a
great collaborative relationship with the otolaryngology department and some of the staff
surgeons with whom I share interest in certain
research questions. It was in this context that
a weekly multidisciplinary research clinic was
initiated wherein all children referred to the
department for concerns related to SDB are seen
concurrently by myself and an ENT surgeon. This
is a wonderful opportunity for me to learn the

Spring 2018  PCSO Bulletin

clinical assessment and management of children
with SDB, and to determine where orthodontics
might play a role. A short time after establishing
the clinic, we began a clinical trial investigating
the efficacy of maxillary expansion as a treatment for children with obstructive sleep apnea.
PT: Tell me more about this clinical trial.
BP: The protocol was to screen all children
between 5 and 10 years of age who presented to
the clinic. To be eligible for the trial, a child had
to present with a posterior crossbite and hypertrophic tonsils and adenoids; each child with
these findings underwent an overnight sleep test
at the hospital to objectively diagnosis OSA and
its severity. A child who met all of these three
main criteria was then treated with maxillary
expansion following a typical protocol. A followup sleep test was performed five months later to
assess the treatment effect.
PT: What did you learn from this trial?
BP: For me, the biggest surprise was that the vast
majority of patients with complaints or eventual
diagnosis of OSA had no obvious malocclusion
or altered facial morphology. I expected a much
greater number of children to present with the
classic long/narrow face, constricted maxilla,
and perhaps anterior open bite, but this simply
wasn't the case. Our subsequent analysis of
screened patients found that the prevalence of
posterior crossbite in this cohort was no greater
than what has been reported in the general population at similar ages.1 Secondly, in patients I
treated with maxillary expansion, there was wide
variation in individual response in terms of OSA
signs and symptoms. Some of these children
had their OSA completely eliminated following
expansion; some saw no improvement at all; and
a few others actually had their OSA objectively
get worse. Our trial was too small to determine
reasons for these differences, but clearly expansion is not always corrective. The challenge will

Table of Contents for the Digital Edition of Pacific Coast Society of Orthodontists Bulletin Spring 2018