PEDIATRIC DENTISTRY V 43 / NO 4 JUL / AUG 21

CROSS-SECTIONAL STUDY

Determinants of Sleep-Disordered Breathing During the Mixed Dentition: Development

of a Functional Airway Evaluation Screening Tool (FAIREST-6)
James S. Oh, DDS1 • Soroush Zaghi, MD2 • Cynthia Peterson3 • Clarice S. Law, DMD, MS4 • Daniela Silva, DDS, MS5 • Audrey J. Yoon, DDS, MS6

Abstract: Purpose: The purpose of this study was to identify patterns of functional, extraoral, and intraoral examination characteristics that cor-
relate with increased risk of sleep disturbances and develop a functional airway screening tool to help clinicians for early diagnosis of pediatric
sleep-disordered breathing. Methods: From March 2018 until March 2019, a cross-sectional study was conducted of 96 mixed dentition children
during dental examinations at the UCLA pediatric dental clinic. Outcome measures included a sleep index score by the Sleep Disturbance Scale
for Children (SDSC) completed by parents. Clinical assessment tool measurements assessing functional, extraoral, intraoral soft tissue, and
intraoral hard tissue determinants were recorded during a routine dental examination by pediatric dental residents. Results: The mean age was
8.9 years (±1.9 years standard deviation), with 46 males and 50 females participating. Mouth-breathing (functional), mentalis strain (extra-
oral), tonsillar hypertrophy and ankyloglossia (intraoral soft tissue), dental wear, and narrow palate (intraoral hard tissue) were found to be the
most clinically deterministic of higher SDSC scores (P<0.01). A clinical assessment tool for sleep-disordered breathing in pediatric dental patients
(FAIREST-6) was developed, comprising these six clinical factors. Conclusions: The FAIREST-6 is a concise and validated clinical assessment tool
that may aid in early diagnosis and intervention of pediatric sleep-disordered breathing. (Pediatr Dent 2021;43(4):262-9.E34-E36) Received
August 20, 2020 | Last Revision April 19, 2021 | Accepted April 20, 2021
KEYWORDS: SLEEP-DISORDERED BREATHING, NASAL BREATHING, MOUTH-BREATHING, PEDIATRIC DENTISTRY, FUNCTIONAL AIRWAY EVALUATION SCREENING TOOL

Obstructive sleep apnea (OSA) is a common, chronic disorder
affecting four percent to nine percent of adults. 1 Comorbidi-
ties associated with OSA are well-documented, including hyper-
tension, cardiovascular disease, stroke, daytime sleepiness, and
reduced quality of life.2,3 Pediatric OSA, on the other hand, was
not recognized as a medical entity until 1976. The understand-
ing of its mechanisms remains limited, although it is associated
with several cardiovascular, metabolic, and neurocognitive
complications that can disrupt overall growth and development.4
The prevalence of OSA among children appears to be relatively
low, estimated to be approximately one to four percent.2,5
By contrast, sleep-disordered breathing (SDB) is increas-
ingly being recognized as a cause of morbidity in young chil-
dren, with a prevalence of up to 25 percent.2 SDB is a diagnostic
1 Dr. Oh is a pediatric dentist and an orthodontic resident at LLU School of Dentistry,
Loma Linda; 2Dr. Zaghi is an otolaryngologist, The Breathe Institute, Los Angeles, and
an attending physician, UCLA Health, Santa Monica; 3Ms. Peterson is a physical
therapist, The Breathe Institute, Los Angeles; 4Dr. Law is a Health Sciences clinical
professor, and 5Dr. Silva is a Health Sciences associate clinical professor, both in the
Section of Pediatric Dentistry, Division of Growth and Development, UCLA School of
Dentistry, Los Angeles; 6Dr. Yoon is an adjunct assistant professor, Stanford Sleep
Medicine, Department of Psychiatry and Behavioral Science, Stanford University, Stan-
ford, and a lecturer, Sections of Pediatric Dentistry and Orthodontics, Division of
Growth and Development, UCLA
category of disease encompassing a broad scope of obstructive
phenomena, ranging from mouth-breathing, noisy breathing,
and snoring to sleep apnea in late stages, 4 with the potential
for significant effects on the growth and development of a
child. Disruptions of respiration during sleep cause adverse im-
plications on cognition, behavior, cardiac function, and
growth.2,6 Yet, SDB remains markedly underdiagnosed. Mild
forms of SDB, such as mouth-breathing and snoring, are
potential risk factors for more severe indices of sleep apnea
later in life.7 In essence, the adult OSA patient is already at
the end of a dynamic spectrum of disease that is first identified
via early signs of SDB in the growing child, such as mouth-
breathing, restless sleep, dental grinding, attention/concentration
issues, and hyperactivity. Prevention-driven therapies should
be developed to identify the factors associated with SDB as
early as possible, with treatments initiated at the earliest recog-
nition of problems.
Although polysomnography is considered the disorder
gold standard for a sleep disorder diagnosis, it presents with
limitations in epidemiologic research due to its extensive time,
cost, and effort involved. Other assessments have been devel-
oped as less invasive diagnostic indicators. The Sleep Distur-
bance Scale for Children (SDSC), developed by Bruni et al.,
is a screening tool for parent-reported symptoms of sleep

e
School of Dentistry, Los Angeles, disorders in children. SDSC has been validated and demon-
all in Calif., USA. Supplemental material available
Correspond with Dr. Yoon at
strated internal consistency and reliability8; however, it consists
xtra in the online version.
jungdds@gmail.com of 26 items in a Likert-type scale and may not be easily included
as a routine element of every patient examination. There are
several clinical findings which can be evaluated as a part of a
HOW TO CITE: periodic dental examination that may raise the suspicion of
Oh JS, Zaghi S, Peterson C, Law CS, Silva D, Yoon AJ. Determinants of SDB. Some predisposing factors to SDB include a narrower
sleep-disordered breathing during the mixed dentition: Development
posterior airway space due to underdeveloped maxillofacial
of a functional airway evaluation screening tool (FAIREST-6). Pediatr
Dent 2021;43(4):262-9.E34-E36.
skeleton or increased lymphoid tissue; low tongue posture due
to mouth-breathing, tongue-thrust habit, or other myofascial

262 FUNCTIONAL AIRWAY EVALUATION SCREENING TOOL


dysfunction; underdeveloped musculature; poor neuromuscular
control; or other sources of low muscle tone and neurological
dysfunction.3,9-12
Downstream implications of SDB are well-
documented. 3,13,14 As such, early diagnosis and intervention
may ameliorate lifelong orofacial and systemic health defects.
Rather than adding a written assessment tool to the subjective
portion of the patient record, it may be more efficient to focus
on key elements of the extraoral and intraoral examination that
may indicate signs of SDB.
The purpose of the present study was to identify functional,
extraoral, and intraoral features associated with increased risk
of sleep disturbances in pediatric patients to develop a func-
tional airway screening tool to help clinicians for early diagnosis
of pediatric sleep-disordered breathing.
Methods
Design. From March 2018 until March 2019, a cross-sectional
study was conducted of 96 healthy children (mean age equals
8.9 years; range equals six to 12 years; participants included
46 males and 50 females) who presented for a dental exami-
nation at UCLA Children’s Dental Center, Los Angeles, Calif.,
USA. Exclusion criteria included craniofacial defects, prior
orthodontic therapy, prior tonsillectomy, and prior oral or
maxillofacial surgery. Outcome measures included a sleep
index score and a clinical factor assessment. Sleep index scores
were determined by SDSC, which was completed by patient
parents. The clinical factor assessments were recorded by one
of three calibrated UCLA pediatric dental residents. This study
was approved by the Institutional Review Board of the Univer-
sity of California, Los Angeles (protocol ID: 18-000810).
Sleep Disturbance Scale for Children (SDSC). SDSC,
developed in 1996 by Bruni et al., is a screening tool for
parent-reported symptoms of sleep disorders in children. It
comprises 26 items in a Likert-type scale with values ranging
from one to five, with higher numerical values reflecting
greater clinical severity of symptoms.8 The sum of the scores
was calculated to be the patient’s sleep index score (range
equals 26 to 130). Scores ranging from 26 to 35 are considered
to be within the normal range; scores of 36 to 44, 45 to 51,
and greater than 52 are considered to be at mildly, moderately,
severely, or increased risk for sleep disturbances, respectively.
Functional Airway Evaluation Screening Tool (objec-
tive measures). The pediatric version of the Functional Airway
Evaluation Screening Tool (FAIREST-15) comprises 15 items
that have been identified as dental, otolaryngologic, and func-
tional characteristics associated with increased risk of breathing-
related sleep disturbances in children15 This clinical examination
screening tool assesses the following characteristics:
1. classification of vertical, normal, or horizontal facial
growth pattern;
2. classification of sagittal facial growth profile (normal,
concave, convex);
3. classification of sagittal dental growth profile (Class I,
Class II, Class III);
4. Tongue range of motion ratio (TRMR, grade one,
two, three, or four)10;
5. Kotlow free tongue measurement, distance from the
tip of the tongue to insertion of the lingual frenulum
(12+ mm, eight to 12 mm, four to eight mm, zero to
four mm)16;
6. Kotlow upper labial frenum attachment (mucosal,
gingival, interdental papilla, palatine papilla)17;
PEDIATRIC DENTISTRY V 43 / NO 4 JUL / AUG 21
7. classification of chin strain upon mouth closure (none,
mild, moderate-severe);
8. Mallampati classification (Class 1, 2, 3, 4)18;
9. tonsillar hypertrophy, as measured by Brodsky scale
(less than 25 percent, 26 to 50 percent, 51 to 75 per-
cent, greater than 75 percent)19,20;
10. maxillary intercanine distance measured between
maxillary canine cusp tips (greater than 37 mm, 31 to
37 mm, less than 31 mm);
11. maxillary intermolar distance measured between max-
illary first molar mesiobuccal cusp tips (greater than
52 mm, 46 to 52 mm, less than 46 mm);
12. incisor display at rest, percentage of maxillary incisor
display during rest (zero to 25 percent, 26 to 50 percent,
51 to 75 percent, 76 to 100 percent);
13. bruxism, dental signs of wear (no wear detected, mild
dental wear, moderate dental wear, severe dental wear);
14. swallow tongue-thrust compensation test (swallow
with ease, swallow with difficulty, unable to swallow
without tongue-thrust compensation); and
15. nasal breathing test, duration of ability to nasal
breathe (three+ minutes, two to three minutes, one to
two minutes, less than one minute).
Clinical assessment tool (subjective measures). The
FAIREST-15 also includes six subjective measures that parents
were asked to rate on a descriptive scale regarding breathing
route, posture, concentration, and anxiety measures. Parents
were asked to rate on a scale of one to four the extent to
which their child breathes through their nose or mouth when
awake and when asleep, slouching seated posture, sleeping
position (primary supine versus nonsupine), and difficulty with
concentration; anxiety measures.15
Statistical analysis. Analysis of variance (ANOVA) was
performed to assess for statistically significant differences in
SDSC outcomes among the categorical clinical traits. Pearson
chi-square was used to identify the odds ratios for the factors
found to be most clinically significant for identifying patients
at risk of achieving a score ≥36 on the SDSC. To test inter-
examiner agreement, 10 patients were selected at random and
measured by all three residents. Intraclass correlation coeffi-
cient (ICC) in a mixed model was used to assess interrater
agreement among the three residents for clinical item mea-
surements. All showed excellent agreement (ICC greater than
0.85) according to Cicchetti’s guideline. Pairwise comparison
was adjusted by Tukey’s method to control for inflation of type
one error rate. Significance for all statistical tests was predeter-
mined at P<0.01.
Results
The mean age was 8.9 years (±1.9 years standard deviation)
among 46 males and 50 females. SDSC scores ranged from
27 to 88. There were 44 (45.8 percent) patients with SDSC
scores within the normal range (less than or equal to 35), and
36 (37.5 percent), 11 (11.5 percent), and five (5.2 percent)
patients had SDSC scores indicating mild (36 to 44), mod-
erate (45 to 51), and severe (greater than 52) increased risk
of sleep disturbances, respectively. Mouth-breathing (func-
tional), mentalis strain (extraoral), tonsillar hypertrophy and
ankyloglossia (intraoral soft tissue), and dental wear and narrow
palate (intraoral hard tissue) were found to be the most clin-
ically deterministic of higher SDSC scores (P<0.01; see
Supplemental Elecronic Data–sTable).
FUNCTIONAL AIRWAY EVALUATION SCREENING TOOL 263
PEDIATRIC DENTISTRY V 43 / NO 4 JUL / AUG 21

Functional findings (Figure 1). The swallowing tongue-
thrust compensation test (swallow with ease, swallow with
difficulty, or unable to swallow without tongue-thrust com-
pensation), nasal breathing test (less than one minute, one to
two minutes, two to three minutes, and three or more min-
utes), breathing route when awake (primarily nasal or some-
times, often, or almost always mouth), breathing route when
asleep (primarily nasal or sometimes, often, or almost always
mouth), and seated posture (rarely, sometimes, often, or almost
always slouches) showed statistically significant associations
with higher SDSC scores (ANOVA, P<0.01). Sleep position
(P=0.51) did not show statistically significant associations
with SDSC scores.
Extraoral findings (Figure 2). Facial pattern (dolichofacial
versus mesofacial/brachyfacial) and mentalis strain (none, mild,
moderate-severe) showed statistically significant associations
with higher SDSC scores (ANOVA, P<0.01). Facial profile
(P=0.23) did not show a statistically significant association
with SDSC scores.
Intraoral soft and hard tissue findings (Figure 3). Tongue
range of motion ratio (grades one to four), Kotlow free tongue
measurement (greater than 12 mm, eight to 12 mm, four to
eight mm, zero to four mm), tonsil size (less than 25 percent,
25 to 50 percent, greater than 50 percent), molar relationship
(Class II or III versus Class I), intercanine distance (less than
31 mm versus greater than 31 mm), intermolar distance (less
than 46 mm versus greater than 46 mm), and dental wear
(none versus mild versus moderate-severe) all showed statisti-
cally significant associations with higher SDSC scores (P<0.01).
Mallampati (M1, M2, M3/4) showed a trend toward signifi-
cance (ANOVA, P=0.013). Kotlow upper labial frenum
attachment (P=0.40) and incisor display (P=0.03) did not
show a statistically significant association with SDSC scores.
Psychosocial findings. There was a statistically significant
association (ANOVA) with higher SDSC scores among chil-
dren who expressed increased difficulty concentrating (rarely
to never equals 35.1±7.1, sometimes equals 39.5±6.1, often
equals 41.1±8.1, almost always equals 45.2±14.9, P<0.001).
Similarly, there was a significant association with higher
SDSC scores among children who expressed increased levels
of stress/anxiety (rarely anxious equals 35.9±7.1, sometimes
anxious equals 38.3±7.6, often stressed equals 42.4±9.0,
almost always stressed equals 54.3±29.9, P<0.001).
Clinical assessment tool for SDB in pediatric dental
patients (FAIREST-6). Among functional findings, the most
clinically significant factor predictive of increased SDSC scores
was mouth-breathing, as assessed by the nasal breathing test
(unable to breathe through the nose with lips sealed for greater
than three minutes), with an odds ratio of 7.2 (95 percent
confidence interval [95% CI] equals 2.5 to 21.2; Pearson
Chi-square test, P<0.001). Among extraoral findings, the
most clinically significant factor predictive of increased SDSC
scores was the presence of mentalis strain (moderate-severe),
with an odds ratio of 102 (95% CI equals 1.3 to 83.5;
P=0.009). Among intraoral soft tissue findings, the most clin-
ically significant factors predictive of increased SDSC scores
were tonsil hypertrophy (Brodsky grade three to four), with
an odds ratio of 16.7 (95% CI equals 3.6 to 76.1; P<0.001),
and ankyloglossia (Kotlow free tongue measurement less than
16 mm and/or TRMR grade three to four), with an odds ratio
of 3.6 (95% CI equals 1.5 to 8.5; P=0.003). Among intraoral
hard tissue findings, the most clinically significant factors

Figure 1. Functional findings versus Sleep Disturbance Scale for Children (SDSC) total score. There was a statistically significant
association with higher SDSC scores among children with swallowing tongue-thrust compensation or inability to swallow without
compensation, reduced nasal breathing capacity, habitual breathing route (nasal versus mouth) when awake and asleep, and
slouching posture with P<0.01 (ANOVA). The sleeping position did not show a statistically significant association with a P-value
threshold of <0.01.

264 FUNCTIONAL AIRWAY EVALUATION SCREENING TOOL

 PEDIATRIC DENTISTRY V 43 / NO 4 JUL / AUG 21

Figure 2. Extraoral findings versus Sleep Disturbance Scale for Children (SDSC) total score. There was a statistically significant
association with higher SDSC scores among children with dolichofacial (versus mesofacial/brachyfacial) pattern and the presence of
mentalis strain (moderate-severe). Facial profile (convex, normal, concave) did not show a statistically significant association with a
P-value threshold of <0.01 (ANOVA).

Figure 3. Intraoral soft and hard tissue findings versus Sleep Disturbance Scale for Children (SDSC) total score. There was a
statistically significant association with higher SDSC scores among children with restricted tongue mobility (TRMR), reduced free
tongue measurement (Kotlow), enlarged tonsil size (Brodsky), Class II/Class III (versus Class I) molar relationship, reduced inter-
canine distance (less than 31 mm versus greater than 31 mm), reduced intermolar distance (less than 46 mm versus greater than 46 mm),
and signs of dental wear (moderate-severe). Mallampati score approached clinical significance with a P-value of 0.013 (ANOVA).
Kotlow upper labial frenum attachment and incisor display did not show a statistically significant association with a P-value
threshold of <0.01.

FUNCTIONAL AIRWAY EVALUATION SCREENING TOOL 265

PEDIATRIC DENTISTRY V 43 / NO 4 JUL / AUG 21

Table 1. CLINICAL ASSESSMENT TOOL FOR SLEEP-DISORDERED BREATHING IN PEDIATRIC DENTAL PATIENTS (FAIREST-6)*
Domain Exam finding Clinical threshold Odds 95% confidence P-value**,
ratio interval Pearson

Functional Mouth-breathing Unable to breathe through nose with lips sealed for >3 minutes 7.2 2.5-21.2 <0.001
Extraoral Mentalis strain Lip incompetence characterized as moderate-severe dimpling of chin 10.2 1.3-83.5 0.009
upon mouth closure

Intraoral Tonsil hypertrophy Brodsky grade 3-4 (tonsils occupy >50% of oropharyngeal width) 16.7 3.6-76.1 <0.001
soft tissue Ankyloglossia Kotlow free tongue measurement <16 mm and/or TRMR grade 3-4 3.6 1.5-8.5 0.003

Dental wear Moderate to severe deterioration resulting in dentin exposure 19.0 4.6-77.4 <0.001
Intraoral
hard tissue Narrow palate Maxillary constriction defined as intercanine distance <31 mm and/ 8.5 3.2-22.6 <0.001
or intermolar distance <46 mm (mesiobuccal cusps)

* A clinical assessment tool for sleep-disordered breathing in pediatric dental patients was developed and validated based on an original 15-item screening tool
(FAIREST-15). The factors highlighted above were found to be the most clinically significant for identifying patients at risk of achieving a score 36 on the
SDSC (increased risk of sleep disturbance). Each of the six factors is an independent “red flag” for sleep-disordered breathing.
** Pearson chi-square test.

Table 2. SCORING TABLE FOR FAIREST-6 *

Number of red flags 0 1 2 3 4 5 6

Risk of sleep-disturbance Normal Mild Moderate Severe

* The score on the FAIREST-6 is equal to the sum of the number of exam findings present. Scores may range from zero (none of the items are present) to six
(all six of the concerning exam findings are present). A score of two corresponds to mildly increased risk of sleep disturbance; four indicates moderately increased
risk; six indicates severely increased risk.

predictive of increased SDSC scores were the presence of dental
wear (moderate-severe), with an odds ratio of 19.0 (95% CI
equals 4.6-77.4; P<0.001), and reduced intermolar distance
(less than 46 mm), with an odds ratio of 8.5 (95% CI equals
3.2 to 22.6; P<0.001).
The six factors highlighted above were found to be the
most clinically significant for identifying patients at risk of
achieving a score of 36 or greater on the SDSC (increased risk
of sleep disturbance. A more concise clinical assessment tool
comprised of these factors was developed (FAIREST-6; see
Table 1). Each of the six factors is an independent red flag for
SDB. Scores may range from zero (none of the items are pre-
sent) to six (all six of the concerning exam findings are present;
see Table 2).
The score on the FAIREST-6 is equal to the sum of the
number of red-flag items present on the clinical examination.
A score of two is associated with mildly increased risk (SDSC
greater than or equal to 36), four is associated with moderately
increased risk (SDSC greater than or equal to 45), six is associ-
ated with severely increased risk (SDSC greater than or equal
to 52; P<0.001). Patients presenting with increased risk
should be triaged to complete the SDSC, which consists of 26
Likert-type questions, 8 or referred for more comprehensive
evaluation (see Figure 4).
Discussion
The objective of the study was to identify determinants of
SDB to develop a concise and validated functional airway
evaluation screening tool for use in assessing the pediatric
dental population. The functional findings associated with
higher SDSC scores in this study include swallowing tongue-
thrust compensation, reduced nasal breathing capacity, habitual
mouth-breathing when awake or asleep, and slouching posture.
Among these, the most clinically significant factor was the
nasal breathing test (unable to breathe through the nose for
greater than three minutes). Traditionally, mouth-breathing and
airway obstruction have been considered to be a function of
soft tissue hypertrophy (tonsils, adenoids, turbinate structures)
as a result of an inflammatory or infectious cascade that sec-
ondarily obstructs the airway, inciting a progression from
mouth-breathing to obstructive sleep apnea and the resultant
implications on facial structure (i.e., the adenoid facies).9 This
has led to medical or surgical treatment of adenotonsillar and/
or inferior turbinate hypertrophy as the first-line approach in
the standard of care for pediatric SDB. Yet, current literature
data indicate that this approach is not often completely suc-
cessful.9,21 This has encouraged a potential paradigm shift in
the hypothesized progression of SDB in children. Guilleminault
et al. purport that orofacial dysfunction underlies structural
dysmorphisms that lead to the onset of pediatric SDB. 9,13,22
This Guilleminault Musculoskeletal Hypothesis purports that
oral, nasal, maxillary, and mandibular structural variations,
systemic inflammation, and/or postural maladaptations are
often one of the inciting factors that predispose children to
mouth-breathing, with variability being attributed to genetics,
evolution, and environment. 9 Mouth-breathing may induce
local inflammation at the site of the tonsils and adenoids,
introducing further obstruction into an already dysfunctional
airway and precipitating a vicious cycle of disease.21 Concur-
rently, postural maladaptations (due to fascial, muscular, neuro-
logical, or craniosacral restrictions) may lead to functional
variations that affect breathing, swallowing, and resting oral
posture. The functional variations, in turn, predispose to low
tongue posture and dysfunctional chewing and swallow habits

266 FUNCTIONAL AIRWAY EVALUATION SCREENING TOOL

 PEDIATRIC DENTISTRY V 43 / NO 4 JUL / AUG 21

interaction between adenoton-

sillar hypertrophy and restricted
development of the nasomaxil-
lary complex (adenoid facies) is
also widely appreciated. 11 In
addition, recent studies are now
recognizing restricted tongue
mobility as a significant risk
factor for mouth-breathing, snor-
ing, upper airway resistance, and
obstructive sleep apnea. 10,13,29,30
Alterations of the lingual frenulum
may contribute to oromyofas-
cial dysfunction and underdevel-
opment of the maxillofacial
skeleton, predisposing to sleep
d i s t u r b a n c e s . Tr a d i t i o n a l l y
assessed by free tongue length
measurement, more contempo-
rary assessment techniques
involve a functional classification
of restricted mobility.10 Other ear,
nose, and throat and medical
factors not assessed in this study
include weight (overweight or
underweight), height (failure to
thrive), and hypertension.28,31,32
The intraoral hard tissue
findings associated with higher
S D S C s c o re s i n t h i s s t u d y
include molar dental relationship
Figure 4. Increased risk of sleep disturbance by the number of red flags (FAIREST-6) in pediatric dental patients. The (Class II), narrow intercanine
score on the FAIREST-6 is equal to the sum of the number of red flag items present on the clinical examination. A score distance (less than 31 mm),
of two is associated with mildly increased risk (SDSC greater than or equal to 36), four is associated with moderately narrow intermolar distance (less
increased risk (SDSC greater than or equal to 45), six is associated with severely in-creased risk (SDSC greater than or than 46 mm), and the presence
equal to 52; P<0.001). Patients presenting with increased risk should be triaged to complete the SDSC, which consists
of 26 Likert-type questions, or referred for more comprehensive evaluation.
8 of dental wear (moderate-severe).
Among these, the most clini-
cally significant factor was the
that lead to the abnormal orofacial growth characterized as presence of moderate-severe dental wear and a narrow
adenoid facies–a decrease in the facial prognathism, a small intermolar distance. Class II molar relationship is most often
nose, a short upper lip, and an open-mouth posture associated characterized by mandibular retrognathia but can also involve
with a downward and backward rotation of the mandible, coincident underdeveloped maxilla. Narrow intercanine dis-
causing an increase in the anterior lower facial height with a tance and intermolar distance represent a transversely con-
resultant narrower anteroposterior upper airway dimension.23 stricted upper jaw. While the pathophysiology of bruxism
The extraoral findings associated with higher SDSC remains poorly understood, the prevalence of bruxism appears
scores in this study include a dolichofacial growth pattern and to be significantly increased in patients with sleep and
mentalis strain. The most clinically significant factor was the breathing disorders.33 It has been associated with fragmented
presence of mentalis strain (moderate-severe). Dolichofacial sleep, 34,35 arousals during sleep leading to increase in para-
pattern is characterized by a long, narrow facial phenotype. It functional activity,36,37 and activation of upper airway muscles
represents a vertical growth pattern, as the lower face length- as compensation for narrowed airway passages. 38,39 These
ens with the mandible growing downward. Mentalis strain is findings are consistent with prior descriptions of dental and
defined as perioral strain upon mouth closure. The etiology is craniofacial changes in children with SDB: long and narrow
often an underlying vertical or anteroposterior skeletal growth face, excessive vertical jaw growth, higher mandibular plane
discrepancy of the jaws. The impact of these craniofacial angle, constricted palatal width, decreased length of mandible
growth markers on airway and breathing is widely appreciated.24,25 and maxilla,40,41 tooth-grinding, clenching, wear facets, cusp
The intraoral soft tissue findings associated with higher fractures, temporomandibular dysfunction, and masseter
SDSC scores in this study include reduced tongue mobil- hypertrophy.42,43
ity (TRMR grade three to four), reduced free tongue length This study shows a significant association between slouch-
(Kotlow measurement less than 16 mm), and tonsillar hyper- ing posture and sleep disturbances in children. Postural charac-
trophy (Brodsky grade three to four). All measures were highly teristics affected by oral breathing (i.e., forward head posture,
clinically significant factors and included in the clinical assess- cephalic posture, slouching posture) are described by Denotti
ment tool. Adenotonsillar hypertrophy is widely recognized as et al.: hyperextension and antepulsion of the head, antepul-
a risk factor for SDB in pediatric patients.26-28 Similarly, the sion of the shoulders, lumbar hyperlordosis, and anteversion

FUNCTIONAL AIRWAY EVALUATION SCREENING TOOL 267

PEDIATRIC DENTISTRY V 43 / NO 4 JUL / AUG 21
of the pelvis. Low tongue position (attributable to mouth-
breathing, low tongue tone, and/or restricted tongue mobility)
has also been characterized to contribute to neuromuscular
imbalances and postural adaptations.44 Furthermore, mouth-
breathing behavior has been linked to the development of low
tongue tone, reduced tongue strength, and chewing inefficiency;
clinically this is observed as reverse swallow habit (i.e., tongue-
thrust) which may contribute to anterior open bite clinical
presentation.41,45 Indeed, this study shows a significant associ-
ation between swallowing tongue-thrust compensation (i.e.,
indicative of orofacial myofunctional disorder) and increased
SDSC scores.
The psychosocial findings associated with higher SDSC
scores in this study include difficulty concentrating and in-
creased levels of stress/anxiety. This may reflect a reduction in
parasympathetic tone and an increase in the HPA axis among
children with SDB.46 Prior studies show that SDB is highly
correlated with disruptive behavior disorders in childhood;
snoring has been associated with a twofold increase in the odds
of attention deficit with hyperactivity disorder diagnosis or
symptoms and obstructive sleep apnea associated with a three-
fold to fourfold increase in the odds of behavioral problems
or conduct disorders. 47 This is consistent with prior studies
showing a reduction in parasympathetic tone in children with
habitual snoring,46 reductions of growth hormone in mouth-
breathing children,32 suppressive effects on the growth hormone
axis and stimulatory effect on the HPA axis among adults with
sleep deprivation and chronic insomnia.6,24,31
In summary, this study shows various functional, extra-
oral, intraoral soft tissue, and intraoral hard tissue findings
that are comorbid in children at risk for pediatric SDB. The
following characteristics were found to be highly associated
with higher SDSC scores in this study: functional–nasal
breathing test (unable to breathe through the nose for greater
than three minutes); extraoral–the presence of mentalis strain
(moderate to severe); intraoral soft tissue–tonsil size (greater
than 50 percent obstruction) and tongue mobility (grade three
to four TRMR and/or less than 12 mm Kotlow free tongue
measurement); intraoral hard tissue–dental wear (moderate to
severe) and narrow palate (intercanine distance less than 31
mm and/or intermolar distance less than 46 mm). Based on
the discussion of the Guilleminault musculoskeletal hypothesis,
it is comprehensible how these three domains may be inter-
related. Recent reviews on the impact of tongue mobility on
the mechanics of resting oral posture and swallow function
suggest that such oral dysfunction may be a primary determi-
nant of malocclusion.45
Conclusions
Based on this study’s results, the following conclusions can
be made:
1. This study proposes a concise and validated screening
tool (FAIREST-6) comprising six clinical determi-
nants that can be used by dentists, physicians, and
allied health professionals in assessing pediatric pa-
tients for sleep-disordered breathing.
2. Because of the high incidence and substantial burden
of the consequences of untreated pediatric SDB, a
team approach that recruits attention from multiple
disciplines can optimize the likelihood of timely
recognition and early intervention for children with
SDB.
268 FUNCTIONAL AIRWAY EVALUATION SCREENING TOOL
3. Future research is needed to better understand the
mechanisms by which postural alterations (such as
low tongue posture, altered swallowing habits, and
inefficient chewing due to mouth-breathing) may
lead to underdevelopment of the maxillomandibular
skeleton that further predisposes to dysfunctional
breathing.
Acknowledgments
The authors wish to thank Dr. Jonathan Hurng (former pedi-
atric dentistry resident, Section of Pediatric Dentistry, Divi-
sion of Growth and Development, UCLA School of Dentistry,
Los Angeles), Dr. Jean Kang (former pediatric dentistry
resident, Section of Pediatric Dentistry, Division of Growth
and Development, UCLA School of Dentistry, Los Angeles),
Julia Peng (former dental student, UCLA School of Dentistry,
Los Angeles), and Michael Nedjat-Haiem (former dental
student, UCLA School of Dentistry, Los Angeles, all in Calif.)
for their assistance in data collection.
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Supplemental Electronic Data

sTable. Comprehensive Results of Total Score on the Sleep Disturbance Scale for Children (SDSC) by Each Exam Finding

n Mean±(SD) Min Median Max % of total P-value*

Functional
Swallowing tongue-thrust compensation test <0.001
Swallow with ease 53 34.3±5.7 27 33 49 50.9
Swallow with difficulty 33 41.4±11.7 27 39 88 38.2
Unable to swallow 10 39.0±8.8 28 37 54 10.9
Total 96 37.3±9.0 27 36 88 100.0
Nasal breathing test (minutes) <0.001
<1 4 48.8±26.5 30 38.5 88 5.5
1-2 11 45.0±11.6 28 46 70 13.8
2-3 15 40.8±6.0 33 41 58 17.1
3+ 66 34.5±5.5 27 34 49 63.6
Total 96 37.3±9.0 27 36 88 100.0
Breathing route when awake (nasal versus mouth) <0.001
Primarily nasal 53 34.6±6.1 27 33 54 51.2
Sometimes mouth 27 36.5±5.4 27 37 49 27.6
Often mouth 10 45.0±10.5 32 44 70 12.6
Almost always mouth 6 51.3±19.6 35 43.5 88 8.6
Total 96 37.3±9.0 27 36 88 100.0
Breathing route when asleep (nasal versus mouth) <0.001
Primarily nasal 48 33.8±5.1 27 33 49 45.3
Sometimes mouth 33 37.5±6.1 27 37 54 34.6
Often mouth 7 45.0±12.8 32 45 70 8.8
Almost always mouth 8 50.5±16.8 35 45 88 11.3
Total 96 37.3±9.0 27 36 88 100.0
Posture <0.001
Rarely slouches 67 35.2±6.8 27 34 70 65.9
Sometimes slouches 18 37.4±6.7 29 35.5 52 18.8
Often slouches 7 48.0±6.4 39 47 58 9.4
Almost always slouches 4 52.5±23.8 38 42 88 5.9
Total 96 37.3±9.0 27 36 88 100.0
Sleep position 0.51
Primarily supine 26 38.1±13.8 27 35.5 88 27.7
Supine >side/stomach 20 36.4±6.6 27 35.5 54 20.3
Side/stomach >supine 31 35.8±5.8 27 34 47 31.0
Primarily side/stomach 19 39.4±7.4 29 38 58 20.9
Total 96 37.3±9.0 27 36 88 100.0
Extraoral
Facial pattern 0.004
Dolicofacial 14 44.4±10.1 32 43 70 17.4
Mesofacial 68 36.2±8.8 27 35 88 68.8
Brachyfacial 14 35.2±5.8 28 36.5 46 13.8
Total 96 37.3±9.0 27 36 88 100.0

* P-value obtained from ANOVA.

270
E34 FUNCTIONAL AIRWAY EVALUATION SCREENING TOOL
 PEDIATRIC DENTISTRY V 43 / NO 4 JUL / AUG 21

sTable. Continued

n Mean±(SD) Min Median Max % of total P-value*

Facial profile 0.23

Convex 29 39.5±9.7 28 37 70 32.0
Normal 66 36.4±8.7 27 36 88 67.1
Concave 1 31.0 31 31 31 0.9
Total 96 37.3±9.0 27 36 88 100.0
Mentalis strain <0.001
No chin strain 51 32.9±4.3 27 32 45 47.0
Mild chin strain 34 39.2±5.6 28 38 49 37.3
Severe chin strain 11 51.3±16.1 33 47 88 15.8
Total 96 37.3±9.0 27 36 88 100.0
Intraoral soft tissue
Tongue range of motion ratio <0.001
Grade 1 29 32.6±4.7 27 32 45 26.4
Grade 2 49 36.5±6.8 28 36 70 50.0
Grade 3 17 47.2±12.5 33 46 88 22.5
Grade 4 1 43.0 43 43 43 1.2
Total 96 37.3±9.0 27 36 88 100.0
Kotlow free tongue measurement (mm) <0.001
>12 37 32.8±4.6 27 32 45 33.9
8-12 40 36.5±6.8 28 36 70 40.8
4-8 18 45.4±6.4 33 46 58 22.9
0-4 1 88.0 88 88 88 2.5
Total 96 37.3±9.0 27 36 88 100.0
Kotlow upper labial frenum attachment 0.39
Mucosal 45 38.6±11.4 27 36 88 48.6
Gingival 29 36.0±5.6 27 36 54 29.2
Papillary 22 36.2±6.9 27 36.5 52 22.3
Total 96 37.3±9.0 27 36 88 100.0
Tonsil size (%) <0.001
<25 33 33.2±5.1 27 33 46 30.6
25-50 38 35.7±5.7 28 35 49 37.9
50-75 23 44.9±12.8 33 41 88 28.9
>75 2 47.0±2.8 45 47 49 2.6
Total 96 37.3±9.0 27 36 88 100.0
Mallampati 0.006
M1 32 34.9±4.8 27 36 45 31.2
M2 43 36.7±8.4 27 35 70 44.1
M3 19 40.9±13.0 29 40 88 21.8
M4 2 53.5±6.4 49 53.5 58 3.0
Total 96 37.3±9.0 27 36 88 100.0

* P-value obtained from ANOVA. Table continued on the next page.

FUNCTIONAL
FUNCTIONAL AIRWAY
AIRWAY EVALUATION
EVALUATION SCREENING
SCREENING TOOL
TOOL E35
271
PEDIATRIC DENTISTRY V 43 / NO 4 JUL / AUG 21

sTable. Continued

n Mean±(SD) Min Median Max % of total P-value*

Intraoral hard tissue

Dental profile 0.012
Class I 63 35.3±6.3 27 35 58 62.2
Class II 27 41.0±12.9 27 37 88 30.9
Class III 6 41.2±7.2 31 42 49 6.9
Total 96 37.3±9.0 27 36 88 100.0
Intercanine distance (mm) <0.001
<31 49 41.3±10.4 28 38 88 56.5
>31 47 33.1±4.7 27 32 45 43.5
Total 96 37.3±9.0 27 36 88 100.0
Intermolar distance (mm) <0.001
<46 27 44.6±11.0 31 45 88 33.7
>46 69 34.4±6.2 27 34 70 66.3
Total 96 37.3±9.0 27 36 88 100.0
Incisor display (%)
0-25 8 33.0±4.9 27 34 40 8.3 0.04
26-50 44 35.3±6.3 27 35 58 45.8
51-75 37 39.7±11.5 27 37 88 38.5
76-100 7 41.7±8.9 31 41 54 7.3
Total 96 37.3±9.0 27 36 88 100.0
Dental wear <0.001
None 47 33.3±4.6 27 33 45 43.7
Mild 37 37.8±6.3 28 37 54 39.1
Moderate-severe 12 51.3±14.3 40 45.5 88 17.2
Total 96 37.3±9.0 27 36 88 100.0
Psychosocial
Difficulty concentrating <0.001
Rarely to never 68 35.1±7.1 27 34 70 70.8
Sometimes 8 39.5±6.2 31 39 52 8.3
Often 8 41.1±8.1 31 38.5 58 8.3
Almost always 12 45.3±14.9 32 42 88 12.5
Total 96 37.3±9.0 27 36 88 100.0
Stress/anxiety <0.001
Rarely 75 35.9±7.1 27 36 70 78.1
Sometimes 11 38.4±7.6 31 35 54 11.5
Often 7 42.4±9.0 32 38 58 7.3
Almost always 3 54.3±29.9 31 44 88 3.1
Total 96 37.3±9.0 27 36 88 100.0

* P-value obtained from ANOVA.

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E36 FUNCTIONAL AIRWAY EVALUATION SCREENING TOOL