CRANIO®

The Journal of Craniomandibular & Sleep Practice

ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/ycra20

Evaluation of the relationship between

malocclusions and sleep-disordered breathing in
children

Sacide Duman & Handan Vural

To cite this article: Sacide Duman & Handan Vural (2020): Evaluation of the relationship
between malocclusions and sleep-disordered breathing in children, CRANIO®, DOI:
10.1080/08869634.2020.1779508

To link to this article: https://doi.org/10.1080/08869634.2020.1779508

Published online: 13 Jun 2020.

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 ®
CRANIO : THE JOURNAL OF CRANIOMANDIBULAR & SLEEP PRACTICE
https://doi.org/10.1080/08869634.2020.1779508

SLEEP

Evaluation of the relationship between malocclusions and sleep-disordered

breathing in children
Sacide Duman DDS, PhD and Handan Vural DDS
Department of Pediatric Dentistry, Faculty of Dentistry, Inonu University, Malatya, Turkey

ABSTRACT KEYWORDS
Objective: To determine the relationship between dental/skeletal malocclusions and sleep- Malocclusion; Pediatric Sleep
disordered breathing (SDB) in the early diagnosis and treatment of sleep disorders in children. Questionnaire; sleep-
Methods: Patients were evaluated by pedodontists to identify dental, skeletal, and functional disordered breathing; snore
malocclusion (n = 240; <15 years). In order to determine the sleep and daytime behavior of the
patients, pediatric sleep questionnaires (PSQ) were applied. Per results of the PSQ, patients with
a mean of ≥ 0.33 were defined as the high-risk group.
Results: A total of 25.8% children were in the high-risk group, with the most convex profile, high-
angle growth direction, and mandibular retrognathy. The prevalence of habitual snoring, mouth
breathing, and dry mouth was 48.4%, 64.5%, and 87.2% among all high-risk children, respectively.
Conclusion: Convex profile, high-angle growth direction, and retrognathic mandible were deter­
mined as risk factors for SDB. The prevalence of dry mouth, mouth breathing, and snoring was
higher in the high-risk group.

Introduction SDB in middle-childhood and adolescence [3]. The most

significant causes of encountering SDB in childhood are
Clinical conditions that emerge as a result of pathologi­
adenotonsillar hypertrophy, craniofacial malformations
cal changes that are encountered in respiration during
(Crouzon, Apert, Pierre Robin syndromes, etc.), max­
sleep and lead to increased morbidity and mortality in
illary narrowness, mandibular retrusion, neuromuscular
patients are known as sleep-disordered breathing (SDB)
diseases (Muscular Duchenne/Becker dystrophy, cere­
[1]. SDB is a clinical problem that is increasingly becom­
bral palsy, etc.), and rhinological reasons (allergic rhini­
ing prevalent among children, and there is a set of
tis, deviated septum, etc.) [2–4]. It is thought that
difficulties in its diagnosis [2]. The nighttime symptoms
bruxism also affects sleep quality in children and plays
of SDB in pediatric patients are highly noticeable, and
a role in the etiology of SDB [5].
these are the reasons that direct parents to physicians.
In the diagnosis of SDB, polysomnography (PSG) is
The typical nighttime symptoms of SDB include mouth
used as the gold standard [1,2]. However, usage of PSG
breathing, night sweats, nocturnal enuresis, irregular
in pediatric patients is a debated issue due to difficulty of
sleep, difficulty in breathing, and snoring. Daytime
application and assessment, lack of standardization, and
symptoms, such as getting tired quickly, hyperactivity,
limitation of epidemiological studies that aim to reach
bad temper, development and growth disability, daytime
broad masses [1–7]. Symptoms in the etiology of SDB
mouth breathing, learning disability, and low school
that affect the quality of life of children, such as cranio­
performance are not noticeable at the initial stages of
facial development anomalies, malocclusions, and brux­
the disease. These symptoms are frequently not noticed
ism may be diagnosed and treated by dentists. In the
by parents, and they are only discovered when asked
diagnosis and treatment of SDB, it is important for
about them. Sleep-disordered breathing problems that
dentists, otorhinolaryngology specialists, and pediatri­
occur on various levels, when they are not treated, may
cians to pursue a collaborative process with
lead to cardiovascular, metabolic, and neurocognitive
a multidisciplinary approach [5]. Questionnaires that
disorders, in addition to behavioral disorders [1–4].
may be easily applied by dentists, which are proven for
SDB is seen most frequently in the age range of usefulness and validity in early diagnosis, may also be
2–8 years in children, but with the increase in predis­ used to diagnose SDB [8,9]. The Pediatric Sleep
posing factors, increases are observed in the incidence of Questionnaire (PSQ) is one of the pre-diagnosis

CONTACT Sacide Duman sacidetuncduman@gmail.com Department of Pediatric Dentistry, Faculty of Dentistry, Inonu University, Malatya 44280,
Turkey
© 2020 Taylor & Francis Group, LLC
2 S. DUMAN AND H. VURAL
methods that may be easily applicable by dentists and
allow timely interventions in children with suspicion of
sleep disorders [9].
Recently, the presence of malformations in craniofa­
cial growth has been associated with SDB in children
[10]. The most frequent craniofacial malformations
reported in SDB children are retrognathia, midface
hypoplasia, narrowness of the upper jaw, macroglossia,
and anterior open bite [11–13]. Systematic reviews evi­
denced the association between maxillomandibular vari­
ables and sleep disorder, suggesting that children with
sleep disorders have a narrower maxilla and posterior
crossbite, anterior open bite, and a dolichofacial man­
dibular growth direction in comparison to normal chil­
dren [14,15].
There are very few studies investigating the relation­
ship between SDB and malocclusions in the use of PSQ
and the role of dentists in the pre-diagnosis and gui­
dance of SDB. The purpose of this study is to determine
the relationship between dental/skeletal malocclusions
and sleep disorders in the early diagnosis and treatment
of sleep disorders in children.
Materials and methods
In this study, 500 pediatric patients who visited the
Pedodontics Department of a Faculty of Dentistry in
Turkey between January 2019 and June 2019 were
evaluated.
All procedures performed in studies involving human
participants were in accordance with the ethical stan­
dards of the institutional and/or national research com­
mittee and with the 1964 Helsinki declaration and its
later amendments or comparable ethical standards. The
necessary permissions and approvals for the study were
obtained from the Ethics Committee of the University
(Approved number:2019/78). Additionally, the children
and their parents were informed about the purpose of
the study, and their consent was obtained. By statistical
analysis, the minimum sample size for determining the
sleep disorder rate in children with malocclusion in the
age group of 7–15 in a 95% confidence interval (α = 0.05)
and with a deviation of d = 0.04 (n = 114) was
determined.
Two hundred-forty patients were included in this
study. The inclusion criteria for the study included the
following: age 7–15 years, having malocclusion but with­
out orthodontic treatment started, having normal or
lower than average weight (<85th percentile), and hav­
ing no serious health problems. Syndrome patients with
craniofacial anomalies, allergic patients, patients with
nasal airway obstruction or deviated septum, patients
with cleft lip and palate, and those with tonsillar
hypertrophy were excluded. While determining tonsillar
hypertrophy, Grade 0 and Grade 1 patients, based on the
Brodsky [16] classification, constituted this sample.
The first dental examination of the children who were
included in the study was performed, and malocclusions
were categorized and recorded. Intramaxillary anoma­
lies, intermaxillary anomalies, and sagittal, vertical, and
transversal direction anomalies were separately grouped
and recorded in the malocclusion form at the clinic by
a pediatric dentist (S.D.), who had at least 5 years of
experience in the field, and a research assistant (H.V.).
Visual clinical evaluation of the dental component of the
malocclusion included molar and canine angle classifi­
cations, number and location of crossbites, and maxil­
lary and mandibular dental arch crowding or spacing.
Ten percent of the patients were re-evaluated in different
rooms by pedodontists (S.D. and H.V.), and interobser­
ver reliability values were found by using Cohen’s
kappa (0.83).
In the clinical diagnosis of malocclusions, the study
by Hyun et al. [17] was used as a reference for skeletal
visual evaluations. The clinical facial assessment of the
patients included the following: (1) a profile analysis
(considering a line from the base of the nose to the
base of the upper lip and the second line from this
point to the chin, convex if there is a narrow angle
between these two lines and concave if there is a wide
angle); (2) frontal appearance for facial thirds analysis
(low, normal, or high face height); and (3) visualization
of the mandibular plane angle with fingers along the
mandibular boundary (flat, normal, or steep). The asym­
metries of the dental medial line with the facial medial
line were noted to assess the relationship of dentition
with the face.
Visual clinical assessment of skeletal variables
involved the following: (1) transverse direction analy­
sis: the widths of the maxilla and mandible were cate­
gorized as decreased when there were black triangles in
posed smiling, normal when there were suitable
widths, and increased when they appeared excessively
broad; (2) vertical dimension analysis of facial ratios in
frontal and lateral appearances, where the face was
assessed by division into three parts; the vertical
dimension was recorded as decreased when the lower
third of the face was smaller than the middle and upper
thirds, normal in well-proportioned faces, and
increased when the lower third was larger; and (3)
anteroposterior dimension analysis was categorized as
decreased when the mandible was in a posterior posi­
tion in reference to the maxilla in the lateral appear­
ance, normal when both jaws were proportional, or
increased when the mandible was in an anterior posi­
tion [17].
 CRANIO®: THE JOURNAL OF CRANIOMANDIBULAR & SLEEP PRACTICE
Pediatric Sleep Questionnaire (PSQ)
To determine sleep disorders, and especially sleep-
related respiratory problems, with a sleep scale, the
PSQ that was developed by Chervin et al. [9] was
utilized. The scale has two different versions, with 22
and 72 questions. In this study, the 22-question version
that was adapted into Turkish by Yüksel et al. [18] and
tested for validity and reliability was used. The PSQ
form consists of 22 questions including four on sleep­
lessness, four on snoring, eight on breathing problems,
and six on behavioral disorders. While assessing the
questionnaire, the items are answered as 1, 0, and for
the missing answers, “yes”, “no,” and “I do not know.”
The total score is the average of the scores of all items,
except for the missing responses. The most effective
cutoff value of the scale for pediatric obstructive sleep
apnea was determined as 0.33 [9,18]. According to the
results of the sleep questionnaire, the patients with
a score of 0.33 and above were defined as the high-
risk group, and the patients with scores below 0.33
were defined as the low-risk group.
The parents were informed about SDB, its symptoms
in children, the content of this questionnaire, and the
study. Necessary permissions were taken from the par­
ents. For the reliability of the questionnaire, attention
was paid to include the children of literate parents who
did not have a noticeable learning disability. To prevent
the parents from providing misleading or incomplete
information, appointments were set to allow at least
one week between the first examination and the appoint­
ment, and the parents were told that they needed to
observe their children until the date of the appointment.
The sleep questionnaire was applied to the parents who
came for the appointments regarding their children.
There were three questions in the PSQ to determine
the snoring frequency (“Do you hear your child snor­
ing?”, “Does your child snore more than half of the
time?”, and “Does your child always snore?”). However,
in order to elaborate the question on “always snoring,”
the question, “How many nights of the week does your
child snore?” was added by the authors as a modification.
The children who were identified as snorers were also
classified according to their frequency of snoring (No
snoring, 1–3 times a week, or 3 or more times a week),
with those who reported to snore 3 or more times a week
considered to be “habitual snorers” [19].
The patients’ mouth breathing activities were assessed
with eight questions. Questions on “daytime mouth breath­
ing” and “dry mouth on awakening” (wet lip corner, wet
pillow, halitosis, feeling of dryness in the throat, etc.) were
evaluated in detail. The patients were classified according to
their low- and high-risk groups about this parameter.
3
Statistical analysis
The data were analyzed by the SPSS 13.0 (Chicago, IL,
USA) statistical package. P-values of < 0.05 were
regarded as statistically significant. Pearson’s chi-
squared test was used to evaluate the statistical relation­
ships between the clinical examination parameters, sex,
and the reported sleep-disordered breathing symptoms.
Results
General data
The sample of the study consisted of a total of 240 chil­
dren in the age group of 7–15 years with the mean age of
11 (± 2.1), including 45% (n = 108) male and 55%
(n = 132) female patients. Fifty-five percent of the children
were in mixed dentition, while 45% were in permanent
dentition. The children mostly had a convex profile
(46.7%) and high-angle growth direction (40%). In all
children, maxillary retrognathia had a rate of 29.2%
(n = 70), while mandibular retrognathia had a rate of
40% (n = 96). In the assessment of dental variables in
the anteroposterior direction, the most common molar
relationship was found in Class II subdivision I (35%) in
all children, followed by Class III (30.8%), Class I (29.2%),
and Class II subdivision II (5%). There was increased
overjet among 38.3% of the children and negative overjet
in 16.7%. There was 14.2% open bite and 20.8% deep bite
in the vertical direction; children with 4 mm or more open
bite constituted 2.5% of the sample, and those with deep
bite in more than 2/3 of the lower incisors constituted
6.7%. In the transversal direction, the presence of posterior
crossbite was at the rate of 31.6%, while the ratio of the
children with crossbite in 3 or more teeth in the posterior
was 17.5%. In the anterior, those with crossbite in at least
1 tooth constituted 40.8% of the sample. There was crowd­
ing in the anterior segment in 70% of the children, while
20% had lip deficiency. When assessed in terms of profile
and growth directions, no statistically significant differ­
ence was found between the high- and low-risk groups
(p > 0.05), but in evaluation of skeletal variables according
to jaws, the difference between the high- and low-risk
groups was statistically significant (p < 0.05).
Assessment of malocclusions in children in the
high-risk group
In the high-risk group, there were a total of 25.8%
(n = 62) children with the mean age of 11 (± 2.4),
including 32 (51.6%) male and 30 (48.4%) female chil­
dren. Just over sixty-one percent (61.3%) of these chil­
dren were in mixed dentition, while 38.7% were in
permanent dentition.
4 S. DUMAN AND H. VURAL

The children in this group mostly had a convex pro­
file (48.4%) and high-angle growth direction (54.8%). In
this group, the boys (n = 32) mostly had a convex profile
(56.3%), but the girls (n = 30) had equal rates of convex
(40%) and concave profiles (40%). When the growth
direction was evaluated, a low-angle growth direction
was the most frequent among the boys (56.3%), while
a high-angle growth direction was the most frequent
among the girls (80%) (p < 0.01) (Table 1).
In the children in the high-risk group, maxillary
retrognathia had a rate of 32.3% (n = 20), while man­
dibular retrognathia had a rate of 54.8% (n = 34). In this
group, 33.3% of the girls (n = 10) and 31.3% of the boys
(n = 10) had maxillary retrognathia. Mandibular retro­
gnathia was present in 66.7% of the girls (n = 20) and
43.8% of the boys (n = 14) (Table 2).
The most common molar relationship was found as
Class III (35.5%) in the high-risk children, followed by
Class II subdivision I (29%), Class I (29%), and Class II
subdivision II (6.5%) (Table 3). There was increased over­
jet in 25.8% of the children in the high-risk group, and
negative overjet was in 22.6%. There was 24% open bite
and 12% deep bite in the vertical direction; the children
with 4 mm or more open bite constituted 7.4% of the
sample, and those with deep bite in more than 2/3 of the
lower incisors constituted 12%. In the transversal direc­
tion, the presence of posterior crossbite was at the rate of
45.2%, while the ratio of children with crossbite in 3 or
more teeth in the posterior was 29%. In the anterior, those
with crossbite in at least 1 tooth constituted 59.2% of the
sample. There was crowding in the anterior segment in
71% of the children, while 20.8% of the children who had
lip deficiency were in the high-risk group.
Assessment of the Pediatric Sleep Questionnaire
The overall prevalence of snoring was found to be
47.50% (n = 114) (Table 4). The prevalence of habitual
snoring (3 or more times a week) was found to be
48.4% (n = 30) among all high-risk children (n = 62),
26.3% among snorers (n = 114), and 12.5% among all
participants (n = 240) (Table 4). In the children in the
high-risk group, the prevalence of habitual snoring was
higher in the girls (53.3%) than in the boys (43.8%)
(Table 5).
In evaluation of the respiratory questions, 45.2%,
19.4%, and 19.4% of the parents of the children in the
high-risk group answered ‘‘yes’’ to the questions about
“children having trouble breathing or struggling to
breathe,” “children having heavy and loud breathing,”
and “having seen children stop breathing during the
night,” respectively. The overall prevalence of mouth
breathing was found to be 37.50% (n = 90) (Table 4).
The prevalence of mouth breathing was found to be
64.5% (n = 40) among all high-risk children (n = 62)
(Table 4), 44.4% among children with mouth breathing
(n = 90), and 16.6% among all participants (n = 240). In
the children in the high-risk group, the prevalence of
mouth breathing was higher in the boys (66.8%) than in
the girls (60.8) (Table 6). Moreover, the prevalence of
dry mouth was found to be 87.2% (n = 54) among all
high-risk children (n = 62), 44.2% among children who
had mouth breathing (n = 122), and 22.5% among all
participants (n = 240) (Table 4). In the children in the
high-risk group, the prevalence of mouth breathing was
higher in the boys (87.5%) than in the girls (86.7%)
(Table 6).

Table 1. Evaluation of skeletal variables, according to profile, growth direction.

Profile Growth Direction
Normal Convex Concave Normal Low High
n (%) n (%) n (%) p- value n (%) n (%) n (%) p- value
Low- risk Girls 26 (25.5) 56 (54.9) 20 (19.6) .011* 30 (29.4) 40 (39.2) 32 (31.4) .219
Boys 22 (28.9) 26 (34.2) 28 (36.8) 14 (18.4) 32 (42.1) 30 (39.5)
Total 48 (27.0) 82 (46.1) 48 (27.0) 44 (24.7) 72 (40.4) 62 (34.8)
High- risk Girls 6 (20.0) 12 (40.0) 12 (40.0) .380 2 (6.7) 4 (13.3) 24 (80.0) .000*
Boys 6 (18.8) 18 (56.3) 8 (25.0) 4 (12.5) 18 (56.3) 10 (31.3)
Total 12 (19.4) 30 (48.4) 20 (32.3) 6 (9.7) 22 (35.5) 34 (54.8)
Chi-square analysis; *p < 0.05; n: number of teeth; %: frequency.

Table 2. Evaluation of skeletal variables, according to jaws.

Maxilla Mandible
Normal n n (%) Prognathic n (%) Retrognathic n (%) p- value Normal n n (%) Prognathic n (%) Retrognathic n (%) p- value
Low- risk Girls 44 (43.1) 36 (35.3) 22(21.6) .018* 48 (47.1) 18 (17.6) 36 (35.3) .007*
Boys 34 (44.7) 14 (18.4) 28(36.8) 22 (28.9) 28 (36.8) 26 (34.2)
Total 78 (43.8) 50 (28.1) 50(28.1) 70 (39.3) 46 (25.8) 62 (34.8)
High- risk Girls 14 (46.7) 6 (20.0) 10(33.3) .580 6 (20.0) 4 (13.3) 20 (66.7) .082
Boys 12 (37.5) 10 (31.3) 10(31.3) 6 (18.8) 12 (37.5) 14 (43.8)
Total 26 (41.9) 16 (25.8) 20(32.3) 12 (19.4) 16 (25.8) 34 (54.8)
Chi-square analysis; *p < 0.05; n: number of teeth; % frequency.
 CRANIO®: THE JOURNAL OF CRANIOMANDIBULAR & SLEEP PRACTICE 5

Table 3. Evaluation of risk groups according to Class I, Class II div. 1, Class II div. II, Class III classification.
Class I Class II Div. I Class II Div. II Class III
n (%) n (%) n (%) n (%) p-value
Low-risk Girls 36 (35.3) 42 (41.2) 4 (3.9) 20 (19.6) .008*
Boys 16 (21.1) 24 (31.6) 4 (5.3) 32 (42.1)
Total 52 (29.2) 66 (37.1) 8 (4.5) 52 (29.2)
High-risk Girls 8 (26.7) 8 (26.7) - 14 (46.7) .111
Boys 10 (31.3) 10 (31.3) 4 (12.5) 8 (25.0)
Total 18 (29.0) 18 (29.0) 4 (6.5) 22 (35.5)
Chi-square analysis; div: division; *p < 0.05; n: number of teeth; %: frequency.

Table 4. Distribution of participants’ response related to snoring frequency, snores loudly, mouth breathing, and dry mouth.
Yes No No idea Total
n (%) n (%) n (%) n (%)
Do you hear your child snoring? 1–3 per week ≥3 per week
Low-risk 44 (24.7) 26 (14.6) 108 (60.7) - 178 (100)
High-risk 14 (22.5) 30(48.4) 18 (29.1) - 62 (100)
Total 114 (47.5) 126 (52.5) - 240 (100)
Snore loudly? Low-risk 10 (5.6) 164 (92.1) 4 (2.3) 178 (100)
High-risk 10 (16.2) 46 (74.1) 6 (9.7) 62 (100)
Total 20 (8.3) 210 (87.5) 10 (4.2) 240 (100)
Tend to breathe through the mouth during the day? Low-risk 50 (28.1) 110 (61.8) 18 (10.1) 178 (100)
High-risk 40 (64.5) 16 (25.8) 6 (9.7) 62 (100)
Total 90 (37.5) 126 (52.5) 24 (10.0) 240 (100)
Have a dry mouth on waking up in the morning? Low-risk 68 (38.2) 104 (58.4) 6 (3.4) 178 (100)
High-risk 54 (87.2) 4 (6.4) 4 (6.4) 62 (100)
Total 122 (50.8) 108 (45.0) 10 (4.2) 240 (100)
n: number of teeth; %: frequency.

Table 5. Distribution of participants’ response related to snoring frequency and snores loudly, according to gender.
No Snoring 1–3 per week ≥3 per week Snores loudly - Snores loudly + No idea
n (%) n (%) n (%) p- value n (%) n (%) n (%) p- value
Low- risk Girls 62 (60.8) 26 (25.5) 14 (13.7) .912 98 (96.1) 4 (3.9) - .030*
Boys 46 (60.5) 18 (23.7) 12 (15.8) 66 (86.8) 6 (7.9) 4 (5.3)
High- risk Girls 6 (20.0) 8 (26.7) 16 (53.3) .308 18 (60.0) 8 (26.7) 4 (13.3) .041*
Boys 12 (37.5) 6 (18.8) 14 (43.8) 28 (87.5) 2 (6.3) 2 (6.3)
Chi-square analysis; *p < 0.05; +: answer = yes; -: answer = no; n: number of teeth; %: frequency.

Table 6. Distribution of participants’ responses related to mouth breathing and dry mouth, according to gender.
Dry
Mouth Breathing - Mouth Breathing + No idea Mouth - Dry Mouth + No idea
n (%) n (%) n (%) p- value n (%) n (%) n (%) p- value
Low- risk Girls 62 (60.8) 30 (29.4) 10 (9.8) .900 56 (54.9) 42 (41.2) 4 (3.9) .528
Boys 48 (63.2) 20 (26.3) 8 (10.5) 48 (63.2) 26 (34.2) 2 (2.6)
High- risk Girls 8 (26.7) 18 (60.0) 4 (13.3) .606 4 (13.3) 26 (86.7) - .018*
Boys 8 (25.0) 22 (68.8) 2 (6.3) - 28 (87.5) 4 (12.5)
Chi-square analysis; *p < 0.05; +: answer = yes; -: answer = no; n: number of teeth; %: frequency.

Discussion reported that skeletal anomalies, such as maxillary or

The upper airway volume, which plays an important role
in development of occlusion and the maxillofacial com­
plex, is in a close relationship with the pharyngeal airway
during swallowing and speech [6]. Narrowing in the
upper airways is one of the main factors in the etiology
of sleep disorders, especially Pediatric Obstructive Sleep
Apnea Syndrome (POSAS). Several studies have
mandibular retrusion, are effective in the narrowing of
upper airways [5,15,19,20]. The purpose of the study was
to reveal the relationship between the factors that nar­
row down the upper airway in children with malocclu­
sion and sleep disorders and support pre-diagnosis of
SDB with a questionnaire that can be easily applicable at
the clinic.
6 S. DUMAN AND H. VURAL
Owens et al. found that 16.5% and 18.2% of pediatri­
cians did not examine the sleep disorders of healthy
infants and toddlers in their routine examinations,
while this percentage rose to 43.9% in adolescents [21].
A similar situation exists among dentists. In the
American Dental Association (ADA) clinical practice
guide for 2015–2016 [22] and the study published in
2017 by Masoud et al. [23], the importance of dentistry
and the necessity of the dentist to play an active role in
assessment of sleep and airways and help in pre-
diagnosis of SDB were emphasized. In terms of deter­
mining the SDB prevalence in the pediatric population
by using PSQ and assessment of the relationship
between malocclusions and SDB, this study is the first
one in Turkey in the field of dentistry.
The data in the study published in 2015 by Kaditis
[24] were data that covered the general pediatric popu­
lation. In children, the incidence of apnea-related sleep-
disordered breathing cases was reported in the range of
0.7–3.0% [19,24,25]. Rohra et al. [20] investigated SDB
risk factors by applying the PSQ on children who visited
their orthodontics clinic and found the prevalence of the
group with a high risk of SDB to be 7.3%. In this study,
the SDB risk rate among the children with malocclu­
sions was noticeably high, at 25.8%. However, as pedia­
tric patients with malocclusions in whom the upper
respiratory pathway may have been majorly or minorly
affected were selected directly, it is thought that the
differences in the rate of patients with SDB risk and
related data in this study were a predictable result.
In the questionnaire study by Huynh et al. that exam­
ined the relationship between SDB symptoms and den­
tofacial morphometry, it was reported that there was
a relationship between patients with crossbite in two or
more teeth and a narrow and long face (dolichofacial);
and increased mandibular plane angle, maxillary nar­
rowness, and severe crowding in the mandible may be
risk factors of SDB [17]. In addition, especially, factors
like narrow and long maxilla and posterior crossbite,
anterior open bite, predisposition to lip deficiency, and
increased frontal face height (adenoid face time) narrow
down the upper airway, the incidence of snoring, mouth
breathing, and SBD is higher among individuals with
malocclusions in comparison to normally developed
individuals [15,17,20,23,26]. Increased frontal face
height, retrognathic mandible, narrow maxilla, posterior
crossbite, and anterior open bite were the SDB risk
factors in this study and were similar to those in the
study by Rohra et al. [20].
In a meta-analysis of published studies, the preva­
lence of habitual snoring was 7.45% [25]. Another
study reported that the prevalence of snoring varied
between 2.9% and 10.9% [17]. In this study, the
prevalence of snoring and habitual snoring in the chil­
dren with malocclusions was found as 47.50% and
26.3%, respectively, and higher than the prevalence
found by Zaimoğlu et al. (37.60% and 16.84%, respec­
tively) [19]. Huyn et al. [17] found that the prevalence of
breathing problems during the night was 1.8% to 5.1%,
while these values were 34% and 36.1% for signs of
mouth breathing and dry mouth on awakening, respec­
tively [17]. In this study, the ratio of the parents who
reported that their children performed mouth breathing
during the day was 37.5%, and the prevalence of dry
mouth in the children was found to be 50.8%.
Additionally, these rates were higher in the children in
the high-risk group, and because habitual snoring,
mouth breathing, and dry mouth were also associated
with sleep-disordered breathing, they may all be related
to increased nasal resistance caused by malocclusion.
Rohra et al. [20] found that boys were affected by SDB
more frequently than girls. In this study, although the
rate of the girls with malocclusion (55%, n = 132) was
higher than that of the boys (45%, n = 108), the percen­
tage of the boys in the high-risk group (51.6%, n = 32)
was higher than the girls (48.4%, n = 30). This may be
explained by the change in body composition during
adolescence between girls and boys: increased total visc­
eral fat mass, different changes in elevation of gonadal
hormone levels (estrogens and progestins usually pre­
dominate on androgens in women, androgen domi­
nance in men). Further studies are needed to examine
the relationship between hormones and SDB in different
sexes [27].
As the numbers of sleep laboratories are low, and
standing appointments are abundant in Turkey and
the world, waiting times are too long. Due to the diffi­
culty of access outside large city centers (especially rural
regions), high costs, and requirement of staying at the
sleep laboratory for a night (especially for the pediatric
population), as well as lack of standardization, routine
usage of PSGs, which are the gold standard of SDB
diagnosis, becomes limited [1–7]. In contrast to this,
applying PSQ is very easy, is specific, considers the
numbers and types of symptoms, takes a short time to
apply (<15 min.), and does not require a specifically
trained doctor or staff member. PSQ focuses only on
patient history (it does not consider the physical exam­
ination of the child). The questions are specific and
usually do not raise a doubt [8,9]. In the existing guides
of the European Respiratory Society Task Force, PSQ is
considered a “useful instrument” in determination of
patients with scores of higher than 5 in the apnea-
hypopnea index (AHI), which is used to predict OSAS,
OSAS-related neurobehavioral outcomes, and/or assess­
ment of these [2,8]. However, several factors, such as not
 CRANIO®: THE JOURNAL OF CRANIOMANDIBULAR & SLEEP PRACTICE
questioning the sociocultural levels of parents despite
their literate status and parent indifference may affect
the completely accurate and careful responses to the
questions in the questionnaire. Additionally, PSQ is
a questionnaire that can be applied for individuals
under the age of 18, and considering the age interval of
the sample, the possibility that most children would not
share the same room with their parents poses some
limitations in monitoring the children. With the objec­
tive of preventing such limitations, the parents of the
children with malocclusions who arrived for their first
examination were first informed about SDB and its
signs, as well as the questionnaire that would be applied,
and the questionnaire was filled later on the dates of
appointments.
Radiological measurements, which are some of the
assisting methods in diagnosis of POSAS and used in
both measurement of the upper airway volume and
assessment of skeletal anomalies, were not included in
this study, although it was considered they could
increase the quality of the results of the study. The
most important reason for this was that the sample of
this study consisted of patients who did not start ortho­
dontic treatment, and their radiographies, in which one
could assess upper respiratory pathway volume and the
pharyngeal airway (cephalometric, CBCT, etc.), were
not readily available. As clinicians must carefully assess
the benefit/harm ratio before requesting radiographic
tests for children, especially in young age groups [28],
no radiography test was requested for the sample;
a clinical assessment was made, and the patients who
were found to be in the high-risk group were directed to
relevant departments (orthodontist, otolaryngologist,
etc.) for diagnoses and treatments. Moreover, in this
study, a priority was placed on raising awareness on
increasing the routine usage of diagnosis instruments
based on clinical examination and questionnaires in
SDB pre-diagnosis by dentists.
Conclusion
In this study, a convex profile, high-angle growth direc­
tion, and retrognathic mandible were determined as
risk factors for SDB. The prevalence of dry mouth,
mouth breathing, and snoring was higher in the high-
risk group. Furthermore, this study may help encou­
rage the widespread use of a Pediatric Sleep
Questionnaire in the evaluation of the relationship
between predisposing skeletal and dental factors and
sleep disorders and to raise awareness about sleep dis­
orders in the field of dentistry.
7
Disclosure statement
The authors declare that they have no conflict of interest.
Funding
There is no funding to report for this manuscript.
ORCID
Sacide Duman DDS, PhD http://orcid.org/0000-0001-
6884-9674
Author contributions
S.D. conceived the ideas; S.D. and H.V. collected the data; S.
D. and H.V. analyzed the data; S.D. wrote, and S.D. and H.
V. reviewed the manuscript.
References
[1] American Academy of Sleep Medicine. ICSD-2: the
ınternational classification of sleep disorders. Duse of
a Pediatric Sleep Questionnaireiagnostic and coding
manual. 2nd ed. Westchester (IL): AASM; 2005.
[2] Krzeski A, Burghard M. Obstructive sleep disordered
breathing ın children–an ımportant problem ın the light
of current European guidelines. Otolaryngol Pol. 2018
29;72(5):9–16. DOI:10.5604/01.3001.0012.1570
[3] Chhangani BS, Melgar T, Patel D. Pediatric obstructive
sleep apnea. Indian J Pediatr. 2010;77(1):81–85.
[4] Vlastos IM, Hajiioannou JK. Clinical practice: diagnosis
and treatment of childhood snoring. Eur J Pediatr.
2010;169(3):261–267.
[5] Paglia L. Respiratory sleep disorders ın children and
role of the paediatric dentist. Eur J Paediatr Dent.
2019;20(1):5.
[6] Huang YS, Guilleminault C. Pediatric obstructive sleep
apnea: where do we stand? Adv Otorhinolaryngol.
2017;80:136–144.
[7] Rosen CL, D’Andrea L, Haddad GG. Adult criteria for
obstructive sleep apnea do not identify children with
serious obstruction. Am Rev Respir Dis. 1992;146(5 Pt
1):1231–1234.
[8] Burghard M, Brożek-Mądry E, Krzeski A. Sleep disor­
dered breathing in children–diagnostic questionnaires,
comparative analysis. Int J Pediatr Otorhinolaryngol.
2019;120:108–111.
[9] Chervin RD, Hedger K, Dillon JE, et al. Pediatric Sleep
Questionnaire (PSQ): validity and reliability of scales
for sleep-disordered breathing, snoring, sleepiness, and
behavioral problems. Sleep Med. 2000;1(1):21–32.
[10] Di Francesco R, Monteiro R, Paulo ML, et al.
Craniofacial morphology and sleep apnea in children
with obstructed upper airways: differences between
genders. Sleep Med. 2012;13(6):616–620.
[11] Defabianis P. Impact of nasal airway obstruction on
dentofacial development and sleep disturbances in
8 S. DUMAN AND H. VURAL
children: preliminary notes. J Clin Pediatr Dent.
2003;27(2):95–100.
[12] Robertson CJ. Obstructive sleep apnoea. Part I: diagno­
sis, aetiology, and current treatment. NZ Dent J. 1996;92
(410):110–113.
[13] Zucconi M, Caprioglio A, Calori G, et al. Craniofacial
modifications in children with habitual snoring and
obstructive sleep apnoea: a case-control study. Eur
Respir J. 1999;13(2):411–417. DOI:10.1183/09031936.99.
13241199
[14] Katyal V, Pamula Y, Martin AJ, et al. Craniofacial and
upper airway morphology in pediatric sleep-disordered
breathing: systematic review and meta-analysis. Am
J Orthod Dentofacial Orthop. 2013;143(1):20–30.
[15] Flores-Mir C, Korayem M, Heo G, et al. Craniofacial
morphological characteristics in children with obstruc­
tive sleep apnea syndrome: a systematic review and
meta-analysis. J Am Dent Assoc. 2013;144(3):269–277.
[16] Brodsky L. Modern assessment of tonsils and adenoids.
Pediatr Clin North Am. 1989;36(6):1551–1569.
[17] Huynh NT, Morton PD, Rompré PH, et al. Associations
between sleep-disordered breathing symptoms and
facial and dental morphometry, assessed with screening
examinations. Am J Orthod Dentofacial Orthop.
2011;140(6):762–770.
[18] Yüksel H, Söğüt A, Yılmaz O, et al. Reliability and
validity of the Turkish version of the Pediatric Sleep
Questionnaire: a tool for prediction of sleep related
breathing disorder. Tuberk Toraks. 2011;59
(3):236–241. DOI:10.5578/tt.2467
[19] Zaimoğlu E, Hoxha S, Özdiler O, et al. Reported pre­
valence of habitual pediatric snoring and the level of
parental awareness. Sleep Biol Rhythms. 2017;15
(1):75–80.
[20] Rohra AK Jr, Demko CA, Hans MG, et al. Sleep dis­
ordered breathing ın children seeking orthodontic care.
Am J Orthod Dentofacial Orthop. 2018;154(1):65–71.
[21] Owens JA. The practice of pediatric sleep medicine:
results of a community survey. Pediatrics. 2001;108
(3):51.
[22] American Academy of Sleep Medicine and American
Academy of Dental Sleep Medicine. Evidence brief: oral
appliances for sleep-related breathing disorders. Darien
(IL): AASM/AADSM; 2016.
[23] Masoud AI, Jackson GW, Carley DW. Sleep and airway
assessment: a review for dentists. CRANIO®. 2017;35
(4):206–222.
[24] Kaditis AG, Alvarez MLA, Boudewyns A, et al.
Obstructive sleep disordered breathing ın 2–18 year-
old children: diagnosis and management. Eur Respir J.
2015;47(1):69–94.
[25] Lumeng JC, Chervin RD. Epidemiology of pediatric
obstructive sleep apnea. Proc Am Thorac Soc. 2008;5
(2):242–252.
[26] Galeotti A, Festa P, Viarani V, et al. Correlation
between cephalometric variables and obstructive sleep
apnoea severity ın children. Eur J Paediatr Dent.
2019;20(1):43–47.
[27] Brockmann PE, Koren D, Kheirandish-Gozal L, et al.
Gender dimorphism in pediatric OSA: is it for real?
Resp Physiol Neurobi. 2017;245:83–88.
[28] Lintag K, Bruhn AM, Tolle SL, et al. Radiation safety
practices of dental hygienists in the United States.
J Dent Hyg. 2019;93(4):14–23.