Journal of Sleep Disorders: Treatment and CareISSN: 2325-9639

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Research Article, J Sleep Disord Treat Care Vol: 6 Issue: 1

Are Sleep Disordered Breathing Symptoms and Maxillary Expansion Correlated? A Prospective Evaluation Study

Detailleur V1, Cadenas de Llano-Pérula M1, Buyse B2, Verdonck A1, Politis C3, Willems G1*
1Department of Oral Health Sciences-Orthodontics, KU Leuven and Dentistry, University Hospitals Leuven, Leuven, Belgium
2Leuven University Centre for Sleep/Wake Disorders, Department of Pulmonology, University Hospitals Leuven, Belgium and Department of Pulmonology, University of Leuven, Belgium
3OIC, OMFS-IMPATH Research Group, Department of Imaging and Pathology, Faculty of Medicine, University of Leuven and Oral & Maxillofacial Surgery, University Hospitals Leuven, Belgium
Corresponding author : Willems G, DDS, PhD
Department of Oral Health Sciences – Orthodontics, Katholieke Universiteit Leuven, Kapucijnenvoer 7, 3000 LEUVEN, Belgium
Tel: +3216332558
Fax: +3216337578
E-mail: [email protected]
Received: June 23, 2016 Accepted: September 08, 2016 Published: January 02, 2017
Citation: Detailleur V, Cadenas de Llano-Pérula M, Buyse B, Verdonck A, Politis C, et al. (2017) Are Sleep Disordered Breathing Symptoms and Maxillary Expansion Correlated? A Prospective Evaluation Study. J Sleep Disor: Treat Care 6:1. doi: 10.4172/2325-9639.1000186

Abstract

Study Background: The aim of this study was to investigate whether Sleep Disordered Breathing (SDB) symptoms are common in patients needing maxillary expansion and whether maxillary expansion could influence Sleep Disordered Breathing symptoms on a short-term.

Methods: In this prospective study, questionnaires were administered at baseline (T1) in 62 children (CST1) and 33 adults (AST1) in need of maxillary expansion. Three months after the start of orthodontic retention (T2), 39 children (CST2) and 31 adults (AST2) filled in the questionnaires for comparison.

Results: Children who needed maxillary expansion (CST1) reported more mouth breathing compared to the control group (CCo) (P=0.003). The mean score of the Pediatric Sleep Questionnaire and the score of the behavior subscale significantly improved after treatment (P=0.010 and P=0.015 respectively). AST1 patients were characterized by a higher prevalence of shortness of breath (P=0.012). No statistically significant improvements were seen in adults after treatment (AST2).

Conclusions: Breathing related symptoms such as mouth breathing and shortness of breath during the night had a higher prevalence in patients in need of maxillary expansion. Sleep Disordered Breathing symptoms improved after treatment in children. Further follow-up is needed to clarify the role of maxillary expansion in the treatment of Sleep Disordered Breathing.

Current Knowledge/Study Rationale: Several studies have shown the positive effect of maxillary expansion on SDB symptoms. This study aimed to document whether SDB symptoms are common in patients needing orthodontic maxillary expansion and if SDB symptoms improve after treatment. Study impact: If SDB symptoms are more common in patients needing orthodontic expansion, screening is advised to improve or prevent SDB symptoms.

Keywords: Sleep disordered breathing; Maxillary expansion

Keywords

Sleep disordered breathing; Maxillary expansion

Abbreviations

SDB: Sleep Disordered Breathing; OSAS: Obstructive Sleep Apnea Syndrome; ME: Maxillary Expansion; RME: Rapid Maxillary Expansion; SARME: Surgically Assisted Rapid Maxillary Expansion; PSQ: Pediatric Sleep Questionnaire; ESS: Epworth Sleepiness Scale; SOS: Snore Outcomes Survey; SPBS: Spouse/Bed Partner Survey; C: Child; A: Adult; S: Study; Co: Control; T1: Baseline; T2: 3 months after start retention; CST1 group: Children Study Group at T1; CST2 group: Children Study Group at T2; AST1 group: Adult Study Group at T1; AST2 group: Adult Study Group at T2; CCo group: Children Control Group; ACo group: Adult Control Group

Introduction

Both children and adults can suffer from Sleep Disordered Breathing (SDB). The severity of the disease is varied and it can be classified into the following categories: snoring, Upper Airway Resistance Syndrome (UARS) and Obstructive Sleep Apnea Syndrome (OSAS) [1]. According to Punjabi (2008) the prevalence of OSAS in the general population is 3 to 7% of adult men and 2 to 5% of adult women, which is therefore often higher than expected [2]. Several co-factors such as age, male gender, obesity, alcohol use, smoking, family history and craniofacial abnormalities are related to a higher risk of OSAS [2-5]. The obesity pandemic is therefore partially responsible for an increasing prevalence of OSAS [6]. Symptoms of SDB include: disrupted sleep of the patient and the patient’s partner, sleepiness during daytime, cardiovascular diseases, neuro-cognitive disorders and respiratory problems. Quality of life can be significantly undermined and severe symptoms can even lead to higher mortality rates [1].
Polysomnography is the gold standard for the diagnosis of OSAS [1]. Patients can be treated for SDB by lifestyle adjustment by losing weight (and lowering alcohol or medication intake), Continuous Positive Airway Pressure (CPAP), positional training, Mandibular Advancement Devices (MAD) or surgery of soft and/or hard tissues if a craniofacial anomaly is present [7,8]. Treatment of children slightly differs and includes the following options: adenotonsillectomy, weight reduction, CPAP, medication (such as intranasal steroids) or oral appliances [9].
In the literature, SDB has been correlated with the presence of a crossbite [10,11]. Solving the crossbite by an oral appliance that transversally expands the upper jaw could thereby possibly improve SDB symptoms. Moreover, Hershey et al. [12] stated that nasal breathing can be ameliorated by maxillary expansion. Both Pirelli et al. and Villa et al. [13,14] studied the effect of rapid maxillary expansion (RME) in children with OSAS. They reported a positive influence on breathing during nighttime suggesting that upper jaw expansion may help improve the symptoms of SDB [13-15]. Many studies concerning the positive effect of maxillary expansion on SDB have been performed in children but a similar positive effect of RME has also been described in young adults [16]. Vinha et al. [17] investigated if the Surgically Assisted Rapid Maxillary Expansion (SARME) in adults could also be beneficial for OSAS symptoms. A positive effect was seen and daytime sleepiness reduced . Babacan et al. [18] investigated if the effects of SARME were similar to RME without surgery. The positive effect of SARME and RME on the airway, namely the decrease of nasal resistance and the increase of nasal volume, was similar.
The aim of the present study was:
To investigate whether SDB symptoms are common in patients (children and adults) needing orthodontic maxillary expansion and to observe if SDB symptoms improve after treatment.

Methods

This study was registered and approved by the Medical Ethics Committee of the University Hospitals Leuven, with the registration number S56398. All patients completed an informed consent.
Sample selection
The sample of the prospective study consisted of 95 patients treated in the Orthodontics Department of the University Hospitals Leuven, Belgium in the period from August 2014 to April 2016. The decision to expand the maxilla was made based on the orthodontic records. In those cases, a cross bite, forced bite or edge to edge occlusion was present and both children (CST1) and adults (AST1) were included (Figure 1). Inclusion criteria were patients treated with (1) a removable expansion appliance, (2) a Hyrax, or (3) a Quadhelix. Due to the mature palatal suture in adults, expansion was accompanied by a surgical intervention (SARME), which was performed at the Department of Maxillofacial Surgery at the University Hospitals Leuven, Belgium, to open the suture and allow expansion.
Figure 1: Overview of the study set-up. The following abbreviations are used: C: Children, A: Adults, S: Study group, Co: Control group, T1: Baseline, T2: After retention period. For example in this prospective study, the children (C) in the study group (S) at baseline (T1) are described as ‘CST1’. Other groups are named similarly with corresponding abbreviations. The study group completed the questionnaires at baseline (T1): CST1 group and AST1 group, and three months after start retention (T2): CST2 group and AST2 group. The control groups, CCo and ACo group completed the questionnaires at baseline (T1). The groups filled in the Pediatric Sleep Questionnaire (PSQ) or the adult questionnaire (Qa) as indicated in the different groups. Arrows indicate comparisons made between groups.
Control groups, with comparable ages, of 62 children (CCo group) and 50 adults (ACo group) filled in the questionnaires at T1 for comparison. Both control groups did not have a cross bite, forced bite or edge to edge occlusion and subsequently did not need expansion (Figure 1).
Methodology
Questionnaires were administered at baseline (T1) and three months after the start of retention of orthodontic expansion (T2). Patients who did not have thorough knowledge of the Dutch language to fully understand the questions were excluded. Different questionnaires were used for children (CS and CCo group) and adults (adult questionnaire was used Whereever SARME was executed) (AS and ACo group). The questionnaire for children was based on a Dutch translation of the validated 22-item Pediatric Sleep Questionnaire (PSQ). Subscales based on different questions concerning breathing, sleepiness, behavior and other symptoms were also scored individually. A cut-off score of 0.33 was used to indicate the presence of SDB symptoms [19]. Adults completed questionnaires based on the Dutch translation of the Epworth Sleepiness Scale (ESS), the Snore Outcomes Survey (SOS), the Spouse/Bed Partner Survey (SBPS) and additional questions used in the Sleep Laboratory of the University Hospitals Leuven, Belgium [20-22]. A cut-off score of higher than 10 in the ESS is often used to detect abnormal daytime sleepiness although this should be confirmed by other tests [20,21].
Statistics
All analyses were performed using SAS software, version 9.2 of the SAS system for Windows. Comparison of the control group and the two patient conditions (T1/T2) was based on non-parametric tests (Fishers exact and exact McNemars test for binary data, Mann- Whitney U and paired Wilcoxon test for ordinal/continuous data). After a Bonferroni correction, P-values smaller or equal as 0.0167 were considered significant.

Results

Questionnaires were obtained from 62 children (CST1 group) and 33 adults (AST1 group) at baseline (T1). 39 children (CST2 group) and 31 adults (AST2 group) filled in the questionnaires at follow-up (T2). Because the study was still ongoing, not all patients already completed expansion. Besides 1 child and 1 adult dropped out, therefore sample sizes were smaller at T2. The demographic information of the sample is available in Table 1.
Table 1: Demographic information of the study and control group.
In children (Table 2), the mean PSQ score was 0.191 in the CST1 group and 0.156 in the CCo group (P=NS). The means of all 4 PSQ subscores were similar, although more mouth breathing during daytime was observed in the CST1 group (P=0.003). Moreover, a higher percentage in the CST1 group tended to be easily distracted by external stimuli but this was not significant (P=0.045). When we compared the control group with the CST2 group, the percentage of children snoring more than half of the time was smaller after treatment, although this was not significant (P=0.042).
Table 2: Results and Comparison of the Pediatric Sleep Questionnaire.
When we compared the CST1 and CST2 group, the mean score of the PSQ improved after treatment from 0.191 to 0.160 (P=0.010). The mean score of the behavior subscale also reduced significantly (P=0.015). The mean score of the breathing subscale improved but this was not statistically significant (P=0.076). A significant improvement was also seen in the lack of being able to sit still (P=0.012).
In adults (Table 3), a higher score in mean values (higher values mean increasing severity of the symptoms) was seen in the AST1 group concerning snoring, sleepiness during daytime, morning headache, night time urination, sexual problems, transpiration during nighttime and shortness of breath during the night compared to the ACo group although all these differences were not statistically significant except for the shortness of breath during the night, which was statistically significantly higher in the AST1 group (P=0.012). No significant difference was seen in ESS and SOS score.
Table 3: Results and comparison of adult questionnaires.
When comparing answers before and after treatment (AST1 and AST2), changes were neither relevant, nor significant.

Discussion

The aims of this study were to investigate whether SDB symptoms are common in patients needing orthodontic maxillary expansion and if an improvement was observed after treatment on a short term. In children, prevalence of mouth breathing during the day was found to be higher in patients needing maxillary expansion. In adults, prevalence of shortness of breath during the night was higher in patients needing maxillary expansion. SDB symptoms, based on questionnaires, improved in children after maxillary expansion.
Breathing
Several studies have shown the positive effect of rapid maxillary expansion on breathing [13-18]. This was confirmed by a metaanalysis by Machado-Júnior et al. [23]. Previous studies were based on rapid maxillary expansion, evidence of the effect of slow maxillary expansion is less clear in the literature. In this study we also detected an improvement in the mean score of the breathing subscale in children, although the amelioration was not significant (P=0.076). Besides, compared to the control group (CCo), a higher percentage of the CST1 group reported mouth breathing while this disappeared after treatment. Similarly, the difference seen in shortness of breath before treatment in adults (AST1 versus ACo group, P=0.012) disappeared when comparing the AST2 group with the ACo group. This might, although the difference was not statistically significant when the AST1 and AST2 group were compared (P=0.051), indicate a slight improvement after treatment.
Behavior
A significant impact of pediatric OSAS on Quality of Life was seen in a meta-analysis by Baldassari et al. [24] Besides sleep problems; behavior, daytime functioning and family life can be negatively influenced as well. The correlation between maxillary expansion and behavioral or attention problems was investigated by Chervin et al. [25] who found SDB to be related to higher snoring scores and higher levels of inattention and hyperactivity in children. Eliminating snoring during the night could thereby possibly improve inattention and hyperactivity during the day. In our study, the behavior subscale score also significantly reduced after treatment (P=0.015). Besides, in our children population with maxillary expansion, some questions, for example the lack of being able to sit still, improved statistically after treatment (P=0.012). However, it must be noted that after treatment patients were older (on average 1 year) which can also influence behavior.
Screening
Prevalence of OSAS is higher in some subgroups of the population. A higher risk of OSAS is seen depending on age, male gender, obesity, alcohol use, smoking, family history and craniofacial abnormalities, so these influences can be considered as co-factors of the disease [2]. A narrow upper jaw could also be considered as a co-factor of OSAS since several studies have noted a positive influence of maxillary expansion on SDB symptoms, although further research is needed.
Chervin et al. [26] concluded that children with a PSQ-identified sleep problem were often not diagnosed or treated. Although orthodontists are not trained to diagnose sleep problems, these questionnaires can be a tool to recognize possible problems and to refer children with PSQ-identified sleep problems to pediatricians.
Limitations of the study
The follow-up time of our study could have been too short to see relevant differences. Oliviera de Felippe et al. [27] investigated the long term effect of maxillary expansion. An improvement of the palatal volume and nasal airway resistance were seen, even a year after removal of the expander. Especially in adults, the expansion happened rapidly and although there was a retention period of three months, the adaptation of the tissues may be slower and bigger improvements could have been seen after longer retention periods. The retainer was often still present which can also influence breathing. Besides, the amount of expansion was not examined because no anteriorposterior radiograph or casts were available. However the aim of the questionnaire was mainly screening for possible problems.
The ESS, PSQ and SOS are validated questionnaires [19-22]. In the SOS, one of the multiple choice answers was ‘I don’t know’ by which some of the questions were not scored and marked as ‘missing answers’. The SBPS was very often not answered because of lack or absence of a partner at the moment of consultation and was therefore excluded from the results. Although the ESS is often used as a questionnaire to detect daytime sleepiness, the Dutch translation of the ESS has not yet been validated. Since the prospective study was still ongoing, results were preliminary. Not all patients who answered the questionnaire at T1 had already completed expansion. Besides, 1 child and 1 adult were not reachable to fill in the questionnaire at T2. CST2 and AST2 groups therefore consisted of a smaller sample size than the CST1 and AST1 group, which also had an impact on the power to detect differences.

Conclusions

The preliminary results from our ongoing prospective study allowed us to conclude the following:
• Patients who started maxillary expansion at childhood reported more mouth breathing compared to the control group.
• The mean score of the PSQ questionnaire and the behavior subscale significantly improved after treatment (P=0.010 and P=0.015 respectively). The breathing subscale also clearly improved but this difference was not statistically significant. This might implicate that orthodontic expansion could aid in the evolution of Sleep Disordered Breathing and possibly in behavioral and attention problems during daytime.
• Adult patients who needed expansion were characterized by a higher prevalence of shortness of breath during the night. No relevant improvements were seen after treatment. This might be due to the short follow-up time.
• Further research is needed to confirm if maxillary expansion can improve SDB symptoms.

Acknowledgments

We would like to acknowledge with appreciation, Steffen Fieuws, for assisting in statistical data-analysis.

References

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