I have decided to review the AAO paper on sleep-disordered breathing. This follows our earlier post from a few weeks ago, where we highlighted the main recommendations of this significant AAO publication. Since then, I have had the opportunity to read the report more thoroughly. I will focus on the sources they used to make their recommendations.
This post is rather long, but I want to cover a lot of information. I will not be posting much about this subject in the next few months, unless a useful research paper is published.
Introduction
First, I would like to examine the definition of a white paper. This varies between countries. The definition for the USA is:
“An authoritative, in-depth report that analyses a specific health issue to educate stakeholders, propose solutions, or influence decision making. They are positioned between peer-reviewed research and marketing.”
Importantly, it is not a high-level research paper or systematic review. It is worth noting that the authors do not adhere to systematic review methodology.
Therefore, we should remember that a white paper presents a series of conclusions based on our best available research. It is important to recognise that these are recommendations, not mandatory requirements, and are therefore not compulsory. Nonetheless, this paper offers guidance for the future, as it contains solid clinical advice.
Is this important?
I also wonder how significant an issue sleep-disordered breathing and orthodontics are worldwide. As with many aspects of orthodontics, the push for “new” treatments and changes seems to originate from the USA. This is probably due to the greater number of orthodontists in the USA compared to other parts of the world.
I am also aware that some of the most vocal social media outputs and groups are USA-based. Subjectively, when I have seen comments from other countries, they tend to be more conservative, traditional, and possibly more grounded in science.
Therefore, we must keep in mind that the content and focus of this white paper are likely more relevant to the United States than to other parts of the world. Certainly, when I consider the UK, there doesn’t seem to be a strong drive to implement airway-focused orthodontics, apart from a few of the “usual suspects” who adhere to the mantra of orthotropics and other fringe treatments.
As a result, we need to be careful not to become dominated by USA-based orthodontics, as there is a risk of wasting a considerable amount of time.
In this context, I have decided to review this white paper.
The panel
It is evident from the information on the panel members that this is a carefully assembled group of experts. The panel comprises a mix of practitioners, representatives of the AAO, and research academics.
The Introduction
This was well written and clear. I was particularly impressed by the way they described the somewhat confusing situation of sleep-disordered breathing (SDB), its medical and surgical treatments, and the role of orthodontics. Importantly, they pointed out that sleep-disordered breathing is a continuum, ranging from snoring to obstructive sleep apnoea (OSA).
They also emphasised that SDB is a medical condition. Consequently, only a physician can diagnose SDB in the USA and Canada (and in the UK). This means that the diagnosis would fall outside an orthodontist’s scope of practice.
Nevertheless, orthodontics does have a role in the interdisciplinary management of SDB, particularly in children. This includes conventional orthodontic treatment, screening, referral, and some interventions.
When we consider the nature of the disease, SDB is a heterogeneous condition with variable treatment responses. It is influenced by both anatomical and non-anatomical factors. The former include soft-tissue volumes, such as enlarged adenoids or palatal tonsils, fat infiltration, and potentially reduced skeletal volume. Non-anatomical factors include the neuromuscular function of the pharyngeal musculature.
Importantly, prepubertal OSA tends to resolve naturally during the transition to adolescence. This, of course, coincides with orthodontic treatment. As a result, we believe that orthodontics can help treat SDB.
Now I would like to review what I consider the most important recommendations and the underpinning research.
Craniofacial form and OSA.
Traditionally, we think that OSA is associated with certain craniofacial features, such as increased facial height, mandibular retrusion and craniofacial disharmony. It is often stated that these are aetiologic factors in OSA. As a result, some suggest that correcting these skeletal problems will cure SDB.
The panel pointed out that there is limited evidence for these concepts. The source of their evidence was 2 systematic reviews.
One of these studies was published in the AJO-DDO in 2013. This review incorporated data from nine trials, of which eight were prospective case-control studies. The authors highlighted a potential association between craniofacial disharmony and paediatric sleep-disordered breathing. However, any differences were unlikely to be clinically significant.
The Journal of Clinical Sleep Medicine published the other study in 2022. The authors identified nine studies. Four were cross-sectional, four were case-control studies, and one was a prospective cohort study. Both reviews were conducted with sound methodology. Nevertheless, they were limited by a small number of studies and high levels of uncertainty in the data. As a result, the AAO panel concluded that there was limited evidence for a connection between OSA and certain craniofacial features.
Their overall conclusion was that, due to the very low to moderate certainty level, ‘an association or lack thereof, between craniofacial morphology and paediatric OSA, cannot be supported by the data.’
Use of imaging in SDB
The panel concluded that imaging of the upper airway using CBCT or lateral cephalograms has no diagnostic value for SDB risk assessment or diagnosis. Furthermore, using changes in upper airway dimensions to suggest the efficacy of orthodontic treatment is scientifically flawed.
They based these conclusions on an International Consensus Statement on Obstructive Sleep Apnoea, published in July 2023. This was a large consensus meeting that evaluated OSA in great detail. The paper included 176 pages with just over 2000 references. I did not have time to read it in detail. However, in addition to the section on imaging, there was a section on the treatment of paediatric OSA. The authors pointed out that the first-line treatment was adenotonsillectomy. Importantly, I did not find a mention of orthodontic treatment.
I thought this paper was very important because it addressed one criticism that the AAO viewpoint was not based on medical research. I wonder if our collection of airway-focused orthodontics has read this paper?
Palatal expansion
The panel concluded that orthodontists should only provide palatal expansion for sleep disordered breathing management in patients with a clear orthodontic indication alongside a confirmed SDB diagnosis. I found this somewhat vague, and I interpreted it to mean that expansion should only be performed if a crossbite with a potential skeletal discrepancy is present.
They based this recommendation on two publications, one of which was a 2023 meta-analysis that found that RPE alone did not significantly reduce the apnea-hypopnea index. This included data from five randomised controlled trials and four non-randomised controlled trials, which together provided information on 595 patients. Most of the trials were rated as high risk of bias due to issues with blinding participants. The meta-analysis revealed limited evidence of a positive effect of rapid maxillary expansion.
The other study was a crossover randomised controlled trial examining the use of adenotonsillectomy and palatal expansion on AHI. I have written a blog post about this trial. I found it well-conducted. Its overall conclusion was that adenotonsillectomy is the primary treatment for OSA, and RPE may not provide benefits.
Again, these were good sources of evidence.
Functional appliances and growth modification
The panel concluded that there was no evidence to support the prophylactic use of functional appliances as a preventive measure for sleep disordered breathing. This is a logical conclusion because there are no studies showing that functional appliances can meaningfully change or alter the skeletal pattern.
Can we help in the treatment of sleep-disordered breathing?
A key message from this research and discussion is that treating sleep-disordered breathing primarily falls to our medical colleagues. We clearly have a role in screening for sleep disordered breathing and referring patients. Once the physician has made an accurate diagnosis, we can contribute to relevant treatment, but we must collaborate closely with sleep specialists and other experts.
We can also offer care with maxillary expansion, but only in a few carefully selected cases. This is when there is a clear skeletal discrepancy, most often accompanied by a crossbite. It is absurd to expand maxillae simply because “we feel they are not wide enough” or that we need to increase the width by 3 to 5 mm to some hypothetical ideal imagined by an advocate who does not understand the existing research in this area.
What did I think?
I did not have the space or time to explore all aspects of this white paper, so I decided to focus on perhaps the four most controversial areas. I believe the evidence they used to support their recommendations was entirely relevant. The studies they selected were generally of good quality. The most striking finding, in my view, was that there were very few studies they could include. This is because there appears to be a lack of high-quality research.
This reinforces my opinion that, across this entire field, there is a surprising lack of evidence. This is a significant finding because, if evidence of benefit is absent, we cannot ethically promote or provide treatment that claims to address a disorder.
FInal thoughts
This is an extremely useful and valuable source of information for all orthodontists. The recommendations are very clear. Importantly, they provide straightforward guidance on what we should and shouldn’t do. This means that if we perform treatment that disregards these recommendations, we may be acting unethically.
The response by some to the white paper has been unbelievably arrogant. Some detractors even suggest that their personal viewpoint or that of their ENT colleagues is more important than anything included in this document. Alternatively, some suggest the White Paper is flawed but do not specify where these flaws lie. Others have claimed that the AAO is protecting organised orthodontics. I don’t even understand what this means.
I have been an orthodontist for 40 years. Over this time, I have witnessed several “waves of nonsense”. These include orthodontic TMD treatment, non-extraction approaches for everyone, orthodontic vibrators, localised trauma to speed up tooth movement, orthotropics, and self-ligation. All have gained momentum, generated profit, and preyed on vulnerable patients. However, when science and the truth catch up with these claims, the new treatments vanish and we return to conventional, sensible orthodontics. This paper by the AAO is a significant step in the right direction.
If we accept and adhere to the recommendations of the White Paper, we can deliver a valuable service to our patients. This should also keep us sufficiently occupied.
What are your thoughts? Would you be interested in discussing this further in the comments?
