Diverging Thoughts About Sleep Apnea and Orthodontics
Dr. Brad Lands
Orthodontist, Toronto
The discussion around orthodontics and sleep apnea is a lively debate, one that Dr. Brad Lands, an orthodontist from Toronto, likens to the conversation in the 1980s around TMD and orthodontics. In this episode of CDA Oasis Live, Dr. John O’Keefe, Director of Knowledge Networks CDA, invites Dr. Lands to share his thoughts and experience to the topic.
Citing recent evidence from literature studies, Dr. Lands lays out the main areas of controversy, including the use of radiology to diagnose sleep apnea, and the impact of both extraction and expansion on the incidence of sleep apnea later in life.
Here are the key takeaways from the conversation...
- As dentists we generally think of sleep apnea as a “plumbing” issue, but studies have shown that almost 69% of obstructive sleep apnea patients present with one or more non-anatomic pathophysiologic traits.
- There are three main areas of controversy:
- Use of radiology to diagnose sleep apnea
- Use of expansion to treat and prevent sleep apnea
- The idea that extraction may cause sleep apnea later in life
- Radiology
- The thinking is that if we can measure airway volume, then we can say if the patient has sleep apnea. This does not always follow.
- We do not have any established norms for what we consider problematic. Many patients with narrow airways do not have sleep issues.
- Studies show much inter-operator variability in measuring airways.
- Arguably, screening with a healthcare questionnaire is a more valuable diagnostic tool than an x-ray.
- Extraction
- Some studies show that removing premolars and closing the space lessens airway volume. But there is a lack of evidence for what that means for patients later in life.
- In studies that do show patients developing sleep apnea later in life, it is difficult to control other external factors such as age, lifestyle changes, weight changes etc.
- There is not enough evidence to link sleep apnea to a cause and effect relationship with tooth extractions at a younger age.
- Expansion
- Research shows that expanding the airway, particularly in children, lowers the Apnea Hypopnea Index (AHI).
- The question is how much we need to expand. There is no standard.
- In the absence of orthodontic reasons to expand, we should only expand if it advised by an ENT physician.
We hope you find the conversation useful. We welcome your thoughts, questions and/or suggestions about this post and other topics. Leave a comment in the box below or send us your feedback by email.
Until next time!
CDA Oasis Team
Resources
- The influence of craniofacial morphology on the upper airway dimensions
- Craniofacial and upper airway morphology in pediatric sleep-disordered breathing and changes in quality of life with rapid maxillary expansion
- Evidence Supports No Relationship between Obstructive Sleep Apnea and Premolar Extraction: An Electronic Health Records Review
- Effect of orthodontic treatment on the upper airway volume in adults
- Rapid maxillary expansion for pediatric obstructive sleep apnea: A systematic review and meta‐analysis
- Defining phenotypic causes of obstructive sleep apnea. Identification of novel therapeutic targets
Thanks for the information and review. I would say that expansion is a better option than extraction when looking at creating space and maintaining arch form and bite. We are not the only country doing this and there is a lot of research showing excellent outcomes for expansion versus extraction. Also, if we look at what smiles people like (from an aesthetic point of view) less black space at the cheeks seems to be better.
Unfortunately, there are still some dentists that believe expansion can only be done up to the age 13 which is an incorrect arbitrary marker.
Why would we extract perfectly healthy teeth when a few months of expansion can get us to a better, significantly stable place? Of course there should be rules about doing it also! This is not a negation of the use of extraction; simply a call to use it judiciously after considering expansion.
Thanks again!