Sleep disordered breathing in children seeking orthodontic care Ashok K. Rohra, Jr, a Catherine A. Demko, b Mark G. Hans, c Carol Rosen, d and Juan Martin Palomo c Cleveland, Ohio Introduction: Our objective was to evaluate the prevalence of high-risk factors for sleep disordered breathing (SDB) in an orthodontic population of children. SDB is a spectrum of breathing disorders ranging from primary snoring to obstructive sleep apnea. Methods: The sample included 303 healthy children between the ages of 9 and 17. High risk of SDB was assessed using the Pediatric Sleep Questionnaire, a validated instrument that consists of 22 questions, and high risk is defined as positive answers to 33% or more of the questions answered. Sixteen randomly selected patients repeated the questionnaire 1 month after the initial survey for reli- ability. Results: In this sample, high-risk status on the Pediatric Sleep Questionnaire was not associated with sex, age, or race. The percentage of patients who were screened as high risk was 7.3% (95% confidence interval, 4.7%-10.6%). Conclusions: The results of this study suggest that approximately 7% of adolescent or- thodontic patients may be at a significant risk for some form of SDB. (Am J Orthod Dentofacial Orthop 2018;154:65-71) S leep is a tightly regulated and well-organized bio- logic process that affects our daily functioning and our physical and mental health. According to the American Sleep Association, there are different stages of sleep, primarily separated into rapid eye move- ment sleep and nonrapid eye movement, which is addi- tionally divided into 3 stages. 1 Humans spend almost 50% of total sleep in the second stage of nonrapid eye movement and about 20% in rapid eye movement sleep. Deep and restorative sleep occurs in the third stage, whereas rapid eye movement sleep provides energy to the brain and supports daytime performance. 1,2 According to the Journal of Clinical Sleep Medicine, children aged 6 to 12 years should sleep 9 to 12 hours, and teenagers aged 13 to 18 years should sleep 8 to 10 hours per night, for the body to fully recover and properly function. On average, nearly half of childhood is dedicated to sleep. 3 However, for high school students in the United States, only 25% have reported sleeping 8 hours or more per night. 4 The health effects of chronic sleep deficiency are immune suppression, cardiovascular disease, neurologic imbalances, compromised quality of life, and ultimately a shortened lifespan. 1,5,6 Several factors can interfere with sound sleep, including sleep disordered breathing (SDB). SDB de- scribes a group of disorders characterized by abnormal respiratory patterns such as apneas or hypopneas or insufficient ventilation during sleep. This complex group of disorders occurs during sleep and is described by extended periods of upper airway resistance (snoring) at 1 end of the spectrum and partial or complete airway obstruction at the other. 7 Craniofacial morphology seems to be often corre- lated to SDB, particularly obstructive sleep apnea, which is related to neurogenic and anatomic factors. In the sagittal dimension, the most common findings in adults are an increased hyoid to mandibular plane angle and an increased length of the soft palate. A narrower posterior pharyngeal space has been found in adolescents who snore compared with those who do not. 8,9 Anatomically, the floor of the nose is the roof of the mouth. Transverse skeletal discrepancies as a result of maxillary constriction are associated with narrower lateral nasal walls, decreased nasal volume, and increased nasal airway resistance. 10 To compensate for the increased upper airway resistance, mouth breathing becomes the primary means of respiration. 11 Angle in a Private practice, Cleveland, Ohio. b Department of Community Dentistry, School of Dental Medicine, Case Western Reserve University, Cleveland, Ohio. c Department of Orthodontics, School of Dental Medicine, Case Western Reserve University, Cleveland, Ohio. d Department of Pediatrics, School of Medicine, Case Western Reserve University, Cleveland, Ohio. All authors have completed and submitted the ICMJE Form for Disclosure of Po- tential Conflicts of Interest, and none were reported. Address correspondence to: Juan Martin Palomo, Case Western Reserve Univer- sity, School of Dental Medicine, 2124 Cornell Rd, Cleveland, OH 44106; e-mail, palomo@case.edu. Submitted, May 2017; revised and accepted, November 2017. 0889-5406/$36.00 Ó 2018 by the American Association of Orthodontists. All rights reserved. https://doi.org/10.1016/j.ajodo.2017.11.027 65 ORIGINAL ARTICLE