Can oral appliances be used to treat mild sleep apnea in children?

Oral Appliances for Children with Mild Sleep Apnea

For children with mild obstructive sleep apnea (OSA) who have specific craniofacial features such as maxillary constriction, oral appliances may be considered as a treatment option, particularly rapid maxillary expansion (RME) devices. 1

First-line Treatment Considerations

• Adenotonsillectomy remains the first-line treatment for most children with OSA 2
• For children with persistent OSA after adenotonsillectomy, treatment options should be carefully evaluated 1

Oral Appliance Therapy in Children

Indications for Oral Appliances

• Oral appliances should be considered primarily for children with:
  • Specific craniofacial features, particularly maxillary constriction 1
  • High and narrow palate, often with posterior crossbite 1
  • Mild persistent OSA after adenotonsillectomy 1

Types of Oral Appliances for Children

• Rapid Maxillary Expansion (RME) devices:
  • Most studied type of oral appliance for pediatric OSA 1
  • Cemented intraoral orthopedic appliance 1
  • Ideally used before puberty, after permanent first molars have erupted (typically ages 6-7) 1
  • Activation period lasts 1-2 weeks, followed by consolidation period 1

Efficacy of Oral Appliances

• RME devices have shown a mean improvement in Apnea-Hypopnea Index (AHI) of 3.3 events/hour (95% CI, 1.8-4.8) 1
• Oxygen saturation improved by 2.8% (95% CI, 2.3-3.5%) after RME 1
• Limited evidence exists for outcomes such as quality of life, behavioral changes, and daytime sleepiness 1
• One case report described successful treatment of severe OSA in a 3-year-old boy using a removable functional oral appliance 3

Limitations and Considerations

• Evidence for oral appliances in children is of very low certainty 1, 4
• The American Thoracic Society provides only a conditional recommendation for orthodontic/dentofacial orthopedic treatment in children with persistent OSA 1
• Cochrane review found insufficient evidence to support or refute the effectiveness of oral appliances for OSA in children 4
• Oral appliances may be considered as an auxiliary treatment in children with craniofacial anomalies that are risk factors for apnea 4

Implementation Considerations

• Children must have an indication for orthodontic treatment based on constricted maxilla 1
• Early treatments are preferred 1
• Qualified dentists should provide oversight of oral appliance therapy 1
• Custom, titratable oral appliances are preferred over non-custom devices (based on adult evidence) 1

Research Gaps

• Need for well-designed studies examining short and long-term adherence to treatment 1
• Large, multicenter studies focusing on quality of life, cognitive function, behavioral changes, and other outcomes are lacking 1
• Standardization of variables used to define OSA in children is needed 1

Conclusion

For children with mild OSA and specific craniofacial features, particularly maxillary constriction, oral appliances (specifically RME) may be considered as a treatment option. However, the evidence is limited, and treatment decisions should be made after careful evaluation of the individual child's anatomical and clinical characteristics.