How should I assess and manage an adolescent or adult with open bite, tongue‑thrust (reverse) swallowing and chronic mouth breathing who presents with snoring, daytime sleepiness or witnessed apnoea, to address possible obstructive sleep‑disordered breathing?

Assessment and Management of Open Bite, Reverse Swallowing, and Mouth Breathing with Sleep-Disordered Breathing

Initial Diagnostic Approach

All adolescents and adults presenting with open bite, tongue-thrust swallowing, and chronic mouth breathing who report snoring, daytime sleepiness, or witnessed apneas should undergo objective sleep testing to diagnose obstructive sleep apnea (OSA), as clinical evaluation alone cannot reliably predict the presence or severity of sleep-disordered breathing. 1

Key Clinical Features to Assess

• Craniofacial anatomy: Evaluate for maxillary constriction, high narrow palate, posterior crossbite, mandibular retrusion, and adenotonsillar hypertrophy, as these anatomic features predispose to upper airway obstruction 1, 2
• Mouth breathing impact: Open-mouth breathing significantly reduces retropalatal and retroglossal cross-sectional areas, lengthens the pharynx, and increases upper airway collapsibility during sleep 3, 4
• Severity indicators: Screen for habitual snoring with pauses/gasps, disturbed sleep, witnessed apneas, and daytime neurobehavioral problems (though daytime sleepiness may be uncommon in younger patients) 1

Diagnostic Testing Requirements

Obtain laboratory-based polysomnography (PSG) rather than home sleep testing when available, as this provides comprehensive assessment of sleep architecture, respiratory events, and oxygen saturation. 1

• PSG is the standard for establishing OSA diagnosis and severity before initiating treatment 1
• Severity classification guides treatment selection: mild (AHI 5-15), moderate (AHI 15-30), severe (AHI >30) 1

Treatment Algorithm Based on OSA Severity

For Mild to Moderate OSA (AHI 5-30)

Mandibular advancement devices (MADs) are recommended as first-line therapy in patients with mild to moderate OSA who have specific craniofacial features, particularly when combined with orthodontic needs. 1

• MADs reduce sleep apneas, improve subjective daytime sleepiness, and enhance quality of life compared to control treatments 1
• Custom, titratable oral appliances fitted by qualified dental personnel trained in sleep medicine are preferred over non-custom devices 1, 2
• Patients require adequate healthy teeth, no significant temporomandibular joint disorder, adequate jaw range of motion, and sufficient manual dexterity 1

For adolescents with maxillary constriction and high narrow palate, rapid maxillary expansion (RME) devices should be considered, ideally before puberty after permanent first molars have erupted (ages 6-7). 2

• RME demonstrates mean AHI improvement of 3.3 events/hour and oxygen saturation improvement of 2.8% 2
• This approach addresses both orthodontic needs and sleep-disordered breathing simultaneously 2

For Severe OSA (AHI >30)

Patients with severe OSA should have an initial trial of nasal continuous positive airway pressure (CPAP), as this demonstrates superior efficacy compared to oral appliances. 1

• CPAP is the gold standard for moderate to severe OSA, showing superior reduction in AHI, arousal index, and oxygen desaturation 5
• Oral appliances may be considered only after CPAP failure, intolerance, or patient refusal 1

Adjunctive Interventions

Weight loss should be recommended for all overweight patients (BMI >95th percentile in adolescents, >25 kg/m² in adults) as obesity is the primary modifiable risk factor. 1, 5

• After substantial weight loss (≥10% body weight), repeat PSG is indicated to reassess need for continued therapy or adjustment of treatment parameters 1

Intranasal corticosteroids (such as fluticasone) can be recommended as concomitant therapy in adolescents with co-existing rhinitis and/or adenotonsillar hypertrophy. 1, 5

• This provides Grade B evidence for improvement in mild to moderate OSA in children with upper airway obstruction 1
• However, intranasal steroids should not be used as single intervention in adults (Grade C recommendation) 5

Surgical Considerations

Adenotonsillectomy can be recommended in the presence of adenotonsillar hypertrophy, particularly in younger patients. 1

• Tonsillectomy as single therapy is recommended for adults with tonsillar hypertrophy (Grade C) 1
• Upper airway surgery may supersede oral appliances when predicted to be highly effective 1

Uvulopalatopharyngoplasty (UPPP) and other soft palate procedures cannot be recommended except in carefully selected patients with obstruction limited to the oropharyngeal area, due to frequent long-term side effects including velopharyngeal insufficiency, dry throat, and abnormal swallowing. 1

Follow-Up and Monitoring

After initiating oral appliance therapy, patients should undergo repeat PSG or attended cardiorespiratory sleep study with the appliance in place after final adjustments to ensure satisfactory therapeutic benefit. 1

• Monitor shortly after treatment initiation and as frequently as needed to assess accommodation, comfort, adequate titration, adherence, symptoms, and side effects 1
• General OSA outcomes including symptom resolution, AHI normalization, and oxygen saturation should be assessed in all patients 1

Critical Pitfalls to Avoid

• Do not rely on clinical history alone: Parents and patients can report loud snoring and mouth breathing, but history is not consistently confirmed by PSG even in severe cases 1
• Do not assume mouth breathing worsens with OSA severity: Paradoxically, patients with more severe OSA tend to breathe less through their mouth during sleep than those with mild disease 6
• Do not use tongue-retaining devices as primary therapy: These cannot be recommended due to insufficient evidence (Grade C) 1
• Do not prescribe positional therapy as primary treatment: This is clearly inferior to CPAP and has poor long-term compliance, though it may be considered in carefully selected younger patients with low AHI and less obesity 1