Prevalence of Sleep-related Breathing Disorders in Children and Its Correlation with Oral Health Status Using FAIREST-6: Cross-sectional Study

Abstract

Aim

The hallmark of sleep-related breathing disorders (SRBDs) is the frequent occurrence of partial or complete upper airway collapse while asleep, which causes recurrent episodes of intermittent hypoxemia and wakefulness. The prevalence of SRBD is very high, yet it remains underdiagnosed and untreated. Initial screening can maximize the chances of early identification and assistance for children with SRBD. The aim was to assess prevalence of SRBD in young patients during mixed dentition period, reporting for dental examination using the pediatric sleep questionnaire (PSQ), and assess its correlation with oral health status utilizing Functional Airway Evaluation Screening Tool (FAIREST-6).

Methodology

A study was conducted from January 2024 to June 2024, of 1,800 mixed dentition children during dental examinations. Outcome measures included a PSQ fulfilled by participating patients' guardians. Children identified at risk through PSQ were further screened using the FAIREST-6 screening tool by dental residents.

Results

The sample consisted of 1,800 screened pediatric patients, 960 males and 840 females, with an overall mean age of 8.74 (1.8) years, with an age range between 6 and 12 years. SRBD was found in 5.2% of the children, with girls having a greater prevalence (52.2%) than boys (47.8%). A positive correlation was seen between variables (Tonsillar hypertrophy, narrow palate, and mentalis activity) and SRBD.

Conclusion

The frequency of SRBDs, as assessed by routine examination of the PSQ and FAIREST-6, was 5.2%. The symptoms of sleep-disordered breathing (SDB) were strongly linked to the existence of mentalis activity, tonsillar hypertrophy, and a narrow palate.

Clinical significance

Dentists, doctors, and allied health providers can utilize the short and validated chairside FAIREST-6 screening test, which consists of six clinical determinants, to evaluate young patients for SDB.

How to cite this article

Shirsat SM, Pawar M, Choudhari KS, et al. Prevalence of Sleep-related Breathing Disorders in Children and Its Correlation with Oral Health Status Using FAIREST-6: Cross-sectional Study. Int J Clin Pediatr Dent 2025;18(11):1373–1377.

Introduction

Sleep-related breathing disorders (SRBD) are a common medical condition and cause a variety of symptoms during the day and night.¹ Snoring, pharyngeal collapsibility, and repeated episodes of partial or complete upper airway collapse are its defining features.² Depending on the degree of airway blockage, Sleep-disordered Breathing (SDB) ranges from benign snoring to Obstructive Sleep Apnea (OSA).³ The most prevalent type of sleep disturbance in children is OSA, with equal frequency rates for both genders in preschoolers and older kids. Approximately 1–5% of children suffer from the prevalent disease pediatric OSA.⁴ Comorbidities such as hypertension, cardiovascular diseases, metabolic disorders, obesity, and problems with neuro cognition and development can result from long-term, underdiagnosed OSA.⁵ Maxillary and mandibular retrognathism, macroglossia, high palatal vault, malocclusion, increased overjet, decreased overbite, anterior and posterior crossbites, dental caries, periodontal disease, and xerostomia are amongst the dentofacial characteristics that children with SDB typically exhibit.⁶ In contrast to treating disease, prevention, early detection, and reversal of compensatory oral function and poor mandibular and maxillary development may represent a very significant paradigm shift.⁶ The gold standard for diagnosing OSA is overnight polysomnography (PSG) since it assesses physiological indicators related to weakness and sleep.⁷ This test is costly and hard to get by outside of major cities, especially for young patients. There are not enough laboratories that have PSG available, which contributes not just to the underdiagnosis but also management of pediatric OSA. For this reason, various less invasive diagnostic assessment tools have been developed. They combine clinical examination, questionnaires, medical history evaluation, and objective measurements.⁸ Numerous studies have shown that questionnaires serve as a valuable and dependable tool for research purposes. The Pediatric Sleep Questionnaire (PSQ) is a cost-effective and efficient method in situations when PSG is not practical.⁹ It is considered to be a reliable substitute as the initial diagnostic tool for children who may be at risk of OSA.¹⁰ According to the American Academy of Dental Sleep Medicine, initial screening can be done best using a sleep questionnaire.¹¹ Italian guidelines recommend the use of a 22-item questionnaire for initial screening in young subjects, as put forth by recent research demonstrating excellent diagnostic precision.⁴ A clinical assessment tool Functional Airway Evaluation Screening Tool (FAIREST-6), was developed by James and colleagues to determine functional, extraoral, and intraoral examination patterns linked with a higher risk of breathing disorders related to sleep. Early signs of SDB in developing children include mouth breathing, restless sleep, bruxism, daytime drowsiness, attention-concentration issues, and hyperactivity. The six clinical factors that make up the brief and validated FAIREST-6 assessment tool are useful for doctors, dentists, and other allied health providers.¹² Given its affordability, using FAIREST-6 as the screening tool can be an excellent start when addressing SDB in the community. Therefore, in this study, we are aiming to assess the prevalence of SRBDs in the pediatric population using the 22-item PSQ and its association with oral health status utilizing FAIREST-6.

Methodology

The current investigation was conducted from January, 2024 to June, 2024 following the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines.

Participants

The study population included 1,800 children, 960 males and 840 females [mean (SD) age, 8.74 (1.8) years; range, 6–12 years]. Data was collected from patients reporting for their first outpatient visit to the Department of Pediatric and Preventive Dentistry as a part of the routine dental history examination. Patients with craniofacial defects, neurological disorders, who received surgical or orthodontic intervention, and patients who underwent adenotonsillectomy were excluded from the study. Intraoral and extraoral examination was conducted using standard infection control protocol by two examiners.

Research Procedure

Written informed consent from the participating children's parent was taken, and a validated PSQ was provided to both parents separately to avoid information bias. There are 22 questions in the parent-reported questionnaire about the frequency of snoring, loud snoring, apnea, breathing difficulty while sleeping, hyperactive and inattentive behavior, along with other characteristics. The responses to the questionnaire were coded as “yes” = 1 or “no” = 0. A PSQ score of more than 0.33 was indicative of potentially elevated risk of SRBD in children. Children identified at risk through PSQ were further screened using the FAIREST-6 screening tool. FAIREST-6 screening tool consists of six clinical determinants that have been identified as functional, extraoral, and intraoral domains. The FAIREST-6 scoring system is used to screen for potential signs of SDB by evaluating six specific clinical indicators: Mouth breathing, mentalis muscle activity, enlarged tonsils, tongue-tie (ankyloglossia), a narrow palate, and signs of dental wear. Each of these findings is considered an independent risk factor. The total FAIREST-6 score is the sum of these observed signs, ranging from 0 (no findings present) to 6 (all six findings present). To assess mouth breathing, patients were asked to keep their lips closed and breathe only through the nose for over three minutes. Mentalis muscle involvement was noted when there was visible perioral strain during lip closure. Tonsillar size was evaluated using the Brodsky scale, which measures how much of the oropharyngeal airway is blocked by the tonsils. Ankyloglossia, or tongue-tie, was assessed using a rapid screening tool designed for quick evaluation. For measuring the width of the palate, alginate impressions were taken to create dental casts, from which intercanine and intermolar widths were recorded.

Statistical Analysis

Data was collected and analyzed, and its analysis was carried out using the Statistical Package for Social Sciences (SPSS) Software. The statistical tests include the point-biserial correlation coefficient and the Pearson correlation coefficient.

This cross-sectional study was initiated with approval from the Institutional Ethics Committee, Dr D Y Patil Vidyapeeth, Pune (Ref. No. DYPDCH/IEC/22/2024).

Results

The sample consisted of 1,800 consecutively screened pediatric patients, 960 males (53.3%) and 840 females (46.7%), with an overall mean age of 8.74 (1.8) years, with an age range between 6 and 12 years. SDB was found in 5.2% of the children, with girls having a greater prevalence of the condition (52.2%) compared to boys (47.8%), of which the majority were between the ages of 8 and 9.

The most clinically established factors determined in this study were mouth breathing, narrow upper jaw, and tonsillar hypertrophy. The study established that 100% (67 patients) of the study participants with sleep disturbance were mouth breathers. Mentalis strain is one extraoral finding in this research/ investigation. The most clinically significant factor was the existence of moderate mentalis strain. The table shows the frequency of severity of mentalis strain, amongst which 25.4% had mild, 67.2% had moderate, and 7.5% had no strain (Table 1 and Fig. 1).

Table 1:

Presence of mouth breathing and severity of mentalis strain in the study participants with sleep disturbance

	Mouth breathing	Mentalis strain
		Mild strain	Moderate strain	No strain
Frequency	67	17	45	5
Percentage	100	25.4	67.2	7.5

Fig. 1:

Presence of mouth breathing and severity of mentalis strain in the study participants with sleep disturbance

Of all six clinical determinants, tonsillar hypertrophy was strongly related to SDB. In children with tonsillar hypertrophy, upper respiratory tract infection and congestion were prevalent signs and symptoms. 85.1% of the study sample had grade III tonsillar hypertrophy, while 9% had grade IV tonsillar hypertrophy (Table 2 and Fig. 2).

Table 2:

Grading of tonsillar hypertrophy in the study participants with sleep disturbance

Grading	Frequency	Percentage
Grade II	4	6.0
Grade III	57	85.1
Grade IV	6	9.0
Total	67	100.0

Fig. 2:

Grading of tonsillar hypertrophy in the study participants with sleep disturbance

The least common symptom seen in the study was ankyloglossia. Complete tongue tie was seen in 6% children with sleep disturbance. Despite the fact that 67 individuals were at risk of SDB, the data showed that of the study population, only 13.4% of subjects experienced dental wear. The mean intermolar width in the study participants with sleep disturbance was 33.30, with a minimum of 30 and a maximum of 36 (Table 3 and Fig. 3).

Table 3:

Mean intermolar width in the study participants with sleep disturbance

Parameter	N	Minimum	Maximum	Mean	Std. deviation
Intermolar width	67	30.00	36.00	33.30	1.83

Fig. 3:

Mean intermolar width in the study participants with sleep disturbance

Discussion

This research aimed to assess the prevalence of SRBD in children using the 22-item PSQ and evaluate its association with the oral health status using the FAIREST-6 tool. Due to the substantial health-related impacts of SDB, prompt and precise identification is essential for efficient treatment and intervention.¹³ PSG is the gold standard, which is cost-effective, laborious, and requires a sleep technician to assess the parameters. The diagnosis of SDB in children involves the use of objective measurements, questionnaires, clinical evaluation, and previous medical illness assessment.^7,8 Several studies have demonstrated the usefulness and reliability of questionnaires as research instruments. In our study, the initial survey assessment questionnaire for sleep disorders in pediatric patients was the PSQ designed by Chervin et al. from the Michigan University.¹⁰ According to American Thoracic Society, PSQ is a suitable initial screening method and could be used in addition with the objective testing for breathing disorders in children and adolescents.¹⁴ According to Gupta et al., PSQ is a validated questionnaire to screen for sleep disorders in children, and found 7.5% of children to have sleep difficulties.¹⁵ Di Carlo et al. found a prevalence of 9.73% in Italy and Spain using PSQ, indicating the importance of SRDB and their comorbidities.⁴ As stated by the American Association of Pediatric Dentistry (2002), 1–4% of all children are affected.⁴ In a study based on a questionnaire, Ng and colleagues found that 11.2% of pediatric patients in Hong Kong, between the ages of 6 and 12, had SDB.¹⁶ A study conducted in pediatric patients of 3–14 years in China, using the PSQ, noted a prevalence of 13.4%.¹⁷ Our study found 5.2% of children in the mixed dentition period had SDB. Compared to the dental implications, the systemic effects of SDB are well studied and reported. Hence, it is more effective to concentrate on important aspects of the extraoral and intraoral examination that could reveal symptoms of SDB rather than including a written assessment tool in the subjective section of the patient record. FAIREST-15, the pediatric version of the Functional Airway Evaluation Screening Tool, consists of 15 items for clinical examination determined to be otolaryngologic, functional, and dental-related characteristics associated with an increased risk of SRBDs in young patients.

Additionally, parents were asked to rate six subjective variables related to posture, breathing pattern, anxiety, and focus on a descriptive scale as part of the FAIREST-15. James et al. developed a precise and substantiated chairside diagnostic tool, the FAIREST-6, to determine functional, extraoral, and intraoral examination patterns in assessing the pediatric dental population. They found functional nasal breathing test (the inability to breathe through the nose for longer than 3 minutes); intraoral hard tissue findings such as dental wear (moderate to severe) and narrow palate (intercanine distance less than 31 mm and/or intermolar distance less than 46 mm), intraoral soft tissue findings such as tonsil size (greater than 50% obstruction) and tongue mobility (grades III and IV TRMR and/or less than 12 mm Kotlow free tongue measurement) and extraoral findings such as the presence of mentalis strain (moderate to severe) to be highly associated with higher SDSC scores.¹² Untreated mouth breathing leads to aberrant dental and maxillofacial development with various types of growth patterns and malocclusion. According to Tamasa et al., 100% pediatric patients were mouth breathers having SDB.¹⁸ Moreover, Alwadei et al. studied the occurrence and determinants of SDB, and the results concluded that 14.4% were mouth breathers.¹⁹ In our study, we found 67 patients of the total study sample to have mouth breathing. Difficulty closing lips together, commonly referred to as “mentalis strain,” is another factor that contributes to SDB. In our study, 25.4% had mild, 67.2% had moderate, and 7.5% had no mentalis strain. The primary root cause of pharyngeal blockage and breathing problems during sleep is adenoidal and tonsillar hypertrophy. It is well known that adenotonsillar hypertrophy raises young children's risk of SDB.^20–22 In Denizli, Turkey, Kara et al. studied the frequency of hypertrophied tonsils and related oropharyngeal ailments in preschool students and found the prevalence to be 11%.²³ Kang et al. found an association between SDB and adenotonsillar hypertrophy in young patients.²⁴ In our investigation, 85.1% and 9% of the cases show a high incidence of grades III and IV tonsillar hypertrophy. Ankyloglossia causes oral dysfunction, which can lead to oralfacial dysmorphism, reduced upper airway lumen size, and an increased risk of reduced airway patency, thereby affecting the proper development of the craniofacial structures.²⁵ The least common symptom seen in our study was ankyloglossia. Camañes-Gonzalvo et al. supported the correlation between ankyloglossia and SDB in children.²⁶ Our results show a prevalence of 6% of the total patients with ankyloglossia and are consistent with a systematic review's findings, by Cruz et al., which reported the prevalence to be 5%.²⁷ da Costa Lopes et al. stated there is no definitive link between bruxism and SDB, and it is not supported by any scientific data.²⁸ The overall rate of bruxism is much lower in children with sleep-related breathing problems, despite the fact that the mechanism of the condition is still poorly understood.^29,30 Laganà et al. investigated the relationship between children's risk factors for developing OSA and sleep bruxism and noted a prevalence of 41.3% of which 11.9% were mouth breathers.^31–33 In our present study, bruxism was seen in 13.4% of the study population. Furthermore, our results show a 67% prevalence of a high arch palate as a contributing element to the onset of OSA, which is in line with Victor's published result of 71.11%.³⁴ Any one red flag untreated can escalate the symptoms, and hence early detection based on six clinical parameters becomes crucial and can be done independently without prior assessment of a questionnaire.

Conclusion

In a representative sample of children, the frequency of SDB, as assessed by routine examination of the PSQ and FAIREST-6, was 5.2%. Dentists, doctors, and allied health providers can utilize the short and validated chairside FAIREST-6 screening test, which consists of six clinical determinants, to evaluate young patients for SDB. The symptoms of SDB are strongly linked to the existence of mentalis activity, tonsillar hypertrophy, and a narrow palate.

Clinical Significance

Dentists, doctors, and allied health providers can utilize the short and validated chairside FAIREST-6 screening tool, which consists of six clinical determinants, to evaluate young patients for SDB. Dentists can also help by identifying anatomical alterations early and treating them to optimize anatomical structure and function during the child's growth and development.

Limitation

This research requires a multicenter approach to ensure a comprehensive demographic and subpopulation diversity and to have more significant data.

Orcid

Shraddha Mahadeo Shirsat https://orcid.org/0009-0006-8039-2236

Madhura Pawar https://orcid.org/0000-0002-8688-8340

Sneha Panamgipalli https://orcid.org/0009-0002-0217-8972

Vaishnavi Mathawala https://orcid.org/0009-0001-2020-6183

Sejal Patil https://orcid.org/0009-0003-7147-8415