Advertisement

BMC Oral Health

, 19:43 | Cite as

Prevalence of sleep-disordered breathing and associations with orofacial symptoms among Saudi primary school children

  • Laila BaidasEmail author
  • Asma Al-Jobair
  • Huda Al-Kawari
  • Aram AlShehri
  • Sarah Al-Madani
  • Hana Al-Balbeesi
Open Access
Research article
  • 115 Downloads

Abstract

Background

This study aimed to determine the prevalence of sleep-disordered breathing among primary school children in Riyadh, Saudi Arabia, and to evaluate associations between sleep-disordered breathing and respiratory conditions/orofacial symptoms.

Methods

In this cross-sectional study, 1600 questionnaires were distributed to Saudi boys and girls aged 6–12 years from 16 primary schools in Riyadh. The questionnaire covered relevant demographic and personal characteristics, presence of respiratory conditions and orofacial symptoms, and the Pediatric Sleep Questionnaire. The latter was used to assess the prevalence of symptoms of sleep-disordered breathing and was completed by the participating children’s parents.

Results

In total, 1350 completed questionnaires were returned (85% response rate). The children’ mean age was 9.2 ± 1.8 years; 733 (54.3%) were boys and 617 (45.7%) girls. Overall, 21% of children were at high risk of sleep-disordered breathing. The prevalence of snoring was 14.4% and that of sleep apnea 3.4%. Boys were at higher risk of sleep-disordered breathing than girls (P = 0.040). Children with respiratory conditions or orofacial symptoms were at higher risk of sleep-disordered breathing (P < 0.0001) than children without these conditions/symptoms.

Conclusions

Around 21% of Saudi children are at risk of sleep-disordered breathing. There is a strong association between sleep-disordered breathing symptoms and the presence of respiratory conditions or orofacial symptoms.

Keywords

Sleep-disordered breathing Obstructive sleep apnea Pediatric sleep questionnaire Asthma Oral habits Saudi children 

Abbreviations

OSA

obstructive sleep apnea

PSQ

Pediatric Sleep Questionnaire

SDB

sleep-disordered breathing

TMD

temporomandibular disorder

TMJ

temporomandibular joint

Background

The term sleep-disordered breathing (SDB) covers a continuum of conditions ranging from primary snoring to severe obstructive sleep apnea (OSA) [1]. Sleep disturbances in children can lead to impairment of normal growth and to developmental problems that may affect behavioral and cognitive abilities [2]. Symptoms of SDB in children include snoring, difficulty breathing, mouth breathing, noisy breathing, sweating during sleep, and unusual sleeping positions that are adopted to overcome breathing difficulties. During the day, children with SDB are characterized by hyperactivity, restlessness, irritability, lack of attention, and loss of appetite [3, 4]. Risk factors for SDB in children are multidimensional and include sex, ethnicity, obesity, adenotonsillar hypertrophy, craniofacial abnormalities, exposure to cigarette smoke, respiratory infections, recurrent otitis media, allergic rhinitis, low socioeconomic status, and family history of snoring or OSA [5, 6, 7, 8, 9].

Habitual snoring, an important indicator of SDB in children, has been reported in primary school-aged children in various countries. In southern Italy, a study involving a large cohort of school- and preschool-aged children found that 4.9% of participants were habitual snorers and 1% had OSA [10]. A Turkish study reported a 7% prevalence of habitual snoring among children aged 6–13 years [11]. In addition, an 11.4% prevalence of habitual snoring was reported among Indian children aged 8–13 years [12] and a prevalence of 12% in Chinese schoolchildren [7]. A study involving Brazilian schoolchildren aged 9–14 years found that parents reported habitual snoring in 27.6% of children and apnea in 0.8% [13]. In Saudi Arabia, BaHammam et al. showed that sleep problems are prevalent among Saudi elementary school children, the prevalence of habitual snoring being 17% [14]. BaHammam et al. also investigated the prevalence of SDB among Saudi adults and found that 33% of middle-aged Saudi men and 39% of middle-aged Saudi women are at high risk of OSA [15, 16]. Al-Jewair et al. assessed the risk of OSA among Saudi adult dental patients and reported that 17% were habitual snorers and 23% at high risk of OSA [17]. Huynh et al. reported that 13.8% of a group of pediatric orthodontic patients were habitual snorers and 1.8% had sleep apnea [18].

The craniofacial development of children with SDB is similar to that of children with adenoid facies [19]. Any airway abnormality (e.g., hypertrophy of the adenoids) may lead to airway obstruction, chronic mouth breathing, and anatomical changes that affect the airway during active craniofacial development [20, 21]. These changes may increase airway instability and collapsibility, which can result in SDB and progression to OSA [22]. Children with SDB have distinct craniofacial morphology, including a posteriorly inclined mandibular plane angle, retrognathic mandible with increased lower anterior facial height, reduced posterior facial height, narrow maxillary arch with deeper palatal height, lateral cross-bites, and anterior open bite [18, 23, 24]. Therefore, it is important to consider any problems that contribute to poor skeletal and airway development in children, especially as these may have a negative impact on facial aesthetics and can be difficult to correct [25]. In addition to the orofacial characteristics associated with SDB, published reports suggest there is some association between SDB and orofacial symptoms. Oral habits such as digit sucking and bruxism, and facial pain such as temporomandibular disorder (TMD) are reportedly linked with SDB [26, 27, 28]. These relationships highlight the role of dentists in the early diagnosis, management, and referral of children with SDB [18, 29].

Increasing sleep problems among Saudi children highlight the need to investigate the prevalence of SDB in this population [14]. This study aimed to determine the prevalence of SDB symptoms in primary school children aged 6–12 years in Riyadh, Saudi Arabia, and to evaluate associations between SDB and respiratory conditions/orofacial symptoms.

Methods

This cross-sectional study was conducted between September 2014 and May 2015 in Riyadh, Saudi Arabia. Approval was obtained from the Ethics Committee of the College of Dentistry Research Center at King Saud University (Registration No. IR 0105).

Setting

Riyadh city is the capital of Saudi Arabia, which covers an area of 600 mile2 (1550 km2). The city has been subjected to high rates of population growth, from 150,000 inhabitants in the 1960s to over 5 million according to recent estimates [30].

Calculation of sample size

A required sample size of 1300 was estimated based on a statistical power calculation of 85% and confidence level of 95%, assuming a SDB prevalence of 19% in Riyadh and 0.25 non-responses.

Selection of schools

A list of all boys’ and girls’ public and private primary schools in Riyadh city was obtained from the Ministry of Education. These primary schools are responsible for providing education for children aged 6–12 years. A stratified randomization method was used to select schools for this study to ensure the sample was representative of schools in Riyadh. All public and private schools in every administrative district of Riyadh (North, East, West, South, and Central) were assigned a number. Schools were then selected randomly using a randomization Table. A total of 16 schools (10 public and six private) were selected: one public school for boys and one for girls from each district, and one private school for boys and one for girls from three districts (North, Central, and Eastern). These three districts were chosen because the majority of private schools are concentrated in these districts. The schools’ principals were invited to participate in this study via a letter explaining the purpose of the study and seeking their permission to distribute the questionnaires.

Selection of children

In total, 1600 questionnaires were distributed to Saudi boys and girls aged 6–12 years. A similar sampling procedure to that used for school selection was conducted to select classes and students in each selected school. Children with known syndromes and compromised craniofacial anomalies were excluded from the study. Overall, 800 questionnaires were distributed to boys’ schools and 800 to girls’ schools.

Questionnaire

The questionnaires were addressed to the children’s parents and sent home with each child. They included a cover page that explained the aim of the study and the importance of investigating the topic. Confidentiality of all information concerning the child was emphasized.

The questionnaire collected relevant demographic and personal characteristics (sex, age, school name, district, and parents’ educational level). The first part of the questionnaire included specific yes/no questions about the presence of specific respiratory conditions (e.g., asthma, respiratory allergy, tonsillitis, adenoiditis, and otitis media). This part of the questionnaire also assessed the presence of orofacial symptoms and included questions about digit sucking habits, tooth grinding during daytime and sleep, temporomandibular joint (TMJ) pain, and facial muscle pain. The second part of the questionnaire comprised the Pediatric Sleep Questionnaire (PSQ), which was used to assess the prevalence of symptoms of SDB. The PSQ includes 22 items that encompass prominent symptoms, such as snoring, breathing problems, mouth breathing, daytime sleepiness, and inattention/hyperactivity problems [4]. The original PSQ was translated into Arabic using the forward-backward translation method described by the World Health Organization [31].

A pilot test was conducted to ensure that the questions were correctly understood after translation. The translated questionnaires were first distributed to 10 mothers, who were asked to highlight any questions that were unclear. Some questions were adjusted in response to their feedback. A pilot study was then conducted with 50 parents of schoolchildren to test the reliability of the respiratory condition, orofacial symptom, and PSQ items. The parents involved in the pilot study were not included in the main sample. Item agreement was verified by the pilot study participants completing the questionnaire a second time after a 2-week interval. The kappa values were 0.87 for respiratory conditions, 0.89 for orofacial symptoms, and 0.91 for PSQ items.

Each PSQ item has three response options (yes, no, don’t know). Items are scored as one (yes) or zero (no or don’t know). On the basis of PSQ scores, children with 33% or more positive responses (scores of 8 or more) were considered at high risk of SDB, whereas children with fewer than 33% positive responses (scores less than 8) were considered at low risk of SDB.

Data analysis

All statistical analyses were performed with SPSS version 22 (IBM SPSS Statistics for Windows, Version 22.0; IBM, Armonk, NY, USA). Participants’ characteristics and prevalence rates are reported using descriptive statistics. Bivariate analyses were performed using the χ2 test to assess differences between low- and high-risk children regarding age, sex, snoring, sleep apnea, mouth breathing, obesity, respiratory conditions, and orofacial symptoms. Univariate analysis and multivariate backward stepwise regression were performed to assess factors associated with the risk for SDB. P-values < 0.05 were considered to denote significance. The Hosmer–Lemeshow goodness-of-fit test and the area under the receiver operator characteristic (ROC) curve were used to assess the validity of the multivariate regression model.

Results

In total, 1600 questionnaires were distributed to 16 primary schools in Riyadh city. Responses for 1350 children were received (85% response rate); 733 boys (54.3%) and 617 girls (45.7%). The children’s mean age was 9.2 ± 1.8 years. The children were divided into two age groups: 6–9 years (52.2%) and 10–12 years (47.8%). The highest response rate was from the Eastern area. The most common level of education for both parents was a bachelor’s degree. Mothers responded to 67.7% of the questionnaires.

In total, 21% of children were at high risk of SDB (8 or more “yes” responses on the PSQ). Habitual snoring (snoring all the time and always snoring during sleep) was reported in 14.4% of children, sleep apnea in 3.4%, mouth breathing in 21%, and overweight in 10.5% (Table 1).
Table 1

Distribution of participants with SDB symptoms (frequency and percentage)

Domain

Question

n (%)

Snoring/breathing problems

Snores all the time during sleep

50 (3.7)

Always snores during sleep

145 (10.7)

Snores loudly

151(11.2)

Snores during day

113 (8.4)

Difficulty in breathing

109 (8.1)

Has stopped breathing during sleep

46 (3.4)

Mouth breathing during day

284 (21.0)

Dry mouth upon waking

289 (21.4)

Wets bed, walks during sleep, or wakes up scared during night

274 (20.3)

Daytime sleepiness and development

Wakes up unrefreshed

403 (29.9)

Wakes up with headache

130 (9.6)

Difficult to wake child up

461 (34.1)

Sleepiness during the day

329 (24.4)

Sleepiness during the day noticed by teacher

133 (9.9)

Has stopped growing at a normal rate

56 (4.1)

Overweight

142 (10.5)

Inattention/hyperactivity

Does not respond quickly when spoken to

294 (21.8)

Difficulty in organizing and managing tasks

276 (20.4)

Easily distracted by external stimuli

589 (43.6)

Seems restless and moves when seated

491 (36.4)

Looks in a hurry all the time

541 (40.1)

Interrupts others during speech

510 (37.8)

Number of children at high-risk of SDB (eight or more yes responses)

283 (21.0)

SDB sleep-disordered breathing

All sleep symptoms were strongly associated with high risk of SDB. Table 2 shows the characteristics that differed significantly between children at low- and high-risk of SDB. Boys were at higher risk of SDB than girls (P = 0.040). Habitual snoring, sleep apnea, mouth breathing, and being overweight were strongly associated with SDB (P < 0.001). All respiratory conditions and orofacial symptoms were more common in high-risk children (P < 0.001).
Table 2

Children’s characteristics according to risk of SDB

Variable

All children

Low-risk

High-risk

P-value

N = 1350

N = 1067

N = 283

n (%)

n (%)

n (%)

 

Personal characteristics

Sex

Female

617 (45.7)

503 (47.7)

114 (40.3)

0.040

Male

733 (54.3)

564 (52.9)

169 (59.7)

Age group, years

6–9

705 (52.2)

555 (52)

150 (53)

0.767

10–12

645 (47.8)

512 (48)

133 (47)

SDB symptoms

Snoring

Yes

196 (14.4)

77 (39.3)

119 (60.7)

<0.001

Sleep apnea

Yes

46 (3.4)

11 (1)

35 (76.1)

<0.001

Mouth breathing

Yes

284 (21)

143 (13)

141 (49.6)

<0.001

Overweight

Yes

142 (10.5)

78 (7.3)

64 (22.6)

<0.001

Respiratory conditions

Asthma

Yes

97 (7.2)

54 (5.1)

43 (15.2)

<0.001

Respiratory allergy

Yes

214 (15.9)

139 (13)

75 (29.5)

<0.001

Tonsillitis

Yes

186 (13.8)

119 (11.2)

67 (23.7)

<0.001

Adenoiditis

Yes

108 (8.0)

48 (4.5)

60 (21.2)

<0.001

Otitis media

Yes

102 (7.6)

54 (5.1)

48 (17)

<0.001

Orofacial symptoms

Digit sucking

Yes

114 (8.4)

70 (6.6)

44 (15.5)

<0.001

Tooth grinding (day)

Yes

47 (3.5)

24 (2.2)

23 (8.1)

<0.001

Tooth grinding (sleep)

Yes

126 (9.3)

78 (7.3)

48 (17)

<0.001

Facial muscle pain

Yes

14 (1.0)

7 (0.7)

7 (2.5)

0.015

TMJ pain on waking

Yes

31 (2.3)

7 (0.7)

24 (8.5)

<0.001

SDB sleep-disordered breathing, TMJ temporomandibular joint

Logistic regression analyses to evaluate possible risk factors for SDB are presented in Table 3. Children with habitual snoring, sleep apnea, or mouth breathing were at a four times higher risk of developing SDB. Overweight children were three times more likely to report SDB symptoms than other children (odds ratio [OR]: 3.3, 95% confidence interval [CI]: 2.1–5.2). Asthma was not significantly associated with SDB at the univariate level, but was significantly associated at the multivariate level. In contrast, tonsillitis was highly significantly associated at the univariate level but was not significantly associated at the multivariate level. Children who had adenoiditis were twice as likely to develop SDB as those without adenoiditis (OR: 2.4, 95% CI:1.0–2.9). Similarly, children with otitis media were at almost three times higher risk of developing SDB (OR: 2.6, 95% CI:1.5–4.5). Children who had digit sucking habits or sleep bruxism were at higher risk of SDB. Children with TMJ pain on waking were six times more likely to report SDB symptoms than other children (OR: 5.8, 95% CI: 2.1–16.3). All of these variables retained significance associations at the multivariate level. The Hosmer–Lemeshow test was not statistically significant (P = 0.135), and the area under the ROC curve was 0.840; both tests thus confirming the suitability of the tested model.
Table 3

Logistic regression analyses of SBD risk

Variables

Univariate analysis

Multivariate analysis

Odds ratio

95% Confidence interval

P-value

Odds ratio

95% Confidence interval

P-value

Snoring

4.319

2.864

6.513

<0.001

4.382

2.915

6.588

<0.001

Obstructive sleep apnea

4.406

1.888

10.281

0.001

4.280

1.833

9.996

0.001

Mouth breathing

4.388

3.104

6.203

<0.001

4.408

3.127

6.214

<0.001

Overweight

3.339

2.131

5.230

<0.001

3.326

2.122

5.212

<0.001

Asthma

    

1.798

1.058

3.054

0.030

Tonsillitis

1.770

1.058

2.971

0.030

    

Adenoiditis

2.404

1.119

5.163

0.024

2.317

1.077

4.984

0.031

Otitis media

2.645

1.544

4.533

<0.001

2.607

1.537

4.424

<0.001

Digit sucking

2.768

1.680

4.559

<0.001

2.771

1.683

4.560

<0.001

Tooth grinding (day)

1.773

1.058

2.971

0.030

1.663

0.955

2.898

0.072

Tooth grinding (sleep)

1.958

1.185

3.234

0.009

1.998

1.214

3.289

0.007

TMJ pain on waking

7.250

2.331

22.546

<0.001

5.871

2.106

16.368

<0.001

TMJ temporomandibular joint

Discussion

SDB affects children’s growth, development, cognitive function, and learning abilities, which may result in poor school performance [1, 2]. It is important to determine the prevalence of SDB in children because of its association with health problems such as hypertension, cardiovascular disease, and brain damage [32, 33, 34].

In the present study we used a validated questionnaire to assess the prevalence of SDB symptoms among Saudi primary school children aged 6–12 years in Riyadh city. The PSQ used in the present study was developed by Chervin et al., and is considered a valid and reliable instrument for identifying SDB risk, having a sensitivity of 81% and specificity of 87% [4].

The response rate was high (85%); only 10% of the questionnaires were not returned and 5% excluded because of incomplete information. The high response rate for the Eastern area of Riyadh city may be because it is more densely populated than the other included areas. The commonest level of parental education was a bachelor’s degree, possibly because educated parents are more aware of their children’s health problems and more willing to participate in research such as our study. Most questionnaires were responded to by mothers, which may be attributable to mothers being closer to their children and knowing more about their sleeping habits.

In this study, 21% of children were at high risk for SDB, 14.4% reported habitual snoring, and 3.4% reported sleep apnea. Sleep problems have previously been reported to be prevalent among elementary Saudi children, the reported prevalence of habitual snoring being 17% [14]. This rate is lower than that in a Dutch study, which reported that 25% of children aged 7–12 years had sleep problems [35], but is higher than rates reported in Italian (4.9%), Turkish (7%), and Indian (11.4%) schoolchildren [10, 11, 12]. However, it is lower than that reported in Brazilian schoolchildren (27.6%) [13]. In the present study, reported sleep apnea among Saudi schoolchildren was higher than that reported for Italian (1%) and Brazilian children (0.8%) [10, 13]. Mouth breathing was present in 21% of our sample, which is also higher than the 15.5% reported for Brazilian schoolchildren [13]. The varying reported prevalences of snoring, sleep apnea, and mouth breathing may be explained by differences in the targeted age groups, questionnaires used, definitions adopted, cohorts studied, and cultural factors.

Our study showed a male predilection regarding risk of SDB, with 23% of boys at high risk compared with 19% of girls. The findings of previous studies have been similar [7, 10, 11, 26]. However, one study found that girls were at a higher risk of experiencing sleep disturbances than boys [36] and several studies involving Brazilian and Indian schoolchildren did detected no differences between boys and girls in the prevalence of SDB symptoms [12, 13]. A systematic review by Lumeng and Chervin [1] concluded that the prevalence of childhood SDB differs according to sex, boys being more frequently affected than girls. Studies in which these differences were not clear may have had inadequate sample size and power to detect any difference. The large sample size of the present study allowed us to detect sex-based differences.

Many studies have investigated the association between respiratory conditions and SDB. We found that respiratory conditions (e.g., asthma, tonsillitis, adenoiditis, and otitis media) are common in children at high risk of SDB and the associations are strong. A previous study involving children aged 5–12 years in which breathing was monitored during sleep found that regardless of race, body mass index, and family history, symptoms of SDB were significantly associated with upper and lower respiratory symptoms [36]. Consistent with our study, Li et al. found a strong association between habitual snoring and several respiratory problems associated with atopy and infection, including chronic/allergic rhinitis, asthma, adenotonsillar hypertrophy, and otitis media [7]. Gozel et al. found an association between habitual snoring and high prevalence of recurrent otitis media among children aged 5–7 years [8]. The mechanisms underlying respiratory problems and habitual snoring are not yet clear. Respiratory problems may increase upper airway resistance and affect airway compliance, resulting in habitual snoring. In turn, habitual snoring may exacerbate some respiratory problems such as asthma by increasing cholinergic tone and promoting bronchial constriction [37, 38]. Repeated and frequent respiratory infections may also disturb a child’s normal sleep pattern and prevent normal nighttime endocrinological function and normal growth, as seen in children with sleep apnea [39, 40]. We found stronger associations between adenoiditis and otitis media and risk of SDB than between asthma and tonsillitis and risk of SDB. Given the prominent role of enlarged adenoids in increased upper airway resistance and in the pathophysiology of eustachian tube dysfunction [8], this difference may be attributable to the greater proliferation of lymphadenoid tissues in the upper airways in the former conditions.

Regarding oral habits, it is thought that non-nutritive sucking habits, (e.g., pacifier use and digit sucking) protects against SDB, possibly because they increase muscle tone and consequently decrease the collapsibility of the pharynx during sleep [41, 42]. However, in the present study we found an association between SDB and a history of digit sucking habits. This is consistent with the findings of Huynh et al., who reported that a statistically significant association between a history of thumb/finger sucking and heavy breathing at night [18]. In contrast, Al-Talib et al. evaluated the relationship between non-nutritive sucking habits and risk of SDB in a sample of 84 children aged 4–12 years and found that non-nutritive sucking habits had no effect on the prevalence of SDB [26]. Our study showed an association between SDB symptoms and tooth grinding. This contradicts the findings of Huynh et al., who reported that a habit of tooth grinding while awake or asleep is not associated with symptoms of SDB [18]. It has been suggested that tooth grinding or bruxism is a complex process and is associated with sleep position [27]. Associations between SDB, sleep position, and parafunctional activities (grinding, clenching) have been found in some patients [43]. A link between SDB and tooth grinding or bruxism is possible, given that these two conditions are both associated with alterations in muscle activity and tone [44]. Furthermore, facial pain reportedly occurs more frequently in children at high risk of SDB and children with TMJ pain are seven times more likely to have SDB than those who do not. Many studies have supported a significant association between symptoms of OSA and TMD [28, 45]. Although a causal association between TMD and SDB remains controversial, bruxism (which is more common in children at high risk of SDB than in those at lower risk) may be implicated in development of TMD [46]. The strong association between SDB and TMD suggests that children with TMD should be routinely screened for SDB and those with significant sleep problems strongly considered for referral for a complete sleep evaluation [45].

One limitation of our study is that the results are based on parents’ subjective views. Implementation of a more objective tool, such as polysomnography, would yield more accurate results. However, use of these tools may be impractical in large studies such as ours. Although our findings are comparable with those of previous studies, some contextual factors should be considered, including sample size, age group, type of questionnaire, variables tested, socioeconomic status, and ethnicity. Further studies that include children from different cities in Saudi Arabia are needed to determine whether our findings can be generalized to all Saudi children. Moreover, combining the use of questionnaires with clinical examinations of participating children may yield more information and thus take future studies to a higher level.

Conclusions

We found that 21% of Saudi children are at risk of SDB, boys being at higher risk than girls. SDB symptoms (snoring, sleep apnea, mouth breathing, and being overweight), all investigated respiratory conditions, and orofacial symptoms were more common in high-risk children. Snoring, OSA, mouth breathing, overweight, otitis media, adenoiditis, digit sucking, tooth grinding, and TMJ pain on waking were all identified as risk factors. Thus, the significance of investigating SDB in younger age groups should not be overlooked.

Notes

Acknowledgements

The authors would like to thank Mr. Nassr Al-Maflehi for his efforts and help in the statistical analysis of the data. We also thank Audrey Holmes, MA, and Trish Reynolds, MBBS, FRACP, from Edanz Group (www.edanzediting.com/ac) for editing drafts of this manuscript.

Funding

The authors have no affiliation or financial involvement with organizations or entities with a direct financial interest in the subject matter or materials discussed in the manuscript. No funding was received for this work from any organization.

Availability of data and materials

The datasets used and/or analyzed during the present study are available from the corresponding author on request.

Authors’ contributions

All authors have read and approved the final manuscript. LB contributed to the conception and design of the study, agreed to be accountable for all aspects of the work and ensure questions related to the accuracy or integrity of any part of the work were appropriately investigated and resolved, was involved in writing the manuscript, and approved the final version to be published. AJ contributed to the conception and design of the study and analysis/interpretation of the data, agreed to be accountable for all aspects of the work and ensure questions related to the accuracy/integrity of any part of the work were appropriately investigated and resolved, and approved the final version to be published. HK was involved in drafting the manuscript and revising it critically for important intellectual content, and approved the final version to be published. ASh contributed to data collection, agreed to be accountable for all aspects of the work, was involved in drafting the manuscript, and approved the final version to be published. SM contributed to the data collection, agreed to be accountable for all aspects of the work, was involved in drafting the manuscript, and approved the final version to be published. HB was involved in drafting the manuscript and revising it critically for important intellectual content, and approved the final version to be published.

Ethics approval and consent to participate

This study was approved by the Ethics Committee of the College of Dentistry Research Center at King Saud University (Registration no. IR 0105). All parents were asked to sign a consent form that had been approved by the Ethics Committee before responding to the questionnaires.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

References

  1. 1.
    Lumeng JC, Chervin RD. Epidemiology of pediatric obstructive sleep apnea. Proc Am Thorac Soc. 2008;5:242–52.CrossRefGoogle Scholar
  2. 2.
    Loghmanee DA, Sheldon SH. Pediatric obstructive sleep apnea: an update. Pediatr Ann. 2010;3:784–9.CrossRefGoogle Scholar
  3. 3.
    Smith DL, Gozal D, Hunter SJ, Philby MF, Kaylegian J, Kheirandish-Gozal L. Impact of sleep disordered breathing on behavior among elementary school-aged children: a cross-sectional analysis of a large community-based sample. Eur Respir J. 2016;48:1631–9.CrossRefGoogle Scholar
  4. 4.
    Chervin RD, Hedger K, Dillon JE, Pituch KJ. Pediatric sleep questionnaire (PSQ): validity and reliability of scales for sleep-disordered breathing, snoring, sleepiness, and behavioral problems. Sleep Med. 2000;1:21–32.CrossRefGoogle Scholar
  5. 5.
    Dayyat E, Kheirandish-Gozal L, Sans Capdevila O, Maarafeya MM, Gozal D. Obstructive sleep apnea in children: relative contributions of body mass index and adenotonsillar hypertrophy. Chest. 2009;136:137–44. doi.org.  https://doi.org/10.1186/1465-9921-11-144.CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Kuehni CE, Strippoli MP, Chauliac ES, Silverman M. Snoring in preschool children: prevalence, severity and risk factors. Eur Respir J. 2008;31:326–33.CrossRefGoogle Scholar
  7. 7.
    Li S, Jin X, Yan Ch WS, Jiang F, Shen X. Habitual snoring in school-aged children: environmental and biological predictors. Respir Res. 2010;11:144.CrossRefGoogle Scholar
  8. 8.
    Gozal D, Kheirandish-Gozal L, Sans Capdevila O, Dayyat E, Kheirandish E. Prevalence of recurrent otitis media in habitually snoring school-aged children. Sleep Med. 2008;9:549–54.CrossRefGoogle Scholar
  9. 9.
    Montgomery-Downs HE, Gozal D. Snore-associated sleep fragmentation in infancy: mental development effects and contribution of secondhand cigarette smoke exposure. Pediatrics. 2006;117:e496–e502; doi https://doi.org/10.1542/peds.2005-1785
  10. 10.
    Brunetti L, Rana S, Lospalluti ML, Pietrafesa A, Francavilla R, Fanelli M, et al. Prevalence of obstructive sleep apnea syndrome in a cohort of 1207 children of southern Italy. Chest J. 2001;120:1930–5.CrossRefGoogle Scholar
  11. 11.
    Ersu R, Arman AR, Save D, Karadag B, Karakoc F, Berkem M, et al. Prevalence of snoring and symptoms of sleep-disordered breathing in primary school children in Istanbul. Chest J. 2004;126:19–24.CrossRefGoogle Scholar
  12. 12.
    Gupta R, Geol D, Kandpal SD, Mittal N, Dhyani M, Mittal M. Prevalence of sleep disorders among primary school children. Indian J Pediatr. 2016;83:1232–6.CrossRefGoogle Scholar
  13. 13.
    Petry C, Pereira MU, Pitrez PM, Jones MH, Stein RT. The prevalence of symptoms of sleep-disordered breathing in Brazilian schoolchildren. J Pediatr (Rio J). 2008;84:123–9.CrossRefGoogle Scholar
  14. 14.
    BaHammam A, AlFaris E, Shaikh S, Bin SA. Prevalence of sleep problems and habits in a sample of Saudi primary school children. Ann Saudi Med. 2006;26(1):7–13.CrossRefGoogle Scholar
  15. 15.
    BaHammam AS, Al-Rajeh MS, Al-Jahdali HH, BinSaeed AA. Prevalence of symptoms and risk of sleep apnea in middle-aged Saudi males in primary care. Saudi Med J. 2008;29:423–6.PubMedGoogle Scholar
  16. 16.
    BaHammam AS, Al-Rajeh MS, Al-Ibrahim FS, Arafah MA, Sharif MM. Prevalence of symptoms and risk of sleep apnea in middle-aged Saudi women in primary care. Saudi Med J. 2009;30:1572–6.PubMedGoogle Scholar
  17. 17.
    Al-Jewair TS, Nazair MA, Al-Masoud NN, Al-Qahtani ND. Prevalence and risk of habitual snoring and obstructive sleep apnea symptoms in adult dental patients. Saudi Med J. 2016;37:183–90.CrossRefGoogle Scholar
  18. 18.
    Huynh NT, Morton PD, Rompré PH, Papadakis A, Remise C. Associations between sleep-disordered breathing symptoms and facial and dental morphometry, assessed with screening examinations. Am J Orthod Dentofac Orthop. 2011;140(6):762–70.CrossRefGoogle Scholar
  19. 19.
    Zettergren-Wijk L, Forsberg CM, Linder-Aronson S. Changes in dentofacial morphology after adeno−/tonsillectomy in young children with obstructive sleep apnoea—a 5-year follow up study. Euro J Orthod. 2006;28:319–26.CrossRefGoogle Scholar
  20. 20.
    Al Ali A, Richmond S, Popat H, Playle R, Pickles T, Zhurov AI, et al. The influence of snoring, mouth breathing and apnea on facial morphology in late childhood: a three-dimensional study. BMJ Open. 2015;5:e009027 doi.org/10.1136/bmjopen-2015-009027.CrossRefGoogle Scholar
  21. 21.
    McNamara J. Influence of respiratory pattern on craniofacial growth. Angle Orthod. 1981;51:123–30.Google Scholar
  22. 22.
    Fitzpatrick M, McLean H, Urton A, Tan A, O’Donell E. Effect of oral or nasal breathing route on upper airway resistance during sleep. Eur Respir J. 2003;22:827–32.CrossRefGoogle Scholar
  23. 23.
    Miyao E, Noda A, Miyao M, Yasuma F, Inafuku S. The role of malocclusion in non-obese patients with obstructive sleep apnea syndrome. Inter Med. 2013;18:1573–8.Google Scholar
  24. 24.
    AlHammad NS, Hakeem LA, Salama FS. Orofacial findings associated with obstructive sleep apnea in a group of Saudi children. Pak J Med Sci. 2015;31:388–92.CrossRefGoogle Scholar
  25. 25.
    Smith RJ. Identifying normal and abnormal development of dental occlusion. Pediatr Clin North Am. 1991;38:1149–71.CrossRefGoogle Scholar
  26. 26.
    Al-Talib T, Koroluk LD, Vann WF, Phillips C. The impact of non-nutritive sucking on the risk for sleep-disordered breathing in children. J Dent Child (Chic). 2017;84:30–4.Google Scholar
  27. 27.
    Miyawaki S, Lavigne GJ, Pierre M, Guitard F, Montplaisir JY, Kato T. Association between sleep bruxism, swallowing-related laryngeal movement, and sleep positions. Sleep. 2003;26:461–5.CrossRefGoogle Scholar
  28. 28.
    Sanders AE, Essick GK, Fillingim R, Knott C, Ohrbach R, Greenspan JD, et al. Sleep apnea symptoms and risk of temporomandibular disorder: OPPERA cohort. J Dent Res. 2013;92(7 Suppl):S70–7.CrossRefGoogle Scholar
  29. 29.
    Verma SK, Maheshwari S, Sharma NK, Prabhat KC. Role of oral health professional in pediatric obstructive sleep apnea. Natl J Maxillofac Surg. 2010;1(1):35–40.CrossRefGoogle Scholar
  30. 30.
    Alriyadh Development Authority. http://www.ada.gov.sa. Accessed 21 Oct 2014.
  31. 31.
    World Health Organization http://www.who.int/substance_abuse/research_tools/translation/en/. Accessed 21 Oct 2014.
  32. 32.
    Sawatari H, Chishaki A, Ando SI. The epidemiology of sleep disordered breathing and hypertension in various populations. Curr Hypertens Rev. 2016;12:12–7.CrossRefGoogle Scholar
  33. 33.
    Vlahandonis A, Walter LM, Horne RS. Does treatment of SDB in children improve cardiovascular outcome? Sleep Med Rev. 2013;17:75–85.CrossRefGoogle Scholar
  34. 34.
    Simmons MS, Clark GT. The potentially harmful medical consequences of untreated sleep-disordered breathing: the evidence supporting brain damage. J Am Dent Assoc. 2009;140:536–42.CrossRefGoogle Scholar
  35. 35.
    Van Litsenburg RR, Waumans RC, van den Berg G, Gemke RJ. Sleep habits and sleep disturbances in Dutch children: a population-based study. Eur J Pediatr. 2010;169:1009–15.CrossRefGoogle Scholar
  36. 36.
    Bixler E, Vgontzas A, Lin H, Liao D, Calhoun S, Vela-Bueno A, et al. Sleep disordered breathing in children in a general population sample: prevalence and risk factors. Sleep. 2009;32:731–6.CrossRefGoogle Scholar
  37. 37.
    Urschitz MS, Guenther A, Eitner S, Urschitz-Duprat PM, Schlaud M, Ipsiroglu OS, et al. Risk factors and natural history of habitual snoring. Chest. 2004;126:790–800.CrossRefGoogle Scholar
  38. 38.
    Basner RC, Simon PM, Schwartzstein RM, Weinberger SE, Weiss JW. Breathing route influences upper airway muscle activity in awake normal adults. J Appl Physiol. 1989;66:1766–71.CrossRefGoogle Scholar
  39. 39.
    Grindler DJ, Blank SJ, Schulz KA, Witsell DL, Lieu JE. Impact of otitis media severity on children’s quality of life. Otolaryngol Head Neck Surg. 2014;151:333–40.CrossRefGoogle Scholar
  40. 40.
    Nieminen P, Lopponen T, Tolonen U, Lanning P, Knip M, Lopponen H. Growth and biochemical markers of growth in children with snoring and obstructive sleep apnea. Pediatr. 2002;109:e55.CrossRefGoogle Scholar
  41. 41.
    Guimaraes KC, Drager LF, Genta PR, Marcondes BF, Lorenzi-Filho G. Effects of oropharyngeal exercises on patients with moderate obstructive sleep apnea syndrome. Am J Respir Crit Care Med. 2009;179:962–6.CrossRefGoogle Scholar
  42. 42.
    Steele CM. On the plausibility of upper airway remodeling as an outcome of orofacial exercise. Am J Respir Crit Care Med. 2009;179:858–9.CrossRefGoogle Scholar
  43. 43.
    Phillips BA, Okeson J, Paesani D, Gilmore R. Effect of sleep position on sleep apnea and parafunctional activity. Chest. 1986;90:424–9.CrossRefGoogle Scholar
  44. 44.
    Ferreira NM, Dos Santos JF, dos Santos MB, Marchini L. Sleep bruxism associated with obstructive sleep apnea syndrome in children. Cranio. 2015;33:251–5.CrossRefGoogle Scholar
  45. 45.
    Smith MT, Wickwire EM, Grace EG, Edwards RR, Buenaver LF, Peterson S, et al. Sleep disorders and their association with laboratory pain sensitivity in temporomandibular joint disorder. Sleep. 2009;32:779–90.CrossRefGoogle Scholar
  46. 46.
    Balasubramaniam R, Klasser GD, Cistulli PA, Lavigne GJ. The link between sleep bruxism, sleep disordered breathing and temporomandibular disorders: an evidence-based review. J Dent Sleep Med. 2014;1:27–37.Google Scholar

Copyright information

© The Author(s). 2019

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors and Affiliations

  • Laila Baidas
    • 1
    Email author
  • Asma Al-Jobair
    • 1
  • Huda Al-Kawari
    • 1
  • Aram AlShehri
    • 2
  • Sarah Al-Madani
    • 2
  • Hana Al-Balbeesi
    • 1
  1. 1.Department of Pediatric Dentistry and OrthodonticsCollege of Dentistry, King Saud UniversityRiyadhSaudi Arabia
  2. 2.College of Dentistry, King Saud UniversityRiyadhSaudi Arabia

Personalised recommendations