Arabic translation and validation of a pediatric sleep questionnaire to assess the prevalence of sleep-disordered breathing among Saudi pre-school children.

OBJECTIVES: (1) To translate to Arabic a validated pediatric sleep questionnaire, (2) To assess the validity and reliability of the translated questionnaire, and (3) To assess the prevalence of sleep-disordered breathing (SDB) among a group of pre-school children in Jeddah, Saudi Arabia. METHODS: Using forward and back-translation, a set of 6 hierarchically arranged questions that comprise the Gozal sleep questionnaire was translated into Arabic. Validity was assessed using face validity and content validity for consistency and clarity, using both item-level and scale-level content validity indices (I-CVI, S-CVI). Consent forms were sent to 1783 mothers recruited from 8 different pre-schools in Jeddah between October 2017 and April 2018, and 209 signed and returned the consent forms. Out of this sample, 34 mothers were contacted to assess internal consistency using Cronbach's alpha, and test-retest reliability using Interclass correlation coefficient (ICC). Finally, all 209 mothers were contacted to answer the questionnaire to obtain the prevalence of SDB. RESULTS: Using face validity and content validity, the translated questionnaire proved to be valid with perfect I-CVI and S-CVI. Internal consistency (Cronbach's Alpha 0.64-0.89) and test-retest reliability (ICC=0.87, p<0.001) showed the translated questionnaire to have good to favorable reliability. Depending on the severity of SDB, the prevalence of SDB was 7.7%, 5.7%, and 3.8% for mild, moderate and severe cut-off values respectively. CONCLUSION: A validated pediatric sleep questionnaire to assess SDB was translated into Arabic and the translation proved to be valid and reliable. The prevalence of SDB was found to be very comparable to other areas in the world.

Comparing two pediatric sleep questionnaires: The Pediatric Sleep Questionnaire (PSQ) and a set of 6 hierarchically arranged questions (6Q).

OBJECTIVE: To compare the Pediatric Sleep Questionnaire (PSQ) and a less time-consuming set of 6 hierarchically arranged questions (6Q) as they relate to the pre-test probability for sleep apnea in pediatric patients. METHODS: Parents of 116 subjects between the ages of 7 and 17 answered two sleep questionnaires (the PSQ and the 6Q) distributed in random order before the subjects had sleep studies. Correlation coefficients were used for apnea-hypopnea index (AHI) prediction, while the area under the curve (AUC) was calculated for sleep apnea classification prediction. RESULTS: The 6Q showed statistical significance, while the more commonly used PSQ did not, both in terms of correlating with AHI (rho = 0.294, p = 0.001) and predicting moderate and severe sleep apnea (AUC = 0.650 and 0.788, respectively). CONCLUSION: Although additional field validation is required, these pediatric sleep questionnaires are sensitive and easy-to-use screening tools that can greatly help in the screening for pediatric sleep apnea.

Multiloop edgewise archwire treatment for a patient with a severe anterior open bite and amelogenesis imperfecta.

Amelogenesis imperfecta is a rare hereditary disorder that affects dental enamel and is often associated with an anterior open bite. Orthodontic treatment of a 16-year-old female patient with hypocalcified amelogenesis imperfecta and a 9-mm anterior open bite was presented. Radiographic examination revealed a steep mandibular plane angle, an increased lower face height, a Class II skeletal pattern, and a convex profile. Additionally, the patient had stainless steel crowns on all upper and lower posterior teeth and composite veneers on the upper anterior teeth. The patient was treated nonsurgically using a multiloop edgewise archwire (MEAW). MEAW mechanics allowed for successful correction of the anterior open bite, with significant reduction in the mandibular plane angle and improvement in the patient's profile. No fixed retainers were used, and the results remained stable 78 months after removal of orthodontic appliances. MEAW mechanics should be considered for patients with large anterior open bites, although this technique requires excellent patient compliance.

Two-dimensional upper airway normative values in children aged 7 to 17 years.

OBJECTIVE: To develop two-dimensional (2D) upper airway normative values in pediatric patients and correlate upper airway measurements with age. METHODS: Cone beam computed tomography scans of 3738 patients were examined, and a sample of 61 patients, divided into two age groups (7-11 and 12-17 years), was used to reconstruct lateral cephalograms. RESULTS: The mean adenoid-nasopharynx (A/N) ratio was 0.45 and 0.44 for age groups 1 and 2, respectively. The mean PNS-ad1 and PNS-ad2 were 24 and 18.7 mm, respectively, for age group 1, and 26.7 and 21.2 mm, respectively, for age group 2. Additional normative values for the hyoid bone, airway space, uvula, and tongue are presented. The highest correlation with age was the upper airway length (r = 0.557, p < 0.001). CONCLUSION: Although cephalometric radiographs remain 2D reconstructions of three-dimensional structures, they have significant value and can aid clinicians in the screening process for pediatric sleep apnea.

Relating three-dimensional airway measurements to the apnea-hypopnea index in pediatric sleep apnea patients.

OBJECTIVES: (a) To evaluate three-dimensional radiographic airway analysis as it relates to the pre-test probability for sleep apnea in pediatric patients, and (b) to develop cut-off values for measurements showing promising results. SETTING AND SAMPLE POPULATION: A consecutive series of pediatric patients between the ages of 7 and 17 years, referred for a sleep study were recruited. Cone beam computed tomography (CBCT) scans were acquired for 103 subjects within one month following the sleep study. METHODS: Three-dimensional airway analysis was performed including volumetric, area and linear measurements. Correlations with the apnea-hypopnea index (AHI) and receiver operating characteristic (ROC) curves were constructed. Sensitivity and specificity were calculated for prediction of AHI ≥ 5 and AHI ≥ 10. RESULTS: 99 CBCT scans were included (median age = 11 years). The nasopharyngeal volume (NPV) significantly correlated with AHI (rho≈-0.4, P < .05). In subjects aged 7-11 years, proposed cut-off values for NPV are 2400mm3 and 1600mm3 for AHI ≥ 5 and AHI ≥ 10, respectively. In subjects aged 12-17 years, proposed cut-off values for NPV are 3500mm3 and 2700mm3 for AHI ≥ 5 and AHI ≥ 10, respectively. Oropharyngeal cross-sectional area (OCSA) demonstrated significant predictive value in ROC curve analysis, and cut-off values for this airway measure are also proposed. CONCLUSIONS: Contrary to findings in adults, the NPV shows promise when screening for sleep apnea in children when CBCT scans are available. The OCSA might also be of value when screening for sleep apnea especially in older children.

The use of decorative braces in Jeddah, Saudi Arabia.

OBJECTIVE: To assess the practice of using orthodontic brackets as tooth decorations among dental offices and patients in Jeddah, Saudi Arabia. MATERIALS AND METHODS: The study was a cross-sectional survey using 2 questionnaires. The first included 14 doctor questions where 300 dental offices in Jeddah, Saudi Arabia were contacted by phone. The second questionnaire included 22 patient questions where 50 patients who currently have or have had decorative braces answered the questions online. RESULTS: Out of 250 dental offices that responded, 91 offices (36.4%) answered "yes" to offering decorative braces. Most dentists use metal brackets (96.3%) on both the upper and lower arches (98.8%) and ligate a wire (83.8%) using colored elastomeric ligatures. Out of 50 patients who answered the patient questions, 28 patients (56%) were females and the mean age was 19.84 years (±2.32). 37 (74%) patients reported that their decorative braces were not placed by dentists and mostly by over the counter glue. Finally, 62% reported they were not satisfied, and 84% said they would not recommend getting decorative braces to their family and friends. CONCLUSION: Our results indicate that the use of decorative braces is prevalent, and most are not being placed by dentist. As healthcare providers, we are obliged to educate the public of potential harm that can result when decorative braces are used, to hopefully limit the spread of this unfortunate practice.

Developing pediatric three-dimensional upper airway normative values using fixed and interactive thresholds.

OBJECTIVE: To develop and compare pediatric upper airway three-dimensional normative values using the two most commonly used cone beam computed tomography (CBCT) software: Invivo5 (fixed threshold) and Dolphin 3D (interactive threshold). STUDY DESIGN: Out of 3738 CBCT scans, scans of 81 pediatric patients were utilized after applying strict exclusion criteria. The sample was grouped into two age groups (7-11 and 12-17 years). Intra-class correlation coefficient was used to test intra-rater and inter-rater reliability and showed coefficients greater than 0.9 indicating good reliability of the methods used. RESULTS: Paired t tests showed that volumetric and area measurements obtained using Dolphin 3D were significantly larger than those obtained using Invivo5 (p < 0.05). The mean minimal cross-sectional areas (MCSA) for Dolphin 3D were 151 mm2 and 177 mm2 for age groups 1 and 2, respectively. The mean MCSA values for Invivo5 for age groups 1 and 2 were 120 mm2 and 145 mm2, respectively. CONCLUSION: Pediatric upper airway volumetric, area, and linear measurements were reported after applying strict exclusion criteria including a validated sleep questionnaire. Our goal is that clinicians utilize the proposed-here normative values for screening and assist in the timely diagnosis and management of pediatric sleep apnea.

Validation of the MediByte Portable Monitor for the Diagnosis of Sleep Apnea in Pediatric Patients.

STUDY OBJECTIVES: Polysomnography (PSG) is considered the gold standard in the diagnosis of sleep apnea. In pediatric patients, because of limited availability and access to laboratory-based PSG, there can be significant delays in the diagnosis and management of sleep apnea that can result in progressive associated comorbidities. The main objective of the current study was to test the diagnostic value of a portable sleep monitor (PM), the MediByte, in comparison with laboratory PSG in pediatric patients wearing both setups simultaneously. METHODS: A consecutive series of pediatric patients referred to the University of Illinois Sleep Science Center wore the MediByte during simultaneous PSG. The apnea-hypopnea index (AHI) was calculated for PSG and both manual and autoscoring functions of the PM. Pearson correlation and Bland-Altman plots were assessed. RESULTS: A total of 70 patients successfully completed simultaneous PSG and PM studies (median age 10.8 years). The AHI obtained both manually and automatically scored PM studies strongly correlated with the AHI obtained from the PSG (r ≥ .932, P < .001). The oxygen saturation obtained by the PM showed significant correlation with that obtained by PSG among children aged 12 to 17 years (P < .001), but not among children aged 7 to 11 years (P ≥ .24). The sensitivity and specificity for detection of severe sleep apnea diagnosed by PSG (AHI ≥ 10 events/h) using both PM scoring methods was very high (> 93% for both). CONCLUSIONS: Although PSG is still recommended for the diagnosis of sleep apnea, PMs can play a valuable role in diagnosing moderate and severe sleep apnea, especially in older pediatric patients. COMMENTARY: A commentary on this article appears in this issue on page 685.

Computerized measurement of the location and value of the minimum sagittal linear dimension of the upper airway on reconstructed lateral cephalograms compared with 3-dimensional values.

INTRODUCTION: Identifying the location and value of the smallest airway dimension can be useful in screening and planning treatment for patients with obstructive sleep apnea. Our objectives in this study were to (1) objectively identify the vertical location and value of the minimum sagittal linear dimension (MSLD) on 2-dimensional reconstructed lateral cephalograms (RLCs), (2) compare the location and value of the MSLD on RLCs with the vertical location and sagittal dimension of the minimum cross-sectional area (MCSA), and (3) investigate the association between the MSLD on RLCs and both the MCSA and the airway volume. METHODS: Cone-beam computed tomography (CBCT) scans of 91 patients, in 3 age groups (<20, 20-40, and >40 years), were used to perform 3-dimensional assessments of the upper airway and reconstruct lateral cephalograms. Airway volume, MCSA, vertical level, and sagittal dimension of MCSA on the CBCT scans were obtained using Dolphin 3D software (version 11.7; Dolphin Imaging, Chatsworth, Calif). Customized software was used to objectively obtain the location and value of the MSLD of the airway on RLCs. RESULTS: In all age groups, correlation tests showed significant correlations between the MSLD on RLCs and both the MCSA (rs ≥0.59; P <0.001) and the airway volume (rs ≥0.37; P <0.05). Additionally, there were significant correlations between the vertical location of the MSLD and the vertical location of the MCSA (rs ≥0.41; P <0.05) and between the MSLD and the sagittal dimension of the MCSA (r ≥0.61; P <0.001). Bland-Altman plots for the MSLD and the sagittal dimension of the MCSA showed much narrower 95% limits of agreement compared with the Bland-Altman plots for the vertical locations of the MSLD and the MCSA. CONCLUSIONS: Two-dimensional images may be used as a screening tool and to identify the sagittal dimension of the smallest airway dimension. However, comprehensive assessment of airway characteristics is better achieved with CBCT-based 3-dimensional evaluation.

Effects of unilateral premolar extraction treatment on the dental arch forms of Class II subdivision malocclusions.

INTRODUCTION: A retrospective study evaluating posttreatment symmetry in dental arch form and midlines was carried out in Class II subdivision patients treated with unilateral and bilateral maxillary premolar extractions. METHODS: Using Geomagic (version 14; Geomagic, Research Triangle Park, NC) and MATLAB (version 8.4; MathWorks, Natick, Mass) software, best-fit curves expressed as quartic polynomials were generated for 13 Class II subdivisions treated with unilateral extractions and 20 treated with bilateral maxillary premolar extractions. Transverse and sagittal measurements were recorded to assess symmetry. Dental models were superimposed on constructed reference planes to generate average posttreatment arches. Statistical comparisons were performed with the significance level set at P ≤0.05. RESULTS: The unilateral extraction group showed significant differences in transverse arch forms between the right and left sides in the anterior, anterior-middle, and middle segments of the arch, and all regions other than the posterior segment in the sagittal dimension. Significant differences were found between groups in the anterior and anterior-middle segments of the arch transversely, the middle and middle-posterior segments sagittally, and the midline deviation relative to the midsagittal plane. Superimposed average arches showed similar results. CONCLUSIONS: Unilateral maxillary extraction treatment generally results in a narrower and more posteriorly displaced arch form on the extraction side, with a deviated maxillary midline toward the extraction side of the arch.

A Proposed Method for Covering a Mini-Screw Head While Maintaining Space for Ligation.

The use of mini-screws, also known as temporary anchorage devices (TADs), to obtain absolute anchorage has become very popular in orthodontics. Nevertheless, potential complications, including traumatic soft tissue lesions, accompany their use. We propose a method to cover the mini-screw head to prevent traumatic soft tissue lesions and promote patient comfort, while maintaining some separation between the composite resin and the peri-implant tissue.

Sleep and airway assessment: A review for dentists.

INTRODUCTION: Dentists can be the first professionals to recognize a patient's potential sleep problem since they typically have more frequent contact with their patients than do physicians. It is important that dentists have a reasonable understanding of sleep disorders and how to assess their patients if they suspect such a problem so that a timely referral can be made or treatment can be provided as appropriate. OBJECTIVE: To review the key literature relevant to sleep-disordered breathing (SDB) characteristics and diagnosis, including history, examination, and investigation with an emphasis on radiographic airway analyses. CONCLUSION: The authors present a concise explanation of SDB conditions and an outline for thorough patient examination and evaluation, including radiographic airway analyses. Limited two-dimensional and three-dimensional norms exist for adult patients with no SDB and even less so for children. Much more research is needed, particularly in the pediatric population.

Force decay and dimensional changes of thermoplastic and novel thermoset elastomeric ligatures.

OBJECTIVES: To compare over a period of 8 weeks (1) the force decay and (2) the dimensional changes between thermoplastic (TP) and thermoset (TS) elastomeric ligatures. MATERIALS AND METHODS: TP and TS elastomeric ligatures were obtained from Rocky Mountain Orthodontics™. The TS ligatures were custom made specifically for this study. The sample included 72 clear TP and 72 clear TS elastomeric ligatures. The experiment was performed in a simulated oral environment (pH of 6.75) at 37°C. The remaining forces and the dimensional changes were measured at different time points over a period of 8 weeks. RESULTS: Student's t-tests revealed significant differences in percent force loss, percent change in outer diameter, percent change in inner diameter, and percent change in wall thickness between TP and TS elastomeric ligatures across all time points (P < .001). The difference in percent change in width between TP and TS elastomeric ligatures was not significant at all time points (P > .05). The mean difference in force loss between TP and TS across all time points was 22.91%. The TP and TS specimens exhibited 93.04% and 77.41% force loss, respectively, at the 28th day. CONCLUSIONS: This novel TS elastomeric ligature showed significantly less force decay and dimensional changes over time; therefore, it might be superior during initial leveling and aligning and during finishing stages. Using a transfer jig to prevent relaxation of the specimens before force measurement showed that force decay of commercially available elastomeric ligatures was greater than that described in previous publications.

Force decay evaluation of thermoplastic and thermoset elastomeric chains: A mechanical design comparison.

OBJECTIVES: To compare the following over a period of 8 weeks: (1) force decay between thermoplastic (TP) and thermoset (TS) elastomeric chains; (2) force decay between light (200-g) and heavy (350-g) initial forces; and (3) force decay between direct chains and chain loops (stretched from one pin around the second pin and back to the first pin). MATERIALS AND METHODS: TP and TS chains were obtained from American Orthodontics™ (AOTP, AOTS) and ORMCO™ (OrTP, OrTS). Each of the four chain groups was subdivided into four subgroups with 10 specimens per subgroup: (1) direct chains light force, (2) direct chains heavy force, (3) chain loops light force, and (4) chain loops heavy force. The experiment was performed in artificial saliva (pH of 6.75) at 37°C. RESULTS: A significant difference was found between TP and TS chains, with an average mean difference of around 20% more force decay found in the TP chains (P < .001, α  =  .05). There was no significant difference between direct chains and chain loops except in OrTP, in which direct chains showed more force decay. There was also no significant difference in force decay identified when using light vs heavy forces. CONCLUSIONS: TS chains decayed less than TP chains, and chain loop retraction was beneficial only when using OrTP chains. Contrary to the interchangeable use of TP and TS chains in the published literature and in clinical practice, this study demonstrates that they perform differently under stress and that a clear distinction should be made between the two.