Kevin O'Brien: Breathe, breathe in the air. Don’t be afraid to care. A conciliatory post on paediatric OSA.

This is a follow-up post to my earlier comments on the lectures on paediatric OSA at the recent AAO meeting. I have decided to revisit this subject as I just listened to Farooq Ahmed’s recent podcast with Audrey Yoon while I was on a relaxing holiday on the Norfolk coast in the UK.

The podcast

This was a wide-ranging discussion about her treatment of paediatric OSA. In this discussion, she let Farooq know that she thought that I was disagreeable in my criticism of her lecture. I want to apologise to her for my tone. While I thought that I was being robust, I clearly upset her. This was not my intention.

I was also very reassured by some of the points she made in the podcast with Farooq. I have summarised them and hope I have got them correct. However, some still concerned me.

Concerns

I want to deal with the concerning ones first. When Farooq asked her about the absence of trials in this area, she felt that this was because treating OSA in children with orthodontics was not like taking a pill that can be tested in a trial. This is a common misconception about orthodontic trials. There are very few interventions that cannot be tested in a trial. This is because if we enrol sufficient participants, we can measure the effects of different phenotypes on treatment outcomes.

Farooq also challenged her claims that orthodontics can stimulate mandibular growth and help reduce OSA in children with mandibular deficiency and OSA. However, current class II research reveals that orthodontic treatment cannot change or stimulate the growth of the mandible.

Important points

In other areas, her views appear to have changed from the lecture that she gave. These were

• There appears to be a trial being planned in the future.
• Orthodontics is not the front-line treatment for OSA.
• If a child has no transverse or AP discrepancy, orthodontics has no role in treating OSA.
• She agrees with the contents of the AAO White paper.
• The evidence underpinning orthodontic treatment for paediatric OSA is weak.

This last point is the most important and was also a conclusion in the AAO White paper.

What did I think?

We do not know if orthodontic treatment has a role in treating childhood breathing disorders. This is because there is a lack of evidence to support this treatment. I think Audrey agrees with this because of her comments about the need for further research, and she indeed showed more caution for treatment in the podcast than in her AAO lecture. I am certainly in equipoise about this treatment. Importantly, if clinicians are in equipoise about a treatment, it is ethical for them to propose and carry out a trial.

This is not difficult to plan. Importantly, this subject should attract the attention of funding bodies as it looks at an important clinical condition and potential treatment. We can factor in the treatment results from the current low-quality studies to calculate the sample size and plan the study.

The wheel keeps turning.

In many ways, this is similar to our speciality’s position in the late 1980s, where early treatment for Class II malocclusion was being promoted. The profession also recognised that there was uncertainty about the effectiveness of this treatment. As a result, they persuaded the funding bodies to fund the early treatment of Class II malocclusion studies. We are at this point with orthodontic treatment for childhood breathing disorders. Importantly, if we do not do these studies now, we are in danger of following the wrong treatment protocols. Furthermore, we may enable some of our less scrupulous colleagues to exploit this uncertainty to promote unnecessary and harmful treatment of vulnerable families. This is also why we need to be cautious in our presentations.