Original Article 2, Issue 13.2

Correlation Between Intraoral Markers and the Risk of Obstructive Sleep Apnea in Children

http://dx.doi.org/10.15331/jdsm.7432

Harmeet K. Chiang, DDS, MS1; Linda K. Powers, DDS, MSD2; Caroline K. Carrico, PhD3; Eser Tüfekçi, DDS, MS, PhD, MSHA4

1Department of Orthodontics, Virginia Commonwealth University, School of Dentistry, Richmond, Virginia, 23298; 2Department of General Practice, Virginia Commonwealth University, School of Dentistry, Richmond, VA, 23298; 3 Department of Dental Public Health and Policy, Virginia Commonwealth University, School of Dentistry, Richmond, Virginia, 23298; 4Department of Orthodontics, Virginia Commonwealth University, School of Dentistry, Richmond, Virginia, 23298

ABSTRACT

Objectives:

This study investigated the relationship between intraoral markers and the risk of obstructive sleep apnea (OSA) in children. Nine clinical characteristics were analyzed, including ankyloglossia, palatal vault height, dental wear, tonsillar grade, Friedman classification, skeletal and dental classifications, and posterior crossbite. The relationship between these features and scores from the Pediatric Sleep Questionnaire (PSQ) and Pediatric Symptoms Checklist (PSC) was assessed.

Methods:

One hundred patients aged 8 to17 years were recruited at the Virginia Commonwealth University Graduate Orthodontic Clinics during their initial records appointment. Intraoral evaluations were performed, and PSQ and PSC screening surveys were completed by parents or guardians. Statistical analyses assessed the prevalence of OSA and the association between intraoral markers and OSA risk.

Results:

The PSQ and PSC identified 13% of patients at high risk for sleep-disordered breathing (SDB) and 10% at high risk for psychosocial problems. Notably, 54% of those at high risk for SDB were also identified as high risk for psychosocial issues, indicating a strong association (P<0.0001). Although no intraoral markers showed statistically significant correlations with SDB, trends were observed with tonsillar grade, Friedman classification, and palatal vault height.

Conclusion:

Thirteen percent of children were at high risk for OSA, with a strong link between SDB and psychosocial concerns. Although intraoral markers lacked statistical significance, tonsillar grade, Friedman classification, and palatal vault height may have clinical relevance in assessing OSA.

Clinical Implications:

The integrated use of the PSQ and PSC can enhance the early detection of SDB and psychosocial issues. Tonsillar grade and palatal height could guide more targeted evaluations.

Citation:

Chiang HK, Powers LK, Carrico CK, Tüfekçi E. Correlation Between Intraoral Markers and the Risk of Obstructive Sleep Apnea in Children. J Dent Sleep Med. 2026;13(2).

INTRODUCTION 

Sleep-disordered breathing (SDB), a pathophysiologic continuum characterized by abnormal respiratory patterns, is common in the pediatric population, with a prevalence of 3% to 12%.1 The symptoms can range from snoring to obstructive sleep apnea (OSA). If not treated, pediatric OSA may have important implications for the child's health, including impaired growth, cognitive development, and emotional stability in the long term.1-3 According to the American Academy of Pediatrics, 1% to 6% of children are affected by pediatric OSA;4 however, it is thought that the prevalence is higher, especially among children seeking orthodontic treatment.5

The current gold standard for diagnosing pediatric OSA is polysomnography, which generally involves an in-center overnight sleep study and interpretation of the results by a sleep medicine physician.1 However, the limited number of sleep centers available and the cost associated with sleep studies pose a challenge to evaluating OSA in children.1

The PSQ is a validated, parent-reported, 22-question survey that assesses snoring, SDB, daytime sleepiness, hyperactivity, and other behaviors.6 Although the tool is not
deemed an acceptable replacement for polysomnography in diagnosing pediatric OSA, it is still an effective screening method for identifying children at risk for OSA, with a sensitivity of approximately 0.85 and a specificity of 0.87 when compared with polysomnography. The PSC is another validated tool designed to identify behavioral, cognitive, and emotional issues in children.7 This questionnaire can supplement the PSQ to address the behavior components of OSA but is not intended to diagnose SDB.

Previous research on children in whom OSA is diagnosed suggests that the condition is associated with various oral and craniofacial manifestations, including increased overjet, reduced overbite, deeper palatal height, and narrower upper dental arches.8-10 Other possible dental variables related to pediatric OSA include occlusal wear, frenulum height, and tonsil size.11-14 However, controversial findings have been reported on the association of intraoral features with OSA in the literature.15-18 For example, although Class II malocclusion and posterior crossbite were not shown to be a risk factor for OSA in some studies, others have reported this association.19-21

In  addition  to  the  use  of  screening  tools  as questionnaires, various clinical factors can help in the early identification of children at risk for OSA. Important risk factors include a high body mass index and obesity, adenotonsillar hypertrophy, craniofacial anomalies such as midface hypoplasia and retrognathia, as well as neuromuscular disorders such as cerebral palsy and muscular dystrophy. Allergic rhinitis and a family history of SDB also are some of the risk factors. Evaluation of these clinical features, along with the results from questionnaires and medical and sleep histories, can lead to early risk identification and timely referral for polysomnographic evaluation.22-24

Although the PSQ and PSC are valuable for screening OSA in children, these lengthy questionnaires may be impractical for a busy orthodontic practice. Oral screening for clinical features could help dental professionals identify children at risk for OSA during routine examinations and refer them to a sleep specialist for further evaluation and diagnosis.25 The purpose of this study was to determine if an association was present between key intraoral clinical structures and PSQ and PSC scores.

 

MATERIALS AND METHODS

This cross-sectional study was approved by the Institutional Review Board at Virginia Commonwealth University (#HM20017896). The patients were recruited among patients seeking orthodontic treatment at the graduate clinic at Virginia Commonwealth University School of Dentistry from March 2022 until August 2023. Participants and their parents/legal guardians were asked if they would participate in the study at the time of initial records appointment according to the following criteria: (1) 8 to 17 years of age; (2) no medical conditions; (3) no craniofacial syndromes; (4) no facial deformities; (5) no behavioral or mental disorders; no history of previous orthodontic treatment; and (6) no multiple missing teeth. Also, the parent/guardian had to be proficient in English to accurately complete the PSQ and PSC forms.

The child's orthodontic appointment proceeded as scheduled, including a clinical examination, intraoral and extraoral photos, radiographs, and intraoral scanning of teeth. In addition to these routine procedures, an intraoral evaluation for nine anatomic and dental features was also performed: ankyloglossia (frenulum attachment), tonsil size, tongue position, palatal vault height, the presence, location, and the amount of tooth wear, the relationship of the maxilla relative to the mandible (skeletal classification), Angle classification of the malocclusion (dental malocclusion), and the posterior transverse relationship (crossbite). These clinical characteristics were chosen based on previous literature suggesting their association with the risk of sleep apnea.8-14 All clinicians were trained and calibrated before data collection.

Ankyloglossia was evaluated using the Kotlow assessment26 as follows: normal (>16 mm); class I: 12 to 16 mm; class II: 8 to 11 mm. Tonsil size scoring was completed using the following criteria27: 0: surgically removed tonsils; 1: tonsils hidden within tonsil pillars; 2: tonsils extending to the pillars; 3: tonsils beyond the pillars; 4: tonsils extending the midline. The tongue position was assessed using the Friedman classification system (modified Mallampati classification)28: Score of I: entire uvula and tonsils are visible; Score of II: entire uvula is visible, but the tonsils are not visible; Score of III: soft palate is visible, but uvula is not visible; Score of IV: only hard palate is visible. The palatal vault form was rated as low, medium, and high using the classification system developed by Kim et al.29 Tooth wear was scored using the tooth wear index on a scale of 0 (no wear) to 4 (severe wear) by Smith and Knight30 The posterior crossbite was determined by clinically evaluating the transverse relationship in the molar and premolar regions.
 

ANALYSES

Data from the PSQ and PSC questionnaires and the intraoral evaluation forms were entered into a database using the Research Electronic Data Capture (REDCap) tool hosted at Virginia Commonwealth University. The PSQ and PSC scores were calculated based on each screening instrument's guidelines. The PSQ scores were calculated by dividing the sum of “yes” answers by the total number of questions answered. A score of greater than 0.33 indicated a high risk for SDB. The PSC score was obtained by adding each item on the screening sheet by assigning zero (never), one (sometimes), or two (often) points. A PSC score of 28 or higher was chosen as a cutoff point, which indicated psychosocial impairment.

Associations between the intraoral features and the risk for SDB and behavioral health problems were assessed using Fisher exact test for the PSQ and PSC scores, respectively. The significance level was set at 0.05. SAS EG. v.8.2 (SAS Institute, Cary, NC) was used for all analyses.
 

RESULTS

One hundred patients (61 females and 39 males) were recruited for the study between March 2022 and August 2023. The mean age of the participants was 12.78 years. Table 1 presents the summary statistics of the intraoral markers. The PSQ scores ranged from 0 to 0.59, with an average of 0.16±0.15. Thirteen patients (13%) were identified as at high risk for SDB. The PSC scores ranged from 0 to 36, with an average of 10.4±10.1 and identified ten individuals (10%) with behavioral and emotional problems.

Most patients had a normal tongue structure (87%). Ankyloglossia (frenulum attachment less than 16 mm), a condition restricting the tongue's motion of range, was detected in only 13% of patients. Similarly, most patients (62%) had an average tonsillar grade (0 or 1); only 38% of the patients had enlarged tonsils (grade 2 and 3). Eighty-three percent of patients exhibited an increased Friedman classification (III and IV). As for the palatal anatomy, 75% of the patients had a typical palatal vault height (medium). Regarding tooth wear, 92% of the individuals had none/mild tooth wear. Among those with tooth wear, it was mainly demonstrated in an incisal or generalized fashion. Sixty-one percent of patients had a Class I molar relationship, whereas 66% of the patients had a Class I skeletal classification. Finally, most of the participants (89%) did not exhibit posterior crossbite (unilateral or bilateral).

The bivariate associations with high-risk SDB are summarized in Table 2. A strong association existed between the PSQ and PSC screening tools (P<0.0001).
Seventy percent of those determined by PSQ at high risk for SDB were also found to have signs of behavioral health problems, as shown by the PSC tool. Only 7% of those determined by PSC not having behavioral health problems were found at high risk for SDB according to their PSQ scores.

None of the intraoral markers demonstrated statistically significant associations with SDB as measured by the PSQ. However, tonsillar grade, Friedman classification, and palatal vault height demonstrated possible clinically relevant trends, suggesting a possible association. Four of the 15 patients, or 27%, with tonsillar grade of 3 were deemed high risk by the validated PSQ screening tool, compared to 9% for grade 2 and 11% for those with 0 or 1 grade tonsils (P=0.2213). Although only four patients had a low palatal vault, 50% had a high risk of SDB based on the PSQ, compared to 12% with a medium vault height and 10% with a high vault height (P=0.1399). Additionally, all of the patients considered high risk for SDB had a Friedman classification of 3 or 4, which may present clinical relevance despite lack of statistical power (P=0.1171).
 

Table 1.
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Table 2.
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DISCUSSION

In the current study, 13% of the screened children were identified as at high risk for SDB, which was higher than the previously reported prevalence of 7% to 11%.31,32 However, in a 2022 study, Choong et al.5 reported that as many as 30% of children seeking orthodontic treatment had OSA. The variation in the prevalence may be due to differences in patient ages, inclusion criteria, and site selection among the studies. In addition, over the years, there has been a continuous increase in the prevalence of OSA. Environmental factors such as diet and allergens causing obesity and allergic rhinitis, respectively, are thought to be the contributing factors to a rise in SDB. Another explanation for this trend is the possible misdiagnosis or underdiagnosis of the OSA cases in earlier studies. 1,2,31-35 The higher prevalence in the current study may also be due to insufficient sample size. Therefore, further testing with a large sample size is needed to determine the prevalence and the effect of intraoral characteristics on SDB.

The PSC screening tool for behavioral health problems indicated that 10% of patients were at risk for psychological disorders, which agrees with previous reports.1,3,36-38 Although depression, anxiety, and other psychological conditions are not within the scope of orthodontics, it is still important to remember that mental health issues are common in young orthodontic patients, who may require referral to specialists.39,40

Intraoral Characteristics
Ankyloglossia: In the current study, frenulum length over 16 mm was considered normal. Ratings of I and II, corresponding to 12 to 16 mm and 8 to 11 mm, respectively, indicated restriction of the tongue's range of motion. Only 1 of the 13 patients deemed at high risk for OSA demonstrated ankyloglossia, and the association between the risk of OSA and frenulum length was not statistically significant. Previous studies have reported a significant correlation between a short frenulum and SBD.12,14,41 Furthermore, Burska et al.42 suggested abnormality in pharynx development in patients with a short lingual frenulum. It is possible that this relationship was not detected in the current study due to the small sample size. Also, the controversy may be due to different screening tools being used to determine ankyloglossia.

Tonsil Size Score: In this investigation, 4 of 13 study participants (31%) identified as high risk for SBD presented with a tonsillar size score of 3. Although the differences were not statistically significant, a trend toward a higher risk of OSA was observed. A study by Kang et al.35 reported that tonsil size was positively related to the apnea-hypopnea index for children ages 1 to 18 years, suggesting further investigation of this feature as a predictor of pediatric OSA.

Friedman Classification: Ingram et al.15 failed to find an association between tongue position and SDB in children. Friedman classification of III and IV is considered a risk factor for obstruction at the hypopharyngeal level. Only 16% of the patients classified as III and IV were also deemed at high risk for OSA as determined by PSQ, but this was in contrast to zero risk among those classified as I or II and may indicate some clinical relevance and warrant further investigation. 

Palatal Vault: The correlation between palatal height and airway resistance has been previously evaluated in the literature.8,10,43,44 However, the results are conflicting, and there is no reliable evidence that palatal anatomy affects breathing during sleep.16-18,45 Also, measurements in previous studies were often carried out on intraoral scans, lateral cephalograms, or casts, which do not mimic the routine initial examination.16,43-46 In the current study, the data suggest that a low palatal vault height may be associated with a higher risk for pediatric OSA since two out of four subjects (50%) with a low palatal vault were shown by the PSQ to have an increased risk of OSA compared to 11% with medium or high. However, this finding should be interpreted with caution due to the limited sample size, particularly in the low palatal vault category which resulted in only 32% statistical power. A future study with a larger sample size is warranted to determine if the association can achieve statistical significance.

Tooth Wear/Spread: Sleep bruxism is suggested to be associated with OSA, and a strong association between sleep apnea and tooth wear has been previously reported.47-
49 In the current study, only 2 of 13 patients at high risk exhibited significant wear, and the association between tooth wear and risk of OSA was not statistically significant.

Skeletal/Molar Classification: Previous literature regarding OSA has investigated airway dysfunction and the Class II hyperdivergent phenotype.9 In this study, the association between high risk of OSA and dental and skeletal classification was not found, implying that both skeletal and dental classification do not have strong predictive power when screening for pediatric OSA. These results are similar to those of previous studies,19-21 which did not conclude that Class II malocclusion is a risk factor for OSA.

Crossbite: A narrow maxilla and a posterior crossbite have been reported to be associated with pediatric OSA.10 However, none of the 13 patients at high risk for sleep apnea had a crossbite in this study. None of the 11 patients with unilateral or bilateral crossbite were found to be at high risk for OSA by PSQ. Similar to the Class II relationships, although it has been suggested that OSA may lead to the development of a narrow maxilla, the opposite finding, namely a narrow maxilla indicating OSA, does not appear to be true. This finding is consistent with a recent study by Abulhamayel,50 which reported no association between constricted maxilla with or without crossbite in 134 children examined.

PSC: SDB in children has been reported to correspond with behavioral issues.1,3,7,36-38 This study found a strong association between high-risk SDB of PSQ and psychosocial problems of PSC. It is well established that children with OSA may present with impaired daily function and attention to tasks, and hyperactive behavior, suggesting an association between OSA and behavioral problems.1,3,7,36-38 Of these problems, the symptoms of attention-deficit hyperactivity disorder (ADHD) are thought to overlap with those of OSA.36,51 In fact, it has previously been shown that 20% to 30% of patients with OSA also have ADHD.5 The strong association found in this study further supports the importance of investigating pediatric OSA to alleviate behavioral issues in young patients afflicted with OSA. Furthermore, the lower prevalence of OSA in previous studies may be due to the misdiagnosis of this disorder because of overlap with ADHD symptoms.36,51

One important limitation of this study is that PSQ and PSC screenings rely on parents’ reporting of their children’s sleeping behavior, which could be inaccurate. Further studies evaluating the intraoral characteristics in children in whom OSA is diagnosed using a sleep test would be ideal.

As mentioned earlier, the small sample size of the current study is a limitation. Therefore, there was insufficient statistical evidence to support the presence of any of the intraoral characteristics as a risk factor for SDB. Further research with a larger sample size is needed to more accurately assess the association between intraoral characteristics and SDB. In addition, exploring the combined effects of multiple intraoral features would be valuable and multivariable analyses were not feasible in the current study due to sample size limitations. It should be kept in mind that it is also possible that no set of intraoral markers can be used as a sole screening tool for pediatric OSA. Other factors, such as body mass index or neuromuscular diseases, may also need to be included in the screening process. Therefore, because of a large variability in children's presentations with OSA, there are significant challenges in composing a simple screening tool. More research is warranted to develop effective and accurate screening tools to identify children at risk for OSA in a dental office.

CONCLUSION

According to the current study, 13% of patients presenting for orthodontic treatment were considered at high risk for OSA based on the PSQ. There is a strong association between the PSQ and PSC screening tools. Although none of the intraoral features demonstrated statistically significant associations with SDB, tonsil size and palatal vault height showed interesting patterns that could be important in a clinical setting. Future research with a large sample size is needed to determine if the anatomic structures could be used to predict OSA in children.
 

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SUBMISSION & CORRESPONDENCE INFORMATION

Submitted July 13, 2025
Submitted in final revised form November 3, 2025
Accepted for publication December 12, 2025

Address correspondence to: Harmeet K. Chiang, DDS, MS. Email: hkchiang@vcu.edu
 

DISCLOSURE STATEMENT

Study was performed in Virginia Commonwealth University Graduate Orthodontic Clinics.

Authors report no conflicts of interest.



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