Interdisciplinary health care has received an increasing amount of attention over the past decade. In numerous reports, the Institute of Medicine has proposed a future in which collaboration and interdisciplinary team-based care are standard in health care delivery.
18,19 This concept is now being applied in various health care environments, as well as within health care professions’ education and training.
20 However, to our knowledge, few reports have objectively demonstrated the beneficial effects of an interdisciplinary approach to pediatric OSA management in a private clinic setting initiated by a dental professional.
The present case is unique in that its large collection of data (
Figure 1 and
Figure 2) showed improvement on HSTs after each stage of treatment. These objective findings illustrate how collaboration and treatment planning by health care professionals from 3 distinct fields of medicine (ie, dental, ENT, and myofunctional rehabilitation) were necessary to address the various issues presented by the patients’ severe OSA. As previously mentioned, SDB is a multifactorial disease affecting several different musculoskeletal structures and functions; thus, members of the multidisciplinary team should be chosen according to individual patient needs. For example, pediatric psychologists may address SDB-related behavioral issues, whereas osteopathic physicians may use osteopathic manipulative treatment to address postural or pain issues that result from the forward head posture that is common in patients with SDB.
21-23 Additional research is warranted to measure the effectiveness of such multidisciplinary treatment approaches.
High-functioning multidisciplinary treatment teams understand that SDB is dynamic and persistent, with symptoms often recurring after treatment.
11 As pointed out by Guilleminault and Sullivan,
24 the ultimate goal of SDB is the restoration of continuous nasal breathing. If mouth breathing recurs at any point after treatment, the patient may experience abnormal airway growth or compromised neuromuscular response in airway tissues. Therefore, treatment teams must recognize and monitor any underlying structures, functions, or behaviors impairing optimal breathing. Of note, the present patients’ concerns were dismissed by 2 health care professionals, despite the severity of the condition. This experience is in agreement with previous findings that pediatricians and other primary care physicians are often unprepared to manage sleep disorders.
25,26 According to Owens,
25 despite empirical evidence, inadequate attention is often paid by health care professionals to sleep disorders and their serious health consequences. This lack of attention may be related to the fact that sleep and sleep disorders traditionally receive little attention in medical schools' curriculae.
26
Polysomnography (PSG)—the preferred method for diagnosing pediatric OSA
27—was never ordered in the present case. By the time the patients and their mother presented to the dental office, they chose to undergo HSTs rather than return to their pediatrician for a PSG referral. This situation is not uncommon—in our experience, some patients may not have access to or wish to subject their children to an overnight stay in a laboratory, which can be costly and traumatic. Research indicates that home sleep apnea testing may be a viable alternative to PSG in such cases.
28 However, health care professionals should pursue PSG before HST because of HSTs’ poor negative predictive value.
29 The limitations of the HST should be considered when interpreting the findings in the present case.
Another factor contributing to low rates of pediatric OSA diagnosis may be the limitations in current screening methods. Pediatric sleep questionnaires such as the one used in the present case
15 are an invaluable screening tool for SDB, but they lack a basic tool of differential diagnosis: clinical observation of craniofacial structures. As previously mentioned, pediatric SDB in the nonobese patient is a craniofacial dysmorphism similar to class II orthodontic malocclusion.
30 Changes in the craniofacial hard tissue are often recognizable in the esthetics of the patient's face. In the present case, the dentist was able to see physical signs of SDB by performing a head and neck examination, which in turn prompted him to administer the questionnaire.
Research
30 has suggested that clinical assessment of craniofacial features considered as risk factors for SDB can be helpful. Even a simple assessment of the patient's facial profile can help clue the provider. Educating physicians to screen by evaluating patients’ jaw and other facial structures may be an important interdisciplinary opportunity to improve pediatric SDB screening methods.