Introduction
Obstructive sleep apnea (OSA) is a common sleep disorder in many children, particularly among younger pediatric populations. Specifically in children, OSA can result in poor sleep, behavior, and quality of life as well as a variety of other severe health conditions and complications. Children are often under diagnosed or misdiagnosed with OSA due many other health conditions that present with the same sleep symptoms.(American Academy of Pediatric Dentistry 2021) Continuing research and effectively educating the population on the importance and severity of OSA and its consequences in children is essential (Al-Shamrani et al. 2020). Although polysomnography (PSG) is the gold standard for diagnosing pediatric OSA, limited access, cost, and logistical barriers often prevent its widespread use, highlighting the importance of effective screening tools (Umano et al., 2022; Chervin et al., 2000). Varying screening tools have been developed to facilitate early identification of OSA in children and support appropriate referral to specialized clinicians for further evaluation. Screening tools such as the Pediatric Sleep Questionnaire (PSQ), the Children’s Sleep Habits Questionnaire (CSHQ), and the Health Related Quality of Life survey (HRQL) have been developed to aid in early detection, however substantial limitations remain regarding their diagnostic accuracy that require further research (Franco et al. 2000; Owens, Spirito, McGuinn 2000). Dental professionals play a critical role in early detection of symptoms of sleep disordered breathing and OSA due to the extent of a typical intraoral and extraoral dental examination (Fagundes & Flores-Mir, 2021). Early detection of OSA symptoms is imperative for identifying children at risk or already suffering from the disease. The purpose of this review is to examine the current screening tools for diagnosing and identifying pediatric sleep apnea as well as evaluating the accuracy and reliability of those tools.
Pediatric OSA and SRBD Tools
Pediatric sleep apnea is a common, but under diagnosed condition in children usually affecting those who suffer from obesity, craniofacial disorders and abnormalities, and/or tonsillary hypertrophy (American Academy of Pediatric Dentistry 2021). It is imperative that children are screened and diagnosed for OSA in order to decrease risk for comorbidities, adverse health conditions, and poor quality of life in children. Polysomnography (PSG), a multi-parameter overnight sleep study that measures apneas and hypopneas, brain activity, oral-nasal airflow, and many other aspects of a night of sleep is the current gold standard test to diagnose OSA. PSG is a diagnostic test as well as a test that determines the severity of the disease. Though PSG is the best test for a true diagnosis, there are limitations for patients who require testing to complete a PSG study including finances and inconvenience, which make alternative screening methods essential to assist in identifying children with OSA (Umano et al., 2022). The Pediatric Sleep Questionnaire (PSQ) is a 22 widely used questionnaire that is typically answered by the parent of a child suffering from symptoms like snoring, difficulty breathing during sleep, daytime sleepiness, and more. Being easy to use, free, and simple to implement into clinics, the PSQ is useful when PSG cannot be completed and can be used mostly to exclude a moderate to severe OSA diagnosis rather than be used as an accurate diagnostic tool (Umano et al. 2022). Pediatric screening tools often demonstrate limited specificity due to reliance on subjective, retrospective parent-reported responses. Questions related to snoring, sleepiness, and behavior are often nonspecific and may reflect a range of sleep-related breathing disorders rather than OSA alone (Trosman, 2013). The Children’s Sleep Health Questionnaire (CSHQ) is a useful screening tool to identify both behavioral and medically based sleep issues in children (Ownes et al., 2021). Though it can be utilized to determine if a patient has a sleep disorder or not, it cannot be used as a diagnostic test. Issues like differing definitions of sleep behaviors, varied symptom presentation, and inaccurate parent reporting create a lack of validity and sensitivity. The PSQ and CSHQ are both commonly used to screen children for sleep related problems, but PSQ was designed specifically to screen for sleep disordered breathing, including OSA, making it the most used screening tool in current literature (Chervin et al., 2000). In comparison, the CSHQ was developed to assess a very broad range of pediatric sleep behaviors and disturbances. When evaluating diagnostic ability, PSQ demonstrates greater relevance for identifying children at risk for OSA because it is specific to symptoms related to airway obstruction during sleep. Multiple studies have demonstrated the utility of the PSQ in identifying moderate to severe OSA, which can lead to referral for PSG testing to confirm a diagnosis (Umano et al., 2000). CSHQ does not share the primary purpose of screening for airway obstructive disorders and both screening tools are parent reported yielding subjective responses that limit the specificity and cannot be used alone to diagnose OSA (Owens et al., 2000). Both tools provide value in screening children for sleep related breathing disorders, and when combined along with clinical evaluations may improve early identification, but cannot replace PSG or other diagnostic testing measures (De Luca Canto et al., 2014; Spruyt & Gozal, 2011). Extensive research has been done to review the results, validity, and accuracy of the PSQ. It is difficult to create a screening tool that is accurate and able to diagnose OSA in children because many of the symptoms present are due to other conditions like ADHD, neuromuscular disorders, and craniofacial malformations (Chervin et al., 2000; De Luca et al. 2014). Snoring is one of the main symptoms of OSA and main reasons for a child to be screened, but snoring prevalence alone does not mean that a child has OSA (Carroll et al., 1995). Symptoms like snoring, mouth breathing, morning headache, attention problems, frequent waking, etc are assessed in the screening questionnaire, but are also symptoms present in a variety of sleep disorders and other medical conditions (American Academy of Pediatric Dentistry, 2021). While both the PSQ and CSHQ are widely used, the literature consistently demonstrates that neither tool possesses sufficient sensitivity or specificity to function as a standalone diagnostic measure (Owens et al., 2000). The PSQ is useful in determining sleep and breathing problems in children, but further investigation is needed in developing a screening tool that can be used as a diagnostic tool for OSA rather than a recognition of symptoms (Spruyt & Gozal, 2020). In a study that reviewed many different screening tools developed from 2010-2020, over 100 studies were evaluated showing similarities in the objective and inaccurate results that come from these tools that assess sleep quality, daytime sleepiness, and disordered breathing during sleep. These tools are able to provide valuable methods to simply identify sleep disorders and symptoms to aid in early identification, but are not accurate enough to replace diagnostic testing like PSG (De Luca Canto et al., 2014, Spruyt & Gozal, 2020).
Role of Dental Professionals in Pediatric OSA Screening:
Screening tools alone cannot be used to diagnose OSA in kids, but are extremely useful in the identification of children with sleep disordered breathing symptoms and the decision to refer those in need of the confirmatory procedure of PSG to diagnose OSA (Incerti et al., 2021). Dental professionals are playing a larger role in this screening process for early identification of kids with OSA as part of routine examinations. Dental professionals frequently encounter children with craniofacial abnormalities, tonsillar hypertrophy, and syndromic oral manifestations that can contribute to upper airway obstructions (Chiang et al., 2015). At a dental visit, a clinical exam should include an evaluation of tonsil size, head and neck exam, as well as an evaluation for malocclusions, and discrepancies in the size and growth of both the maxilla and mandible. Dentists are trained to recognize these abnormalities and, when appropriate, initiate treatment and decide when to refer patients to sleep specialists, otolaryngologists, or orthodontists. Management in a dental setting includes airway treatments like rapid maxillary expansion, mandibular repositioning, and other orthodontic procedures. Orthognathic surgeries can also be done as well as adenotonsillectomy with referrals to the correct provider (Fagundes & Flores-Mir, 2021). The American Academy of Pediatric Dentistry (2025) guidelines recommend that children are screened routinely for OSA during any routine maintenance health visit and suggest that dental providers offer these screening tools paired with clinical examinations that aid in multidisciplinary management of sleep related breathing disorders in pediatric patients and correct diagnoses of OSA (Trosman, 2013). Limitations of Current Screening Quest i o n n a i re s : It is clear that though screening tools are very helpful in identifying children with sleep disordered breathing and other sleep disorders, there are many limitations that require further research to make screening tools more reliable, accurate, and useful as diagnostic tools in a clinical setting. Due to the nature of the PSQ being subjective and answered by parents of the child who is suffering from symptoms, the sensitivity and specificity of the questionnaire are very low and are limited to use for ruling out disease rather of the questionnaire are very low and are limited to use for ruling out disease rather than diagnosing it (Physio-Pedia). The screening tools are best used to identify a child with symptoms and allow for proper treatment before other invasive surgeries, tests, or evaluations are done. After a screening is done, if a patient presents with anything more than mild symptoms, PSG should be performed according to the American Academy of Pediatrics( American Academy of Pediatric Dentistry 2021). Screening is also used to triage and prioritize those with moderate to severe OSA or are at a higher risk for disease to get proper treatment first. Another limitation is that the screenings are not entirely specific to pediatric patients. Many of the symptoms reported by parents in the screenings like snoring and airway obstruction causing the breathing to stop during sleep are not direct indicators of OSA and cannot accurately predict disease because they are prevalent in many different conditions that affect patients of all ages (Chervin et al., 2000). Screenings and questionnaires are also completed by a parent or caretaker, not the patient due to the young age which can cause answers to the questions to be inaccurate and different than what is actually occurring during the night. For example, in a study evaluating the reliability of the PSQ, when parents were sent follow up questionnaires 2-4 weeks after to complete again for measuring accuracy using the “test re-test” method, many parents did not finish the study, or answered the questions differently than the original questionnaire creating results that were inconclusive (Chervin et al., 2000). Questionnaire responses are inherently subjective and influenced by the respondent’s literacy, recall accuracy, and potential bias, limiting their reliability as standalone diagnostic tools for OSA. Detailed instructions, guidelines and norms must be followed in creating future questionnaires that yield results accurate enough to help in the diagnosis of OSA in children. Currently, screening tools serve as valuable preliminary measures that guide appropriate referral for diagnostic testing and management of sleep-related breathing disorders, but improvement is necessary to be considered as diagnostic tools. (Spruyt &Gozal, 2011).
Conclusion:
This review evaluated commonly used pediatric OSA screening tools and the roles that dental providers can offer within screening for sleep related breathing disorders. It can be concluded overall that limitations and inconsistencies exist in the current screening tools causing children to be underdiagnosed, misdiagnosed, or incorrectly treated for disease. Further research and quality assessment in creating questionnaires is imperative in creating tools that will accurately diagnose children with OSA. Pediatric sleep apnea is widely prevalent in the pediatric population and can be the cause for many other health conditions and comorbidities. Future research focused on strengthening early detection, refining screening methods, and leveraging dental expertise has the potential to transform pediatric OSA detection and improve longterm outcomes for children.