A Novel Paradigm for Precision Interdisciplinary Management of Obstructive Sleep Apnea: From Childhood to Adulthood

A Novel Paradigm for Precision Interdisciplinary Management of Obstructive Sleep Apnea: From Childhood to Adulthood | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review A Novel Paradigm for Precision Interdisciplinary Management of Obstructive Sleep Apnea: From Childhood to Adulthood Maen Mahfouz, Eman Alzaben This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8886913/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Obstructive sleep apnea (OSA) is a prevalent disorder traditionally managed in specialty silos, with adenotonsillectomy (AT) for children and continuous positive airway pressure (CPAP) for adults, often yielding suboptimal outcomes. This systematic narrative review proposes a novel three-pillar interdisciplinary precision framework integrating phenotype-targeted interventions across the lifespan. Methods: A systematic literature search of PubMed, Cochrane Library, and Google Scholar was conducted (January 1993 – December 2024). Inclusion criteria comprised clinical trials, systematic reviews, and clinical practice guidelines. A PRISMA 2020-style flow diagram (Supplementary Figure 1) documented the screening process. Methodological quality was assessed using Cochrane RoB, AMSTAR-2, AGREE II, and the Newcastle-Ottawa Scale, with results summarized in Table 2. Results: From 215 identified records, 45 studies met inclusion criteria (complete list in Supplementary Table S1). Synthesis demonstrates superior apnea-hypopnea index (AHI) reductions from combined AT and rapid maxillary expansion (RME) in phenotype-defined children, and validates oral appliances and positional therapy in adults with specific phenotypes. Table 1 summarizes the 67 full-text assessed studies by category, and Table 3 provides a comprehensive multidisciplinary phenotyping framework. Conclusions: This three-pillar framework establishes dentists/orthodontists as lifelong collaborators within a unifying endotype-driven model. This conceptual shift promises improved therapeutic precision and outcomes by matching treatment to individual pathophysiology through interdisciplinary collaboration. A practical decision algorithm for clinical implementation is provided in Appendix A. Dentistry obstructive sleep apnea precision medicine interdisciplinary care rapid maxillary expansion phenotype adenotonsillectomy oral appliance therapy endotype Introduction Obstructive sleep apnea (OSA) represents a significant public health challenge with well-documented cardiovascular, metabolic, and neurocognitive consequences [1]. Historical management approaches have typically followed disciplinary lines: otorhinolaryngologists addressing pediatric cases through adenotonsillectomy (AT), and pulmonologists managing adults with continuous positive airway pressure (CPAP) therapy [2]. This siloed framework fails to address the fundamental pathophysiology of OSA—a complex interplay between anatomical compromise and physiological vulnerability that persists throughout the lifespan [3]. The limitations of current approaches are increasingly apparent. In pediatric populations, adenotonsillectomy alone fails to resolve OSA in approximately 25-50% of cases [4]. In adults, despite being highly effective when used consistently, CPAP therapy suffers from poor long-term adherence, with studies indicating that up to 50% of patients abandon treatment within the first year [5]. These clinical shortcomings highlight the insufficiency of one-size-fits-all solutions. While multidisciplinary care models have been proposed, existing frameworks are characterized by critical gaps: they typically lack true lifespan integration, fail to unify pediatric and adult treatment pathways, do not embed orthodontic and dental professionals as longitudinal collaborators from the point of diagnosis, and rarely incorporate phenotype- or endotype-driven selection of dental interventions such as rapid maxillary expansion (RME) or oral appliance therapy. This conceptual gap has hindered the development of truly personalized, mechanism-based care. This systematic narrative review introduces a novel three-pillar interdisciplinary precision framework for OSA. The model's primary innovation lies in its systematic integration of pediatric and adult care through a shared diagnostic logic centered on phenotypic and endotypic characterization. It strategically positions dentofacial orthopedic interventions—from childhood RME to adult oral appliance therapy—as central components within a physician-directed, collaborative continuum. A visual summary of the screening process used to develop this framework is provided in Supplementary Figure 1. Methods This systematic narrative review was conducted from January to December 2024 following a systematic search protocol. The approach combined narrative synthesis with systematic review methodology to ensure comprehensive literature coverage and methodological transparency. Search Strategy A comprehensive literature search was performed across three databases: PubMed, Cochrane Library, and Google Scholar. · PubMed: ("obstructive sleep apnea"[MeSH Terms] OR "sleep apnea, obstructive"[All Fields] OR OSA[All Fields]) AND ("precision medicine"[MeSH Terms] OR "personalized medicine"[All Fields] OR "precision medicine"[All Fields]) AND ("adenoidectomy"[MeSH Terms] OR "tonsillectomy"[MeSH Terms] OR "adenotonsillectomy"[All Fields] OR "palatal expansion technique"[MeSH Terms] OR "rapid maxillary expansion"[All Fields] OR "orthodontic appliances"[MeSH Terms] OR "oral appliance therapy"[All Fields]) AND ("interdisciplinary studies"[MeSH Terms] OR "multidisciplinary communication"[MeSH Terms] OR "interdisciplinary"[All Fields] OR "multidisciplinary"[All Fields]) · Cochrane Library: Similar strategy adapted for Cochrane syntax · Google Scholar: Broad search with same key concepts Inclusion Criteria 1. Clinical trials, systematic reviews, meta-analyses, or clinical practice guidelines 2. Publication between January 1993 (landmark Wisconsin Sleep Cohort Study) and December 2024 3. English language full-text availability 4. Primary focus on pediatric or adult OSA management strategies 5. Direct relevance to interdisciplinary care, precision medicine approaches, or specific interventions (AT, RME, OAT) Exclusion Criteria 1. Case reports with fewer than 5 patients 2. Conference abstracts without peer-reviewed full text 3. Non-peer-reviewed articles, editorials, or opinion pieces 4. Articles focusing exclusively on central sleep apnea or non-obstructive sleep disorders 5. Studies without accessible methodology or results sections Screening Process A PRISMA 2020-style flow diagram (Supplementary Figure 1) documents the screening process. Initial database searches yielded: · PubMed: 157 records · Cochrane Library: 38 records · Google Scholar: 20 records · Total identified from databases and registers: n=215 After duplicate removal (n=42 duplicates), 173 unique records underwent title/abstract screening. Of these, 106 were excluded at screening stage primarily due to: irrelevant population (n=28), wrong study design (n=35), non-OSA focus (n=43). All reports sought for retrieval were successfully obtained (reports not retrieved, n=0). Full-Text Review 67 articles underwent full-text assessment. The full-text assessment prioritized landmark, guideline-level, and methodologically influential studies across five predefined OSA domains: landmark epidemiology, pediatric OSA management, adult OSA therapies, precision medicine/endotyping, and interdisciplinary care models. Table 1 presents a categorical summary of these 67 studies. Table 1: Summary of Full-Text Assessed Studies by Category Category n Representative Studies Key Contributions Landmark Epidemiology 3 Young et al. 1993; Peppard et al. 2013; Benjafield et al. 2019 Established OSA prevalence, risk factors, public health burden Pediatric OSA Management 22 Marcus et al. 2013; Bhattacharjee et al. 2010; Certal et al. 2015 Evidence for AT, RME, combination therapies Adult OSA Therapies 18 Ramar et al. 2015; Srijithesh et al. 2019; Rotenberg et al. 2016 Guidelines for OAT, positional therapy, CPAP adherence Precision Medicine/Endotyping 12 Eckert et al. 2013; Carberry et al. 2018; Genta et al. 2021 Physiological and anatomical phenotyping frameworks Interdisciplinary Care Models 12 De Luca Canto et al. 2014; Kapur et al. 2017; AAO White Paper 2019 Diagnostic accuracy, multidisciplinary pathways Total 67 Table 1 presents a categorical summary of the 67 articles that underwent full-text assessment during the systematic literature review. Studies were grouped into predefined domains relevant to obstructive sleep apnea (OSA) management. The "n" column indicates the number of studies in each category. Representative studies for each category are listed to illustrate the methodological diversity and scope of evidence considered. Final Selection 22 articles were excluded during full-text review due to: insufficient methodological quality (n=8), overlapping data with included studies (n=6), language barriers in non-English sections (n=3), retracted status (n=1), or inaccessible supplemental data (n=4). 45 articles met all inclusion criteria ( Supplementary Table S1 provides the complete list). From these, key references were selected for detailed synthesis based on methodological quality, guideline relevance, and direct applicability to the proposed paradigm. Quality Assessment The methodological quality and risk of bias of included studies were assessed using standardized, study design–specific appraisal tools. Randomized controlled trials were evaluated using the Cochrane Risk of Bias Tool , assessing domains related to sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, selective reporting, and other potential sources of bias. Systematic reviews and meta-analyses were appraised using AMSTAR-2 (A Measurement Tool to Assess Systematic Reviews 2) , focusing on critical domains including: protocol registration prior to review, comprehensive literature search strategy, justification for excluded studies, risk of bias assessment of included studies, appropriate meta-analytic methods, consideration of publication bias, and reporting of conflicts of interest. Clinical practice guidelines were assessed using the AGREE II (Appraisal of Guidelines for Research and Evaluation II) instrument, evaluating guideline quality across six domains: scope and purpose, stakeholder involvement, rigor of development, clarity of presentation, applicability, and editorial independence. Observational epidemiological studies were evaluated using the Newcastle-Ottawa Scale for cohort studies. These studies were inherently subject to confounding and were not subjected to formal risk of bias tools designed for interventional studies. Quality assessments informed the interpretation of findings and evidence synthesis but were not used as exclusion criteria. Studies with higher methodological quality were given greater weight in the narrative synthesis, particularly when contradictory findings emerged across studies. Table 2 summarizes the quality assessments for key representative studies. Table 2: Risk of Bias / Quality Assessment Summary of Key Included Studies Study Type Reference Study Design Tool Used Key Domains Assessed Overall Quality / Risk of Bias Landmark Epidemiology Young et al., 1993 Observational cohort Newcastle-Ottawa Scale Selection, comparability, outcome Moderate – inherent confounding in observational design Pediatric OSA Management Marcus et al., 2013 RCT Cochrane RoB Sequence generation, allocation concealment, blinding, incomplete outcome data, selective reporting Low risk – high methodological quality Pediatric OSA Management Bhattacharjee et al., 2010 RCT Cochrane RoB Sequence generation, allocation concealment, blinding, incomplete outcome data, selective reporting Moderate risk – some concerns with blinding Adult OSA Therapies Ramar et al., 2015 Clinical practice guideline AGREE II Scope/purpose, stakeholder involvement, rigor of development, clarity, applicability, editorial independence High – rigorous guideline development Adult OSA Therapies Srijithesh et al., 2019 Systematic review (Cochrane) AMSTAR-2 Protocol registration, literature search, risk of bias consideration, meta-analytic appropriateness High – Cochrane standard Precision Medicine / Endotyping Eckert et al., 2013 RCT / Cohort Cochrane RoB / NOS Sequence generation, allocation concealment, blinding, incomplete outcome data, selection Low to moderate risk – generally well-conducted Interdisciplinary Care Models De Luca Canto et al., 2014 Systematic review AMSTAR-2 Protocol registration, literature search, risk of bias consideration, meta-analytic appropriateness Moderate – limited by heterogeneity of included studies Table 2 summarizes the methodological quality and risk of bias assessments for key representative studies. Assessment tools were selected based on study design. Quality ratings reflect methodological rigor across critical domains, with "High" indicating low risk of bias/strong methodology, "Moderate" indicating some methodological concerns. RCT = Randomized Controlled Trial; RoB = Risk of Bias; AMSTAR-2 = A Measurement Tool to Assess Systematic Reviews 2; AGREE II = Appraisal of Guidelines for Research & Evaluation II; NOS = Newcastle-Ottawa Scale. Synthesis Approach The review employed narrative synthesis methodology, identifying consistent themes across studies, noting contradictory findings, and conceptually integrating evidence into the novel interdisciplinary framework proposed. The clinical pathway was developed based on synthesized evidence combined with clinical protocols from the authors' practices in Ramallah and Jerusalem, Palestine. A practical algorithm for clinical implementation is provided in Appendix A . Use of Large Language Models No large language models or artificial intelligence tools were used in the preparation of this manuscript. Results Pediatric Innovations: Beyond Adenotonsillectomy as Monotherapy The traditional pediatric OSA pathway—adenotonsillectomy as first-line therapy with consideration of orthodontic intervention only for residual cases—warrants reconsideration. A randomized controlled crossover trial demonstrated that in non-obese children with balanced maxillomandibular relationships but maxillary constriction, first-line combination therapy with adenotonsillectomy and rapid maxillary expansion produced significantly greater improvements in apnea-hypopnea index (AHI) and oxygen saturation than adenotonsillectomy alone [6]. This finding is physiologically coherent: while adenotonsillectomy addresses lymphoid tissue obstruction at the retropalatal level, RME targets skeletal restriction by increasing nasal cavity volume and improving posterior airway space [7]. Systematic reviews confirm RME's positive effects on airway dimensions [8]. Proactively addressing both soft tissue and skeletal contributors in appropriately phenotype-defined children represents a shift from reactive management to proactive, precision-based intervention. Adult Management: Expanding Beyond CPAP as Default Therapy In adult management, the therapeutic arsenal has legitimately expanded. Clinical practice guidelines now formally recognize mandibular advancement devices as first-line therapy for mild-to-moderate OSA and for CPAP-intolerant patients [9]. Positional therapy has established efficacy for position-dependent OSA, as confirmed by Cochrane review [10]. These modalities, when selected based on phenotype rather than specialty referral patterns, can significantly improve acceptance and outcomes. The critical advancement is systematic selection rather than simple availability. The historical pattern of CPAP as default neglects the opportunity for mechanism-matched first-line therapy that may yield better adherence and efficacy for specific phenotypic presentations. Diagnostic Precision: From Symptom Reporting to Phenotype Characterization Accurate management requires accurate characterization. While validated screening questionnaires like STOP-BANG have demonstrated utility in adult populations [11], polysomnography (PSG) remains essential for definitive diagnosis and phenotyping. Beyond AHI calculation, advanced analysis can reveal physiological endotypes (e.g., low arousal threshold, high loop gain) with therapeutic implications [3]. The economic implications of accurate diagnosis and targeted treatment are substantial, with untreated OSA representing a significant healthcare burden [12]. Anatomical phenotyping benefits crucially from dental/orthodontic expertise. This multidisciplinary diagnostic synthesis enables true precision in therapy selection. Table 3 provides a comprehensive framework for multidisciplinary phenotyping. Table 3: Suggested Components of a Multidisciplinary OSA Phenotyping Assessment Domain Assessing Discipline Specific Assessments Clinical Relevance / Phenotype Identified Sleep Study & Symptoms Sleep Medicine Physician • PSG/HSAT: AHI, RDI, nadir SpO₂, arousal index, positional data • Endotypic traits if analyzable • Standardized symptom questionnaires (ESS, PSQ) • Clinical history: snoring, witnessed apneas, daytime symptoms Quantifies severity, identifies positional OSA, suggests physiological endotypes, assesses symptom burden Otolaryngologic / Airway Otorhinolaryngologist • FNLP: Adenoid/tonsil size, palatal configuration, tongue base, epiglottis • Friedman/Mallampati score • External craniofacial exam: retrognathia, midface hypoplasia Identifies soft tissue obstruction sites, assesses adenotonsillar hypertrophy, evaluates visible skeletal features Dentofacial & Occlusal Orthodontist / Dental Sleep Specialist • Intraoral Exam: Maxillary transverse deficiency (posterior crossbite, high-arched palate), dental crowding, occlusal class (I, II, III) • Cephalometric Analysis: SNA, SNB, ANB angles; mandibular plane angle; PAS (posterior airway space); MP-H (mandibular plane to hyoid) • Model Analysis: Casts for arch width measurement and treatment planning Identifies skeletal phenotype : maxillary constriction, mandibular retrognathia, vertical excess. Essential for planning RME or oral appliance therapy Anthropometric & General All / Primary Care • Body Mass Index (BMI), neck circumference • Blood pressure, cardiovascular history • Medication review (esp. sedatives, muscle relaxants) • Comorbidities: hypertension, atrial fibrillation, type 2 diabetes, GERD Identifies obesity-related phenotype. Assesses cardiovascular risk and comorbid conditions that influence management priorities *Table 3 outlines the essential components for comprehensive phenotyping of obstructive sleep apnea (OSA) patients within a multidisciplinary framework. Abbreviations: PSG = polysomnography; HSAT = home sleep apnea test; AHI = apnea-hypopnea index; RDI = respiratory disturbance index; ESS = Epworth Sleepiness Scale; PSQ = Pediatric Sleep Questionnaire; FNLP = fiberoptic nasopharyngolaryngoscopy; RME = rapid maxillary expansion; GERD = gastroesophageal reflux disease; SNA = sella-nasion-A point; SNB = sella-nasion-B point; PAS = posterior airway space; MP-H = mandibular plane to hyoid. Clinical scales mentioned (STOP-BANG [11], Mallampati, Friedman) are publicly available tools.* A Novel Three-Pillar Interdisciplinary Precision Framework The proposed interdisciplinary precision management model rests on three innovative pillars that collectively redefine standard OSA care delivery. The framework is supported by the evidence synthesized from the 45 included studies (Supplementary Table S1) and assessed for quality in Table 2. Pillar 1: First-Line Phenotype-Targeted Combination Therapy in Pediatrics This pillar reconceptualizes the pediatric treatment sequence. For children presenting with the phenotype of concurrent adenotonsillar hypertrophy and maxillary constriction (evidenced by posterior crossbite, high arched palate, narrow maxilla), first-line therapy should be combined adenotonsillectomy and RME. This approach, supported by randomized trial evidence [6], targets multiple anatomical contributors simultaneously, potentially improving initial success rates. Appendix A provides a clinical decision algorithm operationalizing this approach. Pillar 2: The Orthodontist as a Lifelong Collaborator in Airway Management This pillar expands the orthodontist's role across the lifespan. In childhood, they are co-architects of first-line treatment via RME. In adulthood, they evolve into dental sleep medicine specialists providing oral appliance therapy [9]. This establishes continuity of anatomical expertise within the care team, positioning dental professionals as permanent collaborators rather than occasional consultants. Pillar 3: A Unifying Endotype-Driven Therapeutic Framework This pillar creates a coherent selection matrix organizing interventions by primary therapeutic target. Here, 'phenotype' refers to observable clinical/anatomical characteristics, while 'endotype' denotes the underlying physiological mechanisms driving airway collapse [3]: · Anatomical (Retropalatal): AT (pediatrics), CPAP, upper airway stimulation · Anatomical (Retroglossal/Retrognathic): Oral appliances, maxillomandibular advancement · Anatomical (Nasomaxillary Constriction): RME (pediatrics/select adults) · Position-Dependent: Positional therapy [10] · Physiological: Pharmacological adjuncts, specific PAP modalities This framework depersonalizes treatment selection, basing it on objective phenotypic characteristics rather than specialty tradition, enabling true mechanism-based personalized medicine. Discussion Operationalizing the Paradigm: A Proposed Clinical Pathway 1. Integrated screening & diagnosis: Universal screening in primary care (medical and dental) triggers referral for polysomnography, establishing objective diagnosis. Screening tools such as STOP-BANG [11] may be used for initial risk stratification. 2. Multidisciplinary phenotyping conference: Sleep physician, otorhinolaryngologist, and orthodontist/dental sleep specialist collaboratively review data to determine dominant phenotype/endotype using the framework outlined in Table 3 . 3. Shared decision-making from phenotype-matched options: Treatment selection derives from the endotype-driven framework, considering patient preferences and values. For pediatric patients, Appendix A provides a structured decision algorithm. 4. Objective efficacy verification & iterative management: Follow-up sleep testing assesses response. Suboptimal response triggers re-phenotyping and alternative selection from the framework, creating a dynamic management loop. The complete list of 45 studies informing this pathway is available in Supplementary Table S1 , and the screening methodology is documented in Supplementary Figure 1 . Comparison with Existing Models and Clinical Implications This conceptual shift offers several advantages over current fragmented care models, which typically lack lifespan integration and do not embed dental professionals as longitudinal collaborators: · Improved therapeutic precision through mechanism-based matching · Enhanced patient adherence through personalized options · Reduced treatment burden by targeting first-line therapy to likely responders · Continuity of care across the lifespan with dental professionals as permanent team members · Economic efficiency through reduced trial-and-error approaches, addressing the substantial economic burden of untreated OSA [12] Implementation Challenges Successful implementation requires addressing several barriers: · Interdisciplinary communication: Structured conferences and shared protocols · Educational gaps: Enhanced training in sleep medicine for dental professionals · Reimbursement models: Advocacy for value-based care frameworks · Access equity: Telemedicine and regional referral networks Limitations This systematic narrative review has several limitations. The search, while systematic and documented in Supplementary Figure 1 , may not have captured all relevant non-English literature. Selection of key references from the 45 included studies ( Supplementary Table S1 ), though based on explicit criteria (methodological quality, guideline relevance, direct applicability), introduces potential selection bias, which we have mitigated by providing the full list of included studies. The proposed framework, while evidence-based, requires prospective validation through implementation research. The quality assessment in Table 2 reflects the methodological rigor of included studies but does not substitute for primary research. Conclusions This systematic narrative review presents a novel three-pillar interdisciplinary precision framework for OSA management that systematically integrates pediatric and adult care through phenotypic characterization and mechanism-targeted intervention. The framework is supported by a comprehensive evidence base of 45 studies (Supplementary Table S1), systematically identified through a PRISMA-guided process (Supplementary Figure 1). By expanding the role of dental professionals from childhood RME to adult oral appliance therapy within physician-directed teams, this model addresses documented limitations of current siloed approaches. Successful implementation requires restructuring referral patterns, developing collaborative practice models, and evolving educational curricula. A practical decision algorithm for clinical application is provided in Appendix A. This conceptual shift promises improved therapeutic precision, adherence, and outcomes across the lifespan by moving from treating OSA generically to managing each individual's unique pathophysiology. Declarations Competing Interests The authors declare no competing interests. No financial or non-financial interests could be perceived to influence the work reported in this manuscript. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Author Contributions Maen Mahfouz: Conceptualization, Methodology, Investigation, Writing – Original Draft, Writing – Review & Editing, Supervision. Eman Alzaben: Conceptualization, Investigation, Writing – Review & Editing. Data Availability All data discussed in this manuscript are available from the cited published sources. The complete list of 45 included studies is available as Supplementary Table S1 . The PRISMA 2020-style flow diagram documenting the screening process is available as Supplementary Figure 1 . Additional materials are available from the corresponding author upon reasonable request. Ethics Approval Not applicable. This manuscript is a systematic narrative review of previously published literature and does not involve new human or animal research. Acknowledgements The authors thank the researchers whose work is cited in this review for their contributions to advancing the field of sleep medicine. Use of Large Language Models No large language models or artificial intelligence tools were used in the preparation of this manuscript. References Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S. The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med. 1993;328:1230-1235. DOI: 10.1056/NEJM199304293281704 Ehsan Z, Ishman SL, Soghier I, et al. Management of persistent, post-adenotonsillectomy obstructive sleep apnea in children: an official American Thoracic Society clinical practice guideline. Am J Respir Crit Care Med. 2024;209:248-261. DOI: 10.1164/rccm.202309-1703ST Carberry JC, Amatoury J, Eckert DJ. Personalized management approach for OSA. Chest. 2018;153:744-755. DOI: 10.1016/j.chest.2017.10.004 De Luca Canto G, Singh V, Major MP, et al. Diagnostic capability of questionnaires and clinical examinations to assess sleep-disordered breathing in children: a systematic review and meta-analysis. J Am Dent Assoc. 2014;145:165-178. DOI: 10.14219/jada.2013.20 Rotenberg BW, Murariu D, Pang KP. Trends in CPAP adherence over twenty years of data collection: a flattened curve. J Otolaryngol Head Neck Surg. 2016;45:43. DOI: 10.1186/s40463-016-0156-0 Magalhães MC, Normando D, Soares CJ, et al. Impact of adenotonsillectomy and palatal expansion on the apnea-hypopnea index and minimum oxygen saturation in nonobese pediatric obstructive sleep apnea with balanced maxillomandibular relationship: a cross-over randomized controlled trial. Pediatr Pulmonol. 2024;59:3507-3517. DOI: 10.1002/ppul.27033 Vinha PP, Eckeli AL, Faria AC, et al. Effects of rapid maxillary expansion on the upper airway dimensions and function in children with obstructive sleep apnea syndrome: a systematic review with meta-analysis. Sleep Med Rev. 2016;30:85-94. DOI: 10.1016/j.smrv.2016.03.002 Baratieri C, Alves M Jr, de Souza MM, de Souza Araújo MT, Maia LC. Does rapid maxillary expansion have long-term effects on airway dimensions and breathing? A systematic review. Angle Orthod. 2011;81:1-10. DOI: 10.2319/033010-178.1 Ramar K, Dort LC, Katz SG, et al. Clinical practice guideline for the treatment of obstructive sleep apnea and snoring with oral appliance therapy: an update for 2015. J Clin Sleep Med. 2015;11(7):773-827. DOI: 10.5664/jcsm.4858 Srijithesh PR, Aghoram R, Goel A, Dhanya J. Positional therapy for obstructive sleep apnoea. Cochrane Database Syst Rev. 2019;5:CD010990. DOI: 10.1002/14651858.CD010990.pub2 Chung F, Abdullah HR, Liao P. STOP-Bang questionnaire: a practical approach to screen for obstructive sleep apnea. Chest. 2016;149:631-638. DOI: 10.1016/j.chest.2015.12.034 Léger D, Stepnowsky C. The economic and societal burden of excessive daytime sleepiness in patients with obstructive sleep apnea. Sleep Med Rev. 2020;51:101275. DOI: 10.1016/j.smrv.2020.101275 Additional Declarations The authors declare no competing interests. Supplementary Files MahfouzOSAParadigmSuppTableS1Studies..docx Complete List of 45 Studies Meeting Inclusion Criteria MahfouzOSAParadigmAppendixAAlgorithm..docx Appendix A: Example Decision Algorithm for Pediatric OSA Treatment Selection Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Historical management approaches have typically followed disciplinary lines: otorhinolaryngologists addressing pediatric cases through adenotonsillectomy (AT), and pulmonologists managing adults with continuous positive airway pressure (CPAP) therapy [2]. This siloed framework fails to address the fundamental pathophysiology of OSA—a complex interplay between anatomical compromise and physiological vulnerability that persists throughout the lifespan [3].\u003c/p\u003e\n\u003cp\u003eThe limitations of current approaches are increasingly apparent. In pediatric populations, adenotonsillectomy alone fails to resolve OSA in approximately 25-50% of cases [4]. In adults, despite being highly effective when used consistently, CPAP therapy suffers from poor long-term adherence, with studies indicating that up to 50% of patients abandon treatment within the first year [5]. These clinical shortcomings highlight the insufficiency of one-size-fits-all solutions.\u003c/p\u003e\n\u003cp\u003eWhile multidisciplinary care models have been proposed, existing frameworks are characterized by critical gaps: they typically lack true lifespan integration, fail to unify pediatric and adult treatment pathways, do not embed orthodontic and dental professionals as longitudinal collaborators from the point of diagnosis, and rarely incorporate phenotype- or endotype-driven selection of dental interventions such as rapid maxillary expansion (RME) or oral appliance therapy. This conceptual gap has hindered the development of truly personalized, mechanism-based care.\u003c/p\u003e\n\u003cp\u003eThis systematic narrative review introduces a novel \u003cem\u003ethree-pillar interdisciplinary precision framework\u003c/em\u003e for OSA. The model's primary innovation lies in its systematic integration of pediatric and adult care through a shared diagnostic logic centered on phenotypic and endotypic characterization. It strategically positions dentofacial orthopedic interventions—from childhood RME to adult oral appliance therapy—as central components within a physician-directed, collaborative continuum. A visual summary of the screening process used to develop this framework is provided in Supplementary Figure 1.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis systematic narrative review was conducted from January to December 2024 following a systematic search protocol. The approach combined narrative synthesis with systematic review methodology to ensure comprehensive literature coverage and methodological transparency.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eSearch Strategy\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eA comprehensive literature search was performed across three databases: PubMed, Cochrane Library, and Google Scholar.\u003c/p\u003e\n\u003cp\u003e\u0026middot; \u003cstrong\u003ePubMed:\u003c/strong\u003e (\u0026quot;obstructive sleep apnea\u0026quot;[MeSH Terms] OR \u0026quot;sleep apnea, obstructive\u0026quot;[All Fields] OR OSA[All Fields]) AND (\u0026quot;precision medicine\u0026quot;[MeSH Terms] OR \u0026quot;personalized medicine\u0026quot;[All Fields] OR \u0026quot;precision medicine\u0026quot;[All Fields]) AND (\u0026quot;adenoidectomy\u0026quot;[MeSH Terms] OR \u0026quot;tonsillectomy\u0026quot;[MeSH Terms] OR \u0026quot;adenotonsillectomy\u0026quot;[All Fields] OR \u0026quot;palatal expansion technique\u0026quot;[MeSH Terms] OR \u0026quot;rapid maxillary expansion\u0026quot;[All Fields] OR \u0026quot;orthodontic appliances\u0026quot;[MeSH Terms] OR \u0026quot;oral appliance therapy\u0026quot;[All Fields]) AND (\u0026quot;interdisciplinary studies\u0026quot;[MeSH Terms] OR \u0026quot;multidisciplinary communication\u0026quot;[MeSH Terms] OR \u0026quot;interdisciplinary\u0026quot;[All Fields] OR \u0026quot;multidisciplinary\u0026quot;[All Fields])\u003c/p\u003e\n\u003cp\u003e\u0026middot; \u003cstrong\u003eCochrane Library:\u003c/strong\u003e Similar strategy adapted for Cochrane syntax\u003c/p\u003e\n\u003cp\u003e\u0026middot; \u003cstrong\u003eGoogle Scholar:\u003c/strong\u003e Broad search with same key concepts\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eInclusion Criteria\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003e1.\u0026nbsp; \u0026nbsp;Clinical trials, systematic reviews, meta-analyses, or clinical practice guidelines\u003c/p\u003e\n\u003cp\u003e2.\u0026nbsp; \u0026nbsp;Publication between January 1993 (landmark Wisconsin Sleep Cohort Study) and December 2024\u003c/p\u003e\n\u003cp\u003e3.\u0026nbsp; \u0026nbsp;English language full-text availability\u003c/p\u003e\n\u003cp\u003e4.\u0026nbsp; \u0026nbsp;Primary focus on pediatric or adult OSA management strategies\u003c/p\u003e\n\u003cp\u003e5.\u0026nbsp; \u0026nbsp;Direct relevance to interdisciplinary care, precision medicine approaches, or specific interventions (AT, RME, OAT)\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eExclusion Criteria\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003e1.\u0026nbsp; \u0026nbsp;Case reports with fewer than 5 patients\u003c/p\u003e\n\u003cp\u003e2.\u0026nbsp; \u0026nbsp;Conference abstracts without peer-reviewed full text\u003c/p\u003e\n\u003cp\u003e3.\u0026nbsp; \u0026nbsp;Non-peer-reviewed articles, editorials, or opinion pieces\u003c/p\u003e\n\u003cp\u003e4.\u0026nbsp; \u0026nbsp;Articles focusing exclusively on central sleep apnea or non-obstructive sleep disorders\u003c/p\u003e\n\u003cp\u003e5.\u0026nbsp; \u0026nbsp;Studies without accessible methodology or results sections\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eScreening Process\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eA PRISMA 2020-style flow diagram (Supplementary Figure 1) documents the screening process. Initial database searches yielded:\u003c/p\u003e\n\u003cp\u003e\u0026middot; PubMed: 157 records\u003c/p\u003e\n\u003cp\u003e\u0026middot; Cochrane Library: 38 records\u003c/p\u003e\n\u003cp\u003e\u0026middot; Google Scholar: 20 records\u003c/p\u003e\n\u003cp\u003e\u0026middot; \u003cstrong\u003eTotal identified from databases and registers:\u003c/strong\u003e n=215\u003c/p\u003e\n\u003cp\u003eAfter duplicate removal (n=42 duplicates), 173 unique records underwent title/abstract screening. Of these, 106 were excluded at screening stage primarily due to: irrelevant population (n=28), wrong study design (n=35), non-OSA focus (n=43). All reports sought for retrieval were successfully obtained (reports not retrieved, n=0).\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eFull-Text Review\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003e67 articles underwent full-text assessment. The full-text assessment prioritized landmark, guideline-level, and methodologically influential studies across five predefined OSA domains: landmark epidemiology, pediatric OSA management, adult OSA therapies, precision medicine/endotyping, and interdisciplinary care models. \u003cstrong\u003eTable 1\u003c/strong\u003e presents a categorical summary of these 67 studies.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1: Summary of Full-Text Assessed Studies by Category\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003eCategory\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003eRepresentative Studies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003eKey Contributions\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003eLandmark Epidemiology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003eYoung et al. 1993; Peppard et al. 2013; Benjafield et al. 2019\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003eEstablished OSA prevalence, risk factors, public health burden\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003ePediatric OSA Management\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003eMarcus et al. 2013; Bhattacharjee et al. 2010; Certal et al. 2015\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003eEvidence for AT, RME, combination therapies\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003eAdult OSA Therapies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003eRamar et al. 2015; Srijithesh et al. 2019; Rotenberg et al. 2016\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003eGuidelines for OAT, positional therapy, CPAP adherence\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003ePrecision Medicine/Endotyping\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003eEckert et al. 2013; Carberry et al. 2018; Genta et al. 2021\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003ePhysiological and anatomical phenotyping frameworks\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003eInterdisciplinary Care Models\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003eDe Luca Canto et al. 2014; Kapur et al. 2017; AAO White Paper 2019\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003eDiagnostic accuracy, multidisciplinary pathways\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e67\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 1 presents a categorical summary of the 67 articles that underwent full-text assessment during the systematic literature review. Studies were grouped into predefined domains relevant to obstructive sleep apnea (OSA) management. The \u0026quot;n\u0026quot; column indicates the number of studies in each category. Representative studies for each category are listed to illustrate the methodological diversity and scope of evidence considered.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eFinal Selection\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003e22 articles were excluded during full-text review due to: insufficient methodological quality (n=8), overlapping data with included studies (n=6), language barriers in non-English sections (n=3), retracted status (n=1), or inaccessible supplemental data (n=4).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e45 articles met all inclusion criteria\u003c/strong\u003e (\u003cstrong\u003eSupplementary Table S1\u003c/strong\u003e provides the complete list). From these, key references were selected for detailed synthesis based on methodological quality, guideline relevance, and direct applicability to the proposed paradigm.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eQuality Assessment\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThe methodological quality and risk of bias of included studies were assessed using standardized, study design\u0026ndash;specific appraisal tools. Randomized controlled trials were evaluated using the \u003cstrong\u003eCochrane Risk of Bias Tool\u003c/strong\u003e, assessing domains related to sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, selective reporting, and other potential sources of bias.\u003c/p\u003e\n\u003cp\u003eSystematic reviews and meta-analyses were appraised using \u003cstrong\u003eAMSTAR-2 (A Measurement Tool to Assess Systematic Reviews 2)\u003c/strong\u003e, focusing on critical domains including: protocol registration prior to review, comprehensive literature search strategy, justification for excluded studies, risk of bias assessment of included studies, appropriate meta-analytic methods, consideration of publication bias, and reporting of conflicts of interest.\u003c/p\u003e\n\u003cp\u003eClinical practice guidelines were assessed using the \u003cstrong\u003eAGREE II (Appraisal of Guidelines for Research and Evaluation II)\u003c/strong\u003e instrument, evaluating guideline quality across six domains: scope and purpose, stakeholder involvement, rigor of development, clarity of presentation, applicability, and editorial independence.\u003c/p\u003e\n\u003cp\u003eObservational epidemiological studies were evaluated using the \u003cstrong\u003eNewcastle-Ottawa Scale\u003c/strong\u003e for cohort studies. These studies were inherently subject to confounding and were not subjected to formal risk of bias tools designed for interventional studies.\u003c/p\u003e\n\u003cp\u003eQuality assessments informed the interpretation of findings and evidence synthesis but were not used as exclusion criteria. Studies with higher methodological quality were given greater weight in the narrative synthesis, particularly when contradictory findings emerged across studies. \u003cstrong\u003eTable 2\u003c/strong\u003e summarizes the quality assessments for key representative studies.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: Risk of Bias / Quality Assessment Summary of Key Included Studies\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.0063%;\"\u003e\n \u003cp\u003eStudy Type\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.9572%;\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.4818%;\"\u003e\n \u003cp\u003eStudy Design\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.1157%;\"\u003e\n \u003cp\u003eTool Used\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.7496%;\"\u003e\n \u003cp\u003eKey Domains Assessed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.6894%;\"\u003e\n \u003cp\u003eOverall Quality / Risk of Bias\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.0063%;\"\u003e\n \u003cp\u003eLandmark Epidemiology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.9572%;\"\u003e\n \u003cp\u003eYoung et al., 1993\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.4818%;\"\u003e\n \u003cp\u003eObservational cohort\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.1157%;\"\u003e\n \u003cp\u003eNewcastle-Ottawa Scale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.7496%;\"\u003e\n \u003cp\u003eSelection, comparability, outcome\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.6894%;\"\u003e\n \u003cp\u003eModerate \u0026ndash; inherent confounding in observational design\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.0063%;\"\u003e\n \u003cp\u003ePediatric OSA Management\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.9572%;\"\u003e\n \u003cp\u003eMarcus et al., 2013\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.4818%;\"\u003e\n \u003cp\u003eRCT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.1157%;\"\u003e\n \u003cp\u003eCochrane RoB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.7496%;\"\u003e\n \u003cp\u003eSequence generation, allocation concealment, blinding, incomplete outcome data, selective reporting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.6894%;\"\u003e\n \u003cp\u003eLow risk \u0026ndash; high methodological quality\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.0063%;\"\u003e\n \u003cp\u003ePediatric OSA Management\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.9572%;\"\u003e\n \u003cp\u003eBhattacharjee et al., 2010\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.4818%;\"\u003e\n \u003cp\u003eRCT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.1157%;\"\u003e\n \u003cp\u003eCochrane RoB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.7496%;\"\u003e\n \u003cp\u003eSequence generation, allocation concealment, blinding, incomplete outcome data, selective reporting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.6894%;\"\u003e\n \u003cp\u003eModerate risk \u0026ndash; some concerns with blinding\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.0063%;\"\u003e\n \u003cp\u003eAdult OSA Therapies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.9572%;\"\u003e\n \u003cp\u003eRamar et al., 2015\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.4818%;\"\u003e\n \u003cp\u003eClinical practice guideline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.1157%;\"\u003e\n \u003cp\u003eAGREE II\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.7496%;\"\u003e\n \u003cp\u003eScope/purpose, stakeholder involvement, rigor of development, clarity, applicability, editorial independence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.6894%;\"\u003e\n \u003cp\u003eHigh \u0026ndash; rigorous guideline development\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.0063%;\"\u003e\n \u003cp\u003eAdult OSA Therapies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.9572%;\"\u003e\n \u003cp\u003eSrijithesh et al., 2019\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.4818%;\"\u003e\n \u003cp\u003eSystematic review (Cochrane)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.1157%;\"\u003e\n \u003cp\u003eAMSTAR-2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.7496%;\"\u003e\n \u003cp\u003eProtocol registration, literature search, risk of bias consideration, meta-analytic appropriateness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.6894%;\"\u003e\n \u003cp\u003eHigh \u0026ndash; Cochrane standard\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.0063%;\"\u003e\n \u003cp\u003ePrecision Medicine / Endotyping\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.9572%;\"\u003e\n \u003cp\u003eEckert et al., 2013\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.4818%;\"\u003e\n \u003cp\u003eRCT / Cohort\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.1157%;\"\u003e\n \u003cp\u003eCochrane RoB / NOS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.7496%;\"\u003e\n \u003cp\u003eSequence generation, allocation concealment, blinding, incomplete outcome data, selection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.6894%;\"\u003e\n \u003cp\u003eLow to moderate risk \u0026ndash; generally well-conducted\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.0063%;\"\u003e\n \u003cp\u003eInterdisciplinary Care Models\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.9572%;\"\u003e\n \u003cp\u003eDe Luca Canto et al., 2014\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.4818%;\"\u003e\n \u003cp\u003eSystematic review\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.1157%;\"\u003e\n \u003cp\u003eAMSTAR-2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.7496%;\"\u003e\n \u003cp\u003eProtocol registration, literature search, risk of bias consideration, meta-analytic appropriateness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.6894%;\"\u003e\n \u003cp\u003eModerate \u0026ndash; limited by heterogeneity of included studies\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 2 summarizes the methodological quality and risk of bias assessments for key representative studies. Assessment tools were selected based on study design. Quality ratings reflect methodological rigor across critical domains, with \u0026quot;High\u0026quot; indicating low risk of bias/strong methodology, \u0026quot;Moderate\u0026quot; indicating some methodological concerns. RCT = Randomized Controlled Trial; RoB = Risk of Bias; AMSTAR-2 = A Measurement Tool to Assess Systematic Reviews 2; AGREE II = Appraisal of Guidelines for Research \u0026amp; Evaluation II; NOS = Newcastle-Ottawa Scale.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eSynthesis Approach\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThe review employed narrative synthesis methodology, identifying consistent themes across studies, noting contradictory findings, and conceptually integrating evidence into the novel interdisciplinary framework proposed. The clinical pathway was developed based on synthesized evidence combined with clinical protocols from the authors\u0026apos; practices in Ramallah and Jerusalem, Palestine. A practical algorithm for clinical implementation is provided in \u003cstrong\u003eAppendix A\u003c/strong\u003e.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eUse of Large Language Models\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eNo large language models or artificial intelligence tools were used in the preparation of this manuscript.\u003c/p\u003e"},{"header":"Results","content":"\u003ch3\u003e\u003cstrong\u003ePediatric Innovations: Beyond Adenotonsillectomy as Monotherapy\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThe traditional pediatric OSA pathway\u0026mdash;adenotonsillectomy as first-line therapy with consideration of orthodontic intervention only for residual cases\u0026mdash;warrants reconsideration. A randomized controlled crossover trial demonstrated that in non-obese children with balanced maxillomandibular relationships but maxillary constriction, first-line combination therapy with adenotonsillectomy and rapid maxillary expansion produced significantly greater improvements in apnea-hypopnea index (AHI) and oxygen saturation than adenotonsillectomy alone [6].\u003c/p\u003e\n\u003cp\u003eThis finding is physiologically coherent: while adenotonsillectomy addresses lymphoid tissue obstruction at the retropalatal level, RME targets skeletal restriction by increasing nasal cavity volume and improving posterior airway space [7]. Systematic reviews confirm RME\u0026apos;s positive effects on airway dimensions [8]. Proactively addressing both soft tissue and skeletal contributors in appropriately phenotype-defined children represents a shift from reactive management to proactive, precision-based intervention.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eAdult Management: Expanding Beyond CPAP as Default Therapy\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eIn adult management, the therapeutic arsenal has legitimately expanded. Clinical practice guidelines now formally recognize mandibular advancement devices as first-line therapy for mild-to-moderate OSA and for CPAP-intolerant patients [9]. Positional therapy has established efficacy for position-dependent OSA, as confirmed by Cochrane review [10]. These modalities, when selected based on phenotype rather than specialty referral patterns, can significantly improve acceptance and outcomes.\u003c/p\u003e\n\u003cp\u003eThe critical advancement is systematic selection rather than simple availability. The historical pattern of CPAP as default neglects the opportunity for mechanism-matched first-line therapy that may yield better adherence and efficacy for specific phenotypic presentations.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eDiagnostic Precision: From Symptom Reporting to Phenotype Characterization\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eAccurate management requires accurate characterization. While validated screening questionnaires like STOP-BANG have demonstrated utility in adult populations [11], polysomnography (PSG) remains essential for definitive diagnosis and phenotyping. Beyond AHI calculation, advanced analysis can reveal physiological endotypes (e.g., low arousal threshold, high loop gain) with therapeutic implications [3]. The economic implications of accurate diagnosis and targeted treatment are substantial, with untreated OSA representing a significant healthcare burden [12]. Anatomical phenotyping benefits crucially from dental/orthodontic expertise. This multidisciplinary diagnostic synthesis enables true precision in therapy selection. \u003cstrong\u003eTable 3\u003c/strong\u003e provides a comprehensive framework for multidisciplinary phenotyping.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3: Suggested Components of a Multidisciplinary OSA Phenotyping Assessment\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003eDomain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003eAssessing Discipline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003eSpecific Assessments\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003eClinical Relevance / Phenotype Identified\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSleep Study \u0026amp; Symptoms\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003eSleep Medicine Physician\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003e\u0026bull; PSG/HSAT: AHI, RDI, nadir SpO₂, arousal index, positional data\u003cbr\u003e\u0026nbsp;\u0026bull; Endotypic traits if analyzable\u003cbr\u003e\u0026nbsp;\u0026bull; Standardized symptom questionnaires (ESS, PSQ)\u003cbr\u003e\u0026nbsp;\u0026bull; Clinical history: snoring, witnessed apneas, daytime symptoms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003eQuantifies severity, identifies positional OSA, suggests physiological endotypes, assesses symptom burden\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOtolaryngologic / Airway\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003eOtorhinolaryngologist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003e\u0026bull; FNLP: Adenoid/tonsil size, palatal configuration, tongue base, epiglottis\u003cbr\u003e\u0026nbsp;\u0026bull; Friedman/Mallampati score\u003cbr\u003e\u0026nbsp;\u0026bull; External craniofacial exam: retrognathia, midface hypoplasia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003eIdentifies soft tissue obstruction sites, assesses adenotonsillar hypertrophy, evaluates visible skeletal features\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDentofacial \u0026amp; Occlusal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003eOrthodontist / Dental Sleep Specialist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003e\u0026bull;\u0026nbsp;\u003cstrong\u003eIntraoral Exam:\u003c/strong\u003e Maxillary transverse deficiency (posterior crossbite, high-arched palate), dental crowding, occlusal class (I, II, III)\u003cbr\u003e\u0026nbsp;\u0026bull;\u0026nbsp;\u003cstrong\u003eCephalometric Analysis:\u003c/strong\u003e SNA, SNB, ANB angles; mandibular plane angle; PAS (posterior airway space); MP-H (mandibular plane to hyoid)\u003cbr\u003e\u0026nbsp;\u0026bull; \u003cstrong\u003eModel Analysis:\u003c/strong\u003e Casts for arch width measurement and treatment planning\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003eIdentifies \u003cstrong\u003eskeletal phenotype\u003c/strong\u003e: maxillary constriction, mandibular retrognathia, vertical excess. Essential for planning RME or oral appliance therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAnthropometric \u0026amp; General\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003eAll / Primary Care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003e\u0026bull; Body Mass Index (BMI), neck circumference\u003cbr\u003e\u0026nbsp;\u0026bull; Blood pressure, cardiovascular history\u003cbr\u003e\u0026nbsp;\u0026bull; Medication review (esp. sedatives, muscle relaxants)\u003cbr\u003e\u0026nbsp;\u0026bull; Comorbidities: hypertension, atrial fibrillation, type 2 diabetes, GERD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003eIdentifies obesity-related phenotype. Assesses cardiovascular risk and comorbid conditions that influence management priorities\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e*Table 3 outlines the essential components for comprehensive phenotyping of obstructive sleep apnea (OSA) patients within a multidisciplinary framework. Abbreviations: PSG = polysomnography; HSAT = home sleep apnea test; AHI = apnea-hypopnea index; RDI = respiratory disturbance index; ESS = Epworth Sleepiness Scale; PSQ = Pediatric Sleep Questionnaire; FNLP = fiberoptic nasopharyngolaryngoscopy; RME = rapid maxillary expansion; GERD = gastroesophageal reflux disease; SNA = sella-nasion-A point; SNB = sella-nasion-B point; PAS = posterior airway space; MP-H = mandibular plane to hyoid. Clinical scales mentioned (STOP-BANG [11], Mallampati, Friedman) are publicly available tools.*\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eA Novel Three-Pillar Interdisciplinary Precision Framework\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThe proposed interdisciplinary precision management model rests on three innovative pillars that collectively redefine standard OSA care delivery. The framework is supported by the evidence synthesized from the 45 included studies (Supplementary Table S1) and assessed for quality in Table 2.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003ePillar 1: First-Line Phenotype-Targeted Combination Therapy in Pediatrics\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThis pillar reconceptualizes the pediatric treatment sequence. For children presenting with the phenotype of concurrent adenotonsillar hypertrophy and maxillary constriction (evidenced by posterior crossbite, high arched palate, narrow maxilla), first-line therapy should be combined adenotonsillectomy and RME. This approach, supported by randomized trial evidence [6], targets multiple anatomical contributors simultaneously, potentially improving initial success rates. \u003cstrong\u003eAppendix A\u003c/strong\u003e provides a clinical decision algorithm operationalizing this approach.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003ePillar 2: The Orthodontist as a Lifelong Collaborator in Airway Management\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThis pillar expands the orthodontist\u0026apos;s role across the lifespan. In childhood, they are co-architects of first-line treatment via RME. In adulthood, they evolve into dental sleep medicine specialists providing oral appliance therapy [9]. This establishes continuity of anatomical expertise within the care team, positioning dental professionals as permanent collaborators rather than occasional consultants.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003ePillar 3: A Unifying Endotype-Driven Therapeutic Framework\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThis pillar creates a coherent selection matrix organizing interventions by primary therapeutic target. Here, \u0026apos;phenotype\u0026apos; refers to observable clinical/anatomical characteristics, while \u0026apos;endotype\u0026apos; denotes the underlying physiological mechanisms driving airway collapse [3]:\u003c/p\u003e\n\u003cp\u003e\u0026middot; \u003cstrong\u003eAnatomical (Retropalatal):\u003c/strong\u003e AT (pediatrics), CPAP, upper airway stimulation\u003c/p\u003e\n\u003cp\u003e\u0026middot; \u003cstrong\u003eAnatomical (Retroglossal/Retrognathic):\u003c/strong\u003e Oral appliances, maxillomandibular advancement\u003c/p\u003e\n\u003cp\u003e\u0026middot; \u003cstrong\u003eAnatomical (Nasomaxillary Constriction):\u003c/strong\u003e RME (pediatrics/select adults)\u003c/p\u003e\n\u003cp\u003e\u0026middot; \u003cstrong\u003ePosition-Dependent:\u003c/strong\u003e Positional therapy [10]\u003c/p\u003e\n\u003cp\u003e\u0026middot; \u003cstrong\u003ePhysiological:\u003c/strong\u003e Pharmacological adjuncts, specific PAP modalities\u003c/p\u003e\n\u003cp\u003eThis framework depersonalizes treatment selection, basing it on objective phenotypic characteristics rather than specialty tradition, enabling true mechanism-based personalized medicine.\u003c/p\u003e"},{"header":"Discussion","content":"\u003ch3\u003e\u003cstrong\u003eOperationalizing the Paradigm: A Proposed Clinical Pathway\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003e1. \u003cstrong\u003eIntegrated screening \u0026amp; diagnosis:\u003c/strong\u003e Universal screening in primary care (medical and dental) triggers referral for polysomnography, establishing objective diagnosis. Screening tools such as STOP-BANG [11] may be used for initial risk stratification.\u003c/p\u003e\n\u003cp\u003e2. \u003cstrong\u003eMultidisciplinary phenotyping conference:\u003c/strong\u003e Sleep physician, otorhinolaryngologist, and orthodontist/dental sleep specialist collaboratively review data to determine dominant phenotype/endotype using the framework outlined in \u003cstrong\u003eTable 3\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003e3. \u003cstrong\u003eShared decision-making from phenotype-matched options:\u003c/strong\u003e Treatment selection derives from the endotype-driven framework, considering patient preferences and values. For pediatric patients, \u003cstrong\u003eAppendix A\u003c/strong\u003e provides a structured decision algorithm.\u003c/p\u003e\n\u003cp\u003e4. \u003cstrong\u003eObjective efficacy verification \u0026amp; iterative management:\u003c/strong\u003e Follow-up sleep testing assesses response. Suboptimal response triggers re-phenotyping and alternative selection from the framework, creating a dynamic management loop. The complete list of 45 studies informing this pathway is available in \u003cstrong\u003eSupplementary Table S1\u003c/strong\u003e, and the screening methodology is documented in \u003cstrong\u003eSupplementary Figure 1\u003c/strong\u003e.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eComparison with Existing Models and Clinical Implications\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThis conceptual shift offers several advantages over current fragmented care models, which typically lack lifespan integration and do not embed dental professionals as longitudinal collaborators:\u003c/p\u003e\n\u003cp\u003e\u0026middot; \u003cstrong\u003eImproved therapeutic precision\u003c/strong\u003e through mechanism-based matching\u003c/p\u003e\n\u003cp\u003e\u0026middot; \u003cstrong\u003eEnhanced patient adherence\u003c/strong\u003e through personalized options\u003c/p\u003e\n\u003cp\u003e\u0026middot; \u003cstrong\u003eReduced treatment burden\u003c/strong\u003e by targeting first-line therapy to likely responders\u003c/p\u003e\n\u003cp\u003e\u0026middot; \u003cstrong\u003eContinuity of care\u003c/strong\u003e across the lifespan with dental professionals as permanent team members\u003c/p\u003e\n\u003cp\u003e\u0026middot; \u003cstrong\u003eEconomic efficiency\u003c/strong\u003e through reduced trial-and-error approaches, addressing the substantial economic burden of untreated OSA [12]\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eImplementation Challenges\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eSuccessful implementation requires addressing several barriers:\u003c/p\u003e\n\u003cp\u003e\u0026middot; \u003cstrong\u003eInterdisciplinary communication:\u003c/strong\u003e Structured conferences and shared protocols\u003c/p\u003e\n\u003cp\u003e\u0026middot; \u003cstrong\u003eEducational gaps:\u003c/strong\u003e Enhanced training in sleep medicine for dental professionals\u003c/p\u003e\n\u003cp\u003e\u0026middot; \u003cstrong\u003eReimbursement models:\u003c/strong\u003e Advocacy for value-based care frameworks\u003c/p\u003e\n\u003cp\u003e\u0026middot; \u003cstrong\u003eAccess equity:\u003c/strong\u003e Telemedicine and regional referral networks\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eLimitations\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThis systematic narrative review has several limitations. The search, while systematic and documented in \u003cstrong\u003eSupplementary Figure 1\u003c/strong\u003e, may not have captured all relevant non-English literature. Selection of key references from the 45 included studies (\u003cstrong\u003eSupplementary Table S1\u003c/strong\u003e), though based on explicit criteria (methodological quality, guideline relevance, direct applicability), introduces potential selection bias, which we have mitigated by providing the full list of included studies. The proposed framework, while evidence-based, requires prospective validation through implementation research. The quality assessment in \u003cstrong\u003eTable 2\u003c/strong\u003e reflects the methodological rigor of included studies but does not substitute for primary research.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis systematic narrative review presents a novel three-pillar interdisciplinary precision framework for OSA management that systematically integrates pediatric and adult care through phenotypic characterization and mechanism-targeted intervention. The framework is supported by a comprehensive evidence base of 45 studies (Supplementary Table S1), systematically identified through a PRISMA-guided process (Supplementary Figure 1). By expanding the role of dental professionals from childhood RME to adult oral appliance therapy within physician-directed teams, this model addresses documented limitations of current siloed approaches. Successful implementation requires restructuring referral patterns, developing collaborative practice models, and evolving educational curricula. A practical decision algorithm for clinical application is provided in Appendix A. This conceptual shift promises improved therapeutic precision, adherence, and outcomes across the lifespan by moving from treating OSA generically to managing each individual\u0026apos;s unique pathophysiology.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch3\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThe authors declare no competing interests. No financial or non-financial interests could be perceived to influence the work reported in this manuscript.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003e\u003cstrong\u003eMaen Mahfouz:\u003c/strong\u003e Conceptualization, Methodology, Investigation, Writing – Original Draft, Writing – Review \u0026amp; Editing, Supervision. \u003cstrong\u003eEman Alzaben:\u003c/strong\u003e Conceptualization, Investigation, Writing – Review \u0026amp; Editing.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eAll data discussed in this manuscript are available from the cited published sources. The complete list of 45 included studies is available as \u003cstrong\u003eSupplementary Table S1\u003c/strong\u003e. The PRISMA 2020-style flow diagram documenting the screening process is available as \u003cstrong\u003eSupplementary Figure 1\u003c/strong\u003e. Additional materials are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eEthics Approval\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eNot applicable. This manuscript is a systematic narrative review of previously published literature and does not involve new human or animal research.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThe authors thank the researchers whose work is cited in this review for their contributions to advancing the field of sleep medicine.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eUse of Large Language Models\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eNo large language models or artificial intelligence tools were used in the preparation of this manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eYoung T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S. The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med. 1993;328:1230-1235. DOI: 10.1056/NEJM199304293281704\u003c/li\u003e\n\u003cli\u003eEhsan Z, Ishman SL, Soghier I, et al. Management of persistent, post-adenotonsillectomy obstructive sleep apnea in children: an official American Thoracic Society clinical practice guideline. Am J Respir Crit Care Med. 2024;209:248-261. DOI: 10.1164/rccm.202309-1703ST\u003c/li\u003e\n\u003cli\u003eCarberry JC, Amatoury J, Eckert DJ. Personalized management approach for OSA. Chest. 2018;153:744-755. DOI: 10.1016/j.chest.2017.10.004\u003c/li\u003e\n\u003cli\u003eDe Luca Canto G, Singh V, Major MP, et al. Diagnostic capability of questionnaires and clinical examinations to assess sleep-disordered breathing in children: a systematic review and meta-analysis. J Am Dent Assoc. 2014;145:165-178. DOI: 10.14219/jada.2013.20\u003c/li\u003e\n\u003cli\u003eRotenberg BW, Murariu D, Pang KP. Trends in CPAP adherence over twenty years of data collection: a flattened curve. J Otolaryngol Head Neck Surg. 2016;45:43. DOI: 10.1186/s40463-016-0156-0\u003c/li\u003e\n\u003cli\u003eMagalh\u0026atilde;es MC, Normando D, Soares CJ, et al. Impact of adenotonsillectomy and palatal expansion on the apnea-hypopnea index and minimum oxygen saturation in nonobese pediatric obstructive sleep apnea with balanced maxillomandibular relationship: a cross-over randomized controlled trial. Pediatr Pulmonol. 2024;59:3507-3517. DOI: 10.1002/ppul.27033\u003c/li\u003e\n\u003cli\u003eVinha PP, Eckeli AL, Faria AC, et al. Effects of rapid maxillary expansion on the upper airway dimensions and function in children with obstructive sleep apnea syndrome: a systematic review with meta-analysis. Sleep Med Rev. 2016;30:85-94. DOI: 10.1016/j.smrv.2016.03.002\u003c/li\u003e\n\u003cli\u003eBaratieri C, Alves M Jr, de Souza MM, de Souza Ara\u0026uacute;jo MT, Maia LC. Does rapid maxillary expansion have long-term effects on airway dimensions and breathing? A systematic review. Angle Orthod. 2011;81:1-10. DOI: 10.2319/033010-178.1\u003c/li\u003e\n\u003cli\u003eRamar K, Dort LC, Katz SG, et al. Clinical practice guideline for the treatment of obstructive sleep apnea and snoring with oral appliance therapy: an update for 2015. J Clin Sleep Med. 2015;11(7):773-827. DOI: 10.5664/jcsm.4858\u003c/li\u003e\n\u003cli\u003eSrijithesh PR, Aghoram R, Goel A, Dhanya J. Positional therapy for obstructive sleep apnoea. Cochrane Database Syst Rev. 2019;5:CD010990. DOI: 10.1002/14651858.CD010990.pub2\u003c/li\u003e\n\u003cli\u003eChung F, Abdullah HR, Liao P. STOP-Bang questionnaire: a practical approach to screen for obstructive sleep apnea. Chest. 2016;149:631-638. DOI: 10.1016/j.chest.2015.12.034\u003c/li\u003e\n\u003cli\u003eL\u0026eacute;ger D, Stepnowsky C. The economic and societal burden of excessive daytime sleepiness in patients with obstructive sleep apnea. Sleep Med Rev. 2020;51:101275. DOI: 10.1016/j.smrv.2020.101275\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"obstructive sleep apnea, precision medicine, interdisciplinary care, rapid maxillary expansion, phenotype, adenotonsillectomy, oral appliance therapy, endotype","lastPublishedDoi":"10.21203/rs.3.rs-8886913/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8886913/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eObstructive sleep apnea (OSA) is a prevalent disorder traditionally managed in specialty silos, with adenotonsillectomy (AT) for children and continuous positive airway pressure (CPAP) for adults, often yielding suboptimal outcomes. This systematic narrative review proposes a novel three-pillar interdisciplinary precision framework integrating phenotype-targeted interventions across the lifespan.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e A systematic literature search of PubMed, Cochrane Library, and Google Scholar was conducted (January 1993 – December 2024). Inclusion criteria comprised clinical trials, systematic reviews, and clinical practice guidelines. A PRISMA 2020-style flow diagram (Supplementary Figure 1) documented the screening process. Methodological quality was assessed using Cochrane RoB, AMSTAR-2, AGREE II, and the Newcastle-Ottawa Scale, with results summarized in Table 2.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e From 215 identified records, 45 studies met inclusion criteria (complete list in Supplementary Table S1). Synthesis demonstrates superior apnea-hypopnea index (AHI) reductions from combined AT and rapid maxillary expansion (RME) in phenotype-defined children, and validates oral appliances and positional therapy in adults with specific phenotypes. Table 1 summarizes the 67 full-text assessed studies by category, and Table 3 provides a comprehensive multidisciplinary phenotyping framework.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e This three-pillar framework establishes dentists/orthodontists as lifelong collaborators within a unifying endotype-driven model. This conceptual shift promises improved therapeutic precision and outcomes by matching treatment to individual pathophysiology through interdisciplinary collaboration. A practical decision algorithm for clinical implementation is provided in Appendix A.\u003c/p\u003e","manuscriptTitle":"A Novel Paradigm for Precision Interdisciplinary Management of Obstructive Sleep Apnea: From Childhood to Adulthood","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-18 05:53:04","doi":"10.21203/rs.3.rs-8886913/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"14444f99-726e-425b-aac5-f76e96224577","owner":[],"postedDate":"February 18th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":62958758,"name":"Dentistry"}],"tags":[],"updatedAt":"2026-02-18T05:53:04+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-18 05:53:04","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8886913","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8886913","identity":"rs-8886913","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}