Functional Airway Evaluation Screening Tool-6 (FAIREST- 6): A Boon in Early Diagnosis of Sleep-disordered Breathing

Sir, Sleep-disordered breathing (SDB) is a medical condition and has serious health consequences since it impairs regular breathing pattern and ventilation while asleep.[1] SDB shows sequential night breathing issues, ranging from minor snoring to obstructive sleep apnea (OSA).[2] A study by Ariel A. Williamson highlights the fact that SDB occurs in 10%–17% of the pediatric population.[3] It may progress to comorbidities including obesity, metabolic disorders, cardiovascular disease, hypertension, and developmental and neuropsychiatric problems.[4] Children with SDB generally present with various dentofacial traits such as maxillary and mandibular retrognathism, macroglossia, high palatal vault, malocclusion, increased overjet, reduced overbite, anterior and posterior crossbites, dental caries, periodontal disease, and xerostomia. It can be traced on cephalogram as increased mandibular plane, low hyoid position, and increased lower anterior facial height. Unfortunately, the lack of awareness and ignorance among parents increases the severity of symptoms.[5] Currently, overnight polysomnography (PSG) is the gold standard for diagnosing childhood SDB. The apnea–hypopnea index (AHI) or respiratory disturbance index is one of the sleep factors that PSG measures. Although the cutoff levels for the AHI vary and are frequently arbitrary or ambiguous, it has been commonly utilized to diagnose OSA. An AHI of more than five episodes per hour of sleep is typically regarded as abnormal, and the patient is diagnosed with a sleep disorder. Thus, it is time-consuming, is highly expensive, and has limited resources and accessibility.[6] As a result, additional diagnostic techniques have been developed, including clinical assessment tools, medical history evaluation, questionnaires, and objective techniques. Although they cannot completely replace PSG, these techniques can aid in the early detection and risk assessment of the said condition in the pediatric population.[7] A couple of sleep monitoring applications are available and used for the treatment of sleep apnea such as Sleep Tracker, ShutEye: sleep and relax, SnoreGym: reduce your snoring, and Better Sleep: sleep tracker. These apps are designed to provide personal sleep cycle monitor, snore recorder, and sleep sound provider. Although the development of these apps and devices has a great future, they are not in routine use and as accurate as other conventional alternatives at the moment. These apps provide continuous, affordable, and easily accessible at-home data monitoring for sleep related breathing disorders; however, they are not yet validated and doesn’t count with appropriate testing. A lot of attention has been paid to questionnaires and clinical evaluation tools as a possible low-resource SDB screening technique. Additionally, it can offer valuable insights into how SDB affects a child’s physical and mental well-being, which PSG is unable to do.[8,9] Among the various questionnaires and evaluation tools, Functional Airway Evaluation Screening Tool-12 (FAIREST-12) MFT is used by the Breathe Institute in myofunctional therapy and lingual frenuloplasty research projects. FAIREST-12 comprises two parts of which patients are required to complete Part 1, and myofunctional therapists are required to complete Part 2. Along with the chief complaint, the Epworth Sleepiness Scale, Fatigue Severity Scale, and Self-Evaluation Breathing Questionnaire are included in Part 1 while dental characteristics and the tongue range of motion ratio-tongue to incisive papilla (TIP)/ lingual-palatal suction (LPS) are included in Part 2. FAIREST-15, the pediatric version of the FAIREST, consists of 15 items that have been found to have functional, otolaryngologic, and dental traits linked to a higher risk of sleep disruptions in children.[10] In addition, the FAIREST-15 comprises six subjective measures pertaining to posture, breathing pattern, anxiety, and focus that parents were asked to score on a descriptive scale. On a scale of 1–4, parents were asked to score their child’s breathing via their mouth or nose while they are awake and when they are asleep, as well as their slouching sitting posture, primary supine versus nonsupine sleeping position, trouble in concentrating, and anxiety levels. Additionally, radiographic and cephalometric analysis was required to assess the growth pattern which made it more time-consuming. Among the FAIREST-15 findings, the most clinically significant factors predictive of increased sleep-related breathing disorders lead to the development of a short and simple to utilize chairside screening tool. James et al.’s FAIREST-6 is the only concise screening tool that examines extraoral, intraoral, and functional characteristics, assessing the pediatric population for SDB at early stages. It consists of six clinical determinants, as given in Table 1.[10] The six determinants are mouth breathing, mentalis muscle activity, tonsillar hypertrophy, ankyloglossia, narrow palate, and dental wear.Table 1: Clinical assessment tool for sleep-disordered breathing in pediatric dental patients (Functional Airway Evaluation Screening Tool-6)To assess mouth breathing the patient is asked to breathe through the nose with lips sealed for more than 3 min. Mentalis activity is assessed as perioral strain upon mouth closure. The Brodsky grading scale is used to assess the tonsillar size based on the proportion of the oropharyngeal airway occupied by the tonsils [Figure 1]. Ankyloglossia was measured using the quick tongue tie assessment tool [Figure 2]. To record the intercanine and intermolar width, the cast was prepared by taking the alginate impression and measurements were taken from the cast [Figure 3].Figure 1: tonsillar hypertrophy (Brodsky Grade 3) on both the sides as indicated by the arrowsFigure 2: quick tongue tie assessment toolFigure 3: high arch palateEach of the six factors is an independent red flag for SDB. The FAIREST-6 score is equal to the total number of examination findings. A score of 6 indicates that all six of the pertinent examination findings are present, whereas a score of 0 indicates that none of the items are present. The diagnosis of SDB can be done with ease by dentists and other allied health providers using the FAIREST-6 screening tool. By its virtue, a timely intervention can be achieved to prevent further cranial, dentofacial manifestations and maxillofacial abnormalities. The letter emphasizes the necessity of awareness among dentists about SDB as a factor influencing dental health and integrating the FAIREST-6 screening tool into dental practice. This concise screening tool will aid in identifying and managing young patients with SDB leading to early diagnosis, proper referral, treatment based on a multidisciplinary approach, reduced risk of complications, and hence better quality of life for patients. Spreading awareness among dental professionals would serve as the cornerstone for determining the risk of SDB. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.