# Sleep Breathing Disorders' Screening Among Children
## 2 Materials and Methods
### Protocol  
Patients who met the inclusion criteria outlined in Section 2.1 underwent a comprehensive evaluation during their orthodontic checkup. This standard visit was conducted to diagnose dento-maximilomandibular anomalies and included a pedodontics evaluation at the Orthodontics Department of the San Giovanni di Dio Hospital. Parents or legal guardians were asked to review and sign an informed consent form prior to the dental visit.  
Screening for potential sleep-disordered breathing (SDB), such as simple snoring and/or obstructive sleep apnea (OSA), was performed using a scientifically validated questionnaire, the Sleep Clinical Record (SCR) (Figure 1) [25]. The questionnaire comprises two sections: one completed by the doctor, focusing on dento-maxillofacial features indicative of SDB, and the other filled out by the accompanying parent. All visits were conducted by the same doctor, M.S., to ensure consistency and objectivity.  
Figure 1: Sleep Clinical Record, the questionnaire used in this preliminary prospective trial. The Sleep Clinical Record consists of three items: physical examination, subjective symptoms, and clinical history.  
During the clinical examination, the intra- and inter-arch relationships of the maxillae, facial characteristics (facial phenotype, orbiculars muscle tone, nostril tone, nasal septum deviation, and nasal passage patency), and Mallampati and Friedman scores were assessed [26,27]. The patient's subjective symptoms and clinical history were evaluated using the Brouillette score [28], which consists of concise questions about sleep-related symptoms (mouth breathing, habitual snoring, witnessed apneic episodes, frequent awakenings, or agitated sleep) and daytime symptoms (daytime sleepiness, headaches).  
The second section of the questionnaire, completed by the parent, assessed symptoms of inattention and hyperactivity using the Attention Deficit Hyperactivity Disorder (ADHD) Rating Scale (SDAI Scale) [29]. This scale is an integral part of the SCR and is necessary to calculate the final score. Each parameter in the SCR was scored as positive (+) if present or negative (\(-\)) if absent. Tonsillar hypertrophy of grade III or IV was scored as positive (+), while grades 0, I, and II were negative (\(-\)). Friedman palate positions were classified as positive (+) for classes III and IV, and negative (\(-\)) for classes I and II. A Brouillette score of \(-\)1 or higher was considered positive (+). The final SCR score was calculated for each patient based on these data.  
The completed questionnaires were securely attached to the patients' medical records. This step was deemed crucial for identifying patients who might require further evaluation or treatment in the future. However, this additional phase falls outside the scope of the present study. Data collection and analysis were conducted to ensure complete anonymity for all participants.  
Statistical Analysis  
Descriptive analysis was used to report the scores of the total responses. The data were organized into a spreadsheet (MS Excel Office 365 MSO). Qualitative variables were presented as counts and percentages, while quantitative variables were expressed as mean \(\pm\) standard deviation (SD) and range. The significance of the association between the sleep score and potential determinants was evaluated using the Kruskal-Wallis test for qualitative variables and Spearman's rho for the quantitative variable (age).