Sleep-Disordered Breathing and Behavioral Symptoms in Pediatric Orthodontic Patients: A Multicenter Cross-Sectional Study

Background/Objectives: Sleep-disordered breathing (SDB), including obstructive sleep apnea, is common in children and is associated with mouth breathing, snoring, and neurobehavioral disturbances. In pediatric orthodontic patients, oral habits and craniofacial imbalances may contribute to airway dysfunction, making orthodontic evaluation a potential setting for early identification of SDB. This study aimed to estimate the prevalence of SDB and to evaluate its associations with parent-reported behavioral symptom profiles in a cohort of pediatric orthodontic patients. Methods: A multicenter cross-sectional study was conducted in 186 children aged 7–13 years attending orthodontic clinics in Oradea and Târgu Mureș, Romania. Parents completed a structured questionnaire on oral habits, the 22-item Pediatric Sleep Questionnaire (PSQ), with SDB defined as 8 or more positive responses, and a parent-reported behavioral screening form assessing ADHD symptom subtypes, oppositional-defiant disorder (ODD), conduct disorder, and anxiety/depression. These behavioral outcomes were based on screening measures and were not intended as clinical psychiatric diagnoses. Associations were analyzed using chi-square or Fisher’s exact tests, and multivariable logistic regression analyses were performed adjusting for age, sex, and weight status. Results: Mouth breathing was reported in 61.8% of participants, snoring in 26.9%, and SDB in 13.4%. Positive screens for ADHD-inattentive (p < 0.001), ADHD-hyperactive/impulsive (p < 0.001), ADHD-combined (p < 0.001), ODD (p < 0.001), and anxiety/depression (p < 0.001) were significantly more frequent among children with SDB. In multivariable analysis, SDB remained independently associated with ADHD-combined subtype (OR = 6.22), ADHD-hyperactive/impulsive symptoms (OR = 5.84), oppositional-defiant disorder (OR = 4.91), and anxiety/depression (OR = 4.38). Conclusions: SDB was identified in a meaningful proportion of pediatric orthodontic patients and was significantly associated with multiple screening-defined behavioral symptom domains. These findings support consideration of brief airway- and sleep-oriented screening during orthodontic assessment, particularly in school-aged children presenting with mouth breathing, snoring, or behavioral concerns. Given the cross-sectional and questionnaire-based design, the findings should be interpreted as associative and warrant confirmation in prospective studies using objective sleep measures.