Is sleep bruxism in obstructive sleep apnea only an oral health related problem?

BACKGROUND: The etiology of sleep bruxism in obstructive sleep apnea (OSA) patients is not yet fully clarified. This prospective clinical study aimed to investigate the connection between probable sleep bruxism, electromyographic muscle tone, and respiratory sleep patterns recorded during polysomnography. METHODS: 106 patients with OSA (74 males, 31 females, mean age: 56.1 ± 11.4 years) were divided into two groups (sleep bruxism: SB; no sleep bruxism: NSB). Probable SB were based on the AASM criteria: self-report of clenching/grinding, orofacial symptoms upon awakening, abnormal tooth wear and hypertrophy of the masseter muscle. Both groups underwent clinical examination for painful muscle symptoms aligned with Temporomandibular Disorders Diagnostic Criteria (DC/TMD), such as myalgia, myofascial pain, and headache attributed to temporomandibular disorder. Additionally, non-complaint positive muscle palpation and orofacial-related limitations (Jaw Functional Limited Scale-20: JFLS-20) were assessed. A one-night polysomnography with electromyographic masseter muscle tone (EMG) measurement was performed. Descriptive data, inter-group comparisons and multivariate logistic regression were calculated. RESULTS: OSA patients had a 37.1% prevalence of SB. EMG muscle tone (N1-N3, REM; P = 0.001) and the number of hypopneas (P = 0.042) were significantly higher in the sleep bruxism group. While measures like apnea-hypopnea-index (AHI), respiratory-disturbance-index (RDI), apnea index (AI), hypopnea-index (HI), number of arousals, and heart rate (1/min) were elevated in sleep bruxers, the differences were not statistically significant. There was no difference in sleep efficiency (SE; P = 0.403). Non-complaint masseter muscle palpation (61.5%; P = 0.015) and myalgia (41%; P = 0.010) were significant higher in SB patients. Multivariate logistic regression showed a significant contribution of EMG muscle tone and JFLS-20 to bruxism risk. CONCLUSION: Increased EMG muscle tone and orofacial limitations can predict sleep bruxism in OSA patients. Besides, SB patients suffer more from sleep disorder breathing. Thus, sleep bruxism seems to be not only an oral health related problem in obstructive apnea. Consequently, interdisciplinary interventions are crucial for effectively treating these patients. TRIAL REGISTRATION: The study was approved by the Ethics Committee of Philipps-University Marburg (reg. no. 13/22-2022) and registered at the "German Clinical Trial Register, DRKS" (DRKS0002959).

[Analysis of Snoring in Patients with Obstructive Sleep Apnea (OSA) by Polysomnography and LEOSound]. / Die Analyse von Schnarchen bei Patienten mit obstruktiver Schlafapnoe (OSA) anhand von Polysomnographie und LEOSound.

INTRODUCTION: Snoring was monitored in patients with obstructive sleep apnea (OSA) using the LEOSound-Monitor and simultaneously polysomnographic (PSG) recording. In obstructive apneas snoring is normally apparent after apnea termination and the beginning of ventilation. We wanted to know how often obstructive apneas are terminated by ventilation in combination with snoring. METHODS AND INTENTION: In 40 patients with OSA (AHI > 15/h) simultaneous polysomnographic recordings were performed amongst long-term respiratory sound monitoring using the LEOSound monitor. Patients' average age was 57±11 years. Average weight was 100±19 kg by a mean body mass index (BMI) of 33±7 kg/m2. 12 out of 40 recordings had to be rejected for further analysis because of artifacts. Snoring recorded by polysomnography was compared with snoring monitored by LEOSound. RESULTS: 3778 obstructive apnea episodes were monitored. LEOSound identified snoring in 1921 (51,0%), polysomnography in 2229 (58,8%) obstructive apneas. Only in one patient there was a higher difference in snoring episodes between PSG and LEOSound. DISCUSSION: In nearly 60% of obstructive apnea events we found snoring during apnea-terminating hyperpnoea. LEOSound is a good diagnostic tool to monitor snoring. It is necessary to clarify why only 60% of all obstructive events/hyperpnoea develop snoring. From a pathophysiological point of view opening of collapsed upper airway should lead in a very high percentage to turbulences in airstream and committed snoring.

[Differential diagnosis of hypersomnia in surgical sleep medicine-more than just sleep apnea!] / Differenzialdiagnostik der Hypersomnie in der operativen Schlafmedizin ­ mehr als nur Schlafapnoe!

Otorhinolaryngologists play a vital role in the management of patients with obstructive sleep apnea (OSA) in Germany, particularly with regards to outpatient diagnostics as well as conservative and surgical treatment of patients with intolerance to ventilation therapy. Although establishment of differential indications for surgical therapy and performance of additional preoperative drug-induced sleep endoscopy in patients with sleep-disordered breathing are among the core competencies of otorhinolaryngologists, differential diagnostic considerations and detection of comorbid sleep disorders can be challenging, particularly for those without extensive sleep medicine training and experience. However, detection of comorbid sleep disorders is of particular importance when permanent surgical treatment is considered. Daytime sleepiness is the typical leading symptom of OSA; nevertheless, other disorders of hypersomnolence need to be considered in these patients and can easily be overlooked. This may lead to inadequate indications for surgical treatment. Based on two case reports, narcolepsy is presented as a comorbid disorder and differential diagnosis in patients with OSA.

[Analysis of Snoring in Patients with Obstructive Sleep Apnea (OSA) by Polysomnography and LEOSound]. / Die Analyse von Schnarchen bei Patienten mit obstruktiver Schlafapnoe (OSA) anhand von Polysomnografie und LEOSound.

INTRODUCTION: Snoring was monitored in patients with obstructive sleep apnea (OSA) using the LEOSound-Monitor and simultaneously polysomnographic (PSG) recording. In obstructive apneas snoring is normally apparent after apnea termination and the beginning of ventilation. We wanted to know how often obstructive apneas are terminated by ventilation in combination with snoring. METHODS AND INTENTION: In 40 patients with OSA (AHI > 15/h) simultaneous polysomnographic recordings were performed amongst long-term respiratory sound monitoring using the LEOSound monitor. Patients' average age was 57 ±â€Š11 years. Average weight was 100 ±â€Š19 kg by a mean body  mass  index (BMI) of 33 ±â€Š7 kg/m2. 12 out of 40 recordings had to be rejected for further analysis because of artifacts. Snoring recorded by polysomnography was compared with snoring monitored by LEOSound. RESULTS: 3778 obstructive apnea episodes were monitored. LEOSound identified snoring in 1921 (51,0 %), polysomnography in 2229 (58,8 %) obstructive apneas. Only in one patient there was a higher difference in snoring episodes between PSG and LEOSound. DISCUSSION: In nearly 60 % of obstructive apnea events we found snoring during apnea-terminating hyperpnoea. LEOSound is a good diagnostic tool to monitor snoring. It is necessary to clarify why only 60 % of all obstructive events/hyperpnoea develop snoring. From a pathophysiological point of view opening of collapsed upper airway should lead in a very high percentage to turbulences in airstream and committed snoring.

[Apnea Detection by Means of Respiratory Sound Recordings and Polysomnography - A Comparative Study]. / Ein Vergleich der Apnoeerkennung bei Patienten mit obstruktiver Schlafapnoe (OSA) anhand von Atemgeräuschaufzeichnungen und Polysomnografie.

Introduction In this study, recognition of apnoeas by means of polysomnography (PSG) and nocturnal respiratory sound recordings in patients with obstructive sleep apnoea (OSA) was analyzed and compared. Methods In 45 patients with OSA requiring treatment (AHI > 15/h), concomitant polysomnographic recordings and long term respiratory sound recordings by means of LEOSound were performed. Patients' average age was 58 ±â€Š12 years (mean ± standard deviation), average BMI was 33 ±â€Š7 kg/m2. Audio-visual apnoea detection by LEOSound was compared to polysomnographic apnoea detection. Increased artifact rate due to dislocation of microphones led to rejection of 11 out of 45 recordings for detailed analysis. Results Comparison of apnea detection by audio-visual analysis and polysomnography yielded a median of 164 apneas for LEOSound recordings and 158 apneas for PSG. Median apnoea index (AI) was calculated to be 20/h for respiratory sounds recording and 21/h for PSG. The correlation of apnea indices from acoustic long term registration and PSG was 0.939 (p < 0.001). Discussion Acoustic long term registration of primary and secondary respiratory sounds is also capable to recognize apnoeas. Exact differentiation between apnoeas and hypopnoeas is only possible in a limited fashion.

[Obstructive sleep apnea in neurological diseases: specially as a risk factor for stroke]. / Obstruktive Schlafapnoe bei neurologischen Erkrankungen: Speziell als Risikofaktor für Schlaganfall.

Neurological diseases are frequently associated with sleep-related breathing disorders. In contrast patients with obstructive sleep apnea (OSA) suffer more often from cerebrovascular and cardiovascular diseases. Epidemiological studies have shown that OSA is common among patients with stroke, arterial hypertension or cardiovascular disease. In particular apnea-associated arterial hypertension, atrial fibrillation, activation of the sympathetic nervous system, recurrent hypoxemia and vascular inflammatory response should be considered as risk factors for the vascular system. Early diagnosis and treatment of sleep-related breathing disorders in neurological diseases are required to reduce the risk of subsequent cerebrovascular and cardiovascular diseases.

ECG signal analysis for the assessment of sleep-disordered breathing and sleep pattern.

The diagnosis of sleep-disordered breathing (SDB) usually relies on the analysis of complex polysomnographic measurements performed in specialized sleep centers. Automatic signal analysis is a promising approach to reduce the diagnostic effort. This paper addresses SDB and sleep assessment solely based on the analysis of a single-channel ECG recorded overnight by a set of signal analysis modules. The methodology of QRS detection, SDB analysis, calculation of ECG-derived respiration curves, and estimation of a sleep pattern is described in detail. SDB analysis detects specific cyclical variations of the heart rate by correlation analysis of a signal pattern and the heart rate curve. It was tested with 35 SDB-annotated ECGs from the Apnea-ECG Database, and achieved a diagnostic accuracy of 80.5%. To estimate sleep pattern, spectral parameters of the heart rate are used as stage classifiers. The reliability of the algorithm was tested with 18 ECGs extracted from visually scored polysomnographies of the SIESTA database; 57.7% of all 30 s epochs were correctly assigned by the algorithm. Although promising, these results underline the need for further testing in larger patient groups with different underlying diseases.

[Chronic pulmonary diseases: point of view of partners and their assessments with regard to the effects of lung sports]. / Chronische Lungenerkrankung: Sicht der Partner und deren Einschätzung bezüglich der Effekte von Lungensport.

BACKGROUND: Chronic diseases of the respiratory organs have, besides restrictions of lung function, also physical, mental and social consequences. The chronic disease impacts negatively not only the patient's own quality of life but also that of his/her partner and/or relative. As treatment modalities, besides drug therapy, above all outpatient rehabilitation measures have proved to be effective. In this pilot study we sought answers to three questions: (i) How is the quality of life of the patient's partner and/or relative influenced by the disease? How does the partner/relative assess the effect of the disease on the chronically ill patient? How does the partner/relative assess the effect of lung sports on the chronically ill patient? METHODS: A specially conceived questionnaire was given to the partners/relatives of 25 patients with chronic pulmonary diseases. The patients, 23 with chronic obstructive pulmonary disease and 2 with pulmonary fibrosis, have been participating in lung sports once a week for more than three years. The average age of the patients was 67 years. RESULTS: The patients' illness also negatively influenced the quality of life of the partner to a considerable extent. The impact of the patients' pulmonary disease on the healthy partner was assessed as being rather moderate. Restrictions of social life were essentially influenced by the amount of assistance required by the pulmonary patient. The therapeutic effects of lung sports on the well-being of the patient were aways considered to be positive by the respective partner/relatives. CONCLUSION: A chronic pulmonary illness also has a negative influence on the partner/relative's quality of life. The necessity for extensive assistance in daily life is accompanied by a considerable negative impact on the partner's quality of life. According to the opinion of the partner/relative, lung sports have positive effects in all of the chronically ill patient's fields of life.

[Measuring sleep duration and sleep quality]. / Messung von Schlafdauer und Schlafqualität.

Restorative functions of sleep are of special interest for sleep medicine. For the assessment of these restorative functions, various parameters are taken into account, among which sleep duration and sleep quality play the most important roles. Both terms are essential for sleep perception, expressing the subjective satisfaction of the individual with the time spent asleep. In recent decades, sleep medicine and sleep research have developed methods for the assessment of both objective and subjective dimensions of sleep. Among subjective methods, taking of the medical history focusing on the patient's sleep is important. Standardized and validated questionnaires play a supportive role. Objective methods are, for example, estimation of the sleep-wake cycle by means of actigraphy and polygraphy. Especially in multimorbid patients, polysomnography is still the gold standard method for diagnostics. An important approach during recent years is shifting from bothering overnight examinations into less disturbing procedures for patients that include performing ambulatory, outpatient examinations in the patients' home rather than inpatient surveillance within sleep centers.

A prospective polysomnographic study on the evolution of complex sleep apnoea.

Complex sleep apnoea (CompSA) may be observed following continuous positive airway pressure (CPAP) treatment. In a prospective study, 675 obstructive sleep apnoea patients (mean age 55.9 yrs; 13.9% female) participated. Full-night polysomnography was performed at diagnosis, during the first night with stable CPAP and after 3 months of CPAP. 12.2% (82 out of 675 patients) had initial CompSA. 28 of those were lost to follow-up. Only 14 out of the remaining 54 patients continued to satisfy criteria for CompSA at follow-up. 16 out of 382 patients not initially diagnosed with CompSA exhibited novel CompSA after 3 months. 30 (6.9%) out of 436 patients had follow-up CompSA. Individuals with CompSA were 5 yrs older and 40% had coronary artery disease. At diagnosis, they had similar sleep quality but more central and mixed apnoeas. On the first CPAP night and at follow-up, sleep quality was impaired (more wakefulness after sleep onset) for patients with CompSA. Sleepiness was improved with CPAP, and was similar for patients with or without CompSA at diagnosis and follow-up. CompSA is not stable over time and is mainly observed in predisposed patients on nights with impaired sleep quality. It remains unclear to what extent sleep impairment is cause or effect of CompSA.

[Daytime sleepiness in patients with Obstructive Sleep Apnoea (OSA) - pathogenetic factors]. / Tagesschläfrigkeit bei obstruktiver Schlafapnoe (OSA) - pathogenetische Faktoren.

Excessive daytime sleepiness (EDS) is one of the most frequent symptoms in patients with obstructive sleep apnoea (OSA). EDS can lead to substantial impairments in quality of life and is a major cause of fatal accidents. However, not all patients with OSA develop EDS. The aim of this paper is to review the current literature to identify factors having an impact on sleepiness in patients with OSA. Interestingly, a substantial heterogeneity of the results was found. Summarising these results, causes of EDS in patients with OSA are multifactorial. Severity of obesity and breathing disorders (apnoea/hypopnoea index) seem to be the most important predictors. Continuous positive airway pressure therapy significantly reduces sleepiness in patients with OSA.

[Sleep-disordered breathing in long-term opioid therapy]. / Schlafbezogene Atmungsstörungen bei Opioid-Langzeittherapie.

Chronic opioid use has been known to cause disturbed sleep as well as excessive daytime sleepiness. During induction and maintenance of opioid use there is a reduction of REM- and slow wave sleep. Central sleep apnea (CSA) has been reported in about 30 % of patients with chronic opioid use. Ataxic breathing and CSA are more prominent in NREM- than REM-sleep. CSA does not seem the sole cause of excessive daytime sleepiness in these patients. Further studies are necessary regarding the effects and consequences of chronic opioid use during sleep.

[Long-term opioid therapy and respiratory insufficiency during sleep]. / Chronische Morphintherapie und respiratorische Insuffizienz im Schlaf.

An increasing proportion of the patients with chronic pain are being treated with opioids on a long-term basis. There are indications that the causes of hypersomnia in patients under chronic opioid therapy are primarily related to breathing disorders during sleep. Hence, we compared the polysomnographies of three hypersomnic patients receiving long-term opioid therapy before and during nocturnal non-invasive ventilatory therapy. Significant findings were a central breathing pattern accompanied by reduced deep and REM sleep. On applying non-invasive ventilatory therapy, there was a significant improvement of respiratory status with an increase of deep sleep as well as a moderate decrease in hypersomnia. In patients under chronic opioid therapy with hypersomnia, the presence of central breathing disorders should be considered.

Efficacy of cabergoline in restless legs syndrome: a placebo-controlled study with polysomnography (CATOR).

OBJECTIVE: To assess the efficacy and safety of the dopamine agonist cabergoline in the treatment of patients with idiopathic restless legs syndrome (CATOR study). METHODS: Patients with moderate to severe restless legs syndrome (RLS) were randomly assigned to cabergoline (single evening dose: 2 mg) or placebo and treated for 5 weeks in a double-blind, multicenter polysomnography (PSG) trial. The primary efficacy measures were the periodic leg movements during sleep arousal index (PLMS-AI) and sleep efficiency. These and further PSG variables were monitored by centrally evaluated PSG. Severity of RLS was assessed using the International RLS Study Group Severity Scale (IRLS), the RLS-6 scales, the Sleep Questionnaire Form A (SF-A; quality of sleep), and the Quality of Life for RLS questionnaire. RESULTS: Forty-three patients were treated and 40 patients were evaluated with PSG (age 56 +/- 10 years, 73% women). Cabergoline was superior to placebo in terms of the PLMS-AI (-17.7 +/- 16.4 vs -4.5 +/- 20.0 placebo; p = 0.0024), sleep efficiency (+6.2 +/- 13.9% vs +3.3 +/- 11.7%; p = 0.0443), PLMS index (p = 0.0014), PLM index (p = 0.0012), and total sleep time (p = 0.0443). Improvements in IRLS total score (-23.7 +/- 11.2 vs -7.9 +/- 11.0 placebo; p = 0.0002), RLS-6 severity scales during the night (p = 0.0010) and during the day (p = 0.0018), Clinical Global Impressions severity item (p = 0.0003), sleep quality (p = 0.0180), SF-A sleep quality (p = 0.0371), and QoL-RLS (p = 0.0247) were larger in patients treated with cabergoline compared with the placebo group. Adverse events were only mild and well-known side effects of dopamine agonists. CONCLUSION: Single-evening cabergoline is an efficacious and well-tolerated short-term therapy for sensorimotor symptoms of restless legs syndrome and associated sleep disturbances.

CSF hypocretin-1 levels in restless legs syndrome.

CSF hypocretin-1 levels at 6 PM did not significantly differ between patients with restless legs syndrome (RLS) and control subjects as measured by direct radioimmunoassay and after acid extraction. The authors did not observe significant differences between early onset and late onset RLS. Hypocretin-1 levels did not correlate with RLS severity or polysomnographic measures. These results contrast with previous findings reporting significantly increased CSF hypocretin-1 in the late evening and mostly in early onset RLS.

Proportional positive airway pressure: a new concept to treat obstructive sleep apnoea.

Proportional positive airway pressure (PPAP) was designed to optimize airway pressure for the therapy of obstructive sleep apnoea (OSA). In a randomized crossover prospective study, the clinical feasibility of PPAP and its immediate effects on the breathing disorder and sleep in comparison with continuous positive airway pressure (CPAP) was evaluated. Twelve patients requiring CPAP therapy underwent CPAP and PPAP titration in a random order. Obstructive and mixed respiratory events could be completely abolished with both forms of treatment. This efficacy could be achieved at a significantly lower mean mask pressure during PPAP titration (8.45+/-2.42 cmH2O) compared to CPAP (9.96+/-2.7 cmH2O) (p=0.002). The mean minimal arterial oxygen saturation (Sa,O2) (82.8+/-6.5%) on the diagnostic night increased significantly (p<0.001) to an average Sa,O2 of 93.35+/-1.71% and 93.19+/-2.9% during CPAP and PPAP titration. Total sleep time, slow wave sleep and rapid eye movement (REM) sleep increased significantly by the same amount during both CPAP and PPAP titration (p<0.001), while sleep stage nonrapid eye movement (NREM) 1 and 2 decreased. Six patients preferred the PPAP titration night, four patients did not have a preference, and two patients preferred CPAP. The present data show that proportional positive airway pressure is as effective as continuous positive airway pressure in eliminating obstructive events and has the same immediate effect on sleep. The lower average mask pressure during proportional positive airway pressure implies potential advantages compared to continuous positive airway pressure. Proportional positive airway pressure presents a new effective therapeutic approach to obstructive sleep apnoea.

["Sleep attacks" in Parkinson patients. A side effect of nonergoline dopamine agonists or a class effect of dopamine agonists?]. / "Schlafattacken" bei Parkinson-Patienten. Eine Nebenwirkung von Nonergolin-Dopaminagonisten oder ein Klasseneffekt von Dopamimetika?

Recently, sudden "sleep attacks" have been described in parkinsonian patients taking the nonergoline dopamine agonists pramipexole and ropinirole. Due to this possible side effect, patients must be instructed not to drive vehicles and to refrain from other activities carrying the risk of self-injury. However, the very existence of sleep attacks remains controversial in sleep medicine, since a gradual transition from wakefulness to sleep is normally observed. Accordingly, sudden onset of sleep, e.g., in narcolepsy or sleep apnea syndrome, is usually associated with excessive daytime sleepiness. Prevalence of sleep disorders and daytime sleepiness have been shown to be increased in Parkinson's disease. Nonergoline dopamine agonists are already known to induce somnolence. Currently, it is not predictable whether sleep attacks represent a sudden transition from wakefulness to sleep or result from an increased propensity to fall asleep, with patients perceiving a sudden onset. Possible pathophysiological mechanisms and legal implications of sleep attacks are discussed.

Vigilance stages and performance in OSAS patients in a monotonous reaction time task.

OBJECTIVES: To develop improved methods for objective assessment of daytime vigilance. This is important in the diagnosis and therapy control of sleep disorders associated with excessive daytime sleepiness (EDS). METHODS: Twenty-one patients with EDS due to obstructive sleep apnea were recorded during a daytime 90 min reaction time (RT) test in a monotonous situation. Two EEG, two EOG and a submental EMG channel were recorded simultaneously. The recordings were divided into short, stationary segments of variable length (0.5-2 s) and classified into 7 stages using our previously described system, which includes additional stages for drowsiness. RESULTS: The duration of RT was linearly correlated to the vigilance state (P<0.05). The appearance of slow eye movements (SEM) was more consistently related to performance impairment than EEG changes. CONCLUSIONS: Our system can provide a better tracking of vigilance changes than the standardized sleep stage scoring. A 1-2 h test is useful in the assessment of the performance of a subject suffering from EDS. We found that SEMs indicate more sensitive and consistent EDS-related performance impairment than changes in EEG activity.

[Does sleep apnea increase the risk of myocardial infarct during sleep?]. / Erhöht Schlafapnoe das Risiko für einen Myokardinfarkt im Schlaf?

Myocardial infarction shows a circadian pattern with a maximum in the early morning hours. In patients with sleep-related breathing disorders (SRBD), it is assumed that apnea-associated changes of hemodynamics, blood gases, and rheology lead to a higher frequency of myocardial infarction during sleep. This investigation analyzes the circadian pattern of myocardial infarction in patients with and without SRBD. Within a time period of 20 months, 89 male patients with acute myocardial infarction were consecutively admitted to the intensive care unit. A nocturnal long-term registration of oxygen saturation, heart rate, breathing sounds, and body position by means of a 4-channel recording system (MESAM IV) was carried out in 59 of the 89 patients 6 to 10 days (evaluation I) and in 43 of 59 patients 22 to 28 days after infarction (evaluation II). Sleep apnea with a respiratory-disturbance-index (RDI > or = 10/h was found in 44.1/39.5% of the patients (evaluation I/II). In 22% of the patients, time of infarction was during a sleeping period. Patients with myocardial infarction during sleep had a clearly higher RDI in comparison to patients with a myocardial infarction during wakefulness (evaluation I: 22.7 versus 9.4/h; p = 0.08; evaluation II: 20.3 versus 7.3; p < 0.05). 53.6% of all myocardial infarctions occurred during the time period 5:00-11:00 a.m. Investigations in a larger number of patients are necessary to confirm these results as well as the relevance of sleep apnea as a cardiovascular risk factor.