Combination Therapies with an Oral Appliance in the Management of Obstructive Sleep Apnea.

Combination therapy (CT) with a mandibular advancement device (MAD) and positive airway pressure (PAP) has been advocated for patients for whom neither MAD nor PAP alone provides an efficacious and tolerated therapy. This article reviews the small and limited, but growing body of evidence in support of CT and highlights details in its implementation. In most studies, CT was found to be preferred by many, but not all PAP-intolerant patients. CT can be more efficacious than either MAD or PAP alone.

Differences in temporal profile of brain responses by pleasantness of somatosensory stimulation in autistic individuals.

Purpose/Aim. Autistic individuals may show either hyper- or hypo- responsiveness to touch compared to non-autistic individuals. These behavioural responses depend on perceptual and evaluative mechanisms, which unfold sequentially and thus can be distinguished by exploring the timing of neural responses. In this study, we examined neural response timing to pleasant, unpleasant, and affectively neutral textures, to determine whether these perceptual versus evaluative subprocesses differ in autism and how each subprocess contributes to behavioural responses.Materials and Methods. Our sample included n = 13 autistic and n = 14 non-autistic adults who completed functional magnetic resonance imaging. We analysed early, intermediate, and late phases of the tactile response, derived from studies of noxious tactile stimulation, to three different textures.Results. The autistic group showed distinct differences from the non-autistic group to each of the textures, showing earlier, somatosensory differences in response to the pleasantly and unpleasantly rated textures and later, frontomotor differences in response to the neutrally rated texture. Further, reduced early phase response to the pleasant texture correlated with increased sensory seeking behaviour.Conclusions. While preliminary, these results suggest distinct patterns between autistic and non-autistic individuals in how the neural response to touch unfolds and its correspondence with the perceived pleasantness of tactile experience. The findings suggest perceptual differences in response to affectively charged textures and evaluative differences in response to neutral, ambiguous textures. These temporal properties may inform future studies of tactile processing in autism, lending a better understanding of how individuals differ in their sensory experiences across contexts.

Initially intact neural responses to pain in autism are diminished during sustained pain.

Pain assessments typically depend on self-report of the pain experience. Yet, in individuals with autism spectrum disorders, this can be an unreliable due to communication difficulties. Importantly, observations of behavioral hypo- and hyperresponsivity to pain suggest altered pain sensitivity in autism spectrum disorder. Neuroimaging may provide insight into mechanisms underlying pain behaviors. The neural pain signature reliably responds to painful stimulation and is modulated by other outside regions, affecting the pain experience. In this first functional magnetic resonance imaging study of pain in autism spectrum disorder, we investigated neural responses to pain in 15 adults with autism spectrum disorder relative to a typical comparison group (n = 16). We explored temporal and spatial properties of the neural pain signature and its modulators during sustained heat pain. The two groups had indistinguishable pain ratings and neural pain signature responses during acute pain; yet, we observed strikingly reduced neural pain signature response in autism spectrum disorder during sustained pain and after stimulus offset. The posterior cingulate cortex, a neural pain signature modulating region, mirrored this late signal reduction in autism spectrum disorder. Intact early responses, followed by diminished late responses to sustained pain, may reflect altered pain coping or evaluation in autism spectrum disorder. Evidence of a dichotomous neural response to initial versus protracted pain may clarify the coexistence of both hypo- and hyperresponsiveness to pain in autism spectrum disorder.

Circulating Omentin-1 and Chronic Painful Temporomandibular Disorders.

AIMS: To investigate the relationship between omentin-1 levels and painful temporomandibular disorders (TMD). METHODS: In a case-control design, chronic painful TMD cases (n = 90) and TMD-free controls (n = 54) were selected from participants in the multisite OPPERA study (Orofacial Pain: Prospective Evaluation and Risk Assessment). Painful TMD case status was determined by examination using established Research Diagnostic Criteria for TMD (RDC/TMD). Levels of omentin-1 in stored blood plasma samples were measured by using an enzyme linked immunosorbent assay. Binary logistic regression was used to calculate the odds ratios (ORs) and 95% confidence limits (CLs) for the association between omentin-1 and painful TMD. Models were adjusted for study site, age, sex, and body mass index. RESULTS: The unadjusted association between omentin-1 and chronic painful TMD was statistically nonsignificant (P = .072). Following adjustment for covariates, odds of TMD pain decreased 36% per standard deviation increase in circulating omentin-1 (adjusted OR = 0.64; 95% CL: 0.43, 0.96; P = .031). CONCLUSION: Circulating levels of omentin-1 were significantly lower in painful TMD cases than controls, suggesting that TMD pain is mediated by inflammatory pathways.

Tooth loss and obstructive sleep apnea signs and symptoms in the US population.

PURPOSE: The aim of this study is to investigate the relationship between tooth loss and signs and symptoms of obstructive sleep apnea (OSA) in a representative sample of the general US population. METHODS: Data were from 7305 men and women aged ≥25 years participating in the 2005-2008 National Health and Nutrition Examination Survey. Tooth loss, occlusal contacts, and denture use were determined by dental examination. Four cardinal OSA signs and symptoms were evaluated by questions based on American Academy of Sleep Medicine criteria. Adults with ≥2 signs/symptoms of OSA were classified at high-risk of OSA. Prevalence ratios (PR) and 95 % confidence limits (CL) from log binomial regression models estimated the strength of association between tooth loss and high-risk for OSA, adjusting for demographic characteristics, body mass index, dentures, and sleep duration. RESULTS: Prevalence of high-risk for OSA increased 2 % for each additional lost tooth (PR = 1.02, 95 % CL, 1.01, 1.03) among adults aged 25 to 65 years. When tooth loss was modeled as an ordinal variable with 0-4 lost teeth as the referent category, adjusted prevalence of high-risk for OSA was as follows: 25 % greater in those missing 5-8 teeth (PR = 1.25, 95 % CL, 1.07, 1.46); 36 % greater in those missing 9-31 teeth (PR = 1.36, 95 % CL, 1.06, 1.73); and 61 % greater in the edentulous (PR = 1.61, 95 % CL, 1.11, 2.33). CONCLUSION: Tooth loss may be an independent risk factor for OSA.

Periodontitis and Sleep Disordered Breathing in the Hispanic Community Health Study/Study of Latinos.

STUDY OBJECTIVES: To investigate the association between sleep disordered breathing (SDB) and severe chronic periodontitis. DESIGN: Cross-sectional data analysis from the Hispanic Community Health Study/Study of Latinos. SETTING: Community-based setting with probability sampling from four urban US communities. PARTICIPANTS: 12,469 adults aged 18-74 y. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: Severe chronic periodontitis was defined using the Centers for Disease Control and Prevention/American Academy of Periodontology case classification based on full-mouth periodontal assessments performed by calibrated dentists. SDB was evaluated in standardized home sleep tests, and defined as the number of apnea plus hypopnea events associated with ≥ 3% desaturation, per hour of estimated sleep. SDB was quantified using categories of the apnea-hypopnea index (AHI): 0.0 events (nonapneic); 0.1-4.9 (subclinical); 5.0-14.9 (mild); and ≥ 15 (moderate/severe). Covariates were demographic characteristics and established periodontitis risk factors. C-reactive protein was a potential explanatory variable. Using survey estimation, multivariable binary logistic regression estimated odds ratios (OR) and 95% confidence limits (CL). Following adjustment for confounding, the SDB and periodontitis relationship remained statistically significant, but was attenuated in strength and no longer dose-response. Compared with the nonapneic referent, adjusted odds of severe periodontitis were 40% higher with subclinical SDB (OR = 1.4, 95% CL: 1.0, 1.9), 60% higher with mild SDB (OR = 1.6, 95% CL: 1.1, 2.2) and 50% higher with moderate/severe SDB (OR = 1.5, 95% CL: 1.0, 2.3) demonstrating an independent association between SDB and severe periodontitis. CONCLUSIONS: This study identifies a novel association between mild sleep disordered breathing and periodontitis that was most pronounced in young adults.

Tactile experience does not ameliorate age-related reductions in sensory function.

UNLABELLED: BACKGROUND/STUDY CONTEXT: Sensory function degrades with age, with well-established reductions in tactile spatial acuity, vibrotactile sensitivity, and thermosensation, to name but three aspects of perception. Such age-related losses might be partially stemmed by ongoing experience with tasks requiring high levels of manual dexterity or analogous tactile expertise; individuals who are highly expert in skills that have a fundamental tactile component can show improved tactile function as compared with nonexperts. METHODS: Eighty individuals (17 males, 63 females) in the 18-58 age range were assessed on their tactile experience, as measured by self-assessment on a variety of tasks and competencies, each of which required a high level of skill with the hands. Tactile sensory performance, manual dexterity ("haptic efficiency"), and the subjective response to tactile stimulation were quantified. RESULTS: Degradation in tactile sensory acuity with age was confirmed, but no strong evidence was found for variations in acuity contingent on the tactile expertise of participants. In contrast to the performance measures, differences in tactile experience were associated with differences in the subjective response to touch. Greater tactile experience was associated with the provision of richer descriptions of textured materials manipulated with the digits. CONCLUSION: The range of tactile experience reported in a convenience sample of the population was apparently insufficient to preserve sensory function during aging.

Effect of hydration on the tactile and thermal sensitivity of the lip.

The vermilion lip is a body site particularly susceptible to water loss. Therefore, the role of hydration in tactile perception at the lip was investigated. A series of measures of tactile performance and response were obtained from 22 female subjects, namely: (1) the subjective assessment of lip feel, (2) tactile sensitivity, (3) spatial acuity, (4) thermal sensitivity, and (5) the subjective assessment of thermal stimulation. These measures were obtained from lips in their natural (untreated) state, and lips that had been treated using a hydrating preparation. The preparation altered the subjective feel of the lips consistent with the treatment increasing lip hydration and compliance. Hydrated lips showed greater sensitivity to light touch, and there was a trend toward the lip's thermal sensitivity being altered consistent with the lip treatment having a physical cooling effect. Spatial acuity was unaltered by the state of lip hydration. The sensitivity changes on hydration were proposed to have mechanical basis.

Sleep medicine care under one roof: a proposed model for integrating dentistry and medicine.

Integrating oral appliance therapy into the delivery of care for sleeprelated breathing disorders has been a challenge for dental and medical professionals alike. We review the difficulties that have been faced and propose a multidisciplinary care delivery model that integrates dental sleep medicine and sleep medicine under the same roof with educational and research components. The model promises to offer distinct advantages to improved patient care, continuity of treatment, and the central coordination of clinical and insurance-related benefits.

Obstructive sleep apnea in association with periodontitis: a case-control study.

PURPOSE: Periodontitis is associated with several cardio-metabolic disorders that are co-morbid with sleep-disordered breathing. A relationship between periodontitis and obstructive sleep apnea (OSA) is plausible, but has received little attention. This study investigated the strength of association between periodontitis and risk for OSA. METHODS: In this case-control study, cases had moderate or severe periodontitis (n = 50, 32.5%) and controls had gingivitis or slight periodontitis (n = 104, 67.5%). Sixty-one males (39.6%) and 93 females (60.4%) with a mean age of 61 years were sampled from the dental hygiene preventive care clinic in the School of Dentistry at the University of North Carolina at Chapel Hill between February and April 2011. Patients received a full mouth periodontal examination that included probing pocket depths and clinical attachment levels at 6 sites per tooth. The case definition for moderate or severe periodontitis was that of the American Dental Association (ADA). Risk for OSA was determined by the 4 item "STOP" OSA screening questionnaire, which assesses self-reported snoring, excessive daytime sleepiness, witnessed apnea during sleep and history of hypertension. Demographic, general health and orofacial characteristics were recorded that were considered putative predictors of either periodontitis or OSA. A multivariate binary logistic regression assessed odds of moderate or severe periodontitis according to OSA risk with adjustment for potential confounders. RESULTS: In all, 59 patients (38.3%) screened at high risk for OSA by providing 2 or more affirmative responses on the STOP questionnaire. Sixty percent of periodontitis cases (n = 30) screened high risk of OSA compared with only 28% of controls (n = 29). Cases were 4.1 times more likely (95% CI: 1.9, 11.4) to be at high risk for OSA than controls (p = 0.007) after adjustment for potential confounders. CONCLUSION: A significant association was observed between moderate or severe periodontitis and risk for OSA.

Effects of lip revision surgery on long-term orosensory function in patients with cleft lip/palate.

OBJECTIVE : To determine whether secondary lip revision surgery impacts sensitivity of the upper lip. DESIGN : A three-group, parallel, prospective, nonrandomized clinical trial. SETTING : University of North Carolina School of Dentistry. PATIENTS, PARTICIPANTS : Three groups: (1) patients with repaired cleft lip/palate who were scheduled for lip revision (revision; N = 20); (2) patients with repaired cleft lip/palate who did not receive a lip revision (non-revision; N = 13); and (3) non-cleft control subjects (non-cleft; N = 22). Interventions : Lip revision surgery. MAIN OUTCOME MEASURES : Measures of (1) two-point perception threshold (two-point), (2) warmth detection threshold (warm), and (3) cool detection threshold (cool) were obtained from two sites on the upper lip vermilion. The revision participants were tested approximately 1 week before surgery and then approximately 3 and 12 months after surgery. The non-revision and non-cleft participants were tested at similar times. RESULTS : There were no significant differences among the three groups at baseline for two-point, warm, or cool. The main effects of group, age, sex, and time were not statistically significant for the two-point or warm (p > .05). The mean differences between the 3- and 12-month follow-up visits and baseline for two-point and warm were small for all three groups. For cool, group was statistically significant (p = .04), the difference in the non-revision group between follow-up and baseline was 31% to 34% higher than in the non-cleft group (p = .01). CONCLUSIONS : Although at postsurgery revision participants exhibited threshold values comparable to presurgical values, the sensory differences observed among subgroups of participants with cleft lip are complex.

Reliability and reproducibility of novel methodology for assessment of pressure pain sensitivity in pelvis.

UNLABELLED: Vestibulodynia, the most common type of chronic vulvovaginal pain, impairs the psychological, physical health of nearly 10% of women at some point in their lifetime. The aim of this investigation was to establish reliable standardized methodologies for assessment of pain sensitivity in vulvar mucosa and pelvic musculature. We enrolled 34 women with vestibulodynia and 21 pain-free controls. The participants underwent a nuanced exam that consisted of palpation of precisely located vulvar mucosal and pelvic muscle sites. These measurements remained highly stable when participants were reexamined after 2 weeks, with high within-examiner correlation. Vestibulodynia patients reported greater sensitivity than pain-free controls at the majority of examination sites, particularly at mucosal sites on the lower vestibule. The pain threshold measures at the lower mucosal sites were also associated with the participants' self-reported pain levels during intercourse. These mucosal pain threshold measurements were used to discriminate between vestibulodynia cases and controls with high sensitivity and specificity. This data supports the feasibility of contemporaneous assessment of vulvar mucosa and underlying musculature in the pelvic region, offering the hope of a more precise case definition for vestibulodynia and related disorders. PERSPECTIVE: This study describes performance characteristics of novel methodologies for assessing pelvic muscle and mucosal sensitivity. These pain sensitivity measures were reproducible and associated with subjective pain reports and vestibulodynia case status and represent an important step toward a more precise case definition for vestibulodynia and related disorders.

Perception of fluids with diverse rheology applied to the underarm versus forearm skin.

Little is known about the tactile-perceptual structure of fluids. Therefore, ten fluids with diverse, characterized rheologies were rated by 16 females, on 27 sensory attributes (e.g., "slippery") and 14 emotional attributes (e.g., "enjoyable") via five-point categorical scales. Fluids were assessed against the volar forearm and underarm, sites that commonly experience contact with fluids during the use of personal care products. Application of fluids was either by the participant to their own body ("self-applied") or by the experimenter to the participant's body ("experimenter-applied"). Separate factor analyses of the sensory and emotional attributes for different body sites and modes of touch suggested approximately the same factorial structure in each case. Four general sensory factors emerged, labeled Lubricating, Textured, Silken, and Viscous, and two emotional factors, Comfortable and Arousing. These factors resembled those from equivalent work that used solid materials as stimuli, emphasizing that despite the differences in perceptual structure between fluid-coated and dry, solid surfaces, different body sites, and modes of touch influence the perception of fluid and dry stimuli similarly. As expected, fluids varied widely in how they scored on the factors. Site-wise differences were found, whereby stimuli assessed against the forearm were rated as more Lubricating, less Textured, more Silken, and more Comfortable than they were against the underarm. Self-applied touch was less Comfortable than experimenter-applied. The physical and perceptual were linked insofar as greater measured viscosity at low shear rates was associated with perceptions of cold and wet, whereas at high shear rates, greater viscosity was associated with greater perceived thickness.

Tactile and thermal detection thresholds of the scalp skin.

The tactile and thermal sensitivity of diverse regions of the human body have been documented extensively, with one exception being the scalp. Additionally, sensory changes may accompany the hair loss from the scalp in androgen-related alopecia (ARA), but formal quantitative sensory testing (QST) has not been reported in respect of this. Therefore, light touch detection thresholds were obtained at nine scalp sites and one forehead site, using Semmes-Weinstein filaments (Von Frey hairs), and for warming and cooling from skin baseline temperature, using 28 and 256 mm(2) thermodes. Affective, thermal, and nociceptive sensations experienced at thermal detection threshold were quantified. Thirty-two male participants were recruited, 10 of whom had normal hair coverage, 12 of whom had shaved scalp but with potentially normal hair coverage, and 10 of whom exhibited ARA to some extent. The scalp was relatively insensitive to tactile and thermal stimulation at all tested sites, especially so along the midline and near the apex of the skull. Threshold level warm stimuli were rated less pleasant, the less sensitive the test site. After correction for age-related changes in sensitivity, bald scalp sites were found more sensitive to cooling than the same sites when shaved, consistent with prior informal reports of increased sensitivity for some scalp sensations in ARA. QST on hair-covered sites was subject to methodological issues that render such testing non-ideal, such as bias in measurement of resting skin temperatures, and the near impossibility of delivering filament stimuli to the scalp skin without disturbing neighboring hairs.

Sensory retraining: a cognitive behavioral therapy for altered sensation.

Sensory retraining teaches the patient to ignore or blot out postinjury unpleasant orofacial sensations to optimally tune into and decipher the weakened and damaged signals from the tissues. Sensory retraining is a simple, inexpensive, noninvasive exercise program, which initiated shortly after injury, can lessen the objectionable impression of orofacial altered sensations. Sensory retraining exercises are most effective on decreasing the perceived burden associated with hypoesthetic orofacial altered sensations.

The development and validation of sensory and emotional scales of touch perception.

No comprehensive language exists that describes the experience of touch. Three experiments were conducted to take steps toward establishing a touch lexicon. In Experiment I, 49 participants rated how well 262 adjectives described sensory, emotional and evaluative aspects of touch. In Experiment II, participants rated pairwise dissimilarities of the most descriptive words of the set. Multidimensional scaling (MDS) solutions representing semantic-perceptual spaces underlying the words resulted in a touch perception task (TPT) consisting of 26 'sensory' attributes (e.g., bumpiness) and 14 'emotional' attributes (e.g., pleasurable). In Experiment III, 40 participants used the TPT to rate unseen textured materials that were moved actively or received passively against the index fingerpad, volar forearm, and two underarm sites. MDS confirmed similar semantic-perceptual structures in Experiments II and III. Factor analysis of Experiment III data decomposed the sensory attribute ratings into factors labeled Roughness, Slip, Pile and Firmness, and the emotional attribute ratings into Comfort and Arousal factors. Factor scores varied among materials and sites. Greater intensity of sensory and emotional responses were reported when participants passively, as opposed to actively, received stimuli. The sensitivity of the TPT in identifying body site and mode of touch-related perceptual differences affirms the validity and utility of this novel linguistic/perceptual tool.

Quantitative assessment of pleasant touch.

The hedonic attributes of tactile stimulation are important to one's quality of life, yet they have rarely been studied scientifically. The earliest experimental investigations suggested soft and smooth materials as pleasant, those that were stiff, rough, or coarse as unpleasant. More recent studies conducted by the authors and described herein obtained ratings of pleasantness of different textured materials stroked across the skin of multiple body sites at controlled velocities and forces of application. Statistically significant interactions between materials, sites, velocities, forces and subject sex attest to the complexity of the percept. Less pleasant percepts arose from stimuli that were rougher. However, the difficulty in making further general statements regarding hedonic touch raises questions as to whether the body surface can be mapped affectively in a meaningful manner with a single stimulus and indeed whether pleasantness-to-touch can be viewed as a unidimensional construct.

Sensory retraining after orthognathic surgery: effect on patient report of altered sensations.

INTRODUCTION: The purpose of this analysis was to determine whether, over a 2-year period after bilateral sagittal split osteotomy, patients who received facial sensory-retraining exercises with standard opening exercises in the first 6 months after surgery were as likely to report an alteration in facial sensation as those who received standard opening exercises only. METHODS: 186 subjects were enrolled in a multi-center, double-blind, stratified-block, randomized clinical trial with 2 parallel groups. Patient reports of altered sensations were obtained before surgery, and 1, 3, 6, 12, and 24 months after surgery. A marginal model was fit to examine the effect of sensory retraining while controlling for potential explanatory effects related to demographic, psychological, and clinical factors on the odds of postoperative altered sensations being reported. RESULTS: Age (P <0.0001) and severity of presurgical psychological distress (P <0.0001) were significantly associated with the presence of altered sensations after controlling for the exercise training received. After controlling for age and psychological distress, patients who received opening exercises only were approximately 2.2 times more likely to report postoperative altered sensations than those who also received sensory-retraining exercises (P <0.03). CONCLUSIONS: These results suggest that a simple noninvasive exercise program started shortly after orthognathic surgery can lessen the likelihood that a patient will report altered sensations in the long term after orthognathic surgery.

Sensory and affective judgments of skin during inter- and intrapersonal touch.

Here we report two experiments that investigated the tactile perception of one's own skin (intrapersonal touch) versus the skin of other individuals (interpersonal touch). In the first experiment, thirteen female participants rated, along four perceptual attributes, the skin of their own palm and volar forearm, then that of several of the other participants. Ratings were made using visual analogue scales for perceived smoothness, softness, stickiness, and pleasantness. One's own skin was rated less pleasant than the skin of others. For both intra- and interpersonal touch, the forearm skin was rated smoother, softer, less sticky and more pleasant than the palmar skin. In the second experiment, ten pairs of female participants rated each other's palm and volar forearm skin, with the skin of the touched individual being assessed before and after the application of skin emollients that alter skin feel. As in the first experiment, the untreated skin of others was rated more pleasant than the participants' own skin, and the forearm versus palm differences were replicated. However, the emollient had generally larger effects on self-assessments than the assessments of others, and the site effect showed greater positive sensory and pleasantness increases for palm versus volar forearm. The disparate results of the two experiments suggest that attention, influenced by the ecological importance of the stimulus, is more important to assessment of touched skin than ownership of the skin or the contribution to self-touch made by the additional receptors in the passively touched skin. In both experiments, the pleasantness of touched skin was associated with the skin's perceived smoothness and softness, with weak trends toward negative associations with its perceived stickiness, consistent with prior research using inanimate surfaces (e.g., textiles and sandpapers).

The effect of oral drying and astringent liquids on the perception of mouth wetness.

A feeling of mouth dryness occurs from actual drying of the oral surfaces or from sampling astringent substances such as polyphenols (e.g., tannins in brewed tea and wine), which bind proline-rich proteins in saliva to reduce its lubricity. Here we investigated the interactions between physical drying and the effect of polyphenols on the subjective state of oral hydration. Twelve subjects rated the perceived wetness/dryness of their mouth using a labeled magnitude scale, after the mouth was dried with air for 35 s, or the subjects waited for an equal period of time during which the mouth was not dried. Subsequently, 1.5 mL volumes of an astringent solution (5 g L(-1) tannic acid in distilled water), distilled drinking water, or a sweet solution (40 g L(-1) sugar in mango tea with no tannins) were introduced into the mouth. After swishing and swallowing, the subject rated the wetness of the mouth for 4.3 min. The liquids were found to differ in their ability to wet the mouth (p<0.0001). The least wet sensations were reported for the astringent solution, on average; however, the differences among liquids were not equally pronounced at all times during the observation period (p<0.02). When the mouth was normally hydrated (i.e., had not been dried), the wetting effectiveness of the three liquids, based on the ratings, differed most greatly immediately after they had been received and swallowed. In contrast, when the mouth was dried, the liquids did not differ at this time. That the astringent solution did not have less wetting effectiveness in the dried mouth was attributed to the absence of precipitable salivary proteins. The findings suggest that the refreshment value of astringent drinks, based on their perceived wetting effectiveness, may vary with the state of oral hydration.