Preliminary Assessment of an Ambulatory Device Dedicated to Upper Airway Muscle Training in Patients With Sleep Apnea: Proof-of-Concept Study.

BACKGROUND: Obstructive sleep apnea/hypopnea syndrome (OSAHS) is a prevalent condition affecting a substantial portion of the global population, with its prevalence increasing over the past 2 decades. OSAHS is characterized by recurrent upper airway (UA) closure during sleep, leading to significant impacts on quality of life and heightened cardiovascular and metabolic morbidity. Despite continuous positive airway pressure (CPAP) being the gold standard treatment, patient adherence remains suboptimal due to various factors, such as discomfort, side effects, and treatment unacceptability. OBJECTIVE: Considering the challenges associated with CPAP adherence, an alternative approach targeting the UA muscles through myofunctional therapy was explored. This noninvasive intervention involves exercises of the lips, tongue, or both to improve oropharyngeal functions and mitigate the severity of OSAHS. With the goal of developing a portable device for home-based myofunctional therapy with continuous monitoring of exercise performance and adherence, the primary outcome of this study was the degree of completion and adherence to a 4-week training session. METHODS: This proof-of-concept study focused on a portable device that was designed to facilitate tongue and lip myofunctional therapy and enable precise monitoring of exercise performance and adherence. A clinical study was conducted to assess the effectiveness of this program in improving sleep-disordered breathing. Participants were instructed to perform tongue protrusion, lip pressure, and controlled breathing as part of various tasks 6 times a week for 4 weeks, with each session lasting approximately 35 minutes. RESULTS: Ten participants were enrolled in the study (n=8 male; mean age 48, SD 22 years; mean BMI 29.3, SD 3.5 kg/m2; mean apnea-hypopnea index [AHI] 20.7, SD 17.8/hour). Among the 8 participants who completed the 4-week program, the overall compliance rate was 91% (175/192 sessions). For the tongue exercise, the success rate increased from 66% (211/320 exercises; SD 18%) on the first day to 85% (272/320 exercises; SD 17%) on the last day (P=.05). AHI did not change significantly after completion of training but a noteworthy correlation between successful lip exercise improvement and AHI reduction in the supine position was observed (Rs=-0.76; P=.03). These findings demonstrate the potential of the device for accurately monitoring participants' performance in lip and tongue pressure exercises during myofunctional therapy. The diversity of the training program (it mixed exercises mixed training games), its ability to provide direct feedback for each exercise to the participants, and the easy measurement of treatment adherence are major strengths of our training program. CONCLUSIONS: The study's portable device for home-based myofunctional therapy shows promise as a noninvasive alternative for reducing the severity of OSAHS, with a notable correlation between successful lip exercise improvement and AHI reduction, warranting further development and investigation.

Dental sleep-related conditions and the role of oral healthcare providers: A scoping review.

Dental sleep medicine as a discipline was first described about a quarter of a century ago. Snoring, obstructive sleep apnea, sleep bruxism, xerostomia, hypersalivation, gastroesophageal reflux disease, and orofacial pain were identified as dental sleep-related conditions. This scoping review aimed to: i) identify previously unidentified dental sleep-related conditions; and ii) identify the role of oral healthcare providers in the prevention, assessment, and management of dental sleep-related conditions in adults. A systematic literature search was conducted in PubMed, Embase.com, Web of Science, and Cochrane. Studies that reported an actual or likely role of oral healthcare providers in the prevention, assessment, and/or management of sleep-related conditions were included. Of the 273 included studies, 260 were on previously listed dental sleep-related conditions; the other 13 were on burning mouth syndrome. Burning mouth syndrome was therefore added to the list of dental sleep-related conditions for the first aim and categorized into sleep-related orofacial pain. For the second aim, the role of oral healthcare providers was found to be significant in the prevention, assessment, and management of obstructive sleep apnea and sleep bruxism; in the assessment and management of snoring, sleep-related orofacial pain, and oral dryness; and in the assessment of sleep-related gastroesophageal reflux condition.

Differences in Predicted Therapeutic Outcome of Mandibular Advancement Determined by Remotely Controlled Mandibular Positioner in Canadian and Chinese Apneic Patients.

Background: In-lab mandibular protrusive titration using a remotely controlled mandibular positioner (RCMP) could predict the success rate of mandibular advancement device (MAD) and reliably determine the Optimal Protrusive Position (OPP) for obstructive sleep apnea (OSA) patients. The aim of this study was to compare MAD success rate using in-lab RCMP manual titration performed in Caucasian and Chinese OSA patients. Methods: Manual RCMP titration was performed during an in-lab sleep study using the same procedure that had been previously reported in untreated Caucasian and Chinese OSA patients. Success rate was determined according to classical success criteria or to those previously used for RCMP titration. Results: A total of 160 subjects were included in this study, and conclusive data were obtained from 141 (71 Chinese and 70 Caucasian OSA patients). Chinese patients were significantly younger, with lower BMI and more severe OSA disease than the Canadian counterparts. Among patients with predicted success, the OPP expressed in % of full protrusion position did not differ between the two ethnic groups. Chinese ethnicity, younger age and lower baseline AHI were significant determinants of RCMP success. In a multivariate analysis, only ethnicity and AHI were found to significantly account for success, the odds ratio for success in Chinese compared to Caucasians corrected for AHI being 3.7 and 4.6 depending on criteria used to define success. Conclusion: Although the OSA disease was more severe in Chinese patients, the predicted success rate of MAD according to RCMP titration was higher in Chinese than in Caucasians. This study was registered on ClinicalTrials.gov (NCT03231254).

Dental sleep medicine: Time to incorporate sleep apnoea education in the dental curriculum.

Dental sleep medicine is a discipline that includes conditions such as sleep breathing disorders (eg snoring and sleep apnoea), sleep bruxism, orofacial pain and sleep-related complaints, and to some extent gastro-oesophageal reflux disorder and/or insomnia. Obstructive sleep apnoea (OSA) is a life-threatening condition that dentists need to identify and manage when indicated in order to increase patient well-being and to be taken in consideration in the dental curriculum. The main objective of this paper is to highlight the relevance of dental sleep medicine in the context of dental education, and to discuss potential educational content for integration in the dental curriculum with a focus on OSA, a condition that is not yet integrated in many dental training curricula around the world.

Impact of stepwise mandibular advancement on upper airway mechanics in obstructive sleep apnea using phrenic nerve magnetic stimulation.

Mandibular advancement devices (MAD) represent a potential treatment for obstructive sleep apnea (OSA). However, their mechanisms of actions are not completely understood. This study was aimed to explore the effects of MAD-induced mandibular protrusion on upper airway mechanics. 25 men commencing treatment for OSA with MAD were recruited. Phrenic nerve magnetic stimulation (PNMS) was used to measure flow/pressure relationship during progressive protrusion in three conditions (without MAD, MAD at minimum protrusion, and MAD at maximum tolerable protrusion). Pressures were recorded simultaneously at three different upper airway segments (naso-, velo-, and oro-pharynx). Without MAD, PNMS twitches induced flow-limitation at the velopharyngeal level in 19 subjects and six of them experienced a shift in the flow-limitation site to the lower segment with MAD at maximum protrusion. An association was found between having a velopharyngeal limitation site without MAD and the increase in maximum flow with the advanced MAD. These data suggest that mandibular advancement devices are acting predominantly at the velopharyngeal level.

Position paper by Canadian dental sleep medicine professionals on the role of different health care professionals in managing obstructive sleep apnea and snoring with oral appliances.

The present Canadian position paper contains recommendations for the management by dentists of sleep-disordered breathing in adults with the use of oral appliances (OAs) as a treatment option for snoring and obstructive sleep apnea (OSA). The recommendations are based on literature reviews and expert panel consensus. OAs offer an effective, first-line treatment option for patients with mild to moderate OSA who prefer an OA to continuous positive airway pressure (CPAP) therapy, or for severe OSA patients who cannot tolerate CPAP, are inappropriate candidates for CPAP or who have failed CPAP treatment attempts. The purpose of the present position paper is to guide interdisciplinary teamwork (sleep physicians and sleep dentists) and to clarify the role of each professional in the management of OA therapy. The diagnosis of OSA should always be made by a physician, and OAs should be fitted by a qualified dentist who is trained and experienced in dental sleep medicine. Follow-up assessment by the referring physician and polysomnography or sleep studies are required to verify treatment efficacy. The present article emphasizes the need for a team approach to OA therapy and provides treatment guidelines for dentists trained in dental sleep medicine. Many of the dentists and sleep physicians who contributed to the preparation of the present article are members of the Canadian Sleep Society and the authors reached a consensus based on the current literature.

Impact of CPAP interface and mandibular advancement device on upper airway mechanical properties assessed with phrenic nerve stimulation in sleep apnea patients.

Oronasal mask (ONM) can be used when mouth leaks impair nasal-CPAP effectiveness. However, ONM's constraint on the chin and straps' traction may alter upper airway (UA) mechanical properties. In contrast, mandibular advancement device associated with nasal-CPAP (NM+MAD) may reduce UA resistance. The aim of this exploratory study was to compare the effects of ONM, NM, and NM+MAD on UA mechanical properties. The three interface modalities were assessed in 11 OSAS patients at 6, 8, 10 cmH(2)O CPAP using a phrenic nerve magnetic stimulation (PNMS) protocol. PNMS-twitches' related flow, pharyngeal pressures (nasopharynx, velopharynx, oropharynx) and UA resistances were determined. Regardless of CPAP level, twitch-induced maximum flow was higher with NM+MAD than with ONM. Velopharyngeal resistance was higher with ONM than with NM+MAD. Oropharyngeal resistance was higher with ONM than with NM. In conclusion, NM+MAD reduced velopharyngeal resistance compared to those measured with ONM and NM alone. We hypothesize that this strategy may help reducing the effective pressure level and thus further limit the risk for mouth leaks.

Prediction of oral appliance efficiency in patients with apnoea using phrenic nerve stimulation while awake.

BACKGROUND: In patients with sleep apnoea, primary oropharyngeal collapse of the upper airway during sleep is an important predictor of treatment success with an oral appliance. Phrenic nerve stimulation is able to induce upper airway obstruction and was therefore used to mimic the target for an efficient treatment with an oral appliance. OBJECTIVE: To test if the site(s) of upper airway collapse identified by means of bilateral anterior magnetic stimulation during wakefulness could predict the efficacy of treatment with an oral appliance in patients with obstructive sleep apnoea. METHODS: The site(s) of upper airway collapse while awake were identified by examining the flow-pressure relationship of flow-limited twitches when measuring velopharyngeal and oropharyngeal pressure. Once the mandibular advancement titration had been completed, the efficacy of mandibular advancement was documented during an in-lab sleep study. RESULTS: 33 patients (24 men and 9 women, apnoea-hypopnoea index (AHI) 32.5 ± 17.1/h) participated in the study. Flow limitation was obtained in 29, but 3 of these had no follow-up sleep study with the device. Subjects with oropharyngeal and velopharyngeal collapse did not differ in the phenotypic characteristics associated with a positive response to an oral appliance (gender, apnoea severity, body mass index or positional dependency of breathing disturbances). Complete or partial success was seen in 14/17 subjects with twitch-induced oropharyngeal collapse and in 4/12 patients with velopharyngeal closure. Treatment response was significantly different in subjects with twitch-induced oropharyngeal and velopharyngeal collapse (OR 9.5, 95% CI 1.6 to 52.7). CONCLUSIONS: Identifying the site of upper airway collapse by using bilateral anterior magnetic stimulation of the phrenic nerve during wakefulness can predict treatment success with an oral appliance in patients with sleep apnoea.