Abstracts, Issue 2.3

24th Annual Meeting of the American Academy of Dental Sleep Medicine: Seattle, WA, June 4–6, 2015


Quantitative Evaluation of Upper Airway Using Nasoendoscopy for Prediction of Oral Appliance Treatment Outcome in Moderate and Severe Obstructive Sleep Apnea

Okuno K1,2, Sasao Y3, Nohara K2, Sakai T2, Pliska B1 , Lowe A1 , Almeida FR

1 Department of Oral Health Sciences, Faculty of Dentistry, The University of British Columbia, 2Division of Oral and Facial Disorders, Osaka University Dental Hospital, 3Center of Oral Functional Disorders, Sasao Dental Clinic

Introduction: Treatment with oral appliances (OA) is an alternative to continuous positive airway pressure (CPAP) for obstructive sleep apnea (OSA), although it appears to be less efficacious but more accepted by patients. As the efficacy of oral appliances varies greatly in patients with moderate to severe OSA, the prediction of OA treatment response is of key importance for efficient disease management. Nasoendoscopy has been previously reported as a useful approach to assess the upper airway and as a predictor of OA treatment. However, previous studies have been limited by qualitative assessments and retrospective study designs. In the present study, we report on the prospective and quantitative prediction of OA treatment outcomes using nasoendoscopy.

Methods: A total of 61 patients with moderate to severe PSGdiagnosed OSA were prospectively and consecutively recruited for this study. The velopharynx and oropharynx was assessed via nasoendoscopy for each patient while awake and in the supine position. The airway expansion ratio, defined as the cross-sectional area of the airway during maximum mandibular protrusion divided by the area in centric occlusion, was then calculated at the level of both the velopharynx and oropharynx. Treatment success was defined as an AHI < 10/h in addition to a > 50% reduction in baseline AHI. A MannWhitney U-test was used to compare the expansion ratio between responders and non-responders. A Multivariable logistic regression analysis was performed, with OA treatment outcome as the dependent variable and the independent variables included age, body mass index (BMI), baseline AHI, and the airway expansion ratio in the velopharynx and oropharynx. A receiver operating characteristics (ROC) curve analysis was used to determine the prediction and the best cut-off value for the expansion ratio.

Results: The expansion ratio of the velopharynx was significantly greater in responders than in non-responders (2.9 vs 1.7, P < 0.001). Similarly, the expansion ratio of the oropharynx was also significantly greater in responders than in non-responders (3.4 vs 2.4, P < 0.05). Baseline AHI and the expansion ratio of the velopharynx were found to be independent predictors of OA treatment outcome with the multivariate logistic regression analysis. The estimated area under the curve (AUC) was 75.7 and the cut-off value of the expansion ratio was 2.00. The best combination of sensitivity/specificity and PPV/NPV was 85.7/80.8 and 85.7/80.8.

Conclusions: The airway expansion ratio of the velopharynx was significantly greater in responders than in non-responders, and a cut-off value of 2.0 provided a prediction with a high accuracy. Nasoendoscopy may have significant clinical utility in predicting success of OA treatment.


Effects of a Non-Mandibular Advancement Device in Adults with Severe Obstructive Sleep Apnea

Griffin T1 , Singh GD2

1 Emerald Coast Dental Sleep Medicine, Panama City Beach, FL,2BioModeling Solutions, Inc., Beaverton, OR

Introduction: Mandibular repositioning devices (MRD) have been deployed for the management of mild, moderate and even severe cases of OSA, but there are some concerns regarding unwanted tooth movements, temporo-mandibular joint issues and facial profile changes using that approach. Biomimetic oral appliance therapy (BOAT) differs from conventional MRD therapy as it aims to correct the nasal airway through midfacial redevelopment followed by mandibular correction, which aims to improve the oropharyngeal airway in adults. In this investigation, we test the hypothesis that severe OSA can be addressed without primary mandibular advancement using BOAT.

Methods: In this preliminary study, we included 8 consecutive adults aged > 21yrs that had been diagnosed with severe OSA, following an overnight sleep study that had been interpreted by a Board certified sleep physician. Each subject that participated in this pilot study had failed to comply with CPAP therapy, and was treated under medical supervision by a dentist with advanced training in dental sleep medicine. At each monthly follow-up visit, examination for progress and adjustments of the devices were performed to optimize their efficacy. The mean apnea-hypopnea index (AHI) of the study sample was calculated prior to and after BOAT. The findings were subjected to statistical analysis, using paired t-tests.

Results: There were 5 females and 3 males that were included in this preliminary study. The mean age of the sample was approx. 60.2 yrs. ± 5.6. Prior to treatment the mean AHI of the study subjects was 46.6 ± 12.9. A further follow sleep study was done at a mean of 10.4 mos. ± 2.6. At this time, the AHI decreased significantly (P < 0.001) to a mean value of 13.9 ± 10.5 after BOAT, which represents a fall in the mean AHI by 70% for the study sample. Indeed, three subjects had an AHI of between 3.1 to 5.1 with no appliance in the mouth when the posttreatment sleep studies were done.

Conclusions: BOAT may be a useful method of managing severe cases of OSA in adults, and may represent an alternative to CPAP and MRD therapy. However, long-term follow up using a larger sample size is needed to reach more definitive conclusions on these initial findings.


Oral Appliance Therapy Versus Nasal CPAP in Obstructive Sleep Apnea: A Randomized, PlaceboControlled Trial on Sleep-Related Comorbidities

Aarab G1 , Nikolopoulou M1 , Byraki A1 , Ahlberg J2, Heymans M W3, de Lange J4 , Lobbezoo F1

1 Department of Oral Kinesiology, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and VU University Amsterdam, MOVE Research Institute Amsterdam, Amsterdam, The Netherlands, 2Department of Stomatognathic Physiology and Prosthetic Dentistry, Institute of Dentistry, University of Helsinki, Finland, 3Department of Epidemiology and Biostatistics, VU University Medical Center Amsterdam, The Netherlands, 4Department of Oral and Maxillofacial Surgery of the Academic Medical Centre of the University of Amsterdam and Academic Centre of Dentistry Amsterdam (ACTA), The Netherlands

Introduction: Obstructive sleep apnea (OSA) is associated with several other sleep disorders and sleep-related problems such as insomnia and daytime dysfunction. To our best knowledge, no randomized placebo-controlled trials have been performed comparing the effects of an objectively titrated mandibular advancement device (MAD) and Continuous Positive Airway Pressure (CPAP) on common sleep-related comorbidities. Therefore, the aim of this study was to compare the effects of an MAD with those of nasal CPAP (nCPAP) on symptoms of common sleep disorders and sleep-related problems.

Methods: This study is part of a randomized placebo-controlled trial in which different treatment effects of a titrated MAD are compared with those of nCPAP and an intra-oral placebo appliance in a parallel design. 64 mild/moderate OSA patients (52.0 ± 9.6 years) were randomly allocated to these three therapy groups. All patients filled out the Dutch Sleep Disorders Questionnaire (SDQ) twice: one before treatment and one after six months of treatment. The SDQ is a validated questionnaire that is designed for the assessment of common sleep disorders and sleep-related problems. Based on 88 questions, thirteen scales were constructed, representing the following sleep disorders and sleep-related problems: “insomnia”, “psychiatric sleep disorder”, “periodic limb movements”, “sleep apnea”, “excessive daytime sleepiness”, “cataplexy”, “sleep paralysis”, “daytime dysfunction”, “hypnagogic hallucinations/dreaming”, “sexual/social dissatisfaction”, “restless sleep”, “negative conditioning” and “automatic behavior”. Linear mixed model analyses were performed to study differences between the groups for the different SDQ scales over time.

Results: At baseline, there were no significant differences between the three therapy groups in the symptoms of these sleep disorders and sleep-related problems (F = 1.947–0.015; P = 0.153–0.985). The MAD group showed significant improvements in symptoms over time corresponding with “insomnia”, “psychiatric sleep disorder”, “periodic limb movements”, “sleep apnea”, “excessive daytime sleepiness”, “sleep paralysis”, “daytime disfunctioning”, “hypnagogic hallucinations/ dreaming”, “restless sleep”, “negative conditioning” and “automatic behavior” (F = 29.82–6.86, P = 0.000–0.014). These improvements in symptoms were, however, not significantly different from the improvements in symptoms observed in the nCPAP and placebo groups (P = 0.082–0.949).

Conclusions: There is no significant difference between MAD and nCPAP in their beneficial effects on symptoms of common sleep disorders and sleep-related problems in mild and moderate OSA patients. These beneficial effects may be a result of the time course and/or of placebo effects.




Halitosis and Obstructive Sleep Apnea Have Improved by Lip Muscle Training

Yoshimiura M, Suzuki H, Watanabe A, Iwata Y, Honki H, Asakawa R, Kawara M

Department of Oral function and Rehabilitation, Nihon University School of Dentistry at Matsudo

Introduction: In recent years, patients are increasingly complaining of dry mouth and halitosis, as well as snoring and obstructive sleep apnea (OSA), all of which are problems associated with mouth breathing. Despite the common thread, these conditions are often treated separately and there are few reports in the literature. We herein report a case of a patient who complained of halitosis and snoring, and whose symptoms were improved with lip muscle training.

Methods: The patient is Forty-year-old woman whose chief complaint is halitosis. The patient visited the Department of Comprehensive Clinical Dentistry, Nihon University School of Dentistry at Matsudo hospital in May 2012 for treatment of moderate halitosis following a halitosis test. The patient underwent periodontal treatment for one year according to hospital procedures, after which second halitosis test was given in July 2013. The results showed some improvement in, but no change in unpleasant subjective symptoms. The patient then mentioned that she snored. A simplified sleep test (SAS-2100, Teijin, Tokyo Japan) recorded a Respiratory Disturbance Index (RDI) of 8.2 times/hour, and the patient was diagnosed with mild OSA. The patient was treated with a mandibular advancement device (MAD) and an M-Patakara (PTR, Patakara Co., Ltd., Tokyo, Japan) was used for lip muscle training. PTR is made from flexible plastic and rubber, the resilience of which directly conditions the oral muscles to increase strength. In accordance with the supplied instructions for the use of M-Patakara®, patient underwent this training at the clinic and/ or home for 5 minutes four times a day, every day, for 2 months. After several days of wearing the MAD, the patient complained of soreness in her temporomandibular joints. She discontinued using the MAD, and only continued treatment with the PTR. Two months of PTR use resulted in an increase in lip closure force, a reduction in RDI to 3.2 times/hour, and a decrease in foul odor to a low threshold that the patient could scarcely detect.

Results: Prolonged chronic mouth breathing can reportedly lead to weakening of the orbicularis oris muscles and changes in tongue position. Moreover, mouth breathing may trigger halitosis, snoring and OSA. Through continued lip muscle training, the above patient no longer experienced halitosis upon awakening and her sleeping improved. These results suggest that there is a strong connection between halitosis and OSA via mouth breathing. We plan to conduct further studies on this relationship.

Conclusions: Lip muscle training increased lip closure force. And also, lip muscle training improved halitosis and RDI during sleep.


Elevated Risk for Obstructive Sleep Apnea Predicts Temporomandibular Disorder Independently of Sleep Bruxism and Awake Bruxism

Kornegay EC1 , Sanders AE1, Essick GK1,2

School of Dentistry, University of North Carolina, Chapel Hill, NC, 2Center for Pain Research and Innovation, University of North Carolina, Chapel Hill, NC?

Introduction: Temporomandibular disorder (TMD) is a musculoskeletal disorder characterized by persistent pain in the temporomandibular joint, periauricular region, or the head and neck muscles. Elevated risk for obstructive sleep apnea (OSA) predicts incident TMD; but whether this is a spurious association, confounded by sleep bruxism and awake bruxism, remains unclear. We hypothesized that baseline elevated risk for OSA, sleep bruxism and awake bruxism were each independent predictors of first-onset TMD incidence.

Methods: The prospective cohort, “Orofacial Pain, Prospective Evaluation and Risk Assessment” (OPPERA) study investigated risk factors for TMD incidence in people with no lifetime history of TMD. Between 2006 and 2008, men and women aged 18–44 years were recruited from four study sites: Chapel Hill, NC; Baltimore, MD; Buffalo, NY; and Gainesville, FL. At baseline, participants self-reported sleep bruxism and awake bruxism. To evaluate risk for OSA, they self-reported loud snoring, daytime tiredness, witnessed apnea, and hypertension. Participants with ≥ 2 of these OSA signs/symptoms, or a prior diagnosis of OSA, were classified as having elevated risk for OSA. A baseline clinical examination verified absence of TMD, according to modified Research Diagnostic Criteria. In up to 5.2 years of follow-up, participants completed TMD screening questionnaires every three months to monitor symptoms of first-onset TMD. Clinical re-examination determined TMD in the presence of: (1) ≥ 5 days/month of pain in the masticatory structures and (2) findings of arthralgia and/or myalgia. Risk for OSA, sleep and awake bruxism were modeled in multivariable Cox proportional hazards regression to estimate hazard ratios (HR) and 95% confidence limits (CL) for incident TMD, adjusting for potential confounding.

Results: Of a cohort of 2,660 adults, at baseline 5.8% of participants had elevated risk for OSA; 16.6% reported sleep bruxism at least 1–3 nights/month; and 14.7% reported awake bruxism at least some of the time. Over a median 2.8 years, 252 of the adults developed first-onset TMD. In univariate analysis, elevated risk for OSA, sleep bruxism, and awake bruxism were each significant individual predictors of TMD incidence. In multivariable analysis, the strength of association between OSA risk and TMD incidence was not attenuated with subsequent inclusion of sleep bruxism and awake bruxism. In the fully-adjusted model, incidence of first-onset TMD was 68% higher in participants at elevated risk for OSA (HR = 1.7, 95% CL: 1.1, 2.6) compared to those at low risk for OSA.

Conclusions: In OPPERA, elevated risk for OSA, reported sleep bruxism, and reported awake bruxism were independent risk factors for developing first-onset TMD.


Prediction of the Therapeutic Efficacy of Oral Appliance Therapy Based on AHI and BMI

Dieltjens M1,2,4, Verbruggen AE2,4, Van de Heyning PH2,3,4, Vanderveken OM2,3,4, Braem MJ1,4

1 Department of Special Care Dentistry, 2ENT Department and Head and Neck Surgery, 3Multidisciplinary Sleep Disorders Centre, 4Antwerp University Hospital (UZA); Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp - Belgium

Introduction: Indication for oral appliance therapy (OAT) is often expressed as a function of obstructive sleep apnea (OSA) severity. Classically OAT is indicated when the apnea/hypopnea index (AHI) shows mild (5 < AHI < 15) to moderate (15 < AHI < 30) OSA and/or in patients with severe (AHI > 30) OSA that refuse other treatment. In many patients OSA severity is also linked to their body mass index (BMI). The aim of the present study is to investigate the validity of preselecting patients on the basis of the baseline AHI and BMI with respect to therapy outcome defined as a decrease in AHI with a mandibular advancement device (OAm).

Materials and Methods: In a group of 89 patients (mean age 48 ± 10 years, M/F ratio 87%, BMI 27.7 ± 3.4 kg/m2 , AHI baseline 18.7 ± 11.9/h), OAT with a custom made titratable duoblock “Respident” (Belgium) OAm started in 75% of the maximal protrusion (MP). After 3 months a control PSG with OAm75% (n = 68) was made. Success was defined as “Δ AHI ≥ 50% or AHI < 5/h”.

Results: The OAm75% significantly reduced the AHI to 12.3 ± 12.9/h (P < 0.001) while the changes in BMI did not exceed 1 kg/m2 . Plotting the AHI baseline versus BMI while defining an area delineated by AHI = 30/h and BMI = 30 kg/m2 as the theoretical upper borders of patients treatable with OAm, the results show that n = 45 are within this box of which n = 21 (47%) were successfully treated. Outside the box are n = 23 of which n = 12 were successfully treated (52%). There is no significant difference in therapeutic outcome (P = 1.000) between the patients inside the “30–30 box” versus those situated outside. The same is true when plotting the change in AHI versus BMI.?

Conclusions: Treatment success defined as “Δ AHI ≥ 50% or AHI < 5/h” in a group of patients with a custom-made duoblock titratable oral appliance in 75% of the maximal protrusion, cannot be predicted on the basis of AHI baseline and BMI.


Effect of Titration on the Therapeutic Efficacy of Mandibular Advancement Therapy

Dieltjens M1,2,4, Braem MJ1,4, Verbruggen AE2,4, Van de Heyning PH2,3,4, Vanderveken OM2,3,4

1Department of Special Care Dentistry, 2ENT Department and Head and Neck Surgery, 3Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital (UZA); 4Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp – Belgium

Introduction: Titratable oral appliance therapy (OAT) is generally started in an arbitrary mandibular protrusion. Therefore, additional protrusion or “titration” is required to optimize therapeutic outcome. More protrusion is however not always associated with a corresponding reduction in sleep apnea severity and could lead to increased side-effects. The aim of this study is to investigate whether titration will yield to a higher therapeutic efficacy in terms of an additional decrease in apnea-hypopnea index (AHI) in patients that started OAT in 75% of maximal protrusion (MP).

Methods: This study is an extension to the prospective clinical trial ‘Predicting therapeutic outcome of mandibular advancement device treatment in obstructive sleep apnea (PROMAD)’. In the PROMAD protocol, 100 patients with obstructive sleep apnea (OSA) are included and started OAT at 75% of MP. In patients with a residual AHI > 5/h on a full night polysomnography (PSG) in the 75% of MP, the OAT was adjusted to 90% of MP with constant vertical dimension. This 90% position is a weighted compromise between efficacy and side-effects. After an habituation period but within 2 months after the PSG with OAT, a PSG was performed to assess the efficacy of the 90% position.

Results: Fifty-two OSA patients were included in this study. In 17 out of 52 patients (33%), the 75% position yielded an AHI < 5/h. The remaining 35 patients had an AHI > 5/h under OAT in 75% of MP and gave informed consent to adjust the OAT to the 90% of MP. In this group, the AHI decreased significantly from 22.6 ± 14.2/h at baseline, to 17.6 ± 14.6/h in the 75% MP (P < 0.05). The AHI further decreased significantly to 12.8 ± 8.6 in the 90% MP (P < 0.05). Nineteen patients (54%) showed a lower AHI in the 90% MP when compared to the 75% MP, whereas in 16 patients (46%) the AHI was higher in the 90% MP when compared to the 75% MP. In 6 patients (17%) the 90% MP resulted in AHI < 5/h.

Conclusions: Additional titration from 75% to 90% MP in patients who were not completely treated, an increased therapeutic efficacy could be achieved in 54% of the patients. In 17% of patients, the 90% MP resulted in AHI < 5/h.


The Prospective Power of Drug-Induced Sedation Endoscopy in Predicting Therapeutic Outcome in Obstructive Sleep Apnea Patients Treated with Oral Appliance Therapy in a Fixed Mandibular Protrusion

Verbruggen AE 1,6, Vanderveken OM 1,3,6, Dieltjens M1,2,6, Wouters K5, Vroegop AV1,2,6, Hamans E1,2,6, Verbraecken J3,4,6, De Backer WA3,4,6, Van de Heyning PH 1,3,6, Braem MJ2,6

1 Department of Ear Nose Throat, Head and Neck Surgery, 2 Special Care Dentistry, 3Multidisciplinary Sleep Disorders Centre, 4Pulmonary Medicine and Scientific Coordination and Biostatistics, 5Antwerp University Hospital (UZA), Antwerp, Belgium; 6Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium?

Introduction: There is a high need for the prospective identification of favorable candidates for oral appliance therapy in the treatment of obstructive sleep apnea (OSA). The objective of this prospective observational study was to evaluate the role of drug-induced sedation endoscopy (DISE) baseline findings in the prediction of treatment outcome in terms of treatment response and deterioration with a mandibular advancement type of oral appliance (OAm).

Methods: One hundred OSA patients were included in the study (83% male; age, 47.4 ± 11.5 years; body mass index (BMI), 26.9 ± 3.3 kg/m²; apnea/hypopnea-index (AHI) at inclusion, 21.0 ± 11.2 events/hour sleep) whereafter a new baseline (BL) polysomnography (PSG) was obtained. They started OAm therapy in a fixed protrusion of 75% of the maximal mandibular protrusion. 67 out of 100 patients underwent a DISE as well as a PSG with OAm in that fixed protrusion. Statistical analysis was performed to evaluate the correlation between DISE findings and treatment outcome. Treatment success was defined as a decrease in AHI by PSG of 50% or more with OAm as compared to BL PSG or AHI with OAm < 5/h; whereas deterioration was defined as an increase in AHI with OAm when compared to BL PSG.

Results: Overall, thirty-one patients (46%) were successfully treated with the OAm in the fixed 75% protrusion. Statistical analysis with correction for the confounding factors BMI and AHI at BL, revealed that hypopharyngeal collapse during BL DISE is a negative predictor for success with an odds ratio (OR) of 0.25 (95% confidence interval (CI): 0.08–0.78, P = 0.0165). In addition, a complete concentric collapse (CCC) at the level of the palate was found to be associated with a higher risk for deterioration with an OR of 4.56 (95% CI 1.21–17.16, P = 0.0250). In 30 out of the 67 patients, there was no hypopharyngeal or palatal CCC during BL DISE. The success rate in those 30 patients is 60%.

Conclusions: DISE needs to be recommended as a patient selection tool for OAm therapy to treat OSA. The study shows that hypopharyngeal collapse during BL DISE is a negative predictor for treatment success and that a palatal complete concentric collapse predicts deterioration with OAm therapy.


Longitudinal Survey of Mandibular Advancement Splint (MAS) Usage, Adherence, Side Effects and Interplay with Continuous Positive Airway Pressure (CPAP) Therapy: An Australian Story

Gano C, Ng AT, Lee P

Centre for Sleep Disorders & Respiratory Failure, St. George Hospital, Kogarah and University of New South Wales, NSW, Australia?

Introduction: Although CPAP remains the gold standard treatment for obstructive sleep apnea (OSA), many patients use alternative therapies such as MAS either alone or in combination. However, little is known about how patients use these 2 treatments. We surveyed Australian patients regarding this, their experience with MAS side effects and their adherence.

Methods: A questionnaire was sent using both mail and email to 1,460 patients who had used MAS for the management of OSA or snoring.

Results: Thirty-three percent responded via mail and 25% via email (total 403 respondents for a total response rate of 28%). Median MAS usage was 1.6 +/- 1.5 years. Eighty-two percent of respondents used the device for 6 hours or more per night, 2.5% used it for 4–6 hours/night and 5% stated usage was variable. Fifty-nine percent used MAS as a first-line OSA therapy with 6% switching to CPAP. Thirty-five percent had had a previous trial of CPAP and 85% of these switched to regular MAS usage.

In keeping with accepted MAS guidelines, the device was predominantly used for mild to moderate OSA (71.3%). Other cases were: severe OSA in 21.5%, primary snoring in 0.6% and 6.6% not specified. Eighty-nine percent of patients felt the MAS was comfortable and improved sleep quality. Within this group, 79% reported improvement or resolution of snoring.

Regarding adverse events, 24.8% had minor side effects (e.g. transient temporomandibular joint discomfort, sore muscles, dry mouth) and 1.4 % had major adverse events (e.g. orthodontic side effects). Overall, 7.7% felt MAS was uncomfortable and 19 patients ceased MAS due to side effects. Sixty-one percent felt that MAS should be applied to a larger portion of the population as an effective therapy for OSA/snoring.

Thirteen percent of patients used the combination of MAS and CPAP (e.g. MAS therapy for travel and CPAP for home). An interesting observation was that 19% of these reported simultaneous CPAP and MAS therapy on a nightly basis.

Conclusions: This Australian study has found that MAS is used largely in mild to moderate OSA patients. Tolerance, usage and side effects were generally acceptable. A proportion of MAS patients also used CPAP, occasionally simultaneously.


Three-Dimensional Analysis of the Oropharyngeal Airways in Cleft and Non-Cleft Patients Before and After Maxillary Expansion

Azeredo F1 , de Menezes LM2, Deon Rizzatto SM2, Enciso R3

1Graduate Student, Department of Orthodontics, Pontifical Catholic University of Rio Grande do Sul, Brazil, 2Professor, Department of Orthodontics, Pontifical Catholic University of Rio Grande do Sul, Brazil, 3Clinical Assistant Professor, Division of Endodontics, Oral Surgery and Orthodontics, Ostrow School of Dentistry, University of Southern California

Introduction: The aim of this prospective study was to assess and compare the oropharyngeal airway dimensions in cleft and non-cleft lip and palate growing patients with maxillary constriction, before and after rapid maxillary expansion (RME).

Methods: The sample comprised 63 patients (mean age = 10.3 years), 30 cleft and 33 non-cleft individuals. Conebeam computed tomography (CBCT) scans were taken to measure the oropharyngeal airway differences in terms of volume, axial cross-sectional areas, and anteroposterior and transverse widths before and after RME. Shapiro-Wilk normality test and Generalized Estimating Equations (GEE) with Bonferroni adjustment were used. The intrarater repeatability was calculated with intraclass correlation coefficient (ICC).

Results: The oropharyngeal airway dimensions were not significantly different when cleft and non-cleft patients were compared before the treatment. After RME, the total airway volume and the upper cross-sectional area were significantly increased in cleft patients (P = 0.007 and P = 0.002, respectively). Non-cleft patients presented significant increases in the area and transverse measurements at the upper cross-sectional plane of oropharynx (P = 0.043 and P = 0.005, respectively). Also, in the minimal cross-sectional plane there was significant increase in the transverse width (P = 0.020), and significant decrease in the anteroposterior width (P = 0.042). However, non-cleft patients showed no significant changes in the airway volume. 

Conclusions: There were no dimensional differences in the oropharynx between cleft and non-cleft patients before the treatment. RME increased the airway volume, and it was significant in cleft patients. Non-cleft subjects presented increases in the transverse widths at upper limit and minimal cross sectional planes of oropharynx after RME.


Impact of a Custom-Made Mandibular Repositioning Device on Blood Pressure in Obstructive Sleep Apnea Patients Noncompliant with Continuous Positive Airway Pressure

Vecchierini MF1 , Kerbrat JB2,3, Monteyrol PJ4 , Morin L5, Meurice JC6

1 Sleep and Vigilance Center, APHP, Hôtel Dieu University Hospital, Paris, France, 2 Stomatology and Maxillo-Facial Surgery, Charles Nicolle University Hospital, Rouen, France, 3Stomatology and Maxillo-facial surgery, APHP, Pitie-Salpetriere University Hospital, Paris, France, 4Otolaryngology, Polyclinic du Tondu, Bordeaux, France, 5ResMed Science Center, Saint Priest, France, 6Pneumology, University Hospital of Poitiers, Poitiers, France?

Introduction: Guidelines recommend mandibular repositioning devices (MRDs) as second-line therapy for obstructive sleep apnea (OSA) patients noncompliant with continuous positive airway pressure (CPAP). The prevalence of arterial hypertension (HTN) is high in patients with OSA (OSA) pts and MRD therapy may improve blood pressure (BP).

ORCADES, a French prospective multicenter cohort study, is evaluating the clinical benefits of a custom-made MRD over 5 years in OSA pts who refused or did not tolerate CPAP. Interim 3-month (efficacy) and 9-month (tolerability) follow-up data are presented.

Methods: Sleep data, OSA symptoms, BP, quality of life, side effects and MRD compliance were evaluated in OSA pts fitted with a CAD/CAM MRD (Narval CC™). Treatment success was defined as a ≥ 50% decrease from baseline in the apneahypopnea index (AHI) and complete response was defined as an AHI of < 10/h. HTN was defined as office systolic (SBP) and/ or diastolic BP (DBP) of ≥ 140 and ≥ 90 mmHg, respectively.

Results: 299 OSA patients treated with MRD were analyzed: 222 (74%) without HTN (non-HTN; SBP 122 ± 9 mmHg, DBP 74 ± 8 mmHg) and 77 (26%) with HTN (SBP 140 ± 8 mmHg, DBP 89 ± 8 mmHg). Sex ratio (75% male), age (53 ± 11y) and baseline AHI (29 ± 15/h) were similar in both groups. In the HTN group, body mass index, neck and waist circumferences were higher and nadir SpO2 was lower.?

MRD treatment success rate and mean AHI reduction were greater in the non-HTN vs. HTN group: 83.8% vs. 65.7%, P = 0.0012 and −19.7 ± 12.4 vs. −16.2 ± 12.3, P = 0.042. However, the complete response rate was similar in both groups (66%). Improvements in oxygen saturation, OSA symptoms and quality of life were similar in both groups. In the HTN group, MRD therapy significantly reduced SBP and DBP in HTN patients (by 7.6 ± 12.7 and 6.8 ± 10.2 mmHg; P < 0.0001 vs. baseline and P < 0.0001 vs. non-HTN group); BP was normalized in 59%. BP did not change significantly during MRD therapy in the non-HTN group. There was a significant correlation between DBP decrease and baseline AHI.

MRD compliance was high and similar in both groups (mean 6.6 h/night on mean 6.7 days/week). Half of treated patients from each group reported side effects, 14% of whom had severe events based on investigator assessment. Severe side effects included temporomandibular joint pain (4%, n = 13), dental or jaw pain (3.2%, n = 10), gum or periodontal pain (2.8%, n = 9) and gum irritation (1.5%, n = 5); 25 patients (8%) stopped treatment early due to side effects, mainly pain or irritation.

Conclusions: Custom-made CAD/CAM MRD is effective and has an acceptable tolerability profile in OSA patients noncompliant with CPAP. This treatment may also reduce BP in patients with HTN.


Development of an Auto-Adjusting Mandibular Repositioning Device for In-Home Use

Brugarolas R1 ; Valero-Sarmiento JM1 ; Essick GK2

1Department of Electrical and Computer Engineering, NC State University, Raleigh, NC, 2Department of Prosthodontics, and Center for Pain Research and Innovation, University of North Carolina, Chapel Hill, NC

Introduction: Although continuous positive airway pressure (CPAP) provides a more efficacious therapy than mandibular repositioning devices (MRDs) for the treatment of obstructive sleep-disordered breathing, CPAP is poorly tolerated by many patients. Recent studies suggest that both therapies are comparable in overall effectiveness due to greater patient preference and adherence to MRDs. However, acceptance of MRDs by the medical profession has been hindered by the long periods of time before the maximum efficacy of treatment is achieved and/or confirmed, and by the lack of objective means to assess nightly utilization. These barriers have been overcome for the in-home use of auto-adjusting CPAP, which adjusts the pressure required to minimize respiratory events while recording their occurrence and hours of utilization. The purpose of this ongoing project is to investigate the feasibility of an auto-adjusting MRD for in-home use, recognizing that the patency of the airway is improved by a different mechanism.

Methods: The concept of an auto-adjusting MRD consists of a commercially available MRD, fabricated with a MRD-specific pneumatic actuator (add-on) capable of changing the position of the jaw. A small flexible tube connects the actuator to a small syringe pump connected to a controller. The controller wirelessly receives signals from respiratory sounds sampled from the add-on in the patient’s mouth, from a digital pulse oximeter, and from a body position sensor. Changes in jaw position can be specified in response to respiratory related signals after short (a few consecutive breaths) or longer (a few consecutive nights) periods of time.

In pilot testing, a pneumatic actuator was designed and constructed for a simple prefabricated device, the MyTAP appliance (Airway Management, Inc.). Two different iterations made of a biocompatible polymer were tested, measuring 9.62 cm3 and 16.63 cm3 and weighting 4.52 g and 10.56 g, respectively. To verify their performance both devices were tested on the same male adult, being awake and resting in supine position. His maximum retrusion and protrusion were 5 mm and 9 mm from the incisor edge-to-edge position. The jaw displacement was measured starting at the edge-to-edge position and compared against the air pressure that was required to advance the jaw.

Results: The device with the smallest form factor achieved 4 mm of jaw protrusion at 10 psi and a maximum of 8 mm at a pressure of 24 psi, while the larger device achieved 4.5 mm of jaw protrusion at 2.8 psi and 9 mm at 5.26 psi, reaching the maximum protrusion limit of the subject.

Conclusions: A low-cost, minimally intrusive pneumatic actuator provides an effective means to produce linear horizontal changes in jaw position as part of an auto-adjusting MRD.


Dentofacial Characteristics of Children Suspected of Obstructive Sleep Apnea

Lee J1 , Chadha NK2, Pliska BT1

1Department of Oral Health Sciences, Faculty of Dentistry, The University of British Columbia, Vancouver, Canada; 2Division of Pediatric Otolaryngology, BC Children’s Hospital, Vancouver, Canada

Introduction: Obstructive sleep apnea (OSA) in children is a common and serious disease effecting 1–5% of the population. Potential causes of OSA in children include adenotonsillar hypertrophy, obesity, neuromuscular disease and craniofacial abnormalities. The orthodontic correction of certain malocclusions, namely posterior crossbite and mandibular retrusion have been shown to be effective at ameliorating OSA symptoms. However it is currently unknown to what extent these forms of orthodontic treatment may be suitable in patients presenting to a tertiary care center for assessment and treatment of suspected OSA. The aim of this study is to report the incidence of malocclusion, and therefore indications for orthodontic treatment, of a population of children with suspected OSA.

Methods: Data collection consisted of a retrospective chart review of 110 patients between the ages of 5–10 referred to the Otolaryngology clinic at BC Children’s Hospital between June 2012 and August 2014. All patients underwent a full clinical assessment by the attending otolaryngologist and orthodontist. The patient record provided comprehensive information regarding the patient history and soft tissues, as well as dentofacial features. Characteristics related to specific indications for early orthodontic intervention were recorded, including history of mouth breathing, tonsillar size, anterior crossbite, posterior crossbite, excess overjet and overbite. The Clinical Research Ethics Board of the University of British Columbia approved this study #H14-01596.

Results: The average patient age was 6.79 years. The parents of 47.3% of the patients reported a history of mouth breathing, while 57.5% of the patients presented with either Grade 3 or 4 tonsils on the Brodsky Grading scale. In terms of maxillary constriction, 13.6% of patients had a posterior crossbite, while 4.5% of patients had anterior crossbite. An increase overjet greater than 7mm was reported in 3.7% of patients, and 9.3% of patients presented with an overbite of more than 90%.

Conclusions: Maxillary expansion and mandibular advancement were indicated in 14% and 4% of the sample, respectively.


Three-Year Effect of Oral Appliance Use on Mandibular Position in Patients with Obstructive Sleep Apnea

Furuhata A1,2, Furuhata M1,2, Inoue Y3,4,5, Tsuiki S3,4,5

1 The Nippon Dental University, Tokyo, Japan,2Furuhata Sleepdisordered Breathing Research Institute, Tokyo, Japan, 3Japan Somnology Center, Neuropsychiatric Research Institute, Tokyo, Japan, 4Department of Somnology, Tokyo Medical University, Tokyo, Japan, 5Yoyogi Sleep Disorder Center, Tokyo, Japan

Introduction: In individuals with obstructive sleep apnea (OSA) who use mandibular advancing oral appliances, the occlusal contact area is smaller in the morning than in the evening because of a bite change associated with mandibular protrusion during night. Considering that patients are encouraged to use an appliance daily, we hypothesized that the use of an oral appliance for several years could affect the position of the mandible in OSA patients.

Methods: This study was conducted in accordance with the amended Declaration of Helsinki. Patients who received their oral appliances from October 2000 to August 2008 after a diagnosis of OSA based on polysomnography were recruited. At their first visit to the dental clinic, patients agreed that their data could be used for research and provided their written consent for the anonymous use of their data. When a construction bite was registered to permit manufacture of the initial (i.e., stage 1) and follow-up (i.e., stage 2) monobloc oral appliances, resting mandibular position (RE) and maximum mandibular advancement position (MAX) were both recorded with a George Gauge. The absolute range of the maximum mandibular advancement in mm was then calculated as MAX-RE. Paired t-tests were used to compare the differences in each parameter between stage 1 and stage 2.

Results: The average duration of use of the initial oral appliance was 3 years and 5 months in 77 OSA patients. There were significant differences in RE (−5.8 ± 1.9 vs −4.8 ± 2.3 mm, P < 0.01) and MAX (6.3 ± 2.2 vs 7.8 ± 2.4 mm, P < 0.01) between the two stages. There was a significant change in MAX-RE from 12.1 ± 1.7 to 12.6 ± 1.6 mm (P < 0.01), with an average difference of 0.61 ± 1.5 mm. Moreover, a significant positive correlation was observed between the duration of initial oral appliance use and MAX-RE (r = 0.27, P < 0.05).

Conclusions: These findings suggest that the use of an oral appliance for 3 years can alter the mandibular position, which is associated with a greater change in the absolute range of maximum mandibular protrusion in patients who have used an oral appliance for longer. Since the treatment of OSA is a lifelong process, potential adverse effects should be minimized. We conclude that routine approaches to accelerate the repositioning of the mandible to the normal position, such as the use of jaw exercises in the morning, need to be more strongly emphasized in oral appliance therapy for OSA.


Innovative Technique for the Fabrication of the Custom Face Mask for Hybrid Therapy

Prehn RS1,2,3, Colquitt T4

1Restore TMJ & Sleep Therapy, The Woodlands, TX, 2Inspire Research and Education TX, 3Houston Sleep Consortium, Houston, TX, 4Airway-Centered Dentistry, Shreveport, LA

Introduction: The development of the TAP-PAP™ CM (Custom Mask) has changed the landscape of the treatment of OSA. The CM (Keith Thornton DDS inventor, FDA cleared and manufacture by Airway Management) is a custom CPAP face mask that is fabricated from the impression of the face. This mask is then connected to the post screwed into the TAP 3™ mechanism. This strapless CPAP face mask features efficient and stable CPAP interface with mandibular stabilization (Hybrid Therapy). The effectiveness and seal of the mask against the face is dependent on the accuracy of the face impression. Since observation is the beginning of science, the purpose of this study is to identify the type of impression that results in the most efficient seal of the CM.

Methods: A new technique of a two stage polyvinyl siloxane (PVS) face impression was accomplished on three patients. Preparation of the patient for this impression is the same for the one stage impression. A breathing tube is put over the post that is attached to the patients TAP 3™ and extruding out between the closed the lips. Then a piece of cotton roll is put into both nostrils allowing the border of the nares exposed for impression. Last, Vaseline is applied to the face. Stage one was a light body PVS applied with an impression syringe directly onto the face. Stage two was a medium body PVS applied to a molded thermoplastic perforated disk, then put onto the face over the stage one application. When set, it was pulled off and inspected for any defects.

Results: The impressions were superior to the single stage alginate or PVS impression. Frequent issues with single stage impressions included voids, compressed tissue, inadequate borders and a rushed experience due to setting time of the single stage. Retakes for both alginate and PVS are about 20% based on these authors extensive experience. These issues were all eliminated with the two stage technique. With the first stage being applied to the face via syringe, there was absolute control over all these issues. This technique afforded the time to calmly apply the material, which produced an extremely accurate impression of the face with one attempt, which resulted in a CM that fit accurately on the first insertion.

Conclusions: This study clearly demonstrates, that the two stage face impression technique for the fabrication of the Custom Mask is superior to previous techniques. It eliminates the issues of obtaining accurate face impressions that are inherent of the one stage impression technique. This two stage impression technique will not only reduce the time required for the impression and the delivery of the CM, but will also give a superior seal of the highest quality CPAP interface in our profession at this time.


An Auto-Titrating Mandibular Positioner: Accuracy in Predicting Oral Appliance Therapy Outcome and Efficacious Mandibular Protrusion

Charkhandeh S2,3, Topor, Z1,2, Grosse J2, Vranjes N3, Zareian Jahromi SA1,2, D’Andrea J2, Bruehlmann S2, Remmers JE1,2

1 University of Calgary, 2Zephyr Sleep Technologies, Calgary, Alberta, Canada, 3Snore Centre, Calgary, Alberta, Canada

Introduction: Sleep-disordered breathing is associated with significant morbidity and mortality. A major problem with those who are diagnosed and begin treatment is a low rate of adherence to treatment. One approach to increasing adherence to treatment has been to educate patients about obstructive sleep apnea, it’s causes, treatments and consequences if not treated. The aim of this research was to survey patients who had been given an oral appliance for obstructive sleep apnea for their perceived level of knowledge of, and concern about OSA.

Methods: Study participants (n = 124, mean AHI = 24.9 ± 13.0 hr −1) were derived from 151 patients with OSA, of whom 9 discontinued participation, 14 are currently in progress, and 4 had inconclusive studies. The remaining 124 participants formed our study population. All participants received a two night unattended mandibular titration study at home The mandibular positioner comprised of temporary dental trays attached to a computer-controlled actuator, and during the titration study, apneas and hypopneas were automatically detected from respiratory airflow and oxyhemoglobin saturation. Study 1 involved continuous interaction between detected respiratory events and mandibular position. In Study 2, the positioner held the mandible at an ETPP predicted by Study 1, and further protruded the mandible when the AHI exceeded 10 hr −1. Prospectively established prediction rules applied to the results of each titration study predicted OAT outcome, either predicted success (PS) or predicted failure (PF), and discrepant predictions were resolved by repeating Study 2. Participants classified PS were prospectively assigned a predicted ETPP, and participants classified PF were assigned a sham protrusive target (70% of full protrusion). All participants received a custom dental appliance (G2 Somnomed). Baseline and outcome AHI values were the mean of two nights of home sleep testing, and therapeutic success with OAT was defined as outcome AHI < 10 hr −1 & 50% of baseline AHI.

Results: The unattended auto-titration studies provided satisfactory results in almost all cases (inconclusive study rate: 3%). The overall therapeutic success rate was 73%. Using prospective prediction rules 83 participants were classified as PS and 41 as PF. Values for sensitivity/specificity and positive/negative predictive (P/NPV) were 0.82/0.76 and 0.90/0.61, respectively, with an overall incorrect prediction rate of 19%. A retrospective, classification decision tree analysis reduced this rate to 11% and provided values for sensitivity/specificity and P/NPV values of 0.93/0.77 and 0.91/0.82, respectively. Of the 75 PS participants who experienced therapeutic success, 71 responded at the predicted ETPP (PPV = 0.95). For the 75, the median relative protrusion at therapeutic success was 75% (range: 9–100%) and in 41% therapeutic success occurred at less than 70% of full protrusion.

Conclusions: The results of this prospective clinical trial show that the auto-titrating mandibular positioner is suitable for use in the home and accurately predicts OAT outcome as well as an ETPP. The system may increase OAT efficacy and efficiency while avoiding excessive mandibular protrusion in some cases.

(This research was supported by grants from NRC-IRAP of Canada, Alberta Innovates-Technology Futures, and Zephyr Sleep Technologies.)


Parallel Changes in the Frequency of Respiratory Events and Swallowing during Sleep in Obstructive Sleep Apnea Patients with and without a Mandibular Advancement Device

Yagi K1,3, Lowe AA1 , Ayas NT2, Fleetham JA2, Ichikawa T3, Almeida FR1

1Department of Oral Health Sciences, 2Department of Medicine, 3 The University of British Columbia, Vancouver, Canada. Department of Oral and Maxillofacial Prosthodontics and Oral Implantology, Institute of Health Biosciences, The University of Tokushima, Tokushima, Japan

Introduction: We have previously demonstrated that swallowing frequency during sleep increases with obstructive sleep apnea (OSA) severity in most OSA patients, and that these swallowing events predominately occur subsequent to respiratory events. The findings obtained in the cross-sectional cohort study leave open the possibility that respiratory event frequency may be a key determinant of swallowing frequency during sleep in OSA patients. To test this possibility, we carried out a split-night sleep study and investigated frequency changes in respiratory events and swallowing during sleep in OSA patients with and without a mandibular advancement device.

Methods: Ten patients with previously diagnosed OSA were prospectively and consecutively enrolled in a split-night sleep study for the follow-up of a titratable mandibular advancement device in a hospital sleep laboratory. During the split-night sleep study using standard video-polysomnography, the first half of the night was assigned to a diagnostic phase and the second half of the night was assigned to a mandibular advancement device therapy phase. Swallowing was evaluated with a piezoelectric sensor placed over the neck superior to the laryngeal prominence. A swallowing event was defined as simultaneous signals of an increased chin EMG activity, transient interruption of airflow and a transient elevation of the thyroid cartilage. The frequency of swallowing per hour of sleep was calculated in each phase. P values of < 0.05 were considered significant.

Results: Nine of the 10 OSA patients slept for more than 60 minutes in each phase (diagnostic phase, 118.6 ± 31.4 [mean ± SD] min; mandibular advancement device therapy phase, 213.0 ± 32.6 min) and the phases were compared. Eight of the 9 OSA patients exhibited parallel changes in the apnea hypopnea index (AHI) and swallowing frequency between the two phases. In 5 of the 8 patients, the AHI and swallowing frequency both decreased during the mandibular advancement device therapy phase compared to that of the diagnostic phase. In the remaining 3 of 8 patients, the AHI and swallowing frequency both increased during the mandibular advancement device therapy phase compared to that of the diagnostic phase. An increase in an AHI was significantly correlated with an increase in swallowing frequency between the two phases (rs = 0.85, P = 0.004).

Conclusions: Respiratory event frequency, rather than the presence of a mandibular advancement device in place, can be a determinant of swallowing frequency during sleep in most OSA patients.


Effects of Combined Maxillo-Mandibular Oral Appliance Therapy in Adults with Severe OSA

Cress S1 , Singh GD2

1 Craniofacial and Dental Sleep Medicine, Sugar Land, TX, 2BioModeling Solutions, Inc., Beaverton, OR

Introduction: Mandibular repositioning devices (MRD) have long been deployed for the management of mild to moderate OSA, but there is less evidence on their efficacy in severe cases that have failed to comply with CPAP therapy. Biomimetic oral appliance therapy (BOAT) differs from conventional MRD therapy as it aims to correct the nasal airway through midfacial redevelopment in combination with mandibular repositioning, which aims to improve the oropharyngeal airway in adults. In this preliminary investigation, we tested the hypothesis that severe OSA can be addressed using combined maxillomandibular BOAT in adults.

Methods: In this pilot study, we included 7 consecutive adults aged > 21 yrs that had been diagnosed with severe OSA, following an overnight home sleep study that had been interpreted by a Medical physician. Each subject that participated in this study had failed to comply with CPAP therapy and was treated under medical supervision by a dentist with advanced training in dental sleep medicine. At each monthly follow-up visit, examination for progress and adjustments of the devices were performed to optimize their efficacy. The mean apneahypopnea index (AHI), respiratory disturbance index (RDI) and oxygen desaturation index (ODI) of the study sample was calculated prior to and after BOAT. The findings were subjected to statistical analysis, using paired t-tests.

Results: Prior to treatment the mean AHI of the study subjects was 45.2 ± 8; the mean RDI was 47.4 ± 8, and the ODI was 33.6 ± 9. A further follow home sleep study was done after approximately 9 mos. At this time, the AHI decreased significantly (P < 0.001) to a mean value of 19.5 ± 6 after BOAT, which represents a fall in the mean AHI of 57% for the study sample. The mean RDI fell to 23.7 ± 7.7 (P < 0.001), and the ODI was improved to 11.2 ± 1.9 (P < 0.001).

Conclusions: This pilot study suggests that combined maxillomandibular oral appliance therapy may be a useful method of managing severe cases of OSA in adults, and might represent an alternative to CPAP and MRD therapy. However, long-term follow up using a larger sample size is needed to reach more definitive conclusions on these preliminary findings.


Effects of Neuromuscular Electrical Stimulation on the Masticatory Muscles and Physiologic Sleep Variables in Adults with Cerebral Palsy: A Novel Therapy Approach

Giannasi LC1,2, Matsui MY1 , Nacif SR2, Grossmann E3, Amorim JBO, Oliveira LVF,2 Oliveira CS2, Gomes MF1

1Bioscience/State of São Paulo University “Julio de Mesquita Filho”- UNESP/SJC/São José dos Campos/Brazil, 2Rehabilitation Sciences Master Program/Nove de Julho University-UNINOVE/São Paulo/ Brazil, 3Anatomy Laboratory/Federal University of Rio Grande do SulUFRGS/RS/Brazil?

Introduction: Cerebral palsy (CP) is a term employed to define a group of non-progressive neuromotor disorders caused by damage to the immature or developing brain, with consequent limitations regarding movement and posture. CP may impair oral pharynx muscular tonus leading to a compromised mastication and to sleep disorders (e.g.: obstructive sleep apnea). The aim of the present study was evaluate the effects of NMES on the masticatory muscles and physiologic sleep variables in adults with CP using EMG and PSG. The hypothesis is the NMES will improve masticatory function and sleep variables.

Methods: 15 adults with CP underwent bilateral masseter and temporalis neuromuscular electrical stimulation (NMES) therapy and its effect over masticatory muscle and sleep variables were evaluated through electromyography (EMG) and polysomnography (PSG), respectively, prior and post 2 months of NMES therapy. EMG consisted of 3 tests in different position: rest, mouth opening and maximum clenching effort (MCE).

Results: The EMG values in the resting position were 100% higher prior to therapy for all muscles analyzed (P < 0.05); mean mouth opening rose from 38.0 ± 8.0 to 44.0 ± 10.0 cm (P = 0.03) and MCE was significantly only for right masseter, whereas other muscles exhibited improvements in comparison to baseline. PSG shown that AHI improved from 7.1/h to 1.7/h (P < 0.05), total sleep time improved from 185 min to 250 min (P = 0.04) and minimal SaO2 improved from 83.6 ± 3.0 to 86.4 ± 4.0 (P = 0.04).?

Conclusions: NMES performed over a two-month period led to an increase in the electrical activity of the masticatory muscles at rest, opening and during isometric contraction and improved sleep variables, including the elimination of sleep apneas events in CP patients.