Background Adherence to continuous positive airway pressure (CPAP) for obstructive sleep apnoea (OSA) continues to be low with high termination rates. Alternative therapies to CPAP are needed. Our objective was to compare objective adherence to CPAP and mandibular advancement splints (MAS) and to evaluate their effectiveness, and additionally to identify treatment usage patterns and the clinical effectiveness of having both therapies. Methods This multicentre, double-randomised, three-phase trial (titration/crossover/observation) was conducted at three Canadian universities. Eligible participants were treatment-na & iuml;ve with mild-to-severe OSA. The primary outcome was objectively measured adherence (hours per night) during the crossover phase. Secondary outcomes included efficacy during the crossover phase; adherence during the observational phase; and patient-centred outcomes, blood pressure and side-effects during the crossover and observational phases. Duration of the crossover and observational phase was 2.5 and 6 months, respectively. Results 81 participants were enrolled in the first randomisation. 79 entered the adaptation/titration phase (mean +/- SD age 52.3 +/- 10.8 years; 58 males), 73 entered the crossover phase (included in the intention-to-treat analysis) and 64 completed the observational phase. Mean objective adherence over 1 month: MAS showed higher adherence than CPAP, 6.0 versus 5.3 h night-1 (difference 0.7 (95% CI 0.3-1.2) h night-1; p<0.001). Mean CPAP-MAS difference in efficacy: 10.4 (95% CI 7.8-13.0) events h-1; p<0.001. During the observational phase 55% (35 out of 64) of participants chose to alternate therapies. All treatments led to substantial improvement in patient-centred outcomes. Conclusions Despite the higher efficacy of CPAP and higher adherence to MAS, both demonstrate comparable clinical effectiveness on patient-centred outcomes. Having both CPAP and MAS can improve long-term management of OSA.

BackgroundPrevious study showed that in individuals with obstructive sleep apnea (OSA), the contractions of masseter muscles after respiratory events can be nonspecific motor phenomena, dependent on the duration of respiratory arousals rather than the occurrence of the respiratory events. However, the role of intermittent hypoxia in the occurrence of jaw-closing muscle activities (JCMAs) was not taken into consideration. An exposure to intermittent hypoxia has been shown to initiate a series of activities, including muscular sympathetic activity in patients with OSA. ObjectiveTo determine the effects of mandibular advancement appliance (MAA) therapy on JCMA time-related to oxygen desaturation with and without arousal in individuals with OSA. MethodsEighteen individuals with OSA (age: 49.4 +/- 9.8 years, apnea-hypopnea index (AHI): 10.0|18.4|30.3, JCMA index: 1.7|4.3|5.6), participated in a randomised controlled crossover clinical trial, in which two ambulatory polysomnographic recordings were performed: one with MAA in situ and the other without MAA in situ. JCMAs were recorded bilaterally from both masseter and temporalis muscles. ResultsThere was no significant effect of the MAA on the overall JCMA index (Z = -1.372, p = .170). With the MAA in situ, JCMA index time-related to oxygen desaturation with arousal significantly decreased (Z = -2.657, p = .008), while there was no significant effect of the MAA on the JCMA index time-related to oxygen desaturation without arousal (Z = -0.680, p = .496). ConclusionEffective mandibular advancement appliance therapy significantly reduces jaw-closing muscle activities time-related to oxygen desaturation with arousal in individuals with OSA.

Sleep bruxism is characterized by rhythmic masticatory muscle activity (RMMA). This study aimed to determine the number and type of jaw muscles needed for a valid RMMA scoring in individuals with obstructive sleep apnea. Ten individuals with obstructive sleep apnea (4 males; age, 50.1 ± 8.1 years) were included in this study. RMMA was scored using 1 or more of the following jaw muscles’ electromyography (EMG) traces of polysomnography recordings: bilateral masseter and temporalis (4MT; the reference standard), unilateral masseter (1M), bilateral masseter (2M), unilateral temporalis (1T), bilateral temporalis (2T), unilateral chin EMG (1C), and bilateral chin EMG (2C). 1M, 2M, 1T, and 2T showed excellent agreement with 4MT (intraclass correlation coefficient = 0.751, 0.976, 0.815, and 0.950, respectively), while 1C and 2C presented fair agreement (intraclass correlation coefficient = 0.662 and 0.657). In addition, 2M and 2T displayed good sensitivity (87.8 https://clinicaltrials.gov/ct2/show/NCT02011425 ; Identifier: NCT02011425. Li D, Aarab G, Lobbezoo F, Arcache P, Lavigne GJ, Huynh N. Accuracy of sleep bruxism scoring based on electromyography traces of different jaw muscles in individuals with obstructive sleep apnea. J Clin Sleep Med. 2022;18(6):1609–1615.

To determine the effects of a mandibular advancement appliance (MAA) on sequences of jaw-closing muscle activity (JCMA) and apneic or hypopneic event (AHE) in individuals with obstructive sleep apnea (OSA). Individuals with OSA were included in a secondary analysis of a randomized controlled crossover trial, in which two ambulatory polysomnographic recordings were performed: one with MAA in situ and the other without MAA. A time span of 16 s between JCMA and AHE was applied to classify JCMAs into four sequences: (1) JCMA occurs before AHE (B-type); (2) both events occur simultaneously (S-type); (3) JCMA occurs after AHE (A-type); and (4) JCMA is time-unrelated to AHE (U-type). The effects of MAA on the distribution of these sequences were analyzed by Wilcoxon signed-rank test. Among 16 individuals (10 men, mean age 51.3 ± 8.5 years) baseline apnea–hypopnea index and JCMA index were 23.8 ± 16.0 events/h and 10.8 ± 10.3 events/h, respectively. In both conditions, i.e., without and with MAA, most JCMAs were U-type (48 www.clinicaltrials.gov (NCT02011425); December 13, 2013.

Rationale: Obstructive sleep apnea (OSA) is prevalent (~70%) in type 2 diabetes (T2DM). Mandibular advancement splints (MAS) have similar effectiveness as CPAP due to superior adherence. It is unknown if MAS improve glycemic control in T2DM. This pilot RCT tests the effect of MAS on glucose outcomes in T2DM. Methods: Participants with T2DM and on stable medications were recruited. A home sleep study was done to confirm the presence of OSA (AHI >10). Participants were randomized to MAS or placebo (sham oral appliance) and underwent continuous glucose monitoring, HbA1C, and sleep studies before and after a 3 month treatment period. A tracking chip in the dental device monitored adherence. Results: Fifty-one participants were screened for OSA, and 21 were included and randomized, of which 9 sham and 8 MAS participants completed the study. There were 70% men, of mean (±SD) age 64±10y and BMI 29±3kg/m. The mean AHI was 22.0±11. Groups were balanced with respect to age, sex, BMI and AHI. Between group differences in MAS vs. sham showed improvement of AHI [-9.6 (95% CI 0.9, -20.1)] and oxygen desaturation index [-8.8 (95% CI 0.7, -18.3)] in favor of MAS. Adherence (% days worn ≥4h/day) was 79±28% and 70±25% for MAS vs. sham (p=0.5). The average treatment effect for MAS vs. sham for HbA1C [0.2 (95%CI 0.8, -0.4)] and 24-hour glucose [0.4 (95% CI 1.5, -0.7)] was not statistically significant. Conclusion: MAS reduce OSA severity in T2DM patients with OSA. In this pilot study, no significant differences in glucose between groups was observed after treatment. Ongoing exploratory analyses will elucidate whether treatment responders have improved glucose control.

STUDY OBJECTIVES The main aim of this study was to investigate the effects of mandibular advancement appliance (MAA) therapy on jaw-closing muscle activity (JCMA) time-related to respiratory arousals, and on JCMA time-related to non-respiratory arousals in patients with obstructive sleep apnea (OSA). METHODS Eighteen patients with OSA (mean ± SD = 49.4 ± 9.8 years) with a mean ± SD apnea-hypopnea index (AHI) of 22.0 ± 16.0 events/hour of sleep participated in a randomized controlled crossover trial, in which two ambulatory polysomnographic recordings, one with an MAA in situ and another without the MAA in situ, were performed. JCMA was quantified as the sum of rhythmic masticatory muscle activities and other orofacial activities. RESULTS Significant reductions in the AHI (Z = -2.984; P = 0.003), in the respiratory arousal index (Z = - 2.896; P = 0.004), and in the JCMA time-related to respiratory arousal index (Z = -3.434; P = 0.001) were found with MAA in situ. On the non-respiratory arousal index, and on the JCMA time-related to non-respiratory arousal index, MAA had no significant effect (T = 2.23; P = 0.82; and Z = - 0.66; P = 0.51, respectively). CONCLUSIONS This study shows that effective mandibular advancement appliance therapy significantly reduces jaw-closing muscle activities time-related to respiratory arousals in OSA patients. Future studies are needed to confirm these findings in OSA patients with comorbid sleep bruxism. CLINICAL TRIAL REGISTRATION Registry: ClinicalTrials.gov, Identifier: NCT02011425.

Free AccessLetters to the EditorDental sleep medicine perspectives after COVID-19: interprofessional adaptation and directions Gilles Lavigne, DMD, PhD, Cibele Dal Fabbro, DDS, PhD, Alberto Herrero Babiloni, DDS, MSc, Nelly Huynh, PhD, Luc Gauthier, DMD, MSc, Patrick Arcache, DMD, Jean-Francois Masse, DMD, MSc Gilles Lavigne, DMD, PhD Centre Integre Sante et Services Sociaux du Nord Ile de Montreal (CIUSSS) and Centre Hospitalier de l'Universite de Montreal (CHUM), Montreal, Quebec, Canada Faculty of Dental Medicine, Universtié de Montreal, Montreal, Quebec, Canada , Cibele Dal Fabbro, DDS, PhD Centre Integre Sante et Services Sociaux du Nord Ile de Montreal (CIUSSS) and Centre Hospitalier de l'Universite de Montreal (CHUM), Montreal, Quebec, Canada , Alberto Herrero Babiloni, DDS, MSc Centre Integre Sante et Services Sociaux du Nord Ile de Montreal (CIUSSS) and Centre Hospitalier de l'Universite de Montreal (CHUM), Montreal, Quebec, Canada Faculty of Dental Medicine, Universtié de Montreal, Montreal, Quebec, Canada , Nelly Huynh, PhD Centre Integre Sante et Services Sociaux du Nord Ile de Montreal (CIUSSS) and Centre Hospitalier de l'Universite de Montreal (CHUM), Montreal, Quebec, Canada , Luc Gauthier, DMD, MSc Private practice, Chicoutimi, Quebec, Canada , Patrick Arcache, DMD Faculty of Dental Medicine, Universtié de Montreal, Montreal, Quebec, Canada Private practice, Chicoutimi, Quebec, Canada , Jean-Francois Masse, DMD, MSc Private practice, Chicoutimi, Quebec, Canada Faculty of Dental Medicine, Universtié Laval, Quebec City, Quebec, Canada Published Online:August 15, 2020https://doi.org/10.5664/jcsm.8546Cited by:2SectionsAbstractEpubPDF ShareShare onFacebookTwitterLinkedInRedditEmail ToolsAdd to favoritesDownload CitationsTrack Citations AboutABSTRACTCitation:Lavigne G, Dal Fabbro C, Herrero Babiloni A, et al. Dental sleep medicine perspectives after COVID-19: interprofessional adaptation and directions. J Clin Sleep Med. 2020;16(8):1421.INTRODUCTIONDental clinics are vulnerable to aerosol and splatter contamination when high-speed turbines and other devices spread droplets of saliva, respiration, and blood.1 For decades, we were trained to take special precautions: use gloves and masks, disinfect working surfaces, and sterilize all instruments. However, the droplets can remain suspended in the air long after procedures have been completed, and it is unclear how long viruses remain virulent. For instance, the time and surface survival rates for SARS CoV-2 are still under debate. Oral appliance treatments are normally low-risk procedures. However, with the advent of COVID-19, dental and sleep medicine professionals may have to review the required levels of protection for the sake and safety of patients, families, and staff.Patients and colleagues have raised some questions that need clarification in a post–COVID-19 era:Should we assess the risks for all "healthy" dental and sleep patients?Do mouth-breathing sleepers, patients with positive disease history, and "healthy" carriers pose risks for their sleep partner?Are patients with COVID-19 with positive disease history and "healthy" carriers at zero risk for transmitting the COVID-19 virus during upper airway and oral procedures? (We learned the hard way with human immunodeficiency virus and hepatitis.)What precautions are needed when treating patients with COVID-19 in sleep clinics and dental appliance clinics?What are the best standards for cleaning multiuser medical devices for home sleep recording?Because of the transmission risk, are greater precautions needed when cleaning oral sleep appliances (mandibular advancement appliance for snoring and sleep apnea; occlusal splint for sleep bruxism)?What are the best practices? Can we copy-and-paste the protocols for continuous positive airway pressure hardware sterilization? Continuous positive airway pressure has its own challenges.If the American Academy for Sleep Medicine develops a position on the issue, we hope they will add recommendations for oral devices. It is time to think about the postcrisis reality and to prepare for the next one, because viruses are recurrent.Finally, we hope that patients who become positive for COVID-19 will not develop other health complications, such as neurologic problems.2 In addition, given the unpredictable life trajectories of viruses, we remain concerned about recurrent herpes labialis when patients present concomitant atypical neuropathic pain and history of encephalitis.3,4It is time for all sleep management professionals to add the evidence-based knowledge of the virus-related risks to their practices and to reach a consensus with microbiology and public health experts on the best procedures.DISCLOSURE STATEMENTAll authors have seen and approved the manuscript. GJ Lavigne hold a Canada Research Chair in pain, sleep, and trauma. JF Masse is editor of Journal of Dental Sleep Medicine. All other authors report no conflicts of interest.REFERENCES1. Zemouri C, de Soet H, Crielaard W, Laheij A. A scoping review on bio-aerosols in healthcare and the dental environment. PLoS One. 2017;12(5):e0178007. https://doi.org/10.1371/journal.pone.0178007 CrossrefGoogle Scholar2. Mao L, Jin H, Wang M, et al.. Neurologic manifestations of hospitalized patients with coronavirus disease 2019 in Wuhan, China [published online ahead of print April 10, 2020]. JAMA Neurol., doi: 10.1001/jamaneurol.2020.1127. 10.1001/jamaneurol.2020.1127 Google Scholar3. Kallio-Laine K, Seppanen M, Lokki ML, et al.. Widespread unilateral pain associated with herpes simplex virus infections. J Pain. 2008;9(7):658–665. CrossrefGoogle Scholar4. Tyler KL. Acute viral encephalitis. N Engl J Med. 2018;379(6):557–566. https://doi.org/10.1056/NEJMra1708714 CrossrefGoogle Scholar Previous article Next article FiguresReferencesRelatedDetailsCited by Huang Y, Chen D, Fietze I and Penzel T Obstructive Sleep Apnea with COVID-19 Advances in the Diagnosis and Treatment of Sleep Apnea, 10.1007/978-3-031-06413-5_17, (281-293), . A systematic review of COVID-19 and obstructive sleep apnoeaMiller M and Cappuccio F Sleep Medicine Reviews, 10.1016/j.smrv.2020.101382, , (101382), Online publication date: 1-Sep-2020. Volume 16 • Issue 8 • August 15, 2020ISSN (print): 1550-9389ISSN (online): 1550-9397Frequency: Monthly Metrics History Submitted for publicationApril 22, 2020Submitted in final revised formApril 25, 2020Accepted for publicationApril 28, 2020Published onlineAugust 15, 2020 Information© 2020 American Academy of Sleep MedicinePDF download

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.