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Orofacial motor functions in pediatric obstructive sleep apnea and implications for myofunctional therapy

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... The data most relevant to clinical assessment of suspected childhood OSAHS come from level 1 studies [1][2][3][4][5][6][7]. ...
... Meta-analyses showed that lateral nasopharyngeal radiographs are not to be recommended in this indication [23] (Level of evidence, 1). The degree of adenoid hypertrophy can be semi-quantified on Table 1 Diurnal and nocturnal signs of OSAHS [1][2][3][4][5][6][7]. ...
... Sleeping seated or in cervical hyperextension Frequent snoring (> 3 nights per week) for at least 3 months Cyanosis Night-sweats Agitation Frequent awakening Parasomnia: somniloquy, bruxism, somnambulism, night terror, confusional arousal, nightmares [4,5] Apnea with noisy resumption of in-breath a Enuresis (especially secondary, after ≥ 6 months' continence) Napping after 7 years of age Headache, fatigue, wrinkles on awakening Somnolence (rarer than in adults) Attention disorder, hyperactivity, learning difficulties, memory disorder, difficulties at school Slow mastication/swallowing disorder [6,7] Open-mouth breathing Secondary statural and ponderal growth impairment a Reported or preferably recorded or videoed by parents (e.g., smartphone). • high Mallampati score (GRADE C). ...
Article
Objectives: To present the 2017 Clinical Practice Guidelines of the French Society of Otorhinolaryngology concerning the role of the ENT specialist in the diagnosis of pediatric obstructive sleep apnea-hypopnea syndrome. This article focuses specifically on medical history and physical examination. Methods: A multidisciplinary work-group drew up a first version of the guidelines, graded according to level of evidence following the GRADE grading system. The final version was obtained by including the suggestions and comments from the editorial group. Results: At the end of the process, guidelines were established and graded regarding the following points: interview and analysis of the various interview scores recommended in the literature; clinical examination with awake upper-airway endoscopy; and indications for referral to non-ENT specialists.
... One of the ultimate goals of OMT is to allow the tongue to retain the gains from the rapid palatal expansion procedure discussed earlier. Myofunctional therapy can also reduce the volume and fat in the pharyngeal structure and muscles, thus decreasing upper airway collapsibility [88]. Additionally, weight loss has been found to improve OSA through the reduction of adipose tissue in the upper airway-tongue fat-and abdominal fat, as mentioned previously. ...
... Myofunctional therapy has been explored as a nonsurgical approach to managing OSA. In a study of 54 children with OSA, myofunctional therapy led to improvements in mean oxygen saturation and the desaturation index in the treatment group [88]. One meta-analysis study showed a decrease in AHI by 50% in adults and 62% in children. ...
... An additional benefit of myofunctional therapy is demonstrated in a study of adults, reporting compliance to CPAP in combination with myofunctional therapy (65%) versus CPAP alone (30%). Thus, myofunctional therapy may provide benefits in promoting quality of life and adherence to CPAP in patients with OSA [88]. ...
Article
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Obstructive sleep apnea (OSA) is a clinical disorder within the spectrum of sleep-related breathing disorders (SRDB) which is used to describe abnormal breathing during sleep resulting in gas exchange abnormalities and/or sleep disruption. OSA is a highly prevalent disorder with associated sequelae across multiple physical domains, overlapping with other chronic diseases, affecting development in children as well as increased health care utilization. More precise and personalized approaches are required to treat the complex constellation of symptoms with its associated comorbidities since not all children are cured by surgery (removal of the adenoids and tonsils). Given that dentists manage the teeth throughout the lifespan and have an important understanding of the anatomy and physiology involved with the airway from a dental perspective, it seems reasonable that better understanding and management from their field will give the opportunity to provide better integrated and optimized outcomes for children affected by OSA. With the emergence of therapies such as mandibular advancement devices and maxillary expansion, etc., dentists can be involved in providing care for OSA along with sleep medicine doctors. Furthermore, the evolving role of myofunctional therapy may also be indicated as adjunctive therapy in the management of children with OSA. The objective of this article is to discuss the important role of dentists and the collaborative approach between dentists, allied dental professionals such as myofunctional therapists, and sleep medicine specialists for identifying and managing children with OSA. Prevention and anticipatory guidance will also be addressed.
... Breathing mode was assessed using the Orofacial Myofunctional Evaluation with Scores-expanded (OMES-e) protocol, classifying the function as nasal or oronasal. The examiner attributed scores on a 4-point scale (the lower the score achieved, the more altered the function): 4 = when the lips remained in occlusion without effort, mainly during situations of rest and mastication, with the tongue contained in the oral cavity (normal pattern); 3 = mild alteration, when the subject presented oronasal inspiration but was able to perform inspiration only through the nose without showing signs of fatigue and dyspnea, 2 = moderate alteration when the condition was similar to the previous one but the subject did not maintain a nasal pattern, and 1 = severe alteration when the subject, while trying to perform nasal only inspiration, showed signs of fatigue and dyspnea and opened his mouth to inspire within a few seconds, a pattern observed both at rest and during the mastication of a cookie (22,23). During the interview with the parents, the breathing mode was also verified. ...
... Ours results showed that children with pacifier sucking habit scored less in breathing evaluation and showed more oronasal breathing aspects before the intervention for the cessation of pacifier use. In oronasal breathing mode, lips are not sealed, the jaw is opened by the suprahyoid muscles and this displacement is followed by tongue (23). Similarly, a previous study observed that persistent non-nutritive sucking affected the prevalence of malocclusion and nasal breathing (38). ...
Article
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It is well recognized that pacifier habit leads to occlusal and orofacial functional changes in children. However, the effects of the interruption of prolonged pacifier habit on the development of the dento-facial complex has not yet been fully characterized. Thus, the aim of this study was to investigate the influence of pacifier removal on aspects of oro-dentofacial morphology and function in preschool children. For that, a pacifier group ( n = 28) and a control group ( n = 32) of 4-year-old children with and without pacifier habit, respectively, were followed up by a group of dentists and speech therapists at baseline, 6 and 12 months after habit removal. Bite force and lip pressure were assessed using digital systems, and the evaluation of breathing and speech functions was performed using validated protocols, together with the measurements of dental casts and facial anthropometry. The Two-way mixed model ANOVA was used in data analysis. After 12 months, a decrease in malocclusion frequency was observed in pacifier group. Additionally, a change over time was observed in facial, intermolar and palate depth measurements, as well in bite and lip forces and speech function scores, increasing in both groups ( p < 0.01). The upper and lower intercanine widths and breathing scores differed between groups at baseline and changed over time reducing the differences. The presence of speech distortions was more frequent in the pacifier group at baseline and decreased over time ( p < 0.05). The interruption of pacifier habit improved the maxillary and mandibular intercanine widths, as well as the breathing and speech functions, overcoming the oro-dentofacial changes found. Trial Registration: This clinical trial was registered in the Brazilian Clinical Trials Registry (ReBEC; http://www.ensaiosclinicos.gov.br/ ), protocol no. RBR-728MJ2.
... The OMES is a validated protocol for the clinical evaluation that allows the examiner to express numerically, on a graduated scale, the clinical judgement on oro-facial structures and functions. This protocol allows to differentiate subjects with and without orofacial myofunctional disorders, guiding treatment planning and providing outcome measures [5,8,19,20]. ...
... To analyze the changes on oro-facial structures and functions, the Italian version of the OMES protocol was used in order to provide a semi-quantitative measure of the qualitative clinical judgement. The validity of the OMES had already been tested for clinical applications but in a different population than the one targeted in the present study [19]. In our sample, the MFT showed a significant effect on the oro-facial structures and function as measured by the OMES "Appearance and posture", "Mobility", and "Functions" subscales. ...
Article
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Purpose: The myofunctional treatment (MFT) is a conventional therapy in the treatment of oral disease like atypical swallowing (AS). Functional (standardized surface electromyographic analysis-ssEMG) and clinical ("orofacial muscular evaluation with score" protocol-OMES) analyses were conducted to detect the effects of MFT (10 weeks session) in a group of patients with AS. Methods: ssEMG was performed to analyze the activity of masseter (MM), temporalis (TA), and submental (SM) muscles before (T1) and after (T2) the MFT in a group of 15 patients. OMES was completed at the same timepoints. A Student-t test was carried out to detect differences between T1 and T2 for ssEMG data, and a signed RANK test was used for OMES ones. One-way ANOVA variance test was performed to detect any differences between the different couples of muscles at each timepoint. Results: After MFT, patients showed a shorter duration of the whole act of swallowing (p < .0001), higher intensity of the SM activity (p < .01) than at T1. At T2 masticatory muscles showed lower values for the activation index (ANOVA, p < .0001) and for the spike position (ANOVA, p < .01) than SM. The OMES protocol showed a significant increase for the total evaluation score (p < .01), appearance-posture (p < .01) and functions (p < .001). Conclusions: MFT permits a shortening of the muscular activation pattern and an increase in SM activity. The improvement of oral functionalities is possible and identifiable thanks to the use of standardized protocols.
... This echoes with our postulation that oral breathing may be one of the mediators of OSA development in our cohort as more turbinate and tonsillar enlargement was observed in the group with short frenulum and decreased tongue mobility [36]. On the other hand, a study reported no difference in tongue strength between OSA and PS groups but none of their subjects had abnormal lingual frenulum and the PS group only consisted of subjects without adenotonsillar hypertrophy [37]. The different subject definitions might account for the discrepancy. ...
Conference Paper
Background Childhood obstructive sleep apnoea (OSA) is a prevalent disease, and reported to affect around 5% of primary school-aged children. It is also clinically important as it can lead to neurocognitive, metabolic and cardiovascular complications. The tongue plays an important role in maintaining patency of the oropharynx. Lingual frenulum, a connective tissue between the floor of the mouth and the underside of the tongue, can affect the tongue position, its elevation and movements. Short lingual frenulum has been reported to be a risk factor for OSA. How frenulum length and its mobility affects craniofacial development and morphology remains to be defined. Objectives In this study we aimed to prospectively evaluate the lingual frenulum length by free tongue measurement and tongue mobility in children suspected to have OSA. We hypothesized that OSA children would have shorter lingual frenulum than their non-OSA counterparts. Moreover, we explored the relationship between frenulum length and craniofacial profile using cephalometry. We hypothesized that cephalometric measurements would be different in children with and without short frenulum. Methods Prepubertal Chinese children aged 5–12 years old, suspected to have OSA were recruited. Anthropometric measurements including weight, height, and circumferences of waist, hip and neck were taken on the day of admission. The lingual frenulum was evaluated based on tongue mobility and free tongue length. Tongue mobility obtained by a digital calliper was defined by Mpal/Mmax, which are the maximal distances between incisors during full mouth opening (Mmax) and when the tongue tip touched the palatal papilla (Mpal). The free tongue length was measured from the insertion of the lingual frenulum to the tongue tip using Quick Tongue-tie Assessment Tool (QTT). Normal tongue mobility was defined as mobility ≥50%, and normal free tongue length was defined as ≥16 mm. Cephalometric analysis was performed to evaluate the craniofacial profile. OSA was defined as obstructive apnoea hypopnoea index (OAHI) ≥1/h from overnight polysomnography. Results In this study, 86 subjects (mean age: 8.36 ± 1.69 years) were recruited, and 50 were diagnosed to have OSA (OAHI≥1/h). There was no significant difference in anthropometric measurements between OSA and non-OSA groups. The medians of the free tongue length in OSA and non-OSA groups were 20 and 24 mm (p=0.321), respectively. The mean tongue mobility was 0.583 (± 0.189) in OSA group, and 0.680 (± 0.152) in non-OSA group (p=0.010). Free tongue length was significantly correlated with most of the anthropometric variables including age, weight, height, BMI, waist, and hip circumferences, but did not correlate with any of the PSG variables. Tongue mobility was not correlated with any anthropometric variables, but inversely correlated with OAHI (r=-0.234, p=0.030). In multivariate logistic regression, tongue mobility was independently associated with the presence of OSA after adjusted for age and gender. Tongue mobility was correlated with the cranial base angle (Ba-S-N), which can affect the relative position of the mandible. Conclusions Reduced tongue mobility is associated with OSA in prepubertal children. Furthermore, tongue mobility may be an important factor in driving mandibular development.
... Moreover, objective measures of muscular strength/force, such as validated protocol and IOPI [19••, 20, 29], and electromyography [20], can contribute to the oropharyngeal muscle disorder diagnosis and following the assessment of the results of the treatment. ...
Article
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Purpose of Review We reviewed and discussed studies on the role of oropharyngeal exercises in the treatment of children with obstructive sleep-disordered breathing (SDB). Recent Findings There has been increasing recent evidence on the role of oropharyngeal exercises in the stepwise therapeutic approach in children with SDB. An oropharyngeal evaluation, targeted to explore the presence of orofacial muscle hypotonia, should be part in the assessment of children with SDB, in order to recognize potential oropharyngeal characteristics to be treated. Summary Current literature demonstrates that oropharyngeal exercises help to treat oropharyngeal muscle dysfunction that persists following the standard treatment of SDB, and improve symptoms and polysomnographic sleep variables SDB related in pediatric population. New studies to compare different oropharyngeal exercise programs and to evaluate the long-term effects of this therapeutic approach could contribute to the indication of oropharyngeal exercises for the treatment of obstructive SDB in children.
... Lower limit and upper limit are used to represent 95% confidence interval of difference in mean. The Z value is a significance test for the weighted average effect size, and significant level of intervention is defined as p < 0.05 Fig. 3 Lowest oxygen saturation: significant improvement in means between pre-and postoropharyngeal rehabilitation for OSA patients with different severities Sleep Breath respiration, mastication, deglutition, and phonation [68,69]. ...
Article
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Objectives: Obstructive sleep apnea (OSA) is a sleep-related breathing disorder associated with dysfunction of oropharyngeal muscles to maintain upper airway patency during sleep. Oropharyngeal rehabilitation (OPR) was developed to restore, reconstruct, and reeducate oropharyngeal muscle function, but current protocols and effectiveness of OPR have been inconsistent. The purpose of this study was to review (1) indications of OPR, (2) protocols of OPR, and (3) effectiveness of OPR. Methods: We searched MEDLINE, EMBASE, and the Cochrane Library and then conducted both meta-synthesis and meta-analysis according to the statement of Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). Results: A total of eight studies with 203 patients were included. By means of meta-synthesis, the patients with middle age, BMI < 40 kg/m2, mild-to-moderate OSA, and non-severe upper airway anatomical abnormality were found to benefit from OPR. The protocol of OPR was summarized to be an anatomically based, multilevel approach, including the retropalatal, retroglossal, hypopharyngeal, TMJ, and facial levels. By using meta-analysis, overall outcomes were presented as apnea hypopnea index (AHI) with significant improvement from 25.2 ± 7.8/h to 16.1 ± 6.6/h (mean difference [MD] - 9.8 [95% CI - 11.0 to - 8.6], p < 0.0001); the lowest oxygen saturation (LSAT) improved from 80.2 ± 4.7 to 83.8 ± 2.9% (MD 3.0% [95% CI 2.0 to 4.0], p < 0.0001); Epworth sleepiness scale (ESS) improved from 11.8 ± 1.9 to 6.3 ± 1.6 (MD - 5.9 [95% CI - 7.5 to - 4.2], p < 0.001), neck circumference (NC) from 35.2 ± 1.1 to 34.7 ± 0.9 cm (MD - 0.6 [95% CI - 0.9 to - 0.2], p = 0.002), BMI from 24.8 ± 3.7 to 24.8 ± 4.1 kg/m2 (MD - 0.0; 95% CI - 0.5 to 0.5, p = 0.95). All outcomes except BMI demonstrated significant improvement from OPR. Conclusions: Meta-analysis of previous OPR reports shows an improvement in AHI of 39%, compared with the usual surgical definition of success at 50%. Only mild and moderate cases of OSA were referred for OPR in the prior studies. In order to improve outcomes with OPR, a comprehensive approach to rehabilitation should be emphasized.
... Recently, orofacial myofunctional therapy (OMT) has been suggested as an adjunct treatment of OSA in children [67]. OMT is aimed at targeting abnormal breathing patterns and muscular dysfunction that can impact upper airway patency [68]. It also aims to enhance the tongue position and strength [65]. ...
Article
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Obstructive Sleep Apnea (OSA) is a form of sleep-disordered breathing characterized by upper airway collapse during sleep resulting in recurring arousals and desaturations. However, many aspects of this syndrome in children remain unclear. Understanding underlying pathogenic mechanisms of OSA is critical for the development of therapeutic strategies. In this article, we review current concepts surrounding the mechanism, pathogenesis, and predisposing factors of pediatric OSA. Specifically, we discuss the biomechanical properties of the upper airway that contribute to its primary role in OSA pathogenesis and examine the anatomical and neuromuscular factors that predispose to upper airway narrowing and collapsibility.
... This echoes with our postulation that oral breathing may be one of the mediators of OSA development in our cohort as more turbinate and tonsillar enlargement was observed in the group with short frenulum and decreased tongue mobility [36]. On the other hand, a study reported no difference in tongue strength between OSA and PS groups but none of their subjects had abnormal lingual frenulum and the PS group only consisted of subjects without adenotonsillar hypertrophy [37]. The different subject definitions might account for the discrepancy. ...
Article
Study Objectives Childhood obstructive sleep apnoea (OSA) is an important and prevalent disease. A short lingual frenulum is a risk factor for OSA, but whether tongue mobility also plays a role in OSA aetiology remains unknown. This study aimed to examine tongue mobility in children with and without OSA. We hypothesized that reduced tongue mobility was associated with OSA. We also evaluated the relationship between tongue mobility and craniofacial profile. Methods This was a cross-sectional case-control study. Prepubertal Chinese children aged 5-12 years, suspected to have OSA were recruited from our sleep disorder clinic. All subjects underwent overnight polysomnography (PSG). The lingual frenulum was evaluated based on tongue mobility and free tongue length. Craniofacial measurements were assessed by lateral cephalometry. Results Eighty-two subjects (mean age: 8.32 ± 1.70 years, 57 males) were recruited. The mean tongue mobility was 58.2 (±19)% and 67.4 (±15)% (p=0.019) in subjects with and without OSA, respectively. Tongue mobility was inversely correlated with OAHI (r=-0.218, p=0.049). In multivariate logistic regression, low tongue mobility was independently associated with a higher risk of OSA after adjustment for age, sex, BMI z-score, presence of large tonsils and turbinates and nocturnal oral breathing (odds ratio=3.65, 95% CI= 1.22-11.8). Tongue mobility was found to correlate with the cranial base angle (Ba-S-N) (r=0.262, p=0.018), which determines the relative position of the mandible. Conclusions In pre-pubertal children, reduced tongue mobility is associated with the occurrence and severity of OSA. Assessing tongue mobility is recommended in childhood OSA management.
... Another argument that endorse the strategy to focus on the tongue is the presence of lower lingual tone in children and adults with sleep-disordered breathing compared to healthy controls. [24][25][26] Interestingly, recent studies have shown that the improvement of AHI with MFT correlates significantly with the improvement of tongue strength. 14,27,28 Therefore, we aimed to assess the specific effectiveness of a tongue elevation muscle protocol in reducing OSA severity. ...
Article
Background: Oropharyngeal myofunctional therapy is a multi-component therapy effective to reduce the severity of obstructive sleep apnea (OSA). However, existing protocols are difficult to replicate in the clinical setting. There is a need to isolate the specific effectiveness of each component of the therapy. Objective: To assess the effects of a 6-week tongue elevation training program in patients with OSA. Methods: We conducted a multicenter randomized controlled trial. Eligible participants were adults diagnosed with moderate OSA who presented low adherence to continuous positive airway pressure therapy (mean use < 4h per night). The intervention group completed a 6-week tongue elevation training protocol that consisted in anterior tongue elevation strength and endurance tasks with the Iowa Oral Performance Instrument. The control group completed a 6-week sham training protocol that involved expiratory muscle training at very low intensity. Polygraphy data, tongue force and endurance, and OSA symptoms were evaluated pre- and post-intervention. The primary outcome was apnea-hypopnea index (AHI). Results: Twenty-seven patients (55 ± 11 years) were recruited. According to modified intention-to-treat analysis (n=25), changes in AHI and other polygraphy-derived parameters did not significantly differ between groups. Daytime sleepiness (Epworth Sleepiness Scale) and tongue endurance significantly improved in the intervention group compared to the control group (p=0.015 and 0.022 respectively). In the intervention group, 75% of participants had a decrease in daytime sleepiness that exceeded the minimal clinically important difference. Conclusion: Six weeks of tongue elevation muscle training had no effect on OSA severity.
... Generally speaking, tongue exercises consist of moving the tongue in different directions with or without sticking the tongue out, sucking the tongue against the palate, pressing the tongue against bony and soft tissue structures within the oral cavity, and doing other tongue movements with or without resistance [60]. ...
Article
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Obstructive sleep apnea (OSA) is a common but still underrecognized disorder. A mandibular repositioning appliance (MRA) is used to treat OSA by advancing the mandible and thereby reducing the collapsibility of the upper airway. It has been found that an MRA increases the volume of the upper airway, especially the velopharyngeal area, in OSA patients. We hypothesize that this increase in the velopharyngeal volume is associated with an anterior displacement of the tongue, but likely not with a stretching of the soft tissue connecting the soft palate, lateral pharynx, palatopharyngeal arch, and mandible. Since the function and structure of the genioglossus and hypoglossal nerve are always abnormal in patients with OSA, the tongue does not always move simultaneously with the mandible when an MRA is being used. Oropharyngeal exercises, especially tongue exercises, can improve the quality of life of OSA patients, including reduction of daytime sleepiness and snoring, better quality of sleep, and partial decrease in the AHI. Further, in animal models, tongue exercise is also found to be effective in tongue function recovery and in the remodeling of the hypoglossal nucleus. We suggest that a combination of tongue exercises along with MRA is a promising approach for patients who do not respond to an MRA alone.
... Initial data on a small number of children with repaired unilateral cleft lip and palate showed no marked differences in MIP A when compared to a small group of controls [77]; data on MIP P or in children with bilateral cleft lip and palate are not yet available. Obstructive sleep apnea is the most severe clinical type of sleep-disordered breathing and can be caused by oral breathing, leading to a secondary malposition of the tongue, finally influencing the tongue strength [78,79]. Knowledge of normative data may allow tongue MIP measurements and training to be stratified and randomized for intervention studies, both in children [78,80] and adults [81] with obstructive sleep apnea. ...
Article
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Tongue strength and its role in the pathophysiology of dysphagia in adults are well accepted and studied. An objective and reliable measurement of tongue strength in children necessitates equally good methodology, knowledge of influencing factors, and normative data. Only limited data on testing tongue strength in children are available thereby limiting its potential use. The present study examined tongue strength and several parameters known to be important in adults in the largest sample of healthy children from 3 to 11 years old to date using the Iowa Oral Performance Instrument with standard bulbs. Tongue strength increases markedly for children between 6 and 7 years, with slower increases before and after this age. Unlike adults, no influence of sex or location was found on the maximum tongue strength in children, and visual feedback was found to be counterproductive in obtaining the highest tongue pressures. The normative data obtained can be used for objective assessment of tongue weakness and subsequent therapy planning in dysphagic children.
... even without normalization of the OAHI. However, the long-term outcomes, in terms of symptom relapse and OAHI among operated patients, are more related to the genetic pattern of craniofacial growth and neuromuscular factors than to upper airway obstruction [15][16][17]. The normality criterion adopted in the present study possibly also contributed to this result. ...
Background: Obstructive sleep apnea syndrome in childhood has aroused great interest due to its cardiovascular repercussions and its adverse effects on the quality of life of the affected individuals. However, fundamental aspects of the syndrome remain unknown. Objective: Herein we prospectively assessed pulmonary artery systolic pressure (PASP) and nasal flow in children with obstructive oral breathing with an indication for adenoidectomy and/or tonsillectomy and their relationship to the obstructive apnea and hypopnea index (OAHI). Methods: Twenty-one children were evaluated at the time of the surgical indication (T0) and 18 months later (T1). Polysomnography, and rhinomanometry data were collected when we evaluated PASP. Results: Among the 21 children, 13 (61.9%) presented an altered OAHI at T0. Fourteen children (66.7%) underwent surgery. Of these, nine (64.3%) had an altered OAHI at T0 and seven (50.0%) at T1. Of the seven non-operated children, four (57.1%) had an altered OAHI at T0 and two (33.3%) at T1. Mean nasal flow increased in both groups independently of surgery (p- ≤ 0.001). PASP exhibited a significant reduction between T0 and T1 in the operated group (p ≤ 0.001). OAHI of the operated group did not show a significant decrease over time (p = 0.074). In the non-operated children, the average nasal flow increased (p < 0.001), the PASP values did not reduce (p = 0.99), and the OAHI increased and then decreased over time (p = 0.025). Conclusion: PASP decreased significantly and OAHI did not normalize in the operated group. Mean nasal airflow increased in the operated and non-operated groups.
Chapter
The study of craniofacial growth and development has a long history in the disciplines of Paediatric Dentistry and Orthodontics. Unbalanced facial growth is known to be causative for dental misalignment and malocclusion. However, historically, little emphasis has been placed on the possible link to obstructive sleep apnoea. Through greater understanding from contemporary studies and reflections from past research, we now are bringing to light the interrelationships of all proximal structures in the many chronic issues that ail our children.
Article
Unresolved obstructive sleep apnoea (OSA) after an adenotonsillectomy, henceforth referred to as persistent OSA, is increasingly recognised in children (2–18 years). Although associated with obesity, underlying medical complexity, and craniofacial disorders, persistent OSA also occurs in otherwise healthy children. Inadequate treatment of persistent OSA can lead to long-term adverse health outcomes beyond childhood. Positive airway pressure, used as a one-size-fits-all primary management strategy for persistent childhood OSA, is highly efficacious but has unacceptably low adherence rates. A pressing need exists for a broader, more effective management approach for persistent OSA in children. In this Personal View, we discuss the use and the need for evaluation of current and novel therapeutics, the role of shared decision-making models that consider patient preferences, and the importance of considering the social determinants of health in research and clinical practice. A multipronged, comprehensive approach to persistent OSA might achieve better clinical outcomes in childhood and promote health equity for all children.
Article
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ABSTRACT Introduction: Previous diagnosis and intervention in patients with sleep-disordered breathing involves several health professionals. Speech-Language and Hearing Sciences (SLHS) performance has been solidified through scientific production. Objective: To describe the inclusion of Brazilian Speech-Language Pathologists (SLP) in the field of sleep disorders, through the description of studies, scientific publications and participation in scientific events. Data Synthesis: A search and an analysis of the Brazilian SLP publications in the field of sleep disorders were carried out, including articles, monographs, dissertations, thesis and abstracts published in annals of events. The databases Lilacs, SciELO, Pubmed, Google Scholar tool and Lattes platform were accessed, with final search in January 2018. The analysis consisted of a description of the year of publication, type of publication, area of the SLHS, place of publication and/or event. 40 articles were found in national and international journals, from 1999 to 2017. In relation to publications in books, one book about the subject was published in 2009 and eight chapters of books were published. In the monograph format, 21 studies were carried out, there are 13 dissertations and eight thesis. A total of 151 abstracts were published in annals of scientific events, from 2001 to 2017 and 63 lectures were conducted by SLP. Conclusion: The inclusion of Brazilian SLP in the area of sleep disorders has been supported by scientific publications in the format of articles in national and international journals, monographs, thesis, dissertations, books and publications in event annals. Keywords: Speech; Language; Hearing; Sleep Disorders, Intrinsic; Sleep Apnea, Obstructive.
Article
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Purpose Orofacial myofunctional therapy (OMT) is a modality of treatment for children and adults with obstructive sleep apnea (OSA) to promote changes in the musculature of the upper airways. This review summarizes and discusses the effects of OMT on OSA, the therapeutic programs employed, and their possible mechanisms of action. Methods We conducted an online literature search using the databases MEDLINE/PubMed, EMBASE, and Web of Science. Search terms were “obstructive sleep apnea” in combination with “myofunctional therapy” OR “oropharyngeal exercises” OR “speech therapy”. We considered original articles in English and Portuguese containing a diagnosis of OSA based on polysomnography (PSG). The primary outcomes of interest for this review were objective measurement derived from PSG and subjective sleep symptoms. The secondary outcome was the evaluation of orofacial myofunctional status. Results Eleven studies were included in this review. The studies reviewed reveal that several benefits of OMT were demonstrated in adults, which include significant decrease of apnea–hypopnea index (AHI), reduced arousal index, improvement in subjective symptoms of daytime sleepiness, sleep quality, and life quality. In children with residual apnea, OMT promoted a decrease of AHI, increase in oxygen saturation, and improvement of orofacial myofunctional status. Few of the studies reviewed reported the effects of OMT on the musculature. Conclusion The present review showed that OMT is effective for the treatment of adults in reducing the severity of OSA and snoring, and improving the quality of life. OMT is also successful for the treatment of children with residual apnea. In addition, OMT favors the adherence to continuous positive airway pressure. However, randomized and high-quality studies are still rare, and the effects of treatment should also be analyzed on a long-term basis, including measures showing if changes occurred in the musculature.
Article
Background The tongue plays an important role in oral functions. Reduced tongue strength is often noted among children with mouth‐breathing behavior. Objectives The purposes of this study were to measure the tongue pressure in children with mouth‐breathing behavior, to compare these values to those of children with nasal‐breathing behavior, and to analyze the relationship between age and tongue pressure in children with a mouth‐breathing pattern and in children with a nasal‐breathing pattern. Methods In this cross‐sectional analytical observational study, we enrolled 40 children aged 5–12 years who either exhibited mouth‐breathing behavior (n=20) or nasal‐breathing behavior (gender‐ and age‐matched [±2 years] controls; n=20). Tongue pressure was evaluated using the Iowa Oral Performance Instrument; three measurements were recorded for each participant, with a 30‐s rest interval. Results The average tongue pressure in the mouth‐breathing group was lower than that in the nasal‐breathing group. There was no difference in tongue pressure between genders. There was a strong and direct correlation between tongue pressure and age in the nasal‐breathing group. Conclusion The breathing pattern impacts tongue pressure development. This article is protected by copyright. All rights reserved.
Article
Introduction: Obstructive sleep apnea in children has a prevalence of 5%. Polysomnography is considered to be the gold standard for diagnosis and stratification of the condition. However, it is resource-intensive, expensive and uncomfortable for children and their families. Areas covered: We focus this review on technical developments in sensor technology, materials and predictive analytics for translation to (i) patient comfort and compliance in the laboratory and (ii) validation of home sleep apnea testing in children. Key developments in adult polysomnography that could be considered for adoption in children are also highlighted. This review is organized by Sleep, Cardiovascular, Oximetry, Position, Effort, and Respiratory (SCOPER) parameters of interest. Expert commentary: In the past decade, improvements in respiratory sensors and signal processing strategies have transitioned sleep apnea testing in adults from the laboratory to home, thus reducing costs and improving access. Unfortunately, such benefits have not been observed for children principally due to the lack of high-quality studies. The increasing cost of diagnosis of sleep apnea in children needs urgent attention. Recent technical developments as described in this review have potential to support further evaluation of home sleep apnea testing while improving the current circumstances of in-lab polysomnography for children.
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ABSTRACT – The contribution of orofacial myofunctional reeducation to the treatment of obstructive sleep apnoea syndrome (OSA): a systematic review of the literature. Introduction: Obstructive sleep apnoea syndrome (OSA) is a widespread and under-diagnosed condition, making it a major public health and safety problem. Orofacial myofunctional reeducation (OMR) has been shown to be effective in the multidisciplinary treatment of OSA in children, adolescents and adults and is prescribed at several stages of OSA management. Objectives: The main objective of this systematic literature review was to evaluate the effectiveness of active or passive orofacial myofunctional reeducation (OMR) in the treatment of obstructive sleep apnoea syndrome in children, adolescents and adults. Methods: The systematic literature review was undertaken from the three electronic databases: Medline (via PubMed), Cochrane Library, Web of Science Core Collection, and supplemented by a limited grey literature search (Google Scholar) in order to identify the studies evaluating the effectiveness of the OMR on OSA. The primary outcome of interest was a decrease in the Apnea–Hypopnea Index (AHI) of at least five episodes per hour compared to the baseline state. Secondary outcomes were an improvement in subjective sleep quality, sleep quality measured by night polysomnography and subjectively measured quality of life. Results: Only ten studies met all the inclusion criteria. Eight were randomized controlled clinical trials, one was a prospective cohort study and another was a retrospective cohort study. Six studies were devoted to adult OSA and four to pediatric OSA. All included studies were assessed as “low risk of bias” based on the 12 bias risk criteria of the Cochrane Back Review Group. Based on the available evidence, RMO allows a significant reduction in AHI, up to 90.6% in children and up to 92.06% in adults. It significantly reduces the intensity and frequency of snoring, helps reduce daytime sleepiness, limits the recurrence of OSA symptoms after adenoamygdalectomy in children and improves adherence to PPC therapy. Passive RMO, with the assistance provided to the patient by wearing a custom orthosis, increases adherence to reeducation, significantly improves snoring intensity, AHI and significantly increases the upper airway. Conclusions: Published data show that orofacial myofunctional rééducation is effective in the multidisciplinary treatment of OSA in children, adolescents and adults and should be widely prescribed at several stages of OSA management. Passive RMO, with the pearl mandibular advancement orthosis designed by Michèle Hervy-Auboiron, helps to compensate for the frequent non-compliance observed during active RMO treatments. KEYWORDS: Sleep Disordered Breathing / Obstructive sleep apnea syndrome / Orthodontics / Orofacial myofunctional rééducation / Prefabricated Functional Appliances RÉSUMÉ – Introduction : Le syndrome d’apnées obstructives du sommeil (SAOS) est une affection très répandue et insuffisamment diagnostiquée, ce qui en fait un problème majeur de santé publique et de sécurité. La rééducation myofonctionnelle orofaciale (RMO) a été montrée efficace dans le traitement multidisciplinaire des SAOS de l’enfant, de l’adolescent et de l’adulte et elle est prescrite à plusieurs étapes de ces prises en charge. Objectifs : L’objectif principal de cette revue systématique de la littérature était d’évaluer l’efficacité de la rééducation myofonctionnelle orofaciale (RMO), active ou passive, dans le traitement du syndrome d’apnées obstructives du sommeil chez les enfants, les adolescents et les adultes. Matériel et méthodes : La revue systématique de la littérature fut entreprise à partir des trois bases de données électroniques : Medline (via PubMed), Cochrane Library, Web of Science Core Collection, et complétée par une recherche limitée de la littérature grise (Google Scholar) afin d’identifier les études évaluant l’efficacité de la RMO sur le SAOS. Le critère de jugement principal était une diminution de l’indice d’apnées/hypopnées (IHA) d’au moins cinq épisodes par heure par rapport à l’état initial. Les critères de jugement secondaires étaient une amélioration de la qualité subjective du sommeil, de la qualité du sommeil mesurée par polysomnographie nocturne et de la qualité de vie mesurée subjectivement. Résultats : Seulement dix études répondaient à tous les critères d’inclusion. Huit étaient des essais cliniques contrôlés randomisés, une était une étude de cohorte prospective et une autre était une étude de cohorte rétrospective. Six études étaient consacrées au SAOS de l’adulte et quatre au SAOS pédiatrique. Toutes les études incluses ont été évaluées à « faible risque de biais » d’après les douze critères de risque de biais du Cochrane Back Review Group. D’après les données probantes disponibles, la RMO permet une réduction significative de l’IAH, jusqu’à 90,6 % chez l’enfant et jusqu’à 92,06 % chez l’adulte. Elle permet une diminution significative de l’intensité et de la fréquence du ronflement, participe à une réduction de la somnolence diurne, limite la réapparition des symptômes d’apnée obstructive du sommeil (AOS) après adénoamygdalectomie chez l’enfant et améliore l’adhésion au traitement par ventilation en pression positive continue (PPC). La RMO passive, avec l’assistance apportée au patient par le port d’une orthèse sur mesure à bille, augmente l’observance à la rééducation, permet une réduction significative de l’intensité du ronflement, de l’IAH et un accroissement significatif des voies aérifères supérieures. Conclusions : Les données publiées montrent que la rééducation myofonctionnelle orofaciale est efficace dans les traitements multidisciplinaires des SAOS de l’enfant, de l’adolescent et de l’adulte et devrait être largement prescrite à plusieurs étapes de ces prises en charge. La RMO passive, avec l’orthèse d’avancée mandibulaire à bille conçue par Michèle Hervy-Auboiron, aide à pallier les fréquents défauts d’observance observés lors des traitements par RMO active. MOTS CLÉS : Troubles respiratoires obstructifs du sommeil / Syndrome d’apnées obstructives du sommeil / Orthodontie / Rééducation myofonctionnelle orofaciale / Gouttières préfabriquées
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Résumé Objectifs Présenter les recommandations de pratique clinique (RPC) rédigées en 2017 sous l’égide de la Société française d’ORL-chirurgie de la face et du cou concernant le rôle de l’ORL dans le diagnostic du syndrome d’apnée-hypopnée obstructive du sommeil de l’enfant. Ce manuscrit porte spécifiquement sur les antécédents et l’examen clinique. Méthodes Un groupe de travail multidisciplinaire a rédigé des RPC classées en fonction de leur niveau de preuve scientifique selon le système grade. La première version du texte a été remaniée en fonction des remarques du groupe de lecture. Résultats À l’issue du processus de rédaction, des recommandations pondérées selon leur score GRADE de niveau de preuve scientifique ont été établies dans les domaines suivants : interrogatoire, avec notamment analyse de l’apport des différents scores d’interrogatoire proposés dans la littérature ; examen physique, y compris la fibroscopie ORL vigile en consultation ; indications d’adressage du patient vers d’autres spécialistes que l’ORL.
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Importance: Hypertrophy of the pharyngeal and palatine tonsils can interfere with breathing, physical and cognitive development, and quality of life, including sleep quality. There are important relationships between the muscles of the airways, the anatomy, and the pattern of breathing and swallowing. Objective: The aims of the present study were to evaluate the swallowing process in children after adenotonsillectomy undertaken to treat obstructive breathing disorders. Methods: Subjects were 85 children or adolescents who underwent adenotonsillectomy in a reference hospital between 2003 and 2007. For the clinical evaluation of swallowing, the protocol of orofacial myofunctional evaluation with scores (OMES) was used, videofluoroscopy of deglutition was performed, and the Dysphagia Outcome and Severity Scale (DOSS) and Classification for Severity of Dysphagia to Videofluoroscopy Scale were applied for analysis. Results: Out of the 85 evaluated children, 43 were male (50.59%), the average age at evaluation was 12.11 years, the average age at the time of surgery was 6.73 years, and post-surgery time was 3.00-8.00 years. In the clinical evaluation of swallowing, half the sample (50.59%) recorded the poorest score for lip and tongue behavior. A score of 1 was observed in 67.06% of subjects for other behaviors, and in 15.30% of subjects for efficiency of swallowing. Videofluoroscopic analysis demonstrated that the most frequent swallowing alterations were labial sealing (50.59%), residue in vallecula (51.76%), and use of compensatory maneuvers (61.18%). Analysis of DOSS showed that normal swallowing was attributed to 48.31% of subjects at level 7, 44.95% at level 6, and 6.74% at level 5. For the Classification for Severity of Dysphagia to Videofluoroscopy, 75.28% were classified as having mild dysphagia. Interpretation: Alterations in the dynamics of swallowing are common in children who have undergone surgery of the tonsils, even at late follow-up.
Introduction Multiple anatomic and functional risk factors contribute to Obstructive Sleep Apnea (OSA) in children, most of the screening tools only evaluate clinical symptoms. The aim was to describe the evaluation of the short orofacial myofunctional protocol (ShOM) in OSA children, and to analyze if the inclusion of orofacial myofunctional aspects would influence the screening sensitivity/specificity of the Sleep Clinical Record (SCR). Methods Children from Brazil and Italy with sleep disordered breathing were evaluated by full night polygraphy, the SCR and the ShOM. For the analysis of the correlations, we normalized the distribution of the children based on the percentiles of the Apnea and Hypopnea Index (AHI). The children were divided in: Group1: first percentile AHI up to25% (cut-off value: AHI≤1.9); Group 2: second percentile from 25% to 75% (cut-off values: 1.9˂AHI≤7.9); Group3: third percentile AHI˃75% (cut=off value: AHI˃7.9). The findings of SCR and ShOM were compared for each group. ROC curve of the sensitivity and specificity of OSA diagnosis were compared for SCR alone and the combined results of SCR plus ShOM. Results 86 children, 47 girls, 4 to 11 years, were included, 34 children were obese and 20 overweight. OSA severity and obesity showed a positive correlation (p=0.04). Mean ShOM score was 5.64±2.27, with a positive correlation to the SCR (p=0.002). In Group1, the SCR showed more nasal obstruction, arched palate and OSAS score/positive Brouilette questionnaire and the ShOM scored more alterations to breathing mode, breathing type (p=0.01) and lip competence. In Group 3, we found more tonsillar hypertrophy, Friedman tongue position alteration (p<0.001), malocclusion and obesity at SCR and more alterations in tongue resting position, tongue deglutition position and malocclusion at ShOM. Conclusions The myofuntional evaluation contributed to the screening of OSA in children, while alterations of the tongue (resting and deglutition position) were observed in children with the highest AHI percentile. The combination of SCR and ShOM improved the sensitivity and specificity for the identification of pediatric OSA when compared to SCR alone.
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Introducción: el objetivo de este estudio es develar si la técnica Neuromuscular Funcional (NMF) puede ser considerada como opción de tratamiento en el Síndrome de Apnea Obstructiva de Sueño (SAOS) y si se complementa con la Terapia Miofuncional Orofacial o hace parte de ella. Métodos: la fenomenología trascendental de Husserl es el enfoque metodológico que se adoptó para este estudio, siguiendo la ruta para su desarrollo: epojé, reducción trascendental fenomenológica y síntesis. El contenido real se obtuvo mediante dos entrevistas semiestructuradas, aplicadas a un informante clave que contó con los criterios de inclusión presupuestados. Resultados: en la primera etapa se identificaron 10 noesis y 266 noemas, que fueron relacionados entre sí; en la fase de reducción trascendental las noesis se redujeron a 5 y los noemas a 14. Análisis y discusión: el Método Chiavaro como fenómeno se decanta en las dimensiones: (a) Enfoque Sistémico, (b) Técnica Neuromuscular Funcional y (c) Técnica Respiratoria. La prioridad del fenómeno NMF es la explicación de la alteración dentro del enfoque sistémico a partir de la lógica Función-Estructura-Función, de esta manera el SAOS se considera una manifestación de esas relaciones y como tal se le cataloga como adaptación o como función en disfunción. Conclusiones: la Técnica NMF hace parte de la neurorrehabilitación mientras que la TMO para intervenir el SAOS se inscribe en la fisiología del ejercicio.
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Children with sleep-disordered breathing (SDB) present alterations in posture and mobility of the stomatognathic system components. Orofacial myofunctional therapy is a modality of treatment for children with obstructive sleep apnea syndrome (OSAS) to promote changes in the orofacial musculature of the upper airways. Orofacial myofunctional therapy helps to re-establish correct habits and functioning of orofacial muscles to avoid the residual SDB after surgical or orthodontic treatments. The treatment must be as early as possible for protecting airway health and sleep quality. Orofacial myofunctional therapy could serve as an adjunct to other obstructive sleep apnea treatments. Early identification and intervention during childhood development is essential to optimize normal growth of the airway and to insure a lasting impact in the treatment of SDB.
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Precision medicine requires coordinated and integrated evidence-based combinatorial approaches so that diagnosis and treatment can be tailored to the individual patient. In this context, the treatment approach to mild obstructive sleep apnea (OSA) is fraught with substantial debate as to what is mild OSA, and as to what constitutes appropriate treatment. As such, it is necessary to first establish a proposed consensus of what criteria need to be employed to reach the diagnosis of mild OSA, and then examine the circumstances under which treatment is indicated, and if so, whether and when anti-inflammatory therapy (AIT), rapid maxillary expansion (RME), and/or myofunctional therapy (MFT) may be indicated.
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Study Objectives To evaluate tone, apraxia, and stereognosis dysfunctions in patients with SDB compared with healthy controls, and to monitor the effectiveness of Airway Gym® as an easy-to-use Myofunctional Therapy (MT) modality in terms of the tongue’s motor and sensory responses, comparing results before and after therapy. Methods This was a prospective, non-randomized pilot study of 25 patients with moderate to severe obstructive sleep apnoea–hypopnoea syndrome (OSAHS), 25 patients with primary snoring (PS), and 20 healthy controls.Qualitative and quantitative instruments—Iowa Oral Performance Instrument (IOPI), lingual apraxia, and stereognosis tests were used to assess tongue sensorimotor function. Results 22 patients with PS, 21 with OSAHS, and all 20 controls ended the therapy. In OSAHS, the Epworth Sleepiness Scale score decreased from 16±7.3 to 12±4.5 after therapy (p=0.53). In PS and OSAHS groups, the IOPI scores increased significantly. These measures did not change significantly in the controls. Lingual apraxia testing showed that controls performed all the manoeuvres, whereas PS 5.6±1.4 and OSAHS 4.5±1.9 (p=0.14). In the stereognosis test, the mean number of figures recognized was 2.6±2.2 in OSAHS, 3.3±1.2 in PS, and 5.7±0.9 in control group (p<0.05). Patients with OSAHS recognized circles and ovals less often. Conclusion Using the Airway Gym®app produced improvements in sensorimotor tongue function in patients with SDB, due to, continuous stimulation of the brain based on proprioceptive training required to localize responses when doing the exercises.
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Introduction Sleep-disordered breathing (SDB) ranges from partial obstruction of the upper airway resulting in snoring to total upper airway obstruction leading to obstructive sleep apnea. The impairment in the dynamics of the stomatognathic system is termed as orofacial dysfunction. This study investigates the prevalence of orofacial dysfunction and sleep-disordered breathing in primary school children and identifies their correlation. Methods A total of 560 forms were distributed to 8 primary schools in Belagavi city. Among them, 482 parents responded (86% response rate), which included 239 boys (49.58%) and 243 girls (50.41%). All the participants were screened for orofacial dysfunction using Nordic Orofacial Dysfunction Test-screening (NOT-S) and sleep-disordered breathing using the Pediatric Sleep Questionnaire (PSQ). Result A positive direct correlation of sleep-disordered breathing with orofacial dysfunction (r = 0.47; p ≤ 0.001) was noted. A total of 41(8.58%) children were found to be at risk of sleep-disordered breathing with a score less than or equal to eight, based on (PSQ) Pediatric Sleep Questionnaire, and 156 (32.6%) children showed symptoms of orofacial dysfunction based on Nordic Orofacial Test–Screening (NOT-S). Conclusion The study demonstrates that around 32.6% of children had orofacial dysfunction symptoms, and 8.58% of children were at risk for sleep-disordered breathing, girls having a greater risk as compared to boys. There was a positive correlation between orofacial dysfunction and sleep-disordered breathing among children aged 6–12 years.
Chapter
Orofacial myofunctional therapy (OMFT) in OSAS patients is composed by several combinations of oropharyngeal exercises to improve the functioning of muscles involved in the patency of the airway, increasing its tone, tension, and mobility and remodeling the disposition of fat pads. OMFT is an effective and reversible therapy, without side effects.The scheduled protocols must be detailed, taken into account the load, intensity, frequency, and duration of repetition of each exercise. No accordance upon protocols is found between studies published.OMFT as adjuvant therapy in post-operative treatment to single level velopharyngeal surgery first can be applied with three different purposes: firstly, as rescue therapy for failure or uncomplete success of palatal surgery in terms of AHI and symptoms. Secondly, to recover complications of palatal surgery, especially on swallow disorders. Then, as a physical therapy after surgery to speed up the functional recovery, facilitating innervation and re-innervation phenomena, reducing inflammation, and remodeling surgical wounds.KeywordsMyofunctional therapyOMFTPalatal surgeryOSASOMESOSA rehabilitation programs
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Objective: to investigate the correlation between the tongue pressure and the electrical activity of the suprahyoid muscles. Methods: a across-sectional, observational and analytical study conducted with 15 men and 22 women. Each participant underwent simultaneous assessment of maximal tongue pressure through the Iowa Oral Performance Instrument (IOPI) and the surface electromyography of the suprahyoid muscles. They were asked to press the tongue against the hard palate in the anterior and posterior region, with and without IOPI. The adopted significance level of the performed analyses was 5%. Results: there was a moderate and significant correlation only between suprahyoid electrical activity and tongue pressure in the posterior region. It was verified that the measured electrical potentials, when using the IOPI, were greater in the tasks of anterior pressure than in the tasks of the posterior one, bilaterally. Without using the IOPI, the electrical potentials were greater in the posterior pressure than in the anterior one, bilaterally. Finally, the values of lingual pressure were compared with the bulb positioned in the anterior and posterior parts, and the anterior tongue pressure was higher. Conclusion: there was a moderate correlation between tongue pressure and electrical potential of the suprahyoid muscles, researched by the surface electromyography, only when performing activities with the posterior portion of the tongue.
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Introduction: Studies on Mean Platelet Volume (MPV) in children with Sleep Disordered Breathing (SDB) report conflicting results and the hypothesis of an intermittent hypoxemia leading to a systemic inflammation is reaching consensus. Vitamin D exerts anti-inflammatory properties and its deficiency has been supposed to play a role in sleep disorders. Emerging interest is rising about Primary Snoring (PS) since it is reasonable that also undetectable alteration of hypoxia might predispose to an increased production of inflammatory mediators. In this perspective, in a group of children affected by SDB, our aim was to investigate MPV, vitamin D and C Reactive Protein (CRP) levels, which had been previously evaluated separately in different studies focused only on Obstructive Sleep Apnea Syndrome (OSAS). Materials and methods: We enrolled 137 children: 70 healthy controls (HC), 67 affected by SDB undergoing a polysomnographic evaluation, 22 with a diagnosis of PS and 45 with a diagnosis of OSAS. All patients underwent routine biochemical evaluations including blood cell counts, CRP and vitamin D. Results: Children affected by SDB had a mean age of 8.49±2.19 and were prevalently males (23 females, 34%; 44 males, 66%). MPV levels were higher in OSAS and PS when compared to HC; platelet count (PLT) and CRP levels were higher while Vitamin D levels were lower in children with SDB when compared to HC. MPV levels were correlated with PLT (r = -0.54; p<0.001), vitamin D (r = -0.39; p<0.001) and CRP (r = 0.21; p<0.01). A multiple regression was run to predict MPV levels from vitamin D, CRP and PLT and these variables significantly predicted MPV (F = 17.42, p<0.0001; adjusted R2 = 0.37). Only platelet count and vitamin D added statistically significantly to the prediction (p<0.05). Conclusion: The present study provides evidence of higher MPV and lower vitamin D levels in children with PS as well as in children with OSAS, and supports the underlying inflammation, hence, highlighting the importance of an early diagnosis of this previously considered benign form of SDB.
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Adenotonsillectomy (T&A) may not completely eliminate sleep-disordered breathing (SDB), and residual SDB can result in progressive worsening of abnormal breathing during sleep. Persistence of mouth breathing post-T&As plays a role in progressive worsening through an increase of upper airway resistance during sleep with secondary impact on orofacial growth. Retrospective study on non-overweight and non-syndromic prepubertal children with SDB treated by T&A with pre- and post-surgery clinical and polysomnographic (PSG) evaluations including systematic monitoring of mouth breathing (initial cohort). All children with mouth breathing were then referred for myofunctional treatment (MFT), with clinical follow-up 6 months later and PSG 1 year post-surgery. Only a limited subgroup followed the recommendations to undergo MFT with subsequent PSG (follow-up subgroup). Sixty-four prepubertal children meeting inclusion criteria for the initial cohort were investigated. There was significant symptomatic improvement in all children post-T&A, but 26 children had residual SDB with an AHI > 1.5 events/hour and 35 children (including the previous 26) had evidence of "mouth breathing" during sleep as defined [minimum of 44 % and a maximum of 100 % of total sleep time, mean 69 ± 11 % "mouth breather" subgroup and mean 4 ± 3.9 %, range 0 and 10.3 % "non-mouth breathers"]. Eighteen children (follow-up cohort), all in the "mouth breathing" group, were investigated at 1 year follow-up with only nine having undergone 6 months of MFT. The non- MFT subjects were significantly worse than the MFT-treated cohort. MFT led to normalization of clinical and PSG findings. Assessment of mouth breathing during sleep should be systematically performed post-T&A and the persistence of mouth breathing should be treated with MFT.
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The aim of the present study was to assess the effects of one-week tongue-task training (TTT) on sleep apnea severity in sleep apnea subjects. Ten patients with sleep apnea (seven men, mean [± SD] age 52 ± 8 years; mean apnea-hypopnea [AHI] index 20.9 ± 5.3 events/h) underwent 1 h TTT in the authors' laboratory on seven consecutive days. A complete or limited recording and tongue maximal protruding force were assessed before and after one-week TTT. One-week TTT was associated with a global AHI decrease (pre-TTT: 20.9 ± 5.3 events/h; post-TTT: 16.1 ± 5.1 events/h; P<0.001) and AHI decrease during rapid eye movement sleep (pre-TTT: 32.2 ± 18.4 events/h; post-TTT: 16.7 ± 6.6 events/h; P=0.03), while protruding force remained unchanged. The authors consider these results to be potentially clinically relevant and worthy of further investigation in a large randomized trial.
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There is no standardized protocol for the clinical evaluation of orofacial components and functions in patients with obstructive sleep apnea. The aim of this study was to examine the validity, reliability, and psychometric properties of the Expanded Protocol of Orofacial Myofunctional Evaluation with Scores (OMES-expanded) in subjects with obstructive sleep apnea. Patients with obstructive sleep apnea and control subjects were evaluated, and the validity of OMES-expanded was tested by construct validity (i.e. the ability to discriminate orofacial status between apneic and control subjects) and criterion validity (i.e. correlation between OMES-expanded and a reference instrument). Construct validity was adequate; the apneic group showed significantly worse orofacial status than did control subjects. Criterion validity of OMES-expanded was good, as was its reliability. The OMES-expanded is valid and reliable for evaluating orofacial myofunctional disorders of patients with obstructive sleep apnea, with adequate psychometric properties. It may be useful to plan a therapeutic strategy and to determine whether the effects of therapy are related to improved muscle and orofacial functions. © 2015 Eur J Oral Sci.
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Background: Adenotonsillectomy is commonly performed in children with the obstructive sleep apnea syndrome, yet its usefulness in reducing symptoms and improving cognition, behavior, quality of life, and polysomnographic findings has not been rigorously evaluated. We hypothesized that, in children with the obstructive sleep apnea syndrome without prolonged oxyhemoglobin desaturation, early adenotonsillectomy, as compared with watchful waiting with supportive care, would result in improved outcomes. Methods: We randomly assigned 464 children, 5 to 9 years of age, with the obstructive sleep apnea syndrome to early adenotonsillectomy or a strategy of watchful waiting. Polysomnographic, cognitive, behavioral, and health outcomes were assessed at baseline and at 7 months. Results: The average baseline value for the primary outcome, the attention and executive-function score on the Developmental Neuropsychological Assessment (with scores ranging from 50 to 150 and higher scores indicating better functioning), was close to the population mean of 100, and the change from baseline to follow-up did not differ significantly according to study group (mean [±SD] improvement, 7.1±13.9 in the early-adenotonsillectomy group and 5.1±13.4 in the watchful-waiting group; P=0.16). In contrast, there were significantly greater improvements in behavioral, quality-of-life, and polysomnographic findings and significantly greater reduction in symptoms in the early-adenotonsillectomy group than in the watchful-waiting group. Normalization of polysomnographic findings was observed in a larger proportion of children in the early-adenotonsillectomy group than in the watchful-waiting group (79% vs. 46%). Conclusions: As compared with a strategy of watchful waiting, surgical treatment for the obstructive sleep apnea syndrome in school-age children did not significantly improve attention or executive function as measured by neuropsychological testing but did reduce symptoms and improve secondary outcomes of behavior, quality of life, and polysomnographic findings, thus providing evidence of beneficial effects of early adenotonsillectomy. (Funded by the National Institutes of Health; CHAT ClinicalTrials.gov number, NCT00560859.).
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Purpose: This study evaluated the efficacy of oropharyngeal exercises in children with symptoms of obstructive sleep apnea syndrome (OSA) after adenotonsillectomy. Methods: Polysomnographic recordings were performed before adenotonsillectomy and 6 months after surgery. Patients with residual OSA (apnea-Hypopnea Index, AHI > 1 and persistence of respiratory symptoms) after adenotonsillectomy were randomized either to a group treated with oropharyngeal exercises (group 1) or to a control group (group 2). A morphofunctional evaluation with Glatzel and Rosenthal tests was performed before and after 2 months of exercises. All the subjects were re-evaluated after exercise through polysomnography and clinical evaluation. The improvement in OSA was defined by ΔAHI: (AHI at T1 - AHI at T2)/AHI at T1 × 100. Results: Group 1 was composed of 14 subjects (mean age, 6.01 ± 1.55) while group 2 was composed of 13 subjects (mean age, 5.76 ± 0.82). The AHI was 16.79 ± 9.34 before adenotonsillectomy and 4.72 ± 3.04 after surgery (p < 0.001). The ΔAHI was significantly higher in group 1 (58.01 %; range from 40.51 to 75.51 %) than in group 2 (6.96 %; range from -23.04 to 36.96 %). Morphofunctional evaluation demonstrated a reduction in oral breathing (p = 0.002), positive Glatzel test (p < 0.05), positive Rosenthal test (p < 0.05), and increased labial seal (p < 0.001), and lip tone (p < 0.05). Conclusions: Oropharyngeal exercises may be considered as complementary therapy to adenotonsillectomy to effectively treat pediatric OSA.
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This study collected data on the maximum anterior and posterior tongue strength and endurance in 420 healthy Belgians across the adult life span to explore the influence of age, sex, bulb position, visual feedback, and order of testing. Measures were obtained using the Iowa Oral Performance Instrument (IOPI). Older participants (more than 70 years old) demonstrated significantly lower strength than younger persons at the anterior and the posterior tongue. Endurance remains stable throughout the major part of life. Gender influence remains significant but minor throughout life, with males showing higher pressures and longer endurance. The anterior part of the tongue has both higher strength and longer endurance than the posterior part. Mean maximum tongue pressures in this European population seem to be lower than American values and are closer to Asian results. The normative data can be used for objective assessment of tongue weakness and subsequent therapy planning of dysphagic patients.
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This technical report describes the procedures involved in developing recommendations on the management of childhood obstructive sleep apnea syndrome (OSAS). The literature from 1999 through 2011 was evaluated. A total of 3166 titles were reviewed, of which 350 provided relevant data. Most articles were level II through IV. The prevalence of OSAS ranged from 0% to 5.7%, with obesity being an independent risk factor. OSAS was associated with cardiovascular, growth, and neurobehavioral abnormalities and possibly inflammation. Most diagnostic screening tests had low sensitivity and specificity. Treatment of OSAS resulted in improvements in behavior and attention and likely improvement in cognitive abilities. Primary treatment is adenotonsillectomy (AT). Data were insufficient to recommend specific surgical techniques; however, children undergoing partial tonsillectomy should be monitored for possible recurrence of OSAS. Although OSAS improved postoperatively, the proportion of patients who had residual OSAS ranged from 13% to 29% in low-risk populations to 73% when obese children were included and stricter polysomnographic criteria were used. Nevertheless, OSAS may improve after AT even in obese children, thus supporting surgery as a reasonable initial treatment. A significant number of obese patients required intubation or continuous positive airway pressure (CPAP) postoperatively, which reinforces the need for inpatient observation. CPAP was effective in the treatment of OSAS, but adherence is a major barrier. For this reason, CPAP is not recommended as first-line therapy for OSAS when AT is an option. Intranasal steroids may ameliorate mild OSAS, but follow-up is needed. Data were insufficient to recommend rapid maxillary expansion.
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This revised clinical practice guideline, intended for use by primary care clinicians, provides recommendations for the diagnosis and management of the obstructive sleep apnea syndrome (OSAS) in children and adolescents. This practice guideline focuses on uncomplicated childhood OSAS, that is, OSAS associated with adenotonsillar hypertrophy and/or obesity in an otherwise healthy child who is being treated in the primary care setting. Of 3166 articles from 1999-2010, 350 provided relevant data. Most articles were level II-IV. The resulting evidence report was used to formulate recommendations. The following recommendations are made. (1) All children/adolescents should be screened for snoring. (2) Polysomnography should be performed in children/adolescents with snoring and symptoms/signs of OSAS; if polysomnography is not available, then alternative diagnostic tests or referral to a specialist for more extensive evaluation may be considered. (3) Adenotonsillectomy is recommended as the first-line treatment of patients with adenotonsillar hypertrophy. (4) High-risk patients should be monitored as inpatients postoperatively. (5) Patients should be reevaluated postoperatively to determine whether further treatment is required. Objective testing should be performed in patients who are high risk or have persistent symptoms/signs of OSAS after therapy. (6) Continuous positive airway pressure is recommended as treatment if adenotonsillectomy is not performed or if OSAS persists postoperatively. (7) Weight loss is recommended in addition to other therapy in patients who are overweight or obese. (8) Intranasal corticosteroids are an option for children with mild OSAS in whom adenotonsillectomy is contraindicated or for mild postoperative OSAS.
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This study explored age- and sex-related differences in orofacial strength. Healthy adult men (N = 88) and women (N = 83) participated in the study. Strength measures were obtained using the Iowa Oral Performance Instrument (IOPI). Anterior and posterior tongue elevation strength measures were obtained using a standard method. Tongue protrusion and lateralization, cheek compression, and lip compression measures utilized adaptors allowing the participant to exert pressure against the bulb in different orientations. Lip and cheek strength measures were greater for men than women, but tongue strength did not differ between sex groups. Strong correlations between age and strength were not observed. However, group comparisons revealed lower tongue protrusion and lateralization strength in the oldest participants. The oldest participants also exhibited lower anterior and posterior tongue elevation strength relative to the middle-age group. Cheek and lip compression strength demonstrated no age-related differences. The current study supplements and corroborates existing literature that shows that older adults demonstrate lower tongue strength than younger adults. Sex differences were noted such that men demonstrated greater lip and cheek strength but not tongue strength. These data add to the literature on normal orofacial strength, allowing for more informed interpretations of orofacial weakness in persons with dysphagia.
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Objective: Clinical evaluation of the stomatognathic system is indispensable for the diagnosis of orofacial myofunctional disorders. In order to obtain a more precise diagnosis, the protocol of orofacial myofunctional evaluation with scores (OMES protocol) (Int. J. Pediatr. Otorhinolaryngol. 72 (2008) 367-375) was expanded in terms of number of items and scale amplitude. The proposal of this study is to describe the expanded OMES protocol (OMES-E) for the evaluation of children. Validity of the protocol, reliability of the examiners and agreement between them were analyzed, as also were the sensitivity, specificity and predictive values of the instrument. Methods: The sample consisted of videorecorded images of 50 children, 25 boys (mean age=8.4 years, SD=1.8) and 25 girls (mean age=8.2 years, SD=1.7) selected at random from 200 samples. Three speech therapists prepared for orofacial myofunctional evaluation participated as examiners (E). The OMES and OMES-E protocols were used for evaluation on different days. E1 evaluated all images, E2 analyzed children with recordings from 1 to 25 and E3 analyzed children with recordings from 26 to 50. The validity of OMES-E was analyzed by comparing the instrument to the OMES protocol using the Pearson correlation test complemented with the split-half reliability test (p<0.05). The linear weighted Kappa coefficient of agreement (Kw'), the sensitivity, specificity and predictive values and the prevalence of OMD were calculated. Results: There was a statistically significant correlation between the OMES and OMES-E protocols (0.79>r<0.94, p<0.01) and a significant test-retest correlation with the OMES-E (0.75>r<0.86, p<0.01), with a reliability range of 0.86-0.93. The correlation and reliability coefficients between examiners were: E1×E2 (r=0.74, 0.84), E1×E3 (r=0.70, 0.83) (p<0.01). Kw' coefficients with moderate and good strength predominated. The OMES-E protocol presented mean sensitivity=0.91, specificity=0.77, positive predictive value=0.87 and negative predictive value=0.85. The mean prevalence of OMD was 0.58. Conclusion: The OMES-E protocol is valid and reliable for orofacial myofunctional evaluation.
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Evaluating tongue function is clinically important as the generation of adequate pressure by the anterior tongue against the hard palate is crucial for efficient oropharyngeal swallowing. Research in the evaluation of tongue function in pediatric populations is limited due to questions about the reliability of children's performance on objective measures of tongue strength and the lack of comparative data from typically developing children. The present study examined tongue strength in 150 children and adolescents, 3-16 years of age, with no history of speech or swallowing disorders using the Iowa Oral Pressure Instrument (IOPI). Children as young as 3 years of age were able to tolerate the IOPI standard tongue bulb and were reliable performers on measures of tongue strength with an unconstrained mandible. Tongue strength measurements were elicited in blocks of three trials with a 30-s rest between the trials and a 20-min rest between blocks. Tongue strength increased with age with no consistent best trial across ages and participants. Males showed a slight increase in tongue strength over females at ages 14 and 16. This study suggests maximum pediatric tongue strength may be reliably evaluated using commercially available equipment and provides a limited sample comparative database.
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Upper airway muscle function plays a major role in maintenance of the upper airway patency and contributes to the genesis of obstructive sleep apnea syndrome (OSAS). Preliminary results suggested that oropharyngeal exercises derived from speech therapy may be an effective treatment option for patients with moderate OSAS. To determine the impact of oropharyngeal exercises in patients with moderate OSAS. Thirty-one patients with moderate OSAS were randomized to 3 months of daily ( approximately 30 min) sham therapy (n = 15, control) or a set of oropharyngeal exercises (n = 16), consisting of exercises involving the tongue, soft palate, and lateral pharyngeal wall. Anthropometric measurements, snoring frequency (range 0-4), intensity (1-3), Epworth daytime sleepiness (0-24) and Pittsburgh sleep quality (0-21) questionnaires, and full polysomnography were performed at baseline and at study conclusion. Body mass index and abdominal circumference of the entire group were 30.3 +/- 3.4 kg/m(2) and 101.4 +/- 9.0 cm, respectively, and did not change significantly over the study period. No significant change occurred in the control group in all variables. In contrast, patients randomized to oropharyngeal exercises had a significant decrease (P < 0.05) in neck circumference (39.6 +/- 3.6 vs. 38.5 +/- 4.0 cm), snoring frequency (4 [4-4] vs. 3 [1.5-3.5]), snoring intensity (3 [3-4] vs. 1 [1-2]), daytime sleepiness (14 +/- 5 vs. 8 +/- 6), sleep quality score (10.2 +/- 3.7 vs. 6.9 +/- 2.5), and OSAS severity (apnea-hypopnea index, 22.4 +/- 4.8 vs. 13.7 +/- 8.5 events/h). Changes in neck circumference correlated inversely with changes in apnea-hypopnea index (r = 0.59; P < 0.001). Oropharyngeal exercises significantly reduce OSAS severity and symptoms and represent a promising treatment for moderate OSAS. Clinical trial registered with www.clinicaltrials.gov (NCT 00660777).
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To determine whether primary snoring (PS) could be distinguished from childhood obstructive sleep apnea syndrome (OSAS) by clinical history. Retrospective study of clinical history of 83 children with snoring and/or sleep disordered breathing who were referred for polysomnography. Tertiary referral center; pediatric pulmonary sleep apnea clinic. We evaluated the ability of a clinical obstructive sleep apnea (OSA) score and other questions about sleep, breathing, and daytime symptoms to distinguish PS from OSAS in children. Parents were asked about the child's snoring, difficulty breathing, observed apnea, cyanosis, struggling to breathe, shaking the child to "make him or her breathe," watching the child sleep, afraid of apnea, the frequency and loudness of snoring, and daytime symptoms such as excessive daytime sleepiness (EDS). Based on polysomnography results, 48 patients were classified as PS and 35 as OSAS. Peak endtidal CO2 (49 +/- 3.2 vs 55 +/- 8.2 [SD] mm Hg); lowest arterial oxygen saturation measured by pulse oximetry (95 +/- 1.9 vs 82 +/- 14%); and apnea/hypopnea index (0.27 +/- .3 vs 8.4 +/- 6 events/h) indicated that the diagnostic criteria for PS versus OSA were reasonable. There were no differences between PS and OSA patients with respect to age, sex, race, failure to thrive, obesity, history of EDS, snoring history, history of cyanosis during sleep, or daytime symptoms except for mouth breathing. There were no significant differences in sleep variables between PS patients and those with any severity of OSAS. The OSA score misclassified about one of four patients. Comparing PS and OSA patients, significant findings were daytime mouth breathing (61 vs 85%; p = 0.024); observed apnea (46 vs 74%; p = 0.013); shaking the child (31 vs. 60%; p = 0.01); struggling to breathe (58 vs 89%; p = 0.003); and afraid of apnea (71 vs 91%; p = 0.028). However, none of these were sufficiently discriminatory to predict OSAS. We conclude that PS in children cannot be reliably distinguished from OSAS by clinical history alone.
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This review presents the state of swallowing rehabilitation science as it relates to evidence for neural plastic changes in the brain. The case is made for essential collaboration between clinical and basic scientists to expand the positive influences of dysphagia rehabilitation in synergy with growth in technology and knowledge. The intent is to stimulate thought and propose potential research directions. A working group of experts in swallowing and dysphagia reviews 10 principles of neural plasticity and integrates these advancing neural plastic concepts with swallowing and clinical dysphagia literature for translation into treatment paradigms. In this context, dysphagia refers to disordered swallowing associated with central and peripheral sensorimotor deficits associated with stroke, neurodegenerative disease, tumors of the head and neck, infection, or trauma. The optimal treatment parameters emerging from increased understanding of neural plastic principles and concepts will contribute to evidence-based practice. Integrating these principles will improve dysphagia rehabilitation directions, strategies, and outcomes. A strategic plan is discussed, including several experimental paradigms for the translation of these principles and concepts of neural plasticity into the clinical science of rehabilitation for oropharyngeal swallowing disorders, ultimately providing the evidence to substantiate their translation into clinical practice.
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This study investigated the effect of repeated tongue lift training (TLT) on the excitability of the corticomotor representation of the human tongue and jaw musculature. Sixteen participants performed three series of TLT for 41min on each of 5 consecutive days. Each TLT series consisted of two pressure levels (5kPa and 10kPa). All participants underwent transcranial magnetic stimulation (TMS) and electromyographic (EMG) recordings of motor evoked potentials (MEPs) in four sessions: (1) before TLT on Day 1 (baseline), (2) after TLT on Day 1, (3) before TLT on Day 5, and (4) after TLT on Day 5. EMG recordings from the left and right tongue dorsum and masseter muscles were made at three pressure levels (5kPa, 10kPa, 100% tongue lift), and tongue, masseter, and first dorsal interosseous (FDI) MEPs were measured. There were no significant day-to-day differences in the tongue pressure during maximum voluntary contractions. The amplitudes and thresholds of tongue and masseter MEPs after TLT on Day 5 were respectively higher and lower than before TLT on Day 1 (P<0.005), and there was also a significant increase in tongue and masseter MEP areas; no significant changes occurred in MEP onset latencies. FDI MEP parameters (amplitude, threshold, area, latency) were not significantly different between the four sessions. Our findings suggest that repeated TLT can trigger neuroplasticity reflected in increased excitability of the corticomotor representation of not only the tongue muscles but also the masseter muscles.
Article
Modification to the dental occlusion may alter oral sensorimotor functions. Restorative treatments aim to restore sensorimotor functions; however, it is unclear why some patients fail to adapt to the restoration and remain with sensorimotor complaints. The face primary motor cortex (face-M1) is involved in the generation and control of orofacial movements. Altered sensory inputs or motor function can induce face-M1 neuroplasticity. We took advantage of the continuous eruption of the incisors in Sprague-Dawley rats and used intracortical microstimulation (ICMS) to map the jaw and tongue motor representations in face-M1. Specifically, we tested the hypothesis that multiple trimming of the right mandibular incisor, to keep it out of occlusal contacts for 7 d, and subsequent incisor eruption and restoration of occlusal contacts, can alter the ICMS-defined features of jaw and tongue motor representations (i.e., neuroplasticity). On days 1, 3, 5, and 7, the trim and trim-recovered groups had 1 to 2 mm of incisal trimming of the incisor; a sham trim group had buccal surface trimming with no occlusal changes; and a naive group had no treatment. Systematic mapping was performed on day 8 in the naive, trim, and sham trim groups and on day 14 in the trim-recovered group. In the trim group, the tongue onset latency was shorter in the left face-M1 than in the right face-M1 (P < .001). In the trim-recovered group, the number of tongue sites and jaw/tongue overlapping sites was greater in the left face-M1 than in the right face-M1 (P = 0.0032, 0.0016, respectively), and the center of gravity was deeper in the left than in the right face-M1 (P = 0.026). Therefore, incisor trimming and subsequent restoration of occlusal contacts induced face-M1 neuroplasticity, reflected in significant disparities between the left and right face-M1 in some ICMS-defined features of the tongue motor representations. Such neuroplasticity may reflect or contribute to subjects' ability to adapt their oral sensorimotor functions to an altered dental occlusion. © International & American Associations for Dental Research 2015.
Article
The objectives of this study were to confirm the efficacy of rapid maxillary expansion in children with moderate adenotonsillar hypertrophy in a larger sample and to evaluate retrospectively its long-term benefits in a group of children who underwent orthodontic treatment 10 years ago. After general clinical examination and overnight polysomnography, all eligible children underwent cephalometric evaluation and started 12 months of therapy with rapid maxillary expansion. A new polysomnography was performed at the end of treatment (T1). Fourteen children underwent clinical evaluation and Brouilette questionnaire, 10 years after the end of treatment (T2). Forty patients were eligible for recruitment. At T1, 34/40 (85%) patients showed a decrease of apnea-hypopnea index (AHI) greater than 20% (ΔAHI 67.45% ± 25.73%) and were defined responders. Only 6/40 (15%) showed a decrease <20% of AHI at T1 and were defined as non-responders (ΔAHI -53.47% ± 61.57%). Moreover, 57.5% of patients presented residual OSA (AHI > 1 ev/h) after treatment. Disease duration was significantly lower (2.5 ± 1.4 years vs 4.8 ± 1.9 years, p <0.005) and age at disease onset was higher in responder patients compared to non-responders (3.8 ± 1.5 years vs 2.3 ± 1.9 years, p <0.05). Cephalometric variables showed an increase of cranial base angle in non-responder patients (p <0.05). Fourteen children (mean age 17.0 ± 1.9 years) who ended orthodontic treatment 10 years previously showed improvement of Brouilette score. Starting an orthodontic treatment as early as symptoms appear is important in order to increase the efficacy of treatment. An integrated therapy is needed. Copyright © 2014 Elsevier B.V. All rights reserved.
Article
We aimed to determine the diagnostic test accuracy of the Spanish version of the respiratory symptoms scale of the Pediatric Sleep Questionnaire (PSQ) in habitually snoring children for identifying obstructive sleep apnea (OSA). Habitually snoring children referred for polysomnography (PSG) were recruited. Parents answered the PSQ prior to PSG. Based on an apnea-hypopnea index (AHI) >1.0 in PSG, children were divided into OSA and primary snorers. Correlations to PSG indices and diagnostic test accuracy measures were calculated. Of the 83 (n = 53 males, mean age 9.5 ± 3.6 years) habitually snoring children included, 35 had OSA. The previously validated PSQ cutoff value of 0.33 showed a specificity of 0.72 and sensitivity of 0.78. The PSQ score correlated significantly with the AHI rs = 0.313 (p-value = 0.004). Six items of the PSQ were significantly different between cases and controls. A subscale constructed on these six PSQ items concerning respiratory symptoms showed a good sensitivity (0.886) and an excellent negative likelihood ratio (0.261). PSQ was able to identify 89% of the children with OSA correctly. This version of the PSQ was able to identify children with OSA, separating them from those with primary snoring. The use of this simple, standardized questionnaire tool seems to be helpful and may improve clinical decision making in habitually snoring children. Copyright © 2014 Elsevier B.V. All rights reserved.
Article
Objective To systematically review the literature for articles evaluating myofunctional therapy (MT) as treatment for obstructive sleep apnea (OSA) in children and adults and to perform a meta-analysis on the polysomnographic, snoring, and sleepiness data. Data Sources Web of Science, Scopus, MEDLINE, and The Cochrane Library. Review Methods The searches were performed through June 18, 2014. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement was followed. Results Nine adult studies (120 patients) reported polysomnography, snoring, and/or sleepiness outcomes. The pre- and post-MT apnea-hypopnea indices (AHI) decreased from a mean ± standard deviation (M ± SD) of 24.5 ± 14.3/h to 12.3 ± 11.8/h, mean difference (MD) -14.26 [95% confidence interval (CI) -20.98, -7.54], P < 0.0001. Lowest oxygen saturations improved from 83.9 ± 6.0% to 86.6 ± 7.3%, MD 4.19 (95% CI 1.85, 6.54), P =0.0005. Polysomnography snoring decreased from 14.05 ± 4.89% to 3.87 ± 4.12% of total sleep time, P < 0.001, and snoring decreased in all three studies reporting subjective outcomes. Epworth Sleepiness Scale decreased from 14.8 ± 3.5 to 8.2 ± 4.1. Two pediatric studies (25 patients) reported outcomes. In the first study of 14 children, the AHI decreased from 4.87 ± 3.0/h to 1.84 ± 3.2/h, P = 0.004. The second study evaluated children who were cured of OSA after adenotonsillectomy and palatal expansion, and found that 11 patients who continued MT remained cured (AHI 0.5 ± 0.4/h), whereas 13 controls had recurrent OSA (AHI 5.3 ± 1.5/h) after 4 y. Conclusion Current literature demonstrates that myofunctional therapy decreases AHI by approximately 50% in adults and 62% in children. Lowest oxygen saturations, snoring, and sleepiness outcomes improve in adults. Myofunctional therapy could serve as an adjunct to other OSA treatments.
Purpose: Facial appearance and speech outcome may affect psychosocial functioning in girls and boys. Several studies reported dissatisfaction with facial appearance and more specifically the lip and mouth profile in children with cleft lip and palate (CLP). The purpose of this controlled study was to measure the tongue and lip strength and endurance in boys and girls with CLP. Methods: Twenty-five subjects (mean age: 10.6 years) with a unilateral CLP and a gender- and age- matched control group were selected. All subjects with an unilateral CLP consulted the same craniofacial team and had undergone an identical surgical procedure. Surgical procedure of the lip was performed using a modified Millard technique without primary nose correction at an average age of 5.5 months. The Iowa Oral Performance instrument was used to measure lip and tongue strength and tongue endurance. Results: The results of the Iowa Oral Performance measurement showed no significant differences between the subjects with an unilateral cleft lip and palate and the age and gender matched control group without a cleft lip and palate. Conclusion: There is no significant differences regarding oral strength more specifically the lip and tongue strength and endurance between subjects with and without an unilateral cleft lip and palate. ENT specialists and speech pathologists must be aware of this aspect of the normal lip and tongue functions.
Article
Background: Limited studies suggest that pubertal development may lead to a recurrence of sleep-disordered breathing (SDB) despite previous curative surgery. Our study evaluates the impact of myofunctional reeducation in children with SDB referred for adenotonsillectomy, orthodontia, and myofunctional treatment in three different geographic areas. Methods: A retrospective investigation of children with polysomnographic analysis following adenotonsillectomy were referred for orthodontic treatment and were considered for myofunctional therapy. Clinical information was obtained during pediatric and orthodontic follow-up. Polysomnography (PSG) at the time of diagnosis, following adenotonsillectomy, and at long-term follow-up, were compared. The PSG obtained at long-term follow-up was scored by a single-blinded investigator. Results: Complete charts providing the necessary medical information for long-term follow-up were limited. A subgroup of 24 subjects (14 boys) with normal PSG following adenotonsillectomy and orthodontia were referred for myofunctional therapy, with only 11 subjects receiving treatment. Follow-up evaluation was performed between the 22nd and 50th month after termination of myofunctional reeducation or orthodontic treatment if reeducation was not received. Thirteen out of 24 subjects who did not receive myofunctional reeducation developed recurrence of symptoms with a mean apnea-hypopnea index (AHI)=5.3±1.5 and mean minimum oxygen saturation=91±1.8%. All 11 subjects who completed myofunctional reeducation for 24 months revealed healthy results. Conclusion: Despite experimental and orthodontic data supporting the connection between orofacial muscle activity and oropharyngeal development as well as the demonstration of abnormal muscle contraction of upper airway muscles during sleep in patients with SDB, myofunctional therapy rarely is considered in the treatment of pediatric SDB. Absence of myofascial treatment is associated with a recurrence of SDB.
Article
This study examined whether there is an association between surface electromyography (EMG) of masticatory muscles, orofacial myofunction status and temporomandibular disorder (TMD) severity scores. Forty-two women with TMD (mean 30 years, SD 8) and 18 healthy women (mean 26 years, SD 6) were examined. According to the Research Diagnostic Criteria for TMD (RDC/TMD), all patients had myogenous disorders plus disk displacements with reduction. Surface EMG of masseter and temporal muscles was performed during maximum teeth clenching either on cotton rolls or in intercuspal position. Standardized EMG indices were obtained. Validated protocols were used to determine the perception severity of TMD and to assess orofacial myofunctional status. TMD patients showed more asymmetry between right and left muscle pairs, and more unbalanced contractile activities of contralateral masseter and temporal muscles (p<0.05, t-test), worse orofacial myofunction status and higher TMD severity scores (p<0.05, Mann-Whitney test) than healthy subjects. Spearman coefficient revealed significant correlations between EMG indices, orofacial myofunctional status and TMD severity (p<0.05). In conclusion, these methods will provide useful information for TMD diagnosis and future therapeutic planning.
Article
This review describes evidence in subprimates and primates that the face primary somatosensory cortex (face SI) and primary motor cortex (face MI) are involved in sensorimotor integration and control of orofacial motor functions that include semiautomatic movements (e.g., chewing, swallowing) and voluntary movements (e.g., jaw-opening). The review also notes that the neuroplastic capabilities of the face SI and face MI have recently been documented, and may reflect or allow for functional adaptation (or maladaptation) of the orofacial sensorimotor system to an altered oral state or oral motor behaviour. They may contribute to the processes whereby patients undergoing oral rehabilitation can (or cannot) restore the lost orofacial sensorimotor functions. Such understanding is important since pain, injuries to the oral tissues, and alterations to the dental occlusion induced by tooth loss or attrition are common occurrences in humans that may sometimes be accompanied by impaired oral sensorimotor functions. Furthermore, impaired oral sensorimotor functions are common in many neurological disorders, sometimes making the most vital functions of eating, swallowing and speaking difficult and thereby reducing the patient's quality of life. It has also been well documented that such negative consequences can be improved following oral rehabilitation as patients adapt, for example, to a new dental prosthesis aimed at restoring function. Therefore, understanding the mechanisms and cortical neuroplastic processes underlying orofacial sensorimotor functions and adaptation is also important for the development of new therapeutic strategies to facilitate recovery of patients suffering from orofacial pain and sensorimotor disorders and improve their quality of life.
Article
In order to better understand the pathogenesis and sequelae of obstructive adenoid hyperplasia in children, the anatomic relationships of the adenoids to the hard and soft palates, oropharynx, and nasopharynx were studied in vivo in 94 children. Direct, intraoperative palatal, nasopharyngeal, and oropharyngeal measurements were performed in 19 children with normal, nondiseased adenoids (controls [C]) and compared to 75 children undergoing adenoidectomy for obstructive adenoid hyperplasia (OAH) (n = 44) or chronic adenoid infection (CAI) (n = 31). As expected, the weight and volume of the adenoids removed were significantly greater in the OAH vs. CAI group (P < .001). Before adenoidectomy, the volume of the nasopharynx was significantly smaller in the OAH group; however, nasopharyngeal volumes after adenoidectomy were quite similar in all three groups and ranged from 5.4 to 6.2 cc. Only the change in the volume of the nasopharynx after adenoidectomy for obstruction was significant (2.5 ± 1.2 cc, P < .01). Differences in oropharyngeal and palatal dimensions were not associated with longstanding obstruction from adenoid hyperplasia. These data indicate that the nasal obstruction from adenoid hyperplasia is due to an absolute increase in adenoid size rather than a relatively smaller nasopharynx. Differences in palatal and oropharyngeal dimensions usually described and attributed to longstanding nasal obstruction could not be demonstrated in this study.
Article
The activity patterns of the masseter and the anterior temporal muscles were studied in twenty-one healthy male subjects while clenching at 10, 20, 30, 40 and 50% of the maximum clenching level. At low clenching levels the temporal muscle activity tended to dominate, at high levels the masseter muscle activity was stronger (P less than 0.001). The asymmetry in muscle activity also depended upon the clenching level (P less than 0.001), while at each level the masseter muscle asymmetry was greater than the temporal muscle asymmetry (P less than 0.05-P less than 0.025). By comparing the electromyographic activities of the left and right side within each subject it was found that the masseter muscle with the higher electromyographic activity tended to have the larger cross-sectional area (P less than 0.01) and at the 50% clenching level it tended to be on the side with the greater number of post-canine tooth contacts (P less than 0.001).
Article
Neuromuscular changes were studied by electromyography in rhesus monkeys which adapted to nasal obstruction for 2 years and then in the succeeding year recovered to nasal respiration. Obstructing the nasal passage with silicone plugs induced specific behavioral responses which remained for the duration of nasal obstruction and were lost within 8 days after removal of the plugs. Animals demonstrated individual variations, but more than 80% consistently maintained a lower mandibular posture for the entire 2-year period. Rhythmic mandibular, tongue, and upper lip movements were evident in fewer than 60% of the animals. Certain craniofacial and tongue muscles (the genioglossus, dorsal tongue fibers, digastric, geniohyoid, dilator naris, and vertically oriented fibers of the superior orbicularis oris, that is, lip-elevator fibers) were recruited rhythmically and remained rhythmically active throughout the entire 2-year period of nasal obstruction. This rhythmic activity ceased within 1 week after removal of the nose plugs. A tonic or consistent discharge was also induced in the genioglossus, dorsal tongue fibers, the geniohyoid, superior orbicularis oris, and lip-elevator fibers over the entire 2 years of nasal obstruction. Not all muscles lost their tonic discharge after removal of the nasal plugs. The genioglossus, geniohyoid, inferior orbicularis oris, and lip-elevator fibers discharged tonically during the recovery period. These data suggest that nasal obstruction can induce neuromuscular changes which extend beyond the period of obstruction and remain after the original stimulus for neuromuscular change has been removed.
Article
The influence of occlusal conditions on stomatognathic function can be assessed by electromyography. Electromyographic activity of left and right temporal and masseter muscles was recorded in 30 young healthy adults with a normal occlusion during: (1) a 3-s maximum voluntary clench on cotton rolls positioned on the posterior teeth (standardization recording); (2) a 3-s maximum voluntary clench in intercuspal position; and (3) a 3-s alternate 'maximum' voluntary contraction and relaxation with a 1 Hz frequency. All potentials were standardized as a percentage of the maximum potential of test 1. Waveforms of paired muscles were compared by computing a percentage overlapping coefficient (ratio between each 50-ms overlapped areas and the total areas, up to 100% for symmetric muscles). Waveforms were also analysed for a laterodeviating effect on the mandible given by unbalanced muscular couples, and a torque coefficient (up to 100% for a significant laterodeviating couple on the mandible) was computed. In all subjects, both tests were performed with symmetric muscular patterns (more than 88%) and with negligible laterodeviating couples on the mandible (lower than 10%). The two coefficients allow an assessment of muscular asymmetry during static and dynamic clenching tests, and, together with the standardization of the potentials, could be a useful tool to detect functionally altered occlusal conditions, i.e. conditions where an apparent good morphological situation is not related to a correct neuromuscular status.
Hypertrophy of the adenoids and palatine tonsils is the second most frequent cause of upper respiratory obstruction and, consequently, mouth breathing in children. Prolonged mouth breathing leads to muscular and postural alterations which, in turn, cause dentoskeletal changes. The aim of this study was to determine muscular, functional and dentoskeletal alterations in children aged 3-6 years. Seventy-three children, including 44 with tonsil hypertrophy and 29 controls, were submitted to otorhinolaryngologic, speech pathologic and orthodontic assessment. Otorhinolaryngologic evaluation revealed a higher incidence of nasal obstruction, snoring, mouth breathing, apneas, nocturnal hypersalivation, itchy nose, repeated tonsillitis and bruxism in children with tonsils hypertrophy. Speech pathologic assessment showed a higher incidence of open lip and lower tongue position, and of hypotonia of the upper and lower lips, tongue and buccinator muscle in these children, accompanied by important impairment in mastication and deglutition. Orthodontic evaluation demonstrated a higher incidence of lower mandible position in relation to the cranial base, a reduction in lower posterior facial height, transverse atresia of the palate, and a dolicofacial pattern. Postural and functional alterations anticipate dentoskeletal changes, except for the facial pattern. Postural alterations and the skeletal pattern seem to play an important role in infant dentofacial growth.
Article
Corticomotor control of the human tongue has been reported to undergo neuroplastic changes following several days of training in a tongue-protrusion task. The aims of the present study were to determine if a 1 h tongue-task training is sufficient to induce signs of neuroplastic changes in the corticomotor pathways, and to obtain preliminary information on the time course of such changes. Corticomotor excitability was assessed by changes in electromyographic activity evoked by transcortical magnetic stimulation (TMS) in 11 healthy subjects. Motor evoked potentials (MEPs) recorded in the tongue musculature and the first dorsal interosseous (FDI) muscle were assessed at four sessions: at baseline before training, 30 min after training, and 1 and 7 days after training. All subjects performed successfully the task (success rate: 38+/-4%). Thresholds for evoking MEPs by TMS in the tongue were decreased at 30 min, 1 and 7 days after training compared with baseline (ANOVA: P<0.001). Tongue MEP amplitudes were significantly increased at 1 day follow-up and had returned to baseline values at 7 days follow-up (ANOVA: P<0.001). No significant effect of tongue-task training on FDI MEPs was observed (ANOVA: P=0.160). Corticomotor topographic maps revealed increases (ANOVA: P<0.001) in area at the 1 day follow-up. The success rate was significantly correlated to the net increases in tongue MEPs at 1 day follow-up (Spearman: 0.615; P=0.0039). The present findings confirm that tongue task training is associated with plasticity of corticomotor excitability specifically related to the tongue musculature and further document that plasticity is evident within 30 min post-training and may last up to at least 7 days.
Objective: In the literature there is no validated instrument for the clinical evaluation of the orofacial myofunctional condition of children that will permit the examiner to express numerically his perception of the characteristics and behaviors observed. The proposal of this study is to describe a protocol for the evaluation of children aged 6-12 years in order to establish relations between the orofacial myofunctional conditions and numerical scales. The protocol validity, reliability of the examiners and agreement between them was analyzed. Methods: Eighty children aged 6-12 years participated in the study. All were evaluated and 30 were selected at random for the analyses (age range: 72-149 months, mean=103.3, S.D.=23.57). Individuals with and without orofacial myofunctional disorders were included. The examiners were two speech therapists properly calibrated in orofacial myofunctional evaluation. Two protocols were constructed. One, based on traditional models, was called traditional orofacial myofunctional evaluation (TOME), and the other, with the addition of numerical scales, was called orofacial myofunctional evaluation with scores (OMES). The clinical conditions included were: appearance, posture and mobility of lips, tongue, cheeks and jaws, respiration, mastication and deglutition. Statistical analysis was performed using the split-half reliability method. Means, standard deviations and the Spearman correlation coefficient were also calculated. Results: There was a statistically significant correlation between the evaluations of 30 children assessed with the TOME and OMES protocols (r=0.85, p<0.01). The reliability between protocols was 0.92. The test-retest reliability of the OMES instrument was 0.99 and the correlation was 0.98. Reliability between examiners 1 and 2 using the OMES protocol was 0.99, and the correlation was 0.98 (p<0.01). Conclusion: The OMES protocol proved to be a valid and reliable instrument for orofacial myofunctional evaluation, permitting the grading of orofacial myofunctional conditions within the limits of the selected items.