Effects of orofacial myofunctional therapy on the symptoms and physiological parameters of sleep breathing disorders in adults: a systematic review

Abstract

Recently, the orofacial myofunctional therapy (OMT) has appeared as a possible alternative treatment for obstructive sleep apnea (OSA). Systematic reviews are required to achieve scientific evidence, seeking to direct the decision on therapeutic issues. The aim of this study was to systematically review the literature about the OMT proposals in adults with OSA related to symptoms and physiological parameters. Data sources were Lilacs, MEDLINE, Pubmed, Cochrane and Scielo using the descriptors: obstructive sleep apnea; myofunctional therapy; oropharyngeal exercises; breathing exercises; upper airway exercises; speech therapy. Studies published from 2000 to 2017 that evaluated the treatment with isolated OMT in subjects with OSA were included, obligatorily with polysomnographic data, pre and post therapy. Eight studies, out of 124 articles, were eligible according to the criteria adopted. Two systematic reviews, one clinical trial, three randomized clinical trials, and two case reports were included. Six studies showed a decrease in the Apnea and Hypopnea Index (AHI), five studies showed improvement in the minimum SpO2, decrease in the Epworth Sleepiness Scale (ESS) and in snoring. OMT proposals refer to a three-month program changing the parameters related to partial reduction of AHI, ESS index, snoring, and partial increase of SpO2. There are few randomized studies.

Full text

(1) Pontifícia Universidade Católica de São
Paulo (PEPG-PUCSP), São Paulo, SP,
Brazil.
Research support source: National
Postdoctoral Program/ Coordination for
the Improvement of Higher Education
Personnel (PNPD/CAPES).
Conict of interest: Nonexistent
Effects of orofacial myofunctional therapy on
the symptoms and physiological parameters of
sleep breathing disorders in adults:
a systematic review
Fabiane Kayamori(1)
Esther Mandelbaum Gonçalves Bianchini(1)
Received on: August 29, 2017
Accepted on: October 17, 2017
Mailing address:
Fabiane Kayamori
Alameda Jaú, 1767, conjunto 51,
Cerqueira César
CEP: 01420-002 - São Paulo,
São Paulo, Brasil
E-mail:fabianekayamori@gmail.com
ABSTRACT
Recently, the orofacial myofunctional therapy (OMT) has appeared as a possible alter-
native treatment for obstructive sleep apnea (OSA). Systematic reviews are required to
achieve scientic evidence, seeking to direct the decision on therapeutic issues. The
aim of this study was to systematically review the literature about the OMT proposals
in adults with OSA related to symptoms and physiological parameters. Data sources
were Lilacs, MEDLINE, Pubmed, Cochrane and Scielo using the descriptors: obstruc-
tive sleep apnea; myofunctional therapy; oropharyngeal exercises; breathing exercises;
upper airway exercises; speech therapy. Studies published from 2000 to 2017 that
evaluated the treatment with isolated OMT in subjects with OSA were included, obli-
gatorily with polysomnographic data, pre and post therapy. Eight studies, out of 124
articles, were eligible according to the criteria adopted. Two systematic reviews, one
clinical trial, three randomized clinical trials, and two case reports were included. Six
studies showed a decrease in the Apnea and Hypopnea Index (AHI), ve studies sho-
wed improvement in the minimum SpO2, decrease in the Epworth Sleepiness Scale
(ESS) and in snoring. OMT proposals refer to a three-month program changing the
parameters related to partial reduction of AHI, ESS index, snoring, and partial increase
of SpO2. There are few randomized studies.
Keywords: Obstructive Sleep Apnea; Snoring; Myofunctional Therapy; Speech,
Language and Hearing Sciences; Oropharynx
Review articles
13317
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Myofunctional therapy and sleep apnea | 869
INTRODUCTION
Orofacial myofunctional therapy (OMT) is a set
of techniques and procedures intended to change
orofacial muscular and functional patterns using
isotonic and isometric exercises for orofacial and
oropharyngeal muscles targeting the functions of
breathing, mastication, swallowing and speech1.
For the past 10 years, Speech, Language and
Hearing Sciences intervention using OMT have been
presented in this eld as one of the possible treatments
for snoring and obstructive sleep apnea (OSA), with
evidence found specially in studies on Sleep Breathing
DIsorders in adults1-4.
Every new eld of study with its specic techniques
needs researches that provide evidence of the benets
of each therapy. The rst publications on OMT for
obstructive sleep apnea date from 19995, but the rst
randomized clinical trial (RCT) to use the therapy as
alternative treatment for patients with moderate OSA
was published in 20091. The study reported a decrease
of approximately 40% in the Apnea and hypopnea index
(AHI), a reduction in cervical circumference, reduction
in snoring intensity and frequency, reduction of daytime
sleepiness and better sleep quality after the OMT
program. Right after this rst international publication,
the same journal published an editorial questioning
the benets and objectives of OMT procedures for
improving OSA6.
Physiologically, the pharynx is a highly collapsible
area in the entirety of its extension. The activity of
dilating pharynx muscles, especially the genioglossus
and tensor palatini muscles oppose to the tendency
of the pharynx to collapse as a protective mechanism.
Changes in such mechanism are associated with
the syndrome of obstructive sleep apnea disorder7.
In that sense, OMT applied to OSA has the objective
of strengthening the nasopharynx and oropharynx
musculature contributing to reduce collapse of the
airway during sleep1-4. However, the exact mechanisms
by which OMT helps with Sleep Breathing Disorders
are still not clear to this day.
Contemporary studies show OMT efcient results
in improving the quality of life2, in the reduction of
intensity and frequency of snoring3 and in the better
adherence of CPAP (Continuous Positive Airway
Pressure)4. Such studies endorse the Speech,
Language Therapist interest in this eld and validate
the presence of that professional in the interdisciplinary
realm of Sleep Breathing Disorders, especially in Brazil
with the existence of a specic certication for Speech,
Language and Hearing Sciences in the eld of sleep
disorders8.
At the present stage, systematic reviews are
necessary to attest the level of scientic evidence of
OMT effects in OSA and in snoring, as well as to set
methodological parameters for the decision-making
in therapy matters. However, such parameters are not
always clear or coincident, making difcult a consistent
verication of OMT effects for individuals with Sleep
Breathing Disorders.
The objective of this study is to systematically
analyze the scientic literature available on OMT
programs for adults with Sleep Breathing Disorders,
their effects on symptoms and physiological param-
eters, trying to argue for the relevance of the practice-
based evidence (PBE).
METHODS
Research strategies
The fundamental questions that guide this literature
review are:
“What are the methodological parameters in
orofacial myofunctional therapy programs for Sleep
Breathing Disorders?”
“What are the effects of the isolated orofacial
myofunctional therapy in adults considering symptoms
and physiological parameters of Sleep Breathing
Disorders?”.
Our search was performed in the following online
databases: “Literatura Latino-Americana e do Caribe
em Ciências da Saúde” (Lilacs); ‘‘Medical Literature
Analysis and Retrieval System Online’’ (MEDLINE),
‘‘US National Library of Medicine National Institutes
Health’’ (Pubmed), ‘‘Cochrane Library’’ (Cochrane)
and ‘‘Scientic Electronic Library’’ (Scielo) and we have
selected the studies published between the year 2000
and April 2017.
The descriptors in Health Sciences (DeCs)
used for retrieving the articles, language limiters
considered for Portuguese and English languages,
were: apneia obstrutiva do sono (obstructive sleep
apnea) [All elds]; terapia miofuncional (myofunctional
therapy) [All elds]; exercícios (exercises) [All elds];
exercícios orofaríngeos (oropharyngeal exercises)
[All elds]; exercícios respiratórios/ /exercícios da via
aérea (breathing exercises / upper airway exercises
[All elds]; Fonoaudiologia (Speech, Language and
Hearing Sciences / speech therapy) [All elds]. The
Kayamori F, Bianchini EMG Myofunctional therapy and sleep apnea

Rev. CEFAC. 2017 Nov-Dez; 19(6):868-878
870 | Kayamori F, Bianchini EMG
search was performed with associated descriptors
(e/and).
Selection criteria
The selection of studies published followed the
steps described below:
The search for materials according to the associate
descriptors and that had been published between the
year 2000 to 2017 (April) in the referred databases with
full version available online; the selection of studies
whose titles and abstracts were related to the proposed
subject; observation of inclusion and exclusion criteria;
reading and analysis of the full text articles.
The considered articles should published in
Portuguese or English and approach the method-
ological parameters for the OMT programs related
to Sleep Breathing Disorders or present studies
describing the procedures and effects of isolated OMT
in adults considering the symptoms and physiological
parameters of Sleep Breathing Disorders (snoring
and/or OSA) necessarily reporting polysomnographic
data (pre and post therapy), at least for the Apnea and
Hypopnea Index (AHI).
Repeated articles recovered from different
databases were not considered. An initial selection
was made after reading of titles and abstracts and
exclusion of those that did not match the criteria. The
full text articles were downloaded and the studies were
read and analyzed in their entirety. The references were
evaluated, the studies were identied and listed.
Data analysis
The following topics were tabulated for the articles’
analysis: name of authors, year of publication, infor-
mation on the type of study, study risk of bias (consid-
ering selection, performance, detection, friction and
publishing biases), number of subjects, demographic
characteristics (gender, age), type of Sleep Breathing
Disorder, level of OSA severity, methodological
parameters with respect to therapeutic procedures and
description of results post OMT.
A specic protocol was developed for the present
research based on the selected articles and trying to
answer the question on the methodological param-
eters that guide OMT proposals for Sleep Breathing
Disorders.
The specic research protocol based on method-
ological parameters included:
Therapeutic parameters: procedures, frequency
and period of therapy, therapy follow up;
Parameters for evaluation and reevaluation:
Physiologic parameters: anthropometric measure-
ments such as body mass index (BMI) and cervical
circumference (cc) pre and post OMT, polysomno-
graphic data such as Apnea and Hypopnea Index
(AHI) for each hour of sleep and minimum blood
oxygen saturation (SpO2) and period with SpO2 under
90% pre and post OTM;
Symptomatology: data on daytime sleepiness
(Epworth Sleepiness Scale)9 and snoring reported by
complaint or part of Berlin questionnaire (referring to
intensity and frequency)10.
LITERATURE REVIEW
One hundred and twenty four articles were screened
considering the methodology for this literature review,
initially excluding the studies that did not involve
snoring and/or OSA (N=28) and that did not provide
some form of therapy (N=67). 29 potentially relevant
studies were set apart and their references checked for
other studies not present in our initial search. 10 more
studies were included. After verifying the total of 39
articles, 31 of them were eliminated and 8 articles were
kept for detailed analysis.
The uxogram (Figure 1) illustrates the trajectory
of the present study. It is interesting to point out that 4
studies involve specically the applicability and results
of OMT for children11-14, two case-control reports13,14 and
two retrospective studies11,12.

Rev. CEFAC. 2017 Nov-Dez; 19(6):868-878
Myofunctional therapy and sleep apnea | 871
with systematic literature review15,16, three RCT1-4, one
clinical study17 and two case reports18,19. A description
of the studies can be found in Tables 1 and 2.
Considering the focus of the present systematic liter-
ature review on the effects of isolated OMT for adults
with OSA, 8 studies were considered, two of them
Figure 1. Systematic literature review information uxogram: studies selection stage
Selected articles
(excluding repeated articles)
N=124
Potential relevant studies
N=29
Eligible complete studies
Adults N=8
Additional studies
identied on the
references
N=10
Excluded articles / details:
- does not mention snoring / OSA (N=28)
- no therapy report (N=67)
Excluded articles / details: (N=31)
- airway resistance syndrome (N=1)
- general therapy review (N=6)
- related treatment review/ OMT (N=2)
- non intervention (N=7)
- children (N=4)
- editorial (N=2)
- no date (N=1)
- not OMT treatment (N=8), being:
Electric stimulation (N=1); singing and blowing
instrument (N=3); physiotherapy (electric
stimulation+exercises) (N=1); exercises for the
adherence of the mandibular advancement splint
(N=1); periorbicular musculature therapy (N=1);
intraoral dispositive therapy (N=1)
Table 1. Eligible literature review articles description
Author, year Objective Meta-analysis Number of listed
articles Conclusion
Camacho et al,
2015(16)
Systematic literature review
considering OMT for the
treatment of OSA in children and
adults performing meta-analysis
of polysomnography, snoring and
sleepiness
Yes 9
Data on the adults:
myofunctional therapy reduces AHI
in approximately 50%, improves
SpO2 and snoring.
Valbuza et al,
2010(15)
Literature review on methods
of treatment for OSA improving
musculature tonus as revealed in
the AHI.
No 3
No accepted scientic evidence that
the methods are effective for AHI
decrease under 5.

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872 | Kayamori F, Bianchini EMG
The three RCT were analyzed reported on Table
2 observing, when possible, the possibility of bias
according to the Cochrane Collaboration criteria for the
development of systematic reviews of interventions20.
Little information on this item could be recovered in the
complete version of the published articles or even in
the respective thesis, which were secondarily checked.
To give an example, only one of the studies3 mentions
the intention of treating, which is recommended in the
cases of dropout or loss of subjects in the RCT and this
being a better model for this type of study. The RCT
also presented performance bias in the blinding of the
professionals performing the clinical evaluations pre
and post OMT. That is something important to be taken
into account in future studies.
The last three studies: the clinical study17 and the
case reports18,19 do not provide data related to possible
biases. For the present literature review all types of
studies were analyzed despite possible biases.
Data related to the establishment the studies’
sample, type of Sleep Breathing Disorder, level of
severity of the OSA and therapeutic parameters can be
found in Table 3.
The two systematic literature reviews listed in our
search differ in relation to the objectives and criteria
of analysis (Table 1). Data from the literature review16
performed through meta-analysis attest for the
positive effects of OMT in adults based in parameters
from polysomnography, indicating approximately
50% decrease in AIH, improvement in minimum
blood oxygen saturation and snoring. However, the
systematic literature review previously published15, with
focus in the increase of muscle tonus with exercises did
not present favorable effects for AIH reduction under
ve15. We should reinforce that given the criteria of the
described literature review potential results above this
level were not considered as they would be later16,
understanding that the AIH criteria under ve events
per hour indicates remission of the disorder.
Considering two of the RCTs2,4, they originally
correspond to the same study and although they
bring additional information, the data are from the
same subjects and so were counted only once in our
systematic literature review.
Table 2. Eligible clinical studies description considering type of study and biases
Author, year Type of
study
Selection
bias
Selection
bias
Performance
bias Detection bias Attrite bias Report bias
Random
sequence
generator
Omitted
allocation
Participants and
professional
blinding
Final reviewers
blinding
Incomplete
results
Selective results
report
Diaféria G
et al, 2013(2)
and 2016(4)
RCT unknown unknown
yes (participants)
no(professional
speech therapist)
yes
(polysomnography) unknown unknown
Verma et al,
2016(17) CR NR NR NR NR NR NR
Ieto et al,
2015(3) RCT unknown unknown
yes (participants)
no(professional
speech therapist)
yes
(polysomnography) unknown
Treatment
recommendation,
low risk of bias
Guimarães
et al, 2009(1) RCT unknown unknown
yes (participants)
no(professional
speech therapist)
yes
(polysomnography) unknown unknown
Silva et al,
2007(18) CR NR NR NR NR NR NR
Pitta et al,
2007(19)
CR2
cases NR NR NR NR NR NR
Subtitles: CR=case report; CE=clinical study; RCT=randomized clinical trial; NR=no record

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Myofunctional therapy and sleep apnea | 873
The three RCT1-4 counted on a control group
as intended for this type of study. The subjects did
not undergo OMT, only receiving orientations and/
or nasal wash as placebo effect in order to minimize
performance bias. Trying to analyze the effects of OMT
associated to other forms of therapy, other studies2,4
have considered four groups, one control group
(N=24), one OMT group (N=27), CPAP (N=27) and
a mixed group (CPAP e OTM) (N=22). This literature
review considered only the results referring to OMT
alone, following the methodological criteria.
The analysis section of the studies1-4,17 did not
include sample calculation, which we consider to be a
relevant matter. The challenge of gathering a relevant
number of participants in the groups, especially for this
kind of studies is a known fact, mainly in the search for
homogeneity in the sample. However, observing the
number of subjects in the clinical studies’ OMT group,
we notice a gradual increase in that aspect through the
years, which we consider to be a positive factor.
The Sleep Breathing Disorders and their level of
severity have also changed through the years. Starting
Table 3. Description of data from the studies considering subjects characterization, type of disorder and level of OSA severity and
therapeutic parameters
Author, year
Subjects characterization in the
studies Type and
severity of
the OSA
Therapeutic procedures
(OMT)
Frequency/
Period of OMT Follow up
N Gender Age
(years)
Diaféria et al,
2013(2)
and 2016(4) 27 male 45.2±13.0
mild,
moderate
and severe
OSA
Exercise program:Tongue,
soft palate, pharynx
musculature, facial
musculature.Functional:
breathing, swallowing and
mastication
12 sessions
3 daily
practices, 20
minutes each
After 3
weeks wash
out: decrease
in AHI
Verma et al,
2016(17) 20 male (75%)
female (25%) 41.1±10.6
mild and
moderate
OSA
3 stages exercise
program:Tongue, soft palate,
facial musculature and
mandible musculature.
12 sessions
10 repetitions
5 series per
day
NR
Ieto et al,
2015(3) 19 male (57.9%)
female (42.1%) 48±14
snoring,
mild and
moderate
OSA
Nasal washShort exercise
programTongue, soft
palate, facial musculature.
Functional: mastication
12 sessions
Daily practice
3 times a day,
8 minutes each
NR
Guimarães
et al, 2009(1) 16 male 63 Moderate
OSA
Nasal washExercise
program:Tongue, soft
palate, facial musculature
and mandible musculature.
Functional: speech,
breathing, swallowing and
mastication
12 sessions
Daily practice
30 minutes
each
NR
Silva et al,
2007(18) 1 female 60 Severe OSA
Nasal washExercises
forTongue, soft palate, facial
musculature.Functional:
Breathing and mastication
12 sessions
Note.:1st PSG
10 months
previous to
therapy)
NR
Pitta et al,
2007(19)
1 male 37 Severe OSA Exercises forTongue, soft
palate, pharynx musculature,
facial musculature and
mandible musculature.
16 sessions NR
1 female 55 Severe OSA 16 sessions NR
Subtitles: N=number of subjects; OSA= obstructive sleep apnea; OMT= orofacial myofunctional therapy; AHI= Apnea and hypopnea Index per hour of sleep; NR=no
record; PSG=Polysomnography

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874 | Kayamori F, Bianchini EMG
with clinical case reports of severe OSA19,20, going to
RCT with moderate OSA1, to mild or moderate OSA 3,17
to RCT2,4 with all three levels of OSA severity. We were
able to notice that the search for data on OMT effects
has grown for all levels of OSA.
Regarding the methodological therapeutic param-
eters applied to each of the studies1-4,17,19, the approach
and procedures in OMT were the same considering the
period of therapy, being prescribed 12 sessions, one
time per week. They differ nevertheless in the selection
of exercises, number of repetitions, frequency and
period of daily practice and also in the type of functional
approach. The specicities of the practices were not
properly justied regarding the choices made in each
of the studies.
The analysis section of the case reports are clearly
more specic and direct considering the case matter.
On those studies, the selected exercises are not
described, nor is the amount of exercises. On the
RCTs those descriptions are found. On one of the
case reports17 the amount of exercises changes along
three stages of practice: 13 exercises for the two rst
stages and seven for the third one. The other three
RCTs1-4 seem to suggest the following up of exercises
and functional practice progress without considering
stages. Two of the studies indicate programs with a
higher amount of exercises1,2,4 and another3 shows
a great reduction of such number, maybe trying to
facilitate the technique for the patient or because of the
main focus of the study, which was primary snoring.
It is important to indicate that mostly because of
the type of study, techniques were previously dened
and equally applied for the entire study group in each
of researches regardless of the myofunctional changes
that each of the participants could present. For RCT
studies that is a required procedure in order to observe
the effects of a certain technique. However, studies with
consistent justication for the exercise selection and
its functional approach seem to be necessary to better
fund the therapeutic practice targeted to those cases.
The description of therapeutic parameters only
similar among the studies is probably due to the variety
of aspects and matters that involve a orofacial myofunc-
tional therapeutic approach, besides the recent
presence of such therapy in the eld of sleep disorders.
Other relevant data refer to the follow up of the
studies in relation to the effects obtained with OMT.
Only one of the studies in the present systematic review
brought this important concern2,4, revealing a downsize
of the results previously obtained. Considering that the
follow up was only after a few weeks, it was possible to
attest the necessity of maintaining the therapy program
to solidify the results previously obtained. New studies,
with medium and long term follow ups seem to be
necessary.
The data regarding the methodological param-
eters for evaluation and reevaluation post OMT are
found in Tables 4 and 5. Considering this aspect,
the randomized trials follow similar parameters for
evaluation and reevaluation and they are based on
symptomatology data, specic anthropometric data
and polysomnographic data.

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Myofunctional therapy and sleep apnea | 875
Table 4. Description of data considering the results with orofacial myofunctional therapy (OMYT) based on physiological parameters
Author, year
Anthropometric measurements Polysomnography
BMI (kg/m2) CC (cm) AHI (events/hour) Minimum SpO2 (%)
pre post pre post pre post Pre post
Diaféria G
et al, 2013(2)
and 2016(4)
25.0±7.4 26.7±2.9 41.6±3.7 41.5±2.3 28±22.7 13.9±18.5* 83.7 ±7.7 84.9±8.8
Verma et al,
2016(17) 25.6±3.1 25.4±3.2 38.4±1.3 37.8±1.6* 20.1±9.1 19.7±9.4 87.6 ±1.1 88.5 ±1.6*
Ieto et al,
2015(3) 28.1±2.7 28.2±2.8 37.9±2.5 37.5±2.4**
25.4 (22.1-
28.7)
#
18.1 (15.4-
24.1)
# ***
85.5±7.5 83.8±8.9
Guimarães
et al, 2009(1) 29.6±3.8 29.5±4.3 39.6±3.6 38.5±4.0* 22.4±4.8 13.7±8.5* 83±6 85±7*
Silva et al.
2007(18) 23.3 NC NC NC 44 3 83 92
Pitta et al.
2007(19)
26.3 27.7 NC NC 48.5 8.6 79 87
22.2 22.2 NC NC 40.4 3.3 77 83
Subtitles: Data presenting mean and standard deviation. except for #. which presents the results in median. minimum and maximum; BMI= body mass index; CC=
cervical circumference; AHI= Apnea and Hypopnea Index per hour of sleep; SpO2 = blood minimum saturation; * P signicant (<0.05) test T; ** P signicant
considering test with variation according to period and group; *** P relevant only for the group with moderate OSA; NR= no record.
Table 5. Description of data considering the results with orofacial myofunctional therapy (OMT) based on symptomatological parameters
Author. Year
Symptomatology
Life quality
Sleep quality ESS Intensity of snoring Frequency of snoring
pre post pre post pre post pre post
Diaféria G
et al. 2013(2)
and 2016(4)
FOSQ
WHOQoL-
Bref SF-36(2)
FOSQ
WHOQoL-
Bref *
SF-36*
13.7±3.2(2) 7.5±3.7* 8.5±2.3(4) 4.9±3.2* 7.7±2.3(4) 4.3±2.8*
Verma et al.
2016(17) NC NC 15.4±2.3 13.6±3.1* 2.8±0.5 1.7±0.6 * NC NC
Ieto et al.
2015(3)
Pittsburgh
6±3.2
Pittsburgh
4±2.6*
7 (3-11)
#7 (4-10) #
2(2-3) S
4(2.5-4) C
#
2(1-2) S
1(1-2)C*
#
3(2-4) S
4(3-4) C
#
2(1-4) S
2(1.5-3)C*
#
Guimarães
et al. 2009(1)
Pittsburgh
10.2±3.7
Pittsburgh
6.9± 2.5* 14±5 8±6* 3(3-4)
#
1(1-2)*
#
4(4-4)
#
3(1.5-3.5)*
#
Silva et al.
2007(18) NR NR NR NR NR NR NR NR
Pitta et al.
2007(19)
NR NR 12 10 Disturbs the
partner mild NR NR
NR NR 13 7Disturbs the
partner mild NR NR
Subtitles: Data presenting mean and standard deviation. except for #. which presents the results in median. minimum and maximum; ESS=Epworth Sleepiness Scale;
* P signicant (<0.05) test T; S= information given by the subject of the research; C= information provided by the roommate; NR= no record.

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876 | Kayamori F, Bianchini EMG
Table 4 shows the data of the results obtained with
OMT based in physiologic parameters and they show
signicant differences in relation to anthropometric
measurements considering the reduction in cervical
circumference without BMI reduction in three clinical
studies1,3,17. The authors indicate that the improvement
in oropharynx musculature may have determined such
reduction since the subjects did not lose weight and
their BMI was not altered.
Considering physiologic data obtained with
polysomnography, all three RCT1-4 revealed signicant
differences in OMT showing decrease in AIH. It is worth
to point out that in one of the studies3, which also
considered subjects with primary snoring and mild
OSA, the relevant statistic difference was only for the
subjects with moderate OSA. The author justies that
the AIH for mild OSA is already close to the minimum
limit and thus not provide signicant reduction.
The two articles with case reports18,19 are the ones
presenting a better improvement in the level of apnea
with great differences in AIH, maybe because they
had an individual focus. Those studies also present
improvement in the minimum SpO2, as well as in one
of the ECR1 and the clinical essay17, indicating one
other relevant benecial effect of OMT.
In order to analyze the effects of OMT on snoring
in an instrumental way, a RCT3 measured snoring
recording it with a microphone and then presented a
total snoring index considering sound intensity divided
by the total period of sleep. The analysis of such data
pre and post OMT, comparing the results in both groups
(therapy and control) showed signicant reduction of
snoring considering the snoring index and also consid-
ering the total snoring index in the OMT group 3.
The results in the studies referring to the symptom-
atology pre and post OMT are found in table 5, which
brings the data in quality of life, quality of sleep,
excessive daytime sleepiness, intensity and frequency
of snoring, reported and analyzed with specic
questionnaires.
Only one of the RCT2 brought data on quality of
life using three different questionnaires (FOSQ21,
WHOQoL-Bref22 and SF-3623). Comparing the results
of the group pre and post OMT. Signicant differences
were found in: physical domain of the instrument
WHOQoL-Bref and functional quality of the SF-36,
revealing the effects of OMT in those aspects.
The observation of the quality of sleep was reported
in two studies1,3 using the Pittsburgh24 questionnaire.
The data show improvement with signicant differences
post OMT, although not indicating in which compo-
nents specically.
The data on the symptom of daytime sleepiness
were based on the Epworth Sleepiness Scale (ESS)9 in
four of the clinical essays1-4,17 and in one of the case
reports19. Excluding the results in one of the RCT3, the
studies indicate a signicant reduction of the symptom
after a OMT program.
Considering the data related to snoring, the clinical
studies analyzed the intensity and frequency of the
snoring according to the Berlin questionnaire1,3,17 or
the analogic subjective visual scale4. They indicate a
reduction in intensity1,3,4,17 and frequency of snoring1,3,4.
One of the RCT3 separates the Berlin questionnaire
answers when applied to the subject himself or his
roommate, showing signicant improvement in the
answers of the roommate when comparing pre and
post data for the OMT and the control group. In general
terms, the report on snoring by the patient himself is
uncommon and when it happens is due to information
previously given by the roommate. He is the one that
listens to the subject snoring and is able to report on
changes and is thus the most relevant information for
that variable.
In relation to the case reports, one of them19 analyzed
excessive daytime sleepiness and snoring data in two
cases. The data followed the Epworth Sleepiness Scale
(ESS) and show a relief of the symptom. The data on
snoring, on its turn, followed a scale of 0 to 4 (0 =
absence of snoring, 1= resonate; 2 = light snore, 3
= snoring disturbing partner, 4 = snoring disturbing
family). In both cases there was a reduction in the
symptom post OMT. The other case report18 only brings
information on high intensity snoring and the report of
sleepiness previous to OMT, going to moderate snoring
after OMT with evidence on polysomnographic data.
The lack of data uniformity does not allow us to infer
how those characteristics related to the effects of OMT
in the study.
Considering the data in general, it is worth noticing
that the clinical study17 and one of the RCTs3,4, statistical
analysis were presented in terms of mean and standard
deviation. However, two of the RCTs1,3,4 included
median, minimum and maximum, probably because of
the number of subjects in the sample. Methodological
differences were also identied between the RCTs1-4
and the clinical study17. The RCTs compared changes
pre and post OMT between the study and control
groups after the indicated period and the results
were statistically analyzed. The clinical study brought

Rev. CEFAC. 2017 Nov-Dez; 19(6):868-878
Myofunctional therapy and sleep apnea | 877
statistical analysis considering the changes in study
group post OMT compared with data from previous
evaluation. Regardless of those methodological differ-
ences, which can difcult the comparison of results, the
studies conrm the positive effects of OMT for patients
with OSA.
Systematic literature reviews are a growing
tendency in the eld of health sciences as to gather
evidence on the practice of a certain line of action,
trying to base changes in the works of prevention,
diagnosis, treatment and rehabilitation. The privilege
of a systematic literature review is the possibility of
a detailed approach focused on answering precise
questions. In the eld of Speech, Language and
Hearing Sciences, that is already a challenge, given the
variety of the aspects involved in each of the elds of
competence25,26. However, sleep studies in that context
are a recent and interdisciplinary eld of work and the
search for literature reviews that recover the effects of
therapies is necessary to guide upcoming studies as
well as the clinical practice.
The present systematic literature review found that
there are few controlled randomized trials with adults
and they are necessary to provide scientic evidence
to guide the eligibility criteria for undergoing OMT and
also determine the applicable therapy procedures.
CONCLUSION
The present systematic literature review shows
that the methodological parameters guiding orofacial
myofunctional therapy programs for Sleep Breathing
Disorders mostly compare data pre and post therapy
based on the analysis of: symptomatology related
to quality of life, quality of sleep, daytime sleepiness,
intensity and frequency of snoring; anthropometric data
related to body mass index and cervical circumference;
physiological parameters measured with polysomnog-
raphy related to Apnea and Hypopnea Index and blood
minimum saturation.
The parameters for therapy are related to the
practice of exercises for the orofacial and oropharynx
musculature daily, reinforced by functional practice for
the period of 3 months, with individual therapy one time
per week.
The most relevant effects of the isolated orofacial
myofunctional therapy in adults include: reduction of
daytime sleepiness and snoring, better quality of sleep,
partial decrease in the Apnea and Hypopnea Index and
partial increase in the blood minimum saturation.
There have been few controlled randomized blind
trials and they are important to attest the effects of the
technique based on evidences and guiding the thera-
peutic decisions considering evaluation and diagnosis
and the phenotype of the patient for an accurate
prognosis.
ACKNOWLEDGEMENTS
Coordination for the Improvement of Higher
Education Personnel (CAPES) National postdoctoral
program in the Program of Graduate Studies in Speech
Language Pathology and Audiology (PEPG/PUC-SP) at
the Ponticate Catholic University of São Paulo.
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