Efficacy of occlusal splint versus sleep hygiene and progressive muscle relaxation on perceived stress and sleep bruxism: A randomized clinical trial.

PURPOSE: The objective was the comparison of an occlusal device (OD), and sleep hygiene and progressive muscle relaxation (SH & PMR) on perceived stress and sleep bruxism activity (burst/episode and episode/hour) in participants with sleep bruxism. MATERIAL AND METHODS: Sixty-six participants with self-reported sleep bruxism were selected and randomly allocated into two groups: OD group or SH & PMR group. Assessment of perceived stress and sleep bruxism activity were the primary outcomes. The Perceived Stress Scale-10 (PSS-10 scale) was used to measure perceived stress and bruxism episodes/hour and bursts/episode recorded by electromyography of masseter and temporalis. These outcomes were assessed at baseline, 1 month, 6 months, and 1 year. The paired t-test assessed changes in PSS-10 scores and sleep bruxism activity within the same group over different time points (baseline, 1 month, 6 months, and 1 year). The unpaired t-test compared scores between two groups (OD and SH & PMR) at each time point to evaluate intervention differences. The chi-square test compared gender distribution between both groups. RESULTS: PSS-10 scores were found to decrease with the OD at 1 month and 6 months compared to baseline and SH & PMR at all subsequent follow-ups. This decrease was not statistically significant (p > 0.05) between the OD and SH & PMR groups at all follow-ups. OD and SH & PMR significantly reduced bruxism episodes/hour and bursts/episode at all follow-ups (p < 0.05). There were no adverse effects related to any intervention. CONCLUSIONS: The OD and SH & PMR both effectively reduced PSS-10 scores over 6 months and significantly decreased bruxism episodes and bursts per episode. Both methods are safe and effective for managing sleep bruxism and reducing stress.

Correlation between duration of edentulism and severity of obstructive sleep apnea in elderly edentulous patients.

Objectives: To investigate the correlation between duration of edentulism and severity of obstructive sleep apnea in elderly edentulous patients. Material and Methods: 1,017 patients aged 55-65 years, with a history of edentulism of 12-60 months were screened. Detailed history of tooth loss and period of edentulism was recorded for the 414 patients who tested positive for OSA (obstructive sleep apnea). Complete dentures were prepared for each patient and they were trained to use the dentures as a mandibular advancement device (MAD) during sleep at night. Apnea-hypopnea index (AHI) data at pre-treatment, six months and one-year post-treatment time intervals was recorded. A correlation between the period of untreated edentulism and severity of OSA and improvement post-treatment was derived in this study. Results: Mean duration of edentulism was 12.14±2.57 months and mean AHI was 16.62±13.24. For every three month increase in the duration of edentulism (after initial 6 months of total tooth loss), there was a statistically significant increase in severity of OSA. Patients who are edentulous for more than 15 months are increasingly vulnerable to OSA. Discussion: Severity of OSA in afflicted long-term edentulous patients was in direct relation to the period of untreated edentulism and regressed likewise with concomitant denture wear and mandibular advancement during sleep at night. Early prosthetic rehabilitation of edentulous patients is imperative to obviate morbidity of OSA.

Demographic, clinical and etiological profile of pericardial effusion in India: A single centre experience.

INTRODUCTION: Pericardial effusion (PE) is a life-threatening condition. However, there are very few Indian studies which determined etiological distribution. The current retrospective observational study was carried out to assess etiological factors responsible for PE in a tertiary care centre in India. METHODS: The study enrolled consecutive 55 patients with the diagnosis of moderate to large PE as established by echocardiography between January 2018 and December 2018. The echocardiography guided percutaneous pericardiocentesis was performed by the standard procedure. RESULTS: Amongst the enrolled PE patients in the study, 30 (54.55%) were males and 25 (45.45%) were females, with the average age of 43.00 ± 15.54 years. In clinical assessment, tamponade was found in 52 (94.54%) patients. Tuberculosis was the most common etiology for PE (n=35, 63.64%) followed by hypothyroidism (n = 6, 10.9%), and malignancies (n = 4, 7.27%). Among 12.72% patients, the PE was of recurrent type. Additionally, no death or any complication was encountered during pericardiocentesis. CONCLUSION: Pericardial disease and effusion is a major cause of morbidity in India. Despite developments in the healthcare facilities, tuberculosis was the most common etiology for PE. Additionally, the raised number of hypothyroid and malignant PE cases demonstrates the changing etiological trends, similar to western countries.

Epidermal growth factor receptor mutations in adenocarcinoma lung: Comparison of techniques for mutation detection.

Background: Targeted therapy using tyrosine kinase inhibitors in cases of non-small-cell lung carcinoma (NSCLC) that harbor epidermal growth factor receptor (EGFR) mutations has drastically improved the overall survival rate. The current study estimated the frequency of EGFR mutations in the Indian population by analyzing the diagnostic parameters of various techniques available for the detection of these mutations. Materials and Methods: A case series of 100 histologically diagnosed and immunohistochemically confirmed NSCLC with the adenocarcinoma phenotype comprises the study sample. EGFR mutations were detected using clone-specific immunohistochemistry (IHC), real-time polymerase chain reaction (PCR), and Sanger sequencing. Results: EGFR mutations were identified in 48% cases with 72.78% mutations involving exon 19. Clone-specific IHC had a low sensitivity of 46.43%, and the specificity was 79.17%. Sanger sequencing yielded interpretable results in 16% cases only, which were in concordance with the results of real-time PCR. Conclusion: EGFR mutations are increasingly being explored for targeted therapy and personalized medicine. Real-time PCR was found to be the best and the most accurate method for the detection of somatic EGFR mutations in adenocarcinoma primarily in the lungs.

New combined assessment of chronic obstructive pulmonary disease: Utilization, pitfalls, and association with spirometry.

INTRODUCTION: Classification of chronic obstructive pulmonary (COPD) disease has changed from being solely based on spirometric variables to combined assessment including symptom scores and history of exacerbations/ hospitalizations. There is both lack of awareness regarding change in its assessment as well as underutilization due to time constraints and seeming complexity. Moreover, treatment of COPD needs to be tailored according to the new combined assessment. AIMS: Current study was planned to look at current stratification of patients according to new revised combined assessment (Global Initiative for Chronic Obstructive Lung Disease GOLD 2017) in comparison to old(GOLD 2011) as well as its incorporation in clinical practice. Co-relation between revised combined assessment and spirometric staging was also assessed. METHODS: 418 consecutive COPD patients were enrolled, their dyspnea scores in terms of modified medical research council scale (mMRC), preceding history of hospitalization/ exacerbation over preceding one year and spirometric variables were recorded. Their stratification according to old and new classification recorded. Their past treatment records were reviewed and combined assessment if done recorded. RESULTS: Substantial shift of categories is seen from C and D respectively to stage A and B on applying the new classification compared to old i.e more severe to less severe. Secondly, revised combined assessment is still highly underutilized. Revised combined assessment has positive co-relation with spirometry and post bronchodilator forced expiratory volume in 1 second(FEV1). CONCLUSIONS: Management of substantial number of stable COPD patients may need to be stepped down in accordance with revised combined assessment. There is a need to disseminate information regarding change in COPD classification and stress on its incorporation in our day-to day clinical practice. Revised combined assessment has positive co-relation with spirometry, stressing its utility even in peripheral centers without spirometry facilities.

Incidence of Obstructive Sleep Apnea in Elderly Edentulous Patients and the Possible Correlation of Serum Serotonin and Apnea-Hypopnea Index.

PURPOSE: To estimate the incidence of obstructive sleep apnea (OSA) in elderly edentulous patients (aged 60-65 years) and investigate a correlation of serum serotonin levels with the apnea-hypopnea index (AHI), respiratory effort-related arousal (RERA), and respiratory disturbance index (RDI). MATERIALS AND METHODS: 381 elderly completely edentulous patients (307 male, 74 female) aged 60 to 65 years with a history of edentulism of 12 to 15 months, seeking oral rehabilitation at the prosthodontic clinic at Saraswati Dental College & Hospital, Lucknow, India, between January 2014 and January 2016 were enrolled for the present study. After application of the inclusion and exclusion criteria of this study, 183 patients (162 male, 21 female) who were found susceptible, were subjected to the BERLIN questionnaire and Epworth Sleepiness Scale (ESS) to assess sleep disordered breathing (SDB) and then put through all-night polysomnography (PSG). On the basis of AHI, RERA, and RDI scores, 156 patients (143 male, 13 female) who tested positive for OSA were classified according to its intensity. All 156 patients underwent body-mass index (BMI) estimation, cephalometry, and intraoral examination for skeletal and soft tissue profile record. Serum serotonin was estimated from whole blood samples for the 156 OSA and the 27 normal patients. The 156 (147 nonobese, 9 obese) OSA-positive patients were provided with complete dentures and were trained to use the same as a modified mandibular advancement device (MAD) during sleep at night. These patients were kept on a quarterly follow-up for 9 months. Data collected was subjected to statistical analysis, and inferences drawn. RESULTS: The incidence of OSA in elderly edentulous subjects was found to be 32.03% in males and 8.91% in females. A mere 9 out of 156 (5.76%) elderly edentulous OSA patients were found to be obese (Class I) on the basis of BMI estimation. Cephalometry of the patients showed that they had a skeletal class I maxillomandibular relationship. AHI scores of nonobese patients revealed that most of the patients had moderate OSA, followed by mild OSA and severe OSA. Serum serotonin levels ranged from 53 to 83 ng/dL. AHI score of the 9 obese patients were in the moderate to severe range, and their serum serotonin levels were 60 to 70 ng/dL. A correlation between severity of OSA and serum serotonin level was validated in this study. CONCLUSION: OSA was found to be prevalent in edentulous subjects due to pharyngeal collapse and decreased neuromuscular control. An inverse relationship of serum serotonin levels and AHI scores was established.

A Pilot Study to Determine the Effect of Three Months of Oral Appliance Therapy using a Mandibular Advancement Device on HbA1c in Subjects with Type 2 Diabetes Mellitus and Obstructive Sleep Apnea.

PURPOSE: Continuous positive air pressure (CPAP) is recommended for obstructive sleep apnea (OSA) with type 2 diabetes mellitus (T2DM) but cost and compliance are major barriers. A mandibular advancement device (MAD) may be an economical, feasible alternative to CPAP. Various studies have been published to recommend MAD as an alternative to CPAP for OSA, but not regarding its efficacy for patients having OSA as well as T2DM. This study aims to objectively and subjectively evaluate oral appliance therapy using a MAD in patients having OSA as well as T2DM. MATERIALS AND METHODS: Patients who visited the hospital clinic having OSA as well as T2DM were recruited. After giving informed consent, participants were divided into three equally sized groups of three grades of OSA (mild, moderate, severe) on the basis of a polysomnography report and were given intervention of MAD at 50% of maximum mandibular protrusion and 20% of maximum interincisal opening. Objective outcomes were HbA1c level and apnea hypopnea index score (AHI). Subjective outcomes were Epworth Sleepiness Scale (ESS) and the Berlin Questionnaire. All outcomes were assessed before and after 3 months of intervention. RESULTS: A statistically significant difference was seen in all outcomes after intervention with MAD (p < 0.01) in all groups except HbA1c level in participants having severe OSA. CONCLUSION: MAD may be recommended in patients having OSA as well as T2DM. This study provides evidence to inform health care workers about possible use of MAD in OSA with T2DM.

Obstructive Sleep Apnea and Neurocognitive Dysfunction in Edentulous Patients.

PURPOSE: To record the incidence of cognitive dysfunction in edentulous patients suffering from obstructive sleep apnea (OSA) and establish a plausible hypothesis to explain the correlation of cognitive dysfunction and OSA. MATERIALS AND METHODS: In this study, 315 edentulous patients (aged 60 to 65 years) visiting the outpatient department at Saraswati Dental College, Lucknow were recruited from January 2013 to October 2015. Prosthodontic Diagnostic Index (PDI) classification was used to assess the intraoral condition to relate it with the span of edentulousness. The BERLIN questionnaire and Epworth Sleepiness Scales were used to diagnose sleep-disordered breathing, following which the patients were put through all-night polysomnography. The apnea-hypopnea index (AHI) scores were derived. Mild and moderate OSA patients were classified into mild, moderate, and severe cognitive dysfunction based on SGRQ-C and SCD. Data were tabulated according to a new classification (Cognitive Dysfunction of Dental Sleep Medicine Patients [CDDSMP] Classification) designed specifically for this study. Data were analyzed using SPSS v15.0. Scores were tabulated as mean ± SD and median [IQR] values. Change from baseline was analyzed using Wilcoxon signed rank test. RESULTS: Mean scores at different time intervals were 3.03 ± 1.76 (3 months), 2.98 ± 1.80 (6 months), and 2.81 ± 1.84 (9 months). The median [IQR] values of scores at all time intervals except 9 months were 3 [1 to 5]. At 9 months, median [IQR] was 2 [1 to 5]. A significant change in scores was observed in the 3-month interval (p ≤ 0.001). CONCLUSIONS: The severity of OSA and neurocognitive dysfunction could be directly related to the PDI classification and the span of edentulousness of the patient and modified mandibular advancement device treatment significantly improved the patients' condition, which was reflective from 3 months post-intervention itself.

Lifestyle and Occupational Stress: A Potential Risk Factor for Obstructive Sleep Apnea in Nonobese Male Subjects.

PURPOSE: To record the incidence of obstructive sleep apnea (OSA) in nonobese male subjects and investigate the coexistence of lifestyle stress, sleep deprivation, and upper airway inflammation. MATERIALS AND METHODS: 552 patients were assessed during a survey of banks, government and corporate offices, recruitment agencies, and schools between January 2012 and January 2016. After applying the inclusion and exclusion criteria designed for this study, the number of patients tapered down to 120 patients who underwent diagnostic tests, viz. polysomnography, chemiluminiscence immunoassay, nephelometry, and upper airway endoscopy. This revealed the presence of OSA coexistent with elevated serum cortisol, C-reactive protein (CRP), and upper airway inflammation. RESULTS: Polysomnography showed that 57 of 120 patients suffered from OSA. Objective evaluation of these patients exposed an undercurrent of lifestyle stress in 39 patients. CRP and serum cortisol were found to be significantly high (1.60 ± 0.52 and 7.20 ± 0.76 µg/dL, respectively) in 30 patients. Endoscopy revealed 18 patients with moderate, 7 with severe, and 5 with no upper airway inflammation. CONCLUSION: The results of this study demonstrated that OSA was found to be prevalent in the cohort of nonobese male patients studied. Coexistence of lifestyle stress, sleep deprivation, and upper airway inflammation was revealed.

Swyer-James-MacLeod syndrome-a rare diagnosis presented through two adult patients.

Swyer-James-MacLeod syndrome (SJMS) is a rare syndrome of acute obliterative bronchiolitis following an early childhood infective insult to the lungs. This causes arrest of alveolarization, affecting lung development with hypoplasia of the ipsilateral pulmonary artery and results in a characteristic radiological pattern, such as a unilateral hyperlucent lung with expiratory air-trapping and pruned-tree appearance on pulmonary angiogram. The clinical presentation is either recurrent chest infections, exertional dyspnoea or it may be an incidental finding. Management involves early prevention of infection, airway clearance, and regular vaccinations. We describe two adult patients with SJMS: A 51-year-old female of Indian ethnicity presenting with recurrent haemoptysis and a 40-year-old Indigenous male presenting acutely with sepsis and background history of recurrent chest infections. These cases highlight the importance of being aware of and accurately recognizing this rare condition, to be able to manage patients appropriately and avoid incorrect and unnecessary treatment.

Effect of mandibular advancement device on sleep bruxism score and sleep quality.

STATEMENT OF PROBLEM: The use of mandibular advancement devices (MADs) in the treatment of sleep bruxism is gaining widespread importance. However, the effects of MADs on sleep bruxism scores, sleep quality, and occlusal force are not clear. PURPOSE: The purpose of this clinical study was to analyze the effect of MADs on sleep bruxism scores, sleep quality, and occlusal force. MATERIAL AND METHODS: This uncontrolled before and after study enrolled 30 participants with sleep bruxism. Outcomes assessed were sleep quality, sleep bruxism scores (sleep bruxism bursts and sleep bruxism episodes/hour), and occlusal force before and after 15 and 30 days of using a MAD. Sleep bruxism scores were assessed by ambulatory polysomnography and sleep quality by using the Pittsburgh sleep quality index (PSQI). Occlusal force was recorded by using a digital gnathodynamometer in the first molar region on both sides. Statistical analysis was done by 1-factor repeated measures ANOVA (α=.05). RESULTS: Statistically significant reductions in sleep bruxism bursts/h, sleep bruxism episodes/h, and PSQI scores were found after 15 and 30 days of using a MAD (P<.001). Statistically significant reduction in occlusal force on both sides was found only after 15 days (P<.001) but not after 30 days of using a MAD (P=.292 on left side, and P=.575 on the right side). CONCLUSIONS: The study showed a short-term improvement in sleep bruxism scores, sleep quality, and reduction in occlusal force in sleep bruxism participants after using MADs.

Changes in Upper Airway Volume in Edentulous Obstructive Sleep Apnea Patients Treated with Modified Mandibular Advancement Device.

PURPOSE: This study was an attempt to verify the utility of complete dentures modified as a mandibular advancement device (MAD) in effecting expansion in pharyngeal volume to treat obstructive sleep apnea (OSA) in edentulous patients. MATERIALS AND METHODS: The sample consisted of 17 patients (12 male, 5 female, average age 61 ± 4 years; BMI, 22 ± 5; apnea hypopnea index [AHI] 15 to 30). All patients had worn complete dentures for at least 1 year; all patients had the dentures modified to a MAD. Five variables were assessed preoperatively and 6 months after wearing the modified MADs. These variables were: sleep efficiency, AHI, oxygen desaturation events/hr., mean oxygen saturation, snoring index, and airway volume. This assessment was done by subjecting the patients to all-night polysomnography. RESULTS: Without any prosthesis or device in the edentulous patients, the mean velopharyngeal volume was 8.05 ± 0.58 cm(3) , oropharyngeal volume was 2.14 ± 0.38 cm(3) , and hypopharyngeal volume was 3.26 ± 0.78 cm(3) . With complete dentures (unaltered) in the edentulous patients, the mean velopharyngeal, oropharyngeal, and hypopharyngeal volumes were 10.73 ± 0.98 cm(3) , 2.60 ± 0.48 cm(3) , and 4.31 ± 0.89 cm(3) , respectively. There was a statistically significant change in the airway volume following insertion of the complete dentures modified as MADs with velopharyngeal, oropharyngeal, and hypopharyngeal volume recorded as 11.76 ± 1.07 cm(3) , 3.33 ± 0.51 cm(3) , and 4.94 ± 0.83 cm(3) , respectively. CONCLUSION: From the results obtained in this limited small sample study, it was inferred that the pharyngeal expansion induced by complete dentures modified as MADs effectively reduced symptoms of OSA. Increased volume was most pronounced in the velopharynx region followed by hypopharynx and oropharynx.

Computed tomographic evaluation of the effects of mandibular advancement devices on pharyngeal dimension changes in patients with obstructive sleep apnea.

PURPOSE: The aims of this study were to evaluate the effect of a mandibular advancement device on oropharyngeal dimension in patients with obstructive sleep apnea (OSA) and reveal the predominate site of changes produced by mandibular advancement using computed tomography (CT). MATERIALS AND METHODS: CT scans of 20 patients diagnosed with OSA were taken with and without the appliance. Three-dimensional changes in pharyngeal shape measured on cross-sectional CT images during two respiratory cycles after oral appliance insertion were estimated at five vertical levels using three variables: (1) lateral dimension, (2) anteroposterior dimension, and (3) cross-sectional area. Various parameters related to severity of OSA such as snoring volume, frequency, duration, and episodes; breathing pauses; oxygen saturation; Epworth Sleepiness Scale (ESS) score; and Apnea Hypopnea Index (AHI) score underwent comparative evaluation subjectively and objectively. Data were analyzed using the Student t test for parametric analysis. RESULTS: A significant increase in the lateral and anteroposterior dimension of the pharyngeal lumen was observed at all five levels, but the mean change was greatest at the retroglossal level and smallest at the hypopharyngral level in both the lateral and anteroposterior dimensions. The cross-sectional area at all levels appeared to increase significantly, and apnea indices improved significantly. A significant decrease in snoring volume, snoring frequency, breathing pauses, snoring duration, snoring episodes, ESS score, and AHI score and a significant increase in oxygen saturation were found after treatment with the mandibular advancement device. CONCLUSION: Within the limitations of this study, CT was shown to be useful in evaluating treatment efficacy in subjects with OSA.

A pilot study to evaluate posttreatment cephalometric changes in subjects with OSA.

STATEMENT OF PROBLEM: Obstructive sleep apnea (OSA) is a life-threatening condition that is diagnosed and evaluated primarily by polysomnography (PSG). The procedure is time consuming, expensive, and inconvenient for the patient, and may not be universally available. PURPOSE: The purpose of this pilot study was to evaluate posttreatment results on lateral cephalograms in patients with OSA. MATERIAL AND METHODS: Lateral cephalograms of 16 patients diagnosed with OSA were made at the beginning of treatment and 4-6 weeks following treatment. Treatment modalities used in the study were the mandibular advancement device (MAD) and continuous positive airway pressure (CPAP) therapy (n=8). Pharyngeal dimensions, soft palate area and angle, and hyoid bone position were recorded for the comparisons. The data were analyzed using Student's t test for the parametric analysis (alpha=.05). RESULTS: A significant increase in the pharyngeal area (P<.001), a significant decrease in the soft palate area (P<.001), and vertical changes in the hyoid position were observed, with no significant change in the anteroposterior position of the hyoid bone. CONCLUSIONS: Within the limitations of this pilot study, lateral cephalograms were shown to be useful in evaluating treatment efficacy in subjects with OSA.