Evaluation of the masticatory muscle function, physiological sleep variables, and salivary parameters after electromechanical therapeutic approaches in adult patients with Down syndrome: a randomized controlled clinical trial.

BACKGROUND: There are many comorbidities associated with Down syndrome (DS), including obstructive sleep apnea (OSA) and masticatory muscle alteration. Muscular hypotonia, in particular, of the masticatory and oropharyngeal muscles is one of the main characteristics of individuals with DS, resulting in impairments of speech, swallowing, and mastication in these individuals. In addition, total or partial obstruction of the airways during sleep can occur due to pharyngeal hypotonia, leading to snoring and to OSA. This progressive respiratory disorder is associated with a high risk of morbidity and mortality in individuals with DS. The aim of this research is to assess the therapeutic effects of surface neuromuscular electrical stimulation (NMES), the mastication apparatus (MA), and a mandibular advancement oral appliance (OAm) with an embedded thermosensitive microchip on the functions of masticatory muscles (bilateral masseter and temporal muscles), physiological sleep variables, and salivary parameters in adult patients with DS. METHODS: The patients with DS will be randomly selected and divided into three groups (DS-NMES, DS-MA, and DS-OAm) with a minimum of 10 patients in each group. A thermosensitive microchip will be embedded in the OAm to record its compliance. The therapeutic effects on masticatory muscle function will be investigated through electromyography, a caliper, and a force-transducer device; the sleep variables, in turn, will be evaluated by means of polysomnography. The physicochemical and microbiological properties of the saliva will also be analyzed, including the salivary flow, viscosity, buffer capacity, cortisol levels (susceptibility to psychological and/or physical stress), and Pseudomonas aeruginosa levels (risk of aspiration pneumonia) in these patients. The methods determined for this study will be carried out prior to and after 2 months of the recommended therapies. DISCUSSION: The primary outcomes would be the improvement and/or reestablishment of the function of masticatory muscles and the physiological sleep variables in this target public since individuals with DS commonly present generalized muscular hypotonia and dysfunction of the oropharyngeal musculature. As a secondary outcome indicator, the impact of the applied therapies (NMES, MA, and OAm) on the salivary microbiological and physicochemical properties in DS individuals will also be assessed. Furthermore, the compliance of OAm usage will be measured through a thermosensitive microchip. TRIAL REGISTRATION: Registro Brasileiro de Ensaios Clínicos, RBR-3qp5np . Registered on 20 February 2018.

Effects of the photobiomodulation using different energy densities on the periodontal tissues under orthodontic force in rats with type 2 diabetes mellitus.

To evaluate the impact of the GaAlAs diode laser with energy densities of 160 J/cm2, 320 J/cm2, and 640 J/cm2 on the periodontal tissues under continuous orthodontic force application and on the rate of orthodontic tooth movement in rats with type-2 diabetes mellitus. The intensity of primary alveolar bone formation was also investigated through the immune-positive osteocytes for OPN antibody. Forty adult male Wistar rats were divided into eight groups of 5 rats: normoglycemic (N), 160 J-laser-normoglycemic (160 J-LN), 320 J-laser-normoglycemic (320 J-LN), 640 J-laser-normoglycemic (640 J-LN), diabetic (D), 160 J-laser-diabetic (160 J-LD), 320 J-laser-diabetic (320 J-LD), and 640 J-laser-diabetic (640 J-LD) rats. Diabetes mellitus was induced by a single intravenous injection of 40 mg/kg monohydrated-alloxan. An orthodontic force magnitude of 20cN was applied. The laser parameters were continuous emission of 780-nm wavelength, output power of 20mW, and fiber probe with a spot size of 0.04 cm in diameter. Radiographic, histomorphological, and immunohistochemical analysis were performed after a period of 21 days. The photobiomodulation using the energy density of 640 J/cm2 strongly stimulated the alveolar bone formation and contributed the reorganization of the soft periodontal tissues, followed by the 320 J/cm2. Extensive alveolar bone loss, intense infiltration of inflammatory cells, and degradation of the PDJ tissue were mainly found in the D and 160 J-LD groups. The rate of orthodontic tooth movement was represented by the interdental distance between the cementoenamel junctions of the right mandibular first and second molars . This distance was larger in the diabetic groups (D: 39.98±1.97, 160 J-LD: 34.84±6.01, 320 J-LD: 29.82±1.73, and 640 J-LD: 35.47±4.56) than in the normoglycemic groups (N: 21.13±1.19; 160 J-LN: 22.69±0.72, 320 J-LN: 22.28±0.78, and 640 J-LN: 24.56±2.11). The number of osteopontin-positive osteocytes was significantly greater in the 640 J-LD (14.72 ± 0.82; p < 0.01) and 640 J-LN (13.62 ± 1.33; p < 0.05) groups than with D (9.82 ± 1.17) and 160 J-LD (9.77 ± 1.10) groups. Therefore, the energy density of 640 J/cm2 provided the best maintenance and integrity of the periodontal tissue microarchitecture under continuous orthodontic force when compared with the other dosages, mainly in the uncontrolled diabetic rats. The interdental distance was greater in the D and 160 J-LD groups due to presence of severe periodontitis caused by diabetes plus the mechanical stress generated by continuous orthodontic forces, implying, thus, an insufficient biostimulatory effect for the dosage of 160 J/cm2.

Effects of the photobiomodulation using different energy densities on the periodontal tissues under orthodontic force in rats with type 2 diabetes mellitus

Abstract To evaluate the impact of the GaAlAs diode laser with energy densities of 160 J/cm2, 320 J/cm2, and 640 J/cm2 on the periodontal tissues under continuous orthodontic force application and on the rate of orthodontic tooth movement in rats with type-2 diabetes mellitus. The intensity of primary alveolar bone formation was also investigated through the immune-positive osteocytes for OPN antibody. Forty adult male Wistar rats were divided into eight groups of 5 rats: normoglycemic (N), 160 J-laser-normoglycemic (160 J-LN), 320 J-laser-normoglycemic (320 J-LN), 640 J-laser-normoglycemic (640 J-LN), diabetic (D), 160 J-laser-diabetic (160 J-LD), 320 J-laser-diabetic (320 J-LD), and 640 J-laser-diabetic (640 J-LD) rats. Diabetes mellitus was induced by a single intravenous injection of 40 mg/kg monohydrated-alloxan. An orthodontic force magnitude of 20cN was applied. The laser parameters were continuous emission of 780-nm wavelength, output power of 20mW, and fiber probe with a spot size of 0.04 cm in diameter. Radiographic, histomorphological, and immunohistochemical analysis were performed after a period of 21 days. The photobiomodulation using the energy density of 640 J/cm2 strongly stimulated the alveolar bone formation and contributed the reorganization of the soft periodontal tissues, followed by the 320 J/cm2. Extensive alveolar bone loss, intense infiltration of inflammatory cells, and degradation of the PDJ tissue were mainly found in the D and 160 J-LD groups. The rate of orthodontic tooth movement was represented by the interdental distance between the cementoenamel junctions of the right mandibular first and second molars . This distance was larger in the diabetic groups (D: 39.98±1.97, 160 J-LD: 34.84±6.01, 320 J-LD: 29.82±1.73, and 640 J-LD: 35.47±4.56) than in the normoglycemic groups (N: 21.13±1.19; 160 J-LN: 22.69±0.72, 320 J-LN: 22.28±0.78, and 640 J-LN: 24.56±2.11). The number of osteopontin-positive osteocytes was significantly greater in the 640 J-LD (14.72 ± 0.82; p < 0.01) and 640 J-LN (13.62 ± 1.33; p < 0.05) groups than with D (9.82 ± 1.17) and 160 J-LD (9.77 ± 1.10) groups. Therefore, the energy density of 640 J/cm2 provided the best maintenance and integrity of the periodontal tissue microarchitecture under continuous orthodontic force when compared with the other dosages, mainly in the uncontrolled diabetic rats. The interdental distance was greater in the D and 160 J-LD groups due to presence of severe periodontitis caused by diabetes plus the mechanical stress generated by continuous orthodontic forces, implying, thus, an insufficient biostimulatory effect for the dosage of 160 J/cm2.

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

Cerebral palsy (CP) is a term employed to define a group of non-progressive neuromotor disorders caused by damage to the immature or developing brain, with consequent limitations regarding movement and posture. CP may impair orapharygeal muscle tone, leading to a compromised chewing function and to sleep disorders (such as obstructive sleep apnea). Thirteen adults with CP underwent bilateral masseter and temporalis neuromuscular electrical stimulation (NMES) therapy. The effects on the masticatory muscles and sleep variables were evaluated using electromyography (EMG) and polysomnography (PSG), respectively, prior and after 2 months of NMES. EMG consisted of 3 tests in different positions: rest, mouth opening and maximum clenching effort (MCE). EMG values in the rest position were 100% higher than values recorded prior to therapy for all muscles analyzed (p < 0.05); mean mouth opening increased from 38.0 ± 8.0 to 44.0 ± 10.0 cm (p = 0.03). A significant difference in MCE was found only for the right masseter. PSG revealed an improved in the AHI from 7.2±7.0/h to 2.3±1.5/h (p < 0.05); total sleep time improved from 185 min to 250 min (p = 0.04) and minimun SaO2 improved from 83.6 ± 3.0 to 86.4 ± 4.0 (p = 0.04). NMES performed over a two-month period led to improvements in the electrical activity of the masticatory muscles at rest, mouth opening, isometric contraction and sleep variables, including the elimination of obstructive sleep apnea events in patients with CP. Trial registration: ReBEC RBR994XFS http://www.ensaiosclinicos.gov.br.

Effect of a hyperbolide mastication apparatus for the treatment of severe sleep bruxism in a child with cerebral palsy: long-term follow-up.

PURPOSE: Sleep bruxism is common among the various oromotor alterations found in individuals with cerebral palsy (CP). Few studies have investigated the use of the mastication device denominated "hyperbola" (HB) and none was found describing the use of such a device for the treatment of bruxism in children with CP. The aim of the present study was to evaluate the effect of the HB on electromyographic (EMG) activity in the jaw-closing muscles and the reduction in sleep bruxism in a child with CP using surface EMG analysis before and after nine months of treatment. METHODS: A seven-year-old boy with severe spastic CP and sleep bruxism was enrolled in this study. The HB was chosen as the treatment option for sleep bruxism in this case because the child did not accept an occlusal splint. The HB has a hyperbolic shape and is made of soft, non-toxic, odorless, tasteless silicone. There are five different sizes of HB manufactured based on the diversity of tooth sizes. This device produces proprioceptive excitation in the dentoalveolar nerve, spindles and Golgi tendon organs. HB has been employed for the treatment of temporomandibular disorder, abnormal oro-dental development, abnormal occlusion, xerostomy, halitosis and bruxism. HB therapy was performed for 5 min six times a day over a nine-week period. Surface EMG of the mandible at rest and during maximum contraction was performed on the masseter and temporalis muscles bilaterally to evaluate electromyographic activity before and after nine months of HB usage. RESULTS: HB usage led to a visible tendency toward the reorganization of mastication dynamics, achieving a marked balance in electromyographic activity of the jaw-closing muscles and improving the child's quality of life. CONCLUSION: Based on the findings of the present study, this noninvasive therapy may be useful for individuals with cerebral palsy due to its positive effects and low cost, which allows its use in the public health realm. Further clinical studies with a larger sample size are needed to validate these results and allow the development of a new treatment protocol for patients with spastic cerebral palsy.

Effect of an occlusal splint on sleep bruxism in children in a pilot study with a short-term follow up.

The aim of the present study was to evaluate the effect of the use of an occlusal splint in children with bruxism in a pilot study with a short-term follow up. Seventeen children were recruited, only nine of whom formed the sample following the application of the inclusion criteria: presence of sleep bruxism for at least six months (based on parents' reports); presence of at least the first permanent molars; and no previous history of treatment involving an occlusal splint. The sample was submitted to a clinical exam. Other sleep problems were screened with the use of a sleep questionnaire filled out by parents before and after 90 days of occlusal splint usage. The children received a flat acrylic resin splint with full coverage of the occlusal surfaces to be worn in the maxilla. In children with erupting teeth, a space was created in the splint to allow normal eruption. After the 90-day period, the absence of sleep bruxism and sleep movements was noted in most of children. Moreover, snoring was reduced in nearly 50%, which raises a new issue to be investigated with regard to the pathophysiology of sleep bruxism. The use of an occlusal splint was effective in reducing the symptoms of sleep bruxism and other sleep problems. Further investigations should be carried out on the relationship between snoring and sleep bruxism in children.

Effects of neuromuscular electrical stimulation, laser therapy and LED therapy on the masticatory system and the impact on sleep variables in cerebral palsy patients: a randomized, five arms clinical trial.

BACKGROUND: Few studies demonstrate effectiveness of therapies for oral rehabilitation of patients with cerebral palsy (CP), given the difficulties in chewing, swallowing and speech, besides the intellectual, sensory and social limitations. Due to upper airway obstruction, they are also vulnerable to sleep disorders. This study aims to assess the sleep variables, through polysomnography, and masticatory dynamics, using electromiography, before and after neuromuscular electrical stimulation, associated or not with low power laser (Gallium Arsenide- Aluminun, =780 nm) and LED (= 660 nm) irradiation in CP patients. METHODS/DESIGN: 50 patients with CP, both gender, aged between 19 and 60 years will be enrolled in this study. The inclusion criteria are: voluntary participation, patient with hemiparesis, quadriparesis or diparetic CP, with ability to understand and respond to verbal commands. The exclusion criteria are: patients undergoing/underwent orthodontic, functional maxillary orthopedic or botulinum toxin treatment. Polysomnographic and surface electromyographic exams on masseter, temporalis and suprahyoid will be carry out in all sample. Questionnaire assessing oral characteristics will be applied. The sample will be divided into 5 treatment groups: Group 1: neuromuscular electrical stimulation; Group 2: laser therapy; Group 3: LED therapy; Group 4: neuromuscular electrical stimulation and laser therapy and Group 5: neuromuscular electrical stimulation and LED therapy. All patients will be treated during 8 consecutive weeks. After treatment, polysomnographic and electromiographic exams will be collected again. DISCUSSION: This paper describes a five arm clinical trial assessing the examination of sleep quality and masticatory function in patients with CP under non-invasive therapies. TRIAL REGISTRATION: The protocol for this study is registered with the Brazilian Registry of Clinical Trials - ReBEC RBR-994XFS.

Static balance and function in children with cerebral palsy submitted to neuromuscular block and neuromuscular electrical stimulation: study protocol for prospective, randomized, controlled trial.

BACKGROUND: The use of botulinum toxin A (BT-A) for the treatment of lower limb spasticity is common in children with cerebral palsy (CP). Following the administration of BT-A, physical therapy plays a fundamental role in potentiating the functionality of the child. The balance deficit found in children with CP is mainly caused by muscle imbalance (spastic agonist and weak antagonist). Neuromuscular electrical stimulation (NMES) is a promising therapeutic modality for muscle strengthening in this population. The aim of the present study is to describe a protocol for a study aimed at analyzing the effects of NMES on dorsiflexors combined with physical therapy on static and functional balance in children with CP submitted to BT- A. METHODS/DESIGN: Protocol for a prospective, randomized, controlled trial with a blinded evaluator. Eligible participants will be children with cerebral palsy (Levels I, II and III of the Gross Motor Function Classification System) between five and 12 years of age, with independent gait with or without a gait-assistance device. All participants will receive BT-A in the lower limbs (triceps surae). The children will then be randomly allocated for either treatment with motor physical therapy combined with NMES on the tibialis anterior or motor physical therapy alone. The participants will be evaluated on three occasions: 1) one week prior to the administration of BT-A; 2) one week after the administration of BT-A; and 3) four months after the administration of BT-A (end of intervention). Spasticity will be assessed by the Modified Ashworth Scale and Modified Tardieu Scale. Static balance will be assessed using the Medicapteurs Fusyo pressure platform and functional balance will be assessed using the Berg Balance Scale. DISCUSSION: The aim of this protocol study is to describe the methodology of a randomized, controlled, clinical trial comparing the effect of motor physical therapy combined with NMES on the tibialis anterior muscle or motor physical therapy alone on static and functional balance in children with CP submitted to BT-A in the lower limbs. This study describes the background, hypotheses, methodology of the procedures and measurement of the results. TRIAL REGISTRATION: RBR5qzs8h.

Behavior analysis of electromyographic activity of the masseter muscle in sleep bruxers.

The effects of occlusal splint on the electric activity of masseter were studied in 15 women who presented sleep bruxism using surface electromyography. Sleep bruxism was defined by its clinical characteristics. The signal acquisition was done during mandible occlusion without clenching and maximum voluntary contraction in two situations. The first was after a workday without using the occlusal splint; and the second, after a sleeping night using occlusal splints. Evaluating masseter muscles during mandible occlusion without clenching, it could be observed that lower values were noticed after splint wearing in both sides. The same results were verified in maximum voluntary contraction (MVC). These results confirmed that the use of occlusal splints reduced the electromyographic activity of the right and left masseters, showing its myorelaxing effect.