A Protocol to Determine Circadian Phase by At-Home Salivary Dim Light Melatonin Onset Assessment.

Internal circadian phase assessment is increasingly acknowledged as a critical clinical tool for the diagnosis, monitoring, and treatment of circadian rhythm sleep-wake disorders and for investigating circadian timing in other medical disorders. The widespread use of in-laboratory circadian phase assessments in routine practice has been limited, most likely because circadian phase assessment is not required by formal diagnostic nosologies, and is not generally covered by insurance. At-home assessment of salivary dim light melatonin onset (DLMO, a validated circadian phase marker) is an increasingly accepted approach to assess circadian phase. This approach may help meet the increased demand for assessments and has the advantages of lower cost and greater patient convenience. We reviewed the literature describing at-home salivary DLMO assessment methods and identified factors deemed to be important to successful implementation. Here, we provide specific protocol recommendations for conducting at-home salivary DLMO assessments to facilitate a standardized approach for clinical and research purposes. Key factors include control of lighting, sampling rate, and timing, and measures of patient compliance. We include findings from implementation of an optimization algorithm to determine the most efficient number and timing of samples in patients with Delayed Sleep-Wake Phase Disorder. We also provide recommendations for assay methods and interpretation. Providing definitive criteria for each factor, along with detailed instructions for protocol implementation, will enable more widespread adoption of at-home circadian phase assessments as a standardized clinical diagnostic, monitoring, and treatment tool.

Elastic Bands Improve Oral Appliance Treatment Effect on Obstructive Sleep Apnoea: A Randomised Crossover Trial.

BACKGROUND: Oral appliances (OAs) that limit mouth opening during sleep, such as monobloc appliances, have shown superior treatment effects in subgroups of patients with obstructive sleep apnoea. The application of elastic bands on bibloc appliances may resemble these benefits. OBJECTIVES: The primary objective was to investigate if application of elastic bands to bibloc appliances improves treatment success (> 50% reduction of respiratory event index (REI)), in addition to other subjective variables. Furthermore, we aimed to identify variables predicting the need for elastic bands in OA treatment. METHODS: Included patients (n = 69) were randomly assigned to OA treatment with or without elastic bands. After 3 weeks, treatment effect was investigated with home respiratory polygraphy and questionnaires. Thereafter, patients changed treatment modality, with identical follow-up regime. Statistical analyses were performed using Student's t-test and Pearson's chi-squared test to investigate differences between the two treatment modalities, and logistic regression analysis was conducted to investigate variables tentatively associated with treatment success. RESULTS: Based on REI, the success rate with OA treatment was in favour of elastic bands (53.9% vs. 34.6%, p = 0.002). Male sex and larger maximum mouth opening were identified as predictors for increased treatment success with elastic bands. The main benefit with elastic bands seemed to be greater reduction of REI when supine. However, patients seem to prefer OA without elastic bands. CONCLUSIONS: Elastic bands improved OA treatment effect by reducing the REI in supine position. Patient groups that seemed to benefit from elastic bands in OA treatment were men with large maximum mouth openings.

Partner perceptions are associated with objective sensor-measured adherence to oral appliance therapy in obstructive sleep apnea.

The aims of the present prospective clinical study were to determine objective, sensor-measured adherence to a mandibular advancement device (MAD) in patients with obstructive sleep apnea (OSA) and to identify partner-specific adherence-related factors. A total of 77 eligible participants with mild, moderate, or severe OSA and who were non-adherent to continuous positive airway pressure (mean age 56.2 years) participated in the study (32.5% women). The mean (range) observation time between MAD delivery and final follow-up was 8.3 (3.4-16.5) months. The mean apnea-hypopnea index (AHI) was 26.6 events/hr at baseline and 12.5 events/hr at the 8-month follow-up (both p < 0.001). The mean sensor-measured adherence at the 8-month follow-up was 60.1% for ≥4 hr/night of appliance use for ≥5 days/week. Average usage was 6.4 hr/night, when worn. The mean reduction in the AHI was significantly greater in the "good adherence" (Δ 17.4) than the "poor adherence" group (Δ11.0; p < 0.05). From the partner's perspective, the appliance had a positive effect on sharing a bedroom in the good- (55%) compared to the poor-adherence group (25%; p < 0.05) and on their relationship (51.7% versus 17.9%, respectively; p < 0.05). Regression analyses identified the partner's snoring and apneas to be the most significant factor predicting good adherence to MAD (odds ratio 4.4, 95% confidence interval 1.4-14.0). In conclusion, social factors, like partner perceptions, were positively associated with adherence, which indicate that partner's attitudes and support may be a resource that can be utilised to improve adherence in oral appliance treatment of OSA.

Acoustic pharyngometry - A new method to facilitate oral appliance therapy.

BACKGROUND: There is lack of reliable and accurate methods to predict treatment outcomes of oral appliance (OA) treatment. Acoustic pharyngometry (AP) is a non-invasive technique to evaluate the volume and minimal cross-sectional area of the upper airway, which may prove useful to locate the optimal position of OAs. OBJECTIVE: This retrospective study aimed to evaluate the effect of applying AP to OA treatment of patients with obstructive sleep apnoea (OSA). METHODS: All patients (n = 244) treated with OAs following an AP protocol at two dental clinics between 2013 and 2018 were invited to participate. A total of 129 patients accepted the invitation, and 120 patients (75 men, 45 women) were included in the analyses. Mean baseline age, BMI and apnoea hypopnea index (AHI) were 59.1 ± 0.9 years, 27.8 ± 0.4 and 21.9 ± 1.1, respectively. Mean follow-up time was 318 ± 24 days. RESULTS: AHI at follow-up was 6.4 ± 0.7, resulting in a treatment success rate of 86.7% (≥50% reduction of baseline AHI). The number of failures (<50% reduction of baseline AHI) did not differ significantly among patients with mild, moderate and severe OSA. 87.6% of the patients reported OA usage every night, and 95.5% reported > 5 hours usage per night, when worn. CONCLUSION: The AP protocol applied seems to contribute to the excellent effect of OA treatment in this study. Further research on the application of AP in OA treatment is necessary in order to clarify its possible beneficial contribution to improving OA therapy.

Oral appliance treatment outcome can be predicted by continuous positive airway pressure in moderate to severe obstructive sleep apnea.

BACKGROUND: Studies show that the therapeutic CPAP pressure is associated with oral appliance (OA) treatment outcome in obstructive sleep apnea (OSA) patients. However, these studies included either CPAP adherent patients using fixed pressure devices, or partly CPAP non-adherent patients using fixed pressure or auto-adjusting (auto-CPAP) devices. In many countries, auto-CPAP is predominately used, and only those non-adherent to therapy need a change to OA. Therefore, studies examining the relationship between CPAP pressures and OA treatment outcome should focus on patients non-adherent to auto-CPAP. PURPOSE: The purpose of this paper is to assess if CPAP pressures predicted OA treatment outcome in patients non-adherent to auto-CPAP therapy. METHODS: The OA treatment responders and non-responders were defined by two success criteria ((1) AHI < 5; (2) 5 ≤ AHI < 10 and > 50% AHI reduction). Logistic regression analyses were performed for CPAP pressures and baseline variables. ROC curve analyses were used to identify CPAP pressure cutoff values, alone and combined with other explanatory variables, predicting the OA treatment outcome. RESULTS: Eighty-seven patients with moderate or severe OSA were included. Maximum CPAP pressures (CPAPmax) were higher in non-responders by both criteria and were, together with baseline AHI, associated with the OA treatment outcome in multivariate regression analyses. ROC curves identified an optimal CPAPmax cutoff of 12 cm H2O, corresponding to a positive predictive value (PPV) of 0.85 in predicting non-response using criterion 1. A prediction model combining CPAPmax > 12 and baseline AHI ≥ 30 had a PPV of 1.0 for non-response by both criteria. CONCLUSIONS: Maximum CPAP pressure was a moderate predictor of OA treatment outcome, but combined with baseline AHI, the ability to identify OA non-responders was high.

Objective measures of sleep and dim light melatonin onset in adolescents and young adults with delayed sleep phase disorder compared to healthy controls.

Delayed sleep phase disorder is characterized by a delay in the timing of the major sleep period relative to conventional norms. The sleep period itself has traditionally been described as normal. Nevertheless, it is possible that sleep regulatory mechanism disturbances associated with the disorder may affect sleep duration and/or architecture. Polysomnographic data that may shed light on the issue are scarce. Hence, the aim of this study was to examine polysomnographic measures of sleep in adolescents and young adults with delayed sleep phase disorder, and to compare findings to that of healthy controls. A second aim was to estimate dim light melatonin onset as a marker of circadian rhythm and to investigate the phase angle relationship (time interval) between dim light melatonin onset and the sleep period. Data from 54 adolescents and young adults were analysed, 35 diagnosed with delayed sleep phase disorder and 19 healthy controls. Results show delayed timing of sleep in participants with delayed sleep phase disorder, but once sleep was initiated no group differences in sleep parameters were observed. Dim light melatonin onset was delayed in participants with delayed sleep phase disorder, but no difference in phase angle was observed between the groups. In conclusion, both sleep and dim light melatonin onset were delayed in participants with delayed sleep phase disorder. The sleep period appeared to occur at the same circadian phase in both groups, and once sleep was initiated no differences in sleep parameters were observed.