Focus of dental sleep medicine on obstructive sleep apnea in older adults: A narrative review.

PURPOSE: To review dental sleep medicine in older adults based on the literature. STUDY SELECTION: This narrative review focuses on sleep physiology, common sleep disorders, and obstructive sleep apnea (OSA) in older adults and their management. RESULTS: Sleep physiology differs between older and younger adults, with sleep disturbances occurring more frequently in older adults. The prevalence of insomnia increases in older adults due to age-related changes in sleep physiology. Insomnia, sleep-disordered breathing, periodic limb movement disorder, restless legs syndrome, and rapid eye movement (REM) sleep behavior disorder are common sleep disorders in older adults. OSA is more prevalent in older adults, and its effects on them are considered more substantial than those on younger adults. The treatment of older patients with mandibular advancement devices may be less effective and more complex owing to potential impairments in oral and dental health. Furthermore, the prevalence of edentulism in older adults is decreasing while life expectancy is increasing. CONCLUSIONS: As older adults have comorbidities that affect sleep quality, dentists should consider the effects of sleep physiology and sleep disorders in these patients. OSA may decrease the quality of life and increase the risk of developing other diseases. Therefore, dentists proposing treatment with mandibular advancement devices need to inform patients of their potential lack of efficacy and the requirement for careful follow-up owing to known and unknown side effects.

Evaluation of masticatory performance by motion capture analysis of jaw movement.

BACKGROUND: The assessment of masticatory performance (MP) is conducted in hospitals, but is difficult to perform in nursing facilities that lack specialists in dysphagia. To select the appropriate food textures in nursing practice, a simple method of evaluating the MP should be developed. OBJECTIVE: The purpose of this study was to investigate motion parameters that influence MP by motion capture analysis of maxillofacial movement on chewing gummy jelly in healthy adults. METHODS: The subjects were 50 healthy adults. The state of chewing gummy jelly was photographed using a high-speed camera. Simultaneously, we evaluated the amount of glucose extracted (AGE) obtained with gummy jelly as a reference value for MP. The subjects were divided into two groups: normal and low masticatory groups (NG and LG, respectively) based on the AGE. The cycle of mastication was classified into three phases: closing phase (CP), transition phase (TP) and opening phase (OP) through motion capture analysis of the video photographed. Parameters of jaw movement and their associations with the AGE were examined. RESULTS: The transition phase rate (TR) and opening phase rate (OR) were correlated with the AGE. Furthermore, the TR in the NG was significantly higher than in the LG, whereas the OR was significantly lower than in the LG. The age, TR and opening velocity were significant independent variables. CONCLUSION: Motion capture technology facilitated the analysis of jaw movement. The results suggested that MP can be evaluated by analysing the TP and OP rates.

Relationships between the Nutrition Status and Oral Measurements for Sarcopenia in Older Japanese Adults.

INTRODUCTION: The purpose of the present study was to clarify the relationships between the risk of malnutrition as a preliminary stage of malnutrition and overall and oral measurements for sarcopenia in older Japanese adults. METHODS: Forty-five participants (79.7 ± 6.1 years) were included in the analysis. The nutrition status of the participants was assessed using the Mini Nutritional Assessment-Short Form (MNA-SF) and classified into two groups: normal and at risk of malnutrition. Overall measurements for sarcopenia in the present study were the skeletal muscle mass index, grip strength, and walking speed, while oral measurements were the cross-sectional area of the geniohyoid muscle, tongue pressure (TP), and oral diadochokinesis. RESULTS: MNA-SF correlated with TP (r = 0.347, p = 0.019). We observed decreases of 5.7 kPa in TP and 3.9 kg/cm2 in BMI in the at risk of malnutrition group. A multiple regression analysis of parameters contributing to the risk of malnutrition identified TP as an independent variable (ß = 0.913, p = 0.042). CONCLUSIONS: The present results demonstrate that the risk of malnutrition is associated with TP as an oral measurement for sarcopenia, but not overall measurements for sarcopenia. Therefore, low TP may be related with the risk of malnutrition.

Retained products of conception (RPOC) following delivery without placenta previa: Which patients with RPOC show postpartum hemorrhage?

INTRODUCTION: To clarify the perinatal outcome of retained products of conception (RPOC) after 22 weeks or more. METHODS: The retrospective cohort study reviewed medical records of patients with RPOC without placenta previa at 186 Japanese perinatal centers. RESULTS: Of the 323 patients with RPOC, pregnancies after assisted reproductive technology (ART) accounted for 43%. Transfusion at delivery was required in 33% of the patients. Logistic regression analyses revealed that transfusion was significantly required in the following situations: ART pregnancy (aOR: 6.0, 95%CI: 2.3-16, P < 0.001), and RPOC length ≥4 cm (aOR: 5.3, 95%CI: 2.1-13, P < 0.001). Transarterial embolization (TAE) and/or hysterectomy for subsequent RPOC-related bleeding was performed in 60 patients with RPOC. Logistic regression analysis revealed that additional interventions were significantly required in the following situations: multiparity (aOR: 6.1, 95%CI: 2.1-17.2, P < 0.001), and hypervascular RPOC (aOR: 12.8, 95%CI: 3.2-51.1, P < 0.001). TAE and/or hysterectomy was also frequently employed in ART pregnancy, although this was not significant (aOR: 2.8, 95%CI: 0.9-8.2, P = 0.063). DISCUSSION: Patients with RPOC were significantly more likely to require transfusion at delivery in the presence of large RPOC and ART. They were also more likely to require hemostatic procedures for subsequent bleeding in the presence of hypervascular RPOC and ART.

Compliance and side effects of tongue stabilizing device in patients with obstructive sleep apnea.

Objective: To evaluate the long-term effectiveness, compliance, and side effects of tongue stabilizing devices (TSDs).Methods: Thirty-nine patients were followed up after 12 and 30 months. The subjective effectiveness was assessed using the Epworth Sleepiness Scale (ESS), the Functional Outcomes Sleep Questionnaire (FOSQ-10), the Chalder Fatigue Scale (CFQ), and a sleep-related quality of life questionnaire (QoL). Compliance and side effects were assessed.Results: At 12-months, 35.9% of patients confirmed continuing the therapy, compared to only 15.4% of patients at 30 months. At 30 months, a significant average improvement of ESS (2.0 ± 2.8) was observed compared to baseline levels in six patients. Six patients demonstrated an average increase in blood pressure. The most frequently reported side effects were mouth dryness and excessive salivation. The 3D analysis revealed small tooth movements.Conclusion: The TSD therapy demonstrated a good long-term subjective effectiveness against OSA but had a relatively low treatment acceptance rate.

The efficacy of a titrated tongue-stabilizing device on obstructive sleep apnea: a quasi-experimental study.

STUDY OBJECTIVES: To evaluate the short-term efficacy and self-reported outcomes of tongue-stabilizing device (TSD) therapy as compared to those of mandibular advancement device (MAD) therapy in an adult population diagnosed with obstructive sleep apnea. METHODS: This study is a parallel, nonrandomized clinical trial of the TSD and MAD therapies. The efficacy of both interventions was evaluated objectively by level 3 home sleep apnea testing and by self-report using the Epworth Sleepiness Scale, the Functional Outcomes of Sleep Questionnaire, the Chalder Fatigue Scale, and the 36-Item Short-Form Health Survey. Adherence and adverse effects were self-reported. RESULTS: Of the 39 patients who received TSD therapy, 27 managed to adapt and complete the trial and were matched with 26 patients who received MAD therapy. At the 2-month follow-up, the acceptance rate of the TSD therapy was 53.8%. Both patients receiving TSD therapy and patients receiving MAD therapy showed significant improvements in their respiratory event index (P < .05), with no difference between the treatments (P > .05). In those receiving TSD therapy (n = 27), the only self-reported efficacy measure that significantly improved with TSD therapy was the Chalder Fatigue Scale (P < .05). In contrast, all 4 self-reported measures (Epworth Sleepiness Scale, Functional Outcomes of Sleep Questionnaire, 36-Item Short-Form Health Survey, and Chalder Fatigue Scale) showed a significant improvement with MAD therapy. CONCLUSIONS: This study revealed similar improvements in apneas and oxygen saturation between TSD and MAD therapies. Whereas MAD therapy was a better treatment for obstructive sleep apnea in terms of daytime sleepiness and quality-of-life improvements, TSD therapy had a low treatment acceptance rate. CLINICAL TRIAL REGISTRATION: Registry: ClinicalTrials.gov; Name: The Efficacy of Tongue Stabilizing Device in Patients with Obstructive Sleep Apnea; URL: https://clinicaltrials.gov/ct2/show/NCT02329925; Identifier: NCT02329925; and Registry: ClinicalTrials.gov; Name: Adherence and Preference of Continuous Positive Airway Pressure vs Mandibular Advancement Splints in Obstructive Sleep Apnea Patients: A Randomized Trial (CHOICE); URL: https://clinicaltrials.gov/ct2/show/NCT02242617; Identifier: NCT02242617. CITATION: Alshhrani WM, Hamoda MM, Okuno K, et al. The efficacy of a titrated tongue-stabilizing device on obstructive sleep apnea: a quasi-experimental study. J Clin Sleep Med. 2021;17(8):1607-1618.

Prevalence, O-genotype and Shiga toxin (Stx) 2 subtype of Stx-producing Escherichia coli strains isolated from Argentinean beef cattle.

The aims of this study were to investigate prevalence, O-genotype, and virulence gene profile including Shiga toxin (Stx) 2 gene-subtype of Stx-producing Escherichia coli (STEC) in beef cattle from the Bahía Blanca in Argentina. Rectal swabs were collected from 283 beef cattle in 2012. stx genes were detected in 90 (32%) out of the 283 rectal swabs by stx gene-specific PCR assay. The positive cases were 13 with stx1, 58 with stx2, and 19 with both stx1 and stx2. Among 90 stx gene-positive samples, 45 STEC strains were isolated, which included 3 stx1, 34 stx2, and eight stx1 and stx2 genes positive isolates. O-genotyping grouped 45 STEC strains into 19 different O-genotypes such as Og8, Og145, Og171, Og185 (4 from each), Og22, Og153, Og157 (3 from each) and others. Various stx2 gene-subtypes were identified in 42 STEC strains: 13 positive cases for stx2a, 11 for stx2c, 3 for stx2g, 10 for stx2a and stx2d, 4 for stx2a and stx2c, and 1 for stx2b, stx2c and stx2g. efaI gene, generally prevalent in clinical strains, was detected in relatively high in the STEC strains. These data suggest that stx2a and stx2c were distributed not only in O145 and O157 but also in minor O-genotypes of STEC in Argentina.

The success rate of oral appliances based on multiple criteria according to obstructive sleep apnoea severity, BMI and age: A large multicentre study.

BACKGROUND: The efficacy of oral appliance (OA) varies greatly in patients with obstructive sleep apnoea (OSA). OBJECTIVE(S): The purpose of this cross-sectional study was to investigate the success rate of OA for OSA patients. METHODS: This study was based on a cross-sectional multicentre survey of OA therapy for the management of OSA called the JAMS (Japanese Cross-sectional Multicenter Survey) Study performed at 10 medical institutions. A total of 442 patients fulfilled the selection criteria, which patients had worn OA, and undergone overnight polysomnography to assess both the pre-treatment baseline and follow-up for OA. Age, sex, BMI and apnoea-hypopnea index (AHI) at the time of diagnosis and follow-up for OA were extracted. RESULTS: After OA treatment, the mean AHI decreased from 22.6 ± 13.8 to 10.0 ± 10.2/h, and the mean rate of decrease in the AHI was 52.5 ± 38.4%. Regarding the success rate to OA therapy, criterion 1 (AHI < 5/h), criterion 2 (AHI < 10/h), criterion 3 (AHI < 15/h) and criterion 4 (AHI reduction rate ≥ 50%) accounted for 33.5, 66.3, 80.5 and 63.3%, respectively. The success rate of OA treatment decreased according to the increase in OSA severity, obesity level (higher BMI) and older age. CONCLUSIONS: This study revealed the treatment success rate of OA on multiple criteria according to OSA severity, BMI and age. It may support for the clinician to make a decision on the OSA management.

Development of XRM-MacConkey agar selective medium for the isolation of Escherichia albertii.

Escherichia albertii has increasingly been recognized as an emerging pathogen. However, lack of selective medium for E. albertii is the bottleneck for clinical and epidemiological investigations. In this study, a selective medium for E. albertii named XRM-MacConkey agar, which is modified MacConkey agar supplemented with xylose (X), rhamnose (R), and melibiose (M) instead of lactose, was developed and evaluated. All 49 E. albertii and 6 different species out of 23 grew as colorless colonies, whereas 17 remaining species grew as red colonies. Detection limit of E. albertii by this medium was 105 CFU/g stool when examined with spiked healthy human stool. Furthermore, colorless colonies on XRM-MacConkey agar obtained from 7 E. albertii-positive diarrheal stools were consistently E. albertii. In contrast, 57%, 18%, and 36% colorless colonies on MacConkey, DHL, and mEA agars, respectively, were non-E. albertii. We concluded that XRM-MacConkey agar could specifically be used for isolation of E. albertii.

The relationship between sarcopenia and oral sarcopenia in elderly people.

BACKGROUND: Sarcopenia in the oral region, including the tongue, leads to declined swallowing function and dysphagia. Muscle mass and strength, and motor function in the oral region have not been examined together, and the relationship between generalised and oral sarcopenia remains unclear. OBJECTIVE(S): The purpose of this study is to clarify the relationship between generalised sarcopenia and oral sarcopenia in the elderly in order to facilitate the establishment of a method for assessing oral sarcopenia. METHODS: A total of 54 elderly persons participated in this study. We examined the skeletal muscle mass index (SMI), grip strength (GS) and walking speed (WS) as the index of generalised sarcopenia, and the cross-sectional area of the geniohyoid muscle (CSG), tongue pressure (TP) and oral diadochokinesis (ODK) as the index of oral sarcopenia. RESULTS: We found a moderate correlation between CSG and SMI, a weak correlation between GS and TP, and a moderate correlation between WS and ODK. CSG, TP and ODK were significantly smaller in the sarcopenia group than in the non-sarcopenia group. By multiple regression analysis, SMI and TP were significantly associated with CSG. ODK, BMI and CSG were significantly associated with TP. WS and SMI were significantly associated with ODK. CONCLUSION: CSG, TP and ODK were confirmed as endpoints of oral sarcopenia. All endpoints of oral sarcopenia were influenced by those of generalised sarcopenia.

Japanese Cross-Sectional Multicenter Survey (JAMS) of Oral Appliance Therapy in the Management of Obstructive Sleep Apnea.

We conducted a multicenter survey for oral appliance (OA) therapy to grasp and analyze the current situation of OA therapy, including efficacy, side effects, and follow-up, in Japan. The Japanese cross-sectional multicenter survey (JAMS) for obstructive sleep apnea (OSA) was undertaken by patients in 10 institutions associated with oral appliance therapy during two years, from 2014 to 2015, retrospectively. Age, sex, body mass index (BMI), baseline apnea-hypopnea index (AHI), OA type, adjustment, adverse reactions with OA, and AHI with OA were elicited from the patient clinical record. The number of included OSA patients was 3217. The number of patients with OA therapy was 2947. We evaluated 1600 patients for the OA treatment. The patients treated with OA, both male and female, were most commonly in their 50s. In terms of OSA severity, snoring was 2.3%, mild was 38.5%, moderate was 39.9%, and severe was 19.3%. The use of mono bloc appliance was 91.8%, bi bloc appliance was 7.9%, and tongue-retaining device (TRD) was 0.3%. After OA treatment, AHI decreased from 22.4/h to 9.3/h. The AHI reduction rate with OA was 52.0%. The rate of AHI <5 with OA was 35.6%. Adverse reactions developed in 14.7% of the subjects. OA reassessment was conducted for 54.3%. This study revealed the current situation of efficacy and side effects of OA therapy, and the problem that the reassessment rate of OA was low in Japan.

Tongue Stabilizing Device-Emergent Central Sleep Apnea: A Case Report.

ABSTRACT: Treatment-emergent central sleep apnea is a phenomenon that has been reported after many obstructive sleep apnea treatment modalities. We present a case of demonstrating treatment-emergent central sleep apnea while using the tongue stabilizing device therapy. This case adds to the evidence that showed the effect of the supine position on the severity of central sleep apnea and shows the advantage of polysomnography follow-up after oral appliance therapy for central apnea assessment.

The efficacy of nasal airway stent (Nastent) on obstructive sleep apnoea and prediction of treatment outcomes.

BACKGROUND: Obstructive sleep apnoea (OSA) is characterised by recurrent episodes of partial or complete upper airway collapse during sleep and is highly prevalent in the general population. The nasopharyngeal airway stent (Nastent) is a specifically designed, preformed silicone tube that intends to maintain the upper airway patency during sleep and reduce snoring and sleep apnoea. OBJECTIVE(S): The purpose of this study was to determine the efficacy of Nastent treatment and examine predictors for Nastent treatment outcomes in patients with OSA. METHODS: Consecutive thirty patients were enrolled in this study. Cephalometric radiographs were obtained to analyse the pharyngeal and craniofacial morphology. Before and after Nastent treatment, we evaluated OSA using a portable sleep study. RESULTS: Twenty-nine subjects completed this study. There were significant decreases in the respiratory event index (REI) (22.4 ± 14.1 to 15.7 ± 10.4, P < 0.01) and a significant increase in the lowest SpO2 (81.9 ± 7.5 to 86.6 ± 4.8, P < 0.01) by Nastent treatment. Subjects were divided into responders and non-responders based on reduction in REI of >50% compared with baseline REI. We evaluated the ratio of inferior airway width and middle airway width (IAW/MAW) on cephalograms as the index of the narrowest airway site. The IAW/MAW was significantly higher in responders than in non-responders (1.4 ± 0.9 vs 0.9 ± 0.4, P < 0.01) and predicted treatment responders with high accuracy (sensitivity: 90.9%, specificity: 88.9%, when IAW/MAW was set at 1.10). CONCLUSIONS: The Nastent device improved OSA, and a narrower velopharynx than hypopharynx predicted treatment response with a good sensitivity and specificity.

Novel Cholera Toxin Variant and ToxT Regulon in Environmental Vibrio mimicus Isolates: Potential Resources for the Evolution of Vibrio cholerae Hybrid Strains.

Atypical El Tor strains of Vibrio cholerae O1 harboring variant ctxB genes of cholera toxin (CT) have gradually become a major cause of recent cholera epidemics. Vibrio mimicus occasionally produces CT, encoded by ctxAB on CTXФ genome; toxin-coregulated pilus (TCP), a major intestinal colonization factor; and also the CTXФ-specific receptor. This study carried out extensive molecular characterization of CTXФ and ToxT regulon in V. mimicusctx-positive (ctx+) strains (i.e., V. mimicus strains containing ctx) isolated from the Bengal coast. Southern hybridization, PCR, and DNA sequencing of virulence-related genes revealed the presence of an El Tor type CTX prophage (CTXET) carrying a novel ctxAB, tandem copies of environmental type pre-CTX prophage (pre-CTXEnv), and RS1 elements, which were organized as an RS1-CTXET-RS1-pre-CTXEnv-pre-CTXEnv array. Additionally, novel variants of tcpA and toxT, respectively, showing phylogenetic lineage to a clade of V. cholerae non-O1 and to a clade of V. cholerae non-O139, were identified. The V. mimicus strains lacked the RTX (repeat in toxin) and TLC (toxin-linked cryptic) elements and lacked Vibrio seventh-pandemic islands of the El Tor strains but contained five heptamer (TTTTGAT) repeats in ctxAB promoter region similar to those seen with some classical strains of V. cholerae O1. Pulsed-field gel electrophoresis (PFGE) analysis showed that all the ctx+V. mimicus strains were clonally related. However, their in vitro CT production and in vivo toxigenicity characteristics were variable, which could be explainable by differential transcription of virulence genes along with the ToxR regulon. Taken together, our findings strongly suggest that environmental V. mimicus strains act as a potential reservoir of atypical virulence factors, including variant CT and ToxT regulons, and may contribute to the evolution of V. cholerae hybrid strains.IMPORTANCE Natural diversification of CTXФ and ctxAB genes certainly influences disease severity and shifting patterns in major etiological agents of cholera, e.g., the overwhelming emergence of hybrid El Tor variants, replacing the prototype El Tor strains of V. cholerae This report, showing the occurrence of CTXET comprising a novel variant of ctxAB in V. mimicus, points out a previously unnoticed evolutionary event that is independent of the evolutionary event associated with the El Tor strains of V. cholerae Identification and cluster analysis of the newly discovered alleles of tcpA and toxT suggest their horizontal transfer from an uncommon clone of V. cholerae The genomic contents of ToxT regulon and of tandemly arranged multiple pre-CTXФEnv and of a CTXФET in V. mimicus probably act as salient raw materials that induce natural recombination among the hallmark virulence genes of hybrid V. cholerae strains. This report provides valuable information to enrich our knowledge on the evolution of new variant CT and ToxT regulons.

Dental and skeletal changes associated with long-term oral appliance use for obstructive sleep apnea: A systematic review and meta-analysis.

An oral appliance (OA) is an effective treatment option for patients with obstructive sleep apnea (OSA), but dental and skeletal changes have been detected by many studies after long-term OA use. Better understanding of the long-term side effects may decrease discontinuation of OA use and assist clinicians to make informed decisions. Accordingly, a systematic review and meta-analysis were performed to evaluate the dental and skeletal changes associated with OAs designed to advance the mandible. The quality of the studies was determined by using the risk of bias assessment tool for non-randomized studies (RoBANS), and 12 studies were included in the meta-analysis. OA use was associated with a significant decrease of overjet (OJ) and overbite (OB), and it was suggested that both parameters decreased along with the duration of treatment. Meta-analysis also demonstrated a significant increase of L1-MP. However, there were no significant changes of skeletal modifications or mandibular rotation. Changes of incisor inclination were suggested to make a contribution to reduction of OJ and OB. In conclusion, long-term OA use was associated with dental changes. The results of this study provide information for clinicians about the long-term effects of OAs.

Prevalence and characteristics of extended-spectrum ß-lactamase-producing Escherichia coli in domestic and imported chicken meats in Japan.

The purpose of this study was to investigate the prevalence of extended-spectrum ß-lactamase (ESBL)-producing Escherichia coli (ESBL-Ec) in retail chicken meats in Japan. Fifty-six domestic and 50 imported (Brazil, n=36; United States, n=8; Thailand, n=6) chicken meat samples were analyzed. The 162 ESBL-Ec included 111 from 43 (77%) domestic samples and 51 from 26 (52%) Brazilian samples. Fifty-three and 30 of 111 and 51 ESBL-Ec from domestic and Brazilian chickens, respectively, were selected for ESBL genotyping. The blaCTX-M (91%), blaTEM (36%) and blaSHV (15%) genes were detected in ESBL-Ec isolated from domestic chickens, whereas blaCTX-M (100%) and blaTEM (20%) were detected in ESBL-Ec isolated from imported chickens. Among the blaCTX-M group, blaCTX-M-2 (45%) and blaCTX-M-1 (34%) were prevalent in domestic chicken isolates, whereas blaCTX-M-2 (53%) and blaCTX-M-8 (43%) were prevalent in imported chicken isolates. Domestic chicken isolates were mostly resistant to tetracycline (83%), followed by streptomycin (70%) and nalidixic acid (62%). Imported chicken isolates were resistant to streptomycin (77%), followed by nalidixic acid (63%) and tetracycline (57%). Notably, extensive multidrug resistance was detected in 60% (32/53) and 70% (21/30) ESBL-Ec from domestic and imported chickens, respectively. Virulence genes associated with diarrheagenic and extra-intestinal pathogenic E. coli were detected in ESBL-Ec isolated from domestic and imported chickens. These data suggest that ESBL-Ec in retail chicken meats could be a potential reservoir for antimicrobial resistance determinants and that some are potentially harmful to humans.

Development of a multiplex PCR targeting eae, stx and cdt genes in genus Escherichia and detection of a novel cdtB gene in Providencia rustigianii.

This study was aimed to develop a multiplex PCR (m-PCR) for the detection of Escherichia coli attaching and effacing (eae), Shiga toxin (stx) and cytolethal distending toxin (cdt) genes encoding important virulence factors of diarrheagenic E. coli such as EPEC, STEC, and Escherichia albertii. For this purpose, the m-PCR was designed to detect eae, all the subtypes of stx (stx1, stx2a-g except stx2f) and cdt (I-V) genes. The m-PCR was validated with 58 and 55 target gene-positive and negative strains of different sources, respectively. Sensitivity and specificity of the m-PCR were 100%. The m-PCR could also detect the eae, stx and cdt genes in bacteria spiked into stool specimens with or without enrichment culture. Clinical specimens collected from children with diarrhea were tested by the m-PCR, and 27 eae and 32 cdt genes were detected. Among them, three cdt-II and one untypable cdt gene-positive bacteria were isolated and identified as E. albertii and Providencia rustigianii, respectively. This is the first report demonstrating the presence of cdtB gene in P. rustigianii. These results indicate that the m-PCR is useful for surveillance of eae, stx and cdt gene-positive bacteria, not only EPEC, STEC and E. albertii but also P. rustigianii.

Titration technique using endoscopy for an oral appliance treatment of obstructive sleep apnea.

The degree of mandibular protrusion for an oral appliance (OA) should be customized for each patient with obstructive sleep apnea (OSA). This article describes the mandibular titration technique for OAs to effectively treat OSA by using endoscopy to evaluate the change in the airway at the velopharynx. This technique may minimize the degree of mandible protrusion and contribute to both the efficacy of and compliance with OA therapy.

Predictors of Side Effects With Long-Term Oral Appliance Therapy for Obstructive Sleep Apnea.

STUDY OBJECTIVES: The aim of this study was to investigate the predictors of dental changes associated with long-term treatment with oral appliances (OAs) in patients with obstructive sleep apnea (OSA). METHODS: This was a retrospective study to investigate Japanese patients with OSA receiving long-term treatment with OAs. Comparisons of cephalometric analysis were carried out between the initial and follow-up assessments of dental and skeletal changes. Based on dental changes, predictors that may cause side effects were investigated. RESULTS: A total of 64 patients (average age at start of treatment: 57.7 ± 14.2 years, 44 males) were included in this study. The average duration of treatment was 4.3 ± 2.1 years. Over the total treatment period, there was a significant reduction in overjet (OJ) (1.5 ± 1.3 mm) and overbite (0.90 ± 1.5 mm), and an increase in the lower incisor line to the mandibular plane (3.1 ± 5.4°). A larger reduction in OJ of ≥ 1 mm was associated with treatment duration, use frequency, and mandibular advancement of the OAs. In addition to these predictive factors, the number of teeth was correlated with the amount of OJ reduction. CONCLUSIONS: For long-term treatment with OAs, the risk of dental side effects should be considered, such as a reduction in OJ. A small number of maxillary teeth, as well as the factors associated with OAs, including treatment duration, use frequency, and mandibular advancement of the OAs, was correlated with an increased rate of OJ reduction. COMMENTARY: A commentary on this article appears in this issue on page 7.

Campylobacter upsaliensis isolated from dogs produces high titer of cytolethal distending toxin.

Cytolethal distending toxin (CDT) consisting of CdtA, CdtB and CdtC has been reported to be a possible virulence factor of campylobacters including Campylobacter upsaliensis. In our previous study, the cdtB gene-based PCR-restriction fragment length polymorphism (RFLP) assay for detection and differentiation of 7 Campylobacter species yielded 3 different RFLP patterns (Cu-I to Cu-III). In this study, entire cdt (Cucdt) genes of each pattern were sequenced to see whether there are any differences in cdt genes, its amino acid sequences and biological activity of CuCDT. We found that all 3 representative strains harbor the entire Cucdt genes and homology between prototype and newly determined Cucdt genes was 94 to 98% with cdtA, 93 to 94% with cdtB and 92 to 93% with cdtC, while that between amino acids of CuCDT was 95 to 99% with CdtA, 97 to 98% with CdtB and 92 to 93% with CdtC. Furthermore, CDT activity produced by C. upsaliensis strains was examined by cytotoxicity assay with HeLa cells. Interestingly, C. upsaliensis produced 64 to 2,340 times higher CDT titer in comparison to other campylobacters did. In addition, Cu-III showed 64 times higher CDT titer than Cu-II, although CDT production level was almost the same by western blotting. These data suggest that CDT produced by C. upsaliensis might contribute more to human diseases in comparison to that produced by other campylobacters and Cu-III CDT seems to be more toxic to HeLa cells in comparison to Cu-I and Cu-II CDTs.