Obstructive sleep apnea (OSA) affects an estimated 30 million Americans.¹ OSA is commonly diagnosed and graded using the apnea-hypopnea index (AHI). In practice, however, the AHI reported for the same sleep study may differ depending on which hypopnea criterion is used during scoring. This is why clinicians, laboratories, and payers may refer to AHI-3 and/or AHI-4 when discussing the same patient’s study results. Differences between these two values can affect diagnostic thresholds, severity classification, and insurance reimbursement guidelines.

What is the Apnea-Hypopnea Index?

The Apnea-Hypopnea Index (AHI) is the average number of apneas (complete cessation of airflow) and hypopneas (partial reduction in airflow) per hour of sleep.² The AHI determines disease severity according to AASM guidelines:

• Normal: AHI < 5 events/hour
• Mild OSA: AHI 5-14 events/hour
• Moderate OSA: AHI 15-29 events/hour
• Severe OSA: AHI ≥ 30 events/hour ²

Importantly, AHI-3 and AHI-4 do not represent two different sleep studies; rather, they are two versions of the apnea-hypopnea index, with the same definition of apnea, differing only in the scoring method for hypopnea.

The Two Hypopnea Scoring Rulesetations

AHI-3

The American Academy of Sleep Medicine (AASM) recommended rule, established in the 2012 scoring manual update, defines a hypopnea as:

A ≥30% reduction in airflow lasting ≥10 seconds, associated with either a ≥3% oxygen desaturation OR an arousal from sleep.²

AHI-4

The AHI-4, AASM acceptable rule, historically aligned with Centers for Medicare & Medicaid Services (CMS) requirements, defines a hypopnea as:

A ≥30% reduction in airflow lasting ≥10 seconds, associated with a ≥4% oxygen desaturation.²

This more stringent criterion focuses on events with clear physiological consequences, specifically significant drops in blood oxygen levels. The rationale behind this threshold centers on capturing events with demonstrable cardiovascular and metabolic implications.³

Clinical Implications of the Two Scoring Methods

The choice between AHI-3 and AHI-4 scoring can dramatically affect diagnostic outcomes, particularly across different age groups. According to Abbasi-Moradi et al. in Sleep Medicine (2024) ,⁴ changing from the 4% criterion to the updated 3% recommended rule increases OSA diagnosis rates by approximately 27.6% to 38.8% across different age groups(Table 1). ⁴ This surge in positive diagnoses is particularly prominent among patients under age 40 with mild OSA symptoms — a finding that underscores the importance of screening younger patients who may exhibit relatively healthier oxygen desaturation patterns than older OSA patients yet demonstrate alarming arousal patterns (Figure. 1).

Table 1: According to F. AbbasiMoradi et al. 2024, Age-stratified percentage change in OSA severity classification after switching from AHI-4 to AHI-3

Delta Difference% in diagnosis from 4%AHI to 3%AHI

Figure 1: According to F. AbbasiMoradi et al. 2024, graphical representation of the increase in diagnosis of subjects under the updated AASM recommendation rule (AHI-3) from AHI-4 criteria:

Derived from table 2, Abbasi-Moradi et al. 2024

Diagnostic Sensitivity

The AHI-3 rule demonstrates higher sensitivity in detecting:

• Sleep apnea in younger patients with shallower oxygen desaturation pattern⁴
• Case report where upper airway resistance causes arousals without significant desaturation⁵
• REM-related sleep apnea, where events may cause arousals without deep desaturations (especially in women and young patients)^6–10

Population-Specific Considerations

As mentioned before, the following populations show particular vulnerability to underdiagnosis when using AHI-4:

• Women: Often present with more arousals, less severe OSA during NREM, and greater respiratory events during REM.^10,11
• Younger adults: May have greater respiratory reserve, limiting desaturation.¹²
• Patients with comorbid COPD: Complex interactions between respiratory conditions,¹³ often resulting in more arousals and difficulty falling asleep.

Practical Challenges and Controversies

Sleep laboratories face practical challenges in navigating these dual standards. Recommended approaches include:

1. Dual reporting: Providing both AHI-3 and AHI-4 values on every case
2. AASM-standard reporting: Using recommended criteria with supplementary data for insurance policy

Future Technological Directions

Emerging technologies may influence future diagnostic paradigms:

• Hypoxic burden calculations: Quantifying total oxygen deficit rather than event counting¹⁴ (Stay tuned for future blog posts where we will dive into why measuring the hypoxic burden is so critical.)
• Multi-night testing: Capturing night-to-night variability in AHI

What Belun Offers?

Belun Ring provides multi-night Level 3 Sleep test, providing both AHI-3 and AHI-4 scoring and also hypoxic burden, providing more comprehensive phenotyping of patients’ sleep disorders and enabling long-term monitoring of treatment effects.

Key Takeaways: Guidelines for Applying AHI-3 vs. AHI-4 Criteria

AHI-3 is recommended for:

• Initial clinical diagnosis: Particularly for highly symptomatic patients presenting with a sub-threshold AHI.
• Atypical presentations: Specifically, younger patients with a low-to-moderate BMI who exhibit marked daytime fatigue despite minimal oxygen desaturation.
• Targeted demographics: Women with suspected REM-predominant OSA.

AHI-4 is recommended for:

• Cardiovascular risk assessment: When the clinical focus requires identifying events with a more evident hypoxic burden.
• Administrative compliance: Fulfilling documentation requirements for Medicare, payer preauthorization, or PAP therapy reimbursement.
• Longitudinal analysis: Facilitating historical comparisons with older sleep studies, prior clinical reports, or legacy databases.

Conclusion

The distinction between AHI-3 and AHI-4 scoring rules represents more than a technical detail—it fundamentally affects which demographic differences in patients receive diagnoses and access to treatment. AHI3 offers greater sensitivity and better reflects the full spectrum of obstructive sleep apnea pathophysiology, AHI4 creates coverage challenges for these subsets of patients, in particular to younger and female patients with less steep oxygen desaturation patterns and more arousals. Until standardization occurs, the sleep medicine community must remain vigilant in ensuring that scoring methodology differences do not create barriers to necessary care for patients with obstructive sleep apnea.

REFERENCE:

1.             Benjafield, A. V. et al. Estimation of the global prevalence and burden of obstructive sleep apnoea: a literature-based analysis. Lancet Respir. Med. 7, 687–698 (2019).

2.             Berry, R. B. et al. Rules for scoring respiratory events in sleep: update of the 2007 AASM manual for the scoring of sleep and associated events: deliberations of the Sleep Apnea definitions Task Force of the American Academy of Sleep Medicine. J. Clin. Sleep Med. 08, 597–619 (2012).

3.             Punjabi, N. M., Newman, A. B., Young, T. B., Resnick, H. E. & Sanders, M. H. Sleep-disordered breathing and cardiovascular disease: an outcome-based definition of hypopneas. Am. J. Respir. Crit. Care Med. 177, 1150–1155 (2008).

4.             AbbasiMoradi, F., Mogavero, M. P., Palomino, M., Ferri, R. & DelRosso, L. M. Age related disparities in sleep apnea diagnosis using a wearable device: Implications of 4% vs. 3% hypopnea scoring criteria. Sleep Med. 118, 88–92 (2024).

5.             Guilleminault, C., Stoohs, R., Clerk, A., Cetel, M. & Maistros, P. A cause of excessive daytime sleepiness. The upper airway resistance syndrome. Chest 104, 781–787 (1993).

6.             Mokhlesi, B. & Punjabi, N. M. “REM-related” Obstructive Sleep Apnea: An Epiphenomenon or a Clinically Important Entity? Sleep 35, 5–7 (2012).

7.             Resta, O. et al. Gender difference in sleep profile of severely obese patients with obstructive sleep apnea (OSA). Respir. Med. 99, 91–96 (2005).

8.             Koo, B. B., Patel, S. R., Strohl, K. & Hoffstein, V. Rapid eye movement-related sleep-disordered breathing: influence of age and gender. Chest 134, 1156–1161 (2008).

9.             Goh, D. Y., Galster, P. & Marcus, C. L. Sleep architecture and respiratory disturbances in children with obstructive sleep apnea. Am. J. Respir. Crit. Care Med. 162, 682–686 (2000).

10.          O’Connor, C., Thornley, K. S. & Hanly, P. J. Gender Differences in the Polysomnographic Features of Obstructive Sleep Apnea. Am. J. Respir. Crit. Care Med. 161, 1465–1472 (2000).

11.          Ye, L., Pien, G. W. & Weaver, T. E. Gender differences in the clinical manifestation of obstructive sleep apnea. Sleep Med. 10, 1075–1084 (2009).

12.          Heinzer, R. et al. Prevalence of sleep-disordered breathing in the general population: the HypnoLaus study. Lancet Respir. Med. 3, 310–318 (2015).

13.          Owens, R. L. & Malhotra, A. Sleep-disordered breathing and COPD: the overlap syndrome. Respir. Care 55, 1333–1344; discussion 1344-1346 (2010).

14.          Azarbarzin, A. et al. The hypoxic burden of sleep apnoea predicts cardiovascular disease-related mortality: the Osteoporotic Fractures in Men Study and the Sleep Heart Health Study. Eur. Heart J. 40, 1149–1157 (2019).

Publications by Belun :

1) “Belun® Ring Platform: a novel home sleep apnea testing system for assessment of obstructive sleep apnea” (https://jcsm.aasm.org/doi/10.5664/jcsm.8592),

2) “Detection of obstructive sleep apnea using Belun® Sleep Platform wearable with neural network based algorithm and its combined use with STOP-Bang questionnaire” (https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0258040),

3) “Belun® Ring (Belun® Sleep System BLS-100): Deep Learning-Facilitated Wearable Enables OSA Detection, Apnea Severity Categorization, and Sleep Stage Classification in Patients Suspected of OSA”  (https://pubmed.ncbi.nlm.nih.gov/37380590/), 

4) “Correlation of Pulse Rate Variability(PRV) and Heart Rate Variability(HRV) Metrics During Sleep in Subjects Suspected of OSA” (https://academic.oup.com/sleep/article/46/Supplement_1/A420/7182347)

5) “The Belun sleep platform to diagnose obstructive sleep apnea in patients with hypertension and high cardiovascular risk” (https://pubmed.ncbi.nlm.nih.gov/37071415/)

6) “Integrating Body Sensor into a Wearable Platform to Enhance the Identification of Central and Mixed Apneas”. (https://academic.oup.com/sleep/article/47/Supplement_1/A222/7654683)

7) “Using a Wearable’s Multi-Night Capability to Mitigate Night-to-Night Variability in a Dental Clinic Cohort”. J Dental Sleep Med. 2026; 13(1). (https://aadsm.org/journal/original_article_1_issue_131.php)

Partnering with Belun :

If you would like to know more about how to adopt Belun’s solution in your organization, please feel free to contact us to schedule a meeting by filling out the form below:

The post AHI-3 vs AHI-4 in Sleep Apnea Diagnosis: Understanding the Scoring Rules first appeared on Belun Technology.

Obstructive Sleep Apnea (OSA) is a prevalent and serious sleep disorder that affects millions of Americans. Mandibular Advancement Devices (MADs) are an effective treatment option, especially for those who cannot tolerate Continuous Positive Airway Pressure (CPAP) therapy. However, the titration process—where the device is adjusted to find the optimal advancement that effectively reduces the Apnea-Hypopnea Index (AHI)—can be time-consuming and challenging.

The Challenge: Slow Titration Process

Traditionally, the titration of MADs has relied on periodic sleep studies or follow-up appointments, often spaced weeks or months apart. During this time, patients may continue to experience poor sleep quality, daytime fatigue, and associated health risks due to insufficient control of their OSA. The intermittent nature of monitoring makes it difficult for dentists to quickly determine if adjustments are effectively lowering the AHI, leading to a prolonged titration period and delayed therapeutic outcomes.

The Solution: Daily AHI Monitoring

Integrating AHI monitoring into the treatment process can revolutionize the titration of MADs, offering a faster and more precise approach. By utilizing Belun Ring, the advanced home sleep monitoring device, which can track AHI on a nightly basis, dentists can obtain real-time data on the effectiveness of the current MAD settings.

Key Benefits of AHI Monitoring:

1. Real-Time Feedback: Dentists can access AHI data, allowing them to make timely adjustments to the MAD. This continuous feedback loop accelerates the titration process by quickly identifying the optimal device settings.
2. Increased Patient Engagement: Patients become active participants in their treatment by monitoring their own AHI. This engagement can improve adherence to therapy and encourage patients to report back on their comfortability and any residual symptoms.
3. Reduced Time to Optimal Therapy: By identifying the correct titration settings sooner, patients can achieve therapeutic AHI levels more quickly, reducing the duration of ineffective treatment periods. This leads to faster symptom relief and improved overall health outcomes.
4. Customized Treatment Plans: Daily* monitoring allows for highly individualized treatment. Dentists can fine-tune the MAD to each patient’s specific needs, improving the overall treatment outcomes.
5. Improved Clinical Efficiency: For the dental practice, daily* AHI monitoring reduces the need for frequent in-person follow-up visits solely for MAD adjustments. This efficiency allows for better resource allocation and more focused patient care.
6. Mobile app BelunPro X*: To collect the daily AHI data, Healthcare professionals make the decision if the optional mobile app will be used to get the data remotely. BelunPro X is available at both Apple App Store or Google Play.

Conclusions

AHI monitoring is a game-changer in the management of OSA with MADs. Data empowers dentists to accelerate the titration process, ensuring that patients receive the most effective treatment in the shortest possible time. This approach not only enhances treatment outcomes but also improves the overall efficiency of OSA management in dental practices across the U.S.

Adopting Belun Sleep System in the titration process of MAD treatment could mark a significant advancement in the standard of care for OSA patients, offering a faster path to better sleep and health.

Partnering with Belun :

Up to now, over a hundred organizations, including HK hospital authority hospitals, medical groups, clinic groups, dentists, and elderly centers, have selected to use the Belun Sleep System, Belun Ring, and Belun® remoVital monitoring system. Many doctors read our medical journal papers, including: 

1) “Belun® Ring Platform: a novel home sleep apnea testing system for assessment of obstructive sleep apnea” (https://jcsm.aasm.org/doi/10.5664/jcsm.8592),

2) “Detection of obstructive sleep apnea using Belun® Sleep Platform wearable with neural network based algorithm and its combined use with STOP-Bang questionnaire” (https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0258040),

3) “Belun® Ring (Belun® Sleep System BLS-100): Deep Learning-Facilitated Wearable Enables OSA Detection, Apnea Severity Categorization, and Sleep Stage Classification in Patients Suspected of OSA”  (https://journals.lww.com/jhypertension/Abstract/2023/06000/The_Belun_sleep_platform_to_diagnose_obstructive.16.aspx), 

4) “Correlation of Pulse Rate Variability(PRV) and Heart Rate Variability(HRV) Metrics During Sleep in Subjects Suspected of OSA” (https://academic.oup.com/sleep/article/46/Supplement_1/A420/7182347)

5) “The Belun sleep platform to diagnose obstructive sleep apnea in patients with hypertension and high cardiovascular risk” (https://pubmed.ncbi.nlm.nih.gov/37071415/)

If you would like to know more about how to adopt Belun’s solution in your organization, please feel free to contact us to schedule a meeting by filling out the form below:

The post Accelerating MAD Treatment for OSA Patients through AHI Monitoring  first appeared on Belun Technology.

Photos by DP Dental

DM us if you are a potential partner!

Continued Reading :

Partnering with Belun :

Up to now, over a hundred organizations, including HK hospital authority hospitals, medical groups, clinic groups, dentists, and elderly centers selected to use the Belun Sleep System, Belun® Ring and Sleep App, and Belun® remoVital monitoring system. Many doctors read our medical journal papers, including: 

1) “Belun® Ring Platform: a novel home sleep apnea testing system for assessment of obstructive sleep apnea” (https://jcsm.aasm.org/doi/10.5664/jcsm.8592),

2) “Detection of obstructive sleep apnea using Belun Sleep Platform wearable with neural network based algorithm and its combined use with STOP-Bang questionnaire” (https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0258040),

3)Belun® Ring (Belun Sleep System BLS-100): Deep Learning-Facilitated Wearable Enables OSA Detection, Apnea Severity Categorization, and Sleep Stage Classification in Patients Suspected of OSA  (https://journals.lww.com/jhypertension/Abstract/2023/06000/The_Belun_sleep_platform_to_diagnose_obstructive.16.aspx), 

4) Correlation of Pulse Rate Variability(PRV) and Heart Rate Variability(HRV) Metrics During Sleep in Subjects Suspected of OSA (Accepted in SLEEP conference 2023, Abstract ID: 954).

If you would like to know more about how to adopt Belun’s solution in your organization or home use, please feel free to contact us to schedule a meeting by filling out the form below:

The post Belun in Japan first appeared on Belun Technology.

Part 1 :

Advocated workflow for dental management in Sleep medicine

Management of sleep disorders is an expanding area in medical care, and in recent decades, dentists may play an important role in diagnosing and treating sleep disorders. In the previous article, we addressed the advocated guidelines provided by the American Academy of sleep medicine (AASM) and the American Academy of Dental Sleep Medicine (AADSM) for the treatment of Obstructive Sleep Apnea (OSA) and Snoring with Oral Appliance Therapy (OAT) (1), type of interventions for OSA treatment and comparable benefits using Oral Appliances (OAs) versus Continuous Positive Airway Pressure (CPAP). In this review, we will discuss the actual guidelines for short and long-term dental management, potential factors contributing to the success of OAT, and possible side effects in treating OSA.

Management in dental care for patients with suspected Sleep Related Disordered Breathing

Standards of Practice Committee of the AADSM suggested a management flowchart for dentists in 2018 (2). Two major pathways may lead to a dental patient’s evaluation of suspected sleep-related disordered breathing (SRDB). A patient may start a visit to a qualified dentist and be screened, or a physician may refer the diagnosed patient to a qualified dentist. The first visit to a qualified dentist should implement a screening process including nocturnal and daytime symptoms (e.g., snoring, witnessed apnea, gasping, sleepiness), STOP-BANG questionnaires, chief complaints, medical and family histories, current medications, dental history and findings. It is also important to record baselines such as BMI, blood pressure and neck circumference for OAT monitoring. Then in consultation with the patient, the qualified dentist should then refer the suspected case to a physician for evaluation and assessment of SRDB. Another pathway may be a physician who has diagnosed a patient with SRBD, referring the patient to a qualified dentist for dental assessment and initiation of OAT. Patients undergoing OAT should be educated on their SRBD severity, including AHI, RDI and REI from sleep test results. They should also be informed that OAT success may be affected by fragmented sleep, oxygen desaturation and other co-existing sleep problems. (2)

Clinical characteristics contributing to the success and failure of OAT

Evidence showed that OAT works better on anatomic traits by opening the airway, preventing closure and probably acting as a mandibular and tongue retainer. OA may help to reduce sleep arousals, effective in patients with low loop gain of ventilatory control reflex. Additional characteristics contributing to treatment efficiency are summarized in Figure 2 (3).  

In the long term, patients who have higher respiratory arousal showed better improvement in sleepiness. Patients preferred OA as a first-time treatment or have complete symptom resolution may have higher adherence in the long run. From the perspective of OA fabrication and titration, the use of Bi-Bloc OA enabling relatively free mandibular movement or custom-made OA with regular dental follow-up showed better adherence. Regular follow-ups also help to minimize early side effects and treatment discontinuation. Support from bed partners by improving bed partners’ sleep quality is another important factor in OAT success (4).

Side effects and Contraindications of OAT

Side effects, such as dental pain, muscular pain, excessive salivation or dryness, may result in non-adherence (4). While bite change, dental and occlusal changes, mesial tipping of mandibular molars and distal tipping of maxillary molars, increased mandibular arch length, and downward rotation of mandible were reported. These changes are usually irreversible (5–11). Although side effects may seem substantial, patients should not discontinue the OAT unless there is a better treatment option provided since the preventive benefits of life-threatening outcomes of OSA outweigh the side effects of OAT.

It is also worth noting that edentulous patients with inadequate teeth, patients with severe periodontitis or a history of temporomandibular joint may not be suitable for OAT (12).

Calibration of OA and long-term management

In the previous decades for OAT, evidence on treatment effect and adherence with OA had been limited. In particular, adherence to OAT has recently been limited to self-reported data, with the inherent risks of overreporting (4). While extensive publications have been reported on the efficacy of short-term and long-term treatment of CPAP, the effectiveness and long-term adherence of OAT remain to be investigated. According to guidelines in 2015 (1), home sleep tests should be implemented for follow-up visits for treatment efficacy or even annual follow-ups to evaluate the long-term effects of OAT. Patients are expected to return to a qualified dentist within the first 30 days to assess the comfort and efficacy of the OAT. In addition, the qualified dentist will need to determine an appropriate endpoint for the OA advancement process. Consideration of evidence supporting 50% improvement in baseline AHI may be considered as partial treatment success (11). The AASM and American Medical Association (AMA) have published policies that a physician must order a home sleep apnea test to determine the appliance’s efficacy (13,14). Therefore the interpretation of sleep results should be in consultation with the qualified dentist, patient and physician. Additionally, final calibration of the OA, the qualified dentist should refer the patient back to the physician for assessment of OAT outcomes(2).

For long-term follow-up and management, patients are expected to follow up every 6 months for the first year and at least annually thereafter. The annual examination should include verification of OA efficacy and occlusal stability, check of the structural integrity of OA, symptoms evaluation, patient comfort and adherence rate,and possible short and long-term side effects (2). In case of damage, bacterial or fungal growth, replacement should be made, and additional calibration should be conducted (2).

How Belun can help

According to AASM and AMA published policies, a physician must order a home sleep apnea test to determine the efficacy of OAT. For long-term management, patients are expected to assess their sleep architecture at baseline, 1 month, 6 months, and yearly follow-ups to ensure good adherence and long-term prevention of life-threatening complications associated with OSA. For example, Belun Sleep Platform (BSP), using an FDA-cleared wearable Ring, offers an automated Home sleep test for patients with OSA.

Belun Sleep System (BSP) has the capability of monitoring and analyzing SpO2, heart rate variability (HRV), photoplethysmography (PPG) waveform, and accelerometer-derived actigraphy data. It can calculate an estimated apnea-hyponea index (bAHI). It can also differentiate wakefulness from sleep, perform sleep stage analysis and give REM and NREM sleep duration using its artificial intelligence platform. Furthermore, autonomic nervous system (ANS) activities, including sympathetic and parasympathetic activities, throughout the monitoring period. From the assessment provided by Belun Sleep System, objective sleep impairments data. Although polysomnography is currently the gold standard for measuring sleep quality, the test is costly, not easily available, and requires skilled sleep technicians for assessment. Going forward, Belun Sleep System herein serves to provide a cost-effective, readily available, automated, no-skilled technician-needed solution to dentists, sleep physicians, and patients with sleep-related disordered breathing population-wide.

Partnering with Belun :

Up to now, over a hundred organizations, including HK hospital authority hospitals, medical groups, clinic groups, dentists, and elderly centers selected to use the Belun Sleep System, Belun® Ring and Sleep App, and Belun® remoVital monitoring system. Many doctors read our medical journal papers, including: 

1) “Belun® Ring Platform: a novel home sleep apnea testing system for assessment of obstructive sleep apnea” (https://jcsm.aasm.org/doi/10.5664/jcsm.8592),

2) “Detection of obstructive sleep apnea using Belun Sleep Platform wearable with neural network based algorithm and its combined use with STOP-Bang questionnaire” (https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0258040),

3)Belun® Ring (Belun Sleep System BLS-100): Deep Learning-Facilitated Wearable Enables OSA Detection, Apnea Severity Categorization, and Sleep Stage Classification in Patients Suspected of OSA  (https://journals.lww.com/jhypertension/Abstract/2023/06000/The_Belun_sleep_platform_to_diagnose_obstructive.16.aspx), 

4) Correlation of Pulse Rate Variability(PRV) and Heart Rate Variability(HRV) Metrics During Sleep in Subjects Suspected of OSA (Accepted in SLEEP conference 2023, Abstract ID: 954).

If you would like to know more about how to adopt Belun’s solution in your organization or home use, please feel free to contact us to schedule a meeting by filling out the form below:

References:

1.         Clinical Practice Guideline for the Treatment of Obstructive Sleep Apnea and Snoring with Oral Appliance Therapy: An Update for 2015 [Internet]. [cited 2022 Sep 5]. Available from: https://jcsm.aasm.org/doi/epdf/10.5664/jcsm.4858

2.         Levine M, Bennett K, Cantwell M, Postol K, Schwartz D. Dental Sleep Medicine Standards for Screening, Treating, and Managing Adults with Sleep-Related Breathing Disorders. J Dent Sleep Med. 2018 Jul 10;5(3):61–8.

3.         Lavigne GJ, Herrero Babiloni A, Beetz G, Dal Fabbro C, Sutherland K, Huynh N, et al. Critical Issues in Dental and Medical Management of Obstructive Sleep Apnea. J Dent Res. 2020 Jan 1;99(1):26–35.

4.         Tallamraju H, Newton JT, Fleming PS, Johal A. Factors influencing adherence to oral appliance therapy in adults with obstructive sleep apnea: a systematic review and meta-analysis. Journal of Clinical Sleep Medicine. 17(7):1485–98.

5.         Aarab G, Lobbezoo F, Heymans MW, Hamburger HL, Naeije M. Long-Term Follow-Up of a Randomized Controlled Trial of Oral Appliance Therapy in Obstructive Sleep Apnea. RES. 2011;82(2):162–8.

6.         Doff MHJ, Hoekema A, Pruim GJ, Huddleston Slater JJR, Stegenga B. Long-term oral-appliance therapy in obstructive sleep apnea: a cephalometric study of craniofacial changes. J Dent. 2010 Dec;38(12):1010–8.

7.         Fransson AMC, Kowalczyk A, Isacsson G. A prospective 10-year follow-up dental cast study of patients with obstructive sleep apnoea/snoring who use a mandibular protruding device. Eur J Orthod. 2017 Oct 1;39(5):502–8.

8.         Chen H, Lowe AA, de Almeida FR, Fleetham JA, Wang B. Three-dimensional computer-assisted study model analysis of long-term oral-appliance wear. Part 2. Side effects of oral appliances in obstructive sleep apnea patients. Am J Orthod Dentofacial Orthop. 2008 Sep;134(3):408–17.

9.         Rose EC, Staats R, Virchow C, Jonas IE. Occlusal and skeletal effects of an oral appliance in the treatment of obstructive sleep apnea. Chest. 2002 Sep;122(3):871–7.

10.       Pliska BT, Nam H, Chen H, Lowe AA, Almeida FR. Obstructive sleep apnea and mandibular advancement splints: occlusal effects and progression of changes associated with a decade of treatment. J Clin Sleep Med. 2014 Dec 15;10(12):1285–91.

11.       Hamoda MM, Kohzuka Y, Almeida FR. Oral Appliances for the Management of OSA: An Updated Review of the Literature. Chest. 2018 Feb 1;153(2):544–53.

12.       Ng JH, Yow M. Oral Appliances in the Management of Obstructive Sleep Apnea – Sleep Medicine Clinics [Internet]. [cited 2022 Sep 5]. Available from: https://www.sleep.theclinics.com/article/S1556-407X(18)30092-4/fulltext

13.       Rosen IM, Kirsch DB, Chervin RD, Carden KA, Ramar K, Aurora RN, et al. Clinical Use of a Home Sleep Apnea Test: An American Academy of Sleep Medicine Position Statement. J Clin Sleep Med. 2017 Oct 15;13(10):1205–7.

14.       H-35.963 Appropriate Use of Objective Tests for Obstructive Sle | AMA [Internet]. [cited 2022 Sep 10]. Available from: https://policysearch.ama-assn.org/policyfinder/detail/sleep%20apnea?uri=%2FAMADoc%2FHOD.xml-H-35.963.xml

The post The Emerging Importance of Dental Sleep Medicine (Part 2) first appeared on Belun Technology.

In 2015, the US cost of diagnosing and treating Obstructive Sleep apnea (OSA)  was approximately US$12.4 billion (1,2). The Obstructive Sleep Apnoea Health Economics report by the British Lung Foundation suggests an estimated 1.5 million adults in the UK have sleep apnea, although only around 330,000 are currently diagnosed and treated (3). 

In the past decades, although 5.2% of dental patients were identified as high risk of OSA, none received a referral for further OSA evaluation (4). Furthermore, 54% of dentists never consulted a physician about a suspected OSA patient (5). In light of the growing prevalence and serious health outcomes associated with OSA, the American Academy of sleep medicine (AASM) and the American Academy of Dental Sleep Medicine (AADSM) published guidelines in 2015 for the treatment of Obstructive Sleep Apnea and Snoring with Oral Appliance Therapy (6), dentists are advocated as the frontiers in medical examinations for patients with potential sleep problems. Qualified dentists should have a minimum of 25 hours of recognized continuing education in dental sleep medicine (e.g., American Dental Association Continuing Education Recognition Program [ADA CERP] or Academy of General Dentistry Program Approval for Continuing Education [AGD PACE] ) provided by a dental sleep medicine focused non-profit organization or accredited dental school in the last two years. The major recommendations are as follows:

• Sleep physicians prescribe oral appliances, rather than no therapy, for adult patients who request treatment for primary snoring (without OSA)
• When oral appliance therapy (OAT) is prescribed by a sleep physician for an adult patient with OSA, a qualified dentist should use a custom, titratable appliance over non-custom oral devices
• Sleep physicians should consider prescriptions of an oral appliance (OA), rather than no treatment, for adults with OSA who are reluctant to use CPAP or prefer alternative therapy.
• Qualified dentists should provide oversight rather than no follow-up of OAT in adults with OSA to survey for dental-related side effects or occlusal changes and reduce their incidence.
• Sleep physicians should conduct follow-up sleep tests to improve or confirm treatment efficacy rather than follow-ups without sleep tests for patients fitted with OAs.
• Sleep physicians and qualified dentists should instruct adult patients with OAT for scheduled visits as opposed to no follow-up.

During the COVID-19 pandemic, OAT is even advocated as the first-line therapy for OSA (7) as it does not generate aerosols, is easily disinfected, and does not need replaceable parts, unlike Continuous positive airway pressure (CPAP), which experienced a shortage of supplies during the COVID lockdown. Patients who prefer OAT may be more likely to adhere to the treatment since it does not increase the significant risk of COVID-19 exposure (7).

Types of interventions to treat OSA

While not all patients may be suitable for OA use, several available treatment options are available for patients with OSA. For example, it could be pharmacological to use domperidone and pseudoephedrine to reduce snoring; however, the effectiveness of therapy was not substantially validated with limited evidence (8). Surgery has been advocated to address structural issues, but NICE guidelines state that there is a lack of evidence of the clinical effectiveness of surgery for OSA; thus, it is not routinely used (9). Given the non-invasive, cost-effective, reversible nature of OAs, they are recommended as useful devices to treat mild to moderate OSA. OAs were mainly categorized into the following types: custom titratable; custom, non-titratable; non-custom, titratable; and non-custom, non-titratable. The guidelines in 2015 recommended the use of custom, titratable appliances as the best type of OA for OSA treatment.

Comparable Benefits using OAs vs CPAP

CPAP and OAs can reduce upper airway collapse during sleep, with CPAP having great efficacy in moderate to severe OSA. CPAP reduces the apnea-hypopnea index (AHI), respiratory disturbance index (RDI), or respiratory event index (REI) more than OAs in adult patients with moderate OSA (6). However, there are no significant differences in quality of life and cognitive and functional outcomes (10). Interestingly, it is worth noting that adherence to CPAP is generally lower than OA. Moreover, greater efficacy of CPAP may not necessarily translate into better treatment outcomes. In various randomized control trials comparing CPAP to OA across various severity of OSA patients, the use of CPAP and OA showed comparable results in improving symptoms of sleepiness (11,12), quality of life (13), and drive performance (14), cardiovascular outcomes and short-term effects on blood pressure (15) and even mortality rate in patients with severe OSA (16,17). The possible reason for the similar treatment effect between CPAP and OA was due to the longer adherence to OA compared to CPAP by patients. The adverse side effects, such as pressure sores, mask dislodgement, claustrophobia, air leakage, and nasal congestion had made CPAP intolerable to many patients (18). About 20-50% of OSA patients are reluctant to comply with CPAP (19), and adherence with CPAP is reportedly over 1h/night lower than OA (14). Moreover, OAT was also reported to be effective in two-thirds of patients after 3 years of treatment (20). Combination therapy of CPAP and OA was thus advocated to reduce the upper airway resistance and allow a more comfortable and lower pressure to sustain patency of the airway (21). The benefits of OAT are summarized in the figure below.

How Belun can facilitate OAT

According to AASM and American Medical Association published policies, a physician must order a home sleep apnea test to determine the efficacy of OAT. For long-term management, patients are expected to assess their sleep architecture at baseline, 1 month, 6 months, and yearly follow-ups to ensure good adherence and long-term prevention of life-threatening complications associated with OSA. For example, Belun Sleep System (BSP), using an FDA-cleared wearable Ring, offers an automated Home sleep test for patients with OSA.

Belun Sleep System (BSP) has the capability of monitoring and analyzing SpO2, heart rate variability (HRV), photoplethysmography (PPG) waveform, and accelerometer-derived actigraphy data. It can calculate an estimated apnea-hyponea index (bAHI). It can also differentiate wakefulness from sleep, perform sleep stage analysis and give REM and NREM sleep duration using its artificial intelligence platform. Furthermore, autonomic nervous system (ANS) activities, including sympathetic and parasympathetic activities, throughout the monitoring period. From the assessment provided by Belun Sleep System, objective sleep impairments data. Although polysomnography is currently the gold standard for measuring sleep quality, the test is costly, not easily available, and requires skilled sleep technicians for assessment. Going forward, Belun Sleep System herein serves to provide a cost-effective, readily available, automated, no-skilled technician-needed solution to dentists, sleep physicians, and patients with sleep-related disordered breathing population-wide.

Continued Reading :

Partnering with Belun :

Up to now, over a hundred organizations, including HK hospital authority hospitals, medical groups, clinic groups, dentists, and elderly centers selected to use the Belun Sleep System, Belun® Ring and Sleep App, and Belun® remoVital monitoring system. Many doctors read our medical journal papers, including: 

1) “Belun® Ring Platform: a novel home sleep apnea testing system for assessment of obstructive sleep apnea” (https://jcsm.aasm.org/doi/10.5664/jcsm.8592),

2) “Detection of obstructive sleep apnea using Belun Sleep Platform wearable with neural network based algorithm and its combined use with STOP-Bang questionnaire” (https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0258040),

3)Belun® Ring (Belun Sleep System BLS-100): Deep Learning-Facilitated Wearable Enables OSA Detection, Apnea Severity Categorization, and Sleep Stage Classification in Patients Suspected of OSA  (https://journals.lww.com/jhypertension/Abstract/2023/06000/The_Belun_sleep_platform_to_diagnose_obstructive.16.aspx), 

4) Correlation of Pulse Rate Variability(PRV) and Heart Rate Variability(HRV) Metrics During Sleep in Subjects Suspected of OSA (Accepted in SLEEP conference 2023, Abstract ID: 954).

If you would like to know more about how to adopt Belun’s solution in your organization or home use, please feel free to contact us to schedule a meeting by filling out the form below:

References:

1.          Benjafield AV, Ayas NT, Eastwood PR, Heinzer R, Ip MSM, Morrell MJ, et al. Estimation of the global prevalence and burden of obstructive sleep apnoea: a literature-based analysis. The Lancet Respiratory Medicine. 2019 Aug 1;7(8):687–98.

2.         Watson NF. Health Care Savings: The Economic Value of Diagnostic and Therapeutic Care for Obstructive Sleep Apnea. J Clin Sleep Med. 2016 Aug 15;12(8):1075–7.

3.         Steier J, Martin A, Harris J, Jarrold I, Pugh D, Williams A. Predicted relative prevalence estimates for obstructive sleep apnoea and the associated healthcare provision across the UK. Thorax. 2014 Apr 1;69(4):390–2.

4.         Guess NW, Fischbach H, Ni AA, Firestone AR. Referral rate for obstructive sleep apnea in a pre-doctoral dental clinic using the STOP-Bang Questionnaire. Journal of Dental Education. 2022;86(4):456–62.

5.         Knowledge, opinions, and clinical experience of general practice dentists toward obstructive sleep apnea and oral appliances – PubMed [Internet]. [cited 2022 Sep 7]. Available from: https://pubmed.ncbi.nlm.nih.gov/15211392/

6.         Clinical Practice Guideline for the Treatment of Obstructive Sleep Apnea and Snoring with Oral Appliance Therapy: An Update for 2015 [Internet]. [cited 2022 Sep 5]. Available from: https://jcsm.aasm.org/doi/epdf/10.5664/jcsm.4858

7.         Schwartz D, Addy N, Levine M, Smith H. Oral appliance therapy should be prescribed as a first-line therapy for OSA during the COVID-19 pandemic. J Dent Sleep Med [Internet]. 2020 Jul 10 [cited 2022 Sep 5];7(3). Available from: https://www.aadsm.org/docs/jdsm.7.10.2020.sa1.pdf

8.         Larrain A, Kapur VK, Gooley TA, Pope CE. Pharmacological treatment of obstructive sleep apnea with a combination of pseudoephedrine and domperidone. J Clin Sleep Med. 2010 Apr 15;6(2):117–23.

9.         Tanna N, Smith BD, Zapanta PE, Karanetz I, Andrews BT, Urata MM, et al. Surgical Management of Obstructive Sleep Apnea. Plast Reconstr Surg. 2016 Apr;137(4):1263–72.

10.       Schwartz M, Acosta L, Hung YL, Padilla M, Enciso R. Effects of CPAP and mandibular advancement device treatment in obstructive sleep apnea patients: a systematic review and meta-analysis. Sleep Breath. 2018 Sep;22(3):555–68.

11.       Sharples LD, Clutterbuck-James AL, Glover MJ, Bennett MS, Chadwick R, Pittman MA, et al. Meta-analysis of randomised controlled trials of oral mandibular advancement devices and continuous positive airway pressure for obstructive sleep apnoea-hypopnoea. Sleep Med Rev. 2016 Jun;27:108–24.

12.       Iftikhar IH, Bittencourt L, Youngstedt SD, Ayas N, Cistulli P, Schwab R, et al. Comparative efficacy of CPAP, MADs, exercise-training, and dietary weight loss for sleep apnea: a network meta-analysis. Sleep Med. 2017 Feb;30:7–14.

13.       Gupta MA, Simpson FC, Lyons DCA. The effect of treating obstructive sleep apnea with positive airway pressure on depression and other subjective symptoms: A systematic review and meta-analysis. Sleep Med Rev. 2016 Aug;28:55–68.

14.       Health outcomes of continuous positive airway pressure versus oral appliance treatment for obstructive sleep apnea: a randomized controlled trial – PubMed [Internet]. [cited 2022 Sep 9]. Available from: https://pubmed.ncbi.nlm.nih.gov/23413266/

15.       CPAP vs Mandibular Advancement Devices and Blood Pressure in Patients With Obstructive Sleep Apnea: A Systematic Review and Meta-analysis | Cardiology | JAMA | JAMA Network [Internet]. [cited 2022 Sep 9]. Available from: https://jamanetwork.com/journals/jama/fullarticle/2473494

16.       Anandam A, Patil M, Akinnusi M, Jaoude P, El-Solh AA. Cardiovascular mortality in obstructive sleep apnoea treated with continuous positive airway pressure or oral appliance: an observational study. Respirology. 2013 Nov;18(8):1184–90.

17.       Hamoda MM, Kohzuka Y, Almeida FR. Oral Appliances for the Management of OSA: An Updated Review of the Literature. Chest. 2018 Feb 1;153(2):544–53.

18.       Tallamraju H, Newton JT, Fleming PS, Johal A. Factors influencing adherence to oral appliance therapy in adults with obstructive sleep apnea: a systematic review and meta-analysis. Journal of Clinical Sleep Medicine. 17(7):1485–98.

19.       Sawyer AM, Gooneratne NS, Marcus CL, Ofer D, Richards KC, Weaver TE. A systematic review of CPAP adherence across age groups: clinical and empiric insights for developing CPAP adherence interventions. Sleep Med Rev. 2011 Dec;15(6):343–56.

20.       Attali V, Chaumereuil C, Arnulf I, Golmard JL, Tordjman F, Morin L, et al. Predictors of long-term effectiveness to mandibular repositioning device treatment in obstructive sleep apnea patients after 1000 days. Sleep Med. 2016 Dec;27–28:107–14.

21.       Levine M, Bennett K, Cantwell M, Postol K, Schwartz D. Dental Sleep Medicine Standards for Screening, Treating, and Managing Adults with Sleep-Related Breathing Disorders. J Dent Sleep Med. 2018 Jul 10;5(3):61–8.

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