Belun Technology will partner with Nexter Living (SCG’s subsidiary), a healthcare extension from the conglomerate. A new Brand, “DoCare” is created to cater to the elderly market with the concept of “Making Eldercare Affordable and Convenient for Everyone”. ³

Thailand is among the fastest aging countries in the world; of its 67 million population, 12 million Thais are elderly, according to the latest national statistics report from WHO.² Since 2016, Nexter Living has innovated the smart living series to tackle the aging population.

Source : DoCare’s Facebook

According to the Lancet’s report, 36% of the Thai population has AHI (apnoea-hypopnoea index) >= 5, posing new challenges to the country’s healthcare system with its 20% aging population issue. Research shows sleep health is critical for the overall immune system & treatment effectiveness of chronic diseases. Nexter Living partners with Belun® Ring because of its medical accuracy backed up by the US FDA 510(k) clearance. Belun’s CEO, Lydia Leung, shared: “Belun® Ring is a user and environmentally friendly PPG-based wearable with medical accuracy. Belun will offer a superb convenient option that encourages suspected patients to take action and kick start their treatment journey.”

Nexter Living will promote the Belun Sleep Platform to the local hospital, hotels, wellness centers, elderly homes & new property projects promoting preventive care living. Thailand has been a hub for global medical tourism, and the expanding expatriate communities will also be the target.

Solutions from SCG for the elderly Source: SCG’s website

Chronic Disease Management via AI Preventive Healthcare

Belun’s vision is to help people better manage their chronic diseases through artificial intelligence and big data analytics to alleviate medical expenditures due to the aging population. Its solution allows caregivers and patients to follow their treatment effectiveness, select personalized solutions, and enhance treatment compliance. Lydia further shared: “Long-term monitoring using medical-grade wearables can help people to identify abnormalities earlier to achieve preventive healthcare.” 

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 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) and 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).

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. A.V, Benjafield et al, Lancet Respiratory Medicine, 2019; 2. Susanna Ng et al, PLOS One, 2015

2. https://www.who.int/southeastasia/news/feature-stories/detail/thailands-leadership-and-innovation-towards-healthy-ageing#:~:text=Thailand%20is%20among%20the%20fastest,for%2010%25%20of%20the%20population

3. https://www.scg.com/innovation/%E0%B8%9B%E0%B8%A3%E0%B8%B1%E0%B8%9A%E0%B8%95%E0%B8%B1%E0%B8%A7%E0%B8%AD%E0%B8%A2%E0%B9%88%E0%B8%B2%E0%B8%87%E0%B9%84%E0%B8%A3-%E0%B9%83%E0%B8%99%E0%B8%A7%E0%B8%B1%E0%B8%99%E0%B8%97%E0%B8%B5%E0%B9%88/

The post Belun Technology announces Nexter Living as its Official Distributor in Thailand   first appeared on Belun Technology.

We had a fruitful discussion in the one hour sharing session.

To understand more about how Belun’s applications would help clinical psychologists, see our previous story about CBT-I.

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 Sharing with Clinical Psychologists of HK’s Public Hospital 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.

The post The Emerging Importance of Dental Sleep Medicine (Part 1) first appeared on Belun Technology.

Hypertension is a leading preventable risk factor for Cardiovascular disease (CVD) and all-cause mortality worldwide (1,2). In 2010, a total of 1.38 billion people (31.1% of the global adult population) had hypertension, defined as systolic blood pressure (SBP) ≥ 140mmHg and or/ diastolic BP (DBP) ≥ 90 mmHg. The prevalence of hypertension is 46%, according to a report from WHO in 2021. Men are more prevalent to have hypertension (about 1 in 4), while about 1 in 5 women have hypertension.  The global mean age-standardized DBP was 78.7mHg in men and 76.7 mmHg in women (3). Higher mean SBP and DBP in both men and women were found in South Asia, sub-Saharan Africa, and Central and Eastern Europe, whereas lower mean BPs were found in high-income Western and high-income Asia-Pacific regions (3). Notably, more than half of adult hypertensive patients are undiagnosed and untreated. Even for treated patients, only 1 in 5 these patients have an effective treatment with well-controlled blood pressure.

For more information, you may also refer to the infographics provided by WHO on hypertension: https://cdn.who.int/media/docs/default-source/documents/hypertension-infographic-005-web.pdf?sfvrsn=f0973d0c_2

Social and Economic Burden of HT

The prevalence and absolute burden of hypertension are rising globally, especially in low and middle-income countries (LMICs). Awareness and proper management of hypertension are unacceptably low worldwide, especially in LMICs (4,5). A global burden of disease study estimated in 2015 around 3.5 billion adults worldwide had SBP of at least 110-115 mmHg, a level that is associated with an increased risk of ischaemic heart disease (IHD), stroke, and kidney disease. This prevalence represents a marked increase from 1990 when only 1.87 billion people had an SBP of at least 110-115mmHg (3).

Emerging guidelines for blood pressure proposed on 2017

In 2017, the American College of Cardiology / American Heart Association Task Force on Clinical Practice Guidelines redefined the classification of hypertension (6). While hypertension was commonly defined as SBP ≥ 140mmHg and or/ diastolic BP ≥ 90 mmHg over the past 30 years, new guidelines in recent years advocated the re-classification of hypertension as 130/80 mmHg and higher for all adults. With the lowering of SBP and DBP for hypertension and without stratification of age, the new guidelines provided more stringent criteria to highlight the importance to patients with the potential underlying risk of subsequent cardiovascular development. Based on previous meta-analysis findings from 48 randomized clinical trials involving 344716 participants with a mean age of 65 years, the relative reduction in the risk of developing major cardiovascular events was proportional to the magnitude of achieved reduction in blood pressure. For each 5-mmHg reduction in SBP, the risk of developing cardiovascular events dropped by 10% (7). Furthermore, lowing blood pressure was effective in preventing major cardiovascular events regardless of individuals with previous cardiovascular comorbidities (7). By lowering of SBP to <130 mmHg, compared to the traditional SBP target of <140 (130-139) mmHg, was consistently associated with a 25-30% relative risk reduction in cardiovascular events (8). However, it is worthwhile to note that the prevalence of hypertension in the US increased from 32.0% to 45.4% and 23.2% to 46.4% in the Chinese population respectively. And it is expected to surge in prevalence among LMICs and high-income countries (HICs) after the recent implementation of hypertension re-classification (5).

Blood pressure is now re-categorized in the following:

1. Normal – less than 120/80 mmHg;
2. Elevated: SBP between 120-129 and DBP <80;
3. Stage 1: SBP between 130-139 / DBP between 80-89;
4. Stage 2 : SBP≥ 140 mmHg /DBP ≥ 90 mmHg

Hypertensive crisis: SBP ≥ 180 mmHg/ DBP ≥ 120mmHg, with patients needing prompt changes in medication if there are no other indications of problems or immediate hospitalization if there are signs of organ damage.

Definition of resistant and refractory hypertension, and prevalence of OSA in hypertensive patients

As mentioned before, only a minority of patients (approximately 21%) with HT have well-controlled BP. Poorly controlled hypertension remains a strong cause of cardiovascular morbidity and mortality worldwide. It is, therefore, crucial to control blood pressure well as a small drop of 2 mmHg in DBP on a population-based may result in an overall decrease of 17% in the prevalence of hypertension, a 6% reduction in coronary heart disease risk, and 15% reduction in the risk of stroke and transient ischemic attack (9). Among these 4 in 5 patients with poor control of blood pressure, 25% of the hypertensive patients are classified as resistant HT that patients have elevated blood pressure even after the concurrent use of at least 3 classes of anti-hypertensive drugs. Among these patients with resistant HT, a minor of 5% of patients fall into refractory HT which patients have uncontrolled blood pressure despite the concurrent use of at least 5 different classes of anti-hypertensive drugs. Treatment-resistant hypertension is often associated with a greater risk of end-stage renal disease (ESRD), ischemic heart disease, heart failure, stroke, and mortality compared with non-treatment-resistant hypertension (8).

In addition, OSA and hypertension commonly coexist. About 50% of patients with OSA are hypertensive, whereas more than 50% of hypertensive patients have OSA (10–14). Among the patients with resistant HT, about 70-80% of the patients have OSA (15), and the prevalence of OSA can be as high as 90% in patients with refractory HT (16).

Hypertension and associated sleep-related disorders

Sleep-related disorders (such as insomnia and OSA) that induce increased BP would be anticipated to affect cardiovascular risks (17) significantly. While both sleep deprivation and insomnia have been associated with an increase in the incidence and prevalence of hypertension, extensive studies also demonstrated the strong correlation between the severity of OSA and the risk as well as the severity of hypertension. Cross-sectional studies of 238 adolescents without sleep apnea or severe comorbidities were conducted from Cleveland Children’s Sleep and Heart Study. In their unadjusted analysis, the odds of pre-hypertension were increased 4.5-fold in adolescents with poor sleep efficiency and 2.8-fold in those with short sleep. Adjusted analyses showed that adolescents with low sleep efficiency, with a mean of 4.0 ± 1.2 mmHg higher SBP compared to other children (p<0.001), suggest poor sleep quality is associated with pre-hypertension even in healthy subjects (18).

Ambulatory BP studies indicate that even small increases in BP, particularly night-time BP levels, are associated with a significant increase in cardiovascular morbidities and mortality. Lack or diminished nocturnal reduction of BP is a strong and independent predictor of cardiovascular risk. In fact, large prospective studies reported that ambulatory BP is superior in predicting cardiovascular mortality compared to daytime BP in clinical settings. Moreover, nocturnal BP measurement was the strongest predictor of outcome (19).

The overlapping conditions between hypertension and obstructive sleep apnea

Previous cross-sectional studies showed that moderate to severe OSA (with apnea-hypopnea index [AHI] > 15 events/h) is significantly associated with the risk of having arterial hypertension. Furthermore, a linear relationship between AHI and hypertension was observed, indicating the severity of OSA is proportionally related (dose-dependent fashion) to the increased risk of hypertension and its severity (12). Large observational longitudinal studies also showed subjects with baseline normal BP but with moderate to severe OSA had 3.2-fold increased odds of developing hypertension compared with subjects without OSA after 4 years of follow-up (20,21).  It is also interesting to note that there are several prominent and similar clinical characteristics between patients with OSA and hypertension. Obesity is one of the major indicators in patients with OSA and hypertension. Other predictors include ethnic differences, age, alcohol abuse, and smoking (22).

Effect of Continuous Positive Airway pressure (CPAP) on BP

Although the causal relationship between OSA and hypertension remains unclear, the effective OSA treatment by CPAP has shown a modest antihypertensive effect. In addition, greater beneficial effects were reported among patients with more severe OSA and high CPAP compliance. Trigger on sympathetic activation by OSA has been proposed as a potential mechanism of OSA-induced hypertension. The sympathetic activation in patients with untreated OSA can last during the daytime, and it is not limited to the sleep period. These heightened sympathetic activities may increase BP via increasing vascular resistance and cardiac output, probably triggering the renin-angiotensin-aldosterone system (23). Therefore, it is particularly important that effective OSA treatment should be administered to OSA patients to prevent aberrant activation of the sympathetic pathways (24).

How Belun can facilitate Hypertension treatment

Belun Sleep System 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 and perform sleep stage analysis and give REM sleep duration and NREM sleep duration using its artificial intelligence platform. From the PPG assessment provided by Belun Healthcare Platform, objective sleep impairments data (eg. prolonged sleep latencies, reduced sleep time, fluctuations in heart rate, and heart rate variability) can be provided to clinicians with a more accurate diagnosis of the severity of OSA, monitoring the efficacy of CPAP titration treatment and sleep quality improvements. In addition, we are the only PPG device so far that could also provide parallel autonomic nervous system (ANS) activities, including sympathetic and parasympathetic activities apart from sleep data throughout the monitoring period. This may eventually help improve the blood pressure of patients with both OSA and hypertension in the hope of reducing the development of cardiovascular comorbidities.

Although polysomnography is currently the gold standard for measuring sleep quality, the test is costly, not easily available, and required skilled sleep technicians for assessment. Belun Sleep System herein serves to provide a cost-effective, readily available, automated, no-skilled technician-needed solution to clinicians and patients with OSA population-wide in the hope of reducing the subsequent incidence, prevalence of hypertension, and associated cardiovascular risks.

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.            Global, regional, and national age-sex-specific mortality for 282 causes of death in 195 countries and territories, 1980–2017: a systematic analysis for the Global Burden of Disease Study 2017 – The Lancet [Internet]. [cited 2022 Jul 26]. Available from: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)32203-7/fulltext

2.            Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks for 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017 – PubMed [Internet]. [cited 2022 Jul 26]. Available from: https://pubmed.ncbi.nlm.nih.gov/30496105/

3.            NCD Risk Factor Collaboration (NCD-RisC). Worldwide trends in blood pressure from 1975 to 2015: a pooled analysis of 1479 population-based measurement studies with 19·1 million participants. Lancet. 2017 Jan 7;389(10064):37–55.

4.            Chow CK, Teo KK, Rangarajan S, Islam S, Gupta R, Avezum A, et al. Prevalence, Awareness, Treatment, and Control of Hypertension in Rural and Urban Communities in High-, Middle-, and Low-Income Countries. JAMA. 2013 Sep 4;310(9):959–68.

5.            Mills KT, Stefanescu A, He J. The global epidemiology of hypertension. Nat Rev Nephrol. 2020 Apr;16(4):223–37.

6.            Whelton PK, Carey RM, Aronow WS, Casey DE, Collins KJ, Dennison Himmelfarb C, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2018 Jun;71(6):1269–324.

7.            Canoy D, Nazarzadeh M, Copland E, Bidel Z, Rao S, Li Y, et al. How Much Lowering of Blood Pressure Is Required to Prevent Cardiovascular Disease in Patients With and Without Previous Cardiovascular Disease? Curr Cardiol Rep. 2022 Jul 1;24(7):851–60.

8.            Wang TD, Chiang CE, Chao TH, Cheng HM, Wu YW, Wu YJ, et al. 2022 Guidelines of the Taiwan Society of Cardiology and the Taiwan Hypertension Society for the Management of Hypertension. Acta Cardiol Sin. 2022 May;38(3):225–325.

9.            Cook NR, Cohen J, Hebert PR, Taylor JO, Hennekens CH. Implications of small reductions in diastolic blood pressure for primary prevention. Arch Intern Med. 1995 Apr 10;155(7):701–9.

10.          Fletcher EC, DeBehnke RD, Lovoi MS, Gorin AB. Undiagnosed sleep apnea in patients with essential hypertension. Ann Intern Med. 1985 Aug;103(2):190–5.

11.          Lavie P, Ben-Yosef R, Rubin AE. Prevalence of sleep apnea syndrome among patients with essential hypertension. Am Heart J. 1984 Aug;108(2):373–6.

12.          Worsnop CJ, Naughton MT, Barter CE, Morgan TO, Anderson AI, Pierce RJ. The prevalence of obstructive sleep apnea in hypertensives. Am J Respir Crit Care Med. 1998 Jan;157(1):111–5.

13.          Durán-Cantolla J, Aizpuru F, Martínez-Null C, Barbé-Illa F. Obstructive sleep apnea/hypopnea and systemic hypertension. Sleep Med Rev. 2009 Oct;13(5):323–31.

14.          Sjöström C, Lindberg E, Elmasry A, Hägg A, Svärdsudd K, Janson C. Prevalence of sleep apnoea and snoring in hypertensive men: a population based study. Thorax. 2002 Jul;57(7):602–7.

15.          Logan AG, Perlikowski SM, Mente A, Tisler A, Tkacova R, Niroumand M, et al. High prevalence of unrecognized sleep apnoea in drug-resistant hypertension. J Hypertens. 2001 Dec;19(12):2271–7.

16.          Martínez-García MA, Navarro-Soriano C, Torres G, Barbé F, Caballero-Eraso C, Lloberes P, et al. Beyond Resistant Hypertension. Hypertension. 2018 Sep;72(3):618–24.

17.          Calhoun DA, Harding SM. Sleep and Hypertension. Chest. 2010 Aug 1;138(2):434–43.

18.          Javaheri S, Storfer-Isser A, Rosen CL, Redline S. Sleep Quality and Elevated Blood Pressure in Adolescents. Circulation. 2008 Sep 2;118(10):1034–40.

19.          Dolan E, Stanton A, Thijs L, Hinedi K, Atkins N, McClory S, et al. Superiority of ambulatory over clinic blood pressure measurement in predicting mortality: the Dublin outcome study. Hypertension. 2005 Jul;46(1):156–61.

20.          Peppard PE, Young T, Palta M, Skatrud J. Prospective study of the association between sleep-disordered breathing and hypertension. N Engl J Med. 2000 May 11;342(19):1378–84.

21.          Sleep-Disordered Breathing and Hypertension. New England Journal of Medicine. 2000 Sep 28;343(13):966–7.

22.          Silverberg DS, Iaina A, Oksenberg A. Treating obstructive sleep apnea improves essential hypertension and quality of life. Am Fam Physician. 2002 Jan 15;65(2):229–36.

23.          Somers VK, Dyken ME, Clary MP, Abboud FM. Sympathetic neural mechanisms in obstructive sleep apnea. J Clin Invest. 1995 Oct;96(4):1897–904.

24.          Nocturnal Continuous Positive Airway Pressure Decreases Daytime Sympathetic Traffic in Obstructive Sleep Apnea | Circulation [Internet]. [cited 2022 Aug 12]. Available from: https://www.ahajournals.org/doi/10.1161/01.cir.100.23.2332

The post The pathophysiology of Hypertension and Obstructive Sleep Apnea first appeared on Belun Technology.

Physiological parameters:

• Belun® Ring: SpO₂, pulse rate (beat-to-beat), pulse rate variability, autonomic nervous system response (every 5-minute) and actigraphy
• Belun® Core: breathing effort, posture and body temperature
• Belun® Sleep Platform: machine learning algorithm for obstructive sleep apnea (bAHI), sleep stages (wake, NREM, REM) and central sleep apnea

Applications / Studies for:

• Sleep disorders: OSA, CSA, Insomnia
• Congestive heart failure
• Dementia
• Clinical psychologist, physiotherapist, dentist
• Effectiveness of both pharmaceutical / non-pharmaceutical interventions, e.g., CBT, myofunctional therapy, weight management

After using Belun® Ring for screening of sleep apnea, the Ring is wore for continual monitoring. Treatment effectiveness can be evaluated through:

• the AHI reduced from > 60 events/hour to less than 10 events/hours
• T90 reduced from 4752 seconds to 1 second 
• Mean Pulse rate reduced from 88bpm to 67bpm

Sample ordering

Belun® Ring is currently used by clinical psychologist and CBT-I studies. If you would like to order the sample for reviewing the performance of the Belun Ring for your organization, you can visit our online sample purchase platform here [LINK]

Partnering with Belun

Up to now, over 32 organizations partners including HK hospital authority hospitals, medial groups, clinic groups, dentists and elderly centres selected to use Belun Sleep health platform, 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) and 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). If you would like to know more about how to adopt Belun’s solution in your organization or home use, pls feel free to contact us to schedule a meeting by filling the form below:

The post Digital biomarker for pharma first appeared on Belun Technology.