Obstructive sleep apnea: focus on myofunctional therapy

Figures & data

Figure 1 Study search flowchart.

Table 1 Summary of studies included

Study, design, country	Objectives/participants	Intervention	Outcomes of interest	Results
Guimarães et al^Citation38 RCT Brazil	To verify the effects of oropharyngeal exercises in patients with moderate OSAS on objective measurement of severity derived from PSG OE group – N: 16 Age: 51.5±6.8 Male: 63% BMI: 29.6±3.8 Control group – N: 15 Age: 47.7±9.8 Male: 73% BMI: 31.0±2.8	Three months for all groups, with weekly visits OE group Nasal lavage and OE HT: Three times a day Control group Nasal lavage Deep breathing exercises through the nose while sitting HT: Once a day, 30 min	Full-night PSG AHI Lowest oxygen saturation SaO2 Sleep-related questionnaires Anthropometry	Patients in OE group had significant improvement of PSG measures, snoring symptoms, subjective sleepiness, and sleep quality scores, and decreased NC Before vs after AHI: 22.4±4.8 vs 13.7±8.5 AHI REM: 29.8±12.7 vs 7.4±15.9 AI: 6.6±4.7 vs 3.3±3.2 Lowest SaO2 (%): 83±6 vs 85±7 NC: 39.6±3.6 vs 38.5±4.0 Control group showed no significant changes AHI: 22.4±5.4 vs 25.9±8.5 AHI REM: 29.9±11.6 vs 22.4±5.4 AI: 9.1±6.6 vs 9.6±6.0 Lowest SaO2 (%): 82±4 vs 80±4 NC: 40.9±3.5 vs 40.7±3.7
Baz et al^Citation50 PCS Egypt	To evaluate the effect of OMT as a simple method for treatment of patients with mild- to-moderate OSA N: 30 OMT Age: 44.07±7.54 Male: 73.3% BMI: 33.59±1.98	Three months, with two sessions weekly OMT HT: 3–5 times per day with minimum 10 min for each time	Full PSG History Anthropometry ESS	Patients showed significant improvement of PSG measures, snoring symptoms, subjective sleepiness, and decreased NC AHI: 22.27±4.51 vs 11.53±5.38 Minimum SaO2%: 84±4 vs 87±5 Arousal index: 28.87±8.41 vs 15.33±6.11 % TSTS: 14.05±4.89 vs 3.87±4.12 ESS: 16.40±1.96 vs 9.27±2.89 NC (cm): 42.77±1.67 vs 42.01±1.96 Subjective snoring (n): 30 vs 16 Excessive daytime sleepiness (n): 30 vs 12 Morning headache (n): 18 vs 6
Diaféria et al^Citation40 RCT Brazil	To assess the effect of ST alone and combined with CPAP on the QoL of patients with OSA Placebo group – N: 24 Age: 42.9±10.5 Male: 100% AHI: 27.8±20.3, BMI: 28.6±4.0 ESS: 12.8±3.1 ST group – N: 27 Age: 45.2±13.0 Male: 100% AHI: 28.0±22.7, BMI: 25.0±7.4 ESS: 13.7±3.2 CPAP group – N: 27 Age: 46.4±9.1 Male: 100% AHI: 34.4±22.4, BMI: 28.7±3.3 ESS: 12.0±2.1 Combination group – N: 22 Age: 47.5±10.9 Male: 100% AHI: 30.4±19.8, BMI: 27.9±2.4 ESS: 12.0±2.6	The patients were treated for three months Placebo group: head movements without any therapeutic function HT: Three times a day, with 20 min each ST group: OE HT: Three times a day, with 20 min each CPAP group: device with nasal mask, without humidifier, which was set to the optimal pressure according to the PSG to each patient Combination group (ST+CPAP): both protocols	ESS, FOSQ, WHOQoL-Bref, and SF-36 PSG All outcomes were measured before and after therapy and after 3-week washout	Significant improvement was observed in the physical domain of the WHOQoL-Bref in the ST and combination groups after treatment and washout compared to the pretreatment assessment. The functional capacity domain of the SF-36 improved in the ST group After ST vs washout Placebo group AHI: 30.6±21.8 vs 27.8±15.0 BMI: 28.3±3.9 vs 29.0±4.0 ESS: 12.2±5.2 vs 10.5±5.1 ST group AHI: 13.9±18.5 vs 21.3±21.4 BMI: 26.7±2.9 vs 26.9±2.9 ESS: 7.5±3.7 vs 10.4±4.3 CPAP group AHI: 4.3±4.0 vs 29.7±25.4 BMI: 29.5±3.2 vs 27.4±6.9 ESS: 7.2±3.6 vs 8.8±4.4 Combination group AHI: 3.4±2.7 vs 29.6±25.1 BMI: 28.3±2.6 vs 28.2±2.8 ESS: 7.3±5.7 vs 9.5±6.3
Suzuki et al^Citation51 PCS Japan	To assess the OMT for improving AHI and SpO2 during sleep N: 6 – Age: 22±0.5 Male: 50% BMI: 23.8±1.8	Two months of LCF training at the clinic with lip trainer	LCF measurement SpO2 and AHI obtained during sleep at home	Patients had significant improvement of LCF, AHI, and SpO LCF: 8.8±1.6 vs 12.9±0.6 AHI: 15.1±3.4 vs 9.2±1.5 SpO2 (%): 90.0±2.9 vs 96.8±0.8
Matsumura et al^Citation52 PCS Brazil	To assess perceptions of the bed partner and the self-evaluation of snoring, myofunctional evaluation, AC and NC of individual with snoring or mild–severe OSA, before and after therapy N: 9 (7 OSA, 2 primary snoring) Age: 55.1 Male: 44.44%	Twelve sessions lasting 40 min each OE	Snoring intensity and frequency indexes ESS Myofunctional evaluation Anthropometry	The group had significant improvement of snoring intensity, snoring frequency, and ESS score (11.67 vs 4.67) Positive changes were observed in myofunctional evaluation NC: 40.3 vs 39.4 (p>0.05) AC: 96.8 vs 97.1 (p>0.05)
Ieto et al^Citation39 RCT Brazil	To determine the effects of OE on snoring patients with a primary complaint of snoring and diagnosis of primary snoring or mild-to-moderate OSA OE group – N: 19 Age: 48±14 Male: 57.9% BMI: 28.3±2.7, AHI: 15.6±9.3 Control group – N: 20 Age: 45±13 Male: 55% BMI: 28.3±2.5, AHI: 15.1±9.5	Three months for all groups, with weekly visits OE group Nasal lavage and OE Control group Nasal lavage, deep breathing exercises, nasal dilator strips during sleep	Objective snore index and the total snore index obtained after snore recording during PSG plus anthropometry questionnaires	OE group had significant lower snore index, total snore index, NC, intensity and frequency of snoring as reported by the bed partner Only a subgroup of patients with moderate OSA had a significantly decreased AHI (n=8, AHI: 25.4 [22.1–28.7] vs 18.1 [15.4–24.1], p=0.017) Control group showed only decrease on the subjective frequency of snoring reported by the patient
Villa et al^Citation41 PR Italy	To evaluate the efficacy of OE as a means of reducing residual OSA in children after AT Children with residual OSA after AT (AHI>1) and persistence of respiratory symptoms after AT Group 1 – N: 14 Age: 6.01±1.55, AHI: 4.87±2.96 BMI (centile): 81.85±29.94 Group 2 – N: 13 Age: 5.76±0.82, AHI: 4.56±3.22 BMI (centile): 68.22±28.68	Two months, three meeting with the therapist Group 1: nasal washing and exercises HT: three times a day, with 10–20 repetitions each time Group 2: nasal washing HT: two times a day, in the morning and evening	Full-night PSG before AT, 6 months after AT and after 2 months of exercises The improvement in OSA was defined by ΔAHI: (AHI at T1−AHI at T2)/AHI at T1×100 Morphofunctional evaluation	Group 1 had significantly decreased AHI, reduction in oral breathing, a positive Glatzel test, a positive Rosenthal test, as well as increased labial seal and lip tone Group 2 had no significant difference after two months of nasal washing
Verma et al^Citation53 PCS India	To evaluate the effect of oropharyngeal exercises in graded level of difficulty for mild-to-moderate OSA Patients with OSAS, N: 20 Age: 41.1±10.6 Male: 75% AHI: 20.1±9.1, BMI: 25.6±3.1	Three months, with weekly visits Three phases of OE in graded level of difficulty HT: 5 sets per day, with 10 repetitions of each exercise	ESS PSG	Patients showed significant improvement of ESS and PSG parameters and reduced NC ESS: 15.4±2.3 vs 13.6±3.1 AHI:19.7±9.4 Arousal index: 15.6±9.5 vs 12.8±7.1 Minimum SaO2 (%): 87.6±1.1 vs 88.5±1.6 Time duration for SaO2<90%: 6.7±6.6 vs 5.1±6.1
Diaféria et al^Citation40 RCT Brazil	To evaluate the effect of myofunctional therapy on CPAP adherence N=100 Male: 100% Placebo group – N: 24 Age: 42.9±10.5, AHI: 27.8±20.3 BMI: 28.6 ± 4.0 MT group – N: 27, Age: 45.2±13 AHI: 28±22.7, BMI: 25.0±7.4 CPAP group – N: 27 Age: 46.4±9.1, AHI: 34.4±22.4 BMI: 28.7±3.3 CPAP+OMT group – N: 22 Age: 47.5±10.9, AHI: 30.4±19.8 BMI: 27.9±2.4	Three months for all groups. Weekly visits for placebo, MT, and MT+CPAP groups Three visits for CPAP Placebo: relaxation and stretching of the neck muscles HT: Three times a day, 20 min each MT: OE HT: Three times a day, 20 min each CPAP device with nasal mask, without humidifier MT+CPAP: both protocols	Adherence evaluation PSG, ESS, scale of snoring intensity and snoring frequency, myofunctional evaluation, Malampatti index All outcomes measured before and after three months of treatment, and after a 3-week washout period	The average adherence to treatment was placebo (55%), MT (63%), CPAP (30%), MT+CPAP (65%) Time using the device: MT+CPAP>CPAP after one week and after three months of treatment The AHI decreased in the MT (50%), CPAP (87%), and MT+CPAP (89%). All groups were significantly different from the placebo ESS: Only the OMT group maintained the improvement in the snoring intensity and frequency after the washout period The Mallampati index improved in the OMT and CPAP+OMT groups and it was correlated with the increased strength of the tongue and soft palate
Villa et al^Citation1 PC-C Italy	To evaluate the efficacy of MT to reduce oral breathing in children with SDB and to evaluate the increase in tongue tone 54 children with SDB (14 primary snoring [PSG, AHI 0.35±0.3] and 40 mild–moderate OSA [AHI 2.2±2.0]) MT group: (n: 36) Age: 6.7±2.3 Male: 38.8% Non-MT group: (n: 18) Age: 6.7±2.8 8 Male: 44.4% Healthy group: (n: 38) Age: 7.8±2.2 Male: 65.8%	Two months, with two monthly meetings with a therapist MT group: MT plus nasal washing HT: three times a day, with 10–20 repetitions each time Non-MT group: nasal washing, two times a day, in the morning and evening.	All the patients were evaluated before (T0) and after (T1) two months of treatment: tongue strength, tongue peak pressure, and endurance using the IOPI, myofunctional evaluation, nocturnal pulse oximetry The Healthy group underwent only IOPI measurements	T0: MT vs non-MT (p>0.05) Compared to healthy group, MT and non-MT groups had lower tongue strength, tongue peak, and longer endurance (s) T1: MT group showed significant increase of tongue strength, tongue peak, endurance, mean and minimum SaO2, decrease of oxygen desaturation index, as well as decrease of the number of children with oral breathing habit (15 vs 3) and lip hypotonia (14 vs 6) and abnormal tongue resting position (17 vs 12) No differences were observed in the non-MT
Mohamed et al^Citation54 PCS Egypt	To evaluate the effect of upper airway muscle exercise and rehabilitation as a new and simple technique to treat OSAS Group I moderate OSAS N: 15 Age: 46.39±2.04 Male: 80% BMI: 28.62±1.86 Group II: severe OSAS N: 15 Age: 47.5±9 Male: 86.7% BMI: 27.2±2.03	Three months, with weekly visits OE HT: 3–5 times per day with minimum 10 min for each time	Full-night PSG AHI Lowest SaO2 Snoring ESS Neck circumference	Daytime sleepiness (ESS), AHI, SaO2, and snoring index improved significantly in Group I (all p≤0.003), but not in Group II Group I: ESS: 14±6 vs 9.5±4.9 AHI: 22.51±5.03 vs 12.4±5.12 Snoring index: 312±8.8 vs 237.8±27.4 SaO2 (%): 83±4 vs 86±5 NC: 39.65±3.52 vs 38.92±2.92 Group II: ESS: 20.9±6.2 vs 18.91±5.1 AHI: 46.1±21.1 vs 42.8±15.65 SaO2 (%): 75±5.8 vs 78±4.9 Snoring index: 615±96.8 vs 554.6±81.43 NC: 43.02±2.06 vs 42.86±1.87

Note: Study type: RCT, PR, PC-C, and PCS; diagnosis: OSAS, OSA, and SDB; intervention: OE, MT, OMT, HT, ST, CPAP, AT, and LCF; age and anthropometric measures: age (mean age in years), BMI, AC, NC, and PSG and its variables such as AI, AHI, AHI REM, SaO₂, SpO₂, and TSTS; subjective scale: ESS, QoL, FOSQ, WHOQoL-Bref, SF-36, and IOPI.

Abbreviations: RCT, randomized controlled trial; PR, prospective randomized; PC-C, prospective case–control; PCS, prospective case series; OSAS, obstructive sleep apnea syndrome; OSA, obstructive sleep apnea; SDB, sleep-disordered breathing; OE, oropharyngeal exercises; MT, myofunctional therapy; OMT, orofacial myofunctional therapy or oral myofunctional therapy; HT, home training; ST, speech therapy; CPAP, continuous positive airway pressure; AT, adenotonsillectomy; LCF, labial closure force; Age, mean age in years; BMI, body mass index (kg/m²); AC, abdominal circumference; NC, neck circumference; PSG, polysomnography; AI, apnea index (events/hour); AHI, apnea–hypopnea index (events/hour); AHI REM, apnea–hypopnea index during rapid eye movement (events/hour); SaO₂, oxygen saturation; SpO₂, saturation of peripheral oxygen; TSTS, total sleep time snoring; ESS, Epworth Sleepiness Scale; QoL, quality of life; FOSQ, Functional Outcomes of Sleep Questionnaire; WHOQoL-Bref, World Health Organization Quality of Life Assessment; SF-36, Medical Outcomes Study 36-Item Short-Form Health Survey; IOPI, Iowa Oral Performance Instrument.

Table 2 Strategies and exercises for young and adult patients with OSA recommended in the reviewed studies

	Frequency (times a day)/dose
Nasal lavage with an application of saline in each nostril	Three times/10 mL^Citation38,Citation39
Soft palate
Pronounce an oral vowel intermittently (isotonic exercise)/elevate the soft palate and uvula while intermittently saying the vowel “A”	Three times/3 min^Citation29,Citation38,Citation52
	Five times/10 repetitions^Citation53
	Three times/20 repetitions^Citation39,Citation54
Pronounce an oral vowel continuously (isometric exercise)	Three times/3 min^Citation29,Citation38
	Five times/10 repetitions^Citation53
Elevate the soft palate and uvula without vocalization, after gaining control and coordination of movement (~after 3–5 weeks)	Three times/5 s^Citation39,Citation54
Elevate the soft palate with and without a yawn	Three to five times per day^Citation50
	Five times/10 repetitions^Citation53
Produce lingua-velar sounds by contacting the dorsum of the tongue and the velum several times each	Three to five times per day^Citation50
Produce uvular sounds by contraction of the uvula several times each	Three to five times per day^Citation50
Tongue
Brush the superior surfaces of the tongue while it is positioned in the floor of the mouth. Also, brush the lateral surfaces of the tongue	Three times/5 repetitions^Citation29,Citation38
	Five times/10 repetitions^Citation53
Place the tip of the tongue against the front of the palate and slide the tongue backward	A total of 3 min throughout the day
	Three times/20 repetitions^Citation29,Citation39,Citation54
	Five times/10 repetitions^Citation53
Place the tongue tip as far as possible on the palate	Three to five times per day^Citation50
Press the entire tongue upward against the palate	A total of 3 min throughout the day^Citation38
	Three to five times per day^Citation50
	Three times/20 repetitions^Citation29,Citation39,Citation54
	Five times/10 repetitions^Citation50
Press the tongue against the palate and apply a counterresistance on both cheeks using the hands	Three to five times per day^Citation50
Place the tongue tip in contact with the inferior incisive teeth and force its posterior region of the tongue downward	A total of 3 min throughout the day^Citation38
	Three times/20 repetitions^Citation29,Citation39,Citation54
Protrude the tongue tip forward just in front of the lips, without touching the teeth or lips,^Citation50 and without deviation. Hold, relax, and repeat^Citation53	Three to five times per day/30 s^Citation50
	Five times/10 repetitions^Citation53
Repeatedly stick the tongue in and out as fast as possible	Five times/10 repetitions^Citation53
Spread center of the tongue, so the sides of the tongue touch the bottom of the upper teeth	Three to five times per day/30 s^Citation50
Protrude the tongue outside the mouth and move the tip (lift and down)	Three to five times per day^Citation50
Move the tongue to the right/left corner of the mouth and keep it pointed	Three to five times per day^Citation50
Flick the tongue from corner-to-corner as quickly as possible. Move the tongue all around the lips in a circle quickly	Five times/10 repetitions^Citation53
Stick out the tongue to reach the chin with the tip. Hold at the farthest extension	Five times/10 repetitions^Citation53
Stick out the tongue. Hold a spoon upright against the tip of your extended tongue and try to push it away while your hand holds the spoon in place	Five times/10 repetitions^Citation53
Rotate the tongue in the oral vestibule	Three times/10 repetitions starting in the right side and 10 left side^Citation29
Facial
Pressure the lips (orbicularis oris muscle) with the mouth closed (isometric exercise)	Three times/30 s^Citation38
	Five times/10 repetitions^Citation53
Open and close the jaw slowly and widely, keeping the lips in contact (orbicularis oris muscle)	Five times/10 repetitions^Citation53
Pucker the lips (as if about to kiss). Hold for a count of 10 and relax	Five times/10 repetitions^Citation53
Spread the lips into a big, exaggerated smile. Hold and relax	Five times/10 repetitions^Citation53
Pucker lips–hold–smile–hold	Five times/10 repetitions^Citation53
Pucker the lips with the mouth wide open, without closing the jaws. Hold and relax	Five times/10 repetitions^Citation53
Close the lips firmly, and then make a “slurping” noise, as if sipping a drink	Five times/10 repetitions^Citation53
Perform suction movements contracting only the buccinators. These exercises are performed with repetitions (isotonic) and holding position (isometric)	Unclear^Citation38
	Five times/10 repetitions^Citation53
Suck air from a syringe of 20 mL	Three times a day/5 repetitions^Citation29
Recruitment of the buccinator muscle against the finger that is introduced into the oral cavity	Unclear^Citation38
	Three times a day/10 repetitions each side^Citation29,Citation39,Citation54
	Five times/10 repetitions^Citation53
Alternated elevation of the mouth angle muscle (isometric exercise), with repetitions (isotonic exercise)	Three times a day/10 intermittent elevations three times^Citation38
Lateral jaw movements with alternating elevation of the mouth angle muscle	Unclear^Citation38
	Five times/10 repetitions^Citation53
Open and close mouth as quickly as you can, making sure your lips close each time	Five times/10 repetitions^Citation53
Say the syllable “Ma” quickly and repeatedly. Do the same with “La” and “Kala”	Five times/10 repetitions^Citation53
Sing “A–E–I–O–U” as loud as possible	Five times/10 repetitions^Citation53
Stomatognathic functions
Suction
Suck the yogurt with a narrow straw	Unclear^Citation38
Breathing and speech
Forced nasal inspiration and oral expiration in conjunction with phonation of open vowels, while sitting	Unclear^Citation29,Citation38
	Five times/10 repetitions^Citation53
Balloon inflation with prolonged nasal inspiration and then forced blowing	Repeated five times without taking the balloon out of the mouth^Citation29,Citation38,Citation53
Swallowing and chewing
Alternate bilateral chewing	The patients were instructed to incorporate this pattern whenever they were eating^Citation29,Citation38,Citation39,Citation53,Citation54
Deglutition: swallow with the tongue positioned on the palate, occluded teeth, and without perioral muscle contraction	The patients were instructed to incorporate this pattern whenever they were eating^Citation29,Citation38,Citation39,Citation53,Citation54
Holding the tongue tip between teeth anteriorly while trying to swallow	Three to five times per day^Citation50

Abbreviation: OSA, obstructive sleep apnea.

Figure 2 Apnea–hypopnea index (AHI): mean (or median for Ieto et al³⁹) before and after OMT and percentage of AHI decrease.

Abbreviations: AHI, apnea–hypopnea index; OMT, orofacial myofunctional therapy.

Table S1 Questions for analysis of complete texts

Number	Question
1	Is the document an original research published in a journal with peer-review policies?
2	Does the article include patients with OSA diagnosis based on PSG?
3	Does the article describe the OMT program (oral, facial, or oropharyngeal exercises) or quoted some program?
4	What was the research objective?
5	What were the outcomes measures?
6	Does the article describe the measurement used in a way that can be replicated, or provide quantitative measures of PSG and validated or recognized questionnaires/scales for OSA symptoms?
7	Does the article describe the measurements used in a way that can be replicated, or provide specific quantitative measures of orofacial myofunctional evaluation?
8	Does the article describe participant eligibility criteria such as age, sex, BMI, and AHI?
9	Does the article describe the participant’s characteristics?
10	Were the participants randomized for groups?
11	Were the results express as quantitative measures?
12	What were the main and secondary findings of the study?

Abbreviations: OSA, obstructive sleep apnea; PSG, polysomnography; OMT, orofacial myofunctional therapy; BMI, body mass index; AHI, apnea–hypopnea index.

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