The relationship between sleep bruxism and sleep-related respiratory events under oral appliance therapy in patients with obstructive sleep apnea

The relationship between sleep bruxism and sleep-related respiratory events under oral appliance therapy in patients with obstructive sleep apnea | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The relationship between sleep bruxism and sleep-related respiratory events under oral appliance therapy in patients with obstructive sleep apnea Yuriko Dotsu, George Umemoto, Chikara Yoshimura, Ritsuko Miyachi, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7210470/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction Sleep bruxism (SB), which is associated with obstructive sleep apnea (OSA), has been receiving increased attention. Oral appliance (OA) therapy is likely to indirectly improve SB by reducing the number of respiratory events and arousals that induce SB. Objectives This study aimed to clarify how OA therapy influences SB, which is likely to induce arousal, by analyzing the relationship between muscle activity during SB and sleep-related respiratory events before and after OA therapy in patients with OSA. Material and methods Patients diagnosed with OSA based on polysomnography (PSG) at Fukuoka University Hospital between October 2020 and May 2025 were referred for OA therapy. Twenty-one participants (10 males, 11 females; mean age, 57.8 ± 16.0) were enrolled in this study. The masseter muscle activity was simultaneously measured using an identical single-channel wearable electromyography device. They underwent a second PSG and EMG evaluation after OA therapy, and a comparison of the data between baseline and reevaluation was conducted. Results The results of baseline and reevaluation PSG evaluations showed a significant improvement in AHI from 17.3 ± 7.3 to 12.3 ± 10.7 (p = 0.008). The total number of SB episodes and SB/h significantly decreased (p = 0.002 and p = 0.001, respectively), and the spontaneous arousal index during the rapid eye movement stage significantly increased (p = 0.007). Significant reductions in total SB episodes and SB/h were observed not in the effective group, including 10 participants with apnea/hypopnea index (AHI) reduction ≥50% or AHI in reevaluation <5, but in the ineffective group, including 11 participants with AHI reduction <50% and AHI in reevaluation ≥5 (p = 0.013 and p = 0.013, respectively). The effective group experienced a significant decrease in the respiratory arousal index during total sleep time (p = 0.002) and a significant increase in the spontaneous arousal index (p = 0.011). Conclusions The mechanism underlying the generation of SB appears to be derived not only from the presence of OSA but also from a multifactorial etiology, and OAs may not only be simple respiratory assist devices but also effective for helping to manage SB. Sleep Bruxism Oral Appliance Obstructive Sleep Apnea Respiratory Arousal Index Spontaneous Arousal Index Figures Figure 1 Figure 2 Introduction Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder characterized by apnea and hypopnea in ventilation caused by repeated episodes of complete or partial collapse of the upper airway during sleep. OSA is reportedly related not only to excessive daytime sleepiness, cognitive dysfunction, or a decline in quality of life, but also to chronic diseases, such as hypertension, cardiovascular disease, and diabetes. Therefore, an early diagnosis and appropriate intervention for OSA are strongly needed [ 1 ]. Although continuous positive airway pressure (CPAP) is the first-line therapy for OSA, some patients exhibit poor treatment adherence due to discomfort from wearing the CPAP apparatus or difficulty in adjusting to wearing the mask. One of the most common alternative therapies for OSA is oral appliance (OA) treatment [ 2 ]. An OA can increase pharyngeal dimensions by pulling the mandible forward and physically preventing the collapse obstruction of the upper airway. OA therapy is effective in patients with mild-to-moderate OSA, and some previous reports have shown more favorable treatment outcomes, including higher treatment adherence, in comparison to CPAP therapy [ 3 ]. In 2005, the American Academy of Sleep Medicine (AASM) and the American Academy of Dental Sleep Medicine (AADSM) published practice parameters for the treatment of snoring and OSA using OAs [ 4 ]. OAs are indicated for use in patients with mild to moderate OSA with an apnea/hypopnea index (AHI) of 5–30/h who prefer OAs to CPAP, do not respond to CPAP, are not appropriate candidates for CPAP, or fail treatment attempts with CPAP [ 4 ]. Currently, most indications for OA therapy are considered based on the severity of OSA, which is graded depending on the AHI; however, the applicability of OA treatment should be decided not only based on AHI but also on the prediction of the treatment effect through appropriate examinations and evaluations [ 5 ]. Various studies have reported factors related to treatment outcomes of OA other than the AHI, such as the type of OA, monoblock vs. twin-block [ 6 ], mandibular positions including mandibular advancement amounts and vertical dimension [ 7 ], endoscopic examination of the upper airway and tongue [ 8 , 9 ], pulse oximetry [ 10 ], cephalometric morphology [ 11 – 13 ], impulse oscillation system [ 14 ], and therapeutic CPAP pressure [ 15 , 16 ]. OSA-associated sleep bruxism (SB) has recently received considerable attention. SB is characterized by rhythmic contractions of the masseter muscles and tooth grinding, accompanied by repetitive mandibular movements during sleep. It is considered to originate from multiple central and peripheral factors [ 17 ]. Previous studies have suggested a higher prevalence of SB in patients with OSA than in the general population [ 18 ] and have identified possible pathophysiological relationships between OSA and SB, as the appearance of SB coincides with micro-arousals and an increase in respiratory effort [ 19 , 20 ]. Regarding the effects of OAs on SB, the possibility that the stabilization of the mandible position by an OA could alter masseter muscle activity and prevent masticatory muscle hyperactivity has been reported [ 21 ]. OA therapy is likely to improve SB indirectly by reducing the number of respiratory events and arousals that induce SB. However, studies on these associations and the effects of OA therapy for OSA on the occurrence of SB are limited. This study aimed to clarify how OA therapy influences SB, which is likely to induce arousals, by analyzing the relationship between muscle activity during SB and sleep-related respiratory events before and after OA therapy in patients with OSA. Methods 1. Participants Patients diagnosed with OSA based on polysomnography at Fukuoka University Hospital between October 2020 and May 2025 were referred to the Department of Dentistry for OA therapy. Twenty-one participants (10 males, 11 females; mean age, 57.8 ± 16.0) were enrolled in this study. This study was approved by the Ethics Committee of Fukuoka University Hospital (approval number: H23-05-011), and informed consent was obtained from the hospital website. 2. Examination PSG recordings, including electroencephalography (EEG), electrocardiography (ECG), oro-nasal flow sensors, respiratory effort, oxygen saturation (SpO 2 ), snoring microphone recordings, body position, leg movements, and video recordings, were acquired during sleep using a digital PSG recorder (Somno HD; Fukuda Denshi, Bunkyo-ku, Tokyo, Japan). Sleep studies were manually scored by a polysomnographic technologist certified by the Japanese Society of Sleep Research using the American Academy of Sleep Medicine Scoring Manual (version 2.5) [ 22 ]. Masseter muscle activity was simultaneously measured using an identical single-channel wearable electromyography (EMG) device (Wearable EMG; GC Corporation, Tokyo, Japan) [ 23 ]. The wearable EMG devise was attached to one side of the masseter muscle, and at the start of the measurement, the subjects were required to set the calibration movement by biting in a habitual occlusal position with maximum force, which was defined as 100% maximum voluntary contraction (MVC) for 3 s, separated by an interval of tapping three times with medium force. 3. Data analysis The baseline data of the first PSG evaluation obtained before OA therapy, while the reevaluation data of the second PSG evaluation performed with the subject wearing the OA were obtained at the time when participants showed improvement in daytime sleepiness and subjective sleep satisfaction after OA therapy. 4. Estimation of sleep stages and sleep variables Sleep stages were divided into W (wakefulness), REM (rapid eye movement sleep), and NREM Sleep (non-rapid eye movement sleep). NREM sleep was further divided into N1, N2 (light sleep), and N3 (deep sleep), according to the 2007 AASM Manual for the Scoring of Sleep and Associated Events [ 24 ]. The total sleep time (TST), sleep efficiency (SE), and a breakdown of the sleep stages were calculated. TST is determined based on the minutes of stages of sleep (N1, N2, N3, R), and SE is calculated as TST divided by time in bed, multiplied by 100%. The percentage of each sleep stage (NREM 1–3, REM, and W) based on the TST was calculated as follows: %S1-3, percentage of stages 1–3; %SR, percentage of REM stage; %SW, percentage of W stage. 5. Analysis of respiratory events The AASM Manual [ 24 ] defines apnea to score when there is a drop in the peak signal excursion by ≥ 90% of pre-event baseline using an oronasal thermal sensor for ≥ 10 s and hypopnea to score when the peak signal excursions drop by ≥ 30% of pre-event baseline using nasal pressure for ≥ 10 s in association with ≥ 3% arterial oxygen desaturation. The apnea index (AI) and hypopnea index (HI) are calculated by dividing the total number of apneas and hypopneas in the TST. The AHI is determined as the sum of AI and HI. The participants were divided into effective and ineffective groups according to the following evaluation criteria: effective, AHI reduction ≥ 50% or AHI in reevaluation < 5; ineffective, AHI reduction < 50% and AHI in reevaluation ≥ 5. The lowest SpO 2 and the oxygen desaturation index (ODI), which is defined as the frequency of oxygen saturation decrease by ≥ 3%/h during sleep, were extracted from the records of overnight pulse oximetry. 6. Identification of arousal responses The arousal index (ArI) was calculated by dividing the total number of arousals by the sleep period time (i.e., the duration of time from sleep onset to final awakening), and the ArI in each sleep stage was also calculated. Furthermore, the respiratory arousal index (RAI), which was correlated with respiratory events in the TST, and the spontaneous arousal index (SAI), which was not correlated with respiratory events, flow limitation, SpO 2 , periodic limb movement (PLM), leg movement (LM), snoring, or cardiac events, were calculated. 7. Diagnosis of SB EMG waveforms recorded during sleep were analyzed using the W-EMG viewer software program (GC Co., Tokyo, Japan). The highest peak amplitude within the MVC waveforms was identified as the MVC value for the individual participants on each day. EMG bursts with peak amplitude exceeding and falling below two times the baseline at the starting and ending points, respectively, and with a duration of > 0.08 s were automatically extracted [ 23 ]. From them, an EMG burst with peak amplitude exceeding two times the baseline, with a duration of more ≥ 0.25 s but < 60 s, under 300% MVC, was regarded as one burst wave. The total number of burst waves, or SB, was calculated and divided by the sleep period time as the number of SB episodes; the episodes were then decided based on the International Classification of Sleep Disorders, 3rd edition (ICSD-3), as follows [ 25 ]: 1) Phasic episode: burst occurred ≥ 3 times, and each burst continued for ≥ 0.25 s but < 2 s. 2) Tonic episode: burst continued for ≥ 2 s. 3) Mixed episode: both phasic and tonic episodes were measured. 8. Statistical analysis Data obtained from PSG and the wearable EMG device before and after OA therapy were compared using the Wilcoxon signed-rank test. The paired t-test was used to compare data before and after OA therapy in the effective and ineffective groups. All statistical analyses were performed using IBM SPSS Statistics for Windows (ver. 27.0; IBM Japan, Tokyo, Japan). For all tests, p values of < 0.05 (two-tailed) were considered to be statistically significant. Results Of the twenty-one participants, 14 wore a monoblock OA and 7 wore a twin-block OA. The mean duration from baseline PSG to reevaluation PSG was 308.2 ± 202.5 days. No significant change was observed in body mass index between the baseline and reevaluation PSGs (Table 1). The results of baseline and reevaluation PSGs (Table 1) showed significant improvements in AHI from 17.3 ± 7.3 to 12.3 ± 10.7 (p = 0.008), in AHI during the REM and NREM stages (p = 0.011 and p = 0.007, respectively), and in AI, HI, and lowest SpO 2 (p = 0.046, p = 0.037 and p = 0.007, respectively). There was no significant change in the TST, SE, or percentage of stages (%S1-3, %SR, and %SW). Despite no significant change, ArI increased from 17.1 ± 7.4 to 22.3 ± 19.9; on the other hand, ArI in the REM stage showed a significant increase (p = 0.008). A significant increase was observed in SAI during the REM stage (p = 0.007, Table 2, Fig. 1 ). Total SB and SB/h were significantly reduced (p = 0.002 and p = 0.001, respectively; Table 3). The number of tonic and mixed episodes significantly decreased (p = 0.034 and p = 0.002, respectively), but the phasic episodes did not show any significant change. Twenty-one participants were divided into effective (n = 10) and ineffective (n = 11) groups. The ineffective group showed significant reductions in total SB and SB/h after OA therapy (p = 0.013 and p = 0.013, respectively) and an increase in %SR from 12.0 ± 6.8 to 15.3 ± 8.6 (p = 0.038, Table 4). The effective group showed no significant change in total SB, but a significant increase in ArI during the REM stage from 13.5 ± 6.7 to 21.9 ± 10.6 (p = 0.007). The effective group experienced a significant reduction in RAI during TST (p = 0.002), with an improvement in respiratory events and a significant increase in SAI (p = 0.011, Fig. 2 ). Discussion This study showed significant improvements in AHI, AI, HI, and SpO 2 . An OA protrudes the mandible forward, thereby enlarging the airway space and preventing it from collapsing [ 2 ]. Our results align with the AASM and AADSM recommendations for OA therapy in patients with mild to moderate OSA [ 4 ], supporting the efficacy of OA treatment. The significant reduction in total SB, SB/h, tonic, and mixed episodes while wearing OA suggests the possibility of a physiological association between OSA and SB. Previous studies have shown that SB occurs along with effort respiration and arousal reactions [ 19 , 20 , 26 , 27 , 28 , 29 , 30 ], and it is conceivable that the improvement in respiratory events contributed to the suppression of SB. Furthermore, the reduction in SB episodes suggests controlled muscle activity associated with arousal reactions, which may be influenced by the stabilization of occlusion by the OA [ 21 ]. However, phasic episodes did not change significantly, so the effects of OA may change depending on the type of SB. The significant increase in ArI and SAI during the REM stage after OA therapy was a crucial finding in this study. This suggests that suppression of RAI by OA therapy is associated with respiratory events, whereas non-respiratory arousals that are irrelevant to respiratory events become apparent. Lavigne et al. reported that SB frequently occurs along with micro-arousals [ 5 ], suggesting that arousals triggered by different factors, such as respiratory events, may be involved in the occurrence of SB. Our results suggest that the mechanism to generate SB is derived not only from the presence of OSA but also from a multifactorial etiology [ 30 , 31 , 32 , 33 , 34 ], including central factors, such as sleep stages or arousal threshold. Saito et al. reported that patients with OSA and SB only had a weak interaction between OSA and SB, and SB could not be a direct sign or symptom of OSA [ 21 ]. Previous studies have shown no significant association between OSA and SB [ 28 , 31 , 35 – 38 ]. Therefore, the limitation of OA therapy to completely control SB should be considered. The significant reduction in SB episodes, which was detected in the ineffective group but not in the effective group, indicates that SB does not necessarily depend only on respiratory events, and suggests that the mechanical characteristics of OA, such as the stabilized mandible or limited muscle activity, directly influence the frequency of SB [ 39 ]. These results suggest that OA therapy is effective not only for respiratory disturbance, but also for SB in patients with OSA and SB. These findings align with those of previous studies that reported a significant reduction in SB episodes with both CPAP and OA therapies [ 40 , 41 ]. There was variation in the treatment effects of SB [ 40 ]. Therefore, if SB occurs secondary to respiratory events, respiratory improvements achieved through CPAP therapy could be effective in controlling SB [ 41 ]. Therefore, OA may not only be a simple respiratory assist device but also be effective in managing SB. Personalized treatments considering not only the severity of OSA or AHI, but also the therapeutic response or mechanism of occurrence are clinically important [ 41 , 42 ]. This study had some limitations. The first is the low statistical power owing to the small number of participants (n = 21). The second is the variation in the types of OA (monoblock or twin-block). The third is the short duration of therapy (308 days). Further research is needed to examine the long-term recurrence rate of SB and OSA, as well as the continuity of OA therapy. This study showed that SB interacts not only with OSA but also with many other factors, and a comprehensive approach is needed for SB and OSA. In the future, it will be necessary to build a more effective OA treatment strategy by accurately analyzing the association between the type or custom fitting of OA, such as mandibular advancement or vertical dimension, and SB. The analysis of the temporal relevance between arousal reactions and the occurrence patterns of SB in each sleep stage could expand our understanding of the neurobiological mechanisms involved in SB. Conclusion This study evaluated the effects of OA therapy on sleep and respiratory parameters and SB in patients with OSA. OA therapy improved respiratory events with a marked impact on AHI and a significant reduction in SB episodes, especially in tonic and mixed episodes. An increase in SAI during the REM stage was observed; therefore, not only respiratory events but also central arousals could be involved in the occurrence of SB. It is also possible that SB is not always dependent on respiratory events, because SB only decreased in the ineffective group. SB may be caused by a multifactorial etiology, and an OA may not only be a simple respiratory assist device, but also an effective device for helping to manage SB. In the future, maximization of OA therapy effects is expected through a more accurate applicability assessment of the therapy for individuals and clarification of the mechanisms through which SB occurs. Abbreviations SB, sleep bruxism; OSA, obstructive sleep apnea; OA, Oral appliance; PSG, polysomnography; AHI, apnea/hypopnea index; CPAP, continuous positive airway pressure; AASM, the American Academy of Sleep Medicine; AADSM, the American Academy of Dental Sleep Medicine; EEG, electroencephalography; ECG, electrocardiography; SpO 2 , oxygen saturation; EMG, electromyography; MVC, maximum voluntary contraction; W, wakefulness; REM, rapid eye movement sleep; NREM, non-rapid eye movement; TST, total sleep time; SE, sleep efficiency; AI, apnea index; HI, hypopnea index; ODI, oxygen desaturation index; ArI, arousal index; RAI, respiratory arousal index; SAI, spontaneous arousal index; PLM, periodic limb movement; LM, leg movement; ICSD-3, International Classification of Sleep Disorders, 3rd edition Declarations Ethics approval and consent to participate PSG and EMG evaluations are conducted as part of standard examinations in the Fukuoka University Hospital. All methods were carried out according to relevant guidelines and regulations. The ethics committee (or institutional review board) of the Fukuoka University Hospital, Fukuoka University-Medical Ethics Review Board, approved the analysis of the examinations in this study, an opt-out method to obtain consent, and waiver of informed consent for this study. The notice and opt-out opportunity were provided to all of the participants on the hospital website. The committee’s reference number is H23-05-011. Consent for publication Not applicable Competing interests The authors declare that they have no competing interests in this section. Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Funding This work was financially supported by JSPS KAKENHI Grant number [21K10034] and by funding from Fukuoka University [216007]. 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Landry-Schönbeck A, de Grandmont P, Rompré PH, Lavigne GJ. Effect of an adjustable mandibular advancement appliance on sleep bruxism: a crossover sleep laboratory study. Int J Prosthodont. 2009; 22: 251-9. Li D, Lobbezoo F, Kuang B, Hilgevoord AAJ, de Vries N, Aarab G. Effects of continuous positive airway pressure and mandibular advancement appliance therapy on sleep bruxism in adults with obstructive sleep apnea: a pilot study. Sleep Breath. 2023; 27: 1857-64. doi: 10.1007/s11325-023-02799-z. Martinot JB, Borel JC, Le-Dong NN, Silkoff PE, Denison S, Gozal D, Pépin JL. Bruxism relieved under CPAP treatment in a patient with OSA syndrome. Chest. 2020; 157: e59-e62. doi: 10.1016/j.chest.2019.07.032. Manfredini D, Guarda-Nardini L, Marchese-Ragona R, Lobbezoo F. Theories on possible temporal relationships between sleep bruxism and obstructive sleep apnea events. An expert opinion. Sleep Breath. 2015; 19: 1459-65. doi: 10.1007/s11325-015-1163-5. Tables Table 1 and 4 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Table1and4.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7210470","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":498327809,"identity":"7ad12ed3-f87a-4132-80ca-552575f80602","order_by":0,"name":"Yuriko Dotsu","email":"","orcid":"","institution":"Fukuoka University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yuriko","middleName":"","lastName":"Dotsu","suffix":""},{"id":498327810,"identity":"d83639f3-472c-46e7-bd6f-4bddf9cb4984","order_by":1,"name":"George Umemoto","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA90lEQVRIiWNgGAWjYPACG34GHgYGxgYYX4KwljTJBlK1HEbTgg/Iuzcf+/il4ryEwZkzhg9n1DAkNrAffsBguQO3FsMzx5Jny5y5LWFwtsfYcMMxoBaeNAMGyTN4tMzIMWaWbLtdZ3Cex0zyAdv/xAaGHAYGyTY8Wua/AWr5d04CouUf0Bb+N/i1yEvwGDN+bDgAcpiZ5MY2oBYJArYY8KQlMzMcS5aQPHOs2HBmH4Nxm8QzgwP4/CLffvgw448aOwm+M8kbH/Z8Y5Dt509++FgST4gZHGBgYOZBFmFjAEcTHluAcow/0EWBvsOtZRSMglEwCkYcAADTAk/2I3EPrQAAAABJRU5ErkJggg==","orcid":"","institution":"Fukuoka University Hospital","correspondingAuthor":true,"prefix":"","firstName":"George","middleName":"","lastName":"Umemoto","suffix":""},{"id":498327811,"identity":"24b6dffc-4046-44e8-9ad0-7333a898bdee","order_by":2,"name":"Chikara Yoshimura","email":"","orcid":"","institution":"Fukuoka University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Chikara","middleName":"","lastName":"Yoshimura","suffix":""},{"id":498327813,"identity":"18a1e5c0-496e-420d-b1de-adeeaaa6197a","order_by":3,"name":"Ritsuko Miyachi","email":"","orcid":"","institution":"Fukuoka University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Ritsuko","middleName":"","lastName":"Miyachi","suffix":""},{"id":498327814,"identity":"0add4df4-d453-4c93-9c00-80bbc514266f","order_by":4,"name":"Mitsuko Kuchiishi","email":"","orcid":"","institution":"Fukuoka University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Mitsuko","middleName":"","lastName":"Kuchiishi","suffix":""},{"id":498327816,"identity":"9b3351ca-1466-42a0-bda2-26c1a12d890a","order_by":5,"name":"Hideo Toyoshima","email":"","orcid":"","institution":"Fukuoka Urasoe Clinic","correspondingAuthor":false,"prefix":"","firstName":"Hideo","middleName":"","lastName":"Toyoshima","suffix":""}],"badges":[],"createdAt":"2025-07-25 05:08:26","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7210470/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7210470/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":88890939,"identity":"076a4493-a7e9-4ca9-acc7-9b1685410543","added_by":"auto","created_at":"2025-08-12 12:47:55","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":199049,"visible":true,"origin":"","legend":"\u003cp\u003eChanges in arousal reactions and components during the REM stage before and after OA therapy\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7210470/v1/366a16be021286e759c75458.png"},{"id":88890938,"identity":"5fd0121a-a76c-46bb-99de-f08e5515ab22","added_by":"auto","created_at":"2025-08-12 12:47:55","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":55456,"visible":true,"origin":"","legend":"\u003cp\u003eChanges in arousal reactions and components during the REM stage in the effective group\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7210470/v1/6726237cc80b1347b9c223dc.png"},{"id":90378436,"identity":"fa9f2d1a-72db-4076-8021-b0332831ab31","added_by":"auto","created_at":"2025-09-02 06:24:05","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":787425,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7210470/v1/3f89a9fa-6940-4d24-9a64-79a7d9a9ff39.pdf"},{"id":88897142,"identity":"38393270-a806-4008-b832-5a854790b38a","added_by":"auto","created_at":"2025-08-12 13:11:55","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":17238,"visible":true,"origin":"","legend":"","description":"","filename":"Table1and4.docx","url":"https://assets-eu.researchsquare.com/files/rs-7210470/v1/a6a5ee36c9db36f21ad0a0af.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"The relationship between sleep bruxism and sleep-related respiratory events under oral appliance therapy in patients with obstructive sleep apnea","fulltext":[{"header":"Introduction","content":"\u003cp\u003eObstructive sleep apnea (OSA) is the most common sleep-related breathing disorder characterized by apnea and hypopnea in ventilation caused by repeated episodes of complete or partial collapse of the upper airway during sleep. OSA is reportedly related not only to excessive daytime sleepiness, cognitive dysfunction, or a decline in quality of life, but also to chronic diseases, such as hypertension, cardiovascular disease, and diabetes. Therefore, an early diagnosis and appropriate intervention for OSA are strongly needed [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAlthough continuous positive airway pressure (CPAP) is the first-line therapy for OSA, some patients exhibit poor treatment adherence due to discomfort from wearing the CPAP apparatus or difficulty in adjusting to wearing the mask. One of the most common alternative therapies for OSA is oral appliance (OA) treatment [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. An OA can increase pharyngeal dimensions by pulling the mandible forward and physically preventing the collapse obstruction of the upper airway. OA therapy is effective in patients with mild-to-moderate OSA, and some previous reports have shown more favorable treatment outcomes, including higher treatment adherence, in comparison to CPAP therapy [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn 2005, the American Academy of Sleep Medicine (AASM) and the American Academy of Dental Sleep Medicine (AADSM) published practice parameters for the treatment of snoring and OSA using OAs [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. OAs are indicated for use in patients with mild to moderate OSA with an apnea/hypopnea index (AHI) of 5\u0026ndash;30/h who prefer OAs to CPAP, do not respond to CPAP, are not appropriate candidates for CPAP, or fail treatment attempts with CPAP [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Currently, most indications for OA therapy are considered based on the severity of OSA, which is graded depending on the AHI; however, the applicability of OA treatment should be decided not only based on AHI but also on the prediction of the treatment effect through appropriate examinations and evaluations [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Various studies have reported factors related to treatment outcomes of OA other than the AHI, such as the type of OA, monoblock vs. twin-block [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], mandibular positions including mandibular advancement amounts and vertical dimension [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], endoscopic examination of the upper airway and tongue [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], pulse oximetry [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], cephalometric morphology [\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], impulse oscillation system [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], and therapeutic CPAP pressure [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eOSA-associated sleep bruxism (SB) has recently received considerable attention. SB is characterized by rhythmic contractions of the masseter muscles and tooth grinding, accompanied by repetitive mandibular movements during sleep. It is considered to originate from multiple central and peripheral factors [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Previous studies have suggested a higher prevalence of SB in patients with OSA than in the general population [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] and have identified possible pathophysiological relationships between OSA and SB, as the appearance of SB coincides with micro-arousals and an increase in respiratory effort [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Regarding the effects of OAs on SB, the possibility that the stabilization of the mandible position by an OA could alter masseter muscle activity and prevent masticatory muscle hyperactivity has been reported [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. OA therapy is likely to improve SB indirectly by reducing the number of respiratory events and arousals that induce SB. However, studies on these associations and the effects of OA therapy for OSA on the occurrence of SB are limited. This study aimed to clarify how OA therapy influences SB, which is likely to induce arousals, by analyzing the relationship between muscle activity during SB and sleep-related respiratory events before and after OA therapy in patients with OSA.\u003c/p\u003e"},{"header":"Methods","content":"\n\u003ch3\u003e1. Participants\u003c/h3\u003e\n\u003cp\u003ePatients diagnosed with OSA based on polysomnography at Fukuoka University Hospital between October 2020 and May 2025 were referred to the Department of Dentistry for OA therapy. Twenty-one participants (10 males, 11 females; mean age, 57.8\u0026thinsp;\u0026plusmn;\u0026thinsp;16.0) were enrolled in this study. This study was approved by the Ethics Committee of Fukuoka University Hospital (approval number: H23-05-011), and informed consent was obtained from the hospital website.\u003c/p\u003e\n\u003ch3\u003e2. Examination\u003c/h3\u003e\n\u003cp\u003ePSG recordings, including electroencephalography (EEG), electrocardiography (ECG), oro-nasal flow sensors, respiratory effort, oxygen saturation (SpO\u003csub\u003e2\u003c/sub\u003e), snoring microphone recordings, body position, leg movements, and video recordings, were acquired during sleep using a digital PSG recorder (Somno HD; Fukuda Denshi, Bunkyo-ku, Tokyo, Japan). Sleep studies were manually scored by a polysomnographic technologist certified by the Japanese Society of Sleep Research using the American Academy of Sleep Medicine Scoring Manual (version 2.5) [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eMasseter muscle activity was simultaneously measured using an identical single-channel wearable electromyography (EMG) device (Wearable EMG; GC Corporation, Tokyo, Japan) [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. The wearable EMG devise was attached to one side of the masseter muscle, and at the start of the measurement, the subjects were required to set the calibration movement by biting in a habitual occlusal position with maximum force, which was defined as 100% maximum voluntary contraction (MVC) for 3 s, separated by an interval of tapping three times with medium force.\u003c/p\u003e\n\u003ch3\u003e3. Data analysis\u003c/h3\u003e\n\u003cp\u003eThe baseline data of the first PSG evaluation obtained before OA therapy, while the reevaluation data of the second PSG evaluation performed with the subject wearing the OA were obtained at the time when participants showed improvement in daytime sleepiness and subjective sleep satisfaction after OA therapy.\u003c/p\u003e\n\u003ch3\u003e4. Estimation of sleep stages and sleep variables\u003c/h3\u003e\n\u003cp\u003eSleep stages were divided into W (wakefulness), REM (rapid eye movement sleep), and NREM Sleep (non-rapid eye movement sleep). NREM sleep was further divided into N1, N2 (light sleep), and N3 (deep sleep), according to the 2007 AASM Manual for the Scoring of Sleep and Associated Events [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. The total sleep time (TST), sleep efficiency (SE), and a breakdown of the sleep stages were calculated. TST is determined based on the minutes of stages of sleep (N1, N2, N3, R), and SE is calculated as TST divided by time in bed, multiplied by 100%. The percentage of each sleep stage (NREM 1\u0026ndash;3, REM, and W) based on the TST was calculated as follows: %S1-3, percentage of stages 1\u0026ndash;3; %SR, percentage of REM stage; %SW, percentage of W stage.\u003c/p\u003e\n\u003ch3\u003e5. Analysis of respiratory events\u003c/h3\u003e\n\u003cp\u003eThe AASM Manual [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] defines apnea to score when there is a drop in the peak signal excursion by \u0026ge;\u0026thinsp;90% of pre-event baseline using an oronasal thermal sensor for \u0026ge;\u0026thinsp;10 s and hypopnea to score when the peak signal excursions drop by \u0026ge;\u0026thinsp;30% of pre-event baseline using nasal pressure for \u0026ge;\u0026thinsp;10 s in association with \u0026ge;\u0026thinsp;3% arterial oxygen desaturation. The apnea index (AI) and hypopnea index (HI) are calculated by dividing the total number of apneas and hypopneas in the TST. The AHI is determined as the sum of AI and HI. The participants were divided into effective and ineffective groups according to the following evaluation criteria: effective, AHI reduction\u0026thinsp;\u0026ge;\u0026thinsp;50% or AHI in reevaluation\u0026thinsp;\u0026lt;\u0026thinsp;5; ineffective, AHI reduction\u0026thinsp;\u0026lt;\u0026thinsp;50% and AHI in reevaluation\u0026thinsp;\u0026ge;\u0026thinsp;5. The lowest SpO\u003csub\u003e2\u003c/sub\u003e and the oxygen desaturation index (ODI), which is defined as the frequency of oxygen saturation decrease by \u0026ge;\u0026thinsp;3%/h during sleep, were extracted from the records of overnight pulse oximetry.\u003c/p\u003e\n\u003ch3\u003e6. Identification of arousal responses\u003c/h3\u003e\n\u003cp\u003eThe arousal index (ArI) was calculated by dividing the total number of arousals by the sleep period time (i.e., the duration of time from sleep onset to final awakening), and the ArI in each sleep stage was also calculated. Furthermore, the respiratory arousal index (RAI), which was correlated with respiratory events in the TST, and the spontaneous arousal index (SAI), which was not correlated with respiratory events, flow limitation, SpO\u003csub\u003e2\u003c/sub\u003e, periodic limb movement (PLM), leg movement (LM), snoring, or cardiac events, were calculated.\u003c/p\u003e\n\u003ch3\u003e7. Diagnosis of SB\u003c/h3\u003e\n\u003cp\u003eEMG waveforms recorded during sleep were analyzed using the W-EMG viewer software program (GC Co., Tokyo, Japan). The highest peak amplitude within the MVC waveforms was identified as the MVC value for the individual participants on each day. EMG bursts with peak amplitude exceeding and falling below two times the baseline at the starting and ending points, respectively, and with a duration of \u0026gt;\u0026thinsp;0.08 s were automatically extracted [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. From them, an EMG burst with peak amplitude exceeding two times the baseline, with a duration of more\u0026thinsp;\u0026ge;\u0026thinsp;0.25 s but \u0026lt;\u0026thinsp;60 s, under 300% MVC, was regarded as one burst wave. The total number of burst waves, or SB, was calculated and divided by the sleep period time as the number of SB episodes; the episodes were then decided based on the International Classification of Sleep Disorders, 3rd edition (ICSD-3), as follows [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]:\u003c/p\u003e\u003cp\u003e1) Phasic episode: burst occurred\u0026thinsp;\u0026ge;\u0026thinsp;3 times, and each burst continued for \u0026ge;\u0026thinsp;0.25 s but \u0026lt;\u0026thinsp;2 s.\u003c/p\u003e\n\u003ch3\u003e2) Tonic episode: burst continued for ≥ 2 s.\u003c/h3\u003e\n\u003cp\u003e3) Mixed episode: both phasic and tonic episodes were measured.\u003c/p\u003e\n\u003ch3\u003e8. Statistical analysis\u003c/h3\u003e\n\u003cp\u003eData obtained from PSG and the wearable EMG device before and after OA therapy were compared using the Wilcoxon signed-rank test. The paired t-test was used to compare data before and after OA therapy in the effective and ineffective groups. All statistical analyses were performed using IBM SPSS Statistics for Windows (ver. 27.0; IBM Japan, Tokyo, Japan). For all tests, p values of \u0026lt;\u0026thinsp;0.05 (two-tailed) were considered to be statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eOf the twenty-one participants, 14 wore a monoblock OA and 7 wore a twin-block OA. The mean duration from baseline PSG to reevaluation PSG was 308.2\u0026thinsp;\u0026plusmn;\u0026thinsp;202.5 days. No significant change was observed in body mass index between the baseline and reevaluation PSGs (Table\u0026nbsp;1). The results of baseline and reevaluation PSGs (Table\u0026nbsp;1) showed significant improvements in AHI from 17.3\u0026thinsp;\u0026plusmn;\u0026thinsp;7.3 to 12.3\u0026thinsp;\u0026plusmn;\u0026thinsp;10.7 (p\u0026thinsp;=\u0026thinsp;0.008), in AHI during the REM and NREM stages (p\u0026thinsp;=\u0026thinsp;0.011 and p\u0026thinsp;=\u0026thinsp;0.007, respectively), and in AI, HI, and lowest SpO\u003csub\u003e2\u003c/sub\u003e (p\u0026thinsp;=\u0026thinsp;0.046, p\u0026thinsp;=\u0026thinsp;0.037 and p\u0026thinsp;=\u0026thinsp;0.007, respectively). There was no significant change in the TST, SE, or percentage of stages (%S1-3, %SR, and %SW).\u003c/p\u003e\u003cp\u003eDespite no significant change, ArI increased from 17.1\u0026thinsp;\u0026plusmn;\u0026thinsp;7.4 to 22.3\u0026thinsp;\u0026plusmn;\u0026thinsp;19.9; on the other hand, ArI in the REM stage showed a significant increase (p\u0026thinsp;=\u0026thinsp;0.008). A significant increase was observed in SAI during the REM stage (p\u0026thinsp;=\u0026thinsp;0.007, Table\u0026nbsp;2, Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Total SB and SB/h were significantly reduced (p\u0026thinsp;=\u0026thinsp;0.002 and p\u0026thinsp;=\u0026thinsp;0.001, respectively; Table\u0026nbsp;3). The number of tonic and mixed episodes significantly decreased (p\u0026thinsp;=\u0026thinsp;0.034 and p\u0026thinsp;=\u0026thinsp;0.002, respectively), but the phasic episodes did not show any significant change.\u003c/p\u003e\u003cp\u003eTwenty-one participants were divided into effective (n\u0026thinsp;=\u0026thinsp;10) and ineffective (n\u0026thinsp;=\u0026thinsp;11) groups. The ineffective group showed significant reductions in total SB and SB/h after OA therapy (p\u0026thinsp;=\u0026thinsp;0.013 and p\u0026thinsp;=\u0026thinsp;0.013, respectively) and an increase in %SR from 12.0\u0026thinsp;\u0026plusmn;\u0026thinsp;6.8 to 15.3\u0026thinsp;\u0026plusmn;\u0026thinsp;8.6 (p\u0026thinsp;=\u0026thinsp;0.038, Table\u0026nbsp;4). The effective group showed no significant change in total SB, but a significant increase in ArI during the REM stage from 13.5\u0026thinsp;\u0026plusmn;\u0026thinsp;6.7 to 21.9\u0026thinsp;\u0026plusmn;\u0026thinsp;10.6 (p\u0026thinsp;=\u0026thinsp;0.007). The effective group experienced a significant reduction in RAI during TST (p\u0026thinsp;=\u0026thinsp;0.002), with an improvement in respiratory events and a significant increase in SAI (p\u0026thinsp;=\u0026thinsp;0.011, Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study showed significant improvements in AHI, AI, HI, and SpO\u003csub\u003e2\u003c/sub\u003e. An OA protrudes the mandible forward, thereby enlarging the airway space and preventing it from collapsing [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Our results align with the AASM and AADSM recommendations for OA therapy in patients with mild to moderate OSA [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], supporting the efficacy of OA treatment.\u003c/p\u003e\u003cp\u003eThe significant reduction in total SB, SB/h, tonic, and mixed episodes while wearing OA suggests the possibility of a physiological association between OSA and SB. Previous studies have shown that SB occurs along with effort respiration and arousal reactions [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], and it is conceivable that the improvement in respiratory events contributed to the suppression of SB. Furthermore, the reduction in SB episodes suggests controlled muscle activity associated with arousal reactions, which may be influenced by the stabilization of occlusion by the OA [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. However, phasic episodes did not change significantly, so the effects of OA may change depending on the type of SB.\u003c/p\u003e\u003cp\u003eThe significant increase in ArI and SAI during the REM stage after OA therapy was a crucial finding in this study. This suggests that suppression of RAI by OA therapy is associated with respiratory events, whereas non-respiratory arousals that are irrelevant to respiratory events become apparent. Lavigne et al. reported that SB frequently occurs along with micro-arousals [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], suggesting that arousals triggered by different factors, such as respiratory events, may be involved in the occurrence of SB. Our results suggest that the mechanism to generate SB is derived not only from the presence of OSA but also from a multifactorial etiology [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e], including central factors, such as sleep stages or arousal threshold. Saito et al. reported that patients with OSA and SB only had a weak interaction between OSA and SB, and SB could not be a direct sign or symptom of OSA [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Previous studies have shown no significant association between OSA and SB [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan additionalcitationids=\"CR36 CR37\" citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Therefore, the limitation of OA therapy to completely control SB should be considered.\u003c/p\u003e\u003cp\u003eThe significant reduction in SB episodes, which was detected in the ineffective group but not in the effective group, indicates that SB does not necessarily depend only on respiratory events, and suggests that the mechanical characteristics of OA, such as the stabilized mandible or limited muscle activity, directly influence the frequency of SB [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThese results suggest that OA therapy is effective not only for respiratory disturbance, but also for SB in patients with OSA and SB. These findings align with those of previous studies that reported a significant reduction in SB episodes with both CPAP and OA therapies [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. There was variation in the treatment effects of SB [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Therefore, if SB occurs secondary to respiratory events, respiratory improvements achieved through CPAP therapy could be effective in controlling SB [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Therefore, OA may not only be a simple respiratory assist device but also be effective in managing SB. Personalized treatments considering not only the severity of OSA or AHI, but also the therapeutic response or mechanism of occurrence are clinically important [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThis study had some limitations. The first is the low statistical power owing to the small number of participants (n\u0026thinsp;=\u0026thinsp;21). The second is the variation in the types of OA (monoblock or twin-block). The third is the short duration of therapy (308 days). Further research is needed to examine the long-term recurrence rate of SB and OSA, as well as the continuity of OA therapy.\u003c/p\u003e\u003cp\u003eThis study showed that SB interacts not only with OSA but also with many other factors, and a comprehensive approach is needed for SB and OSA. In the future, it will be necessary to build a more effective OA treatment strategy by accurately analyzing the association between the type or custom fitting of OA, such as mandibular advancement or vertical dimension, and SB. The analysis of the temporal relevance between arousal reactions and the occurrence patterns of SB in each sleep stage could expand our understanding of the neurobiological mechanisms involved in SB.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study evaluated the effects of OA therapy on sleep and respiratory parameters and SB in patients with OSA. OA therapy improved respiratory events with a marked impact on AHI and a significant reduction in SB episodes, especially in tonic and mixed episodes. An increase in SAI during the REM stage was observed; therefore, not only respiratory events but also central arousals could be involved in the occurrence of SB. It is also possible that SB is not always dependent on respiratory events, because SB only decreased in the ineffective group. SB may be caused by a multifactorial etiology, and an OA may not only be a simple respiratory assist device, but also an effective device for helping to manage SB. In the future, maximization of OA therapy effects is expected through a more accurate applicability assessment of the therapy for individuals and clarification of the mechanisms through which SB occurs.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eSB, sleep bruxism; OSA, obstructive sleep apnea; OA, Oral appliance; PSG, polysomnography; AHI, apnea/hypopnea index; CPAP, continuous positive airway pressure; AASM, the American Academy of Sleep Medicine; AADSM, the American Academy of Dental Sleep Medicine; EEG, electroencephalography; ECG, electrocardiography; SpO\u003csub\u003e2\u003c/sub\u003e, oxygen saturation; EMG, electromyography; MVC, maximum voluntary contraction; W, wakefulness; REM, rapid eye movement sleep; NREM, non-rapid eye movement; TST, total sleep time; SE, sleep efficiency; AI, apnea index; HI, hypopnea index; ODI, oxygen desaturation index; ArI, arousal index; RAI, respiratory arousal index; SAI, spontaneous arousal index; PLM, periodic limb movement; LM, leg movement; ICSD-3, International Classification of Sleep Disorders, 3rd edition\u003c/p\u003e\n"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003ePSG and EMG evaluations are conducted as part of standard examinations in the Fukuoka University Hospital. All methods were carried out according to relevant guidelines and regulations. The ethics committee (or institutional review board) of the Fukuoka University Hospital, Fukuoka University-Medical Ethics Review Board, approved the analysis of the examinations in this study, an opt-out method to obtain consent, and waiver of informed consent for this study. The notice and opt-out opportunity were provided to all of the participants on the hospital website. The committee\u0026rsquo;s reference number is H23-05-011.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Consent for publication\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Competing interests\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests in this section.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Availability of data and materials\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Funding\u003c/p\u003e\n\u003cp\u003eThis work was financially supported by JSPS KAKENHI Grant number [21K10034] and by funding from Fukuoka University [216007]. However, this funding source had no role in the design of this study, the collection, analysis, and interpretation of data, or in writing the manuscript.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Acknowledgments\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank Japan Medical Communication (www.japan-mc.co.jp/) for the English language review.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Authors\u0026rsquo; contributions\u003c/p\u003e\n\u003cp\u003eYD and GU were involved in the research project, statistical analysis, and manuscript writing. CY and HT were involved in the review and critique of the manuscript. RM and MK were involved in the organization and execution of the research project. The author(s) read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Clinical trial number\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003ePunjabi, Naresh M. 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Relationship between sleep bruxism and sleep respiratory events in patients with obstructive sleep apnea syndrome. Sleep Breath. 2014; 18: 837-44. doi: 10.1007/s11325-014-0953-5.\u003c/li\u003e\n\u003cli\u003eLobbezoo F, Naeije M. Bruxism is mainly regulated centrally, not peripherally. J Oral Rehabil. 2001; 28: 1085-91. doi: 10.1046/j.1365-2842.2001.00839.\u003c/li\u003e\n\u003cli\u003eCastroflorio T, Bargellini A, Rossini G, Cugliari G, Deregibus A. Sleep bruxism and related risk factors in adults: A systematic literature review. Arch Oral Biol. 2017; 83: 25-32. doi: 10.1016/j.archoralbio.2017.07.002.\u003c/li\u003e\n\u003cli\u003eBłaszczyk B, Waliszewska-Pros\u0026oacute;ł M, Więckiewicz M, Poręba R, Niemiec P, Przegrałek J, Martynowicz H. Sleep bruxism (SB) may be not associated with obstructive sleep apnea (OSA): A comprehensive assessment employing a systematic review and meta-analysis. 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Theories on possible temporal relationships between sleep bruxism and obstructive sleep apnea events. An expert opinion. Sleep Breath. 2015; 19: 1459-65. doi: 10.1007/s11325-015-1163-5.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1 and 4 are available in the Supplementary Files section.\u003c/p\u003e\n\u003cp\u003e\u003cimg 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\"\u003e\u003c/p\u003e\n\u003cp\u003e\u003cimg 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Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Sleep Bruxism, Oral Appliance, Obstructive Sleep Apnea, Respiratory Arousal Index, Spontaneous Arousal Index","lastPublishedDoi":"10.21203/rs.3.rs-7210470/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7210470/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eIntroduction\u003c/p\u003e\n\u003cp\u003eSleep bruxism (SB), which is associated with obstructive sleep apnea (OSA), has been receiving increased attention. Oral appliance (OA) therapy is likely to indirectly improve SB by reducing the number of respiratory events and arousals that induce SB.\u003c/p\u003e\n\u003cp\u003eObjectives\u003c/p\u003e\n\u003cp\u003eThis study aimed to clarify how OA therapy influences SB, which is likely to induce arousal, by analyzing the relationship between muscle activity during SB and sleep-related respiratory events before and after OA therapy in patients with OSA.\u003c/p\u003e\n\u003cp\u003eMaterial and methods\u003c/p\u003e\n\u003cp\u003ePatients diagnosed with OSA based on polysomnography (PSG) at Fukuoka University Hospital between October 2020 and May 2025 were referred for OA therapy. Twenty-one participants (10 males, 11 females; mean age, 57.8 ± 16.0) were enrolled in this study. The masseter muscle activity was simultaneously measured using an identical single-channel wearable electromyography device. They underwent a second PSG and EMG evaluation after OA therapy, and a comparison of the data between baseline and reevaluation was conducted.\u003c/p\u003e\n\u003cp\u003eResults\u003c/p\u003e\n\u003cp\u003eThe results of baseline and reevaluation PSG evaluations showed a significant improvement in AHI from 17.3 ± 7.3 to 12.3 ± 10.7 (p = 0.008). The total number of SB episodes and SB/h significantly decreased (p = 0.002 and p = 0.001, respectively), and the spontaneous arousal index during the rapid eye movement stage significantly increased (p = 0.007).\u003c/p\u003e\n\u003cp\u003eSignificant reductions in total SB episodes and SB/h were observed not in the effective group, including 10 participants with apnea/hypopnea index (AHI) reduction ≥50% or AHI in reevaluation \u0026lt;5, but in the ineffective group, including 11 participants with AHI reduction \u0026lt;50% and AHI in reevaluation ≥5 (p = 0.013 and p = 0.013, respectively). The effective group experienced a significant decrease in the respiratory arousal index during total sleep time (p = 0.002) and a significant increase in the spontaneous arousal index (p = 0.011).\u003c/p\u003e\n\u003cp\u003eConclusions\u003c/p\u003e\n\u003cp\u003eThe mechanism underlying the generation of SB appears to be derived not only from the presence of OSA but also from a multifactorial etiology, and OAs may not only be simple respiratory assist devices but also effective for helping to manage SB.\u003c/p\u003e","manuscriptTitle":"The relationship between sleep bruxism and sleep-related respiratory events under oral appliance therapy in patients with obstructive sleep apnea","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-12 12:47:50","doi":"10.21203/rs.3.rs-7210470/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6bb1d4ee-d0db-4022-9ecc-5ddbb9f20d18","owner":[],"postedDate":"August 12th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-09-02T06:23:56+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-12 12:47:50","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7210470","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7210470","identity":"rs-7210470","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}