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Journal of Prosthodontic Research 57 (2013) 195–199

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Original article
Pilot study to assess the potential of oral myofunctional therapy
for improving respiration during sleep
Hiroshi Suzuki DDS, PhDa,*, Aito Watanabe DDSa, Yoshiaki Akihiro DDS, PhDa,
Megumi Takao DDSa, Takenao Ikematsu DDS, PhDb, Suguru Kimoto DDS, PhDc,
Takashi Asano DDS, PhDa, Misao Kawara DDS, PhDa
a
Department of Oral Function and Rehabilitation, Nihon University School of Dentistry at Matsudo, Japan
b
Laboratory Medicine for Dentistry, Nihon University School of Dentistry at Matsudo, Japan
c
Department of Removable Prosthodontics, Nihon University School of Dentistry at Matsudo, Japan
Received 1 November 2011; received in revised form 3 February 2013; accepted 10 February 2013
Available online 20 March 2013

Abstract
Purpose: The present study was designed to assess the potential of oral myofunctional therapy (OMFT) for improving respiration parameters,
Apnea-Hypopnea Index (AHI), and saturation of peripheral oxygen (SpO2) during sleep.
Methods: The Epworth Sleepiness Scale (ESS) was administered to 92 students in class time at the Nihon University School of Dentistry at
Matsudo. The results showed that 15 students had a high ESS. Of the 15 students who had learnt about their excessive sleepiness, six students
expressed their intention to receive treatment for their sleep condition. They volunteered as subjects for the study. The Lip Trainer Patakara1 was
used for labial closure force (LCF) training for 2 months. LCF, AHI and SPO2 during sleep were measured before training and after 2 months
training. The paired t-test was applied for statistical analyses.
Result: LCFs before and 2 months after training were 8.8  1.6 and 12.9  0.6 N, respectively. LCF significantly increased after training
compared to that before training. SpO2 before training and after training were 90.0  2.9% and 96.8  0.8%, respectively. SpO2 after training was
significantly increased compared to that before training. AHI before and after training were 15.1  3.4 and 9.2  1.5 events/h, respectively. AHI
after training was significantly decreased compared to that before training.
Conclusion: From this study, the following conclusions were made: (1) OMFT significantly increases LCF; and (2) the AHI and SpO2 during sleep
are significantly improved after OMFT.
# 2013 Japan Prosthodontic Society. Published by Elsevier Ireland. All rights reserved.

Keywords: Labial closure force; Oral myofunctional therapy; Apnea-Hypopnea; Saturation of peripheral oxygen

1. Introduction OSAS is caused by prolonged partial airway obstruction

Compromised sleep has been identified as a risk factor for
driving accidents, neurocognitive dysfunction, depression,
deteriorated quality of life, and increased health care costs [1].
Seventeen percent of adults aged 30–69 years have mild or worse
sleep-disordered breathing, whilst 5.7% of adults have moderate
or worse sleep-disordered breathing [2]. One of the main causes
for this is obstructive sleep apnea syndrome (OSAS) [3].
* Corresponding author at: Department of Oral Function and Rehabilitation,
Nihon University School of Dentistry at Matsudo, 870-1 Sakaecho, Nishi-2,
Matsudo, Chiba 271-8587, Japan. Tel.: +81 47 360 9641; fax: +81 47 360 9615.
E-mail address: suzuki.hiroshi91@nihon-u.ac.jp (H. Suzuki).
1883-1958/$ – see front matter # 2013 Japan Prosthodontic Society. Published by Elsevier Ireland. All rights reserved.
http://dx.doi.org/10.1016/j.jpor.2013.02.001
and/or intermittent complete obstruction, which interrupts
normal ventilation during sleep and normal sleep patterns
[4–6]. Patients with OSAS often exhibit obstructed breathing
and snoring, as the tongue falls posteriorly due to gravity and
relaxation of the genioglossus.
There are 2 major modalities for OSAS. One is the
continuous positive airway pressure modality applied by
medical doctors [7,8], and the other is an oral appliance, most
of which are designed on the general principal of achieving
unobstructed breathing by advancing the mandible and holding
it forward during sleep [9,10]. Dentists have previously treated
OSAS using oral appliances.
However, oral appliances as a supportive measure cannot
completely cure sleep disorders. Given that weakened labial
196 H. Suzuki et al. / Journal of Prosthodontic Research 57 (2013) 195–199

Table 1
Characteristics of six subjects.
Subject Age BMI Gender Previous OSAS treatment Chief complaint
1 22 25.0 Male Not receive Snoring, mouth breathing
2 22 23.5 Male Not receive Snoring
3 23 25.6 Male Not receive Snoring
4 22 22.2 Female Not receive Snoring
5 22 21.1 Female Not receive Snoring, mouth breathing
6 23 25.4 Female Not receive Snoring, mouth breathing
Mean (SD) 22 (0.5) 23.8 (1.8)

Table 2
Instructions for using Patakara.
(1) Close the mouthpiece and insert into the oral vestibule between the upper and lower lips
(2) When the lips are closed, they should be in contact with the projections on the upper and lower sides of Patakara
(3) At this time, it is best to close the lips without clenching the teeth for about 5 min
(4) With the lips closed, carry out stretching movements by pulling the plastic tabs on the front of the mouthpiece 10 times each to the front,
upper and lower sides, and right and left sides
(5) At this time, the lips should be kept firmly closed to prevent Patakara from coming out of the mouth
(6) Each treatment session consists of these two actions (taking about 5 min); rehabilitation is carried out 3 times per day or more

closure force (LCF) induces oral breathing and snoring [11–
14], oral myofunctional therapy (OMFT) for LCF training
could alleviate OSAS-related symptoms during sleep, such as
oral breathing and snoring. That is to say, LCF training could
significantly improve respiration during sleep.
The purpose of this study was to assess the potential of
OMFT for improving Apnea-Hypopnea Index (AHI), and
saturation of peripheral oxygen (SpO2) during sleep. The
hypothesis was that the AHI and SpO2 would improve
following OMFT for LCF training.
2. Materials and methods
2.1. Subjects
The Epworth Sleepiness Scale (ESS) was administered to 92
students in class time at the Nihon University School of
Dentistry at Matsudo. The results showed that 15 students had a
high ESS score of 311. Of the 15 students who had learnt about
their excessive sleepiness, six students expressed their intention
to receive treatment for their sleep condition. They volunteered
as subjects for the study (Table 1). Volunteers with systemic
illness and/or stomatognathic abnormalities were excluded.
This study has been conducted in accordance with the
Declaration of Helsinki and each subject received oral and
written information about the study and provided informed
consent. This study was approved by the Ethics Committee of
Nihon University School of Dentistry at Matsudo (EC 10-023).
conditions the oral muscles and increases strength. In
accordance with the supplied instructions for the use of
Patakara1 (Table 2), the subjects underwent this training at the
clinic for 5 min twice a week day, 4 times per week, for
2 months (Fig. 1). The training was continually monitored by
instructors in order to ensure that the same conditions were
maintained for each training session.
2.2.2. Measurement method
LCF was measured using the Lip De Cum1 (Cosmo
Instruments, Tokyo, Japan) in the clinic (Fig. 2). With the
Frankfurt plane parallel to the floor, the subjects, while seated
upright, were asked to close their lips while separating the
upper molars from the lower molars for 5 s. Measurements
were repeated 3 times, with the mean value calculated.
2.3. Measurements of AHI and SpO2
The AHI and SpO2 during sleep were measured twice,
before training and 2 months after training. Subjects were
instructed to wear a SAS-2100 (Teijin Home Healthcare
Limited, Tokyo, Japan) when going to sleep. The SAS-2100
automatically records oral and nasal airflow, pulse rate, and
SpO2. Using data continuously collected for about 6 h, AHI was
determined on a personal computer installed with software
(QP-021W, Ver.01-10, NIHON KOHDEN, Tokyo). As per
Kushida’s report, the degree of sleep-related breathing
disorders was evaluated, based on AHI [15].

2.2. OMFT for labial closure force
2.2.1. Training method
The Lip Trainer Patakara1 (PATAKARA Co., Ltd., Tokyo,
Japan) was used for LCF training. Patakara1 is made from
flexible plastic and rubber, the resilience of which directly
2.4. Time schedule of measurements of AHI, SpO2, and
LCF
AHI, SpO2, and LCF were measured twice as shown in
Fig. 3. LCF, AHI and SpO2were obtained during the same time
period.
 H. Suzuki et al. / Journal of Prosthodontic Research 57 (2013) 195–199
Fig. 1. Labial closure force training with Lip Trainer Patakara1. Insert the
device between teeth and lips, close the lips without teeth contact, and then
perform the lip-stretching movement.
Fig. 2. Measurement of labial closure force using the Lip De Cum1. Labial
closure force was measured using the Lip De Cum1. With the Frankfurt plane
parallel to the floor, the subjects, while seated upright, were asked to close their
lips while separating the upper molars from the lower molars for 5 s.
2.5. Statistical analyses
After verifying the normality of data using the Kolmogorov–
Smirnov test, parametric statistical analyses were applied.
Paired t-tests were used to assess differences in AHI and SpO2
between time-points before and after LCF training. The level of
significance was set at p < 0.05. Data were analyzed using IBM
SPSS Statistics version 20 (SPSS, Chicago, IL).
3. Results
3.1. Labial closure force
LCF before and after training was 8.8  1.6 and
12.9  0.6 N, respectively (Fig. 4). Labial closure force after
training was significantly greater than that before training
(paired t-test, p = 0.001).
3.2. Respiration quality during sleep
3.2.1. AHI
AHI before and after training was 15.1  3.4 and
9.2  1.5 events/h, respectively (Fig. 4). AHI after training
significantly decreased compared to that before training (paired
t-test, p = 0.002). Before training, the profile of sleep-related
breathing disorders, based on AHI, included 0 normal, 3 mild, 3
moderate, and 0 severe subjects. However, after training this
changed to 0 normal, 6 mild, 0 moderate, and 0 severe subjects.
197
Fig. 3. Time schedule of OMFT and measurements of AHI, SpO2, and LCF
OMFT was done for 5 min twice a week day, 4 times per week, for 2 months.
And LCF, AHI and SpO2 were measured twice, before training and 2 months
after training. LCF, AHI and SpO2, were obtained during the same time period.
3.2.2. SpO2
SpO2 before training and after training was 90.0%  2.9%
and 96.8%  0.8%, respectively (Fig. 4). SpO2 after training
was significantly increased compared to that before training
(paired t-test, p = 0.003).
4. Discussion
Dentists have focused on OMFT in the treatment of mouth
breathing and tongue thrusting, which are considered risk
factors for malocclusions, such as maxillary protrusion and
open bite; thus, there are many reports on OMFT [16–20].
However, few researchers in the field of dentistry have focused
on the effect of using OMFT to train LCF with respect to
improving respiration during sleep. The present study was
designed to clarify whether OMFT has the potential to improve
respiration during sleep. This study revealed the following: (1)
OMFT significantly increased LCF; and (2) the AHI and SpO2
during sleep improved after OMFT.
Two months of OMFT significantly increased LCF
compared to that before receiving OMFT. Patakara1 has been
reported to be effective for training oral muscles by placing a
direct load on the muscles of expression, particularly the
orbicularis oris and buccinator muscles [21]. Although the
present study did not confirm which muscles affect the
improvement of LCF, OMFT was found to be very effective in
improving LCF.
AHI before training and after training was 15.1  3.4 and
9.2  1.5 events/h, respectively. AHI is a parameter corre-
sponding to the sum of the number of apneas and hypopneas
divided by the total hours of sleep. OSAS severity is classified,
according to AHI, as follows: mild (5–15 events/h), moderate
(15–30 events/h), and severe (>30 events/h) [15]. The present
study demonstrated that AHI in half of the subjects with OSAS
improved from moderate to mild following the OMFT for LCF.
SpO2 is the other main physiological parameter of ventilation
disruptions associated with OSAS during sleep [22]. SpO2
before training and after training was 90.0%  2.9% and
96.8%  0.8%, respectively. This increase in SpO2 may have
been caused by improvement in AHI, corresponding to
occurrences of apneas and hypopneas, to exacerbate oxygen
desaturation in arterial blood during sleep. Improvements in
both major objective parameters during sleep suggest that the
198 H. Suzuki et al. / Journal of Prosthodontic Research 57 (2013) 195–199
Fig. 4. Changes after OMFT. The measurements at ‘‘before training’’ and ‘‘after training’’ were taken at the days when each subject started training and at 2 months
after training, respectively. Labial closure force after training significantly increased compared to that before training (paired t-test, p = 0.001). SpO2 after training
was significantly increased compared to that before training (paired t-test, p = 0.003). AHI after training was significantly decreased compared to that before training
(paired t-test, p = 0.002).
OMFT intervention for LCF has the potential to improve
respiration quality during sleep. One randomized controlled
clinical trial showed that upper airway muscle training, using a
didgeridoo music instrument, significantly improved sleepiness
in patients with moderate snoring and OSAS, and reduced sleep
disturbance [23]. Another study found that oropharyngeal
exercises involving the orbicularis oris muscle with the mouth
closed significantly reduced OSAS severity [24,25]. Although
the OMFT used in these studies differed from that used in the
present study, these reports agree that OMFT can improve sleep
quality in patients with OSAS.
This pilot study had several limitations, such as the lack of a
control group and a small sample size. Considering these
limitations, we plan to conduct a randomized controlled clinical
trial to investigate the effects of OMFT on sleep quality using
Additional polysomnographic measurements that would enable
the evaluation of sleep quality.
In conclusion, the following results were obtained:
1. The OMFT significantly increased labial closure force.
2. The AHI and SpO2 during sleep were significantly improved
after OMFT.
Conflict of interest
The authors declare that they have no conflict of interest.
Acknowledgment
This study was supported by a Nihon University Individual
Research Grant for 2008 (08-111) and a Grant-in-Aid for
Scientific Research (B23792252) from the Ministry of
Education, Culture, Sports, Science and Technology, Japan.
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