Dental Sleep Medicine: A Clinical Guide

Foreword
Preface
Contents
Part I: Science/Research
1: Metascience in Dentistry and Medicine
1.1 Introduction
1.2 Metascience
1.3 Defining the Bibliome
1.3.1 Stating the Question
1.3.2 The Analytic Framework
1.4 Capturing the Best Available Evidence
1.4.1 The Level of the Evidence
1.4.2 The Quality of the Evidence
1.5 Analysis
1.5.1 Acceptable Sampling
1.5.2 Overarching Statistical Significance
1.5.3 Clinical Relevance
1.6 Reporting and Dissemination
1.6.1 Dissemination for Clinicians and Researchers
1.6.2 Dissemination for Patients and Caregivers
1.7 Biases and Fallacies in Clinical Decision-Making
1.7.1 Cognitive Biases
1.7.2 Fallacies
1.8 Implications for TMJ and Airway Disorders in Dental Sleep Medicine
1.8.1 Obstructive Sleep Apnea
1.8.2 Obstructive Sleep Apnea and Cognitive Decline
1.8.3 Obstructive Sleep Apnea in Children and Young Adults
1.9 Conclusion
References
2: Physiology of Sleep and Diagnosis: Basic Information for Dentists
2.1 Introduction
2.2 Generation and Maintenance of Sleep and Wakefulness
2.3 Basic Mechanisms Coordinating and Governing Sleep and Wakefulness
2.3.1 Autonomic Nervous System Balance During Sleep
2.3.2 Homeostatic and Circadian Regulation of Sleep
2.3.3 Interplay Between S and C Processes
2.4 Effect of Sleep on Organ Systems
2.4.1 Cardiovascular System
2.4.2 Respiratory System
2.4.3 Renal System
2.4.4 Gastrointestinal System
2.4.5 Thermoregulation
2.5 Selected Clinical Sleep Disorders
2.5.1 Obstructive Sleep Apnea (OSA)
2.5.2 Obstructive Sleep Apnea-Related Hormonal Dysregulation
2.5.3 Growth Hormone Secretion in Obstructive Sleep Apnea
2.6 Neurotransmitters for Wakefulness
2.6.1 Histamine
2.6.2 Acetylcholine
2.6.3 Dopamine
2.6.4 Glutamate
2.6.5 Serotonin and Norepinephrine
2.6.6 Hypocretins
2.7 Neurotransmitters for Sleep
2.7.1 Gamma-Aminobutyric Acid
2.7.2 Adenosine
2.8 Hormone Control of Sleep
2.8.1 Melatonin
2.8.2 Ghrelin and Leptin
2.8.3 Follicle-Stimulating Hormone and Luteinizing Hormone
2.8.4 Thyroid-Stimulating Hormone
2.8.5 Cortisol
2.9 Diagnostic Process
2.9.1 Diagnosis
2.9.2 Objective Testing
2.9.3 Polysomnography
2.9.3.1 Electroencephalography (EEG)
2.9.3.2 Electrooculography (EOG)
2.9.3.3 Chin Electromyography (EMG)
2.9.3.4 Masseter EMG
2.9.3.5 Leg EMG
2.9.3.6 Electrocardiogram (ECG)
2.9.3.7 Respiratory Parameters
2.9.3.8 Blood Oxygenation (Oxygen Saturation: SpO2)
2.9.3.9 Capnography
2.9.4 Sleep Stages
2.9.4.1 Stage Wake
2.9.4.2 Non-REM Sleep
2.9.4.3 REM Sleep
2.9.5 Sleep Cycles
2.9.6 Home Sleep Apnea Testing (HSAT)
2.10 Technical Aspects of Polysomnography
2.10.1 Machine Calibration
2.10.2 Biocalibration
2.11 Understanding Findings of a Polysomnography Report
2.11.1 Definitions of PSG Report
2.11.1.1 Total Recording Time
2.11.1.2 Sleep Latency
2.11.1.3 Total Sleep Time
2.11.1.4 Sleep Fragmentation
2.11.1.5 Sleep Efficiency
2.11.1.6 WASO and WASF
2.11.1.7 Rapid Eye Movement Latency
2.12 Stages of Sleep
2.12.1 Non-rapid Eye Movement Sleep
2.12.2 Rapid Eye Movement Sleep
2.12.3 Practice Implications
2.12.4 Insomnia
2.12.5 Parasomnias
2.12.6 Confusional Arousals
2.12.7 Sleepwalking (Somnambulism)
2.12.8 Sleep-Related Eating Disorders
2.12.9 Sleep Terrors (“Pavor Nocturnus” Incubus)
2.13 Basics of Sleep Hygiene
2.14 Sleep-Related Medications and Their Effect on Sleep
2.14.1 Benzodiazepines and Barbiturates
2.14.2 Gamma-Hydroxybutyrate (GHB)
2.14.3 Neuroleptics
2.14.4 Dopamine
2.14.5 Adrenergic Drugs
2.14.6 Recreational Drugs
2.14.7 Antidepressants
2.14.8 Antihistamines
2.14.9 Melatonin
2.14.10 Modafinil
References
Untitled
3: Current Classification of Sleep Disorders
3.1 Introduction
3.2 Insomnia
3.2.1 Chronic Insomnia Disorder
3.2.2 Short-Term Insomnia Disorder
3.2.3 Insomnia in Children
3.2.4 Other Insomnia Disorder
3.2.5 Isolated Symptoms and Normal Variants
3.3 Sleep-Related Breathing Disorders
3.3.1 Obstructive Sleep Apnea Syndromes
3.3.2 Central Sleep Apnea Syndrome
3.3.2.1 CSA with Cheyne-Stokes Breathing
3.3.2.2 CSA Due to a Medical Disorder Without Cheyne-Stokes Breathing
3.3.2.3 CSA Due to High-Altitude Periodic Breathing
3.3.2.4 CSA Due to a Medication or Substance
3.3.2.5 Primary CSA
3.3.2.6 Treatment-Emergent Central Sleep Apnea
3.3.2.7 Primary Central Sleep Apnea of Infancy
3.3.2.8 Primary Central Sleep Apnea of Prematurity
3.3.3 Sleep-Related Hypoventilation Disorders
3.3.4 Obesity Hypoventilation Syndrome
3.3.5 Congenital Central Alveolar Hypoventilation Syndrome
3.3.6 Other Sleep-Related Hypoventilation Disorders
3.3.6.1 Late-Onset Central Hypoventilation with Hypothalamic Dysfunction
3.3.6.2 Idiopathic Central Alveolar Hypoventilation
3.3.6.3 Sleep-Related Hypoventilation Due to a Medication or Substance
3.3.6.4 Sleep-Related Hypoventilation Due to a Medical Disorder
3.3.7 Sleep-Related Hypoxemia Disorder (SRHD)
3.3.8 Isolated Symptoms and Normal Variants
3.3.8.1 Snoring
3.3.8.2 Catathrenia
3.4 Central Disorders of Hypersomnolence
3.4.1 Narcolepsy Type 1
3.4.2 Narcolepsy Type 2
3.4.3 Idiopathic Hypersomnia
3.4.4 Kleine-Levin Syndrome
3.4.5 Hypersomnia Due to a Medical Disorder
3.4.6 Hypersomnia Due to a Medication or Substance
3.4.7 Hypersomnia Associated with a Psychiatric Disorder
3.4.8 Insufficient Sleep Syndrome
3.5 Circadian Rhythm Sleep-Wake Disorders
3.5.1 Delayed Sleep-Wake Phase Disorder
3.5.2 Advanced Sleep-Wake Phase Disorder
3.5.3 Irregular Sleep-Wake Rhythm Disorder
3.5.4 Non-24-h Sleep-Wake Rhythm Disorder
3.5.5 Shift Work Disorder
3.5.6 Jet Lag Disorder
3.5.7 Circadian Sleep-Wake Disorder Not Otherwise Specified
3.6 Parasomnias
3.6.1 NREM-Related Parasomnias
3.6.1.1 Disorders of Arousal
Confusional Arousals
Sleepwalking
Sleep Terrors
3.6.1.2 Sleep-Related Eating Disorder
3.6.2 REM-Related Parasomnias
3.6.2.1 REM Sleep Behavior Disorder
3.6.2.2 Recurrent Isolated Sleep Paralysis
3.6.2.3 Nightmare Disorder
3.6.3 Other Parasomnias
3.6.3.1 Exploding Head Syndrome
3.6.3.2 Sleep-Related Hallucinations
3.6.3.3 Sleep Enuresis
3.6.3.4 Parasomnia Due to a Medical Disorder
3.6.3.5 Parasomnia Due to a Medication or Substance
3.6.3.6 Parasomnia, Unspecified
3.6.3.7 Isolated Symptoms and Normal Variants
Sleep Talking
3.7 Sleep-Related Movement Disorders
3.7.1 Restless Leg Syndrome
3.7.2 Periodic Limb Movement Disorder
3.7.3 Sleep-Related Leg Cramps
3.7.4 Sleep-Related Bruxism
3.7.5 Sleep-Related Rhythmic Movement Disorder
3.7.6 Benign Sleep Myoclonus of Infancy
3.7.7 Propriospinal Myoclonus at Sleep Onset
3.7.8 Sleep-Related Movement Disorder Due to a Medical Disorder
3.7.9 Sleep-Related Movement Disorder Due to a Medication or Substance
3.7.10 Sleep-Related Movement Disorder, Unspecified
3.7.11 Isolated Symptoms and Normal Variants
3.7.11.1 Excessive Fragmentary Myoclonus
3.7.11.2 Hypnagogic Foot Tremor and Alternating Leg Muscle Activation
3.7.11.3 Sleep Starts (Hypnic Jerks)
References
4: Cone Beam Computerized Tomographic Imaging for Sleep Disorders
4.1 Introduction
4.2 Radiographic Anatomy and Clinical Correlation
4.2.1 Sinonasal Complex
4.2.1.1 Nasal Cavity
Nasal Valves
Nasal Cavity
Nasal Septum
Nasal Turbinates
4.2.1.2 Paranasal Sinuses
4.2.2 Nasopharynx
4.2.3 Oropharynx
4.2.3.1 Soft Tissues
Soft Palate
Tonsils
Tongue
4.2.3.2 Hard Tissues
Jaws, TMJs, and Hyoid Bone
Cervical Spine
4.3 Conclusion
References
5: Medical Comorbidities of Obstructive Sleep Apnea
5.1 Introduction
5.2 Risk Factors for OSA
5.2.1 Genetics
5.2.2 Gender
5.2.3 Nasal Obstruction
5.2.4 Developmental or Congenital Narrow Airways
5.2.5 Smoking
5.2.6 Medications/Alcohol
5.3 Signs and Symptoms of OSA
5.3.1 Excessive Daytime Sleepiness
5.3.2 Snoring
5.3.3 Nocturnal Sweating
5.3.4 Nocturia
5.3.5 Decreased in Sex Hormones
5.4 Comorbidities
5.4.1 Obesity
5.4.2 Hypertension
5.4.3 Insomnia
5.4.4 Diabetes
5.4.5 Asthma
5.4.6 Gastroesophageal Reflux Disorder
5.4.7 Irritable Bowel Syndrome
5.4.8 Cardiovascular System
5.4.9 Trigeminal Cardiac Reflex
5.4.10 Arrhythmias
5.4.11 Stroke
5.4.12 Renal Failure
5.4.13 Metabolic Syndrome
5.4.13.1 Adiponectin
5.4.13.2 Leptin
5.4.13.3 Ghrelin
5.4.14 Chronic Pain
5.4.15 Sleep Apnea Headache
5.4.16 Mood Disorders
5.4.17 Alzheimer’s Disease
References
6: Dental Comorbidities and Risk Factors of Sleep-Disordered Breathing
6.1 Introduction
6.2 Causes of OSA
6.3 Orofacial Risk Factors
6.3.1 Obesity
6.3.2 Narrow Airway Passages
6.3.3 Nasal Congestion/Obstruction
6.3.4 Mouth Breathing
6.3.5 Large Tongue
6.3.6 Tongue Scalloping
6.4 Bruxism and Related Conditions
6.5 Dental Clinical Signs of Bruxism
6.5.1 Attrition
6.5.2 Abfraction
6.5.3 Tori and Buccal Exostosis
6.5.4 Loss of Vertical Dimension
6.5.5 Soft Palate and Elongated Uvula
6.5.6 Tonsils
6.6 Malocclusion
6.7 Bicuspid Extractions and Maxillary Expansion
6.8 Temporomandibular Disorders and OSA
6.9 Headaches
References
Untitled
7: Sleep Diagnosis: Polysomnography and Home Sleep Apnea Testing
7.1 Introduction
7.2 Polysomnography: In-Lab Testing
7.3 Home Sleep Apnea Testing
7.4 Pros and Cons for In-Lab PSG Testing and HSAT
7.5 Most Private Health Insurance Companies Will Follow the Same CMS Criteria
References
Part II: Clinical
8: Examination for Dental Sleep Medicine
8.1 Introduction
8.2 Medical History
8.3 Dental History
8.4 Screening
8.5 Radiographic Evaluation
8.6 Nasal Evaluation
8.7 Evaluation of the Temporomandibular Joint
8.7.1 Joint Sounds
8.7.2 Jaw Movement
8.8 Muscle Examination
8.9 Intraoral Examination
8.9.1 Tongue Assessment
8.9.2 Tonsil Assessment
8.9.3 Tori
8.9.4 Nasal Evaluation
8.9.5 Airway Evaluation
8.9.6 Dentition
References
9: Beneficial Effects of Continuous Positive Airway Pressure Therapy
9.1 Introduction
9.2 CPAP Therapy
9.2.1 Metabolic Syndrome
9.2.2 Alzheimer Disease
9.2.3 Seizures
References
10: Dental Sleep Appliance Therapy for the Treatment of Obstructive Sleep Apnea
10.1 Introduction
10.2 History and Evolution of Dental Sleep Appliance Therapy
10.3 Definition of Dental Sleep Appliance
10.3.1 Mechanism of Action of DSA
10.3.2 Predictors of Success
10.3.3 Dental Sleep Appliance Design and Effects
10.4 Types of Oral Appliances
10.4.1 Over the Counter
10.4.2 Temporary Sleep Appliances
10.4.3 Tongue Retainer Device
10.4.4 Dental Sleep Appliances
10.5 Combination Therapies
10.6 Record Taking
10.6.1 Impression and Scanning
10.6.2 Bite Registration Techniques
10.6.2.1 George Gauge
10.6.2.2 Pro Gauge
10.6.2.3 SOMGauge
10.6.2.4 Andra Gauge
10.6.2.5 Airway Metrics
10.6.2.6 Pharyngometer
10.6.2.7 Phonetic Bite
10.7 Managing Side Effects Associated with DSA Therapy
10.7.1 Short-Term Side Effects and Management
10.7.1.1 Tooth Sensitivity
10.7.1.2 Temporomandibular Joint Dysfunction or Pain
10.7.1.3 Myalgia/Myofascial Pain
10.7.1.4 Joint Sounds
10.7.1.5 Salivation and Drooling
10.7.1.6 Tongue, Soft Tissue, and Gingival Irritation
10.7.1.7 Dry Mouth
10.7.1.8 Bite Instability
10.7.1.9 Interproximal Gaps
10.7.2 Long-Term Side Effects and Management
10.7.2.1 Bite Changes
10.7.2.2 Bite Exercises/Morning Repositioners
10.8 Long-Term Follow-Up
10.9 Adherence
10.10 Health Outcomes
References
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11: Surgical Approaches to Treatment of Obstructive Sleep Apnea
11.1 Introduction
11.2 Surgical Treatment of Obstructive Sleep Apnea
11.3 Nasal Surgery
11.4 Palatal Surgery
11.5 Base of the Tongue and Hypopharyngeal Surgery
11.6 Transoral Robotic Surgery
11.7 Skeletal Surgery
11.8 Hypoglossal Nerve Stimulation
References
12: Adjunctive Therapies for Dental Sleep Appliances
12.1 Introduction
12.2 Positional Therapies
12.2.1 Positional Obstructive Sleep Apnea: Prevalence and Definitions
12.2.2 Mechanisms of Action of Positional Therapies
12.2.3 Efficacy of Positional Therapy
12.2.4 Compliance with Positional Therapy
12.2.5 New Generation Design Modifications
12.2.6 Combinations of Positional and Dental Sleep Appliance Therapy
12.2.7 Efficacy of Combination Dental Sleep Appliance and Positional Therapy
12.2.7.1 Active Devices
12.2.7.2 Passive Devices
12.2.8 Modifying the Dental Sleep Appliance to Counteract Positional Apnea
12.2.8.1 Practice Points
12.3 Positive Airway Pressure as an Adjunct Therapy for Dental Sleep Appliances
12.3.1 Continuous Positive Airway Pressure
12.3.2 Expiratory Positive Airway Pressure
12.3.2.1 Definition
12.3.2.2 The Rationale for EPAP Therapy
12.3.2.3 Mechanisms of Action of Expiratory Positive Pressure Devices
12.3.2.4 Efficacy and Compliance with nEPAP Therapy
12.3.2.5 Efficacy and Compliance of oEPAP Therapy
Practice Points
12.4 Adjunct Therapy for Anatomical Compromise in Dental Sleep Appliance Therapy
12.4.1 Surgery as an Adjunct Therapy
12.4.2 Drug-Induced Sleep Endoscopy for Assessment of Airway Collapse and Prediction of Treatment Outcomes in Dental Sleep Appliance Therapy
12.4.3 Improving Compromised Nasal Airway Anatomy
12.4.3.1 Behavioral Modifications
12.4.3.2 Intranasal Medications
12.4.3.3 Nasal Dilators
12.4.3.4 Nasal Surgery
12.5 Improving the Compromised Oropharyngeal Anatomy
12.5.1 Soft Palate
12.5.2 Tongue
12.6 Obesity
12.6.1 Dietary Interventions
12.6.2 Bariatric Surgery
12.6.2.1 Practice Points
12.7 Adjunctive Therapies for Sleep Quality During Dental Sleep Appliance Therapy
12.7.1 Insomnia
12.7.1.1 Comorbidity of Insomnia and Obstructive Sleep Apnea
Cognitive Behavioral Therapy for Insomnia
Sleep Restriction Therapy
Stimulus Control Therapy
Sleep Hygiene
Psychoactive Substances
Caffeine
Alcohol
Nicotine
Relaxation Therapy
Exercise
Pharmacological Agents
12.8 Circadian Rhythm Disorders
12.8.1 Chronotherapy
12.8.2 Bright Light Therapy
12.8.3 Melatonin
12.8.3.1 Practice Points
References
13: Oropharyngeal Development Through Dental Orthopedics and Orthodontics
13.1 Why Do We Have a Problem?
13.2 Facial Changes from Lifestyle Changes of Agriculture and Industrialization
13.3 Example of Face Falling Back with Growth
13.4 What Is Commonly Recommended for OSA in the Orthodontic Literature?
13.5 What Should Be the Focus of Orthodontics in Treating the Airway?
13.6 Orthodontics Traditional Focus on the Anteroposterior Plane of Space
13.7 Tools to Evaluate Jaw Position to Optimize Facial Balance/Airway
13.8 Retraction Reducing the Airway
13.9 Practical Application of Treatment to Optimize Facial Balance and Airway Size in Varying Ages and Situations
13.10 Treatment in the Primary Dentition
13.11 Treatment in the Early Mixed Dentition
13.12 Treatment in the Permanent Dentition
13.13 Missing Lateral Incisor Teeth in Adolescents
13.14 Adult Class II Nonsurgical Correction
13.15 Adding Extra Bicuspid Teeth
13.16 Reopening Extraction Spaces
13.17 Class II Camouflage Treatment
13.18 Surgical Correction of OSA with Double-Jaw Advancement Surgery
13.19 Palliative Solutions
13.20 Alternatives to Palliative Treatment
13.21 Dentistry: The Gateway to the Airway
References
14: Pediatric Obstructive Sleep Medicine
14.1 Introduction
14.2 Etiology/Prevalence
14.3 Distinction Between OSA and the Upper Airway Resistance Syndrome
14.4 Sleep Testing
14.5 Obesity
14.6 Genetics? Could Obstructive Sleep Apnea be Syndromic?
14.7 Consequences of Pediatric OSA
14.8 Cognition and Behavior
14.9 Growth Failure
14.10 Nocturnal Enuresis
14.11 Sleep Bruxism
14.12 Gastroesophageal Reflux
14.13 Snoring
14.14 Screening Questionnaires and Clinical Assessment
14.15 Physical Examination
14.16 Sleep Assessment Tools
14.17 Ankyloglossia and Airway
14.18 Oral Restrictive Complex
14.19 Orofacial Myofunctional Disorders and Therapy
14.20 Sleep Team Collaboration
14.21 Role of the Dentist
References
15: Orofacial Myofunctional Therapy for Sleep-Related Breathing Disorders
15.1 Introduction
15.2 Orofacial Myofunctional Disorders
15.3 Sample of Exercises
15.3.1 Soft Palate, Uvula, and Lateral Walls of Pharynx
15.3.2 Lateral Pharyngeal Walls
15.3.3 Tongue: Elevation and Strengthening
15.3.4 Tongue: Depression of the Posterior Tongue
15.3.5 Lip: For Lip Seal and Strengthening
15.3.6 Facial Exercises
15.4 Stomatognathic Functions
15.4.1 Breathing
15.4.2 Swallowing and Chewing
References
16: Dental Sleep Medicine Case Studies
16.1 Introduction
16.2 Case Studies
16.2.1 Case Study #1: Severe Apnea Treated with DSA, Positional Therapy, and Nasal Aids
16.2.1.1 Background
16.2.1.2 Clinical Exam
16.2.1.3 Radiographic Exam
16.2.1.4 Treatment Recommendations
16.2.1.5 Treatment
16.2.1.6 Treatment Summary
16.2.1.7 What We Learned
16.2.2 Case Study #2: Severe Apnea Treated with a Dental Sleep Appliance
16.2.2.1 Background
16.2.2.2 Clinical Exam
16.2.2.3 Radiological Exam
16.2.2.4 Treatment Recommendations
16.2.2.5 Treatment
16.2.2.6 Treatment Summary
16.2.2.7 What We Learned
16.2.3 Case Study #3: Noncompliant CPAP Patient with Moderate Sleep Apnea Treated Successfully with an EMA DSA
16.2.3.1 Background
16.2.3.2 Clinical Exam
16.2.3.3 Radiological Exam
16.2.3.4 Treatment Recommendation
16.2.3.5 Treatment
16.2.3.6 Summary of Treatment
16.2.3.7 What We Learned
16.2.4 Case Study #4: Severe Noncompliant CPAP Patient with TMD Treated Successfully with a DSA
16.2.4.1 Background
16.2.4.2 Clinical Exam
16.2.4.3 Radiological Exam
16.2.4.4 Treatment Recommendations
16.2.4.5 Treatment
16.2.4.6 Summary of Results
16.2.4.7 What We Learned
16.2.4.8 What to Do
16.2.5 Case Study #5: A Patient that Developed a Significant Bite Change During DSA Treatment But Needed Further Advancement to Treat the Apnea Along with Positional Therapy
16.2.5.1 Background
16.2.5.2 Clinical Exam
16.2.5.3 Radiological Exam
16.2.5.4 Treatment
16.2.5.5 Summary of Results
16.2.5.6 What We Learned
16.2.6 Case Study #6: Moderate Apnea with Severe Oxygen Desaturations Treated with DSA and Positional Therapy
16.2.6.1 Background
16.2.6.2 Clinical Exam
16.2.6.3 Radiological Exam
16.2.6.4 Treatment Recommendations
16.2.6.5 Treatment
16.2.6.6 Summary of the PSG Tests Before and During the Oral Dilator
16.2.6.7 Treatment Summary
16.2.6.8 What We Learned
16.2.7 Case Study #7: Moderate Sleep Apnea with Excessive Daytime Sleepiness Treated with DSA and Nasal Components
16.2.7.1 Background
16.2.7.2 Clinical Exam
16.2.7.3 Treatment Recommendation
16.2.7.4 Treatment
16.2.7.5 Efficacy Sleep Study
16.2.7.6 Treatment Recommendations
16.2.7.7 What to Learn
16.2.8 Case Study #8: Moderate Sleep Apnea Treated with DSA and Recommendation of Supplemental Oxygen
16.2.8.1 Background
16.2.8.2 Clinical Exam
16.2.8.3 Treatment Recommendation
16.2.8.4 Treatment
16.2.8.5 Efficacy PSG Sleep Study
16.2.8.6 Treatment Recommendations
16.2.8.7 What to Learn
16.2.9 Case Study #9: Noncompliant CPAP Patient with Moderate OSA and TMD Present Treated with DSA, Nasal Surgery, and Supplemental Oxygen
16.2.9.1 Background
16.2.9.2 Clinical Exam
16.2.9.3 Treatment Recommendation
16.2.9.4 Treatment
16.2.9.5 Efficacy PSG Sleep Study
16.2.9.6 Treatment Recommendations
16.2.9.7 Follow-Up to Efficacy
16.2.9.8 What to Learn
16.3 Synopsis
References