Obstructive sleep apnea is a potentially-serious medical disorder. Patients with obstructive sleep apnea need treatments that are based on science. I am writing this post because over the last several months, I have seen a disturbing number of patients with obstructive sleep apnea who have tried and failed myofunctional therapy and/or frenuloplasty/frenectomy or who have seen something online about it and are asking for my opinion. Enough is enough. It is time for someone to speak up. There is no proven benefit to oral myofunctional therapy or frenuloplasty for the treatment of obstructive sleep apnea in adults as it is commonly practiced in the United States. So that you do not think this is just the rant of a surgeon, I will state that I do not know of anyone respected in the sleep apnea scientific community that would disagree with this, other than one person that I will mention below. If you are an adult and want to use exercises to treat your sleep apnea, go to Brazil for people that are using tested approaches. Do not undergo a frenuloplasty/frenectomy for obstructive sleep apnea. That is really all adults with sleep apnea need to know, but I will explain what I mean in the rest of the post.
What is oral myofunctional therapy for sleep apnea?
Oral myofunctional therapy includes exercises drawn from the world of speech therapy that can address speech and swallowing disorders that are felt to be related to poor function or coordination of muscles of the tongue, throat, and face. These exercises were developed for treatment of speech and dental problems. Practitioners of oral myofunctional therapy looked to expand to the world of obstructive sleep apnea and snoring after the 2009 research publication from the team of Geraldo Lorenzi-Filho, MD, PhD at the Heart Institute (In-Cor) at the University of Sao Paulo in Brazil. Their randomized controlled trial showed an improvement in adults with moderate obstructive sleep apnea with performing a series of 10-20 mouth and throat exercises (depending on how you count them) that was not seen in the control group. The improvement in the apnea-hypopnea index (number of times with blockage in breathing per hour) was from an average of 22.4 to 13.7 events/hour. This is not that impressive by itself, but was more interesting to many in the field was the fact that the change in apnea-hypopnea index was seen in those whose neck became somewhat thinner (smaller neck circumference). This suggests that a potential reason for an improvement in sleep apnea, namely that the exercises might tone muscles, decrease fat in the neck, or have some other effect, all of which could improve sleep apnea, based on existing and subsequent research. This article was published in the medical journal Sleep, and an editorial from Catriona Steele, PhD, an established speech therapy researcher, expressed doubts about the value of many of these exercises for treating sleep apnea. As an expert in the field, Dr. Steele made it clear that not all speech therapy exercises are the same and that most (even in this paper) would have absolutely no benefit in obstructive sleep apnea.
I have been fortunate to visit Brazil several times, once as President of the International Surgical Sleep Society when we organized our scientific meeting there in 2016 and on multiple occasions for a sleep surgery course at the Hospital Israelita Albert Einstein in Sao Paulo. I have had the pleasure of getting to know Dr. Lorenzi-Filho and learning about these speech therapy exercises that were used in their study. He really is one of the world’s leaders in sleep apnea research, and I respect him tremendously. His group has performed another high-quality study showing that oropharyngeal exercises achieved about a 50% reduction in snoring, and another Brazilian group that I know has shown a modest benefit of these speech therapy exercises in obstructive sleep apnea. However, the exercises that they have studied are not what is being offered to patients in most countries, including this United States.
The problem: oral myofunctional therapy offered in the United States has not been studied
Since that publication, practitioners of oral myofunctional therapy have seized on this as a business opportunity to treat a much larger group of patients than they had been. Groups like the Academy of Orofacial Myofunctional Therapy and Academy of Applied Myofunctional Sciences were either formed or grew in membership, but the reality is that they have developed interest but done little to advance science. They are business-savvy, charging high prices for courses in rooms that they rent on the campuses of various universities and then presenting their work as endorsed by these same universities. My unhappiness with their work is based on my experience when giving a lecture at one of their courses. I specifically asked their established leader in myofunctional therapy, Joy Moeller, and Marc Moeller, her son and Managing Director/co-founder of the organizations, some basic questions. I was shocked and dismayed to learn that they were offering this course and telling practitioners (most of the course attendees were dental hygienists) to treat patients with obstructive sleep apnea but had absolutely no method to guide the selection of exercises. This was a potentially-serious medical condition of obstructive sleep apnea, but there was no plan on how to treat these patients with anything approaching a scientific basis. They were not recommending the same set of exercises as the Brazilian groups have and, in fact, were just letting the course attendees choose their favorites without any protocol or decision making process to follow. I felt that this randomness in treatment planning was irresponsible and inappropriate. I am not aware of any advances in the educational curriculum for their courses over the last couple of years.
There are some people who believe in oral myofunctional therapy. Dr. Christian Guilleminault has recently retired after a distinguished career as an authority on obstructive sleep apnea. For many years, he has been a proponent of approaches that target facial growth and development in children, and on this account he has advocated for orthodontic treatments like maxillary expansion and, in some cases, also for myofunctional therapy. I know Dr. Guilleminault pretty well from my own days as a sleep surgery fellow at Stanford and in numerous interactions over the years. Dr. Guilleminault is brilliant, but some of his strong opinions are based on his personal experience without rigorous scientific investigation. Although he may be recommending myofunctional therapy for some adults with obstructive sleep apnea, almost everyone in the sleep community is not convinced.
What is frenuloplasty? Why perform it for sleep apnea?
Furthering the issue is the formation of groups like The Breathe Institute, with a surgeon (Dr. Soroush Zaghi) as a co-founder. I am extremely reluctant to criticize colleagues, and it is difficult to write this about someone who is very bright and likeable. However, his collaboration with practitioners of oral myofunctional therapy and performance of a surgical procedure called a frenuloplasty or frenectomy (described below) is not helpful and may actually be harmful to patients. There is no real scientific evidence supporting frenuloplasty or frenectomy in treating obstructive sleep apnea in adults. In fact, Dr. Zaghi has admitted that the science does not really exist to support frenuloplasty in adults or myofunctional therapy as practiced in the United States, so it is especially odd that he continues to recommend them.
Frenuloplasty is basically the release of tongue-tie (ankyloglossia in medical terms) by cutting a band of tissue underneath called the frenunlum or frenum. This procedure has generally been performed in children who have problems with speech, feeding/swallowing, or dental hygiene because of tongue tie. There is limited evidence that having the tongue move forward to fill the space behind the upper teeth is helpful for development (mainly widening) of the upper jaw. This would provide another reason to release tongue tie. However, all of this relates to children. There are certainly adults who have tongue tie (either from birth or starting later in life), but the aggressive claims about the benefits of frenuloplasty are often taking benefits seen in children and thinking the same applies to adults. This is just not true. For example, many patients have indicated that frenuloplasty or frenectomy is being advocated to help with jaw development in adults. This ignores the very basic biological fact that jaw development is complete by the time someone reaches adulthood. There is simply no way that frenuloplasty could affect jaw development in adults unless one were to undergo a surgical procedure to cut the upper jaw and allow it to grow again with the use of special mouthpieces, followed by orthodontic braces.
Is there any value in myofunctional therapy or frenuloplasty for sleep apnea?
There probably is some value in oral myofunctional therapy, but right now as practiced in the United States it is too haphazard as to what exercises are selected for different patients. For frenuloplasty, there really is no evidence to support it as part of treatment for adults with obstructive sleep apnea. Unfortunately, there are many surgeons, dentists, and other practitioners out there offering these completely unproven treatments for sleep apnea. For my patients interested in oral myofunctional therapy, I tell them they have to go to Brazil to get anything close to a proven therapy. They will need to make multiple trips for the initial evaluation and then the follow up visits, but there are worse places to visit. Brazil is an incredible, fascinating country with wonderful people, so they can think of this as a good excuse to travel there.