A Brief History Of the MAD
Everyone knows that snoring can create domestic disharmony, (ending in divorce) but few are aware of how this can harm the perpetrator’s performance while awake.
An understanding, therefore, of the mechanism of this sleep-breathing disorder will make clear the cause of the noise, the after effect on the snorer, its relation to OSA, and what can be done to prevent it.
Snoring occurs when the airway is constricted. The constriction accelerates the air passing through the airway causing the tissues of the pharynx, mainly the soft palate and uvula, to vibrate; just like the reed of a bassoon.
A number of factors can cause the narrowing of the airway e.g. nasal constriction or congestion, enlarged tonsils and adenoids, micrognathia or retrognathia, macroglossia, and adipose tissue in the pharyngeal area. All these factors will predispose one to snore, but chief of them all is a super relaxed tongue.
It is normal for the muscle tonicity in the pharyngeal area to decrease during sleep, but in snorers this tendency becomes greater. Since the back of the tongue is the side wall of the airway its rearward movement obviously narrows this vital lumen.
Therefore, when the diaphragm contracts and creates a vacuum, in an attempt to suck in air through the nose or mouth, it also sucks back the flaccid tongue. The resultant narrowed airway accelerates the airflow that, in turn, causes the audible vibrations of the soft palate and uvula.
When the tongue is sucked back into complete apposition with the posterior wall of the pharynx the oral and nasal air cannot reach the lungs. This is obstructive sleep apnoea. The term “apnoea” literally means “without breath”. Once the tongue makes a seal with the posterior pharyngeal wall, the diaphragm intensifies its efforts to suck in air; however, it only succeeds in making the seal tighter. This is analogous to sucking on a straw after contacting a lump of ice cream— the greater the suction, the flatter the straw.
The obstruction in the pharynx will not release until the blood carbon dioxide levels rise high enough to awaken the patient. This usually occurs with a loud snort, and within seconds the patient is asleep again. This can repeat hundreds of times per night with the patient completely unaware of its occurrence the following morning.
However, the main daytime symptoms of OSA are those of sleep deprivation, namely sleepiness.
The first patient to wear a modified functional orthopaedic appliance for the relief of snoring and/or OSA was a 45-year-old man of Japanese decent. He had an apnoea index of 79, i.e., an average of 79 apnoeas per hour during the entire night. His breathing would stop for 10 to 60 seconds on the average of every 45 seconds. He got practically no sleep, and during the day he was known to fall asleep while talking to a client sitting across the desk from him. His physician advised him to have a tracheotomy with a valve, which he could close during the day and open at bedtime.
When he refused, the physician suggested that an oral surgeon evaluate him for mandibular advancement. The surgeon rejected the option of surgery when he found that the patient had a Class I occlusion with an ANB of only 3 degrees.
During a discussion with the oral surgeon, details of this case came to the attention of this author who then suggested constructing a modified functional orthodontic appliance, which could maintain his mandible in a protruded position only while sleeping. The patient readily consented to trying this device. The main modifications of the appliance were complete occlusal coverage to prevent movement of the teeth in any direction and clasps on upper and lower dentitions to preclude any functional movement of the mandible that might create an orthodontic effect. The appliance as modified was named Nocturnal Airway Patency Appliance (NAPA)
The first NAPA was delivered on September 21, 1983 to Rodney Takeuchi. He has worn a NAPA practically every night since then. The results were dramatic. His snoring stopped immediately, he was no longer sleepy during the day and his performance at work improved. He and his family consider him a new man. Objectively, an overnight sleep study with polysomnography indicated his sleep apnoea index dropped from 79 to 5.3 and his blood oxygen saturation markedly improved
Snoring has long been the butt of many jokes, but it has been the source of tragedy, not humour, to those whose families have been broken because of it. Equally gratifying has been the response of middle age men who assumed their vim and vigour was solely due to advancing age and not related to their snoring.
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