Snoring and Wedding Rings

Wedding rings, those outward signs of commitment and endearment are attractive, long lasting items of hand jewellery. On the wedding day are then worn indefinitely as a sign of love and fidelity. Any newly wed will tell you that the ring took a couple of days to get used to but then became an invaluable friend being easily tolerated.

So what have wedding rings got to do with snoring?  What are the features of the wedding ring that may relate to the problems of snoring?
People who snore are often married or in a long term relationship. Snoring on the whole is a life long problem, usually to the long suffering partner, female or male.  Snoring and its related more serious sleep apnoea condition, can add strain to a relationship, disturb sleep, result in banishment of the guilty snorer to a separate bedroom or the sofa, affect health, aggravate cardio vascular problems and in the most serious of cases lead to premature death.

Many remedies have been proposed for dealing with this problem ranging from the gold standard, a continuous positive airway pressure pump (CPAP) which takes the form of a face mask attached to a positive pressure air pump, various unpleasant often painful surgical procedures, jaw forward posturing devices, to the bizarre e.g. the infliction of an electric shock on the snorer. For those readers who say, “oh my partners snoring is worse following alcohol or whilst sleeping on the back and rolling on the side seems to help”, then read on as your partner may have snoring or obstructive sleep apnoea which is related to reduced oropharygeal airway space i.e. limited space at the back of the throat.

One of the most well researched and successful treatments is posturing the lower jaw forward in sleep. These include joined plastic gum shields, plastic trays, acrylic jaw posturing devices, orthodontic functional appliances, postural head pillows and many more.  Essentially all of these systems rely on the action of posturing the lower jaw into the “recovery position” and in so doing, advancing the mandible, tongue, and tongue base. As the tongue adopts a more forward position, it has been shown that the uvula and the soft palate, that little dangly thing and the soft piece of skin at the top back of the mouth, follow the tongue forward. Both the advancement of the tongue and soft palate lead to an opening of the airway, improving air flow and stopping snoring, relieving the obstruction being the primary case of obstructive sleep apnoea.

The snoring is made worse if the jaw and the tongue plus soft palate drop backwards against the back of the throat under the influence of gravity.  Rolling the snorer onto the side will partially overcome the gravitational pull and open the airway by the jaw and tongue moving forward and to the side.

In papers, magazines, and on the internet you can find suppliers of an inexpensive one part plastic or acrylic mandibular advancement appliance. These are either “one size fits all” or have the facility of the user moulding these to fit the shape of their own teeth and jaws.  Moving up the scale dentists and Orthodontist take detailed impressions of the teeth and jaws upon which stone models are constructed in the laboratory. Customised plastic or acrylic mandibular advancement appliances are made. Again these are usually a one part appliance meaning that during wear, the jaws are held forward and are clamped in this position until the appliance is removed or discarded. In some more sophisticated designs the upper component is separate from the lower but carry a plastic, acrylic or steel component that is attached between the upper and lower appliances forcing the jaw forward whilst allowing a degree of jaw opening and side movement.

Whilst in many cases these appliances have been found to be highly successful, in fact there is a whole industry building up to deliver these appliances, they have their limitations and complications in the short and more importantly in the long term.

The main problem with all of these jaw posturing appliances, worn in the mouth, is their bulk causing the patient discomfort. Patient intolerance and non-compliance is the single most common reason why people give up on wearing these devices.  The off the shelf devices are notoriously bulky and have the worst compliance record. The customised appliances are somewhat better but are still very bulky. Unfortunately a side effect of these approaches is that the teeth and jaws placed in a new position will undergo unwanted and uncontrolled tooth movements especially if the device is poorly fitting, if teeth are not included in the device and if the new bite position is not carefully positioned. Some patients will also suffer from jaw joint pain and discomfort, unexplained headaches which again may be related to inappropriate jaw positioning. Thus the DIY approach is not to be recommended.

All the mouth worn mandibular advancement appliances owe their origins to functional appliances which have been used by Orthodontists and dentists, over many years, to permanently change tooth and jaw position in children, adolescents and more recently adults.

Plastic and acrylic though initially an attractive material, are weak in thin section, they tend to be porous, they distort easily especially if heated. In the mouth they pick up stain, harbour plaque, bacteria, fungal infestation and are difficult to clean. Many of these materials become brittle with time and the active linking hinges often break and do not stand the test of time.  Plastic and acrylic dentures are known in the trade as “gum strippers”.  Patients will often complain of the bulk, the inability to open the mouth unless the brace is removed. This is an inconvenience especially if the individual needs water in the night or is in need of regular nightly oral medication. The bulk severely affects speech, though is not known as a remedy for sleep talking. Patients often complain of a dry mouth and some report an increase in the frequency of head colds, though this has not been scientifically validated. Most adults are obligate nasal breathers. We do not like breathing through the mouth and we will naturally try and close off the mouth by bringing the lips together or plugging the gap with the tongue or sucking the thumb. Thus the unfortunate bulk of these plastic and acrylic devices whilst advancing the jaw, also introduce a largely unwanted vertical opening component. This jaw opening can reduce the amount of the more desirable forward movement. The size of the plastic and or acrylic appliances can in themselves occupy mouth tongue space.  These devices have a limited life span and will need regular replacement. As we get older our ability to accept new demands and the wearing of a new and foreign contraption in the mouth reduces. So in prescribing these plastic or acrylic devices are we storing up long-term problems for the hapless snorer?

So what is the answer, what are we looking for and is there a long term solution?

Let’s draw parallels with the humble wedding ring. The ring and appliance needs to be made of inert materials that do not react with the skin nor mouth environment. A metal, if used, must be thin and strong in cross section. It must be light. It should be malleable. You must be able to keep it clean and it should not tarnish nor change its properties with age. It should not be porous and should not harbour bacteria, fungi and other germs. To be successful, the wearer should find it attractive and be able to learn to tolerate the ring or appliance within a couple of days. It should not fall off the finger or be easily displaced from the mouth. Under pressure it should become more retentive. It should be capable of being adjusted.  It should not cause any unwanted side effects to the fingers hands or in the case of the mandibular advancement appliance, should not aggravate unwanted tooth movements or unwanted permanent changes in jaw positions.  Though initially expensive this is accepted if the ring or appliance can be worn successfully over many years. The appliance should not interfere with other functions of the mouth e.g. the user should be capable of opening the mouth and move the jaws to the side, be capable of drinking water or taking medication, it should not interfere with speech and not cause any deleterious side effects.

A relatively new design called a Somnowell has been developed, this is constructed of chrome cobalt metal or gold which are inert. The device has two very thin quite delicate frameworks one seated on the bite surfaces of the top teeth and one sits on the bite surface of lower teeth. The two tooth covering frameworks are connected by two rod and piston arrangements which sit outside the tooth arches in the commeasures spaces between the cheeks and the teeth. The appliance resembles delicate jewellery. The trick has been in overcoming the problem of attaching the stainless steel rod and piston components to the chrome frameworks. Because the frameworks are so thin and the active jaw posturing devices are located in the cheek commeasures there is minimal encroachment by the device into the mouth space. Since the appliances are so thin the jaws can be held well forward with minimal adverse vertical opening of the jaw. This means that it is considerably easier for the wearer to bring the lips together and there is less need for mouth breathing. This in turn has resulted in fewer complaints of a dry mouth or frequency of head colds.

Chrome cobalt, stainless steel, and gold are easily cleaned. They are less likely to attract or harbour plaque or other mouth organisms. For snoring and sleep apnoea these are new and exciting developments. Has mouth jewellery got the answer?

1. What is snoring?

Snoring is usually caused by a constriction of airflow most commonly at the back of the mouth in the area above the voice box known as the oro -pharynx.  Because the airway is reduced, the normally flaccid tissues inside the oro-pharynx vibrate with the increased air flow.

2. What is obstructive sleep apnoea?

This is a more severe condition often associated with snoring, where the airway is temporarily and repeatedly fully constricted. 

3. What is CPAP and is there an alternative?

CPAP is short for continuous positive airway pressure and is essentially air forced through the restricted oro-pharyngeal space by way of a face mask worn at night attached to an air pump. The two principle alternatives to CPAP are surgery to the soft palate and uvula or mandibular advancement appliances.

4. How long will my plastic mandibular advancement appliance last for?

These devices have a limited life span and will need regular replacement. As we get older our ability to accept new demands and the wearing of a new and foreign contraption in the mouth reduces. So in prescribing these plastic or acrylic devices are we storing up long-term problems for the hapless snorer?

5. How long will my chrome cobalt snore stop last?

Providing the mouth teeth and gums are well maintained then these appliances should work in the mouth indefinitely. They can be simply adjusted if the amount of advancement needs to be increased.