ArticlePDF Available

The History Behind the Mechanics of Oral Appliance Therapy for the Treatment of Obstructive Sleep Apnea

Authors:

Figures

Journal of Dental Sleep Medicine
Vol. 6, No.1 2019
ORIGINAL ARTICLES
JDSM
http://dx.doi.org/10.15331/jdsm.7054
The History Behind the Mechanics of Oral Appliance Therapy for
the Treatment of Obstructive Sleep Apnea
B. Gail Demko, DMD, D.ABDSM
Sleep Apnea Dentists of New England, Newton Centre, MA
The past actually happened, but history is only what people wrote down.
A. Whitney Brown The Big Picture
When studying history for the roots of knowledge, one can only go back to the first time that an idea was written down. This does not
necessarily mean that the author of that prose was the innovator, only that the author was committing to paper an idea, common
knowledge, or belief present at that time. Some authors take a piece of knowledge and are able to bring that idea to a wide audience,
spreading ideas and thoughts far from the point of origin. This first in a series of papers hopes to acquaint the reader with the long history
behind oral appliance therapy for the treatment of obstructive sleep apnea.
Keywords: jaw thrust, tongue extension, history, von Esmarch, chloroform, resuscitation, oral appliance, obstructive sleep apnea, ob-
structive sleep apnea treatment
Citation: Demko, BG. The history behind the mechanics of oral appliance therapy for the treatment of obstructive sleep apnea. J Dent
Sleep Med. 2019;6(1)
INTRODUCTION
History repeats itself. Historians repeat each other.
Philip Guedalla
Although it is possible that some procedures in medi-
cine are completely new, more often they are rediscoveries
of techniques from the past. This first article looks at the
history of the jaw-thrust and tongue extension maneuvers
that provide the basis of oral appliance therapy (OAT) for
the treatment of obstructive sleep apnea (OSA) and snor-
ing. The history of OAT for the treatment of OSA is based
in centuries of scientific experimentation and advance-
ments. None of the concepts required for dentists to treat
this potentially dangerous disease are new. They come to
current practitioners through their medical training, “com-
mon knowledge”, and shared experience. In medicine, en-
tirely new ideas are rare, but rediscoveries are common.
This segment of OAT history looks at the concepts of jaw
advancement and tongue extension that have existed for al-
most 200 years and briefly discusses what went before.
The idea of the four humors being the source of health
and illness dominated Western medicine for 2,000 years;
disease was thought to be the result of an imbalance of the
four elements: yellow bile, black bile, phlegm, and blood.1-
3 Although advances in physiology, microbiology, and
chemistry in the 19th century eventually discredited the hu-
moral theory in Western medicine, treatment of airway ob-
struction during these early years involved both active me-
chanical intervention coupled with the standard humoral
approach of bleeding, cupping, and using stimulants or
emetics.
The initial concept of reviving or resuscitating a per-
son who was not breathing is lost in the distant past. Early
treatment of airway obstruction addressed closure of the
airway caused by trauma, infection, foreign bodies, drown-
ing, and stillbirth. Mechanical interventions (insufflation
by direct pressure or manipulation of the rib cage and tra-
cheostomy) as well as humoral balancing have been de-
scribed for millennia.
To understand a science, it is necessary to know its
history.
Auguste Comte
BEFORE THE MID 19TH CENTURY
Many historians harken back to biblical times and
quote 2 Kings 4:34-354 as evidence that artificial respira-
tion/ resuscitation had been practiced for millennia.
34. He went to the bed and lay on the boy, putting
his mouth on the boy's mouth, his eyes on the boy's
eyes, and his hands on the boy's hands. He stretched
himself out on top of the boy. Soon the boy's skin be-
came warm. 35. Elisha turned away and walked
around the room. Then he went back and put himself
on the boy again. The boy sneezed seven times and
opened his eyes.
Although this reference may be taken as implying
Journal of Dental Sleep Medicine
Vol. 6, No.1 2019
The History Behind the Mechanics of Oral Appliance Therapy for the Treatment of Obstructive Sleep Apnea Demko
some sort of mouth-to-mouth respiration, it is far from
strong evidence. (Others believe that Elisha actually caused
compression of the rib cage by ‘throwing himself’ on the
child, indicating mechanical resuscitation).5 Ancient Egyp-
tians are also cited in attempts to restore respiration. Other
active mechanical techniques for resuscitation throughout
millennia have included hanging a person by the feet (in-
version technique), rolling the victim over a barrel, rocking
the person on a teeter board, and carrying the person face
down on the back of an ox.5
Stimulants and irritants were used to urge the muscles
into action. Some were verbal, such as yelling and shouting
at the victim to waken; others were physical, such as rub-
bing the skin, injecting tobacco juice into the rectum or
snuff into the nose, shining a bright light into the eyes, plac-
ing hot coals on the abdomen, or injecting into the stomach
or bowel strong camphorated oils, peppermint, nutmeg, or
emetics.6 These recommendations for resuscitating drown-
ing victims were translated into most European languages
by 1773.5 Rubbing the skin continued into Victorian times,
such as rubbing the wrists of women who had fainted. It
seems reasonable to add a jab from a bed partner’s elbow
to this category.
Instances of insufflation of air into the lungs of drown-
ing victims or those overcome by noxious gases appear
throughout history. Use of positive pressure for resuscita-
tion in the 17th and 18th century (in Europe) involved the
use of a bellows placed in the mouth or nose of a drowning
victim, a technique originally credited to Swiss-born Para-
celsus in the 16th century.7 In 1667, the physiologist Rob-
ert Hooke, MD was able to keep a dog alive for more than
an hour by using a bellows to provide air to the lungs via a
tracheostomy.7 Mouth-to-mouth resuscitation was de-
scribed in 1744, when William Tossach wrote a report
about resuscitating a man who had been overcome by nox-
ious gases and smoke in a mine. In this publication, Mr.
Tossach reports “I applied my mouth close to his, and
blowed as strong as I could…raising his chest fully with
it.8 In addition to mouth-to-mouth resuscitation, Tossach
also pulled, pushed, and rubbed the body to assist the mo-
tion of the blood, washed the victim’s face with water,
rubbed sal volitale (smelling salts) on his nose and lips and
bled him from his arm.8 Later in the 18th century, John
Fothergill, a devotee of Tossach, reported that “bleeding
…and chafing, rubbing, pulling; the application of stimu-
lants [to the victim] are too often ineffectual. The method
of distending the lungs of person, dead in appearance, hav-
ing been tried with such success in one instance, gives just
reason to expect, that it may be useful to others.”9 In 1770,
mouth-to-mouth resuscitation was reported superior to the
use of bellows by the French Academy of Sciences. Nev-
ertheless, the idea of mechanical rubbing, rocking, and
splashing the victim’s face with cold water was well in-
grained in popular culture and continued throughout the
19th century.7
The history of tracheostomy is better known. Alt-
hough Galen reported that the procedure was first per-
formed by Asclepiades of Bithynia (a Roman province in
Asia Minor) around 100 BC,10 the procedure was de-
scribed earlier by ancient Egyptian physicians to relieve
high respiratory obstructions.11 It was rarely successful and
was periodically denounced and revived as a medical pro-
cedure throughout history. The Talmud, a compendium of
Judaic cultural life and legal commentary on the Torah,
contains a description of inserting a reed through the tra-
chea to assist breathing in newborns.12 Although many
physicians knew about the procedure, the decision to im-
plement such a radical therapy was fraught with indecision.
It is commonly believed that the first president of the
United States, George Washington, died of upper airway
obstruction caused by bacterial epiglottitis.13 He slowly
suffocated while the physicians attending him tried to de-
cide whether to do a tracheostomy or continue blood-
letting.14 The first successful tracheostomy in modern times
was credited to Pierre-Fidèle Bretonneau, MD in 1825.15
In the 18th century, John Fothergill promulgated the
use of electric stimulation as did John Kite.6 Use of electri-
cal shock should be “administered to the heart and brain
…neither…so gently as to produce no effect, or so vio-
lently as to cause mischief…[these shocks] should be trans-
mitted through every part of the body, but more particularly
through the diaphragm and intercostal muscles; the heart,
the brain, and the spinal marrow”.6 Fothergill added that,
after every other attempt to inflate the lungs had failed, tra-
cheostomy was the last option.9
Most of the things worth doing in the world had been de-
clared impossible before they were done.
Louis B. Brandeis
MID-LATE 19TH CENTURY
It was the advent of widespread use of general anes-
thesia in the 1840s that altered the course of medical his-
tory and brought to light the action of jaw advancement and
tongue extension. No longer were stillbirth and drowning
the main causes of death by asphyxia; it was now the med-
ical community and their use of general anesthesia that was
at fault.
Discovered by Joseph Priestly in 1776, nitrous oxide
was used recreationally by the British upper class as early
as 1799 to cause euphoria and slight hallucinations.16 Sir
Humphry Davy first described the use of nitrous oxide as a
general anesthetic in 1800.17-19Sulfuric ether, described in
scientific treatises as early as 1550, was well known by
chemists, pharmacists, and physicians in the late 18th cen-
tury.20 In 1818, Michael Faraday described the great resem-
blance between the effects of the vapor of ether and nitrous
oxide.17, 21 By the 1830s, social use of ether and nitrous ox-
ide as excitatory drugs was common and showmen traveled
the countryside demonstrating their use. G. Q. Colton was
Journal of Dental Sleep Medicine
Vol. 6, No.1 2019
The History Behind the Mechanics of Oral Appliance Therapy for the Treatment of Obstructive Sleep Apnea Demko
one such showman and during a demonstration in Connect-
icut in 1844, 22 he introduced Horace Wells, DMD to the
use of nitrous oxide.18 Wells asked Mr. Colton to come to
his office and administer nitrous oxide for the dentist’s own
molar extraction,23 which was described as a painless pro-
cedure. Wells’ knowledge of nitrous oxide and ether was
related to his student William Morton, DMD who, in a col-
laboration with John Collins Warren, MD, presented the
first successful demonstration of general anesthesia at Mas-
sachusetts General Hospital on October 16, 1846.24 This
demonstration was the catalyst that led to the revolution of
general anesthesia use worldwide. Within a few days of its
being used in London, ether anesthesia was administered
in a surgical case in Paris. On January 19, 1847, 1 month
after the first continental application of ether for the pre-
vention of pain, Dr. James Young Simpson in Edinburgh
used it for making childbirth pain free.17 (p 19), 25 Rapid dis-
semination of this technique for removing pain was aston-
ishing. This explosion in the use of general anesthesia was
met with steep opposition in many circles because of the
high number of fatalities. Despite this, its use in medicine
was widespread by 1847.17 (p 19) Chloroform (not a flamma-
ble gas, as was ether, a major advancement in a time of gas
lighting) was in medicinal use as early as 1831,20, 26 but it
was expensive and did not come into general use as an an-
esthetic for some years. Although frequently used in Eng-
land, Massachusetts General Hospital forbade the use of
chloroform until 1854 and ether remained the anesthetic of
choice in Italy, France, and the US for years to come.17 (p 23)
Concern about death secondary to general anesthesia
was reported simultaneously with the advent of widespread
general anesthesia. A report of a young lady in Newcastle,
England, who died during a procedure to remove her toe-
nail was published in 1847.27 Letters to the editor of the
journal Lancet suggested that her death was secondary to a
stimulant (brandy) introduced into her mouth in an attempt
to revive her, or that she had suffered from the shock of the
operation, syncope, or chloroform poisoning. Early deaths
from asphyxia were blamed on the direct action of the an-
esthetic on the heart, brain, or by “combining with the
blood”,17, 28 unrelated to airway obstruction or other reme-
diable causes.
Mouth-to-mouth resuscitation and the use of bellows
fell out of favor with erroneous reports of lung tissue dam-
age in the early 19th century.7 The subsequent change to
external body movement used various techniques of arm
movements and body positions to cause expansion of the
rib cage, thus inducing inspiration. Dr. Leroy d’Etoilles
a
The Schafer Technique and Holger Nielsen maneuver
a
soon
followed. The Van Hasslet method used the fingers as hooks to
catch under the edge of the ribcage. It was “rediscovered” in
1879 and coupled with external chest compression as the Van
Hasselt-Schűller method. (Karpovich 1953 p 28)
b
In 1907, a mechanical resuscitator was developed to provide
supplemental oxygen for those in respiratory distress or uncon-
wrote a paper about an early technique in 1829.5 Marshall
Hall introduced the “Ready Method” [Fig. 1] in 1856;29 the
Sylvester technique followed almost immediately in
1858.30, 31 [Fig 2.]
a
Although each developer of a technique
had a following, Henry Robert Silvester seemed to find the
widest audience. These mechanical methods of resuscita-
tion continued in use for almost 100 years. Among these
innovators was a French physician, J.V. Laborde, who in
1891 developed a repetitive tongue traction method rather
than using gross limb movement. Laborde used his tech-
nique in stillborn infants, but stated that, if his method did
not work, the rescuer should try the Silvester method.32 It
was not until some 60 years later that that James Otis Elam
demonstrated that mouth-to-mouth ventilation was effec-
tive and far superior to those manual artificial methods.14
b
Figure 1. Hall Method
From Hall M. New mode of effecting artificial respiration. Lancet 1856 Mar
1;67(1696):229
It was Marshall Hall who, in 1856, voiced additional
procedural concerns when discussing manual methods for
resuscitation of drowning victims. “The term Asphyxia,
ought to be exchanged for Apnoea” he stated.33 “It is evi-
dent that artificial respiration is to the blood-poisoning as-
phyxia [carbon dioxide build-up was thought to be the
cause of death] what the stomach pump is to poison in the
stomach”. “But there is an Impediment to artificial respira-
tion never before pointed out. It is the obstruction of the
glottis or the entrance to the windpipe, in the supine posi-
tion by the tongue falling backwards and carrying with it
the epiglottis-an event which can only be remedied by
adopting the prone position;”29 then rolling the victim onto
the side, rocking the patient back and forth. Thus, the pos-
sibility of airway obstruction by the tongue had been
scious.
b
The Draeger Pulmotor was the harbinger of modern in-
termittent positive pressure ventilation (IPPV); this mechanism
did not move to the operating room until the middle of the 20th
century. Used in the operating room for fewer than 30 years,
IPPV moved into the world of sleep medicine in 1981 as contin-
uous positive airway pressure (CPAP) for the treatment of ob-
structive sleep apnea (OSA).
Journal of Dental Sleep Medicine
Vol. 6, No.1 2019
The History Behind the Mechanics of Oral Appliance Therapy for the Treatment of Obstructive Sleep Apnea Demko
Figure 2. Silvester’s Method
From von Esmarch. The surgeon’s handbook on the treatment of
wounded in war: a prize essay. New York: Schmidt; 1878.
https://books.google.com/books?id=01XLIqbopq4C&dq=the%20sur-
geon's%20handbook&pg=PP3#v=onepage&q=the%20sur-
geon's%20handbook&f=false. Accessed December 27, 2018. (Available
on Google Books).
acknowledged in the medical literature as early as 1856.
c
In 1860, Joseph Lister wrote a chapter on chloroform
anesthesia for Timothy Holmes’ surgical textbook. In this
article he reported that airway obstruction may not be
caused only by the tongue relapsing into the airway, but
also by the unexpected folding of the epiglottis. He recom-
mended that, when clear respiration was impeded, the
tongue should be grasped with artery forceps and be drawn
firmly forward34 to open the obstructed airway. Five years
later, E.A. Clarke, MD wrote an article on another case of
c
The Greek roots for asphyxia, a term coined in 1706, is “ces-
sation of a pulse”; the implication that it is synonymous with
suffocation first appeared in 1778.
c
Asphyxia became the term
associated with a lack of oxygen that leads to unconsciousness
and death if not immediately treated. The term apnea, meaning
“without breath”, was first used in 1719, and implied an inter-
mittent or temporary cessation of breathing either voluntary or
involuntary. From:www.dictionary.com/brouse/asphyxia.
death from the administration of chloroform. When the pa-
tient ceased breathing, “he was immediately placed upon
his back with his head lowered, and cold water was dashed
upon his face and chest, with the effect of causing three or
four long inspirations, without however, affecting the cir-
culation in the least. We then commenced a vigorous arti-
ficial respiration, at the same time withdrawing the tongue
from the mouth and elevating the epiglottis with the fin-
ger”.35 When Lister’s chapter on chloroform anesthesia
was published in the 1871 edition of Holmes’ surgical text-
book, 36 Lister added that the tongue frequently falls back
during chloroform anesthesia and becomes a mechanical
impediment to respiration… and the tongue advancement
mechanism of action does not appear to be solely mechan-
ical, but also acts through the nervous system. He went on
to recommend that the obstruction is easily overcome by
pulling the beard or fold of skin below the chin to act on
the tongue through the muscle fibers attached to the maxilla
[mandible] or by turning the head to the side.37 J.T. Clover,
a British dentist, responded to Lister’s account that he had
never had to seize the tongue with artery forceps and that
the retropositioning of the tongue was merely due to an “act
of swallowing imperfectly performed.”38 He had, however,
seen partial obstruction of the larynx, “where the mere de-
pressing or raising of the chin was enough to close or open
the passage.”39 Clover added in other publications that he
“would not advise tracheostomy in such a case, but trust to
artificial respiration by Silvester’s method. Although this
would be useless whilst the glottis is closed.”39 Within a
very short time of the advent of general anesthesia, tongue
extension, jaw thrust, head tilt, or moving the head to a lat-
eral position as ways of opening an obstructed airway be-
came well known in the field of anesthesia.
Worldwide exposure to these concepts came with the
1877 publication of the Handbuch der Kriegschirurgischen
Technik. Eine gekrönte Preisschrift40 by Friedrich von
Esmarch [Fig. 3], hailed as the most important textbook of
surgical procedure ever written.
d
He graduated from medi-
cal school in 1848 just as ether and chloroform anesthesia
revolutionized surgical treatment, making the study of sur-
gery very appealing. After graduation, he visited England
and Scotland and was an early convert to Lister’s antiseptic
technique.41 Written for a prize offered by the Empress Au-
gusta Viktoria on the occasion of the Vienna Exhibition in
1877,42 this text was translated into English within 1 year.43
The book included extensive instructions
Online Etymology Dictionary 2010 Douglas Harper. Last ac-
cessed Aug 23, 2010 and Webster’s Ninth New Collegiate Dic-
tionary. Springfield, Massachusetts: Merriam-Webster;1985
d
von Esmarch used his experience on the battlefield (Schles-
wig-Holstein Wars of 1848-1851 and Second Schleswig-Hol-
stein War of 1864 as well as the Franco-Prussian War 1870-
1871) and interaction with other physicians in correspondence
and visits, to create the most up-to-date handbook for surgical
technique and operations on the battlefield.
Journal of Dental Sleep Medicine
Vol. 6, No.1 2019
The History Behind the Mechanics of Oral Appliance Therapy for the Treatment of Obstructive Sleep Apnea Demko
Figure 3. Friedrich August von Esmarch (from his obituary
in the British Medical Journal)
Reproduced from His excellency Johann Friedrich August von Esmarch.
Br Med J. 1908;1:719 with permission from BMJ Publishing Group Ltd.
that explained how to deal with patients who had suffered
airway closure secondary to chloroform anesthesia. In it,
he explains that after the glottis closes and there is “spasm
of the muscles of the larynx and tongue, prompt action is
now imperative to free the upper entrance to the larynx.
The jaws must be separated, the tongue must be drawn well
out of the mouth.”43 In a second scenario, he describes a
typical jaw-thrust maneuver, stating one must “apply both
hands to the neck in such a manner that the forefingers
come to lie behind the ascending rami of the lower maxilla
[mandible]; push the whole lower jaw forward until the
lower row of teeth projects beyond the upper”
e
. [Fig. 4.]
This second maneuver von Esmarch credited to the British
dental surgeon J.S. Little, who in 1866 visited him in Kiel,
Germany prior to leaving for India in 1868.44 von Esmarch
also endorsed the Silvester technique of artificial respira-
tion, helping it to become that most the widely used form
e
The jaw-thrust maneuver is closely tied to von Esmarch’s text-
book and, on the continent, is often referred to as Esmarch ma-
neuver.
Figure 4. Illustration of maneuvers to open an obstructed
airway
From von Esmarch. The surgeon’s handbook on the treatment of
wounded in war: a prize essay. New York: Schmidt; 1878.
https://books.google.com/books?id=01XLIqbopq4C&dq=the%20sur-
geon's%20handbook&pg=PP3#v=onepage&q=the%20sur-
geon's%20handbook&f=false. Accessed December 27, 2018. (Available
on Google Books).
of manual artificial respiration.44
20TH CENTURY
Ether and chloroform anesthesia continued to be given
by open dropper administration until well into the 20th cen-
tury.45 Mechanically assisted ventilation for use during a
surgical procedure was not developed until the mid 20th
century.46 In the intervening century, physicians had to
temper their use of anesthetics to maintain a patient’s spon-
taneous breathing. Thus, the need to understand techniques
that open the airway of a patient with an obstruction under
general anesthesia was part of the training for every medi-
cal practitioner.
Marshall Hall, in his paper on the resuscitation of
Journal of Dental Sleep Medicine
Vol. 6, No.1 2019
The History Behind the Mechanics of Oral Appliance Therapy for the Treatment of Obstructive Sleep Apnea Demko
drowning victims in 1856, was the first to state, whether
truthfully or not, that “in the supine position, the tongue
falls backwards and closes the glottis. All inspiration is
therefore impossible. In the prone position, the tongue falls
forwards, and leaves the glottis freely patent. Inspiration is
therefore possible.” 29 Research about the effect of passive
head and jaw position on airway obstruction continues. In
1959, Safar et al. studied airway obstruction in uncon-
scious, spontaneously breathing patients to determine the
effect of passive maneuvers, e.g.: body position (prone or
supine), head position (flexed or extended) and jaw posi-
tion (supported forward manually or left alone), and the ef-
fect of these maneuvers on airway patency. Complete air-
way obstruction developed in all of his subjects when the
head was flexed regardless of body or head position; in
none of the subjects did airway obstruction develop with
head extension and mandibular support in a protrusive po-
sition.47 Similar passive movements were studied by Isono
in 200348 and currently, a research group in Amsterdam
continues to study the effect of passive maneuvers on the
airway.49 Physicians had more than a century of knowledge
on the success of jaw thrust in opening an occluded airway
when OSA syndrome was first described in the medical lit-
erature in 1973.50 The deep-rooted knowledge of the effec-
tiveness of jaw-thrust maneuver and tongue extension pro-
vided all the background required for future development
of noninvasive therapy for OSA with OAT.
CONCLUSION
The development of general anesthesia created an en-
vironment in which several thousand people risked as-
phyxia and the number of people with airway obstruction
was greatly increased beyond the number of drowning vic-
tims and stillborn births. Knowledge about tongue relapse
in those who were unconscious was acknowledged by the
mid 19th century and the medical field united to find solu-
tions to airway obstruction. The knowledge that the tongue
could be moved bodily forward with a forceps or a towel,
and the entire mandible could be moved forward by push-
ing on the distal border of the rami or simply extending the
entire head resulted in resolution of airway obstruction was
advanced early. Although the actual mechanics were still
in question, all the knowledge was in place to be used after
OSA had been defined as a disease related to upper airway
obstruction during sleep. Physicians were the first to call
for oral appliances to hold the tongue or jaw forward and
dentists were in the best position to fabricate this new treat-
ment modality. Thus, 200 years of medical experiments,
education, and discussions led to the development of OAT
for OSA.
If you want to understand today, you have to search yes-
terday.
Pearl S. Buck
The next segment on the history of OAT will look at
orthodontic therapy and the evolution of knowledge and
advancement of dental techniques from 16th to the 20th
centuries that led to development of the first modern oral
appliances for the treatment of OSA in 1982-1983.
ACKNOWLEDGMENTS
I would like to thank Alice C. Grover for her assis-
tance in completing this manuscript.
ABBREVIATIONS
CPAP: Continuous positive airway pressure
IPPV: Intermittent positive pressure ventilation
OAT: Oral appliance therapy
OSA: Obstructive sleep apnea
REFERENCES
1. Jewson D., N. (1974). Medical Knowledge and the Patronage System
in 18th Century England. Sociology, 8(3), 369385.
https://doi.org/10.1177/003803857400800302
2. Fox, N. J. (1988). Scientific theory choice and social structure: the
case of Joseph Lister's antisepsis, humoral theory and asepsis. History
of Science, 26(4), 367-397
3. Manderson, L. (1987). Hot-cold food and medical theories: overview
and introduction. Social Science & Medicine, 25(4), 329-330
4. The Holy Bible, New Century Version. Nashville, TN: Thomas Nel-
son; 1984.
5. Karpovich PV. Adventures in Artificial Respiration. New York: As-
sociation Press;1953
6. Kite C. An essay on the recovery of the apparently dead. London: C.
Dilly in the Poultry;1788. Accessed by Hathi Trust Aug 20, 2018
7. Baker AB. Artificial Respiration, The history of an idea. Med Hist.
1971 Oct 15;(4):336-351
8. Tossach W. A man dead in appearance, recovered by distending the
lungs with air. In Medical essays and observations revised and pub-
lished by a society in Edinburgh. Vol Y. Part II pg. 605: Edinburgh
1744. p. 605-608. Available at:
https://books.google.com/books?id=DrYMgZM1YZgC&pg=PA605
&dq=Tossach&hl=en&sa=X&ved=0ahUKEwjb3vW1oPncAhXYqY
MKHTCNCK8Q6AEIWzAJ#v=onepage&q=Tossach&f=false Last
accessed August 20, 2018
9. Elliot J.A. A complete collection of the medical and philosophical
works of James Fothergill. 1781. London: John Walker;1781 p 110-1
10. Banerjee S. History of tracheostomy. Indian J Otolaryngol Head Neck
Surg. 1996 Oct-Dec;47(4):262-5
11. Musso CG. Imhotep: The dean among ancient Egyptian physicians-
An example of a complete physician. Humane Medicine
2005:5(1):169-171
12. Szmuk P, Ezri T, Evron S, Roth Y, Katz J. A brief history of trache-
ostomy and tracheal intubation, from the Bronze Age to the Space
Age. Intensive Care Med. 2008;34(2):222-228
13. Sittig SE, Pringnitz JE. Tracheostomy: Evolution of an airway. AARC
Times. 2001 Feb;25(2):48-51
Journal of Dental Sleep Medicine
Vol. 6, No.1 2019
The History Behind the Mechanics of Oral Appliance Therapy for the Treatment of Obstructive Sleep Apnea Demko
14. Webb RT, Bacon D. History of resuscitation. Int Anesthesiol Clin.
2017 Summer;55(3):117-129
15. Flagg PJ. The art of resuscitation. New York: Reinhold Publishing
Corp;1944 p.8
16. Nitrous Oxide. https://en.wikipedia.org/wiki/Nitrous_oxide. Wikipe-
dia. Last accessed Aug. 20, 2018
17. Snow J. On chloroform and other anesthetics: Their action and admin-
istration. London: John Churchill;1858.
18. Boyle HEG. Nitrous oxide: history and development. Br Med J. 1934
Jan 27;1(3812):153-155
19. Davy H. Researches, chemical and philosophical: chiefly concerning
nitrous oxide, or dephilogisticated nitrous air and its respiration. Lon-
don: J. Johnson;1800 https://books.google.com/books/about/Re-
searches_Chemical_and_Philosophical_Ch.html?id=jhU-
AAAAAQAAJ&printsec=frontcover&source=kp_read_but-
ton#v=onepage&q&f=false Accessed Aug 21, 2018
20. Jackson CT. A manual of etherization containing directions for the
employment of ether, chloroform and other anesthetic agents, by in-
halation. Boston: J.B. Mansfield;1861
21. Faraday M. Some experiments and observations on a new acid sub-
stance. [Article V.] Quarterly Journal of Science and Arts. No V. Vol
III. New York: Eastburn& Co; 1818. Hathitrust. https://babel.ha-
thitrust.org/cgi/pt?id=mdp.39015059725336;view=1up;seq=7 Ac-
cessed Aug 21, 2018
22. Sims JM. The Discovery of Anaesthesia. Article III. Gorgas FJS and
Hodgkin JB Eds. American Journal of Dental Science. Vol II-third
series. Baltimore: Snowden & Cowman ;1878
23. Wells H. A history of the discovery of the application of nitrous oxide
gas, ether and other vapors to surgical operations. Hartford: J. Gaylord
Well;1847. P. 6-8
24. William T. G. Morton. Wikipedia. https://en.wikipedia.org/wiki/Wil-
liam_T._G._Morton. Last accessed Aug 20, 2018
25. Simpson JY. On a new anaesthetic agent, more efficient than sul-
phuric ether. The Lancet. 1847. 50:549-550.
26. Guthrie S. New mode of preparing a spirituous solution of chloric
ether. American Journal of Science and Arts. 1832. 21;64-65:405-8.
https://books.google.com/books?id=iuzRAAAA-
MAAJ&pg=PA64#v=onepage&q&f=false accessed Aug 21, 2018
27. Simpson JY. The alleged case of death from the action of chloroform.
Lancet. Feb 12 1848;51(1276):175-176
28. Snow J. The fatal choloroform case at Newcastle (correspondence).
Lancet 1848 Feb 26; 9(1):239.
29. Hall M. New mode of effecting artificial respiration. Lancet 1856 Mar
1;67(1696):229
30. Silvester HR. A new method of resuscitating still-born children, and
of restoring persons apparently drowned or dead. Br Med J. July 17
1858;2:576
31. Silvester HR. Treatment of asphyxia. Lancet. 1858 June
19;71(1816):616
32. Laborde JV. Sur un nouveau moyer de remédier à la mort apparente
par submersion. Bulletin Médical. Sixieme Année 1892 Paris Bu-
reaux: 82 rue des Mathurins, 82; 1044-1045
33. Hall M. Asphyxia, its rationale and its remedy. Lancet. Apr 12
1856;56:393-394
34. Lister J. Chloroform. In T Holmes editor. A system of surgery Theo-
retical and Practical in Treatises by various authors. London: Parker,
Son and Bourn; 1862 p 101
35. Clark EA. Case of death from the administration of chloroform. In
Piggot AS, Gorgos FJS, editors. American Journal of Dental Science
Vol 2. Baltimore: Snowden and Cowan. London: Trubner and Co,
1867
36. Lister J. Chloroform. A system of surgery Theoretical and Practical
in Treatises by various authors Vol. 5. Ed. T Holmes. London: Long-
mans, Green and Co.1871 p 499.
37. Lister J. Operative and Minor Surgery. In: Holmes T. editor. A sys-
tem of surgery Theoretical and Practical in Treatises by various au-
thors. Part V. 2nd edition. London: Longmans, Green and Co. 1871. p
535.
38. Clover JT. Chloroform Accidents. Br Med J. July 8, 1871 p33
39. Clover JT. On the administration of chloroform in dental operations.
(Abstract) The British J of Dental Science Vol XI. Jan-Dec, 1868 Lon-
don: John Churchill & Sons, New Burlington Street. P. 123-141
(Available on Google Books)
https://books.google.com/books?id=_PoaAQAA-
MAAJ&pg=PP7&dq=The+British+Journal+of+Dental+Sci-
ence+Vol+XI,+January-December+,+1868.+Lon-
don:+John+Churchill+%26+Sons,+New+Burling-
ton+st.&hl=en&sa=X&ved=0ahUKEwivlemTjPrcAhVH6oM-
KHWcgD-8Q6AEIKTAA#v=onepage&q=The%20British%20Jour-
nal%20of%20Dental%20Science%20Vol%20XI%2C%20January-
December%20%2C%201868.%20Lon-
don%3A%20John%20Church-
ill%20%26%20Sons%2C%20New%20Burlington%20st.&f=false
Last accessed Aug 20, 2018
40. Esmarch F. Handbuch der Kriegschirurgischen Technik. Eine
gekrönte Preisschrift. Hannover: Carl Rűmpler;1877
41. Herzenberg JE. Johann Freidrich August von Esmarch: his life and
contributions to orthopaedic surgery. Iowa Orthop. l1988;8: 85-91
42. Friedrich von Esmarch. Wikipedia. https://en.wikipe-
dia.org/wiki/Friedrich_von_Esmarch Accessed Aug 21, 2018
43. von Esmarch F. The surgeon’s handbook of the treatment of wounded
of war. A prize essay. Trans: Clutton HH and Cantar BA. Hanover:
Charles Rűmpler;1878 p. 116
44. Defalque RJ, Wright AJ. Who invented the “Jaw Thrust”? Anesthesi-
ology 2003;99(6)1463-464
45. Chang CY, Goldstein E, Agarwal N, Swan KG. Ether in the develop-
ing world: rethinking an abandoned agent. BMC Anesthesiol.
2015;15(1):149. doi:10.1186/s12871-015-0128-3
46. Slutsky AS. History of Mechanical Ventilation from Vesalius to Ven-
tilator-induced lung injury. Am J Resp Crit Care Med.
2015;191(10):1106-1114
47. Safar P, Escarraga LA, Chang F. Upper airway obstruction in the un-
conscious patient. J Appl Physiol. 1959;14(5):760-764
48. Isono S, Tanaka A, Tagaito Y, et al. Influences of head positions and
bite opening on collapsibility of the passive pharynx. J Appl Physiol.
2004 July;97(1):339-346
49. Vonk PE, Beelen AMEH and de Vries N. Towards a prediction model
for drug-induced sleep endoscopy as selection tool for oral appliance
treatment and positional therapy in obstructive sleep apnea. Sleep
Breath. Epub 2018 Mar 9
50. Guilleminault C, Eldridge FL and Dement WC. Insomnia with sleep
apnea: a new syndrome. Science. 1973 Aug 31;181(4102):856-858
SUBMISSION AND CORRESPONDENCE
INFORMATION
Submitted in final revised form September 2, 2018
Accepted for publication November 8, 2018
Address correspondence to: B. Gail Demko, DMD, 6409
Prairie Dunes Drive, Grand Blanc, MI 48439, Email:
bdemko@yahoo.com
DISCLOSURE STATEMENT
Journal of Dental Sleep Medicine
Vol. 6, No.1 2019
The History Behind the Mechanics of Oral Appliance Therapy for the Treatment of Obstructive Sleep Apnea Demko
The author has no financial conflicts of interest to disclose.
APPENDIX
Major Innovators:
Bretonneau, Pierre-Fidèle (1778-1862) French physician
Clarke, E.A. (19th century) British physician
Clover, Joseph Thomas (1825-1882) British dentist and anesthesiologist
Colton, G.Q. (1814-1898) American showman, former medical student
Davy, Humphry (1778-1829) British chemist and inventor
Elam, James Otis (1918-1995) American physician and respiratory researcher
D’Etoilles, Leroy (1798-After 1855) French surgeon
Faraday, Michael (1791-1867) British scientist and physicist
Fothergill, John (1712-1780) British physician, botanist
Hall, Marshall (1790-1857) British physician, physiologist and anatomist
Hooke, Robert (1635-1703) British physician and physiologist
Kite, Charles (1760?- 1811) English physician, surgeon and scientist
Laborde, J. V. (early-mid 19th cent-1903) French physician and physiologist
Lister, Joseph (1827-1912) British physician and pioneer of antiseptic surgery
Little, J.S. (19th century) British surgeon
Morton, William T. G. (1819-1868) American dentist
Paracelsus (1493-1541) Swiss physician, alchemist and astrologer
Priestly, Joseph (1733-1804) British theologian, chemist, philosopher, educator
Silvester, Henry R. (1829-1908) British physician
Snow, John (1863-1858) British physician and anesthesiologist
Tossach, William (1700-1771) British physician and physiologist
Von Esmarch, Friedrich (1823-1908) German physician, surgeon
Wells, Horace (1815-1848) American dentist
Warren, John Collins (1778-1856) American surgeon
ResearchGate has not been able to resolve any citations for this publication.
Article
Full-text available
Purpose: To evaluate the effect of different passive maneuvers on upper airway patency during drug-induced sleep endoscopy (DISE) compared to recent literature on treatment outcomes of positional therapy (PT), oral appliance therapy (OAT), and combined treatment in obstructive sleep apnea (OSA) patients. Methods: A retrospective, single-center cohort study including a consecutive series of 200 OSA patients. All patients underwent DISE with and without manually performed jaw thrust and lateral head rotation by using the VOTE classification. The effect of these maneuvers were analyzed by using the sum VOTE score comparing non-positional (NPP) and positional OSA patients (PP). Results: Two hundred patients were included (80.5% male) with a mean age of 50.1 ± 11.7 years, a BMI of 27.0 ± 3.1 kg/m2, and a median AHI of 19.2 events per hour. Forty-four percent of the patients were NPP; of the remaining 56%, 34% was diagnosed with supine isolated and 66% with supine predominant POSA. Manually performed jaw thrust showed a reduction of sum VOTE score of 66.7% in all subgroups. The effect of lateral head rotation was a reduction of 33.3% in NPP and supine predominant PP and 50% in supine isolated PP. Combining these maneuvers a reduction of more than 75% was seen in all patients. Conclusions: The present model leaves room for improvement. The effect of manually performed jaw thrust is greater and the effect of lateral head rotation alone is less than what was expected compared to recent literature on treatment outcome of OAT, PT, and combined treatment.
Article
Full-text available
Study objectives: Continuous positive airway pressure (CPAP) therapy is considered the front-line treatment for moderate-severe obstructive sleep apnea (OSA). However, nonuse rates are very high, such that adherence to CPAP has become a major concern. Although the literature on CPAP use is vast, further research is required to understand patients' experiences of CPAP use and nonuse. This is the goal of this study. Methods: This study draws on in-depth interviews with 61 Jewish-Israeli patients with OSA who received a recommendation to use a CPAP device. The sample includes both patients who started using CPAP devices as well as patients who rejected this course of treatment. It follows principles of constructivist-grounded theory in both sampling and analysis. Results: The study shows that regardless of patients' status of adherence, their attitudes toward CPAP devices are characterized by ambivalence. Users of CPAP expressed ambivalent adherence, pondering whether they should stop using the device; and patients who rejected the CPAP expressed ambivalent nonadherence, wondering whether they should give the CPAP another chance. This study identifies the experiences involved in using, as well as not using, CPAP devices that produce patients' ambivalence. Conclusions: Both adherence and nonadherence to CPAP are dynamic processes that are characterized by patients' ambivalence and contingent upon diverse factors. These findings have practical implications as they suggest that all patients, regardless of their initial adherence status, would benefit from a close follow-up.
Article
Full-text available
The characteristics of non-obese patients with mild to moderate Obstructive Sleep Apnea Syndrome (OSAS) who will present with a good response to Mandibular Repositioning Appliance (MRA) treatment have not yet been well established in the literature. The aim of this study is to assess whether polysomnographic (PSG), demographic, anthropometric, cephalometric, and otorhinolaryngological parameters predict MRA success in the treatment of OSAS. Forty (40) males with mild and moderate OSAS were assessed pretreatment and 2-months post-treatment after wearing an MRA. Demographic, anthropometric, otorhinolaryngological (ENT), cephalometric, and polysomnographic parameters, including continuous positive airway pressure (CPAP) titrated pressure, dental models, Epworth Sleepiness Scale, quality of life (Short Form SF-36), and mood state (Profile of Mood States – POMS), were assessed. The responders exhibited fewer oropharyngeal alterations, increased upper pharyngeal space, reduced lower airway space, and increased mandibular intercanine width, and they had milder disease. Nevertheless, no predictive factors of MRA success could be found. MRA was more successful among men with a more pervious airway, a larger interdental width and milder OSAS. However, a combined [1] functional and structural assessment is needed to successfully predict the [2] effectiveness of MRA treatment of OSA.
Article
Airway patency was studied in 80 anesthetized, spontaneously breathing patients, who received no muscle relaxants. With the neck flexed (chin towards chest) the airway was obstructed in all patients, both in the supine and prone positions, with and without an artificial oropharyngeal airway in place. With extension at the atlanto-occipital joint (chin up) in the supine position approximately 50% of the patients had an open airway. The other 50% required, in addition to extension of the neck, forward displacement of the mandible or the insertion of an oropharyngeal airway or both. Roentgenograms demonstrated that the tongue is pushed against the posterior pharyngeal wall when the neck is flexed and the mandible is not held forward. The incidence and degree of obstruction was similar in the prone and supine positions, with comparable positions of the head, neck and mandible. Submitted on December 19, 1958
Article
Objective To identify potential risk factors of response to oral appliance in patients with obstructive sleep apnea (OSA). Methods Fifteen OSA patients were enrolled. Clinical characteristics, cephalometric measurements, and the results of home sleep testing were retrospectively obtained at baseline, and a sleep test was done again at the end of treatment. Results Twelve subjects were responders and three were non-responders. The diastolic blood pressure, minimum pulse rate, SNA (Angle between sella-nasion and nasion-A point), ANB (Anteroposterior maxilla/mandible discrepancy), and facial convexity of non-responders was higher than those of responders. Unlike AHI, non-responders showed a lower lowest oxygen saturation (%) than responders. Discussion Elevated diastolic pressure and minimal pulse rate, higher skeletal convexity and lowered lowest oxygen saturation might be risk factors to oral appliance efficacy in the OSA patients. More research in a large sample is needed to verify the results of the current study.
Article
Background: Obstructive sleep apnea (OSA) results from the collapse of different pharyngeal structures (soft palate, tongue, lateral walls, epiglottis). The structure involved in collapse has been shown to impact non-CPAP OSA treatment. Different inspiratory airflow shapes are also observed among OSA patients. We hypothesized that inspiratory flow shape reflects the underlying pharyngeal structure involved in airway collapse. Methods: Subjects with OSA were studied with a pediatric endoscope and simultaneous nasal flow and pharyngeal pressure recordings during natural sleep. The mechanism causing collapse was classified as tongue-related, isolated palatal, lateral walls, or epiglottic. Flow shape was classified according to the degree of negative effort dependence (NED), defined as the percent reduction in inspiratory flow from peak to plateau. Results: Thirty-one subjects with OSA (apnea-hypopnea index=54±27 events/hr; mean±S.D.) aged 50±9 years were studied. NED was associated with the structure causing collapse (P<0.001). Tongue-related obstruction (n=13) was associated with a small amount of NED (19[14-25]%; median[I.Q.R.]). Moderate NED was found among subjects with isolated palatal collapse (45[39-52]%) (n=8) and lateral wall collapse (50[44-64]%) (n=8). The epiglottis was associated with severe NED (89[78-91]%) and abrupt discontinuities in inspiratory flow (n=9). Conclusions: Inspiratory flow shape is influenced by the pharyngeal structure causing collapse. Flow shape analysis may be used as a non-invasive tool to help determine the pharyngeal structure causing collapse.