Complete Health Study Club- "Airway-Centric Dentistry" 5.19.21

Hello, Everybody. I am Dr. Michelle Huckey with Jack Speeches Family Dentistry and coming to you in our Complete Health Study Club. I am so excited tonight for many reasons. We started this Complete Health Study Club as a way to expose multiple dentists throughout the country to the concept of collaborating with other medical professionals. It's something I'm super passionate about. I meet every week with a group of amazing health and wellness people, and we're constantly collaborating because we all know that as a dentist, as an md, as a massage therapist, or whatever you do in health and wellness, we strive to get our patients and our clients super healthy, but we can't really do it alone. I'm really happy tonight for lots of different reasons. One of them is I really admire Dr. Michael Bennett. Wave at us. Dr. Bennett.

Yeah.

He is a sleep dentist that I've had the pleasure of working with and collaborating and learning from. He has an amazing podcast series which we are all going to encourage him to continue on about airway and getting people healthy in that regard. And he's going to speak tonight alongside a sleep MD that he collaborates a lot with. And that's one of the best relationships you can have if you're doing sleep and dentistry. So they're going to talk a lot about how they work together to get their patients healthy, and I'm really excited about that. One of the things I want to let everyone know before we get started is that the chat is open. I know on a lot of these sessions they close down the chat, but our chat is going to be open and we really encourage you to ask questions because if you have the opportunity to ask Dr. Bennett questions, you should. So. And then my partner in crime is with us also tonight. That's Dr. Jason Lewis. He's also here in Jacksonville, and he is going to talk a little bit about how much he loves having sleep in his practice, too.

Well, thank you, Michelle, and it's great to see everybody on the call tonight. And yeah, one of the topics that is near and dear to Michelle and my heart is know, treating airway. And, you know, I've been treating airway in my practice for over 10 years. And I think one of the things that I really enjoy about treating airway is seeing this, the people get healthier and the satisfaction of the patient once they start, you know, doing the treatment. But there's sometimes when you don't know what you don't know, you realize like, oh, there's definitely different ways to treat airway. As Michelle mentioned, Dr. Michael Bennett a few minutes ago, he's going to talk to us about his experiences and his sleep practice and how he collaborates with the sleep physician. But we're excited to bring this topic to our study club tonight and look forward to the information that's going to be presented. But another person that's been part of our team in regards to our the sleep part of our club, or complete Health club is Corbin Cowan. He is our director of the Complete Health Airway Group. And we're going to turn it over to him and he's going to tell you a little bit bit about himself and then introduce our speaker.

Fantastic. Well, I appreciate that kind introduction, Jason. And you know, I'm going to just take a brief second and tell my story and talk a little bit about, you know, what I've kind of termed the rededication day. So my story is that I invested in the technology company that we now represent in the Vivos appliance, and through that process found out that I had sleep apnea. But before I could get into treatment, two weeks before I was getting ready to run a, you know, race a triathlon, I had a stroke at the age of 43 in peak physical condition. And so the only thing that the doctors could point to really, in my medical history for a reason of having a stroke is the years and years of untreated sleep apnea. Luckily, my journey obviously ends happily in that I got the opportunity to work closely with Dr. Bennett, got into treatment with Dr. Bennett, and have been successful in dramatically reducing the risk of stroke and heart attack. In my personal life, for a lot of people, they're not so lucky. I know that that Dr. Bennett has had this happen. But as I've recruited and trained dentists on how to screen and diagnose and ultimately treat the dental abnormalities that cause sleep apnea, there started to be a common theme as they got into practice. And over the last couple years, I've brought on about 75 dental providers and brought them into the training and helped them integrate these protocols in their office. And I would say about 20% of those as I've gone back and met them at conferences and had conversations, they have this theme that they've rededicated themselves to massive integration and massive action. I said, well, what's changed? What has got you so fired up? And they said, well, we had a patient that we talked to in our office and we scheduled an appointment to do a screening. And before they showed up, we got a call to cancel the appointment because they didn't make it. They passed away in their sleep and so I've deemed that to be the rededication day that hopefully none of you here on this phone call have to go through because you rededicate yourselves. Now to screening all of your patients. One of the best practices that I have to share to get a Vivoscore device, which you don't have to be a complete health airway group doctor or a vivos doctor to get Vivoscore, but Vivoscore is a simple, cost effective way to deliver a sleep test to every single one of your patients. And I promise you that if you do this, not only will your sleep practice be greatly enhanced, but your general dentistry practice will start to increase. You will start to get more referrals. And without a doubt, I think Dr. Bennett will back me up on this. You will save some lives with that. I want to turn the time over to Dr. Bennett, who is my personal doctor. The struggle is real. I still struggle with it. I just had a conversation with Dr. Bennett today about my device broke and what do I do? And I'm on my way to complete health, but I'm not there yet. And it's a journey. And I'm so grateful to have Dr. Bennett in my corner and the network of clinical providers that he has surrounded himself with. So with that, I will turn the time over to you, Dr. Bennett.

Thank you, Corbin. That's quite a sobering story you have there to be in such peak condition. I've heard it before and it doesn't get old for me. It's interesting that such an athlete could be so focused being able to exercise right, eat right. But it's interesting that the emphasis on sleep in athletics isn't really where it needs to be at the same level of priority as nutritiously eating and getting right nutrition and exercising properly to develop athletes. I'm in a PhD program right now where I'm studying about different types of athletics and groups that use sleep hygiene, where they get adequate numbers of sleep and where they get adequate quality of sleep, and they screen for those and what it relates to in terms of their athletic performance. And it's fascinating that injury rates are lower in those teams that have a focus on getting adequate hours of sleep and then also screen for it. So it's interesting. Go into the literature and take a look yourself and Google Scholar and you'll find some really cool things, especially in your athlete population of your patients that might resonate with them and help them achieve their goals. So interesting. When you build a sleep practice, people don't come in and say, hey, I'VE got a small airway and I just need you to help me. It's usually I snore, my wife's kicked me out of bed or I can't, I don't have enough energy to go to work and pursue my dreams and things like that. And when you're armed with the knowledge of, hey, you know what, the body repairs itself during sleep. And so every activity, every facet of your life can be enhanced and improved if you just optimize your sleep quality and quantity. So it is fun to think about the power we possess as oral health professionals to improve the lives of mankind. And it is interesting, Corbin, that you bring up those stories about providers integrating and then finding out that people don't make up come to their appointments. That happened this week with me. This guy was supposed to come in today to get his oral device and it turns out 40, 43 year old truck driver Mel has a heart attack and is in the hospital and couldn't come to his appointment. So he's conscious, he's, you know, he's able to come later, but boy is he motivated more than ever to get a delivery on this. He definitely is. So. And then, and then I'll never Forget a lady, 51 year old man who, who his wife physician made an appointment for him at my office for Tuesday morning at 9:00am Tuesday morning comes, he's not there, we call 9:05, she's on the phone sobbing and she literally said my husband passed away in the middle of the night and it won't be a disappointment. And of course I got on the phone later and talked with her and what do you say? It's just like you're, you're a physician, you know, why didn't you ever screen out for whatever? I didn't say that obviously, but I just was thinking, oh, how sad. 51 is so young. You know, now that I'm there, it's so young, so young, so young. But anyway, I just, I'm excited for everybody on the call and hopefully there's something that may resonate with you. My doctor, my doctor friend, Dr. Shukarat should be coming on. He said he was running late with patients, but hopefully he'll be jumping on here soon and I'd like to just share my brief story and then I guess. Do you want me to answer questions kind of after that?

Yeah, until, until you, you know, talk to us a little bit. Because you know, there's, there's a lot, a lot of different people on the phone right now. Some of them are just dabbling in sleep. Some of them are doing traditional sleep. And you know, all of them I think can benefit by, you know, hearing how you really pioneered the sleep and TMD practice that you've got today. And you know, how you were able to connect with a doctor like Dr. Sugarat and some of the other occupational therapists and chiropractors and other healthcare practitioners in the community that are constantly referring to you.

Okay, okay, gotcha.

Alright.

So for those of you who are dabbling in it, I dabbled in it early on and I found that there's so many risk factors, oral conditions that were, you know, the crown that broke being on the implant because they're bruxing. And I made a beautiful crown. We use the best materials that still break or the filling developed micro leakage or gosh. What was my favorites were dentures that wouldn't fit on the implant abutments or things would just break down. And I'm scratching my head thinking what is going on in this person's body that creates such forces to break? My great dental work. And as you look in the literature, sure enough, bruxism is forces measured up to 3 to 400 pounds per square inch. So that led me on the journey from connecting oral breakdown to conditions related to airway that trigger the reflex to clench and grind the teeth through the night. Why is the body doing that? Well, it's trying to maintain an airway and trying to keep a person alive. And so that led me into, well, if they're bruxing all night long, then the trauma, micro trauma of that excessive movement disorder then is producing TMJ problems. So they have tendonitis, they have clicking, popping, they have migraines, they have oral facial pain. And it literally took me through this journey where, wow, if I start screening for sleep disorders in my patient population and treat those issues to the root cause, then I can help my patients save money and prevent their suffering. And then they can save their money and do maybe cosmetic work or do other cool things with their life that they would want to do. So so I practiced for about 12 years before I decided I didn't have any mentors at the time. And I thought I need to do this independent of my general practice. So I sold my practice to my younger brother who is a dentist. He used to be my custodian and we had practiced for five years together. He bought it and then it was about 2010 that I broke off and, and started a full time TMJ practice treating sleep and craniofacial pain. And the interesting thing about that experience was, yes, I did simplify and yes, I was doing great work. I felt by giving everybody mandibular advancement devices or combination therapy with CPAP and oral devices, and working with an ear, nose, throat specialist, allergy specialist, anyone else I needed to, to get the upper airway functioning. But I found after a few years of those patients wearing those oral devices, they were coming back and they had skeletal changes and oral and dental changes in the form of posterior open bites. And I was also finding that when we would do another baseline sleep test on those individuals that had the mandibular advancement devices or, you know, CPAP in combination with it or alone, that their apnea was actually getting worse because nothing was being done really to target the obstructive anatomy. And, and so I, you know, what, what are my options? Well, I got into expansion appliances, ALFs and fixed appliances. And I was just looking around anything I could find to grow the airway. It turns out that went to Dr. Singh seminar and he started talking about biomimetic appliance therapy, saying that we could stimulate stem cells and grow bone, call it maxillary morphogenesis. That intrigued me and he had science to support it. And I thought, well, I need to look into this because I need another tool in my toolbox. As it turns out, the research does support the fact that when we put oral devices in somebody's mouth and they wear it long term, their apnea actually gets worse. In one particular study of a sample of 15 individuals, their AHI went from 17 to 31 over, I think as a 10 year period or so. You can look it up on Google Scholar, it's in there. But I mean, that's great. You're saving life, but at the expense of, you know, all these oral skeletal changes and the dependence on it. You doing okay, Corbin?

Doing great.

All right, good.

All right. So.

So anyway, as I was working through the traditional methods of treating sleep and then being exposed to this biomimetic appliance therapy, I really obviously got into it more and more and thought, you know, this is, this is cool. The MRNA device is an FDA cleared device to treat sleep apnea because it has fins on it and that supports the mandible to open the airway. And then it has the components of the expansion screws and 3D springs and other things that Dr. Singh has information on that he has grown airways with and so have a lot of other doctors. And at that point there definitely weren't as many doctors doing it, but there were Enough that they had had over a couple thousand cases completed. And I thought, you know, I could wait around for double blind randomized studies to check the validity of this type of treatment, or I could jump in and start saving lives right now, you know, and getting people targeting their tissue just because it made sense. Almost everybody had hypoplastic maxillas. They couldn't breathe because the maxilla is so small. The nasal passages were so narrow and so retro. That would just make sense if I could correct those with a device that is a mandibular advancement device plus an expansion device jumped in, been doing that ever since. And I love the fact that I can offer that to people now. I couldn't be successful treating these patients without my team like Dr. Shukarat. Hopefully he'll be on soon because ultimately he's the one that diagnoses it, kind of manages it along with the primary care physician. And what I do is I use the Vivoscore, which is an awesome system, like Corbin said, where you can do multiple nights. And it's so nice to get an average night because, you know, maybe one night's really bad and maybe another night's good. And you get the average and you get closer to the truth, the true sleep of that person, the more samples you get, just like you do in research. And then Vivos hires a physician to review it and score it. And then because the information is so unique with sleep image and that it produces more than just ahi, it actually produces information that tells us if there's possibility of central sleep apnea. There's a category called periodicity. Then there's another one that talks about how often a person experiences bradycardia and tachycardia. You know, the gas and the brake pedal are on all the time, just like in Corbin's life. I think he's working out, he's doing great, but then he goes to sleep that night and his heart stress is incredible. It's incredible during the day because he's working out, but his heart never gets a break and so inflammation increases. And it just makes sense in my mind that a person with sleep apnea then would be at a higher risk for having stroke or heart attack. And sure enough, if you go online and look at the Wisconsin study, it's an 18 year study where they followed people with sleep apnea and they found, and they tell you in their conclusions in the abstract that you have a 5.2 times higher risk for all cause mortality, which means 5.2 times higher risk of dying sooner than the average population. If you have an untreated obstructive sleep apnea, of course, that's an article that I printed out and for years I would give it to patients in my office. Here's an article, just read this, highlighted. And they would take it and take things more seriously. That team was important. Dr. Sukharat, I'll get with him. If my study comes back and there are things like lots of bradycardia, tachycardia measurements on the sleep report, then I'm thinking this person probably has upper airway resistance syndrome, which is a condition that's a mild variant of obstructive sleep apnea. When it comes to feeling unrefreshed, feeling fatigued or having chronic pain, it's not so much how often you stop breathing that causes those conditions, it's how often your brain activity is altered or fragmented out of the normal sleep architecture that it should have. Just in general, if you had a pie and you divided it in half, half of that pie should be light wave sleep, lightened sleep, stage one and two non rem. Then quarter of it should be approximately REM sleep and the other quarter should be deep delta wave sleep. If your nervous system is being triggered frequently through the night, it may not be due to breathing issues. It could be due to the fact that you ate a cheeseburger that night and you've been doing that for the last 12 nights. You've got all this inflammation in your digestive tract or you've got a rotator cuff injury that every time you roll over on it, it sends a jolt of pain up to your brain and puts you into the lighter stage of sleep or any other things. It can be medications, notoriously anti anxiety, antidepressant medications have side effects to affect REM and non REM cycles, especially stage three non rem, delta wave sleep. So I know there's a lot of science, I won't get into a lot of that, but it's just, it's so important to when you're doing sleep, when you're getting into it. Yes, it's wonderful that as you progress, produce this benefit for the patient that they can enjoy complete health at a higher level. But it's also important to start thinking like a physician where you're thinking about the person's whole body and the impact of that upper airway dysfunction is on their overall health. The other team member that I have that's a must have is the ear, nose and throat specialist. And for me, I'm probably referring to, to this person at least two or Three. Every day I do a full time practice in sleep and craniofacial pain. It's all I do. And so I'm seeing maybe 20 to 30 patients. And by the way, my stress levels in this type of practice is about a 4 out of 10 compared to what it was as a general dentist. 8, 9 out of 10. You know, every day it seemed like because you're just running roller skates, got a bleeding root canal, you got to run in and do an exam and oh, dang, got to get back because there's a screaming kid. And anyway, it's just I really have enjoyed my practice. I feel like I could practice in my 80s easily, you know, by doing this. I really don't have to have. Perfectly steady. They're still steady. I just want you to know, guys, they're still. I could jump back. But anyway, I just want you to be impressed upon the idea that you're not an island unto yourself. You develop a team that is similarly interested in saving lives by opening airways and make sure your sleep physician and your ENT are involved. Both of them. The ENT has come to my office and that to me was incredibly.

I.

Guess, good in terms of his commitment. And ever since then, 10 years later, we've been working together. We've got hundreds and hundreds of patients that we've really helped and I'm sure we've saved a lot of lives in the process. An allergy specialist is an important one. Even a chiropractor who is able to work the upper cervical area is an important one as well. For example, my daughter has a pretty significant hyperlordosis, pretty good curvature. That curvature causes a constriction in her upper airway. So part of her treatment is chiropractic care. In addition to this expansionary morphogenesis activity where she's using an mRNA, she used to have significant severe eczema and respiratory disturbances. She was sent to the ER three times in one year as a little girl. And I'll just tell you now she is a totally different person and enjoying the benefits of good airway, which. Oh, go ahead. Were you going to say something?

Yeah, I was just going to say that, you know, I think every, you know, all of the, all of the dentists on the call and all of them that I talk to have or are receiving a tremendous amount of pushback from the medical community. And we have a couple of things that we're doing at the Complete Health Airway Group that will completely break down those barriers, but nothing will break down that barrier more than having them come to the office and having them and their family members worked up for free, because if they can get in and they can recognize that their wife had no idea that she had issues. And like my wife, who doesn't have sleep apnea, doesn't have an ahi, but has upper airway resistance syndrome and it has deeply fragmented sleep, still has the need for our treatment. And so getting them committed to coming in and doing a workup, even though you're absolutely certain that they don't have any reason to do it, you just want them to experience it, they will be just like me. Like, I was fully in denial. There's no way I've got sleep apnea. Sleep apnea is for fat old people. And I'm getting ready to do a triathlon. I'm good, but I'm gonna take the test just so I can feel what the patients feel and then uncover this, you know, life threatening, you know, situation. And so that, to me, is the way to get the walls completely broken down.

That's perfect. That's great. Especially if you can create a presentation like the Airway Intelligence PowerPoint. I love how Vivos has created that because it's a great analysis of where the problem is, you know, how far off it is. Hey, I just got a text from Dr. Shukrot and he said he didn't get the link, so I just sent it to him.

Send it to him right now again.

Okay. It's T A L A A T10mail.com. Okay.

You know, it's interesting that you said earlier that you've treated patients with a mandibular advancement appliance and realize that their sleep apnea got worse. You know, I've been in a mandibular advancement appliance for almost two years now for my sleep apnea. I'm like moderate, close to severe. And I realized that there are some nights that I feel like, oh, my gosh, I felt like I slept worse. And so saying. And certainly I'm gonna be, you know, doing the Vivos appliance for myself. But it's interesting that you said that. And I don't know, I know you kind of talked about. Talked about it a little bit, but, you know, in the event of. I know you probably don't have much time here before he comes on the call, but did you find. Are you finding that happen more and more when you see someone come in with that type of appliance and then realize that their sleep apnea has gotten worse?

Yeah, it's pretty frequent and when I say it's gotten worse, it. When I took the device out and had them do a baseline test, they were measuring worse than they were back five years ago when they got their original one. But nobody had done a titration test, which is they wear the device and you do a sleep test, and then you know whether or not you need to adjust and oh yeah, that's rampant. If you want a pandemic, there's a pandemic right there of unadjusted, untested oral appliances for sure. But I just want to be clear too, that it's a tool in my toolbox. I still do. I'd say 10, 15% mandibular advancement devices in my practice, because some people just can't wear their device 14 hours every day. And we'll just have a temporary plan. Our temporary plan is to put you in this mandibular advancement device for now, and then when your life changes so that you can wear a device longer to change the anatomy, then we'll transition to that. If it's two years, five years, 10 years down the road, we'll be here and you can come back and get that done. And people love that, that they can have that option later as well. But so often I'll just say, since the maxilla is such the offending problem in upper airway issues, that means the nose is the other offending problem because it's so small and so frequently. I would say 70% of my OSA patients have to have some sort of nose evaluation by the ENT to take a look at that. In addition to the soft palate and uvula. The soft palate and uvula. I use the fotana light walker laser to tighten up and kind of shrink that area back there. That's been a nice little adjunct. So when I started, it was just throw a mandibular advancement device in it, everybody, and, you know, hope for the best kind of thing. But. But now it's. There's always. There's something you can do for each area of anatomical obstruction, which is awesome.

I just noticed that Dr. Shucharat is on and live. Dr. Shukarat, welcome. We've already done a pretty pretty in depth introduction to you and your relationship with Dr. Bennett. We so greatly appreciate you taking some time. Of course, my pleasure to jump on. Why don't you just take a few minutes, Dr. Shukarat, and talk about your experience in working with Mike and how you guys collaborate and, you know, and one of the things that we're trying to really encourage the dentists to do is obviously develop their network. So Maybe from an MD's perspective, talk about how, you know, how they could potentially approach, you know, some sleep physicians and other physicians in their community with success.

Well, first of all, I'm glad to kind of join you guys and I understand from Dr. Bennett there's like 84, you know, dentists out there that actually listening to this. So, you know, I think, you know, when it comes for osa. Can you guys hear me?

Yep.

Okay, perfect. So essentially when it comes for obstructive sleep apnea management, I think it's very important to have actually a dental extension to the practice because there's quite a few patients who actually would benefit from evaluation for oral appliances. So first of all, I think from a sleep medicine standpoint, mild to moderate obstructive sleep apnea can very well be managed with an oral appliance. And so patients who have retrognathia or, you know, especially if they have, you know, supine dependent obstructive sleep apnea, these patients are very good candidates for amandibular advancement device. I often, you know, kind of like if I have somebody with retrognathia, we bring that up, you know, right from the beginning that this is a potential, you know, modality for treatments. And there are times when patients do actually have severe obstructive sleep apnea. And then we use a hybrid model where we actually combine CPAP and an oral appliance. So, you know, Dr. Beth and I do have a few patients that we actually co manage. You know, it's either somebody who actually he's started with a mandibular advancement device and their sleep apnea is not fully controlled, so we actually add cpap or someone who actually have sleep apnea and they've been on CPAP therapy but they could not really target the cpap and we end up exploring other options for it. I think, to me, I think what we really like to see as sleep doctors, we like to see kind of the follow up from the dentist. I think one of the things that I do, there's quite a few dentists in the community who do these devices. Some of them I honestly don't know very well. I know Dr. Bennett, so I don't even know if they're really trained in doing that. And one thing that we notice is that, and I have a very busy sleep practice is that we don't really see the follow up. I think a lot of the time we see that patients do get the device and we don't really feel that there is support afterwards, further adjustments, making sure that we actually evaluate for making sure that this is fitting well, that we're evaluating the patient clinically. Or they may stop following. Even with CPAP therapy, patients do sometimes struggle with follow ups. Their sleepiness may persist. There could be some other sleep disorders that could be associated with this. So someone who may come to you with obstructive sleep apnea. Typical obstructive sleep apnea, he's a mandibular adjustment device, but he's not sleeping well. Making sure that actually we're doing ess. Maybe this patient has narcolepsy too. And so that could be an issue. I think one thing that I actually see as well is that it's very important for dentists to realize that obstructive sleep apnea is one disorder, when on the other hand, patients can have other sleep disorders like other sleep related breathing disorders. So for example, central sleep apnea is another modality there or another entity that sometimes can be easily missed. And I know that most of the time it's a home sleep test that actually is done, but that's not really what we recommend or what the guidelines recommend for someone you suspect for central sleep apnea. So if you have a patient who comes in with osa, but they're using chronic narcotics, keep that in mind that this patient shouldn't really have a home sleep test. They actually should have a psg because home sleep testing is not indicated for those. And I can go over home sleep testing indications here in a second if you guys like. But those patients may have two components. And so the Mandiba advancement device or the Mandiba oral appliance will really help with the obstructive components. But we need to kind of pay attention to the central component too. And the problem with central sleep apnea is that although OSA is one entity, central sleep apnea is different diseases like different problems and there's different kinds and they're managed differently as well. I think follow up, I think we would love to see the follow up. We would love to see the collaboration in terms of following with the patients, not just making the device, and then be on their own. And then sometimes we struggle with what else can be done in terms of fitting the device and so on. I think there's definitely a role for the appliances. There are patients who just, no matter what you do, they struggle with the cpap. I think the compliance report, I mean, what you may read is that there's 60% or 70% of patients only who comply with CPAP. I tend to disagree with that. I think in my practice about like 85, 90% do well with CPAP, but there's still significant number of patients who just don't do well with CPAP therapy, no matter what we actually try. Do you guys have any questions that I can actually help you with from an MD standpoint?

Yes, I have a question. My name is Jason Lewis. I'm one of the, the co founders of this group. And one thing that I've struggled with over the years in treating obstructive sleep apnea is communication with the physician and the sleep physician. What is a. And kind of where I'm going with this is what would you like to see from a dentist who is treating a patient with oral appliance therapy? How often would you like to see like a letter, you know, from the, from the dentist, you know, like every time they come in for a follow up or maybe like every six weeks. Do you want us to do the titration study? Should the dentist do the titration study or the epic. Epic C study, sorry, the follow up study to see like what, what do you recommend for that?

So I, I think it's a great question. I think, you know, the problem is that with, you know, how you guys do your notes and I mean, do you guys do EMRs? Is that what you guys have like in your offices? Like do you have a specific EMR like that you guys use or what kind of software you guys use or you know, to kind of document?

We do have, some dentists do have software that will take a dental note and convert it, convert it to like a SOAP format. So is that what you mean?

Yeah, that's what I meant. So, so same thing. Likewise for us. So pretty much now I, I don't know of any doctor now who doesn't have an EMR because you know, we're just obliged to use those. And that's how it is. Now the problem is that even among doctors themselves, like if I'm in a certain practice, like let's say if I have a patient at the University of Utah who's actually, you know, the other big or the main academic center in Utah, a lot of the time if, you know, I would not really get their notes, you know, on a timely fashion because I have the different EMR than their emr, so they, they send, they tend to send letters and we scan them. So that would take some time. But I'd have to say it's still not perfect. I, yet kind of, I don't think I've ever actually had a letter from a dentist before. Dr. Ben is great because he would call, he would text, or he would communicate by email because, you know, we share patients together. But the other dentist, I don't really. I don't really get to hear from them. One thing that I do sometimes when I have a patient who comes to see me and I know he sees, let's say, a rheumatologist that's not part of our group, is that if I had my notes ready or I probably would specifically make sure that I finish the note, I give the patient a copy of the note and I give it to the patient to give it to the rheumatologist to kind of tell them what's really happening. So if you give that to the patient, that'd be very helpful. I think it would be very good that we continue that level of communication. So faxing would be great, you know, and then at the same time, I think at minimum, giving the patient like a copy of the note if it's available, that'd be very helpful. I think we probably would rather do the titration. Like I format myself. What I usually do. I don't always titrate right from the beginning. So if you've done. If I sent a patient and the patient has an oral appliance and they're coming back for follow up, I actually start with an overnight oximetry. If the overnight oximetry looks really good, then maybe at that time I probably may not need to do anything. If it looks suspicious, then I may actually do maybe a study to make sure that this is fine. If it looks really bad, then I know I don't need to do anything. I think this needs to be adjusted because there's obviously significant descents. And when I look at the overnight oximetry, I look at the graph itself. I don't look at the numbers. So if you see this. Oscillatory desaturations, I call those. Let me actually show you this. I'm actually right now in my office. I don't kind of turn the camera. Actually, this. Let me see how I'm going to actually turn. Yes. Where's the camera?

Here.

So do you guys see this here?

Yeah.

Yeah. So I actually have. These are two subjects in my practice, and I have those in all the rooms in two locations to kind of educate patients on what an overnight oximetry does. So if you look at this, this is like perfectly fine. And I don't really see any kind of desaturations here you see the heart rate is following that. But if you look at someone like this, you'll see we call these oscillatory desaturations. Sometimes you may read the term sawtooth desaturation in some textbooks, but when you see this, this is very classic for obstructive sleep apnea. And often what you would see, you will see clusters of those happening as the night goes by because you will tend to see more REM cycles toward the second half of the night if you see the same thing, but the amplitude is really small and, and the DSAs in the mid to high 80s. This is when you start thinking of central sleep apnea. So central sleep apnea will cause something similar, but they're a lot more frequent and they will be actually in a lot less desaturation. Typically, patients sensory sleep apnea, they don't desaturate as much as they would do in osa. And so if I see this in someone who already had an appliance, I know this is not really working likely. So, so this is kind of one way that I would do it. And if that's the case, then maybe we should adjust it first and take it from there. Then eventually, if patient's not doing well and we know we've kind of maxed it out, there isn't much to do, then maybe at that time we'll decide on a CPAP titration. But again, the desaturation is only one aspect. But running an ESS and asking about symptoms and making sure patient is clinically improving is very important.

Could you explain for everybody what ESS means?

So ESS is actually, it's upward sleeping scale. Let me show it to you. So I don't know if you guys see this here. So this is, I have this on clipboard. So every patient who comes in, I actually, we have them fill one of those. I typically have it filled for all patients with, you know, new patients. And every patient who comes in for a follow up, we fill those. Do you guys do those? Do you do this sleeping scale?

Yes, yes. And that's a great one. Because of follow up visits, I like to have them fill it out again so that we can get some subjective data on how well they're doing, they're progressing, you know, so and so the.

Questions are, I mean like you're asking about, you know, so basically you give the patient, you ask him about, you ask patients on eight activities and you want to know in a scale from 0 to 3, what's the chance they doze off normal is less than 9. But some of the questions will always be positive. Like, for example, sitting. If you lay down less in the afternoon, if circumstances permit, all of us will get probably three. That's still normal. But somebody asked, sitting and talking quietly to someone, no one should actually answer, even a one there. That actually does have a more clinical significance. Same thing like in a car while stopped for females in traffic, but eventually they fill this, and then that should be how they feel over the last couple of weeks. And so it would be good to actually know what their score is. Historically, though, if you look at patients with sleep apnea, and if you look at the graphs that plot what the ESS is for different sleep disorders, you'll find that patients with obstructive sleep apnea, they will probably be in the range of 10 to 16 or so. They will be on the lower end of the range. If you look at patients with narcolepsy, you'll see the 16 and plus. So if somebody comes in and they're like 20 on their sleeping scale, that's actually usually a trick. I mean, you'd have to think of some other things too. I mean, there could be maybe narcolepsy in this patient, or there could be a medication induced hypersomnus. So it's kind of like one of the. Probably the best objective way of assessing sleepiness, because one thing that we struggle with sometimes is fatigue. Like, you know, sometimes patients can't tell the difference between fatigue and sleepiness. So are you actually sleepy or you're fatigued? So one way I. One trick that I usually say is, okay, well, do you feel that you need to lay down to rest, or do you think you want to lay down to sleep? You know, and, and because if you're fatigued and tired, you know, a lot of the time you lay down and you end up sleeping. And so I've had patients who come to see me because they're sleepy. And we do everything, including mslt, and we actually, at the end, we find that they're actually fatigued, they're not actually sleepy. They have a fatigue syndrome like fibromyalgia or chronic fatigue syndrome or adrenal insufficiency. Something in that regard. Yeah.

So a pearl, Dr. Shukra. Thank you. What you're teaching us. So one of the pearls that I'm pulling out of this is, number one, you want dentists to communicate with you when they see your patient. Let's say you have a mild to moderate. They don't want cpap. You refer them to the dentist, if you get back a report that says, hey, I saw your patient, this is what we're doing for them, this is where we're going to start and what we plan to do to follow up and send you a report, what is the likelihood of you sending another referral to that dentist who does that type of communication?

I think it's very, very high. I mean, honestly, I'll have to tell you, I really think that dentists should be an extension of the clinic. It's part of lucky, the way you kind of use ENT for dental evaluation. We'd like to see that. I think if we feel that you guys are managing the whole thing from A to Z, it's a problem because we really think that those patients are not fully, comprehensively managed from a sleep medicine standpoint. And so we would like you to be part of the practice, and we will kind of continue to support you that way. But if we feel that the patient is going and we're not seeing the patient back or, you know, we're not really seeing other elements in the evaluation, we don't like that. I think most sleep doctors don't really like it that way. I think, on the other hand, I think, you know, it should be. It's bad on the sleep doctor's side standpoint, though, that, you know, you know, that we want to give cpap. The truth is, I mean, all appliances do work for patients. I mean, they really do. And now what I see is that there's quite a few doctors, dentists, who do that. But I think the process is very different. I mean, some people are really. Some dentists are really, you know, educated on sleep disorders, and they're certified and they understand what this could actually involve. A lot of the time it just taking an impression and making an appliance and then sending the patients out. But we really don't know what else is going on. I do see patients who had an appliance. They paid $2,000, $3,000 for it, and they're not using it. So it's really tough. And that makes referring back for an appliance is really difficult.

Yeah, yeah, that's great. And just so everybody knows, my protocol is when I have a patient that comes in, let's say they're referred by Dr. Shukrona. I'll do my workup and identify is it just the oropharyngeal airway, or is there a nasopharyngeal component to that, and then we'll work up potential referrals to the ent I'll plan a three month period where I'm following up after the delivery of the device to make sure the patient's wearing it. And then I'll do a screening sleep test to make sure that their numbers are improving. And usually it's one or two. And then we know whether or not we need to change the bands and adjust the device to obtain maximum medical improvement. And then usually at the end of the three months, it's okay, patient, now that I've done everything to titrate your device and your nose is clear, you're eating low inflammatory foods, metabolic inflammation is dropping, then it's time to get a final PSG with Dr. Shukrot or a pulse ox, because he ultimately is managing your case. I'm like a pharmacist filling a prescription, you know, for, for Dr. Shukarat. And then that's a nice situation where we're kind of working together, you know, to make sure the patient's completely managed well.

So, Mike, we've got about. We've got about 10 minutes left. Okay, let's see if we've got any questions for you and Dr. Shukrot from the audience.

All right, cool.

And Jason, can you facilitate those questions?

Yes. I have a question too, if no one else does.

Shoot.

So what do you recommend? Dentists? If a patient comes in and they suspect obstructive sleep apnea, what do you recommend? And they've never been to a sleep physician before, what do you recommend that the dentist does? Do you recommend if they have the ability to do a home sleep study, do you recommend they do that first and see where they are? And then if they're severe, then they contact the or if they're mild or moderate, or should they go ahead and connect with the sleep physician and share the study with them, regardless of how severe it is? Like what, what do you recommend?

So. Good question. I think. So, first of all, I think this question is the same question, like, what are the indications for a home sleep test and what's. When do I do a home sleep test compared to a psg? So I think so it's really simple. You and I do that too. I do a home sleep test on a patient that pretty much I know 100% that he's going to have OSA. So this patient typically would be a younger patient, patient who doesn't have a lot of comorbidities, maybe hypertension, has significant daytime sleepiness, crowded or pharynx or craniofacial abnormalities that puts him at risk or her at Risk for sleep apnea. I know that they have sleep, I know that, that they actually have sleep apnea. This patient should not have cardiopulmonary disease, should not have any suspicion for central sleep apnea. So that's not a patient that should he is on chronic narcotics or she is on chronic narcotics or somebody who may have chain strokes breathing because they have CHF or cardiac disease. That patient is absolutely the best candidate for a home sleep test because you just need to kind of diagnose that. And if you do and you know, you find that they have obstructive sleep apnea, then I think you can definitely talk to them about oral appliances the way we do. And if you're, you know, planning on following them with an ESS and all of that, that's great. If you feel that you diagnose them, you start the treatment. But they need to follow up. I'm sure any sleep specialist would be happy to see him. I'd be happy to see them for sure. And I don't mind that you started the diagnosis, you started the treatments and you want us to follow up with that. Now I think if the one thing that you need to know as well is that home sleep testing tends to underestimate the severity of obstructive sleep apnea. And the reason is when we score hypopneas, we, we actually use both flow criteria, but on the PSG we actually use arousal criteria too. So when we have the eeg, we would capture more of those hypotenuse based on the arousal as well. So we would have the 10 seconds or longer of decrease in flow and then an arousal. That's that. And if they did not desat, I'm still fine with that. So I can either use the desaturation criteria or I can use the arousal criteria. And that's pretty much a 3 second increase or change in EEG activity. So you may actually have somebody who's more severe than you think. But at the same time, the home sleep test did not show that. But again, if they have really classic sleep apnea, hypersomnolence, obesity and all of that, that's your typical obstacle, sleep apnea. I think that should be fine. I think that would be great actually. You guys do that, don't please do a home sleep test on any of the other ones that I mentioned could have some other problems. So don't do it on somebody who has COPD or who uses oxygen at home or who's in chronic narcotics because those patients are prone for central sleep apnea. And home sleep testing is not indicated for those. And if your suspicion is not very high, that's not an exclusive test. So I don't do home sleep testing for patients that I'm not really sure if they're really sleep apnea or not. Somebody who comes in and their BMI is normal, but at the same time, or maybe slightly overweight and they're slightly sleepy, but at the same time I'm not really sure. I did an overnight oximetry and it's not like classic, like I showed you. So if you're really sure, then home sleep testing is the best or that's kind of definitely the indication if it is. If you're suspicious and not sure PSG is the way to go, or you can do home sleep testing, understanding that's not actually a conclusive test. So home sleep testing is not conclusive by any means. And, and then if the level, if it's severe obstructive sleep apnea and then at that time, you know, definitely our appliance is not really my first choice there. But if patients want to try it and you want to start that and then with the plan you're going to follow up with, you know, with the sleep clinic and you know, making sure that there is no other concomitant, you know, concomitant kind of like illnesses, sleep rates, problems, I think that's absolutely fine. That's absolutely fine. You know, there are patients who actually, you know, you can start that and there are primary care doctors who actually do home sleep testing. They diagnose the sleep apnea and they put patients on self adjusting cpap and that's another way to do it. And the indications for apap, which I do as well, without having to go back to the sleep app or even going to the sleep lab, is pretty much that those patients who have typical obstructive sleep apnea and they don't really have any possibility for a central component, they don't have chf, they have good seal, then you can actually consider apap. And then as long as you follow the compliance and then at that time you're going to move on to, you know, how you manage. So I don't know if you guys ever kind of continue to manage and do other, other modalities of treatment. But, but you know, I don't really know. I mean, does, does any, do any dentists do that? I mean, do you guys kind of do full, full range of treatment? Like you know, maybe an appliance, maybe an APAP? Does anybody do I mean, I know Dr. Bennett sends patients over often. Like, he feels that there are appliances, like, I've seen referrals from him that are really appropriate, that, you know, they were central components. So he sent them over or their own appliance, and he feels that they need a cpap. So he does he. And we are happy to see those. But if you were ever to do CPAP on your own, just keep in mind that APAP is a possibility as long as you kind of do a compliance report and download the data and know what to look for on the compliance report.

Typically, the dentists aren't doing any Pap therapy, but in my office, I often have patients bring their masks and we'll put it on. Because the oral appliance can alter the shape of the lips, sometimes the mask needs to be altered. That Dreamwear mask by Respironics has been a really good one for those craniofacial pain patients. And one other point you made was about the arousals that you like to measure with psg. I love that, because in the chronic pain practice, like I'm in, those patients that have lots of arousals or a high arousal index, they tend. Even if their breathing is okay, you know, they're being aroused. And it could be various reasons, not just respiratory arousals. And that's a good indicator to know what we need to do to kind of get their sleep into this more restorative mode, and that becomes our indicator to watch for.

Yeah. You know, Dr. Ben, we used to actually have AHI, and we used to have something called, you know, respiratory disturbance index. So it used to be at the previous, you know, kind of manuals for staging sleep, we used to kind of diagnose the hypopneas, just basically on the flow requirement and the desaturation requirements. And then sometimes I just see patients with snoring, and then they have a high arousal index, like you said. And we call this upper airway resistance syndrome. And if there, you know, arousal index more than five, then that's. That's that. But now with the new staging, we kind of lumped it together. So when you see it, when you see a total ahi, then that's actually. That's actually a combination of both. And, you know, talking about this, remember to. With the home sleep testing, we don't really call that an HI anymore. We call this respiratory event index. And the reason is an rei. And the reason is, you know, we don't really know if those patients are sleeping or not. So what we do basically is that you ask them, you can just ask them how many hours they slept and then when they actually. So I actually have all my home sleep testing scored by an rspgt and at the same time, we use the total sleep time report by the patient to actually measure the index. And the index is actually a respiratory event index, rei. And that's. And we deal with it the same way like we did with an AHI. If it's more than 5, it's positive. It's less than 5, it is negative. So that is actually the accurate now terminology for the ASHI on a home sleep test or an out of center sleep testing.

I'm sorry, I want to direct you to another question in the chat before we run out of time. It looks like if a patient has central sleep apnea and also mid face under development, wouldn't it be a good idea to also wear epigenic appliances to develop better anatomy?

Oh, yeah. I mean, so they have both combined obstructive and central sleep apnea.

Yeah, I'm pretty sure that's what she means.

Yeah, yeah, yeah. Oh, of course. Yes, of course. Yeah. I mean, so. And central sleep apnea, we don't necessarily always do. So there's actually, it's kind of interesting. So central sleep apnea, there's different forms of central sleep apnea. There's obviously idiopathic central sleep apnea, which is rare, and then there's central sleep apnea that's related to high altitude where they live, or sometimes central sleep apnea related to chain stalks breathing. So we categorize them into different categories. But if they have, I would. In that patient, I probably first treat the obstructive component before I treat the central sleep apnea and then evaluate the patient afterwards.

That's great.

Awesome. Michelle, can you, can you close us out? And Dr. Sukharat, I'm so grateful for your time and this has been fantastic. I want to let everybody know that they're going to put my contact information in. If you want to get more information on how to work with us or how we can help you with your, with your sleep practice and get this integrated. So, Michelle, close us out.

All right. I just want to thank everybody for coming and I really appreciate you, Dr. Shakarat, for taking the time out. I know you, you're super busy. And thank you too, Dr. Bennett, for everything that you do for all of us. It is so awesome to watch you guys cooperate together and it's great that you know that we all understand that we're not an island. I also want to thank some of my other health and wellness people that joined us tonight and all the other dentists on this call. I want to let you know that we're having another study club meeting. It's going to be on Wednesday, August 18th at 7. We will be having a panel discussion that will be even bigger than this one. So we're going to have some nutrition people on there ents Maryland that we work with here in the Jacksonville area. And we're going to talk about well Dr. Bennett referred to it a little bit anti inflammatory foods and how to facilitate getting your patients to to lose some weight, eat better, get their upper airway open and so I'm really looking forward to that. So we'll see all of you for that. If you're on this call, you're going to get the recording to this and the invitation to the next meeting. So thank you so much. Appreciate all your time. Make sure that you reach out to Dr. Bennett and to Corbin for more information. We'll see you in August. Thank you so much. Bye. Thank you.