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A View From 10,000 Feet: Understanding Sleep Apnea in Orthodontics · Hey Docs!

0:04
Speaker 1: Welcome to the Haydocks Podcast with your host Jill Allen.
0:07
Speaker 1: I am excited to have doctor David McCarty from Empowered
0:11
Speaker 1: sleep Apnea joining me today. David McCarty will be discussing
0:15
Speaker 1: the connection between sleep apnea and ORTHODONICX, the red flags
0:20
Speaker 1: orthodontis should be looking out for in their exam, and
0:23
Speaker 1: innovative tools for diagnosing and managing sleep apnea in your practice.
0:29
Speaker 1: There's a lot to cover, so let's get into it,
0:34
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1:14
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1:16
Speaker 1: That's contact kl dot com. All right, Dave, I am
1:23
Speaker 1: so excited to have you on Haydocks today.
1:27
Speaker 2: Thanks for being here.
1:28
Speaker 3: It's a delight. Thank you so much, Jill for having me.
1:31
Speaker 2: Yes, yes, well, I would love it.
1:34
Speaker 1: The way I like to start off Haydocks is to
1:36
Speaker 1: just have my guests tell our audience a little bit
1:39
Speaker 1: about who they are. I'd love for you to talk
1:42
Speaker 1: about your book and your company, Empowered Sleep Apnea, and
1:46
Speaker 1: kind of why you got into this field. I know
1:49
Speaker 1: it's going to be a good listen for sure today.
1:52
Speaker 3: Yeah. Well, it's an interesting story. At least it's interesting
1:55
Speaker 3: to me because it was it was never preordained that
1:57
Speaker 3: this was going to happen. I like to start my
2:00
Speaker 3: life story in medicine by saying I'm a recovering primary
2:03
Speaker 3: care doc, you know, That's what I went to medical
2:06
Speaker 3: school kind of very naive about the medical system. I
2:09
Speaker 3: was the first doc in our family, or our immediate family,
2:12
Speaker 3: so I didn't really know what it was all about.
2:14
Speaker 3: And my heroes were Hawkeye Pierce and Marcus Welby, you know.
2:18
Speaker 3: So I just wanted to go and be someone's doctor,
2:21
Speaker 3: and off I go to medical school in nineteen ninety three.
2:23
Speaker 3: I go to medical school at Duke University, and when
2:26
Speaker 3: I emerged from there, I decided I was going to
2:28
Speaker 3: be just someone's doctor again. So I decided I was
2:31
Speaker 3: going to be a primary care internist, and off I
2:34
Speaker 3: go to mass General Hospital and I learned how to
2:37
Speaker 3: become an internist. And I'm pointing out the years I
2:40
Speaker 3: graduated from residency in two thousand and these years are
2:44
Speaker 3: going to become important as we review kind of where
2:46
Speaker 3: sleep at me I came from, because it's a pretty
2:49
Speaker 3: young disease as far as we understand diseases, and this
2:53
Speaker 3: has to do this explains why it's so hard to
2:56
Speaker 3: get our hands around, because it's a really complex phenomenon
2:58
Speaker 3: as it turns out. But getting back to the story,
3:01
Speaker 3: I emerged as a primary care internist, and I considered myself,
3:06
Speaker 3: you know, the end of the line for these for
3:08
Speaker 3: these people that were coming to see me, you know,
3:09
Speaker 3: I had to help them or provide someone who would.
3:12
Speaker 3: And this was at a time when blood pressure management
3:15
Speaker 3: was getting a lot of attention. You know, we were
3:18
Speaker 3: given guidelines about how it was supposed to be worked
3:21
Speaker 3: up and what we were supposed to do, and what
3:22
Speaker 3: medicines to use and what evidence space there was, and
3:25
Speaker 3: this was through a document called the Joint National Committee
3:29
Speaker 3: for the Management of Hypertension. And it was right when
3:31
Speaker 3: I was starting my career that someone made the observation
3:36
Speaker 3: in this committee that a very common cause of refractory
3:40
Speaker 3: hypertension and that has a definition, requires more than three
3:43
Speaker 3: medicines to keep it under control. Right, But refractory hypertension
3:48
Speaker 3: the most common cause of all is something called obstructive sleep.
3:51
Speaker 3: At me now, my medical schooling nineteen ninety three to
3:54
Speaker 3: nineteen ninety seven, we had one lecture about sleep, as
3:58
Speaker 3: I recall, and Man's greatest hospital right Mass General Hospital
4:02
Speaker 3: in Boston, the seat of medicine here in this country.
4:06
Speaker 3: We had I think a couple of lectures about sleep,
4:10
Speaker 3: and we learned about this esoteric diagnosis called sleep atnu.
4:13
Speaker 3: So this is just speaking to the idea that curriculum
4:16
Speaker 3: in advanced institutions it takes a while for it to evolve,
4:20
Speaker 3: you know. And we'll understand why and where this came
4:22
Speaker 3: from when we go through the story of sleep Amnu.
4:24
Speaker 3: But it was through my sort of recognition that hey,
4:27
Speaker 3: all of these problematic hypertension cases aren't being managed well
4:32
Speaker 3: because they all have a sleep problem. Then I started
4:35
Speaker 3: sending sleep studies and then I started to recognize how
4:38
Speaker 3: many people had this diagnosis. It was through my introduction,
4:42
Speaker 3: through trying to manage other problems. And you know, long
4:45
Speaker 3: story short, I bought a textbook. So I bought Mere
4:49
Speaker 3: Krieger's Principles in Practice of Sleep Medicine, third edition at
4:52
Speaker 3: that point, and I read it cover to cover. And
4:55
Speaker 3: you know, that's something a strange thing to do. A
4:57
Speaker 3: one of my mentors in medical school says, you need
4:59
Speaker 3: a regimended reading program. That's what you need. And so
5:02
Speaker 3: he gave me an assignment and he says, here, here's
5:05
Speaker 3: Harrison's Principles and Practice of Internal Medicine. Read that. And so,
5:09
Speaker 3: as part of my medical school training, I read that
5:12
Speaker 3: book cover to coveries like it doesn't even matter if
5:14
Speaker 3: you remember it. Run your eyes over it because it
5:16
Speaker 3: will leave a mark. And so that's what I did
5:18
Speaker 3: with Kreeger's textbook, and I recognized how enormous this problem was.
5:25
Speaker 3: And I think that's what the legacy of that textbook
5:27
Speaker 3: is is it stitches it all together to make you
5:30
Speaker 3: see how many areas of life this touches. And in
5:33
Speaker 3: that textbook, that in two thousand and whatever. I read
5:37
Speaker 3: the chapter about oral appliance therapy mandibular advancement devices. I
5:41
Speaker 3: read the chapter about the Stanford Approach for surgery for
5:45
Speaker 3: treating sleep appian and at the time, the light bulb
5:48
Speaker 3: went on in my head is holy smokes, this is
5:51
Speaker 3: a complex phenomenon, and holy smokes, I don't feel prepared
5:55
Speaker 3: to deal with this as a primary care doc. So
5:58
Speaker 3: that's when I called doctor Andy Chessen, who happened to
6:01
Speaker 3: be a past president of the American Academy of Sleep
6:04
Speaker 3: Medicine and one of the authors of the first edition
6:07
Speaker 3: of the Scoring Manual that replaced rnk Okay. So this
6:10
Speaker 3: was a luminary in the field. He happened to be
6:12
Speaker 3: there in Shreveport, where I lived, and he ran a
6:14
Speaker 3: very small sleep program there at LSU Shreetport. And so
6:17
Speaker 3: I called him up and I said, listen, I want
6:19
Speaker 3: to learn how to read sleep studies. And he says, well,
6:22
Speaker 3: you know, there's a certification process for this that's kind
6:24
Speaker 3: of in the works, and you know there's going to
6:27
Speaker 3: be you know, a whole board certification process that you
6:30
Speaker 3: can do, but you have to go through training. This
6:32
Speaker 3: was a whole new thing, because this was in two
6:34
Speaker 3: thousand and four, okay, two thousand and five. The first
6:38
Speaker 3: combined board in sleep medicine for medicine didn't happen until seven,
6:42
Speaker 3: so all of this was still in the process of
6:44
Speaker 3: being defined. But what he offered me was a chance
6:47
Speaker 3: to come and basically be a mentee, and it was
6:50
Speaker 3: an apprenticeship style fellowship program. But I followed Andy Chesson
6:54
Speaker 3: around for two years and I closed my primary care
6:57
Speaker 3: practice down to halftime, so basically I stopped making money
7:00
Speaker 3: because he couldn't pay me. And I learned how to
7:03
Speaker 3: read sleep studies, and you know, we read them on
7:05
Speaker 3: those big freaking phone books. At the time, they were
7:08
Speaker 3: just making the transition into the computer record. So I
7:11
Speaker 3: was kind of on the cusp of going from what
7:14
Speaker 3: was a lab rat kind of weird toy to an
7:18
Speaker 3: actual deployable diagnostic device. And I was there at the
7:22
Speaker 3: med school when we were trying to figure out how
7:24
Speaker 3: we're going to teach people how to do this. So
7:27
Speaker 3: at any rate, that's my background. I came into this
7:30
Speaker 3: as you know, I want to be someone's doctor. And
7:33
Speaker 3: what I found was sleep medicine was a rabbit hole
7:37
Speaker 3: and I've heard that from so many different people that
7:40
Speaker 3: have found themselves caught in this race, that once you
7:42
Speaker 3: sort of dip your foot in, it sucks you in
7:45
Speaker 3: with a gravity that's a little bit alarming. And that's
7:48
Speaker 3: how I felt. It was a vertigo feeling of oh
7:50
Speaker 3: my gosh, there was so much in here. And I
7:53
Speaker 3: think it's because it appeals to the generalist in me.
7:55
Speaker 3: You know, there's so much overlap. How do you know
7:59
Speaker 3: if someone come and it says, hey, doc, right, that's
8:02
Speaker 3: the pocket, Hey doc, Yeah, I feel sick, I feel tired,
8:05
Speaker 3: and I'm not sleeping well. And I heard sleep at
8:08
Speaker 3: me is related to orthodontia somehow I read that somewhere.
8:12
Speaker 3: Tell me about that. Yes, it's such a complex question
8:17
Speaker 3: that I think many of us are tempted to sort
8:19
Speaker 3: of step away and say, well, that's you know, that's
8:21
Speaker 3: not my job. I don't know about that. Yeah, And
8:24
Speaker 3: the truth is my truth after having cared for people
8:28
Speaker 3: for a long time with my primary care and mindset
8:31
Speaker 3: and my Marcus well Be ideals, the truth is this
8:36
Speaker 3: complexity needs to be understood by not just the provider,
8:41
Speaker 3: but by the patient because that's the only way we
8:44
Speaker 3: can solve problems, you know, because you know, getting back
8:47
Speaker 3: to our example, Let's say I feel sick and tired
8:51
Speaker 3: and could it be sleep at me? Could it be
8:54
Speaker 3: something to do with my breathing at night? The answer
8:56
Speaker 3: is always well, yes it could, right, But the answer
8:59
Speaker 3: is all ways, could it be something else? Right? And
9:04
Speaker 3: the sensible person will recognize that yes it could be.
9:07
Speaker 3: So what I've seen in a healthcare system that is
9:10
Speaker 3: really battling hard against being more and more fragmented, with
9:14
Speaker 3: more and more specialized thinkers doing what they do within
9:18
Speaker 3: their silo and not really kind of seeing how the
9:21
Speaker 3: person has to navigate. So what I've seen is that
9:24
Speaker 3: this problem is addressed with different language in different spaces.
9:29
Speaker 3: So let me pose a question. And this is rhetorical
9:32
Speaker 3: because of course I'm not expecting an answer, but I
9:34
Speaker 3: kind of want our listeners to think, I ask you
9:38
Speaker 3: what is sleep apnea? Doc? And then just like, don't
9:44
Speaker 3: even bother coming up with words yet? But what picture
9:46
Speaker 3: comes to mind? And the challenge is that if you
9:50
Speaker 3: were to pose this question to healthcare providers of different stripes,
9:55
Speaker 3: you might get different answers. You go to a typical
9:59
Speaker 3: wes in medical pulmonology trained sleep medicine doctor, and you'll
10:04
Speaker 3: probably get an answer something like this, Well, it's about
10:07
Speaker 3: the airways being disproportionately floppy at certain parts with the
10:10
Speaker 3: inspiratory effort and you get collapse and that causes you know,
10:14
Speaker 3: disruption and sleep and gas exchange irregularities, and so there
10:19
Speaker 3: you have it. So the solution for that problem is
10:21
Speaker 3: going to be a seatpath machine because it helps embrace
10:23
Speaker 3: that open But what I've discovered in the Empowered Sleep
10:26
Speaker 3: ATNA journey, and I'll get to why I had to
10:28
Speaker 3: do Empowered Sleep at Me a minute, but along this
10:31
Speaker 3: journey is I've discovered that depending on whom you speak to,
10:35
Speaker 3: the explanation is going to be very different, and the
10:38
Speaker 3: picture that comes to mind is very different. Right, So
10:41
Speaker 3: if we were to approach one of my airways centered
10:44
Speaker 3: ministry friends and say what is sleep atna, the painting
10:49
Speaker 3: that they will create for you will be a very
10:51
Speaker 3: different image than if I had asked one of my
10:54
Speaker 3: colleagues here from the Western medical side. And so it
10:57
Speaker 3: calls to mind the idea that it lay. The term
11:01
Speaker 3: sleep apnea needs unpacking, sure, because it means different things
11:07
Speaker 3: to different people, and we take that concept and then
11:10
Speaker 3: we go a little further and we say, well, you know,
11:12
Speaker 3: what is sleep at me? Is it all obstructive? Is
11:15
Speaker 3: it an obstructive problem? And the answer is no. There's
11:18
Speaker 3: two flavors of sleep at me and those two flavors
11:22
Speaker 3: are obstructive sleep APNOR and central sleep at right. What's
11:25
Speaker 3: the difference, Well, the obstructive sleep ATNA kind is where
11:28
Speaker 3: you're trying to breathe but you can't, right, So it's
11:32
Speaker 3: it's like breathing against a closed or a semi closed airway.
11:36
Speaker 3: There's another word for that in English. The word is choking, right, right,
11:41
Speaker 3: So obstructive sleep ATNA is episodes of choking at night,
11:45
Speaker 3: and that obviously brings to mind a different set of
11:48
Speaker 3: repercussions than central sleep ATNAN. What is central sleep at mean?
11:54
Speaker 3: Central sleep ATNA is a pause or you can think
11:57
Speaker 3: of it as a physiology, so it's a spectrum, but
12:00
Speaker 3: it's a paused or reduced effort to breathe. Okay, So
12:04
Speaker 3: the way we simulate this in everyday life, every time
12:07
Speaker 3: after we sigh, we will sit quietly for a number
12:10
Speaker 3: of seconds without feeling a need to breathe. That can
12:14
Speaker 3: be considered a central apnea of sorts. It's not pathologic,
12:18
Speaker 3: it's physiologic, right, And this is kind of where central
12:21
Speaker 3: sleep ATNA can be confusing because it is a whole
12:24
Speaker 3: spectrum of a physiology that has many moving parts contributing
12:28
Speaker 3: to this phenomenon of having paused effort or reduced effort
12:32
Speaker 3: to breathe with physiologic consequences at night. But it's not
12:37
Speaker 3: the same for everybody, right. And Now, when we take
12:40
Speaker 3: those two concepts obstructive sleep ATNA central sleep up, they're
12:43
Speaker 3: not mutually exclusive. You know, they will usually coexist to
12:48
Speaker 3: some degree, So you can think about each of them
12:50
Speaker 3: as sort of like on a volume knob. And how
12:53
Speaker 3: much is the central sleep ATNA in the mix today, folks?
12:56
Speaker 3: That has to do with a lot of other moving parts,
12:58
Speaker 3: And I got familiar with one of them those, which
13:00
Speaker 3: is altitude here in Colorado, because altitude can be considered
13:04
Speaker 3: an accelerant for central sleep apnea physiology. Now, when we
13:07
Speaker 3: combine those two notions that we have two flavors, right,
13:11
Speaker 3: the sleep tests that we do are not very good
13:16
Speaker 3: at discerning when we're talking about an event called a hypopnia. Okay,
13:20
Speaker 3: there's apneas and there's hypopnia, and apnea is when you're
13:23
Speaker 3: not breathing at all, a hypopnia. It's theoretically it's easy
13:27
Speaker 3: to understand. It's like, well, for whatever reason, the airflow
13:31
Speaker 3: is limited for a few breaths and it leads to
13:33
Speaker 3: something bad, like an arousal from sleep or a drop
13:36
Speaker 3: in O two. Okay, So everybody agrees that hypotnia can
13:40
Speaker 3: be either obstructive or central, right, because they can come
13:44
Speaker 3: from either phenomena. But telling the difference in the lab
13:48
Speaker 3: requires specialized equipment. So really the best way to do
13:52
Speaker 3: it is by using something esophageal pressure monometry, which is
13:56
Speaker 3: where you put a thing down the person's throat into
13:58
Speaker 3: the esophagus, measure the pressure in there, and when you're
14:01
Speaker 3: struggling to breathe against a closed airway, that pressure is
14:04
Speaker 3: going to dropesophagains. Sure, now we have an idea of
14:08
Speaker 3: why obstructive sleep apne is related to reflux, right, that
14:12
Speaker 3: concept comes to mind. But if that's the only way
14:15
Speaker 3: to tell the difference and no one does that, what
14:18
Speaker 3: results from that on a sleep study is that all
14:21
Speaker 3: hypopnias are just hypopnias. They're generic. In my podcast, I
14:27
Speaker 3: refer to this as the generic hypopnia conundrum, right, because
14:31
Speaker 3: here's the thing. Here's the thing. Central apnea physiology can
14:36
Speaker 3: be provoked by non breathing, non airway sources. What So,
14:44
Speaker 3: a really striking concept is there is a everybody has
14:48
Speaker 3: probably heard by now of a problem called restless leg syndrome. Right, So,
14:53
Speaker 3: restless leg syndrome is part of a spectrum of different
14:56
Speaker 3: neurologic weirdness that the eggheads in academia are now collectively
15:01
Speaker 3: calling Willis ekbum disease. Willis ekbum disease. But just calling
15:07
Speaker 3: it restless leg syndrome is okay, because that's how most
15:10
Speaker 3: people know it. But the reason to call it willis
15:12
Speaker 3: ekbum disease is because it recognizes there's so many other
15:16
Speaker 3: things that go along with this physiology you know, or
15:18
Speaker 3: this pathology, depending on which side of the lens you're on.
15:21
Speaker 3: But one of these things is something called periodic limb
15:25
Speaker 3: movements of sleep. This is when you're asleep, you're not
15:28
Speaker 3: wanting to move, but your legs are doing something over
15:32
Speaker 3: and over again, almost like a metronome. And honestly, when
15:34
Speaker 3: you see it on a sleep study and you zoom out,
15:37
Speaker 3: it is very regular, this motor activation in the legs,
15:40
Speaker 3: and it can be associated with arousals from sleep. It
15:43
Speaker 3: can be associated with symptoms of non restorative sleep. And
15:47
Speaker 3: because it causes sleep wake dysregulation, right, it causes surfacing
15:52
Speaker 3: like a dolphin kind of coming in and out of
15:54
Speaker 3: the water. Because it causes that, and because ventilatory control
15:59
Speaker 3: is different for wake than it is for sleep, you
16:02
Speaker 3: can get an oscillation of the breathing mechanism. Okay, so
16:06
Speaker 3: if you imagine sort of overbreathing on the arousal, having
16:09
Speaker 3: a bit of underbreathing when you go back under, which
16:12
Speaker 3: causes the oxygen to drop. Now we've got somebody who
16:15
Speaker 3: can get themselves a diagnosis of sleep ATNA because they've
16:19
Speaker 3: got Willis eckbum disease. Interesting, right, So, all of a sudden,
16:25
Speaker 3: when we recognize that that can happen, we recognize one
16:29
Speaker 3: of my teaching points, which is that all sleep apnea
16:33
Speaker 3: must be deconstructed. Right, We've got to do it in
16:36
Speaker 3: a deconstruction responsibly. And this is where sort of understanding
16:41
Speaker 3: the complexity is a good place to start. And that's
16:44
Speaker 3: where I think when we're educating people about sleep apnea,
16:46
Speaker 3: we always try and break it down to the simple things,
16:49
Speaker 3: you know, because we want to make it simple. But
16:52
Speaker 3: what if it's not simple? How do we present this complexity?
16:56
Speaker 3: You know, these bi directional relationships, and these relationships change
17:00
Speaker 3: over time? Right, how do we present that in a
17:03
Speaker 3: way that providers of all stripes can get their hands
17:07
Speaker 3: around it and patients can get their hands around it too,
17:11
Speaker 3: so they can share in the discussion. Because that's really
17:14
Speaker 3: where this is all going, is that because there's no
17:17
Speaker 3: one size fits all solution to sleep at Me, it's
17:20
Speaker 3: a complex problem that needs to be co discovered. Right.
17:25
Speaker 3: Co discovered. That's a word that I learned from a
17:27
Speaker 3: dentist on this journey of mine named doctor Paul Henny,
17:31
Speaker 3: and co discovery is the name of his book, And
17:33
Speaker 3: what he talks about is this process by which the
17:37
Speaker 3: solutions are revealed. But it's a collaborative process. And in
17:42
Speaker 3: order for a patient to productively collaborate with their provider
17:46
Speaker 3: on something like sleep at Me, they have to understand
17:48
Speaker 3: what the situation looks like from ten thousand feet. So
17:52
Speaker 3: if I could sort of give an explanation for what
17:54
Speaker 3: the empowered Sleep at Me A project is about, It's
17:56
Speaker 3: about all of that it's about helping everyone grasp this
17:59
Speaker 3: complexity but in a non threatening way.
18:03
Speaker 1: Yeah, I love it, And what a great explanation and
18:06
Speaker 1: you know, really taking us on the journey of how
18:10
Speaker 1: you've got from where you were to where you are now.
18:13
Speaker 1: And I can see and feel the passion in you
18:16
Speaker 1: about really trying to, you know, educate doctors on all
18:21
Speaker 1: different levels, coming at it with all different lenses to say, hey,
18:24
Speaker 1: it's not just something as simple and generic as sleipepnea.
18:27
Speaker 1: But depending upon what lens you're looking at it, as
18:30
Speaker 1: you may be approaching it from one thing and it
18:33
Speaker 1: could be you know, multiple levels as we're looking at it.
18:36
Speaker 1: And that kind of brings me to my thought. As
18:39
Speaker 1: you know, on my podcast, we've got a lot of
18:41
Speaker 1: younger doctors, and you know, it's a lot of orthodontists
18:45
Speaker 1: and maybe even some dentists out there that are kind
18:47
Speaker 1: of just getting in and getting their practices started. And
18:50
Speaker 1: one of the reasons that I wanted to have you
18:53
Speaker 1: on this show is because I feel like it is
18:56
Speaker 1: so much easier when we're younger in our practices to
19:01
Speaker 1: kind of bring technology in and philosophies in, and we've
19:07
Speaker 1: got the time, especially in a newer practice, we've got
19:10
Speaker 1: the time to spend with patients and really think about
19:15
Speaker 1: what they're telling us. And so I'm wondering if you
19:18
Speaker 1: can kind of talk to how does this and if
19:22
Speaker 1: you're thinking about this from a younger orthodontis lens, how
19:28
Speaker 1: does this kind of correlate into patient care and you know,
19:32
Speaker 1: maybe things that they need to be thinking about, because
19:36
Speaker 1: I'll have to tell you, you know, I see a lot
19:38
Speaker 1: of times in our industry, a lot of times it's
19:41
Speaker 1: more of our seasoned orthodonists that have been practicing for
19:44
Speaker 1: a while that are like, I think I want to
19:47
Speaker 1: start focusing on this as well. And I don't tend
19:51
Speaker 1: to see a lot of our younger doctors that are
19:54
Speaker 1: starting with that as kind of one of their functions
19:57
Speaker 1: that they are focusing on as they are getting started.
20:00
Speaker 1: So I'm wondering if you can kind of speak to
20:01
Speaker 1: that a little bit.
20:02
Speaker 3: I'll try, you know, I think I'll start by saying,
20:05
Speaker 3: you know, they don't teach us everything in school, for sure,
20:10
Speaker 3: And once that sort of got through my thick head,
20:12
Speaker 3: and you know, not everything that's important in the world
20:15
Speaker 3: is in a textbook already, you know, And because this
20:18
Speaker 3: is a new science, and sleep is a new science
20:21
Speaker 3: relatively speaking, Maybe this is a good time to sort
20:24
Speaker 3: of review because we throw these terms around, Like everybody
20:26
Speaker 3: knows what sleep ATNA is. I introduced the challenge what
20:29
Speaker 3: is sleep ATNA? You know, like if I say what
20:32
Speaker 3: is mild lower extremity cellulitis? I think every doc in
20:37
Speaker 3: the country is going to have a visual and have
20:39
Speaker 3: a general game plan what to do. But sleep ATNA.
20:42
Speaker 3: You know, it's on and people are putting their boxing
20:44
Speaker 3: gloves on, you know about you know, defending what they
20:47
Speaker 3: think is right. So maybe a little story.
20:50
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20:55
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20:59
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21:02
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21:43
Speaker 3: Let's go back to nineteen eighteen. Okay, let's go back
21:48
Speaker 3: even further. Let's go back to the eighteen hundreds.
21:50
Speaker 2: Okay, We're going way way back.
21:51
Speaker 3: We're going way back because this is kind of like
21:54
Speaker 3: the anthropology of sleep them. We're going to go back
21:56
Speaker 3: to Charles Dickens's first novel, Okay, the Posthumous Papers of
22:00
Speaker 3: the Pickwick Club was his very first published novel that
22:03
Speaker 3: was in the eighteen thirties, I believe. And in this
22:07
Speaker 3: novel was a character that is just called Fat Joe. Okay,
22:12
Speaker 3: And this character literally makes his appearance in the novel.
22:15
Speaker 3: He enters like, you know, the way Kramer would enter
22:18
Speaker 3: into Seinfeld. His entrance into the novel is he is
22:20
Speaker 3: standing at the door, knocking at the door, snoring and
22:24
Speaker 3: falling asleep on his feet. Okay. And so we flash
22:28
Speaker 3: forward now to the early twentieth century and the very
22:32
Speaker 3: first modern medical institution in America, the practically sainted doctor
22:37
Speaker 3: William Osler. He just makes an observation that it's a
22:40
Speaker 3: very common thing. He says, in obese people that they're
22:43
Speaker 3: often sleepy, just like the young fellow in Pickwick. He says.
22:48
Speaker 3: We flash forward now to the nineteen fifties and we
22:51
Speaker 3: have a publication by a guy called Burwell that discusses
22:56
Speaker 3: something that he terms a Pickwickian syndrome, extreme obese associated
23:00
Speaker 3: with alvel or hypo ventilation. This is now known as
23:05
Speaker 3: obesity hypoventilation syndrome. But he's connecting the dots saying, you know,
23:10
Speaker 3: we have this pickwick In phoenotype, right, heavy snoring, sleepy
23:14
Speaker 3: phoenotype yep. And now we have a purported mechanism for sleepiness.
23:19
Speaker 3: They are hypercarbic. They are hypoventilating because of their obesity. Right.
23:24
Speaker 3: So this is the mindset of why are obese people
23:28
Speaker 3: sleepy at this point, is that, oh, they're hypercarbic. It's
23:31
Speaker 3: obesity hypoventilation Pickwickian syndrome. Flash forward now to nineteen sixty six.
23:38
Speaker 3: We now have a new method called a polysomnogram that
23:42
Speaker 3: is available. It had been developed basically since the EEG
23:46
Speaker 3: was discovered in the nineteen twenties, so we started to
23:48
Speaker 3: investigate sleep in the forties and fifties. It wasn't until
23:51
Speaker 3: nineteen fifty three that we even knew that something called
23:54
Speaker 3: rem sleep existed. Up until the mid nineteen fifties, we
23:58
Speaker 3: thought sleep was just an off sweat, okay, So this
24:01
Speaker 3: idea that the brain could be active during sleep was weird.
24:05
Speaker 3: So this is the context we get to nineteen sixty six.
24:07
Speaker 3: There's a guy named Enri Gusteau. He is an epileptologist.
24:12
Speaker 3: So this is a very new field in medicine, in neurology,
24:15
Speaker 3: and this guy's job is to see the patterns within
24:18
Speaker 3: patterns of the squiggles of the EEG and try and
24:22
Speaker 3: localize seizure activity. And he becomes world famous, and he's
24:26
Speaker 3: got a lot of syndromes named after him. At any rate,
24:29
Speaker 3: he decides that he's going to take a Pickwickie and
24:31
Speaker 3: a true Pickwickian patient, somebody who's heavy, somebody who snores,
24:35
Speaker 3: and somebody who's sleepy, and use a nocturnally acquired EEG
24:41
Speaker 3: with other parameters parameters that monitored breathing, for example, and
24:45
Speaker 3: see what happens to that person during sleep. It was
24:48
Speaker 3: the very first time anybody ever did this. Isn't that weird? Yes,
24:52
Speaker 3: that somebody could be sleepy and nobody's ever like, let's
24:55
Speaker 3: study your sleep nineteen sixty six. Okay? Is it any
25:01
Speaker 3: coincidence that the number one song on the worldwide pop
25:05
Speaker 3: charts that year was.
25:07
Speaker 2: Lightning Strikes Again?
25:10
Speaker 3: It's like lightning strikes man. Okay. And so now all
25:14
Speaker 3: of a sudden, we have this understanding that this phenotype
25:18
Speaker 3: is related to breathing disturbances, and we have all of
25:23
Speaker 3: a sudden boom, this is why they're folks. They can't
25:26
Speaker 3: breathe at night. Okay, So now we have this new idea.
25:30
Speaker 3: What do we do for them? Well, you can lose weight,
25:34
Speaker 3: that's a good idea. Or we can cut a hole
25:36
Speaker 3: in your neck trachyostomy. Those were the only treatments we
25:40
Speaker 3: had for this weird new idea called obstructive sleep out. Mean,
25:44
Speaker 3: from nineteen sixty six until nineteen eighty.
25:48
Speaker 2: One, unbelivable.
25:50
Speaker 3: That is thirteen How long is that? Thirteen years? Right?
25:54
Speaker 3: So until thirteen years. But in that thirteen year timeframe,
25:58
Speaker 3: sleep labs began to spring up in academic communities where
26:03
Speaker 3: it was mainly kind of kept behind closed doors because
26:05
Speaker 3: you know, big phone book, you got to look through
26:07
Speaker 3: with each one, very time intensive to make this so
26:10
Speaker 3: they're seeing the worst or the worst. They're seeing these
26:14
Speaker 3: very very large people, probably most of them were true
26:17
Speaker 3: alveol or hypoventilation people, and they're starting to collect and
26:21
Speaker 3: experience about what this disease looks like. Right, and as such,
26:25
Speaker 3: we're starting to now make some you know, regulations, how
26:30
Speaker 3: do we score these things? You know, what is a hypopnia?
26:33
Speaker 3: And this is where we started to sort of write
26:35
Speaker 3: things down and keep track and this big discussion about
26:38
Speaker 3: what constitutes a hypopnia and what is an event and
26:42
Speaker 3: what's meaningful. And this is where the ossification of thinking
26:46
Speaker 3: kind of comes in, is that we come up with
26:48
Speaker 3: standards that you know, a hypopmana is when it causes
26:50
Speaker 3: a four percent oxygen drop, and that's currently is still
26:54
Speaker 3: the Medicare criteria for scoring a hypopmia. Now, of course
26:57
Speaker 3: we know that nondsaturating events are meaning right if you
27:01
Speaker 3: have an obstructive event that just causes you to have
27:03
Speaker 3: an awakening, that can mess with your life too. So
27:07
Speaker 3: you know, we've tried to keep up and the scoring
27:09
Speaker 3: criterion have changed, but the payers have not kept up.
27:13
Speaker 3: So you know, we're dealing with a science that is
27:16
Speaker 3: literally going through its adolescence. And how do we talk
27:19
Speaker 3: about this? What's the language that we use? And at
27:22
Speaker 3: this point now it's broken out of the academic prison. Right.
27:25
Speaker 3: I wrote an op ed about this called Happy fifty
27:27
Speaker 3: seventh Birthday. You know, the monster is fully awake. Because
27:31
Speaker 3: this monster that we've created called sleep at me is
27:34
Speaker 3: kind of like a Frankenstein's monster. It's a label now,
27:38
Speaker 3: and you know, now it's not just the eggheads and
27:40
Speaker 3: the academia scratching their heads wondering what it means. Now
27:42
Speaker 3: we have this idea sleep at me, a bad sleep
27:45
Speaker 3: at me, A need treatment. Everybody has their own treatment
27:48
Speaker 3: that they're going to give. But when we go back
27:50
Speaker 3: to the notion that well, sleep at me is complex, yes,
27:53
Speaker 3: And before we talk about treatment, are we dealing with
27:56
Speaker 3: the obstructive flavor or the central flavor? How do we
27:58
Speaker 3: know right which treatment would be best? Maybe many of
28:02
Speaker 3: the above. Maybe it should be like a shmortgage board.
28:05
Speaker 3: When we finally sort of get our minds around that,
28:08
Speaker 3: I think that's a terrifying moment. And the pioneers that
28:12
Speaker 3: I've met along the way. Many of them have sort
28:14
Speaker 3: of had the moment where I call it seeing the
28:16
Speaker 3: whole Leviathan. They've seen the whole beast, and it can
28:20
Speaker 3: be a really kind of scary time because you sort
28:23
Speaker 3: of think to yourself, Oh my gosh, I'm just a
28:26
Speaker 3: fill in the blank, I'm just a primary care doc.
28:28
Speaker 3: I'm just a sleep doc. I'm just an orthodontist. How
28:32
Speaker 3: am I going to deal with this? The answer is,
28:35
Speaker 3: you can't buy yourself. So we have to talk about
28:38
Speaker 3: this in a way that prepares people to crossover silos,
28:41
Speaker 3: and you know, at the risk of being self promotional,
28:43
Speaker 3: that's what this whole empowered Sleep at MEA project is about.
28:46
Speaker 3: So in case you know, no one's heard of this,
28:48
Speaker 3: it's an educational cross platform project that's designed to bring
28:52
Speaker 3: the language of complexity of sleep at me to providers
28:55
Speaker 3: of all stripes that in such a way that they
28:57
Speaker 3: can share it with their patients. So patient is then
29:01
Speaker 3: prepared to be cared for in your silo, but could
29:04
Speaker 3: also like walk across the street to the person who
29:06
Speaker 3: practices a completely different facet and can have the same
29:11
Speaker 3: overall game plan. Yeah, I think that that's an important
29:14
Speaker 3: step forward.
29:15
Speaker 1: Yeah, I love that and just you know, thinking about
29:18
Speaker 1: kind of that holistic approach to looking at it on
29:22
Speaker 1: all levels and this group of specialists working together, and
29:26
Speaker 1: I would agree with you too.
29:27
Speaker 4: Man.
29:27
Speaker 1: Man, you hear sleep app now all over the place,
29:30
Speaker 1: you know from I think I'm in the generation where
29:32
Speaker 1: I've got aging parents and you know, I can't think
29:35
Speaker 1: of a single aging parent that I know of that
29:38
Speaker 1: doesn't have some type of a breathing machine. You know,
29:40
Speaker 1: that's kind of the it seems to me.
29:42
Speaker 3: The yes, yes, it's so ubiqu was it's terrifying. Yeah,
29:46
Speaker 3: don't you feel it? It's like a tidal wave that's coming.
29:48
Speaker 1: Yes, you know, yes, yes, for sure. So I'm curious
29:51
Speaker 1: if you can knowing that probably most of my docs
29:54
Speaker 1: have not heard about this project, and I am sure
29:57
Speaker 1: we're going to have a lot looking it up and
29:58
Speaker 1: you know, reading and you know, jumping on data.
30:01
Speaker 3: Is there for you? It really is, It's there for you.
30:03
Speaker 1: Yeah, thank you for doing that for everyone that's listening.
30:07
Speaker 2: What would be some red flags?
30:09
Speaker 1: So if somebody's just brand new thinking, Okay, man, he's
30:12
Speaker 1: really piquing my interest here, but I don't have enough
30:15
Speaker 1: education yet. But what are some things I need to
30:18
Speaker 1: be thinking about or I can just do in my office.
30:22
Speaker 3: This isn't something that you have to kind of work
30:24
Speaker 3: out from scratch anymore because people are kind of doing this.
30:28
Speaker 3: There is a screening tool that was developed collaboratively by
30:31
Speaker 3: dentists and sleep physicians, and it's called Fairest six, so
30:36
Speaker 3: spelled like I'm the fairest one of all Fairest okay,
30:39
Speaker 3: pipe and six. You can get it off the internet,
30:41
Speaker 3: and it's really a set of physical I guess you'd
30:44
Speaker 3: call them risk factors red flags is kind of I
30:48
Speaker 3: think their terminology. Yeah, that can be obtained directly from
30:51
Speaker 3: the chair side, correct. So this is something that you
30:53
Speaker 3: can train your hygienis to do. On their website, which
30:56
Speaker 3: is Fairest dot org slash tools, you can find this
31:00
Speaker 3: and they've got sort of a little thing that you
31:03
Speaker 3: can print out. But there are six basic red flags
31:06
Speaker 3: and i'll just read them off here. The first is
31:08
Speaker 3: difficulty with exclusive nasal breathing for three plus minutes, so
31:12
Speaker 3: that's something you could do while taking their vitals or
31:14
Speaker 3: something like that. There is a physical sign of mentalist
31:18
Speaker 3: strain down.
31:20
Speaker 2: Here yep, yep, which we look for a lot.
31:23
Speaker 3: Documentation of tonsil coverage, which is your standard one plus
31:26
Speaker 3: two plus three plus four plus a documentation of the
31:30
Speaker 3: degree of ankyloglossia measured from with the mouth open and
31:33
Speaker 3: the tongue all the way up. Recognition of parafunctional dental
31:36
Speaker 3: attrition is the fifth one dental wear and the final
31:40
Speaker 3: one is an obviously narrow pallette. So once one gets
31:44
Speaker 3: good at sort of doing this, this is an assessment
31:46
Speaker 3: that can be done in a manner of minutes. And
31:49
Speaker 3: you know, they've got a little scale at the bottom.
31:51
Speaker 3: But the more of these that you have on there,
31:53
Speaker 3: the more likely it is that we're going to have
31:55
Speaker 3: some sort of functional difficulty with breathing. And then you
31:58
Speaker 3: know what next is the question, and you know the
32:01
Speaker 3: answer is if you're going to screen for something, then
32:04
Speaker 3: one has to have an action plan. So one would
32:06
Speaker 3: hope that one is able to partner with some other
32:09
Speaker 3: providers who can do the testing in one's community. And
32:12
Speaker 3: this is why I think having a common language is
32:14
Speaker 3: so important. You know, once we start getting screening for orthodontia,
32:17
Speaker 3: then they're going to need to be able to speak
32:18
Speaker 3: the same language as the sleep medicine position down the road.
32:21
Speaker 3: So that they can effectively collaborate.
32:24
Speaker 2: Yeah, yeah, for sure.
32:25
Speaker 1: And as they start doing this, where do you suggest
32:28
Speaker 1: that my listeners are, you know, go if they want
32:32
Speaker 1: to learn more about this. And I know you've been
32:34
Speaker 1: talking about your website and that's probably the best place
32:37
Speaker 1: to start. But you just opened up the curtains a
32:40
Speaker 1: little bit and you're realizing, oh.
32:42
Speaker 4: My gosh, there's a whole lot here.
32:46
Speaker 3: This is my overall desire is that if you're wanting
32:50
Speaker 3: to dip your foot in this pool, prepare to be delighted.
32:53
Speaker 3: First understand how gloriously complex this is, and you can
32:57
Speaker 3: see how it all fits together first, and it's going
33:00
Speaker 3: to make sense how the smaller pieces are so vital.
33:04
Speaker 3: If one gets into it with like what kind of
33:06
Speaker 3: devices should I be ordering, it starts to get very
33:09
Speaker 3: very large, very fast, and it gets overwhelming. So, you know,
33:13
Speaker 3: the empowered sleep at in a project you can digest
33:16
Speaker 3: the basic gist of this in just a matter of
33:18
Speaker 3: hours because it's free. The first season of the podcast,
33:21
Speaker 3: which is called The Aisle, I imagine that getting a diagnosis
33:25
Speaker 3: of sleep at Me is like washing up on a
33:27
Speaker 3: deserted island. And the imagery came from you know what
33:31
Speaker 3: was the last thing I remember reading That was like
33:33
Speaker 3: I was really intently studying it because it was so cool,
33:38
Speaker 3: And it took me all the way back to when
33:40
Speaker 3: I was eight and I was reading an illustrated version
33:43
Speaker 3: of Peter Pan and they had a really beautiful drawing
33:47
Speaker 3: of the island of Neverland in the front, and you know,
33:51
Speaker 3: when you're reading and they mention a place you can
33:52
Speaker 3: go back to the map and you can look at it,
33:54
Speaker 3: and it was cool, and I remember that feeling of
33:57
Speaker 3: adventure totally different from the shut down, glazed over sleep apneas,
34:03
Speaker 3: you know what I mean, when you're just like you
34:05
Speaker 3: just shut down, And I mean it's equally tough to
34:09
Speaker 3: explain the circular time of circadian misalignment to people in
34:14
Speaker 3: terms of their problem solving. So if one can get
34:16
Speaker 3: past the idea that yes, it's complex, but there is
34:20
Speaker 3: a way to communicate complexity that helps us all be
34:24
Speaker 3: in the same room together and have the same vocabulary
34:27
Speaker 3: and know how the journey goes from a much larger elevation,
34:30
Speaker 3: then the process forward of learning your role is going
34:33
Speaker 3: to be so much easier. So start with this. Listen
34:36
Speaker 3: to season one of empowered sleep ATNA learn the jargon,
34:39
Speaker 3: understand the vocabulary, understand the complexity of the decision making.
34:44
Speaker 3: And then after that it's going to be finding mentors
34:48
Speaker 3: because we don't learn everything in school, and so you
34:50
Speaker 3: know there are there are many mentors out there in
34:53
Speaker 3: the established orthodontia world. We've got doctor Bill Harroll down
34:57
Speaker 3: in Alabama. We've got doctor Brian Hockele in California, and
35:03
Speaker 3: a lot of these folks are lending their wisdom to
35:06
Speaker 3: teaching efforts. So I would say you can get on
35:10
Speaker 3: the internet and start learning from what's available on say
35:13
Speaker 3: free podcasts. That's a good resource. There is a general
35:18
Speaker 3: dentist by the name of doctor Mike de Luke d
35:20
Speaker 3: e l uk E who has a podcast. It's not
35:24
Speaker 3: Hey Doc, it's called the Doc Podcast. But he is
35:29
Speaker 3: a very curious fella and he's been following this story
35:32
Speaker 3: and has presented a lot of the teachers that I've
35:34
Speaker 3: interacted with. So if one is interested, one can access
35:38
Speaker 3: more information through doctor de Luke's coaching and website. And
35:42
Speaker 3: of course there's actual meetings, so there's continuing ad meetings
35:45
Speaker 3: that you can go to. I'm going to be speaking
35:48
Speaker 3: this September at a meeting called Collaboration Cures in Reno.
35:52
Speaker 3: And this is a combined effort of the American Academy
35:56
Speaker 3: of Physiologic Medicine and Dentistry, the AAPMD, and American Association
36:01
Speaker 3: of or Systemic Health. And these are all kind of
36:04
Speaker 3: people that are sitting on the fighting edge of figuring
36:08
Speaker 3: out these clinical concepts in real time with field engineered solutions,
36:12
Speaker 3: and they're trying to come together to learn from each
36:15
Speaker 3: other and teach what they know. And I think it's
36:17
Speaker 3: a great opportunity for your listeners if they want to
36:19
Speaker 3: do that. Plus, my band is.
36:21
Speaker 2: Playing really Oh, that's awesome.
36:24
Speaker 3: I haven't mentioned, but the music has been a big
36:26
Speaker 3: part of this project, and the collaborative project has taken
36:30
Speaker 3: an artistic term. So there is a collaborative music project
36:34
Speaker 3: that's called the Pulmonats. We got our name from James
36:37
Speaker 3: Nester's book Breath That's awesome, and it's someone who's exploring
36:40
Speaker 3: the science of breathing. And it's basically airway adjacent professionals
36:45
Speaker 3: of all stripes. So in the band, our Dennis orthodontis
36:50
Speaker 3: airway advocates. We've got an airway marketing executive. We've got
36:54
Speaker 3: a neurologists, We've got me. I'm an internist slash sleep
36:57
Speaker 3: medicine specialist. And we get together and we learn songs.
37:01
Speaker 3: And the whole idea is that it's living proof that
37:04
Speaker 3: collaboration can work. And the beauty of it is I've
37:08
Speaker 3: learned so much of what I know from my fellow
37:10
Speaker 3: bandmates because the relationship that you have with music is
37:14
Speaker 3: just different. You trust each other differently and you have
37:17
Speaker 3: different conversations. So it's been a really, really fun and
37:21
Speaker 3: interesting couple of years.
37:23
Speaker 1: Yeah, oh that's great, and I just I love even
37:26
Speaker 1: thinking about the analogy of a band and then thinking
37:30
Speaker 1: about this and everybody working together. You know, it kind
37:33
Speaker 1: of takes everybody collaboratively working together to make really good music.
37:38
Speaker 1: Right when you're in a band, and you know, kind
37:40
Speaker 1: of the same thing when we're working through this, we'll
37:43
Speaker 1: say kind of hard score of music here. You know,
37:45
Speaker 1: if everybody isn't kind of working together and all of
37:49
Speaker 1: the different specialties aren't pulling together and saying hey, like
37:53
Speaker 1: you've said already, you know, it isn't just one thing
37:56
Speaker 1: that fits into one silo. There could be multiple things
38:00
Speaker 1: that are affecting it, and from the dental side to
38:03
Speaker 1: the orthodonic side, to the airway side to the internal side,
38:06
Speaker 1: you know, all these different pieces that are pulling it together.
38:10
Speaker 3: We've got to fit together. Yeah, yea. The music really
38:13
Speaker 3: does for me. It really does it because it's a
38:15
Speaker 3: self correcting system. If you're not listening to each other,
38:18
Speaker 3: the music sounds crappy, you know. But when you're listening
38:22
Speaker 3: to each other and you're paying attention to what the
38:25
Speaker 3: other players are doing, and then you can add in
38:27
Speaker 3: your part and you know what the piece is supposed
38:29
Speaker 3: to sound like, right. So there's this lateral connectivity thing,
38:33
Speaker 3: right where you trust each other and you're actually paying
38:35
Speaker 3: attention and you respect each other and you like each other,
38:37
Speaker 3: and then there's this idea of this shared consciousness that
38:40
Speaker 3: we know what the piece is supposed to sound like, right.
38:43
Speaker 3: And that's really how it works in sleep, haven't you.
38:45
Speaker 1: Yep.
38:45
Speaker 3: If one is sort of attached to the notion like
38:48
Speaker 3: I'm a seapap slinging dock and there's just one way
38:51
Speaker 3: to do this and that's the only way, then the
38:53
Speaker 3: patients that are alienated by that simply won't come back,
38:56
Speaker 3: and I can't learn from them.
38:58
Speaker 2: Right, right, And.
38:58
Speaker 3: So you know the practice of medicine is supposed to
39:01
Speaker 3: be that you're learning from your failures too, and I
39:03
Speaker 3: fear that that's one of the biggest things that's wrong
39:05
Speaker 3: with our fragmented system is that people cancel out when
39:08
Speaker 3: they get disaffected and then they don't come back, and
39:12
Speaker 3: that prevents that provider from ever learning what went wrong.
39:16
Speaker 1: Yeah, So, as we kind of finish up here, I'm
39:19
Speaker 1: curious if you had some two or three thoughts that,
39:23
Speaker 1: again speaking to our younger docs, that we have not
39:26
Speaker 1: already talked about. If you're like, here would be my
39:29
Speaker 1: three thoughts for you that I want to leave you with,
39:32
Speaker 1: or my two thoughts that I want to leave you with,
39:33
Speaker 1: what would that be?
39:35
Speaker 3: You know? I would say that there is a changing
39:38
Speaker 3: understanding of the development of our airway and our face.
39:44
Speaker 3: And I think that's one of the biggest scientific paradigm
39:47
Speaker 3: shifts that we're all having to square off with, is
39:49
Speaker 3: that this notion of having crowded teeth crowded front of
39:53
Speaker 3: face isn't necessarily preordained by our genetic code, and that
39:58
Speaker 3: there are environmental in bluences that seem to be relevant.
40:02
Speaker 3: And I think that this is a sort of a
40:03
Speaker 3: mind blowing idea that the bones that we inhabit are
40:07
Speaker 3: constantly being redeveloped. But you know, it makes sense to
40:11
Speaker 3: a sensible person when we sort of recognize we've seen this.
40:14
Speaker 3: You know, headbinding can change the shape of the skull.
40:18
Speaker 3: Having hydrocephaly will make the skull ginormous. So pressures from
40:23
Speaker 3: within and without make a difference. And you know, it
40:25
Speaker 3: just comes to the understanding that the tongue is a
40:28
Speaker 3: respiratory organ. The tongue sculpts the roof of the mouth
40:32
Speaker 3: based on what it's doing, and if it doesn't have
40:35
Speaker 3: mobility and the person is usually breathing with the mouth open,
40:39
Speaker 3: the face will develop differently.
40:41
Speaker 2: Yeah. Absolutely, And once.
40:43
Speaker 3: We sort of get our heads around that that the
40:45
Speaker 3: things we do change the shape of our face, which
40:47
Speaker 3: obviously the roof of the mouth is the floor of
40:50
Speaker 3: the nose. It's a townhouse, folks, they share the wall. Yeah, yeah, exactly,
40:55
Speaker 3: change the shape of the other without changing the other.
40:58
Speaker 3: And I think that this is the part and certainly
41:00
Speaker 3: medical education that we were missing. We didn't get any
41:03
Speaker 3: discussion about how feeding and breathing and swallowing changes the
41:08
Speaker 3: shape of the face. That wasn't in my education. I
41:11
Speaker 3: think in many standard dental curricula it's not. So you know,
41:15
Speaker 3: I think we need to organize our thinking and how
41:18
Speaker 3: do we approach this new scientific paradigm and how do
41:21
Speaker 3: we educate ourselves and how do we move forward with
41:24
Speaker 3: this understanding that things are more complex than we thought.
41:27
Speaker 2: Yeah, yeah, that's great.
41:29
Speaker 1: Well, if somebody wants to get a hold of you,
41:31
Speaker 1: learn more about your book or the podcast, or just
41:36
Speaker 1: just reach out and say, hey, ank you some questions.
41:41
Speaker 2: What's the best way.
41:42
Speaker 3: Yeah, this is really about cross collaboration. Go to the
41:45
Speaker 3: website and go contact us if you want. The email
41:49
Speaker 3: is simply Dave at empowered sleep ATNA dot com. Great
41:54
Speaker 3: and I am very passionate as you as you saw,
41:57
Speaker 3: and I will always answer. So I'm very interested to
42:00
Speaker 3: see if this reached anybody, if this messaging felt like
42:04
Speaker 3: it was needed. I really think that this information needs
42:08
Speaker 3: to get out for sure, and we need to empower ourselves.
42:11
Speaker 3: Empowerment saves.
42:12
Speaker 2: Yeah, yeah, that's to hold up a copy of my book.
42:15
Speaker 4: Of course, you are absolutely yes, all the Beautiful Blue Book,
42:20
Speaker 4: because it is beautiful and it's supposed to be delightful
42:23
Speaker 4: it's not supposed to be scary, and it's something you
42:24
Speaker 4: can put in your exam room and you know, if
42:27
Speaker 4: you've read it, then people can talk to you about it,
42:29
Speaker 4: and that's the whole point.
42:30
Speaker 3: It's supposed to open up conversations.
42:32
Speaker 2: Yeah.
42:32
Speaker 1: Yeah, And for any listeners out there, we will also
42:35
Speaker 1: put the book. Dave can give us the information in
42:37
Speaker 1: the show notes too, so that you can go and
42:40
Speaker 1: reference that as well. So as we finish up here,
42:43
Speaker 1: one of the ways that I like to finish up
42:45
Speaker 1: Haydocks is to do a little speed round. So are
42:49
Speaker 1: you ready for the speed round challenge? I think so
42:54
Speaker 1: that tends to be the answer I get from a.
42:57
Speaker 2: Lot rrect I prepared, but I lost my notes, so
43:02
Speaker 2: it really is a speed round. You just don't know
43:04
Speaker 2: what I'm gonna throw at you. All Right, here we go.
43:07
Speaker 2: If you could start any business right now, what would
43:09
Speaker 2: it be.
43:11
Speaker 3: I would start an airway centered megacenter where the docks
43:16
Speaker 3: and the dentists and everybody work together.
43:19
Speaker 2: I love that. What's the best investment you've made?
43:23
Speaker 3: Listening to my wife, Hey, that's.
43:25
Speaker 2: A good one.
43:26
Speaker 1: Happy wife, happy life. How do you handle work related stress?
43:32
Speaker 3: I call it urban hiking. So I live in Bolder,
43:36
Speaker 3: and Boulder has the advantage of having lots of things
43:40
Speaker 3: kind of within a walking radiance. So at one point
43:43
Speaker 3: in this journey, I killed my car because I just
43:45
Speaker 3: neglected to drive it. So I walked to the grocery store,
43:48
Speaker 3: and you know, I think about it as you know,
43:50
Speaker 3: walking is sort of like my prozac, you know, and
43:53
Speaker 3: walk with that rhythmic exercise, you know, that movement, it
43:57
Speaker 3: kind of stirs things up. So yeah, that's my mental health,
44:00
Speaker 3: is my urban hiking.
44:01
Speaker 2: I love it.
44:01
Speaker 1: And you're just right up the road for me. So,
44:03
Speaker 1: I mean, not a better place to be walking than
44:05
Speaker 1: a Boulder. I'm just down here in Golden So you.
44:07
Speaker 2: Know, I didn't know you were, that we were neighbors. Yeah,
44:11
Speaker 2: that's awesome.
44:13
Speaker 3: Golden is beautiful too. Yeah, it's it's an opportunity for
44:16
Speaker 3: nature therapy out there.
44:17
Speaker 2: Absolutely absolutely.
44:19
Speaker 1: All Right, what's one trend do you think in our
44:22
Speaker 1: industry that you're excited about?
44:24
Speaker 2: I bet I know the answer.
44:26
Speaker 3: Well, I'm very excited about several things actually, but one
44:31
Speaker 3: is I'm very interested in nasal rhinometry. Second is I'm
44:36
Speaker 3: interested in where capnography is going. That's where you study
44:39
Speaker 3: not oxygen saturations, but co two levels. There is a
44:43
Speaker 3: new company. You can look this up if you want,
44:45
Speaker 3: and they're not paying me. I think this is interesting though,
44:48
Speaker 3: called shark Bite and it's shark b and this is
44:53
Speaker 3: an artificial intelligence kind of big data way of looking
44:56
Speaker 3: at cone beam cts and they're trying to find they're
45:00
Speaker 3: trying to teach a computer to read the tea leaves
45:02
Speaker 3: for different diseases. And Sleep at Me is on the list.
45:05
Speaker 3: And the last one is a product called sleep Image,
45:09
Speaker 3: which is a really cool device that's based on heart
45:13
Speaker 3: rate variability data, but you can basically wear it on
45:16
Speaker 3: your thumb and it will give you a report that
45:19
Speaker 3: will give you information that is pretty compatible with what
45:22
Speaker 3: you get on a sleep study in terms of the
45:24
Speaker 3: numbers that we were talking about. So it can be
45:26
Speaker 3: really useful information. And you know, if you're empowered with
45:30
Speaker 3: like how am I going to deal with this complexity
45:32
Speaker 3: and you've got this really good feedback tool, I think
45:35
Speaker 3: that's important.
45:36
Speaker 2: Yeah, Oh that's great. Technology is just amazing. It's amation
45:40
Speaker 2: cool what what we've got going on.
45:43
Speaker 3: The toy deployed carefully and responsibly, I would say, yes,
45:46
Speaker 3: the complexity needs to be responsibly unpacked.
45:49
Speaker 2: Yeah yeah, yeah, Well what great advice.
45:52
Speaker 1: So and that may be your next answer, but what's
45:54
Speaker 1: the most valuable piece of advice you would give somebody
45:57
Speaker 1: just maybe starting their career.
46:00
Speaker 3: Don't be afraid to unpack the complexity and find good mentors.
46:04
Speaker 1: Yeah that's great. Well, thank you so much for being
46:08
Speaker 1: on Haydocks. This was a wonderful episode.
46:11
Speaker 2: Man.
46:11
Speaker 1: We could probably talk for hours and hours and hours
46:14
Speaker 1: and still not get through it all. But thank you
46:17
Speaker 1: for keeping it simple and digestible. And I know that
46:21
Speaker 1: a lot of my younger ducks are like this was
46:24
Speaker 1: like the perfect waiting in point that I needed to
46:27
Speaker 1: find out more information.
46:28
Speaker 3: So thanks a welcome to be here, change your life
46:31
Speaker 3: empowerment saves.
46:34
Speaker 2: All right, Thank you so much, See you.
46:36
Speaker 3: Thank you bye.
46:38
Speaker 1: Are you ready to start a practice of your own?
46:41
Speaker 1: Need a new fresh set of eyes or some advice
46:43
Speaker 1: on your existing practice?
46:45
Speaker 2: If so, reach out to me Jill Allen.
46:48
Speaker 1: At www dot practice results dot com. If you like
46:52
Speaker 1: what we're doing here on Haydocks and want to hear
46:55
Speaker 1: more of this awesome content, be sure and give us
46:57
Speaker 1: a five star rating on your prefer listening platform and
47:01
Speaker 1: subscribe to our show so you never miss an episode. Remember,
47:06
Speaker 1: new episodes drop every Thursday.
47:08
Speaker 2: See you next week.