Airway – Dentistry’s Elephant in the Room – PDP033

Jaz’s Introduction: 
Now airway for me what I think is that in dentistry, it really is the elephant in the room like we qualify from dental school, and this mammoth topic of airway and how relevant it is to dentistry. I mean, come on, we’re looking down the mouth, we’ve got a huge view of the airway. And it’s something that’s completely neglected in dental education. But the more I sort of delve deeper into this, it’s actually neglected in medical education as well. But it was taught turning that around slowly. So that me and Prof Ama Johal, who’s the guest today.

We’re thinking that perhaps in 10 years time, it’s going to have its rightful place near towards the top of what we learned at Dental and medical school for that fact. So we’re talking about what is the elephant in the room and it’s airway. The way that I got into airway in my journey is something I discussed with Prof Ama Johal was when I was a DCT1 at Guy’s Hospital, I’d have like this one clinic like every two weeks, where I’d be making these mandibular repositioning appliances, and they were like, it’s like a soft splint for a top, a soft splint for the bottom and this sort of glue together with a mandible in a slightly protruded position or what Prof Ama Johal describes a very much as a first generation appliance. So that was my first real exposure into treating the airway or creating sleep disordered breathing flat back. And when I learned some years later, that there is an association between sleep apnea and parafunction. You know, that got me excited, which hardly surprised any of you. I know that for a fact. So I’m really stoked to have Prof Ama Johal, we recorded this episode in about April.

We’re now in July. So the sort of vibes you’ll be getting is like, Oh, my God, it’s lockdown kind of thing. But it’s full of a lot of useful information. This this episode here is really to wet your appetite, about airway and the role that dentists and the dental team can play in spotting sleep disordered breathing, obstructive sleep apnea, and obviously treating snoring as well actually, which goes hand in hand and you’ll learn about the sort of definitions what role we have, what works and what doesn’t work the different oral appliances. So really cool episode, I hope you like it. Very niche, very different, something that really needs to get out there some more. The Protrusive Dental Pearl I have for you was donated by my good colleague, Tristan. Tristan has been listening to podcast some time. It’s been great to connect with him on Instagram. And like many of you that listen to podcasts, and I’ve made so many friends to this.

So thanks so much Tristan for reaching out. And Tristan reached out to me and said like Jaz, I’ve got like the next pearl for you. It’s basically when you’re doing rubberdam instead of using floss, use the little flossettes. And you know me, I was like Tristan, kind of been doing this for three years. But then Tristan threw in this absolute knowledge bomb, that is definitely going to change the way I now place rubberdam and I think it’s gonna it’s a really helpful tip. So what I usually do in my workflow for rubberdam is I hold it in place. I try and stretch it into a contacts if I can, but a lot of the contacts are tight and they need flossing, right? So I train my nurses and how to floss effectively.

Sometimes people get their nurses to hold the rubberdam and the dentist flosses, whatever, so the nurses flossing, but when I switch to using the flossettes, it became so much easier the nurse found it so much easier, especially to reach like between the first and second molar, it’s so much easier. But what Tristan shared with me which is the real Protrusive Dental pearl for today is to buy the floss sets, which had a double floss so they had like one higher up and then one lower down. because quite often when you’re flossing the rubber dam through the contact, it actually misses or it doesn’t quite drag the rubber dam past the contact area sufficiently. So having that second floss in the flossettes gives you a second bite at the cherry. So then you don’t have to keep flossing. So thank you Tristan for donating that Protrusive Dental pearl today. We’ll dive right into the episode with Prof Ama Johal And join me back in the outro

Main Interview:
[Jaz]
Prof Ama Johal, it’s great to have you on the Protrusive Dental podcast. How are you?

[Prof Ama]
Very good. Thank you. Yeah, interesting times we’re living it but yeah, really good. Thanks.

[Jaz]
Absolutely. So to put some context in for those watching or listening, we are in the middle or it’s end of April now 2020 and we’re in the middle of the sort of COVID-19 lockdown period. So how are you keeping busy at the moment and maybe it’s a good point for you to tell? Because I usually like to do a little introduction for someone. But before I give my little introduction of you, can you please tell the listeners what you’ve been up to and what you’re usually up to when you’re not in a lockdown period?

[Prof Ama]
Okay, so, so my if you like daytime job is professor of orthodontics, training undergraduates, postgraduates and specialist orthodontic treatment. In addition to that, I work as a consultant for Bart’s charity, Funds, I should say not charity, although it is like a charity.Treating patients with you know, multiple complex needs. And then I suppose proportion of my week is spent in private practice. So treating sleep disordered breathing, which I also treated at the Hospital and as a specialist orthodontist, so yeah, my week is really quite busy.

Actually, it’s pretty full on. Lockdown has actually meant for us just really getting on with an awful lot more academic work, so I’m doing a lot of academia, we have noticed you probably are aware of the challenges of presenting their assessments for them during this lockdown period. And from the NHS side I’ve been redeployed and I’m working in a&e which is very very interesting place to be right now. So we’re very much at the front line. And that’s been quite interesting but again I’ve managed to kind of relate a little bit of my respiratory understanding. And so as you’re probably aware, one of the treatments for some of these patients is one of the treatments we’re going to talk about this afternoon so it’s been yeah I’ve quite enjoyed it but a little bit out of the comfort zone, let’s say!

[Jaz]
Well, sounds like you’ve been very busy indeed not only with the academia, but with the this great role that you’re doing as working on the front lines so I think a thank you for the hard work to people like you and my wife is also an assistant swabber for COVID-19 and everyone who’s, you know, being redeployed is great stuff, so my version of your introduction is, you are quite famous in my orthodontic diploma that I did, because every time we’d see like, oh, “what’s the reference for that one” we don’t know when we’re revising for exams, and we all had an in-joke that if you just reference Johal et al you’re probably gonna get the mark! So that was that was why you’re famous.

[Prof Ama]
Thank you.

[Jaz]
Tell us so we’re gonna talk about airway and obstructive sleep apnea, and sleep disordered breathing. How did you get into this sort of micro niche within dentistry.

[Prof Ama]
Yeah, I mean I suppose it’s very unique because when I was training as an orthodontist who was a senior lecturer at Bart’s developed this initial interest in sleep medicine, and because of the MSC that was doing at the time she sort of roped me into it with her. And so it’s been almost 25 months just over 25 years actually I’ve been involved in research and clinical work so yeah it’s kind of escalated from there and now we’ve run a sort of a PhD programme I took on a PhD in dental Sleep Medicine, which was, you know, interesting and fairly novel at the time actually. So, yeah, that’s where my interest really was born out of academia, and then I started to manage and treat these patients. And I, you know as a profession I think it’s incredibly exciting I mean, the opportunities for us to shine are amazing.

[Jaz]
I think it’s a it’s one of those. I mean At dental school I was always taught that there are two chances you can save someone’s life. One is oral cancer if you diagnose it, and two is actually a gastric esophageal reflux disease because you know Barrett’s oesophagus, but then no one ever mentioned the third one, which was obstructive sleep apnea and the role of dentistry so I think that leads us nicely onto what my main question is can you firstly give us an overview to all the dentists watching lots of gdps listening into this. What is obstructive sleep apnea, or sleep disordered breathing. And what is the role of the dentist in the diagnosis management at the moment and perhaps what you think it could be in the future.

[Prof Ama] Okay. Really good question really. So, the sort of global term that’s often applied is is referred to as sleep related breathing disorders or sleep disordered breathing, and that covers a panacea of challenges so I suppose if we go back, very briefly to the anatomy of the area of interest, we’re talking about the back of the throat so the really the point from where you see on dangling soft palate, to the base of the tongue. And this is a very small piece of anatomy and the analogy I often give dental colleagues and common courses and so forth is to think of a, like a party balloon long and thin. And if you’ve inflated it stays inflated otherwise it’s it’s just kind of completely collapsible, and that is your upper airway. So what makes it quite unique is it’s devoid of any sort of skeletal framework. And it relies almost entirely on muscle action to keep it paid.

So, sleep disorders is essentially dealing with either a partial or a complete collapse of that airway, that small tissue area. And so one extreme we talked about snoring. And snoring is obviously quite a people laugh and smile about what snoring but for those who suffer it’s an incredibly anti-social condition and it has some serious impact from a health perspective and quality of life perspective. In these individuals, what happens is the area doesn’t collapse it just partially closes momentarily as the tissues, touch, and it’s that vibratory action of the soft tissues hitting each other that gives rise is allowed, or not. And, at the other end of the spectrum you’ve got obstructive sleep apnea, which is significantly associated with a lot of comorbidity. So in this condition what makes it very very unique is that airway doesn’t partially collapse it completely closes. So the individual suffers this mini episode of suffocation. And we talk about sort of apneas which are complete cessation of breathing and they have to last for at least 10 seconds for them to count a lesser form of respiratory disturbances something called a hypopnea, which is a milder respiratory obstruction but nevertheless is associated with a drop in arterial oxygen. So whether you have apnea or hypopnea is we tend to talk about obstructive sleep apnea in terms of its severity, as a condition called the apnea hypopnea index. And that’s a summation of the number apneas and hypopneas in any one hour of sleep. And this can range from five upwards to what an endless number almost but we classify it between five and 30 has cut offs between mild and severe amongst that plethora of conditions there are milder respiratory disturbances but that’s for fundamentally that that’s really what we’re dealing with we’re dealing with an airway that’s collapsing andnkind of our Dental Sleep Medicine which has really evolved.

So, in terms of your question, you know, how did I get involved or what contribution Can we make well the contribution is significant now, and it’s probably taken me the best part of 25 years to really get that to the forefront of not only our medical colleagues, but the dental profession itself, because as you quite rightly recognised that this isn’t something that’s routinely trained or taught, and there was a lot of inertia towards this initially, primarily because the evidence base wasn’t supportive, but now we’ve got an immensely strong evidence base, and it’s probably safe for me to say that the government in 2018, set up a nice committee, National Institute of Clinical Excellence, the set of guidelines for sleep related breathing disorders. And I was quite privileged to be interviewed and appointed as the dental expert on that panel, and the report would have been published in May of this, this year.

But because of it’s because of COVID-19, we’ve had to push that date back so I was really optimistic that by the end of this year, people will be reading an awful lot more and we’ve tried to embrace the multidisciplinary nature of this condition. So as a dental professional, if you think back to what I was saying about the collapse of this airway. The one predominant tissue that features in all of this is the tongue, and nobody has better control of the tongue than the dentist. So, you know, we’re in a very very unique position because we are the only qualified professional to get involved in this. Insofar as the simple mechanism of action really is that if you advance your mandible you advance your tongue. And by doing so, you stop these obstruction episodes, or these intermittent collapsing. So, at least you resolve the snoring at very best we start resolves up there. And there are some now very established international guidelines which accredit this work. So we tend to follow the American Academy of sleep medicine, and they’ve been updated largely to reflect the amount of research, this has been undertaken this field. So we’re in quite a privileged position. And you know, my role has been probably the last 10 years to really push dentists to get involved in this because it’s by far the easiest level of dentistry we actually undertake, we can talk about what it involves.

[Jaz]
Well, I actually came across, you and I learned about the role that you’re playing in a political and international and dental level within sleep disordered breathing when I came across your coupon, I think DVD series that you did with S4S, and my that’s where in that lecture was a real eye opener for me when I when I watched it. And what I want to know is, why is it that the American Academy of dental Sleep Medicine, had produced all these guidelines all these years ago and they’ve been, I mean seems to be when I speak to my American colleagues on, I actually worked in Singapore for a while, and I met some American dentists and their understanding, and they’re sort of perception about the role of dentistry in sleep was completely different to my background. Why do you think that in the US, they’re the way and Is it because of the way insurance pays or is there something else going on?

[Prof Ama]
And again a really good question. I mean, I suppose at the cutting edge really of sleep medicine in general has been the Australians. They take credit for an awful lot of the innovative technology that’s taken place. And the Americans as you quite rightly identify have have gone on to this. Probably a lot more quicker and much sooner than we did. I just think it’s probably scales of economy to one extent. The second is, I think, the element of funding that comes into play. Also is an issue because in the States as you know it’s almost, I would get funded health care. And one of the big things that takes place that differentiates the UK from America and other parts of the world is that insurance companies pay for an immense amount of the investigative work that takes place.

So sleep physicians are often then confronted with this plethora of patients as well as conditions, which I often can’t managed and, and they were often restricted because the gold standard for treating obstructive sleep apnea so if we just park for one minute snoring to one side and focus on the coma because obstructive sleep apnea tracks, you know, most of the attention because of its profound effect on people. So, the treatment of choices, is called CPAP (Continuous positive airway pressure) which has been popularised during the covid, and because it is basically a machine which takes normal air filters it humidifiers it, and then forces it under pressure into the back of the throat so if you go back to that party balloons scenario. Everyone gets why it works so efficiently. It’s basically a pneumatic splint it has no other feature other than a pure anatomical role it just literally blows the Airway up. The biggest challenge they have with that treatment is compliance so it’s incredibly effective, but patient compliance is, is quite poor, to say the least.

And so consequently these sleep physicians are either confronted with patients who are really severely ill unwell symptomatic, with no treatment of choice, or the patient simply looks at the device and thinks well, there’s no way I’m going to comply with that, Even if the monitoring has a spectrum. And I think it made the Americans, perhaps, and certainly the Australian citizen think when actually, you know where where are we going with it so when I completed my PhD back in 2004, the Australians completed the biggest international research trial, which was funded by multi million pounds. We’re looking at the effectiveness of oral appliances versus CPAP so they were really ahead of the game. And that’s a kind of a pinnacle paper that you know we really regularly recommend people to read. So I think partly that has evolved and then naturally, because of the availability of that treatment in the US and because it was funded treatment. They, I suspect have always remained ahead of the game I wouldn’t say they’re particularly ahead of the game at the moment. It’s just that from a regulatory point of view, the UK has been behind so once the nice guidelines come out. We will probably have the most up to date guidance on the management to speak to and breathing. So we will respond, a little bit slower than that.

[Jaz]
Well it’s good that we’re finally getting there. And for a lot of people who are listening. A lot of dentists young dentists, they probably have never seen what a CPAP looks like. Now, from the research that I be doing in a run up to this episode so I wanted to make sure I had some some knowledge in front of you is that it’s not a very sexy device to wear and that may have something to do with the poor compliance? Is that right?

[Prof Ama]
Yeah I mean there’s a couple of elements to it that certainly it’s not the most attractive. It used to be a little bit noisy because it’s like going to bed with an air conditioning unit home but they’ve made that better. Its primary problem from a patient point of view is travelling with the wretched thing because it is space consuming and in these in these days of heightened airport security or former days of high airport security. And these patients used to put this in the hole, and it would have to justify this treatment so one of the sort of almost, I suppose proactive elements for patients that come to me and say look I need something I can travel with, or that doesn’t need an electricity supply, because that’s the other thing it’s bound to. Beyond that, actually the mask itself is incredibly uncomfortable that’s where all the issues arise for patients it’s, it’s got certainly multiple side effects that it tends to be constructive. Despite the millions that are invested.

[Jaz]
Brilliant, well then what this does nicely to next question, why has the dental Sleep Medicine, do you think become, I think it’s like the elephant in the room in our profession, especially at undergraduate level I don’t remember a single lecture about the role of airway at the time. Is that changing now because I know you’re involved in education, are you now starting to teach undergraduates?

[Prof Ama]
Well it’s interesting you say that because there’s, there’s not just a change needed in undergraduate dental, but undergraduate medical as well, has changed. Consequently, because. Sadly the knowledge, amongst GPS of the training available to them, has been rather limited as well so I used to work a lot with Primus sleep groups are trying to raise the knowledge base so not only within dentistry but medicine. Within dentistry there’s no formal acknowledgement in the curriculum that this would be a key component, let’s say, however, a Queen Mary we I’ve integrated it. So we have students that moment to do a selective study model module a choice module is sort of a, an elective if you like. And they kind of really enjoy it. I’ve had a few of them in fact one of them wrote something for the dental mouthpiece because you know just raise dental awareness and again within postgraduate training we’ve obviously got it going now and introduced it basic orthodontic training and but it’s not just orthodontics elite effects clearly, it affects any dental professional.

[Jaz]
Brilliant well then fast forward from students which hopefully will, you know, it will get embedded both in the medical and the dental sort of curriculum and in looking at the dental profession as a whole at the moment. How can we help our patients who we suspect may have an airway issue. Obviously, the first thing that we need to do as oppression is learn. So for me, my initial learning was not only watching your lectures, which was an eye opener for me but also during my DCT position at Guy’s hospital. I used to. I used to give some mandibular advancement splint.

These were like the to describe it to those it’s like an upper, lower soft spint, where the mandible is advanced and they’re just sort of stuck together. And that’s what that was my initial sort of introduction to it, and then went on to treat snoring. Following the S4S framework so we had the patient fill out the Epworth scale, and I liked the sort of letter that was attached so you can send to the GP, but I never once had a GP write back to me and to fact even the patients, once they got their device to help them snoring. They, they didn’t pursue it with the, with the GP. As you know as strongly as perhaps I would want them want them to. So I guess the question I’m asking is, is it just these mandibular advancement splint that we ought to eventually hopefully get involved with, or is there much more to it than that and how can we take it further as a profession.

[Prof Ama]
Okay, so I mean these are really crucial questions really because. So before I could open this. Let’s say treatment modality to to dentists within the UK, what I did was I engaged with the sleep societies, the British Thoracic Society the British sleep society. And I kind of wrote to the mall and I said, Look, if I was to train dentists, would you support them in clinical practice because ultimately this is a, an MDT approach, it’s not something that as a dead fish we can get in on our own or neither we want to my second port of call was the defence organisations because many of them would not support, or even recognise this as being treatment under the umbrella of dentistry.

So, there was kind of a huge basic educational training needed so I managed to then demonstrate to the defence organisations that this is mainstream treatment, this is not peripheral care that we’re offering. And so they were bought they bought into it but on the premise that if dentist came into this industry of dental Sleep Medicine, they did so on the formal understanding that it was part of a team approach, and they need to require acquire the necessary sort of skill set, hand in hand with that, what I was trying to develop with the sleep physicians themselves was something that as a dental professional, we can instigate and do because one of the luxury positions where we have a humongous patient base. We know that sleep disorder breathing is actually far far more prevalent in the population than it is recognised. So, in developing a, if you like, pre questionnaire screening tool is what is what we all agreed that they thought it was an excellent idea and overwhelmingly supported this initiative.

Once I demonstrated that to the defence organisations that the pathway that we were setting up for dental professionals coming into this would be the Firstly, you would gain an understanding of sleep disordered breathing because clearly we need to understand the condition. The analogy I sometimes give is if you diagnose someone as having a name yeah yes you might give them some iron supplement tablets or bitten. You know B or whatever you felt was they were short on But fundamentally, our cause is to know why they got the anaemia what is the underlying cause of that. And same in this scenario we can treat snoring and sleep apnea, but we need to have a better understanding that the diagnosis is established, and as a dental professional we’re not capable, or indeed trained to diagnose we’re not medical professionals and we don’t need to pretend to be either. What we can do, though, is without patient base existing, we can apply some very simple screening questionnaires, one of which you refer to the Epworth sleepiness scale. And for those who are unfamiliar This is a again an Australian developed initiative. It’s eight basic questions which ask a patient their probability of falling asleep during daytime, and they range from zero to three so you get a maximum score of 24. This gives us an indication of how sleepy this patient is because sleepiness if you like is a sort of a direct clinical outcome but it’s an indirect measure of what happens at night so these patients have to wake up completely fatigued.

In addition, we developed one or two other questionnaires which will be pertinent to our care, so we put together this package and part of the you refer to very carefully ago that there’s a tear off which you sent to the GP. So in negotiating with the defence organisations what they wanted dentist to be trained in is one understanding of the condition. And secondly, a better understanding of what these devices do how they work and how you provide them. And finally the other feature you just touched on is the sort of appropriate level of follow up care that we instigate. So, all of this is well well well within our capabilities, but requires us to interface, a little bit. The analogy I often give is that as an orthodontist you might refer me a patient to the hospital for treatment, and my role is to provide care for that patient under your umbrella of general dental care, it would be highly inappropriate for me to take that patient and then to do a filling in them as an orthodontist not wish to. And what I would do then is I write back to you say just thank you very much your patients had their own treatment, and, over to you for their continued dental care.

The same happens in the sleep world, the sleep physicians are, if you like the team leaders within that team is dentistry, an absolute second in the pecking order. It used to be ENT – ENT have progressively withdrawn, the levels of care that they’re prepared to provide because surgery out surgical outcomes aren’t particularly beneficial long term. Sadly, there’s no evidence to support the long term benefits to patients despite the optimism of the procedure, so you know you’re looking at CPAP appliances. So what why I instigators that as dental patients we provide the treatment. This is really easy treatment for us to undertake. But then we give the patient and we refer the patient back to their sleep physicians accordingly, or in some instances of snoring. We may liaise with the GP, because the GP, whether or not they have more training than you do after you’ve been on these courses. Nevertheless is medically qualified, and therefore has the indemnity to protect the patient’s care overall. That’s a long winded answer but I hope that makes sense

[Jaz]
I know but yeah I think I like the way that you ended that question about the medical professional yes they are the medical freshmen so they need to be taking a role, a role that unfortunate dentist we cannot fulfil what. To give you an example, I had one patient who I helped with a mandibular advancement after following the correct protocols of getting their stock bang for steepness scale and following up the patient for occlusal changes all the locks, but my stumbling point was the lack of knowledge and training of the medical threshold GP because my patient said to me, when I went to a GP. She looked really puzzled and views. So in some ways, do you think they’ll ever come a time where as dentists, you know, hopefully 10 years from now where our general sort of involvement in this is further advanced that we will be able to refer our patients directly to the sleep position for a sleep test because the more I read the more I’m thinking that hang on a minute these patients should be getting a sleep test.

[Prof Ama]
Okay, that’s a really good question because that now comes down to where we suspect the remit of the impending nice guidelines will sit. The challenge we have at the moment is that the NHS does not fund in the UK, the provision of these appliances per se, hence why we’ve probably not been at the forefront, back to a question about the states of pushing the guidelines, where this could all change profusely is that if there is NHS funding available. Now, it’s very much like you negotiating or contracting or patient back to me for orthodontic services. You become in primary care the provider of the care. And you could have passage, and liaison with the sleep physicians, so often I say to patients on the dentist on the course that if you get a patient for example who comes to you with a clear diagnosis of obstructive sleep apnea and for example is managing being managed on CPAP or not managed on CPAP. They somehow gain knowledge because the other thing that’s, there’s a disjointed is the patients do not associate dentists, at all with the condition of snoring or sleep apnea. Never in a month of Sundays would they think that their dentist is personally would help them. So that’s another educational cycle with we’re engaging with.

But let’s assume that a patient came into your surgery and said to you know Jaz Listen, I understand. I saw a brochure or something that you’ve advertised that you managed snoring and sleep apnea. And I’ve been treated by a sleep physician I’ve been using this CPAP machine but I don’t tolerate it. And at the moment I haven’t got any treatment. Now, this is a fantastic opportunity for us as a dental profession to then engage with sleep physicians because as a sleep physician they have a responsibility to that patient’s care and they know it’s unfortunately being left in limbo if you like. So there’s an immediate have in your report that you start to establish and what I try to encourage you to embrace. It’s very interesting just because when I talk to sleep physicians and I’ve taught them a lot and presented conferences to them. You know that. They used to be all of what we could achieve now they know what we can achieve the principal questions we almost always is, where is, where are the dentists that we can provide, we can provide this care and we try and create an app available to the list of trained dentists that’s the key word. So, we don’t want for our own professionals and standards we clearly don’t want to get involved in this field if you haven’t had that basic training and it’s acquirable within an introductory course which is usually a day.

And these courses, you’re going to find either aren’t commercially available to companies that sponsor these events and you know I’m on and others do the same. Alternatively, and equally We do that through the British society of dental Sleep Medicine. We do these introductory courses again to get you the sort of startup skill set and equally we work with you to try and keep you engaged and actually provide you additional training so we have follow members days and so forth, where we bring in invited speakers so it most certainly is something that we’re working hard towards because, and the feedback of much like you know you’re a living example of this that the feedback I get from patients or dental professionals and got involved in this is wow, you know, it’s quite humbling. When you get this gratitude bestowed upon you, because you think well actually, all I fundamentally did was a basic examination to impressions, and possibly a bite registration. And in respect in return for that. You know I’ve changed someone’s quality of life, to really quite an effectual level.

[Jaz]
Brilliant. Well, the reason I took it further and further is my interest lies in occlusion parafunction, managing my bruxism patients and then I came across some research that actually when you treat the airway with example a mandibular advancement splint that actually do reduce the parafunctional events. Now I know you are very evidence based orthodontists, have you. You think there is good enough evidence to support the correlation between sleep disordered breathing and parafunction.

[Prof Ama]
Yeah, I mean that’s a very very good point yes and I think. But I think one thing I do like to try and dispel is that practising evidence based dentistry is that you know there are three pillars upon what it sits. One of them is the research what does the research tell us and that is obviously pivotally an important a good resource for us. The other second sort of pillar if you like of this tripod is that it depends very much on your clinical experience as well because clinical experience has an awful lot to offer not everything is susceptible or amenable to, you know, crucial microscopic level research. And the third factor in all of this is the patient’s concerns of wishes. So, if you think of that tripod and you put a patient in the middle of that you say okay where’s the evidence for this.

So, the first thing to say the reassuring thing is there is an association a strong association between parafunctional habit and sleep disordered breathing. There was some very good research published in the Journal of Applied physiology which demonstrates that essentially what happens to these patients will go back to their physiology just for a moment, because their airway is obstructed, the oxygen levels are beginning to diminish the co2 levels are beginning to write this rise in co2, can cause increased parafunctional activity, for example a massive has been shown to increase and hyper hyperflex and hypertense.

So, then, you know, I never quite made that correlation for quite a while actually because anecdotally when I started to treat up the numbers of these patients and when I was doing my PhD patients would frequently come back to me and say one of the observations that that Dentists have noticed, noted is that they’re no longer fracturing their restoration so if you imagine the population we’re treating, they’ve got these large amalgam MODS which were put in, you know, back in the back in the day sort of four decades ago almost, very little customer support and they were fracturing these restorations that compromise the fit of the device, but all equally made more work for the, for the profession, and I hadn’t really quite thought about it in those lights until I started to read this literature, and I thought well actually, we are having a beneficial effect, not only are we, by putting a splint between the teeth stopping the fact that the teeth are contacting the teeth. But equally if we’re reducing the co2 levels which we clearly do, then the activity of those muscles is most definitely reduced as well. So, You know, I think. Your, your clinical experience is well supported by evidence as well, and it has a lot of the patient feedback you’re getting if you put three together. You have a good evidence based practice.

[Jaz]
Brilliant so it’s good to know that I haven’t been brainwashed by by the wrong type of evidence, if you like, but you know what I one thing I do do is when I whenever I prescribe such an appliance, the one that as far as do I believe is called asleep. Well, it’s got the metal portion and then they come back with all these scratches in the in the metal too which is obviously them in a lateral sort of a left to right so ParaFunctions I, I like to take a photo I’m a geek like I like take a photo of those crunches I show the patient and, and also stuff but it’s a it’s very interesting and that so I mean for those listening and watching right now I’m thinking you realise already that there’s so much more to this that this episode should really be like something to whet your appetite. And I think I am certainly waiting for these guidelines to come out I think wow what a great thing that’ll be from refreshing UK to take things forward.

[Prof Ama]
The other thing, Jaz, I think is often people ask me you know as a dentist Should I get involved in this. And one of the things I can say with absolute confidence that I don’t say a lot of things with absolute confidence but this I can say to you is that when you go into any innovation in dentistry you know there’s always a learning curve where you never want to get into something but we’re on the on the climbing good of that learning curve because no one wants to be a guinea pig and no one’s patient when they’re paying for treatment wants to be at that end of the spectrum, we’ve we’ve got a very much of a plateau environment at the moment, because when I first started this field. I was inundated from dentists technologists around the world with devices that were being designed, literally month by month, they’d say to me, would you would you like to travel this device.

I can safely say that’s all stopped, and it stopped because we’ve reached relatively a happy medium where at this point what I termed as, third generation devices. The device that you referred to earlier is almost a first generation device. So what makes us so powerful and so effective at the moment is that we can offer a device to a patient, which if you imagine if you put anything into someone’s mouth, it’s foreign it’s uncomfortable retreating huddles them, particularly warm to it, add to that, a protrusion of their mandible now you’ve got the ability to cause a muscle discomfort toothache and all the other added symptoms, and if you’re treating a snore you’ve just given him enough motivation to not use your device, where we’ve arrived at now is that we fit these devices in relatively neutral position.

There’s no protrusion added to that there’s no necessary need for it. And this was taken really from C pap because what we realised in C pap is that no patient arrives gets a diagnosis sleep apnea and has a pressure of let’s say 10 centimetres of water whacked on them because that would be immensely high and literally intolerable. So what they do is they build up the pressure because the patient adapts to it. And that’s exactly what we’ve created so we have what’s called titratable mandibular devices. And there’s a really good, solid evidence base for this now, and patient acceptance is phenomenal. It really is good because we’ve, we’ve almost minimised the unwanted effects by one. But the majority are not increasing or experiencing that level of discomfort that was, was was, hand in hand with initial treatment. So from that point of view I would say to you know dentists getting involved, definitely good time, and you’ll be amazed at the kind of outcomes you get.

[Jaz] I’ve been, I’ve been very happy with my patients are happy so I’m happy but it’s a, I think it’s an area I do want to learn more about and how I can take it further. So I am cautious when I can’t, you know, when I prescribes appliance I know that still is an area, developing within our profession. And like you said, sometimes being an early adopter, and that now is reaching a plateau which is which is which is good to know but I had just a few more questions now because I think people realise.

Okay, this is gonna be like a something to whet their appetite, but some people may have come across this term. I came across it from USA orthodontists marketing themselves as airway friendly, Orthodontist. And when I, when I looked in further into this, these are orthodontists which are the type of treatment they’re doing is very much a MARPE or S.A.R.P.E so there’s this thing that’s micro implant assisted rapidly platelet expansion or surgically assisted. Is that overkill or is that strong is that good evidence that that is the way to be more, you know, comprehensive treating the patient as a whole, rather than just the standard orthodontics with you if you’d like.

[Prof Ama]
Yeah, I think this is good, this. There is a degree of controversy about this topic. So the first thing I would say is that we need to distinguish two patient populations here. What we’ve been primarily talking about his adult population so we’re talking about individuals over the age of 18. Otherwise we’re talking about young patients, and when the young patients were going from children up to 18 Let’s see. The reason we have the distinguishing features is primarily a reflection of growth and growth potential. So, in the world of the adult therapy, which is where we primarily trained the dental professions and the dentist is because there’s very little variability in that field it’s a safe environment because you’re not dealing with an adult who’s growing likely to encompass different changes and responses to treatment is pretty fairly predictable.

Generally I would always recommend that as a dentist you don’t go into the field of young. people’s treatment because especially with any sort of sleep disorder, primarily because you’ve really got to have a very very very good grasp of the underlying tissues, and the response of these tissues to age change, alone, let alone the treatment modality. So I recently was invited to speak at an international meeting where my remit was pre-, let’s say adolescent and pre adolescent and the goal I was given is address the question you just asked me, can S.A.R.P.E, should S.A.R.P.E be undertaken surgically assisted surgically assisted expansion is largely reserved for the adult population so now you’re expanding palates in adults, but surgically. And the thing I would say to any clinician and just be orthodontist be dead be under the whole umbrella of dentistry is, you know, if you want to take something, then you know nothing is free for life. If you’re going to expand some of these tools, quite considerably as what you have to do. Yes, there may be change, and it’s been shown that there is an improvement in the airway passage through the nasal passages.

And that’s a distinguishing feature we need to make. If you improve the passage of air through the nasal passages that does not by definition guarantee that the back of the throat the airway tube that we were referring to gets the benefit. So yes, you’ll deliver more oxygen to that site of obstruction versus if you go back to the child patient if you start to treat, we do this treatment modalities, you probably know this is why you’ve got orthodontic friendly ones is that all they’ve done is they’ve. If you like expanded their role, inverted commas. So this rapid mixing or expansion therapy or playful expansion or splitting of a palette is largely reserved for children who have bilateral crossbites.

So what you have to picture now is if you’ve got a child or an adult sitting there with a normal occlusion, and you split their palate, and we’re talking about a centimetre to affect the change. You’re having to leave them with bilateral scissor bites. So functionally they’re going to be in a very very bad place, and potentially go on to develop other symptoms and signs which are not going to be very helpful. So, I would hand on heart ear people towards caution in that respect. There are markets within America within Europe, other parts of the world where they do this fairly, what I would call was gung ho approach where they they’re they’re quite convinced by their evidence that this is effective, and yes, as I said, there is some good evidence to support short term benefits, but always there are some complication risk factors which can be quite considerable and and growing patient that you’ve got to bear in mind.

And secondly, you’ve got to think long term for this patient population group because you know they are growing. So, initially I thought you were going to pose me that there are orthodontists who say their airway for me and then provided this treatment I was gonna say well, Orthodontist you know feel comfortable with this because we provide functional appliances for children so this is an extension of a functional pioneer in an adult, if you like. Yeah but, yeah, I think, and also, you know, the GDC are very very focused on us advertising within our capabilities and competencies so I think you’ve got to be very cautious promoting yourself but certainly if you train in dental Sleep Medicine, you know, that is bonafide recognised training. So, I think for anyone coming into this profession I would always err on the side of caution say stay safe initially get some experience behind you. And then the world is a more mega exciting place, treating snores for example is far, far less challenging than treating sleep apnea patients, and can be incredibly, just as rewarding. In that respect. I don’t know whether that answers that?

[Jaz]
No, it does. And that makes sense. But related to that, when I went, when I was looking more into some lectures here. Some theories by very eminent orthodontist in USA, they showed case reports or cases are treated of adults who had pre molar extractions, when they were younger as a first round of orthodontics. And then now, they were opening up these spaces again to place implants in to improve the airway. Yeah. Now, what that, what, what question that leads to for me is, is there any strong evidence to suggest that premolar extractions adversely affects the airway?

[Prof Ama]
In a simple word, NO. What we have to always be conscious of…And this goes back to these three pillars of evidence based practice. You can always look for literature that might support or impart support your practice, and you have to be slightly careful interpretation there. So, this whole, the challenge they’ve got in the states is that the whole provision of Orthodontic Care is in the private sector. And there are many many competing interests. Aside of the dental professionals getting involved in orthodontics so there’s the orthodontist and there’s a paediatric dentist who do this and every other profession is doing a version of. So somehow they’re trying to reinvent themselves. And, you know, it makes a lot of sense if you had to say to a patient well if I take teeth out in your mouth I’m going to make your jaw small make you feel smaller I’m going to impinge on your tone. What I can safely say to you is that even in patients in the opposite extreme where we try and open up the airway quite considerably let’s talk about the RME we said we’re expanding those patients a centimetre across the palate. Now an extraction is going to achieve. Best millimetres small millimetres two to three millimetres of expansion at very best.

So where we expand them a centimetre 10 millimetres. We’re only affecting a small change in the nasal passage of air measured very objectively and very reliably scientifically. So then to extrapolate that and say well actually, if you extract teeth by definition closing the door, jaw like transverse dimension, you’re going to exacerbate snoring problems. It kinda doesn’t really add up. And if I went one further than that and said to you really tested this theory by actually taking patients with a class three jaw, breaking their jaw doing an osteotomy for them because as you know we treat class threes. One of the things we were interested to know is if you treated a class three patient group, it was a move the jaw back naturally you’re impinging on the tongue space, quite considerably.

Do we create these patients snoring and sleep apnea, and then short and midterm results were No, we didn’t. So, where are we physically moving the jaws backward we don’t impinge on it. The thing about the airway and its collapse, is that no one true one treat modality addresses all patients and this is the complexity of it. It’s multifactorial it’s anatomical, so see puppets that theory or appliances have their effect on the anatomy. But there’s also a strong underlying physiological tendency back to the muscles again. And this is where there are emerging schools of thought at the moment about using muscle stimulation exercises or electrical stimulation so there’s a number of multicenter studies going on around the world looking at this. And these have shown some exciting results in selected populations. In other words, there are those patients who have the physiological problem, but not necessarily the anatomical problem. And this is why the results tend to be slightly varied when you look at outcomes, all appliances. Generally speaking, we do incredibly, incredibly well because we’ve shown that their role is not just anatomical there is a physiological reaction to that we do stimulate a [ ? ] with every muscle activity. And so we kind of hit a number of spheres and vectors. But yeah, I think it’s in that space is definitely evolving

[Jaz]
Brilliant and so the last question, Prof, I have for you is just based on my own observations and something that you know I spoke to some of my listeners I said look I’m getting Prof Johal on, any questions for him? and one question I got was, I sometimes see children with large tonsils and signs of mouth breathing. Should I be concerned and what can I do about that?

[Prof Ama]
And that is a very good question because. So this is where the nasal passage does have potentially can have an impact on mouth breathing, and possibly obstructive sleep apnea as well. So this is what I was saying to you that there are snippets of research which are very relevant to this field as well. So if you have a child with enlarged tonsils or adenoids. Typically, that will cause and as you probably remember back to your BDS days there are remind you of them, but lymphoid tissue follows a very specific growth curve, away from somatic growth, General Growth and lymphoid tissue. And if you like accelerates up to puberty, and then starts to shrink away so this is why tonsils and adenoids were routinely being removed in the adolescent phase because children would obstruct or snore. Quite profusely. And, you know, teenagers, it was called tonsils and adenoids was a routine procedure. So the reality is if the back of the nasal passage’s blocked, then the child does become a mouth breather. The problem for us as a mouth breathers is that humans are obligatory nasal breathe. So if we breathe through your mouth, a jaw is lowered by definition that potentially can impinge on tongue space, which potentially that can cause Sleep Disorder breathing.

So, there is this relationship most definitely that we wouldn’t deny. And so in children for example if you’re suspicious of this is certainly worth getting an ENT opinion because again it’s an invasive procedure as you probably know the government changed the guidelines in early 2019 regarding tonsils and adenoids. So most of us as a dental professional more likely now to engage and encourage or see observer should see patients with enlarged tonsils and adenoids because they’re not routinely been removed. If you do have that concern my first, the first protocol would be to refer them for an ENT and

[Jaz]
Via the GP right? They’ll be via the GP

[Prof Ama]
Via the GP. Yes of course sorry yes because the GPS are the gatekeepers of the commission of the fund if you like. Just again just to elaborate just to show you the potency of this intervention in children first line strategy for sleep disorder breathing and snoring and sleep apnea is to consider removing toxins in adults, that is how high and pivotal it is. So I think you made a really good point really, and that is something again as a dental profession, we can certainly be observant of.

[Jaz]
I think as a you know certainly some years ago I was not looking for this stuff as actively, it’s only through learning more and developing more interest that I’m actually observing for the signs and the role that the tongue plays in the sort of expansion of the maxilla. So it’s really quite interesting and I think we can sort of conclude that watch this space, in terms of airway and how as dentists we can get more and more involved. Prof, Are there any final things that you’d like to you know you have the microphone to general dentists in the nation and the world, anything you’d like to add?

[Prof Ama]
Yeah, I mean what I would say is firstly I would implore you to get involved, I think it will descend in ritual practice, add variety to your day. As a when you choose to get involved. Look for a certified course, and that will provide you that basic introduction level, and ongoing support as well. And, certainly if you’re in the UK. Yeah, let’s await the publication of this report but irrespective of what this report say is that this these patients are not going to go away, and they’re just as demanding and needing of care. And so yeah i’d implore you to get involved and I’m very very happy to hear from you know from questions and be able to get in touch with me as well but we were pushing hard to develop the Academy. And the Association, the Bridgestone Society for Dental Sleep Medicine so that would be an excellent protocol as well.

[Jaz]
Well, what I’d love for you prof is if you don’t mind just emailing me a few links perhaps that I could leave as the footnote to this podcast episode for dentists who I think a lot of dentists will be interested in because this is an area that generally a lot of dentists feel like they’re very uncomfortable with. They don’t know enough. So I think there’s lots of hungry dentists for knowledge. So if you can provide a few resources, whether it’s, you know, be the British Academy of Dental Sleep or private companies whatever just anyway we’ve gained some knowledge we’d appreciate that.

[Prof Ama]
Yeah. Absolutely. I’ll happily do that.

[Jaz]
Well, thank you very much.

[Prof Ama]
Thank you. It’s been a pleasure. Thank you.

Jaz’s Outro: Well, there we are. I hope you enjoyed that episode. I’m sure it was something very different. I hope you found some useful takeaway points about the role of airway, perhaps you’re going to start introducing this to your practice. So I want to say thanks to Matt Everett, who helped me get in touch with Prof Ama Johal. And they’ve got some airway online courses. So I’m gonna put a link to that. There is a 50% discount until the end of August, I’m told from Matt. So this is the course that I did when I started to prescribe the sleep well appliances. So I’ll put that in the on the website protrusive.co.uk/airway so that if you’re interested, you can join that. And when the NICE guidelines are out, I’ll also stick it on that web page dedicated to the episode.

So thanks again for joining me, I think next episode, I will let you guys decide. I have, you know, the fact that this is recording April, you get an idea that actually I have got a bit of a backlog. I’m in a sort of good position, I’ve got so much awesome content ready to go. It’s just about finding the time and actually spreading it out a little bit. So the next episode, you will get to decide what it is. So watch the Instagram that’s @jazzygulati and Protrusive Dental community. So if you’re like, you really enjoy the podcast, and you want get involved more with the people who listen to the podcast, then join the Protrusive Dental community Facebook group, because these are two places that I’m putting the polls so you can decide which episode will be next. So thanks so much for listening, and I’ll catch you in the next one.