Sleep Disordered Breathing and Dentistry – PDP139

Jaz’s Introduction:
We want to ADD YEARS to our patient’s lives. And if we can diagnose or we can’t diagnose, but we can screen for sleep apnea and airway issues and get the patients the help, and then we can be involved in potential therapy such as removal appliances to bring the mandible forward and that way we can have a huge impact in someone’s life.

I was always taught that the two times you can save someone’s life dentistry is A) if you detect or diagnose a mouth cancer, or B) a barrett esophagus or someone’s got acid reflux and for them to get investigated and have a camera to explore that area. However, I think a third one that wasn’t mentioned to me in dental school, but definitely should be there is sleep disorder breathing or sleep apnea because on average that can take 10 years off of your life expectancy.

And in case you think that sleep apnea is a disease of the fat old man, you are totally mistaken. So whether it’s in children or in adults, this episode with Dr. Aditi Desai, who’s just the most incredibly passionate woman ever on this topic, it’s gonna open your mind. So please lend me your ears.

And for those of you on YouTube and on the app, your eyes to this Protrusive Dental Podcast episode. Hello Protruserati. I’m Jaz Gulati.

Protrusive Dental Pearl:
I’m your host and I’ve got your Protrusive Dental Pearl for you today, which you can access in the show notes. So essentially the Protrusive Dental Pearl I have is my sequence for removing Invisalign attachments.

So it’s like a video. I’ll show you exactly what I do, how I use a UV torch to see if there’s any resin still left. The different burs I use and the polishes I use. I don’t think I have the best, I don’t know about different protocols and stuff. I just do what I’ve been doing for many years and it works really well now and then we get the Optragate in.

We use a series of burs and polishes. We get a really nice result. A few of you did ask me for a video on removing attachments, so you got it. The Protrusive Dental Pearl will be in the show notes. Just scroll down wherever you are listening or watching, scroll down and you’ll see that video. And if you like that one, give it a thumbs up and let me know.

Do you do anything different? Is there a hack that I’m missing that you want to share with the Protruserati? Let’s join the main episode with Dr. Aditi Desai, and I’ll catch you in the outro. Occlusion is just so confusing. Does occlusion even matter? Wait, don’t you just grind away all the blue marks, right?

You mean like plant it low, let it grow or leave it high and let them cry. Listen, one of these interferences even interfering with, is it safe to lengthen teeth? How much can I raise my patient’s bite? How can you stop your composite restorations from chipping? Can you raise the OVD on a patient with clicking TMJs?

Is canine guidance always better than group function? Why can’t I just use the DAHL technique on all my wear cases? Can I stop my patients from grinding? What the bloody hell is crossover? What should the occlusion look like after orthodontics? How and why do you check for fremitus? What on earth is a custom societal guide table?

How do you use a leaf gauge? Do you always need to use a facebow? Does everyone really need a perfect occlusion? What is the difference between edge wear and pathway wear? Is it naughty to adjust the opposing tooth? What the is centric relation? Occlusion is covered. One does not simply just open the bite. May the force mitigation be with you

To make sure you don’t miss the crucial update about the launch of our occlusion course, OBAB, head over to occlusion.wtf. That’s right. It’s actually occlusion.wtf. It’s almost released and you’re gonna love it.

Main Episode:
Dr. Aditi Desai. Welcome to the Protrusive Dental Podcast. How are you?

[Aditi]
Thank you very much for inviting me, Jaz. I’m pretty good. I think.

[Jaz]
You just told me you’d like to run your admin sessions and do your zoom meetings and stuff, so I’m very glad to catch you on a productive day because we want to fill the ears and the eyes of dentists, those who are watching with a very important topic, which is on the huge list of topics that are barely scratched at Dental School.

And so many dentists I know, they will gladly admit that, you know what, when it comes to airway, I have zero idea. It’s something that we’re openly saying that, you know what? We don’t know at the moment. And I feel as though, I dunno how you feel, but as a nation, we are so far behind the States and Australia. Is that something that you feel?

[Aditi]
You know, I thought that we were much further behind the States and Australia, but actually we are not. I think we are a little bit more measured in how we actually conduct ourselves. You know, we are not sort of trick in our presentation, our presence. So I think dental sleep medicine in this country has been around for a very long time.

But what we don’t have is we don’t have the regulation that we require. And for me, I think that is the most important aspect of it because we need to establish that credibility. And until we have that credibility, how are we going to actually close that gap between medicine and dentistry? Because I think that the subject matter is such that this is the one area in medicine and dentistry that’s gonna bring the two fraternities together, which I think is important. I mean, how can you possibly dissect the head from the rest of the body?

[Jaz]
Yes. It’s often the way that dentistry is like completely segregated. And I agree with you. Sleep is such a great connector of both the medicine world and the dental world. But before we dive into that and we talk about the guidelines and the changes and how dentists, no matter where you are in the world, I mean particularly UK cuz talk about UK based guidelines, but wherever you are in the world, how you can get involved, what are the things they need to look out for in general practice and how to better serve our patients.

That’s the mission of this podcast episode. But I wanna learn a little bit about you. Tell us about your journey, how you ended up interested in this niche field of dental sleep medicine.

[Aditi]
You know, I’ve been a dentist graduated 45 years ago, and I’ve pretty been, I’ve been a very lucky person. I’ve had a wonderful career.

I’ve done dentistry in every field that you can think of. But the one spot of dentistry that really rang my belts was airway and I actually came across this when, many years ago when asked the BBC dentist, a patient, came into my clinic from Australia, gave me some really stinky, smelly silicone monoblock and said to me, ‘Can you fix this?

And I looked at it. I thought, what is this? And he said, it helps me sleep. And you know, he wasn’t a pleasant man. So I thought, well actually I don’t know what it is. So I think it’s better to say you know, to learn to say no is so powerful. So I said, I’m really sorry, but I can’t.

But my mind took me back a little bit and I thought, you know, what was that? What do you mean silicon monoblock that helped you sleep? So I started looking a little bit into it that I came across a British Society of Dentist Sleep Medicine, and that is my journey. And I started to learn a little bit more, you know, attended a course, then they invited me to join the board and then, I think about seven years ago I was elected president and I remained president.

I wish somebody would want to take over my job now. But we’ve been very lucky because it’s actually given me an idea of how dentistry goes beyond drilling, filling, restoring, whitening, and aligning. I think all of that is very important of course, but to be able to actually look at a patient and be able to help them with their quality of life is as important as whitening somebody’s teeth. And making them feel good about themselves. So that’s my-

[Jaz]
Agreed. This is something that can add years to our patients’ lives and improve their quality of life. How I am early on in my journey, but definitely something I’ve looked at thought, wow, I need to start screening my patients more. And the way it happened with me was a similar experience to you.

I was at Guy’s Hospital, I was a DCT, and I was working on the consultant clinics and we had one clinic. About once a month, every two weeks where we would see patients who had a positive diagnosis from the sleep condition of mild to moderate sleep, to breathing or sleep apnea. And then we would be making the exact same.

Can you believe it? This was 2015, the monoblock silicon appliances at the hospital. And then I was like, what on earth is happening here? And then as I delve further into the world of bruxism and TMD then I realized, whoa, this is connected so much to sleep. And we’ll touch on that. So, it is great to hear of your drive and your passion to spread the word.

So I guess the first starting point for the dentist listening to this, who has no idea what’s going on, what is this sleep apnea? Can you just start by probably saying something that you probably say to a lot of introductory talks. What is it that we’re up against? What is the main issue? What is sleep disorder breathing, essentially?

[Aditi]
Right. So sleep disorder breathing is a syndrome. It’s a collection of disorders which create a syndrome where people are not able to sleep and breathe efficiently enough when they do try and do that together. So it’s really a disease of sleep. It’s also a disease of breathing together. So whether you sleep in the day or you sleep at night, whenever you sleep, you have a problem.

It’s really all about the collapsible airway. It’s the unsupported part of your airway, which has no bony or ligamental support, which tends to collapse now when you have complete collapse, for 10 seconds or more, that’s called a sleep apnea. An obstructive sleep apnea. Now, that has got to be distinct from central sleep apnea, which is a neurological condition.

So that’s got nothing to do with us, and we don’t get involved in treating patients with central sleep apnea. So for us, obstructive sleep apnea is at one end of the spectrum, and at the other end of the spectrum are people who snore. So you know, we all snor. Now and again, we have a good night out. We come back, lie on our backs up.

You know, we’re snoring away. That’s okay. That’s benign snoring. But when somebody’s snoring every night through the night, that actually becomes pathological. So if somebody’s just snoring all night, they still can wake up in the morning feeling tired, because the brain is being aroused constantly through the snoring.

And not only is it affecting them, it’s also affecting their bed partners and people who are in the house. So it’s almost like treating two or three for the price of one. When you treat somebody snoring. And when you try and think about, I think there are a billion people globally who have this disorder syndrome, and only about 20% of them have been diagnosed and treated. In this country, we are looking at over 2 million people who have this disorder and only 20% may have been treated and diagnosed.

[Jaz]
My son is actually in that category. He’s only three. He’s having his adenoids removed in two weeks. He had a positive diagnosis. He had a home sleep test.

It was 21 seconds where he was not breathing, actually. They found that. So, again, from my own experiences, again, another reason I’ve taken an interest in myself. So, the dentist might be thinking, wait, what has this got anything to do with teeth?

[Aditi]
When I mentioned the number of 2.2 million, I was talking about adults. And children, men are managed differently, although their symptoms may be the same. You know, they don’t perform that well at school. They are sort of somewhat, they might even have bad, bad wetting. They might have behavioral issues. You know, all of these are part of a child’s sleep apnea problems and they always get put away as the naughty child or the difficult child because they may even have ADHD.

But, you know, to treat a child patient who has deep apnea as a result of tonsils. It is actually, it’s amazing cuz I’ve seen some of my patients, one or two child patients who’ve had their tonsils removed and by the time the GA is gone and they’re awake again. They’re a different child. It’s as remarkable as that.

[Jaz]
I’ve heard that a lot myself, a load from dentist, parent dentist whose own children, have been through it. They’ve told me that they’d actually have to keep checking if my child is still breathing because what they realize actually their breathing is much quieter.

[Aditi]
Yeah.

[Jaz]
That’s the first thing that people / parents told me actually.

[Aditi]
So, but you see, this disease is no longer a fat and 50 man’s disease. I mean people used to, when I first got into this field, any man that walked into my clinic had a big punch of big fat neck and his posture was trying to open up his airway.

I kept thinking, he’s sleep apnic, he’s sleep apnic. I could be on a bus, on a train. I said, he’s sleep apnic. But I’m very wrong. It was almost like a hammer and nail situation. It was absolutely not that at all. But now I, the majority of my patients are not fat and 50. They’re females. They’re males. They’re very young.

My youngest patient is 17 years old. You know, adult. When I say adults, 17, almost 18 years old. They are slim. They’re incredibly thin. They have very long, thin, narrow face. They’re very slit noses. These are the things that we look at, the very sort of narrow arches. And these are the patients that I see a lot of.

So it’s no longer a fatten 50 man’s disease. Of course there are fatten 50 who are sleep apnic, but you can’t stereotype them anymore. You can’t just look at a thin person and say, well, you’re tired, you’re snoring. It’s fine. You’ll be fine. They may not be fine. They may have serious sleep apnea. So that’s where, I’m very keen.

Every dentist who looks at a patient, looks in the mouth and sees their telltale signs and has the telltale symptoms, they should just have their red flag up thinking, let me just assess them mentally. Once they’ve done the mental assessment, then they can ask a couple of pertinent questions and then get them screened officially and formally diagnosed by a Sleep physician and then treated.

So if a patient comes in, for example, and says, ‘Mr. Gulati, I’m actually snoring and my wife will not sleep with me anymore. Can you please help me?’ And you say, of course. You know, let me make your mandibular advancement device or a mono block or whatever you decide to make them. You will be actually working against guidelines.

Because our guidelines have changed. We have to assess these patients, have them formally diagnosed by a medical professional, that medical profession will then give us an outline of what they believe to be the right pathway. But that doesn’t mean that you don’t treat the patient while they’re being assessed.

[Jaz]
Mm-hmm.

[Aditi]
Because remember we look at the NHS pathways and the NHS pathway we’ve got a long, long waiting list.

[Jaz]
Absolutely.

[Aditi]
You get these patients to wait for two years before they’re seen. In fact, I spoke to one of my ENT consultants this morning. He said he has a five year waiting list in the ENT Hospitals.

[Jaz]
Wow.

[Aditi]
Five years. Now, whether that is for surgery or whether that’s for CPAP, I don’t believe that CPAP will be five years. Although we have had this latest CPAP debacle where the Phillips recalled all their CPAP machines, so there’s been a huge shortage. Now, these patients need treatment. If you’re a snorer, yes, let your wife sleep in the second bedroom for a couple of nights, you know, maybe a couple of months.

That’s okay. That’s not gonna be too much of a slippery slope, however, these patients giving them treatment with a mandibular advancement device while they’re waiting for their CPAP Machines giving them some treatment rather than no treatment at all.

[Jaz]
Can I just stop you there cuz I think we’re touching on something really, really good and I like how you’ve gone right in and this is gonna be very, very good, but let’s make it even more tangible because many dentists actually have been on a course to treat snoring and then maybe fell into, oh, hang on, if I’m treating snoring, I also need to do this tickbox of exercise of screening for obstructing sleep apnea.

And then they sort of back off and refer. if it’s high risk and then medium risk, they just go ahead and treat. So with the new guidelines, I think it’s August, 2021, right?

[Aditi]
Yes.

[Jaz]
So we’re referring to the same guidelines here, and I’ll share that in the show notes for those listenings so you can download those.

So if you’re wanting to treat a snorer and you have done your screening and you feel as though that this patient is a simple snorer only and you feel as though that they don’t have the high risk signs of obstructive sleep apnea, can a dentist go ahead and make that mandibular advancement splint without referring to the gp? So that’s the first thing I wanna unpack.

[Aditi]
So what the British Society of Dental Sleep Medicine have come up with is it’s almost like an algorithm. It’s a guideline. You know, it’s giving you a pathway of risk, high risk, low risk, moderate risk, and you know what to do. See, if a patient is low risk, asymptomatic, the word is asymptomatic.

That is the most important one. Okay. And as soon as they’re asymptomatic and they’re snorers, yes, go ahead and make the device, the mandibular advancement device. But documented record that says that you made this only for snoring and advise their GPs that you’ve actually made a splint for snoring only.

The next important thing is these patients need to be followed up because this disease or syndrome is one that gets worse over time, age and weight. So somebody is just a benign snorer or a pathological snorer and asymptomatic may get worse as they get older and fatter. And we all get fat as we get older. Now I’m also, I’m a little bit floppy as we get older. You know, that’s a fact of life, unfortunately, much as I deny it. But there we go.

[Jaz]
With those in the medium and high risk, now before we follow the algorithm and you can share that, what are the symptoms that we are listening for and what are the signs that we are looking for as a general dentist so that we can start to have an involvement in this very important area of what is the interface of medicine dentistry?

[Aditi]
So a patient will not come to you saying, I’m going to the bathroom three times a night. Cause we are dentist, they’re not gonna come to you and say, you know, I may come to you with a headache but they’re not gonna come to you and say, you know, I wake up feeling terrible every morning cuz that’s not what we do.

But they will come in and say, I snore. And they might so say, gosh, I just feel so tired. Or you are treating them and suddenly fall asleep. Or they might start snoring just that they’re go into that light sleep. They might just start snoring. These are telltale signs. The other symptoms are that they might be tooth grinding.

They might be complaining to you of TMD or facial pain or headaches. These are the most important cardinal symptoms and signs that they would present to a dentist with. If on the other hand, a patient is coming in to see you and you think that they’re looking red-faced, they’re punchy, they’re fat, and they’re on a cocktail of hypertensive drugs.

Or they’re diabetic or they’ve had a stroke, and you look in the airway and you can’t see the airway. These are things that you need to look at and say, well, okay, maybe let me just ask the question. By the way, how do you sleep? How do you feel when you wake up in the morning and he says, oh God, I feel terrible when I wake up in the morning, when I wake up with a headache.

Or people are not aware. They don’t know what to say to a dentist when they come in. It’s all about education. It’s all about education, raising awareness, and then providing access to treatment. For me, that’s my mantra. Raise the awareness, provide the education, and then give them access to treatment.

That treatment may be something that we are providing. Or provided by somebody else. Now going down the algorithm. So if they’re asymptomatic and snores, you provide them with a mandibular advancement device, but make sure that it’s documented that you’ve done that and advise the GP that this has been done so.

[Jaz]
Got it.

[Aditi]
That’s the most important thing that we have to look out for. If, on the other hand, they come in complaining of snoring, but they’re symptomatic and they’re very tired and they’re sleepy in the day, then they must go for a formal diagnosis.

[Jaz]
Formal diagnosis. Even before you’re make an appliance only for the snoring.

[Aditi]
Yeah. If you make that, well, not the diagnosis. If you think that this patient is symptomatic, they are at risk of OSA. The guideline says that you refer them on for a formal diagnosis, okay?

[Jaz]
Mm-hmm.

[Aditi]
But you can make them a mandibular advancement device just to combat their snoring while you send them off for a formal diagnosis and make sure that you advise whoever you’re referring to or the GP that you’ve actually made that the splint only for them to be able to sleep or sleep with a bed partner for snoring. That’s it.

Not because you’re saying, oh, actually the treatment for this patient is a mandibular advancement device. Because doctors do not like us treading on their territory. The other message is to make sure everyone realize it, this is not a dental condition, it’s a medical condition.

[Jaz]
Mm-hmm.

[Aditi]
It’s a medical condition that needs dental intervention. And this is the first time that the NICE guideline actually acknowledges the role of dentistry. It’s taken me almost 10 years to get recognize that actually dentistry has a pivotal role in managing these patients. And not just dentists, but also the whole dental care professional.

The hygienist, the therapists, cause who sees the therapist and the hygienist more than anyone else. The patients will see them more often than us. Right?

[Jaz]
Absolutely. I think you’ve covered a really wonderful thing there. How we should not be writing in our notes the diagnosis of obstruct sleep apnea.

That’s for the medical, that’s for the physicians to do. We can write, screened for, and moderate high risk and then arranged the referral. So the first question is, in the, in the UK obviously it might vary in different country, but in the UK we need to be referring this to the GP. Now I use our little S4S, have a little docket that, that is a very nice little template to GP. Do you guys have something to give the dentist to help the referral?

[Aditi]
Absolutely. So the British Society of Dental Sleep Medicine, we’ve actually just about to launch us, our new website. And when people become members, you have access to not only the, the algorithm, the pathway.

And we also, and that pathway by the way, is accepted by the ARTP, which is, you know, the British Sleep Society, ARTP, where they will actually they’ve actually said, yes, we recognize this as an acceptable pathway for dentists to follow. And that’s also very powerful. So it’s not just dentists telling dentists that we are okay.

It’s the medical fraternity that’s telling us that yes, actually what you’re doing is correct. So we’ve got that pathway. They also have access to screening documents. Screening questionnaires, and they also have access to consent form that we have actually gone through over and over again to make it fairly robust to make sure that we don’t fall into the pitholes because, you know, now this is now on the actual radar of certain, maybe even some of the indemnity insurers we need to make sure that everyone who is protected, you know, we may think that a bit of tooth movement, a bit of jaw pain may be okay, but actually there’s no need for that to happen.

We can do everything we can to mitigate those side effects with the use of the appropriate device. So the one thing I always stress to all my members and to anyone who comes to me for any advice or help is yes, go ahead and do your courses.

Go ahead and get industry led courses if you want to, but if you really want to do the right thing, learn to use more than one device because one device does not fit all. There’s no such thing as one device. It’s almost like the CPAP masks, right? One CPAP mask does not fit every person, so each one has to be personalized. We have to do the same thing for oral appliance therapy, so we are about to create a consortium of Oral appliances that people will be able to pick and choose from.

[Jaz]
This is brilliant. And just wanna add I have the same philosophy with occlusal appliances. I manage a lot of bruxism stuff and part of the very first thing I do is an airway screening.

So if anyone is as high risk, I would not make that occlusal appliance, cuz from what I believe and what I follow in the literature I’ve read and occlusal appliance for bruxism can make your obstructive sleep apnea worse by opening the OVD and distalize manual, making someone more class two. So, if anyone’s high risk, I’ll always refer them on before making the appliance or because the correct appliance made for them may be something that will also help the airway. So yes, it’s not just everyone gets a Michigan spin or everyone gets soft bite guard in that regard as well. So it’s very similar.

[Aditi]
You can make a splint upper or lower or whatever you wanna make for every patient, but if there is a risk of sleep disorder breathing for you, like you said, make it protrusive.

If you’re making a protrusive splint, then the patient will be fine. But you know, we have so many patients that have been treated with Michigan’s and tanners and we’ve made them apnic. I’ve just seen a medical legal case that I’ve been treating recently, and this gentleman had a class three jaw alignment, went to Maxfax surgeon.

And instead of looking at his maxilla, which was underdeveloped, they retruded it with surgery and orthodontics. They’ve made that patient severely apnic. Now, you know, we are gonna have to do corrective surgery, so I’ve just made him an occlusal appliance, you know, with all his pins and screws and everything, and it’s gonna be a really long, protected legal case.

But I’m terrified because I, having to protrude that jaw, with all this you know, surgery that it’s had is quite challenging. But, you know, we have to be careful that patient assessment is so important. Making them if you don’t assess the TMD, for example, that’s your baby, right?

So if you don’t assess the patient properly, for potential TMD issues, with the splint, then you are really going to, you know, get yourself into trouble.

[Jaz]
And I had one colleague recently who posted on one of our forums on Facebook that a patient came and he had snapped a post crown on the upper lateral incisor, and the patient felt as though it was from the pressureof the appliance and she wanted to know, is that, is that possible?

So can you please explain about what kind of adverse effects could happen with these oral appliance therapies to bring the mandibular advancement splints because we need to appreciate, just like you said, for there’s main different designs and therefore we need to pick the correct design based on the occlusal features and the dental features that were presented with.

[Aditi]
Do you know? You’ve hit a very important point there. I have learned, all have learned through my mistakes. That’s the best way to learn cuz you don’t wanna make them again. I remember I was sent a patient by one appliance company through their marketing and they asked me to make a device for them.

And that device was not suitable for this patient because this patient’s mouth was full of bridges and crowns that I had not provided. And because they were metal ceramic, we took the radiographs, they all looked fine. No problem at all. No root care is nothing. And then of course, in my wisdom, which was not a good element at the time, this many years ago, I provided him with a device that was holding onto the teeth in a different manner to what other devices do.

So he was literally gripping within the triangles between the teeth. So the next day he came, I provide the device. He was really happy off he went. Two days later, he comes back into my clinic and he chucks the device at me with the bridge in the devices. And I looked at and I thought, oh, you know, and it was completely rotted.

It was so badly rotted. And he said to me, you have done this. And I said, no, I haven’t actually. But what had happened is because I could not assess that treatment, and it wasn’t treatment I had provided, I couldn’t tell how good or bad that restorative work was. So we dug the bridge out and we repaired it and we you know, put a root post in, put it back in.

But you know, it never really worked well because of that, I was always worried and the next time, that post came off again and I realized actually that I had made him the wrong device. I should have been a bit more knowledgeable about what kind of device that gentleman needed.

He wanted something that was gonna be easily repaired, easily adjusted to a new bridge. Where there might have been a silicone lining, perhaps, maybe a SomnoMed® device, which would have a silicone lining that is adjunct, that is actually replaceable. Say for example, the S4S device, the SleepWell.

That also has a silicone lining, but that lining is not replaceable. You can’t replace it. So, but this silicone lining in the SomnoMed® devices, you can replace it. So if a patient comes in, tooth breaks, you put a onlay, inlay, crown, whatever you do, all you do is re-scan or re-impression, send the device back to the lab, and they just put a new lining in. So that’s why I go back to the thing. You must have knowledge of more than one device.

[Jaz]
A hundred percent.

[Aditi]
And this thing about TMD for example, you know, it’s a myth that you can’t treat any patients with TMD. In fact, sometimes with the right assessment you actually make these TMD patients better. By opening up that jaw and protruding is slightly-

[Jaz]
Down and forward.

[Aditi]
We can get that disc recapture. So these are facts that we need, so the blanket statement do not touch patients with TMD. Do not make a device for people who are bruxing cause they’ll break it.

It’s not true. It’s just not true. In the same way with periodontal disease, do not treat people with periodontal disease. That’s half the population.

[Jaz]
There’s just other appliances that we need to learn about that you can use the appliance without putting pressure through the periodontal ligament.

[Aditi]
Not only that, but did you know that there’s a bidirectional link between periodontal disease and obstructive sleep apnea?

One makes the other work. Inflammatory Disease. Both of them create inflammation and periodontal disease gets worse when people have always say there’s absolute, there’s quite a lot of work that’s been done by Jill Levine from –

[Jaz]
Yes.

[Aditi]
And also by Maria Carra Clotilde a great friend of mine from Paris. Now, she gave a wonderful talk at the RSM last year on periodontal disease. Now, if you see a patient with periodontal disease, not people that you just blow or click it and the tooth drops out. Of course, these people need a bit more care, but you know, people who have got uncontrolled periodontal disease, you should be thinking, why can I not control this?

Do they have the additional signs and symptoms of OSA? You treat OSA and that periodontal disease can be controlled, not in every case, but they can be controlled.

[Jaz]
It’s another factor to consider, isn’t it?

[Aditi]
Exactly. So I think that if you then have a device that you treat the OSA.

Motivate these patients who are not, who are pretty gently feeling crap anyway, and they don’t want to, they’re not motivated to seek help, make them feel better, and then they can go and seek help. So, I wouldn’t discard every patient with periodontal disease. You have to guard the guideline actually does say that, you know, we guarded with TMD and periodontal disease, but I’ve just written a big document for the transformation services, of sleep services in this country with the NHS.

It’s gonna be published soon. And in that I have actually documented provisors that do not discard patients with perio disease. Do not discard patients with TMD. Treat them with a little bit further assessment.

[Jaz]
Yeah, I think that’s needed rather than a blanket statement. Now, Aditi, just so following on the path, let’s say we have that moderate to high risk patient and we’ve been a very good GDP.

We’ve done the screening, we look beyond caries, and perio. We are looking at a patient as a whole, but we make that referral. Using, let’s say the society sort of pathway and form. And it goes through a GP now, hopefully, and I, I want this episode to be listened to by GPS as well.

Cuz some GPs, they speak to some patients and they say, nah, you’re under 50. Uh, what’s your BMI? Nah, you probably don’t have a obstructed sleep apnea. So this very much, I know you know this. Very much exists in the medicinal world as well. They need more training. I think they realize that as well, actually.

So there’s a huge change and shift coming in terms of medicine and dentistry, in terms of learning more about this condition. Now, let’s say you get a GP who I find that with these referral letters, which are quite nice, they actually give the GP a lot of information to go by and that GP is then able to make the referral to a sleep physician.

Am I right in saying that I as a GDP cannot refer directly to a sleep physician? I have to go via a GP? Is that correct?

[Aditi]
Not necessarily anymore. We are actually looking at direct referral into a sleep service, and that is something I’ve been driving for as well, because-

[Jaz]
Absolutely.

[Aditi]
I’m sorry, but not everyone has the, they’re not, everyone’s not the favorite view. They can afford private care. We need to make the pathway simple and less onerous for the patient. I mean, come on, this is about patient not about us. And the GPs are not interested in a lot of cases. Not everyone, but a lot of GPs are not trying to actually train GPs to make them more aware of what their role is has been a bit of a challenge for everyone.

The RSM, the sleep section of which I sit on the council, the dental section, we’ve all been trying to get the GPs to be a bit more engaging, but they’re so busy and inundated. This is the last thing they want to do.That’s my opinion. Okay. That’s my own personal opinion.

[Jaz]
I hundred percent agree, from what I’ve seen, I know you’ve seen much more, but from my experiences with other colleagues and the fact that one of my patients the other week told me that he had to literally get a heart attack to be able to be see a GP face-to-face nowadays.

So again, another barrier because the times that are actually getting to even see a GP is, can only be slowing down the workflow.

[Aditi]
Yeah. So that’s why we are trying to get these referrals straight into the sleep service. The NHS sleep services and make it less on risk. But again, the other drive is that’s assessment, screening, and diagnosis is actually going to be brought into primary care, and that is why the dental role has become even more important.

So we are looking at dentists. pharmacist, GPs, all of them are gonna be more and more involved in the initial screening and assessment of the sleepy patient. And once that’s been established, then they can be sent into secondary care and then into tertiary care if necessary.

Cause a lot of them are tertiary referrals. They do need tertiary care. I mean, at one end of the spectrum, you’ve gotta be nice snores. At the other end of the spectrum are people who cannot sleep and breathe at the same time. They just can’t do both together. So these are the people who need to be artificially ventilated.

And these are the tertiary referrals. But I mean, we don’t get involved with those. Cause the moment you see someone who comes in and says, by the way, , I’m sleepy. For example, if they want to say, oh gosh, I’m always sleepy, or you think they’re looking a bit sleepy. Did you know that the bags, the bluish gray tinge around the eyes is also a very cardinal symptom of somebody who might have OSA?

So, especially in a child, you know? So if you look in the mouth and you think, you know, airways blocked, tooth grinding, you know, neck is fat, he’s snoring. You know, gray eyes. I mean, isn’t that enough to say to you, let’s get this patient screened. Just to go one step further, Jaz, home sleep testing.

In the states, they have been very adamant to not allow dentists to carry out home sleep testing. That’s the ambulatory sleep testing. You know, the way their patient is given the kit, they either bring it back or they throw it away and you get the result through the cloud , they have actually relented somewhat in some states, but in this country now we can give out home sleep tests as a dentist.

However, that sleep test must be formally reported and assessed by a sleep physiologist or a sleep physician. You know, who has the expertise to-

[Jaz]
Could you recommend a service that you use in terms of a dentist who may a little bit more switched on and wanna start, you know, listening today? Then we like, oh, I didn’t know I could do this.

[Aditi]
Absolutely. So what I do is I use a kit called the WatchPAT One , which is an ambulatory one that you give to the patient, you lock it on the system that do the test at night and then throw it away. I get the results through the cloud, but I also elect for that on the system.

I elect for that test to be reported formally by one of my medical colleagues for example, and they, I’ve got a dearth of them, so I get the report back saying, this patient has, is snoring in this body position is positional snoring or positional sleep apnea stops breathing. So many times the AHI score or the oxygen levels are desaturating to the point where we recommend that this patient should have a CPAP trial or they might just say if the patient is a bit sort of on the borderline, they’ll say, well, actually they could also try a mandibular advancement device. So that’s for me medical legally that keeps me in the clear. If by then, make them a medical oral appliance, that’s fine. The guidance does say that, you know, for anyone sleepy, whether there’s a snorer, mild, moderate, or severe sleep apnic, they should have a CPAP trial no matter what the level of disease.

[Jaz]
Yeah, I was gonna ask you about that because I felt, when I read that in the guidelines, I know it’s great that they’ve mentioned dentists for, in the guidelines, but from reading that it’s like every patient who gets that diagnosis, the gold standard is a CPAP. And then, so what we’re waiting for is really a leftovers.

So, how do we work with the, how do you get busy because you wanna help these patients who can’t get on with their CPAP. How do we filter those patients? How do we get, how do we attract those patients? I guess that’s a big topic as well.

[Aditi]
So that in itself is quite, that’s a very moot point actually. So if a patient is, they’re go into sleep service and they are all given CPAP, we know that we have as much, as many as 50% of people who will either be intolerant or unaccepting of the CPAP. So this is plan B for us, which is why the next one.

[Jaz]
Aditi, can you just mention for those young dentist listening who’ve never heard of CPAP before, why it’s not so sexy, or why it might not be so sexy and what it does and how it works?

[Aditi]
So, CPAP is actually a mask that you wear over your face. All the nose and what it does, it’s like a pneumatic splint. It’s got a big sort of elephant trunk with a little machine that sits on the side of the bed and what it’s doing is actually pumping air into the airway and it’s actually opening up that airway.

What it’s not doing is not pumping oxygen or air into your lungs. It’s only opening up that airway, which has collapsed in order to keep it open so the patient can continue breathing normally. So these are the patients where the claustrophobia of the mask or the nasal, where if they’ve got nasal congestion, they may not be able to tolerate the mask itself, the air going through the nostrils and some people, because it’s quite an unrest thing to wear.

It’s not sexy, like you said. They don’t wanna wear it. And some of machines are quite sophisticated, but they may not be the ones that are available on the NHS, the ones that are available on the nhs. Some people might find them noisy. Bad partner might find them noisy. Pregnant women find them intolerant because you know they have to sleep on the side and the mask keeps on shifting away.

So there are lots and lots of side effects. People talk about the side effects of all appliances.

[Jaz]
Yes.

[Aditi]
If I give you a list of side effects where if you ever come to any of my courses, I’ll give you a list of side effects that have been shown for CPAP, including skeletal changes, including dental changes. These are important points that one needs to remember. It’s not just your appliances that have side effects. Everything in sciences has a consequence.

[Jaz]
I guess the other thing worth mentioning is I know of some colleagues who spoke of some patients who might travel a lot and they can’t take their CPAP on their flight with ’em, and they’re afraid to fall asleep on their flight because they’re worried about the whole snoring and whatnot.

And the fact that if they go camping and whatnot. So sometimes, these patients may be in a situation where they rely on their CPAP at home cuz they get along well with it, but for holidays of other times, they may well benefit from an oral appliance. How do you see that fitting into it?

[Aditi]
So that’s actually quite a good way of describing it because I think it’s all got to do with raising awareness. If you let the public know that there’s hope beyond CPAP, then they will come to you for help. People don’t always want to wait for the NHS. They’re long waiting lists. They’re fed up.

They feel that the wife or the husband, and I don’t wanna be sexist here, if one of them gets into the second bedroom or sleeps on the couch, they see that as a slippery slope for their marriage. And I think for them, they need help. And they need help desperately. So when they come and see me, for example, they never say to me, oh my God, I just want you to treat my snoring.

I’m fed up with it. They will never say that to me. They’ll say to me, look, I’m doing this for my bed partner, my wife, my husband, or girlfriend, or whatever, because she is not getting a good night’s sleep or she’s fed up or she’s in the other room, you know, so they’re doing it for others, not just for themselves, but they don’t care whether they’re snoring or not because they don’t wake up if they are waking up constantly and they’re waking up choking as a result of, because all snorers are not sleep apnics. But all sleep apnics are pretty much snorers.

[Jaz]
Yeah.

[Aditi]
That is a distinction you have to make. So if you’re treating a snorer, are you treating just the snorer or are you treating the sleep apnic? If you’re treating the sleep apnea, the byproduct of sleep, treating the sleep apnea is they’re gonna treat their storing as well.

So that’s more important to remember. So you were asking me about how do we get these patients, well, you get these patients by raising awareness, providing the patient with knowledge of what is available out there. And if the patient then decides and elect not to try the CPAP, as long as it’s documented, then you can safely make them an oral appliance. But everything has to be documented. Remember, medical legally, if it’s not written, it did not happen.

[Jaz]
Yeah.

[Aditi]
I cannot tell you how important that is.

[Jaz]
Well, I really appreciate everything you covered and also for sharing that difficult experience you had with a patient with a bridge. I think that’s so real world for us as general dentist and restorative dentists it’s great to really be nice to hear over your experiences and your learning journey.

The main thing we wanna wrap up with is getting this information to the dentist so that. I’m hoping was a real eyeopener and an ear opener for dentists who are just very new or haven’t heard of steep soil breathing and how we have a role in screening. And then for those patients who do not get along with their CPAP or as an adjunct too for when they go on holiday and stuff, may need a mandibular advanced splint.

We need to learn more and we don’t need to just go on one industry led appliance and give that same appliance to everyone. We need to give a few different appliances. So please, how do we get involved in the UK as a dentist and around the world? How do we get involved to learn more from you guys?

[Aditi]
Call me, I think, no. I think the most important thing is get on the British Society of Dental Sleep Medicine website. There’s a death of information there. Yes. You know, we’ve got a new website coming. It’ll hopefully, I hope it’ll be launched by the end of the week or next week. If it doesn’t, it’s not my fault. But to attend a course that’s led by a credible society because we are now part of the British Sleep Society. So we are actually working with the medical people. Not just dentistry on its own.

[Jaz]
Perfect.

[Aditi]
It’s not a coffee club anymore. So I think for me that is important, having industry led courses, which are, you know, industry is so desperate to get into since the publication of NICE Guideline Industry is in here, running courses, you know, showing them how wonderful their devices are, of course they are.

Please, let’s be measured about this. Learn about the basics of sleep disorder breathing. Learn about how to treat this patient effectively and safely, and then learn about the various devices afterwards because you know you will find your own favorites. You’ll find the ones which were favorites.

I mean, for example, I was the face of Novel. You know, I’ve done videos with them, I’ve done photographs with them. I’m on the internet, but you know what? I don’t make any of their devices because I’ve had more problems with those than any others. But that doesn’t mean I’m stating it. It’s in my own hands what works for me.

There are others who will have other devices, but that for me is if you go into the BSDSM website, you will be able to. courses, which are unbiased, totally unbiased, you know, and we have mentorship-

[Jaz]
And there’s one on the 16th or so. I just saw on your Facebook, you didn’t tell me, I just saw the 16th September in Manchester. So that’s an example of one of the courses that you guys run. would the course like that obviously covers a lot of theory in terms of screening, diagnosis, how to work with the GP, but to what extent does it cover oral appliance therapy?

[Aditi]
It covers all of that. The only thing that we are not doing face to face is because of Covid, but now we are going to get back into face-to-face where we’ll have a hands-on element. So on the 16th, although I’m not running that course, cuz I’m doing, I’m not running another course on the 16th, the people that are running the course, that my board members, they are very experienced.

And they will show everyone how to take a George Gauge registration, for example. Cause if you get that wrong, scanning and taking impressions is pip squeak. We all know that. That’s not skill. The skill is getting that jaw registration correct. Cause if you have any aviation, then you’re running into trouble.

And that’s what is the most important thing, especially when you’re working with precision devices that are so accurate. You’ve got to make sure that absolutely.

[Jaz]
Like the Somnowell, right. I’ll just name a brand. Is that classified as a precision device?

[Aditi]
I wouldn’t call the Somnowell, a precision device. I haven’t used Somnowell for the last 10 years, maybe. I work with ProSomnus very closely. They’re the American company. I work with Panthera, which is from Quebec. I do provide so devices as well. They’re very good. They’re market leaders too, but I think those three are probably the ones that I work with most closely.

[Jaz]
Mm-hmm. And I like that. And just like, and it very much backs up what you said, you know, and I’ll say it’s, look, I’m friends with S4S look, I’ve used our appliance for, but I just feel a lot of my colleagues are GDPs because they’re so good at marketing GDP, all they know is a Sleep Well appliance.

And that’s it. and so, I think we owe it to the presion in our patients to, to think, you know, beyond the soft sprint for everyone, beyond the Michigan for everyone beyond the sleep well. So we need to do that. And I think BDSM is a great place to start. So I’ll put all the links in a show notes.

When I email out my list, when I launch this episode, I’ll make sure there’s a direct link to go through website so you can learn more. So this could be the starting point, at the very least, if you can screen patients and start making those referrals and having those conversations, I think we’re gonna improve the health of the nation.

[Aditi]
Absolutely. And Jaz, one other thing before I go. So we also have an Academy of Dental Sleep Medicine, of which I’m also the president. And what we are doing is we are actually working with the Academy on behalf of the society to run courses, which are not just foundational courses, but you know, going that little bit more.

Cuz what I don’t want to do is end up like the, when you ended up years ago, becoming an implant dentist, you went to a table, you had a pig jaw, you drilled a hole, you put the screw in, and you thought, I’m now an implantologist on Monday morning. We have gone beyond that now, and we want to teach, I want to teach the members what can go wrong and how to manage it and what not to do more than how to do the right thing.

Because you know, like I said, scanning and impressions are not that important. So we have a website for the Academy of Dental Sleep Medicine as well, and they’re gonna have modular courses online. And then eventually, very soon, we are about to launch. Well, we, we’ve got the master class that we launched in 2019, but then Covid hit.

So we are gonna relaunch it in October, September, and then the PG cert also goes out, hopefully.

Jaz’s Outro:
Brilliant. I’m gonna share that link with everyone. Check it out myself as well. So, amazing. You’ve been, you know what? I love your style, Aditi. You’re so direct. I hope you hear that.

I hope people praise you for this, because I just love, like, boom, boom, boom, boom, boom. You’re so succinct. There’s no waffling. I love that type of educator. I definitely wanna learn more from you. Really appreciate you coming on and sharing so concisely, so beautifully with all the dentists listening, and you are more than welcome to come again.

Well, there we have it guys. Thank you for listening all the way to the end, and if you did so then just answer a few cheeky questions and get some CPD. My team will email you certificate and we’ll keep doing so for as many episodes as you want. It’s just one of the many benefits of being Protrusive Premium Member.

So if you download the app or go on the app on Chrome, if you just use type in on your URL browser protrusive.app, it’ll take you to the app homepage. Once you actually have an account, you can actually access the app through iOS, Android, and the website using that same login. Because let’s face it, some people just like to learn on a laptop and not on their device.

If you felt inspired by Dr. Aditi Desai to learn more, then the best thing I can recommend wherever you are in the world is to attach or align yourself with your local dental Sleep Medicine Society. Now in the UK we do have the British Society of Dental Sleep Medicine, and they’ve got an event on the 4th of March.

It’s like a member’s day. And if you’re interested in getting into space now, you should totally check this out. I’ll put the link in the show notes below. But like I said, if you’re in the US or Australia or wherever you’re around the world, there’s some lots of great societies to align yourself with. If you found this episode useful, please do leave a thumbs up if you watch you on YouTube, and don’t forget to hit that subscribe button. Thank you again, my friend. I’ll catch you next time.