Dentists Prescribing Home Sleep Tests? – Our Role in Airway Screening and Management – PDP243

Teaser:
You end up looking at these studies and there’s actually more time spent not breathing than there is breathing. In some areas, you are six weeks away from a test because they’re not only on top of their list, but their numbers are lower. In other areas, you’ve got high population density and low service output.

So you know, I have seen sleep departments that have got 60 week wait list just for the initial diagnostic tests. You already got the suspicion that they have obstructive sleep apnea. They’re already telling you that they’re struggling, and then they’re told to-

Sleep apnea is one of those things that a patient may need to report and they may need to report it in the case where they have moderate or severe obstructive sleep apnea with sleepiness.

And it’s really important that with sleepiness part is the main focus of the DVLA guidance. ’cause the sleepiness is the symptom that affects safety on the road. If the patient has sleep apnea, but they don’t wake up frequently from their breath holds, they don’t have the interruption to sleep, they don’t have the reduced cognitive function in the day. That sleepiness is what? This is all contingent on. 

Jaz’s Introduction:
Protruserati, I think this is one of the most profound episodes we’ve done to date. You see, the problem is that everyone’s telling us that sleep apnea is this huge thing and that as dentists we ought to know about it. And there’s plenty of podcasts now out there. Plenty of content out there, plenty of courses out there that are kind of filling that gap of knowledge.

The issue is we’re still hungry. I’ll tell you what we’re hungry for. We’re hungry for the following. Okay, so now you know what sleep apnea is. Now you’ve asked your patient, you’ve done some screening questions to your patient, but then what?

What happens then? Because if you’re not already actively in this space and you kind of refer and you lose that patient forever, what if you as a dentist want to do the sleep test? That’s what I do. I’ve incorporated sleep testing into my clinic for about 15 months now and it’s amazing the results we come back.

Now, I just wanna start by saying that we as dentists, we cannot diagnose sleep disorder breathing. Okay, let me repeat. We as dentists cannot diagnose sleep disorder breathing, but we can screen and we play a pivotal role in its management. So what this episode will do is we’ll bridge that gap between actually knowing about sleep apnea and actually doing something about it as a dentist.

And that is only achieved by those who are testing in their clinic. And let me tell you, it’s not mega expensive. It can be very convenient for your patients. And hey, even if you don’t start testing yourself, you ought to find someone near you or a center near you that can get your patient tested for sleep disorder breathing, such as obstructive sleep apnea.

And correctly reported so that you can genuinely help your patients, help them live a healthier life with more energy, less dozing off during the day ’cause of sleepiness, better quality of sleep for them and their partners, and adding quality life to their years.

Hello Protruserati. I’m Jaz Gulati and welcome back to your favorite dental podcast. If you’re new to the podcast, welcome, you picked a great one, and of course, if you’re a returner, thank you so much. Really means a lot. Your time is important to me, so I’m gonna make sure we absolutely smash it in this episode.

This episode is a bit longer than usual, but let me tell you, it is full of gold, full of protrusive pearls when it comes to sleep apnea and actually doing something about it as a GDP being proactive, rather than just screening and then leaving it there and doing a big tick. Like, oh yeah, I’ve screened, I’ve done my job, actually helping your patients get the correct treatment.

And the person who’s helping me today is a clinical sleep scientist. His name’s Max Thomas, and he’s such a knowledgeable guy and he explains things really well. The funny thing about this episode is we’re talking about sleep here, right? And I was recording this like 10:00 PM after my evening shift at clinic, and Max said this just come from Japan, suffering the most major jet lag ever.

Yet, I still think we’ve created a piece of art, which I hope you will love and you may wish to listen to again as a reference. But most importantly, I think this is the one where the penny drops and things actually make sense in terms of how you can play a role to help and serve your patients. Let me tell you, the done for you notes of this episode are absolutely brilliant.

You’re gonna absolutely love them because our premium notes, what we do with our premium notes is we ensure that you can actually retain the information. Look, I listen to podcasts, I listen to audio books. Sometimes you get home, you sleep and you forget so much of it. When you actually read a handout, that literally takes about 10 minutes to read.

It really cements and reinforces your learning and it helps you take the next actions. So if you wanna download the premium notes, please head over to the Protrusive Guidance app. It’s all there for you. Head over to the Protrusive Guidance app. It’s all there for you in the Protrusive Vault section.

It’s also under each episode we’ve got the transcript and the premium notes, which are like the done for you, revision notes. And yes, this episode is eligible for CE or CPD. We are a PACE approved provider.

Dental Pearl
Every PDP episode I give you a Protrusive Dental Pearl and this one’s very relevant to airway and sleep and it is the following. If in your patient’s history they have elicited that someone has observed them stop breathing or gasping or choking in their sleep, and that is pathognomonic, I hope I’m saying it right, pathognomonic. Let me just make sure I get that right pathognomonic, there we are. I said it correctly.

Now what that means is that if someone says that they’ve been choking or they’ve been observed holding their breath or gasping in their sleep, that means they’ve pretty much have a sleep disorder breathing.

You can, with a high degree of certainty, screen them as positive and probably will benefit from a sleep test. So it’s a helpful question to ask in your history. Now, of course, we cover that in good detail, but we cover about all the different questions we should be asking, all the different signs and symptoms and how exactly am I testing my patients and how Max report these, and then what happens when we get the patients some sort of treatment.

This could be them having a CPAP. This could be a mandibular advancement splint, or a mandibular advancement device. So I hope you
enjoy this deep dive and I’ll catch you in the outro.

Main Episode:
Max Thomas, welcome. A very warm welcome to the Protrusive Dental Podcast, my friend. I like to start the podcast in terms of how I came under someone’s radar or how I met someone virtually, or how someone came into my universe and it’s Mahmoud, right? My brother from another mother, Mahmoud, we’re both occlusion enthusiasts. We do courses together. We teach together, and he was like, oh, you know what?

I play basketball and there’s this guy called Max, man. He’s really into the sleep stuff. I was like, man, I need a sleep guy. Put me in touch and I’m so, so glad that, I don’t know, a couple of years ago that he put us in touch. Man, it’s been so nice to learn from you to sort of manage these cases together, man, you’ve been pivotal in that.

And so what I really want to do is today I want this to be the most tangible piece of content that dentists hear while they’re on the train, while they’re driving, whatever they’re doing on the treadmill, so that they can actually feel like, you know what?

I’m actually gonna do something about sleep disordered breathing, because most lectures and most content you get out there is like, either come on my course or it’s like the basics and overview, but that nitty gritty detail of what do I actually do? Okay. Which you’ve helped me massively with. So Max, please tell us about yourself, my friend. 

[Max]
Thank you for the introduction. Yeah, so we met when I was still working up in Birmingham, actually. We haven’t met in person yet, but yeah, our link was Mahmoud. I’ve still got him saved as Mahmoud ‘Dent Baller’ because I never knew his surname. So shout out to Mahmoud. 

[Jaz]
Well, he’s still saved on my phone as Mahmoud Occlusion still. 

[Max]
Yeah, fair enough. I mean, I did that with all of my contacts, how I remember them. But yeah, so, I’d actually heard your podcast before I met you ’cause my wife is a, she’s a big fan, so shout out to Beth.

She was playing one on a drive up between Birmingham and Bryson. And in order for me to get a Spurs podcast on, she also had to have a dental podcast. And it was a really nice episode. Where you had a physiotherapist on, and I still got something you mentioned tangible. I still got something that I use in my day-to-day practice from that, which is the best posture is the next posture.

Keep moving around, particularly if you’ve got issues. And man, that stuck with me, so I appreciate the sort of yeah, keeping it tangible, making it, sure there’s nuggets to take away. 

[Jaz]
Excellent. And that episode, Sam, he actually came on again recently to talk about some more, the current concepts and the different types of loops that we have. So man, I’m so glad. That was a long time ago. That was like 270 episodes ago, so, wow. Like, we connected years ago, but tell us about you professionally. Like how do you define you? Because when Mahmoud was trying to explain your role, he was struggling. 

[Max]
Yeah, yeah, yeah. So- 

[Jaz]
He’s some sleep dude.

[Max]
Some sleep dude, I get called sleep man at some of the talks I do. I’m fine with either. I’m a clinical scientist that practices in clinical physiology and that is essentially the measurement of either lung function or sleep. And obstructive sleep apnea is where those things overlap.

The airways and sleep and breathing is kind of our forte is measuring breathing whilst people are sleeping, looking at interruptions to those breath. And so our job really is about the diagnosis and management of conditions relevant to our practice. So for me, that’s obstructive sleep apnea, that’s insomnia and used to be a lot more sort of narcolepsy, really complex sort of sleep stuff.

When we were first introduced, we’re in a big lab in Birmingham. Now I’m a smaller lab, but I deal more with obstructive sleep apnea, so probably, still doing quite a bit in the field that we were introduced in. I haven’t had any referrals from you recently. 

[Jaz]
Yeah, well I had my pneumothorax and that kind stuff. But, I get the same conversation with my lab technicians, right. It’s like, for me it’s like buses. Like patients, when they come to me, it is like two, three a pop and then suddenly nothing for a while. And very much, it depends on how many conversations I’m having with patients.

So it really can vary week to week. But we’ll talk about, how I started to send my cases to you for reporting. ‘Cause I think that’s what dentists want to hear. How do you get started in your journey? 

And when you talk about, just a little bit about you, about your day-to-day work, does that mean that you’re literally watching people sleep and you’ve got like, your clipboard or you’re just ticking things off and you are clicking things? Like do you do any element of that? 

[Max]
Yeah, so when you have these full polysomnograph where you’re doing, you’re measuring everything throughout a night’s sleep. You have them in as an inpatient, well, we don’t have that kind of lab anymore where I’m at actually, we had that in my old site. But you would have someone who was there observing them overnight, just making sure that all the readings were occurring.

And if there was any issues, you’d be there to help. But the main job of a sleep scientist is to go through those data the next day and try and look at all of these different channels and work out what’s going on under the hood. If you’ve got a patient that’s complaining about the fact that they’re sleepy, well, you’re looking at the quality of their sleep overnight.

You’re looking to see if there’s any interruptions that might be related to breathing, and if there are, you count how many of those sort of interruptions there are. We get this hourly rate out the other end. 

[Jaz]
Don’t you get the AI to do that though? You know what? There’s a list of jobs of where AI is gonna take over your job. Are you dangerously close to losing a job? 

[Max]
Yeah. So do you know what? I would say- 

[Jaz]
Sorry if I touched the nerve. 

[Max]
I would say no, you’re not, I would like it to be able to support us. ‘Cause a lot of the stuff with AI and healthcare is, we’re actually better with the device having some form of AI.

But it’s to support clinicians and AI on its own can’t literally do the job and actually quite often need pointing in the right direction. But sometimes, people go to on holiday to Japan and then their body clock is the other side up and you’ve just got an AI to point you in the right direction and you kind of, it’s symbiotic in that sense.

There’s a lot of work in the world of respiratory moving towards like automated interpretation of lung function tests and things like that. But actually in the world of sleep, we’re not quite there yet. We have assisted scoring, but then we go through and check it. We make sure it’s right. There’s quite a lot of nuance to the things that we do.

And the traces are these tiny little squiggles and after years of experience you can interpret those squiggles, but quite often these interpretation algorithms, they get some of the big decisions wrong. 

So we’re at a point, the only thing I’d say on the back of that is the uptake of technology in healthcare systems is so slow. We might have these AI technologies about, but then they’re not gonna be uptaken at a rate that will see me before I’m retired. I think. 

[Jaz]
Good, your job is safe then. And that makes me happy because guys, the way me and Max have been working together is, I screen my patients and we’ll talk about that, which questions I ask.

And Max has been instrumental in helping me and I just wanna just go through his journey with you all and explore, okay, how did I detect, the first ever patient I sent you was like severe off the scale. I dunno if you remember this actually over a year ago. 

And so it’s amazing, man, for me as a dentist, at dental school, they taught me that I can save someone’s life if I diagnose oral cancer or I see like lots of evidence of acid in the mouth and therefore they could have a Barrett’s esophagus and therefore.

That’s a very indirect way. But no one mentioned at that stage, dental school, they didn’t say, we have a important role to play in the airway ’cause that’s another way to save someone’s life.

And some of the studying I’ve done, some of the courses I’ve been on, were much like, we can add 10 quality years, not just 10 years, but 10 quality years in someone’s life. If you make such a diagnosis, if you help these patients. And you said something earlier that dentists are in the best position to do so. So just tell us why are we in such a great position to be able to help screen? Because we cannot diagnose, but we can screen and assist patients. 

[Max]
Yeah. So you are in a great position. You’re in a great position for a lot of reasons. The first reason is you are genuinely, truly general practitioners. As in everyone will come to a dentist and see you. Whereas actually at GPs, they have this sort of sample bias of people turning up when they’re super duper ill and they’ve got one thing that they need to talk about and that’s all they get.

And sometimes GPs will catch other stuff and sometimes people will go to their GP saying that I’m very sleepy, my partner says I snore. That sort of thing. Whereas you kind of see everyone and you get this opportunity to have them sat in a chair and be still for a bit. And that’s when you start noticing symptoms.

Another person who’s having a conversation with them might not. You’re in a very unique position, not only because of that, but also because you are looking, as you said at the start of the airway. And the main crux, or the main point that causes an issue in obstructed sleep apnea is the upper airway back of the throat, crowding at the back of the throat, causes obstructions when they go to sleep, and all those muscles relax and everything collapses across.

[Jaz]
When you say crowding dentist, think teeth being crowded, right? So, no, you’re right. But see, so let’s spell it out for a younger colleague. ‘Cause I know what you’re talking about now, but there was a stage where I’d be like, wait, crowding at the back of the mouth? Like posterior crossbites? What do you mean by crowding back of my, what are we looking at?

[Max]
Yeah, so that, I mean it’s almost all the structures in the jaw and the upper airway, the soft palate, the tissues at the back, all of that can contribute to crowding. So what you tend to see, your classic obstructive sleep apnea patient is someone that’s overweight, very thick neck, all the tissues that are in the back of their throat, there’s a lot of fat mass.

And that’s taking up a lot of space whilst they’re awake and they’re operating their upper airways, muscles, the airway’s perfectly patient. It’s the moment they go to sleep. And when they get into the deeper stages of sleep, such as REM and all those muscles have really relaxed, they start getting obstructions that can’t be overcome by just trying to breathe in.

And what they have to do is they have to wake themselves up periodically in order to be able to breathe. And they don’t always fully wake up, but they are having interruption to their sleep. It affects their sleep architecture and the next day they feel rotten. So you can see all those structures in the mouth.

You could see retrognathia, you can see in a large tongue. You can see the soft palate is almost covering the entirety of the back. You can’t even see to the back of the throat. I don’t, I don’t dunno- 

[Jaz]
Let’s talk about that The Mallampati score. Let’s talk about- 

[Max]
That’s what I was about to say.

[Jaz]
So it’s good. So let’s talk about that ’cause I do that as part of my assessment, especially for my TMD patients. When I ask my series of questions, I’ll get the patient to open really big, as big as they can go and stick their tongue out all the way and just have a look. And there’s degrading from zero, is it zero or one? I forget the first. 

[Max]
I think it’s one to four. 

[Jaz]
Yeah, one to four. 

[Max]
It’s four different grades. 

[Jaz]
Mm. And so I think it was named after an anesthetist. Is that right? 

[Max]
The history of its loss to me. Sorry, I could have done some Googling.

[Jaz]
But anyway, the anesthetists, they are looking at, they are giving the score a lot because it is important for them for what they do, but actually for the dentist it’s important.

But I won’t steal your thunder. You are the man of the knowledge. Please tell us about how easy it is for us to test Mallampati. I kind of gave a description of how to do it, but then how do you score it, and more importantly, what is the significance of that? 

[Max]
Yeah, so you actually knocked a memory loose when you said it was about anesthetist. ‘Cause it was talking about the risk of in, or the need of intubation or the difficulty intubating as a result of the crowding at the back of the airway. And actually I think the evidence was a little less clear for that than it is for obstructive sleep apnea.

The higher your grade, the more sort of obstructed that area is the back of the throat. And for every step up in grading of the Mallampati, and I’ll talk about that in a second, but for every step up in grading, you almost double the risk of obstructed sleep apnea. 

And the severity increase as it goes. And that’s sort of essentially those soft tissues contributing towards obstruction of the upper airway. A grade one, and now you’re testing me up. I should have had this up for me to look at, but a grade one is- 

[Jaz]
I mean, grade one you can see everything, right? 

[Max]
Yeah, you can see right through to the back. You can see beyond the uvula. The soft palate is way up and it’s all sort of in place. Grade two, you start getting the soft palate coming down.

The uvula is still visible, but you can just about see through to the back of the throat. Grade three, it might be at the point where the uvula is even just. Sort of hiding behind the back of the tongue down, and then grade four, you literally can’t see beyond the soft palate. And yeah, it correlates quite well with the risk of obstructive sleep apnea.

So your dental population are out there who are looking into the back of the throat, so their patient, you can spot this quite easily. You can see it without even telling them that I want to do an assessment here. You just pick this up as you’re going through your assessment. 

[Jaz]
But what I wouldn’t want people to do is just, fair enough. Some people, this might be the one thing that they take from this podcast. They might doing it. Yeah. But it’s just one piece of the puzzle. You also need the history. You also need the sleepiness, which we’ll get into obviously. But that is one important point. I’m glad we start with something quite actionable for dentists.

Okay. So they actually realize, okay. There’s something to measure here, right? Dentist’s like to measure. So there’s something to measure. We like indices and scoring. So a Mallampati is such an easy one. I’ll just put you a word of caution actually for dentists is our patients with reduced mouth opening, right?

They will bias towards a higher Mallampati score. But that would be a false positive, right? So my patient’s got TMD and they can only open 35, okay, on that day. And so I’m giving them a grade three, a grade four on the Mallampati, but actually they’re grade one, two because could they open 45, 47, right?

They used to be that. So just take that with caution. But a really cool thing I like to ask my patients who are like, got normal mouth opening, but they’re still a Mallampati four is like, how did you find taking COVID tests? And they’re like, no, I can’t do COVID tests. I just never could get the damn swab to my tonsils. Have you thought about that? 

[Max]
Well, I dunno. So you say that and I think because their gag reflexes so much, I don’t think that is in any way related, or you might be telling me different, but I haven’t correlated that with our patients. Mainly because COVID absolutely slammed sleep as a medical science because obstructive sleep apnea is the coldest of things.

It’s the last thing you sort out. If a patient’s got raring type two respiratory failure and all these other things going on, those services keep running lung cancer. Yeah, we’re gonna keep our two week weights going, but sleep was the first thing to get knocked on the head and yeah, it’s sort of been still recovering since, if I’m perfectly honest.

There’s a lot of sleep services, the sleep service that in the department I joined recently that was absolutely, yeah, it was shut down. Its diagnostics are only just picking back up. We’re talking four years later. 

[Jaz]
I mean, everything’s been so slow, Max, and this is one of the reasons why I really wanted to just start helping my patients. So I started to do my own sleep tests and that that’s where you played such a huge role. And so we’ll talk about that. And I think we’ve jumped the gun. I mean, I’m so glad we talked about Mallampati score because most dentists that I speak to don’t know about it. They don’t look at it, they don’t know about it.

And so I think it’s good that we covered that. But I know we’ve done it in previous podcasts, but this might be the first podcast someone might be listening to Protrusive. So what is sleep disorder breathing? What actually is sleep apnea? And you’ve kind of said that, yes, crowding in the back of the mouth will predispose someone. But as a condition, how do you define it? 

[Max]
Yeah, so obstructive sleep apnea or sleep disorder breathing, we should start with is about interruptions to respiratory function during sleep, quite simply. Now, the majority of cases we’ll see, or the majority of cases we are talking about here, are those where the upper airway is obstructed, usually by those soft tissues and crowding at the back of the mouth or enlarged tongue or something like that.

They interrupt the airway. You can have other forms of sleep disorder breathing that are related to the central system, the drive to breathe, which can be affected by damage at the brain stem, brain damage affecting respiratory function, but also some heart disease can cause altered chemo sensitivity and they start breathing funny when they’re asleep.

But putting that aside, ’cause that’s definitely outside of the remit of dentistry, the upper airway, you’ve got your obstructive sleep apnea. Now they have these breath hold events when they go to sleep, more common on their back often because of the way in which gravity affects those structures in the airway and they obstruct that airway during sleep, the more frequent these breath holds occur, which can be up to about, I’ve seen patients who have breath holds up to about a minute.

A minute and a half. When they have, yeah, exactly. When you think about the number they have per hour, less than five is normal, right? Less than five of these breath holds is normal. Between five and 15 is your mild category. 15 to 30 is moderate and above 30 is severe. You see patients that have what we call an AHI, Apnea Hypopnea Index of 60, and sometimes these breath holds can be 30 seconds. You end up looking at these studies and there’s actually more time spent not breathing than there is breathing. 

[Jaz]
I’m trying to interject, but I just wanna just add a story and add some context into this. One of the reasons Max, I dunno if you know this, actually, I dunno if I may told you. One of the reasons that, you told me before we hit recording that oh, Jaz, you are quite proactive, whereas other people don’t care.

You were proactive, but maybe it’s because my children were affected by this. So my 5-year-old had to have his tonsils. Was it? No, he had his adenoids. It’s not his tonsils, just his adenoids removed because he was diagnosed with sleep apnea. He had a sleep test. We had to literally tell him, he was like two and a half and we had to tell him, look, we’re gonna pretend to be Iron Man and we’re gonna put this like stuff up.

I’ve got the video of him pretending to be Iron Man while he is kited up with his sleep stuff as a home sleep study. And so they found that, yeah, also the amazing thing is when I spoke to the surgeon afterwards, he said that, yeah, we removed this fat pad of adenoids, right? And we drained his ears and so much fluid came out. And so the next day I switched on the kettle and he was like, whoa, what is that sound? 

[Max]
No way. 

[Jaz]
And so like no wonder his speech was delayed. Like and I look back, he was always into Spider-Man since is like 18 months. But he would never say Spider-Man. He’d say Berman. He’d say Berman. And so we thought that was cute, but actually it’s because he wasn’t hearing properly.

Okay. And so that made sense. Now that was my first born, right now he sleeps well it’s awesome that’s fine. My now nearly 2-year-old has it worse. So he also had a sleep test ’cause I pushed for it. ‘Cause I knew what I was looking for now. And he came back with a moderate sleep apnea. And so this actually took the doctors by surprise because a 1-year-old to get a diagnosis of moderate sleep apnea is almost like usually children with down syndrome or syndromic patients have this.

So that was very concerning for me and my wife actually. Right. But anyway, so, he is a terrible sleeper. My almost 2-year-old. Okay. I talk about this regularly on the podcast, like, yeah. I had to get milk this many times to comfort him. I have to go get milk at night and he will hold his back to the main story.

He holds his breath so much. He constantly is gasping in the middle of the night. He’s constantly like sleeping and suddenly you go and then he’ll wake up. And so just very distressing to see your child do this, but this is what adults are doing and they’re holding their breath.

And these are the apnea hypopnea indices. The AHI. And so how well does that correlate that score? Like for example, you just made a really good example. You said someone could hold their breath for 60 seconds. That would come down as one event. Now someone doing that for one minute, 15 times as a AHI of 15. Right? But someone could be doing it shorter 45. Who’s gonna be worse off? 

[Max]
Yeah. So the minimum time that breath hold has got to be counted is 10 seconds. But you’re right, that number that we use at the other end, the AHI, breath holds per hour. It doesn’t always fully explain what’s going on under the hood. Those people with really long breath holds.

They’re gonna have a large hypoxic burden. During those breath holds, obviously they’re not exchanging gases ’cause they’re holding their breath so their oxygen levels drop. It has a massive consequence physiologically down the line, and we think it’s associated, or that hypoxic burden is associated with later development of heart disease, high blood pressure, a whole profile of metabolic issues.

Yeah. And to some degree cognitive function and all these things. So, the number that you get about severity is more about how frequently they’re holding their breath. But actually there’s other variables that you can get from more complex sleep studies that give you a bit more about, well, this kind of explains other aspects of their physiology. This explains the memory loss and all these things. 

[Jaz]
The reason I mention this is because I was always taught by someone, Jamison Spencer in the US who’s done some of the courses I’ve done is that, just ’cause someone’s AHI is 30 and someone else is 60 doesn’t mean that 31 is necessarily gonna be better in all the other metrics.

Feeling less sleepy, et cetera doesn’t mean someone who’s in the moderate category can sometimes be really hit hard, right? Whereas someone could have an AHI of 80 and not really feel it as much. It was really, really fascinating when I was learning about how people’s physiology responds and you know you, that’s exactly what you study really.

[Max]
Yeah. Yeah. So another concept that we talk about is how quickly they react to these breath holds, something called loop gain. So some people can tolerate these breath holds and that their internal sort of regulatory systems don’t put them into action as quickly as somebody else. There’s some people that might not even reach that ten second threshold for breath hold, but it will cause an arousal, which is our term for waking up.

And these arousals are what’s associated with your sort of interruption to your sleep quality. But some patients who desaturate, they don’t reach that arousal until it’s the point where you know, it is time to wake up. And often that could be the partner sticking an elbow in saying, you’ve held your breath for a minute now.

Just like you were saying you were distressed, looking at the breath hold of your child. We often have patients that come into the lab. And they’re not bothered about their snoring. They’re not bothered about this. They’re bothered about it, my partner says that I hold my breath and I’m disturbing her.

Is there anything we can do about that? And this is where the history taking and the conversation with the patient comes into it really, because what they want out of it isn’t always, fix my sleep apnea. I’m worried about my health. I’m snoring and it’s annoying my wife. 

[Jaz]
This is where AI hasn’t got shit on you, mate. You can see the whole patient, right? So, screw you, AI, Max is gonna keep his job. He’s gonna see the patient as a whole, listen to their concerns, yada, yada, yada. Dude, there’s so much to cover in this podcast. We’re just literally getting started here.

Okay. So this is awesome so far. So, we talked a little bit about what sleep apnea is and there’s so many other dental lectures people can go to, but I actually wanna really get into okay, what our role is and how we can actually get started.

So what kind of questions should we be asking our patients? So you said, yeah, no examination. We look into their mouth and we do a soft tissue exam anyway, so at that point I’ll do my Mallampati check. Okay. But a little bit before then I kind of look at ’em as they walk through. They look tired and sleepy.

That first patient I ever picked up and my first sleep study I did using the AcuPebble device and I sent to you that the reason I sent it through, he was a TMD patient, but he literally yawned like eight times in a one hour consultation. And I was like, again, that is not to say that, I had another patient who yawned at similar times and I sent her a steep test view and she came back as normal.

But for me there was a lot of things going on here. And I think with our, I dunno quote unquote my positive screening rate in terms of your clients, I think it’s good to get the data to help us to choose the best care for the patient. 

[Max]
I should have kept numbers on that. We could have seen what your hit rate was, but you are right. Do you know what it starts even before they walk in the room. ‘Cause you go out to the waiting area, don’t you? And you look at them sat in the chair and I mean, we’re in a sleep service so I see like, I see a lot of it, but the patients who are literally asleep when you go to get them and they’ve only been there 10.

They think that’s normal though. Their whole life has been like that. And so sometimes when you’re asking questions, you say, look, do you feel sleepy? They’re like, ah, you know, I’ll sleep when I go home after work when I’m watching the television, and then I’ll be awake for a couple hours and I’ll go to sleep pretty much all night.

And the questions you really need to ask are not so much about, do you feel sleepy? Do you wake feeling refreshed when you wake in the morning? Do you feel like you’ve had a good night’s sleep? And this can help lead the conversation to somewhere else that makes you think, ah, this is sleep apnea. Because sometimes I say, well, not in the morning, but when I sleep in the afternoon, I have a lovely sleep. And you say, okay, why is that? And that’s- 

[Jaz]
Someone said that to me literally yesterday, right? And she’s someone, I really strongly suggested a steep test and I’m not the first person. An ENT doctor in India also told her to get a steep test, but she never actioned it. And now I’m said, look. We can really help you.

I’m convinced like she’s got Mallampati four TMD, which is obviously associated linked, but like, just exactly what you said, she struggles to sleep and then she has poor quality sleep. And every day when she has that nap at about 5:00 PM then she feels great. 

[Max]
Yeah. So, and where is that nap?

[Jaz]
It can be anywhere from what I asked her, like the kind of questions I ask as well is sofa or something. And then when you’re watching telly, do you those off? 

[Max]
That’s it. Yeah. So why I mention that is ’cause I always ask, the nap feels good, right? So your night sleep is in bed, where’s the nap? And they say, oh, it’s on a sofa.

And that means they’re either set up right and they’ve fallen asleep like that and had a really good, their airway is not being obstructed by gravity or they’re on a sofa where they can’t turn on their back. And you’ve got somebody who probably has supine-predominant obstructive sleep apnea. It’s worse on their back.

And then when they’re stuck on their side on a sofa, they do much better. So that exact situation has happened to you. That’s brilliant to hear. I’ve had plenty of patients like that who say, look, actually, I sleep all night on a sofa now because I get better sleep. And that I really just like to follow them up and see them afterwards and just say, look, are you now sleeping in your bed more comfortably now that you’ve got CPAP from us?

[Jaz]
But as a dentist, we can do this as well. The beautiful thing is that yes, we’re greatly, so I can tell you some stories, right? Whereby some patients, they couldn’t afford the sleep test that I usually send to you, for example, right? And therefore I send ’em to their GP, right? NHS GP and the GPs actually where I work, they’re pretty good.

And like I kind of tell my patients what to say and whatnot. And they managed to get the steep test from the NHS and then they managed to get the CPAP from the NHS ’cause my suspicion was correct. And they come back and there’s one particular lady, she says that i’m dreaming again. I can now remember my dreams.

I’m actually dreaming Jaz and so I thought about it for a minute, so correct me if I’m wrong, she’s dreaming because actually now she’s getting a better quality sleep and now she’s actually entering a proper REM cycle for her to actually get sleep. Am I right in my thinking with sleep? 

[Max]
Yeah. Well, it is possible to dream at any stage of sleep. You just have more vivid, probably emotional dreams in REM and they tend to stick with you. You can do, because I mean, sleepwalking happens in non-REM sleep and you can often remember what you’re doing in non-REM. But yeah, REM is your main sort of having highly emotional dreams that really stick with you.

And you’re right, that’s the one that’s probably most interrupted as is slow wave sleep with obstructive sleep apnea. You sometimes get patients who present, actually they present with sleepwalking. And actually they have obstructive sleep apnea that’s causing the sleepwalking. And that’s because you’re not really supposed to wake straight up from deep sleep.

You’re supposed to work your way down from light sleep to slightly deeper, but still light sleep into deep sleep and then REM to awake. If you wake up straight in the middle of slow wave sleep, you are likely to trigger or more likely to trigger a sleepwalking event. So you might have all sorts of what we call parasomnias behaviors during sleep that are actually related to obstructive sleep apnea. Yeah. Your group are in a fabulous position to try and not only identify it, but yeah, as you say, treat it, diagnoses the issue.

[Jaz]
And follow up and diagnosing and yeah, managing, but then also the ability to follow up. ‘Cause like you said, sometimes you don’t get that follow up, right. You guys have managed it and then you go and get to see them again maybe.

Whereas we, every six months we see them. So it’s so rewarding to be able to be, I mean, sleep is a small percentage of my practice as you know, Max. I love my restorative dentistry. But I’m so glad I added sleep to my diagnosis set, my screening set, because I feel like I’m really helping these patients.

I feel great about it. Whether I get a negative diagnosis or positive diagnosis, at the end of it, I feel happy that I screened, I help, and those who get a positive diagnosis and I’m able to get them a better quality of sleep. And I’m thinking, wow, I just might have added 10 years. Quality is this patient’s life that makes me feel so good.

And so again, the whole follow up thing. I’ll tell you another story. Ricky, one of the dentists, one of the good buddies, he came to me because he won’t mind me saying this ’cause he was gonna post a video on Instagram about it. So I don’t think he’ll mind saying this Snoring, snoring is an issue. Okay? So he gets the elbow in the rib, right?

So he said, Jaz, you gotta help me, you gotta save my marriage, et cetera, et cetera. Okay? So he comes to see me, I’m make a typical dentist. I listen, just skip the tea sleep test. Just sort me out mate. Okay? All like, fine, let’s just quickly do a mandibular advance splint. I think for him, I made a ProSomnus.

And the cool thing is literally the next day, right, he sends me a screenshot from his phone. ‘Cause what I love nowadays, everyone’s got Apple watch, right? And so he send me a photo. Well done, or congrats. Your blood oxygen was 4% higher than ever recorded before last night. 

[Max]
Good stuff, man. In action.

[Jaz]
More importantly, I did save his marriage. 

[Max]
Yeah. Nice. Yeah, yeah. Like we honestly see patients in clinic who say, well, I haven’t been able to share a bed for the last 30 years. And if you are in a position to fix that and see them, you’re right about our follow up situation. It is a bit awkward.

We would like to be able to see every patient every year as a minimum. We try and follow people up after we set them up on treatment, but trying to get patients back in year on, year out with the fact that once patients get on our list. They never go off. I suppose that’s true of dentists as well, actually.

I’ve never really thought about that outside of sleep apnea services. But our services grow and grow and grow and grow and grow. And if healthcare leaders don’t allow us to add more staff, we have to either get AI to do some of the work, but we already know how that’s gonna go or, we have to be a bit more efficient in how we see them.

[Jaz]
So I just wanted to share those stories obviously, of patients and how we get to follow up. But again, there are lots of resources out there, like for example, indices or tests or screenings that we can do. So STOP-Bang, Epworth Sleepiness Scale, but for the general dentist who’s busy, like, but we also care about implementing this into our into actual service and care.

Yes. You said the clinical exam, Mallampati, and then talking about are they sleeping in the waiting room? Ask ’em about their sleep quality. Are they a sleepy person? Do they wake up refreshed? All these questions are important, but where can we find some structure? Where can we find checklist? So yes, STOP-Bang is one, is that highly rated?

[Max]
I think STOP-Bang is the best for identifying the risk of sleep apnea. Epworth is more about having a quantitative measure of how sleepy they are during the day, and it’s important if you think you’re diagnosing, obstruct sleep apnea, to ask the Epworth, you need this quantitative assessment because this conversation that then happens later on around driving and sleepiness the DVLA.

Now this can be, there’s nothing that is more of a rapport killer than telling somebody that your condition may affect your ability to drive or you might need to be monitored a bit more closely. 

[Jaz]
I mean, I definitely wanna talk about this Max, but this is one of my last questions because there’s so much I wanna cover before we get to that. And yes, we’re gonna talk about the DVLA, ’cause it is obviously linked to Epworth. But what we should be checking for is STOP-Bang, Epworth. Do you think as dentists we should be asking for this or not? 

[Max]
Yeah, well mainly because most of the stuff that you’re gonna do for your sleep studies will have incorporated questionnaires that you can stick in. So- 

[Jaz]
But it’s more about figuring out, for example, I’m in practice, right? And so I’m using AcuPebble , I have a fee for that. That fee, or outta that fee, I also pay your fee for the report, for example, right? And so it needs to work in care, so you gotta be in an ideal world, yeah, everyone should get screened.

[Max]
Oh, I see. 

[Jaz]
It’s a wonderful health thing to do, but how do we pick it so that it’s a good worthwhile punt. So how do we pick the patient that, okay, actually this patient, I think the patient, I think you will actually benefit. I’m hoping it’s negative, but you might actually come up with a positive. How do we pick the patients who are gonna spend money? Do you see what I mean? 

[Max]
Yeah. So I think that you have some very high risk stuff that you see on clinical history. If somebody tells you that they have been observed holding their breath, witness apnea, do whatever questionnaires you need to do, get ’em the sleep study, because that’s quite uncommon, that’s limited almost exclusively to sleep apnea, sleep disorder breathing.

If they tell you they wake choking and gasping regularly. So not everyone has a bed partner to see, but if they say they wake up choking and gasping, and then still quite high risk, but less specific is unrefreshing sleep. Now if you’ve got any of those things, add a STOP-Bang. And if that’s even slightly towards the end of the scale, give them the information.

Just say, look, I suspect that it may be worth screening you for obstructive sleep apnea. Now these new screening technologies are quite uninvasive. We give you this thing to take home, you slap it on, you either have an app on your phone or you bring the device back and it gets downloaded and that is analyzed for you and we come and sit back and have a conversation with you about the results.

I think if you’ve got any of those high risk symptoms or you’ve got real suspicions based on their sleepiness, their neck size, they look like there’s crowding, bruxism is something. 

[Jaz]
So you mentioned neck size. So basically the form that I really like to use right, is there’s a lab in the US, S4S Solutions for snoring. Good lab. I know the guys that own it really well and they have a fantastic form on their website, which I really like and all my delegates on my TMD course, I said listen for airway screening, use this form for your patients because for those who come as high risk, it’s actually got a pre-written letter to send to the GP.

Like it’s just done all the work for the dentist for them. And I love this form, so I’ll put it in the show notes. I’m sure S4S will be very happy about that, but essentially it does Epworth, it does questions about like do you fall asleep? How sleepy did you get during driving?

How sleepy did you get sat on the house, how likely you go sleep while you’re sat on the sofa. Got really great questions in there. And also the impact on their life. Like because of this snoring, are you sleeping in a different room? Like you get to understand that aspect as well in that form. And then Flemon’s, it gets the patient to actually measure their neck circumference. So how significant you think Flemon’s score is to all this? 

[Max]
I don’t think I’ve ever heard that phrase before. 

[Jaz]
Well, on the form, so Flemon’s basically is that you measure the neck circumference and you measure it. So it’s like, 43 centimeters or whatever. And there’s a certain, I think it is 43 or 48, there’s a certain cutoff, which puts you more high risk, low risk. 

[Max]
Yeah. So is that 17 inches? ‘Cause the STOP-Bang is very US-centric. Actually a lot of our sleep medicine is because we follow the guidance of the AASM, the American academy for sleep medicine. So a lot of it is sort of, yeah, more US-centric. 17 inches, I think the one. So what’s that conversion probably about. 

[Jaz]
Alright, lemme do it right now. Right. So on the podcast, just doing this guy 17 inch, good old Google, 17 inch to cm, 43. There we are. 43 centimeters. 

[Max]
Yeah. So yeah, that, I mean, that’s just the cutoff for adding a point on that STOP-Bang. But it makes sense. So this doesn’t have to just be fat mass. We have rugby players. Enormous thick necks, muscle and fat both still obstruct the airways when they’re fully relaxed. And that’s what happens when you sleep. 

[Jaz]
I didn’t appreciate that. I just thought it was fat. But no, if it is muscle. That’s interesting. 

[Max]
Yeah, we have a lot of rugby players that have, I think there’s screening in, at least in the, I dunno, anything about positions in rugby, but where the larger players play, they screen those chaps ’cause they just have enormous mass in the neck. And so when they go to sleep, that just relaxes and contributes to obstruction of that upper airway.

[Jaz]
Now you said you’re a Spurs fan, so firstly I’m very sorry about that. Secondly, like some of these, documentaries that you see, like for example, like, not that I’d ever watch such a rude thing, but the whole documentary on Man City and their successes and whatnot. And how I know, right?

So how every athlete, like they have their, each player will have their special drink with their special formulations specifically for their biology. I wonder. And maybe if you know this, do these professional level highest football teams, do they do sleep screening for all and sleep tests? I just think why wouldn’t you? Why wouldn’t you for the highest performing athletes? 

[Max]
Yeah. So in general, it’s all about marginal gains at that sort of level. Everyone’s elite, right? So how do you get that extra 1%? Cycling was the first sport to do that, and they did everything. And they started having people take maybe their own mattress, but, or a mattress they know that they get very good night’s sleep on.

When they go and do the Tour de France, they take this around. They have teams that are responsible for that. I mean, I’ve gone and done a talk for a premier league football club. I did one for knocking Forest and that was at the start of last season.

[Jaz]
So they’re having a cracking season this year. 

[Max]
Ah, I’m not gonna say it’s cause and effect, but I think what they were doing is they were no way, I can’t say that, but what they doing- 

[Jaz]
The Max effect. 

[Max]
Yeah, the Max effect. I came in bush, but what they were doing is that they were demonstrating that they were an organization that is concerned with marginal gains and sleep is one of those. They do a lot of going on the road. They do a lot of late games and the recovery benefit from a good night’s sleep. You have patients who have been woken up by their own airways 30 times an hour for their entire life. Their entire adult life as much as they remember. Imagine how grumpy you’d be if you were poked awake 30 times an hour every night. 

[Jaz]
Totally. 

[Max]
You’d be really grumpy, you’d be forgetful. You would be really, really not your best self. And then I have patients come back to me in clinic and they’re like, this has absolutely changed my life. And you know your listeners can be part of that process. They can be the people that do that on the- 

[Jaz]
It’s magic.

[Max]
Honestly, when you find a patient who is really badly affected and they don’t realize quite how badly affected they were, and they start treatment, that is a very special feeling when they come back in and they’re like, you have saved my marriage. I can actually remember the things that are happening to me in the day time. It’s remarkable how important sleep is. 

[Jaz]
I think what this episode’s gonna do is that, we’ve set the scene in terms of trying to find that patient, that winning horse, if you like, so that you know it’s worth it for them. Because you can’t just sleep test everyone. The healthcare facility is just, that’s not how healthcare works. You’ve gotta no have a suspicion, a hypothesis or preliminary diagnosis or a screening that okay, this patient would benefit from screening. So that’s what we’re talking about. But I just wanted to mention this.

As a parent of two young kids, one who just does not like sleeping, ’cause you’ve got moderate sleep apnea, like sometimes you have to really look at their entire history and don’t think that someone is not sleeping well because sleep quality is not good because of sleep apnea. It could be that their baby’s crying every hour and waking up.

So you really look at that social history, like I sleep tested myself as well, right? Using the AcuPebble as well as one of the first patients. I did my own self, right? Just to test the tech out. And I was really curious ’cause obviously I wasn’t sleeping very much. I felt like not very good at all. But I was thinking, hmm, is it because I’ve actually got a small mandible. I have actually got retrognathia- 

[Max]
Hidden behind. 

[Jaz]
Exactly that. Why do you think I have such a voluptuous beard is to make me look class one and normal, right? So anyway, so I thought, wait, what if I do right? And no, I didn’t. My AHI was like two or something, right? So I’m golden in that regard, but it’s because I’m not getting great steep ’cause of the kids.

So you gotta really look at a patient’s social history. So we talked about, you mentioned some great things there. I’ll attach the form so that people can start using this form with their patients. And then, so now we’re getting into the real meat and potatoes of it, right? Okay, so we’ve just identified a patient who would likely benefit, and you’ve already said what you could say to a patient that, look, it’s a non-invasive thing to do.

You can have it done and if you’re in private practice like me and your patient can’t afford it, whatever, that’s fine. You fill in that form like S4S one and send ’em to their GP and maybe even a cover letter and some GPs will hopefully help. The problem is there’s big waiting lists in the an chest.

Now you are probably in a great position to tell us about that. Obviously this podcast goes out around the world, but for those in the UK, how long do you think that they’re waiting typically to get assessed and then seen? 

[Max]
So the unfortunate answer to this question is that that is essentially a postcode lottery. It depends on where you are. It honestly depends on where you are. In some areas you are six weeks away from a test because they’re not only on top of their list, but their numbers are lower. In other areas, you’ve got high population density and low service output. So, I have seen sleep departments that have got 60 week wait lists just for the initial diagnostic tests.

You already got the suspicion that they have obstructive sleep apnea. They’re already telling you that they’re struggling and then they’re told they’re gonna have to wait a year for a test that, at the moment can be in the range of just over a hundred quid. Most people would pay for that level of diagnostics.

I wish they didn’t have to, to be honest. But I think we’re in a situation where the options now are for people to be diagnosed that in the community, in the comfort of their own home with these devices sent out to them. I won’t talk about any specifics. You’ve got one that you use, but the whole paradigm has shifted a bit for sleep apnea detection. We’ve got these screening tools that we can use to see the bulk of patients. 

[Jaz]
I mean, we’ll talk about the other options now then I guess. So yes, you could refer, but depending on where you are in the world and also depending where you’re on in the UK for example, for those in the UK it’s a postcode lottery and so there are some devices available to dentists to help assist get the screening.

Now let’s talk about the legality of that. Now, before we do, there’s one thing, annoying. I’m so sorry about this to go back now, but we need to address it. ‘Cause otherwise it’s not gonna flow. It’s snoring because in the dental sector, when they market to dentists, they’re like, hey, you can help with someone snoring.

And that’s how dentists might get into it, rather than you can help with someone’s obstructive sleep apnea kind of thing, right? ‘Cause very much, we can’t really treat obstructive sleep apnea. We can under the instruction of a sleep physician consider it kind of thing. But the snoring, we can do our screening and then go straight to a mandibular advancement device for their storing, right, providing you have some level of training. So is snoring a risk factor for obstructive sleep apnea firstly? 

[Max]
Yeah. So if you snore you’re more likely to have obstructive sleep apnea and that’s a pretty clear relationship, but not everyone that snores that. 

[Jaz]
And we have like a spectrum, right? Can you explain it as a spectrum? ‘Cause I’ve heard this term simple snoring. So you either, you’re a simple snorer and then you have this upper airway resistance syndrome and then you have full fledge obstructive sleep apnea and it’s all sleep disordered breathing as like a spectrum. But I have some colleagues, Max, and tell me what you think about this. Have some colleagues, very intelligent colleagues, and they believe there’s no such thing as simple snoring.

Like if you are snoring, then potentially there’s something going on and that should be looked into. What do you think about that? 

[Max]
So I just think in general, what you’ve got with that noise is you’ve got an indication that there is a reduced size of that airway. Those structures are vibrating ’cause the air is squeezing between them and they’re rattling as that air goes through.

That means that they’re closer than they were when you were awake. Doesn’t necessarily mean that you’ll get obstruction that interferes with sleep, but you can have what we call hypopnea, which is where the H and AHI comes from. And that’s not necessarily breath holds, but that’s a reduction in flow so much that it’s interrupted oxygenation, it’s probably caused an arousal.

It’s not necessarily a complete blockage. You’re not having a complete apnea. And yeah, I dunno whether or not I agree that there is or isn’t simple snoring, but for me, I’ve got a very different sort of, you know, the bias that I get is that people come to me because they’re sleepy, because they’re in a situation where somebody suspects, they have obstructed sleep apnea and very rarely, for me it’s simple snoring.

Just snoring. It’s almost always obstructive sleep apnea by the time they’ve reached secondary care. So I think maybe to you out in the community, it might be a little bit more difficult to unpick, but that’s where these screening tools come in. 

[Jaz]
Well, yeah. It’s one more thing, you know, are they storing, are they sleepy? What’s their Mallampati score? You bring it all together and then, what’s the patient’s values? Are they also on, two different, three different types of blood pressure medicines? And we know that actually sleep apnea is what’s driving up the blood pressure. And then despite the medicine, it’s still not coming down.

And so we know that already as well. Are they bruxist? Like you mentioned that, and I didn’t wanna cut you off at that point, so I apologize about that. But you’ve rightly made the link between sleep disordered breathing, and bruxism. And so let’s say that you really want to help your patients and that pathway in wherever you’re working is not fluid enough.

It’s not good enough. So what I did was I got in touch with AcuPebble and I paid for my AcuPebble device. And then it was basically like bulk buying, like 15 tests. And now I pay per test basically right now as a dentist who does that, my missing link was you, Max. ‘Cause they kept telling me, oh, you can’t just screen.

Although the metric will give you kind of like a diagnosis, it doesn’t mean anything until someone with the power can actually sign off on it and report it. Right? And so that’s you. And so I’m so glad to have found you so that you can do that. For a lot of people who they go to is like a sleep physician who’s actually like consultant, sleep physician.

And so correct me if I’m wrong, legally as dentists, if we’re doing some screening, not diagnosis screening tests like the AcuPebble or the WatchPAT, these are two leading brands which dentists are using. We still need to get someone to report. So how do you find someone who reports, I found you by accident. I’m so glad I did. 

[Max]
Yeah. Well, I mean, what you could do is you can put my contact details in your description of the podcast. 

[Jaz]
Of course. I’d love to. 

[Max]
Yeah. So for sure. But you are right in saying at the moment it’s not really set up for dentists to be involved in a diagnosis, and I think that’s mainly from your regulatory body.

I think it’s not like the GDC will come and get your first born, but I’ve heard that they’re pretty quick to act and they want you to act within your scope of practice. And I think Aditi Desai put something out in just saying, look, you should have a sleep physiologist or a sleep consultant report your sleep study because- 

[Jaz]
And I agree with that because I’m looking at those metrics. You are picking up things which I’m just looking at the AHI and stuff, but you are really going deep and I love the reports that you make and I totally respect that. 

[Max]
Yeah, yeah. So we’re so used to seeing all these patterns that we can see sort of like a shape of a squiggle and we realize that actually, well this might be a bit more than just obstructive sleep apnea.

This might be something central and actually this needs referring on to a center where they can do a bit more. ‘Cause you can’t just treat central sleep apnea in the same way and not all daytime sleepiness with an AHI of six can be explained just by sleep apnea. They might have something else and you get concurrent other sleep disorders.

So yeah, I think in order for you more from a governance perspective and compliance with your regulatory body, having someone else just chip in to that point of diagnosis, you can do all the management. And what you can do is you can retest them once you’ve developed an appliance or you can ask the patient to take that screener study and go to a sleep service or go back to their GP and get referred on and they’ll be taken a bit more seriously because you’ve got some concrete proof that there’s sleep disorder breathing.

[Jaz]
Yep. And so what I’m gonna do also in the show notes, guys, is like, yes, I use AcuPebble, but I’m not tied with them. There are other brands available. So I also spoke to WatchPAT. I’ll put their links below and that’s how you screen. I’ll put your link below as well so that if they want someone a very reasonable rate to do some reporting, then Max can do that for you as well.

And so now we have something that whereby you can actually do a very high quality screening for someone very quickly in the comfort of their own home. And you’re really, helping ’em now. One thing is dentists, when we get taught from the trade, we are taught that, okay, you can treat a snorer the way that we’re taught.

And so tell me what you think about this Max, if you agree with this. The way dentists are taught is when you have someone whose main complaint is snoring, like, I don’t like the fact that I’m snoring. Okay. And then you do all the Epworth, you do the Mallampati, do the clinical exam and sleepiness and everything, and they’re coming up as low risk.

So based on those algorithms, everything they’re saying suggests they’re low risk of obstructive sleep apnea. But their concern is snoring. We can go straight to a mandibular advancement device providing we’ve done some sort of basic training. So this could be like some sort of CPD you’ve done. Do you agree with that? 

[Max]
So do I agree that you can go ahead and try and treat snoring without assessing for sleep apnea and doing the whole diagnostic shebang? Is that the question? 

[Jaz]
Well, we have screened with the using the algorithm and then if they are low risk, then we are not needing to get an official sleep report before treating just the snoring. And it’s kind of like the disclaimer there is like, by the way, we are just treating snoring. We’re not actually dealing with any sort of obstruct sleep apnea. That’s kind of like the consent disclaimer that we have. What do you think about that? 

[Max]
I don’t see a risk with that. You told me once that the reason why you started doing the sleep diagnostics was also to do with something with the airways. I don’t know. You wanted to screen for another- It is an indication I’d not really come across before, mainly because I’m trying to diagnose and treat obstructive sleep apnea. But weren’t you trying to identify if there was issues with the upper airway when you were treating for another splinting or something?

[Jaz]
Yeah. Yeah. So, okay. I’m so glad you mentioned this, Max. Okay. So guys, the American College of Prosthodontists suggest that before you raise someone’s vertical dimension, so before you open their bite, okay? And so the way the jaw opens, right, is like when you open someone’s bite, the jaw goes protrudes a bit, it goes back a bit, right? And so we are potentially making someone’s airway worse. 

[Max]
Right. Yeah. 

[Jaz]
And so if I have someone who’s already like borderline or on, they’re giving me like the radars going off that, okay, actually they could have a sleep disordered breathing and I’m potentially gonna be giving them an appliance to open their bite or doing some serious dentistry to open their bite.

Could I be doing a disservice or injustice to their airway. And so sometimes I will send a patient for a steep test to see where they are before I commit them to an appliance basically. Or before I commit them to opening the vertical dimension. Right? So that was the rationale there. And I still stand by following the American College of Prosthodontic advice, that that was the first piece of literature I saw that and really made me think about it.

And then this has been shown by lectures and stuff that look, if you open this patient’s bite or if you use something called centric relation, and their jaw goes back a whole 15 millimeters, then you may have made their airway worse. And so you raised a wonderful point there. But in a case of just snoring only, right?

And then everything else, all the other parameters are good. Like what are your options? Like if the patient generally doesn’t wanna do it and they’re low risk anyway, and then you are letting them suffer the psychological and the social disadvantages of the snoring. At least you can help them with their snoring. And even if they have an underlying sleep issue that is not being picked up, you’re probably helping that anyway. 

[Max]
The only problem I would see with that is if you’d managed to identify daytime somnolence and weren’t then seeking a diagnosis. I think if they’re not sleepy and they’re just telling you they’ve got a problem with snoring and their main concern with snoring is it’s a social problem.

I hate going on planes. It’s something I hear from my patients that snort and I’m like, why do you hate going on planes? Then he said, well, because it’s really embarrassing. ‘Cause when I fall asleep, you know, I snore the whole place down. I wake up and everyone’s looking at me and you know that, I mean, you are treating with your dentistry a psychological conditions there, aren’t you? I honestly, I don’t see an issue. Someone raised this with you as something that they thought, actually- 

[Jaz]
I’m not even raising. 

[Max]
Oh, I see. 

[Jaz]
It’s just I’m not raising it, this is what we’re taught and I just want to hear your perspective and what you thought, in case I was putting masala and some spice into the conversation kind of thing.

Just me kind of thing. But I’m glad you don’t see an issue with that ’cause that’s kind of what we’re doing. And that’s fine. Just to let you know. So I want to cover what options exist. So these like WatchPAT or AcuPebble and then you get it reported. Okay. And then based on that, you kind of are guided as how to manage this patient.

‘Cause in your, the person who reports it, they’ll kind of give you, this patient may benefit from a CPAP or this patient may benefit from a mandibular advancement device. So what are the guidelines that you guys follow suggest the different pathways- 

[Max]
Treatment modality.

[Jaz]
That’s it. 

[Max]
Yeah, so I mean the main guidance we follow is nice. The nice guidance is related to severity. So the more severe end of the spectrum, we start with CPAP. 

[Jaz]
Can, you just, what it stands for, what it is because dentist dunno. 

[Max]
So it’s essentially, sort of single level ventilation device. It’s called continuous positive airway pressure. It acts like a pneumatic stent. You’ve got air pushed into the airways that keeps the airways apart. ‘Cause with the obstructions and obstructive sleep apnea, it’s kinda like a whoopie cushion. I dunno if the current generation is gonna recognize what Whoopi cushion is really, to be honest.

But the way in which we generate force to breathe in is by making that lung larger. Your chest wall moves out, the diaphragm comes down, the lung gets larger. But if there’s a closed top as if the whoopi cushion’s closed, you don’t get any air in. What you have to do is you have to open the upper airway.

And so that’s what CPAP is doing. It’s acting like a pneumatic stent that’s pushing that airway open so that anytime you open and close or move the chest wall and push out air, it can freely pass. And so CPAP is the absolute gold standard of treatment because it pretty much treats almost any level of sleep apnea.

A mild, moderate, severe, very severe. There are some cases where so overweight, so obese that the pressures they need require more complex machines, but I’m sure that you are not gonna be screening those patients. They’re gonna be picked up before. So yeah, that’s how CPAP works, and honestly, it was a game changer developed in Australia and has been a mainstay of sleep apnea treatment.

[Jaz]
Tell me this Max, because that patient, I told you who I sent to the GP and my suspicion was correct, and then she’s telling me she’s dreaming better, she’s sleeping better. She’s ever so grateful. Her health is just looking way better, which is awesome, right? Everything we want out of healthcare. But interesting she’s told me that they’re able to dial into a CPAP and change it remotely. Tell me about that. 

[Max]
Yeah, yeah, yeah. Yeah. So remote monitoring was, it was a thing before COVID, but it became a necessity during, so that was the one good thing about COVID. We had this massive paradigm shift to using all these remote technologies.

This is where we first started sending sleep studies out to patients rather than them coming into hospital, being set up and shown how to use the device. We were doing all these things remotely, but most of the CPAP devices that are made now, in fact, all of them, unless it’s the absolute budget versions, will have like a sim card in it.

And that will send a signal back to our servers after it’s been used. Typically, sort of they use it for the night, they leave it plugged in, but off and then it sends a message back to us and we can see their usage, but also we can read other things off it. We can read off if the machine suspects they’ve got any breath hold events.

So it gives you an AHI quite crude the way it’s measured, but it’s still quite helpful in managing patients. So I can get this series of days of usage. I can see how many hours they used it for. I can see when they turned it on and off and all this stuff. And it really helps us to manage patients. ‘Cause back in the day before we had that, I’d have patients come in and be like, yeah, I’m using it all the time.

It’s fine. I’m brilliant. Yeah. Great. And then you actually go and download their software and they didn’t know, they download their usage. They didn’t know you could do that. And you come back with this report and you’re like, you haven’t even used it in the past month. And then they start telling you the truth. So this remote monitoring is almost like, yeah, it prevents the conversation from some drifting away from fact. 

[Jaz]
The question I have based on CPAP then is, and the reason I ask about remote monitoring is appliances. I do a lot of appliances for my TMD patients, right. And so when I give an appliance again, I worry about their airway getting worse.

Okay. And so the question I have is when they’re wearing something in their mouth, like an appliance that opens their bite. Would that then mess up how their mask fits? Do I need to be worrying about how effective the CPAP is? What type of delivery of air? Is it through the nose? Is it through the mouth? How is the air actually going in? 

[Max]
Yeah, good question. So both. So you can have a full face mask. And a full face mask isn’t like that. Although we do have masks like that called shields. A full face mask sits over the nose. I’m pointing to my face for those listeners who are just well done listening on.

[Jaz]
Yeah, it’s like a Guedel airway kind of thing, right? Like? 

[Max]
Yeah. So exactly. Your bag valve mask that front. Exactly right. So that’s a full face mask. It goes around the nose from the bridge of the nose and then it sits just above the chin, but around the mouth. So that’s the most common style of mask, although we are having more of a shift to- 

[Jaz]
But the air is actually going through your nostrils, right? It’s going through your nostrils and open the airway like that? 

[Max]
Yeah. Or if you’re someone that sleeps with your mouth open, we would recommend using a full face mask. ‘Cause the moment that you’ve got, you have nasal masks as well, but the moment you’ve got a nasal mask, in a mouth breather, you sometimes have the most uncomfortable sensation of the air just being pumped from the back of the nostrils out of the mouth.

And the CPAP’s obviously not doing its job at maintaining airway pressure there. So you can have nose masks, you can have full face, you can have these combination masks that do a bit of the mouth and the nose, but they fit slightly differently. So there’s a load of different styles of masks.

All I’d say to your patient is, if you’re gonna try one of these devices, is there to stop their TMD, you would want them to just be very aware if they’re getting increased leak, if they’ve got a sleep team just to say, reach out to them first and say, look, I’m trying this new mouth guard and over the next couple of nights, can you just tell me whether or not, my leak has gone up? ‘Cause we can see that stuff from a remote monitor. 

[Jaz]
See that’s the magic of it. That’s why remote monitoring really piqued my interest is that, now as long as you give your sleep team a heads up, like, hey, can you just watch me closely over the next couple of weeks I’m gonna outta this appliance and is my AHI getting worse?

Because the thing is, look, if you’re opening the bite a bit and maybe the airway is getting smaller and then you guys titrate it, you guys will just pump up more air. But once you have that data from the other side of the country, you guys can just lift up the air pressure, right? 

[Max]
Even better. AI is our friend. So you can have automatic machines that titrate the air as it detects an obstruction. ‘Cause it sounds like it’s all just one pressure, but actually it starts at a very low pressure when they put the mask on ’cause going to sleep, it’s like having your head out of a moving car window. You know that feeling of the air rushing.

It can sort of take your breath. You get very used to it after a while. But we start off with low pressures and then we ramp it up. We build it up. But during light sleep, you might not need as much pressure. Then they turn on their back and they hit deep sleep. Suddenly they’re getting more obstructions. The machine can drill in a bit more pressure. 

[Jaz]
Wow. 

[Max]
So most of the devices from a CPAP perspective, now we’ll be auto titrating and therefore, you know that concern of yours will be alleviated if they tell you they’ve got an auto trading machine. Or if they don’t know, they could ask their sleep team.

But I think that would be less of an issue. It’s more if it causes a leak ’cause those machines. They aim to try and deliver a certain pressure at the back of the throat. And so sometimes if you introduce a leak, what happens is the machine overshoots because it thinks there’s air leaking out. I need to try and maintain pressure at the back of the throat, and patients can get quite uncomfortable when their mask leaks as a result of that sort of cycle.

[Jaz]
Well, there we are. So tangible advice there guys. If you are doing appliance work for patient who may already have a CPAP, just give them a heads up to speak their sleep team and tell the patient to be wary or hypervigilant about a leak. Now, CPAP is the gold standard. But if someone’s got AHI of five and someone’s got an AHI of a hundred, then are they both getting CPAP or is the modality changing to a mandibular advancement device or the lower AHI?

[Max]
Yeah. Well, so I suppose the question in that is, where is mandibular advancement more effective or where is CPA more effective? And so there’s quite a lot of work on this and actually really the tourist out, there’s some signal coming from the noise, which is generally if you’ve got a patient in front of you who is thinner, their sleep apnea is not a result of extreme obesity.

They’re younger, they’re retrognathic, and there’s other sort of structures and features that are related to that lower jaw and the the crowding at the back of the throat rather than body mass, then it’s more likely our mandibular advancement will be beneficial. CPAP is always gonna win this war ’cause it just treats everything.

[Jaz]
So why not just treat everyone with CPA? Is that what happens in this country? Or is it ’cause of cost saving measure to give a mandibular advancement advice then? 

[Max]
In all honesty, the pathways and what the NHS has done to dentistry in general has been our own downfall. Other countries have got really well integrated, mandibular advancement device pathways that are integrated.

America’s way ahead of all of that stuff. But everything in there is private. So the cost is immaterial to the patient at the point where they’re unsure, but over here you’ve only got mandibular advancement services in specifically commissioned services that have applied for that and got funding from their ICBs.

It’s not just a given, like with CPAP, if a patients got moderate or severe obstructive sleep apnea and they’re sleepy, they’ll get CPAP. 

[Jaz]
What about if they’re milder? 

[Max]
Yeah, so you can opt to choose to give CPAP and it will treat the obstructive sleep apnea. But the thing about CPAP is it’s really quite comfortable.

I’ve just said, it’s like having your head out of a window when your car’s driving. But also, I struggle to have anything on me when I’m sleeping, you know? And it could be really unsettling. Patients get insomnia from the treatment now where- 

[Jaz]
It’s not very sexy either. 

[Max]
Oh, it’s certainly not sexy unless you’re into –

[Jaz]
Darth Vader, right? 

[Max]
We’re selling it now. But yeah, you see a sort of cost benefit, pay off more in CPAP when people are very obstructed and very sleepy because they’re so tired they could fall asleep. Mid conversation, they put this mask on and they wake up in the morning like this has been a godsend.

This is amazing. And they get this big benefit. The cost seems like nothing to them. You’ve got someone who’s got an AHI of six, they only have six breath holds an hour, and it doesn’t really disturb them as much as it does. This chap that has 30, they don’t get as big payoff. And actually the disturbance from the machine may be more than their sleep apnea in the first place, you know?

But sleep medicine is about trying to reduce the amount of interruptions to sleep, not increase it. So that’s where it comes in. Also, patients who are a 28-year-old coming to my clinic, a 28-year-old man, still single, you’ve mentioned it’s not sexy. They don’t want to have to wear CPAP in front of new partners.

They don’t want to have to wear CPAP for the rest of their life. It’s not a cure. This is a for maintenance of their airway. So yeah, usually a patient who’s younger- 

[Jaz]
Small mandible.

[Max]
Severe disease. Yeah, small mandible, that sort of thing. But also not super severe disease. Mandible advancement might do a great job of treating severe disease, but the evidence is kind of out there.

If a patient is intolerant, a CPAP, I would almost always want ’em to try something else. If they’ve got proven sleep apnea, they can’t use CPAP, have a go at something because it might not cure all my understanding. 

[Jaz]
That’s 50% though, isn’t it? 50% of people. Am I right in saying that they don’t tolerate CPAP?

[Max]
Yeah. I mean if not more. 

[Jaz]
That’s huge. It is really, really uncomfortable. And some patients have both, right? Because they have their CPAP at home and when they go abroad or they go on flights, they have their mandibular advancement. 

[Max]
Yeah. And more portable there’s, yeah, exactly. And you can use those both at the same time. If you’ve got really severe disease and you’ve got somebody who’s super obese and they’ve also got retrognathia and things that are causing crowding, you can do lots to create space, but also you still need that pressure going in and you can buy treat. I don’t think that’s gonna affect most of the people in that listen to your podcast, but it’s worth mentioning, you can have both to treat it just, most people, they do struggle.

We are getting better with getting patients on CPAP when we’re employing skills like motivational interviewing. I don’t want healthcare to be sales. Actually, I’m talking to dentists and you are put in a weird situation where actually sometimes healthcare and sales overlap. For me, they don’t. But actually a lot of the skills we use are sales skills. I’m trying to convince someone to do a thing that is in their interest, but not really what they want. 

[Jaz]
That’s dentistry, man. 

[Max]
Yeah, yeah, mate. It takes a lot of energy. You have to be enthusiastic and you have to really be saying, look, you are gonna get something outta this, but you have to try and it’s not gonna be easy.

I always tell them, when you first put a CPAP mask on, you are gonna remember my face and be really annoyed at me. And next time you see me will be after a period of a few nights of it, and then you’ll be happy to see me. And that’s only if you’ve persevered. If you’re annoyed the first time and you didn’t put it back on, I’ll see you again.

You’re annoyed again. I know that you haven’t really tried your machine on. Yeah, it is very tricky and I wish we just had pathways that were a bit more integrated. I wish we had dentists that could come into hospital, see our patients and fit them for mandibular advancement when they can’t tolerate CPAP, that’s half of our patients.

[Jaz]
I mean, that’s the dream man, Max. That’s the dream that we can work together better. But again, so it’s great to have you, and I’ll put your link in the show notes for those who want to get their sleep test reported by you. But I guess what I want to do in this episode is just share my journey in terms of getting a sleep clinician like yourself and sleep scientists on board to help report, but also my own journey of learning and just share out loud kind of the key things that we’re looking for, which I think we’ve done.

So talk about CPAP, we talked about mandibular advancement. The big worry with mandibular advancement devices is the bite change risk, which there are some things that can be done to mitigate it, like AM aligners and that kind of stuff. But what you know while in the short few minutes I have left with you is should patients have a retest after?

So actually no, this was more relevant before you told me about remote monitoring. So my question was, when patients start a mandibular advancement device, do they get a retest to see if it’s working because they don’t have a CPAP at that point, therefore they can’t be measured remotely. So actually our patients, should they be getting retested?

‘Cause it costs ’em money. So for example, if I give them mandibular advancement device, right? I often debate myself, hang on a minute, they’re saying to me they’re feeling better, their snoring is getting better. Is that enough? Or do I legally need to get this retested in the private sector where it all began for them as well?

[Max]
Yeah. Legally, no, we haven’t really talked about the DVLA, but that’s where the legal stuff comes in. But you don’t need to retest them if you suspect if their symptoms have resolved. Can we come back to this question after? We’ll do the DVLA stuff first because- 

[Jaz]
Yes, actually yes, just because that’s the last question actually. So, DVLA guys around world- 

[Max]
Well, the answer to that is contingent on the way it works for the DVLA is- 

[Jaz]
Can I just say for those around the world, DVLA is like the governing body for driving, who can drive, who can’t drive in the UK. So basically, if your patients are too sleepy to drive, it ain’t happening.

[Max]
Something vehicle licensing authority. 

[Jaz]
Something like that. 

[Max]
I guess it’s driving, but yeah, so they’re the ones that hold people’s licenses and they have rules about all sorts of medical conditions when it comes to driving. Vision is obviously a clear one, but sleepiness and things that contribute to increased sleepiness such as diseases that affect sleep, but also drugs that cause drowsiness.

You know, you have to report some of these things. Sleep apnea is one of those things that a patient may need to report and they may need to report it in the case where they have moderate or severe obstructive sleep apnea with sleepiness. And it’s really important that with sleepiness part is the main focus of the DVLA guidance.

‘Cause the sleepiness is the symptom that affects safety on the road if the patient has sleep apnea but they don’t wake up frequently from their breath holds. They don’t have the interruptions to sleep. They don’t have the reduced cognitive function in the day that sleepiness is what this is all contingent on.

And then you can have mild sleep apnea where they’ve been sleepy and it’s been three months or so. So they’ve had that for a long period of time. Moderate or severe obstructive sleep apnea with sleepiness. They need to report to DVLA. They should stop driving until their symptoms have yeah, ceased and they need to have been on treatment. At that point, so it gets- 

[Jaz]
But then you know there was an answer. Okay? So if they self claim that, oh, my symptoms are better, and they’re wearing a mandibular advancement device, they can just drive again and just tell the DVLA, hey guys, I’m feeling better now. I’ve got a mandibular advancement, or I’ve got a CPAP. Or they need to send in a test result saying, hey, actually I am better. 

[Max]
So they do the first, and then the DVLA will write to their sleep clinician and say, we need a review of this patient because we know that they’ve been diagnosed with obstructive sleep apnea. We need you to tell us what treatment they’re on.

We need you to tell us whether or not it’s effective. And there’s some other questions in that form that’s sent to us as clinicians to fill out. And at that point, you may need to ask for a retest. That’s the only reason. If your patient is still sleepy and you are treating them, it might be worth retesting.

And the reason why it might be worth retesting is because you haven’t fully treated it. If you’ve now got no AHI and you’ve still got sleepiness, it comes down to probably refer them onto a sleep service. There’s a lot of things that can cause somnolence. There’s a lot of drugs. There are other health conditions, but also you need to take quite a detailed sleep history because patients often conflate sleepy for fatigue, and there’s lots and lots of conditions that cause fatigue.

The one thing I’ll say about the Epworth, we hadn’t talked about this. At one point, but you mentioned that patients that struggle to fully open their mouth might have a raised Mallampati score, for instance. Well, the Epworth really hyper selects, sleepiness and people that are night shift. So if they work night shifts, all the questions are about, you know, if you’re in a meeting, are you likely to fall asleep?

Well, when do meetings occur? If you’re in a theater, are you likely to fall asleep? All these things happen when they’re usually asleep. And so if you’ve got someone who’s doing night shifts, the Epworth, pinch a salt with that one and also pinch a salt with your professional drivers. Talking about professional drivers, the DVLA guidance is very different for bus drivers and lorry drivers.

They need yearly review and they need special monitoring, so I would recommend that dentists don’t try and. If they find out that the patient in front of them is they suspect has sleep apnea and is also a bus or lorry driver or a professional, like a taxi cab driver or something, they really need to be sent onto their GP. They need to be managed. 

[Jaz]
I’m so glad you’re saying that because that could affect someone and I think it’s better. They’re a special case and they need special considerations. 

[Max]
Yeah. Yeah, and usually as in taxi firms, we’ll have screening services and they’ll go to, either they’ll have an agreement with a local hospital or they’ll have a agreement with the private sector and they’ll screen their own. They do their sort of health checks yearly. Bus companies. 

[Jaz]
Well, I promise. Then last question then, right. As the dentist who may be recommending a sleep test in their best interest, right? Because you are onto something, you’re thinking, okay, I can help this patient, right? And you give them the form, or in my case, when they get AcuPebble, they fit in the Epworth on the device, right?

And they do the sleep test. Is it my responsibility to warn them that, hey, by the way, if you do score sleepy and you come with a high AHI, then we’re gonna have to tell the DVLA, because that’s jumping five steps ahead and potentially, and definitely biasing them because then now, they’re gonna be thinking about that and they’re gonna be scoring lower on the Epworth, which we had a chat about that privately. So what do you think? 

[Max]
Yeah, I think it’s a really awkward place for us to be put. I think it’s something, as you say, biases the outcome. Your professional drivers will know exactly what’s happening when they fill out an ES. They’re the only people I ever see score zero. Have you ever done your own E Ss?

[Jaz]
Yeah, yeah, yeah. You always own sort of score. 

[Max]
Yeah. So eight questions with a maximum of three points per question, and therefore 24 is the highest score above 10. We start thinking there’s excessive daytime sleepiness. And most people, I’ll score an eight consistently, even when I’m doing well because it’s like, if you lay down in the afternoon, would you dose? I’m like, well, yeah. 

[Jaz]
And a night shift worker, like you said, might score 15, but that’s ’cause the nature of the questions, which absolutely are biased against the night shift worker. 

[Max]
Absolutely. And only people that are willfully trying to obscure their sleepiness score zero. Or you know, the complete nutters that you get come into your clinic. I’m sure you have them, every single field of medicine has them, but they come in and they either score 24 or 0, 24 or zero. You are pretty sure that less likely to be accurate. 

[Jaz]
And so what do you think then, do you think, I know you said it’s awkward for us to, is there a legal requirement firstly for dentists to warn someone that, hey, by the way, if you score too high, you know you can’t drive.

You gotta be careful kind of thing. So because that’s happened with us, with a patient who is upset about not being able to drive and I understood that, but I just worry about them biasing it because they suddenly change their scores. 

[Max]
So you’ve got this balance, you have this balance between doing what’s right for the public and the people that need to be protected from sleepy drivers. 

[Jaz]
And the patient themselves. A sleepy driver is a- 

[Max]
Yeah, and themselves, but also not adequately informing them. But in our sleep clinics, the DVLA conversation. The DVLA conversation comes towards the end. So we’ve gone through the whole, I’ve asked ’em questions about their sleep. They filled out their Epworth when they were in the waiting area.

We’ve done all the stuff. I have as accurate a measure of their actual sleep history, what their main presenting complaint is. How often it occurs and all this stuff, none of that’s been biased by the later conversations. And then I bring up the DVLA conversation towards the end, but with enough time for them to ask questions, which they guarantee they will have.

And that’s kind of how we do it. And I feel bad for those of private sector or, you crossing over between cosmetic dentistry and other things where you, the rapport is so important for what you’re doing. They have to trust you and you are doing what they want and you are getting them on a treatment pathway.

That’s exactly what they wanted and what they needed. But at the moment they see you as the face of taking your license. All the other avenues feel like they might get closed off. And so yeah, it is one of those situations and I quite often, during my consultation at the start, I will just make sure that I understand what they value, what they’d like, what, you are sleepy now, would you like to not be sleepy?

How do you feel you would be in 10 years having treated your sleepiness and really get ’em focused on other things before you say like, by the way, you’ll need to treat this if it’s very severe because you’re quite sleepy and the DVLA might want you to stop driving. It’s not your job to go and directly, if I’m correct, it is for a GP.

They can go to the DVLA and report the patient themselves, but we in secondary care tell the patient to report to the DVLA. Because there’s penalty for not doing so. That’s kind of how it works. They’re told that if, if they haven’t reported their moderate or severe sleep apnea or sleepiness. There’s a thousand pound fine and then if they’re found at fault, it is talking about criminal proceedings at that point. 

[Jaz]
Well, I’m glad we talked about that and I think it talks about the rapport building and the ethical dilemmas and there’s no, it’s a gray area, but I think we need to be careful. I think the great advice you shared was that if someone is, they do driving for their money, you know they’re living, then you definitely need to refer that patient. So that’s great. Any final points? Yes, please. 

[Max]
I think I probably wouldn’t let it, hang on it being a gray area. I think you’ve got a responsibility to make sure that they’re safe, but their conversation doesn’t have to be like, by the way, you are at risk of using your license through, through going through this diagnostic process.

The conversation is about, you’ve actually got the opportunity to identify and treat a condition that could be life limiting, not just the quality of your life, but also the length of your life. And these are all the avenues that are available to you. But actually just know that, sleepiness whilst driving is, and I won’t labor that point anymore.

I struggled not to have that conversation at the end of it ’cause you know, the what if. That kind of thing. 

[Jaz]
Mm-hmm. Okay. Great point. I’m happy with that. Max, you’ve gone beyond the call of duty. You’ve been here for an hour and a half now and you must be so tired, man. You’re jet lag. You’re gonna hate me tomorrow, man.

I’m sorry, but thank you. Honestly, thank you so much. And guys, honestly, if anyone wants a service from Max whereby you can do your sleep reporting for your tests, if you are at that level in your journey into sleep disordered breathing as a dentist for screening, then I’ll heavily recommend Max. I’ll put everything in the show notes below so you can reach out to Max.

And I just wanna thank you Max, for helping me be a better clinician like in a big way. 

[Max]
I really appreciate you. 

[Jaz]
Any final points that you wanna give to dentists out there? 

[Max]
Honestly, I said this at the start, no, you’re in a very unique position because you get to see literally every kind of patient you are seeing mostly this general population and you can pick out something we’ve diagnosed 5% to 10% of sleep apnea and you could be there absolutely reaping up the rest of that population that we haven’t managed to diagnose at this point.

[Jaz]
So you’re saying that you are diagnosing 5% to 10% of the sleep apnea in the nation. So really there’s 90% of people out there with sleep apnea that are undiagnosed. Is that what you mean? 

[Max]
Yeah. So that from the sleep apnea trust, those numbers. They think that we’ve diagnosed about, yeah. I mean, I believe it. Yeah, I believe it. The incidents about that. 

[Jaz]
Totally. Yeah. I mean, I think we have a great role and Max, thank you for supporting me in that role. For everything you do, and guys you’re listening, I hope you enjoy this one. Thank you so much, Max. I appreciate. 

[Max]
All the best. Cheers, mate.

Jaz’s Outro:
Well, there we have it guys. Thank you so much for listening all the way to the end. I know it was a longer one than usual, so maybe you had a couple of commutes to listen to. Do not miss the premium notes for this one. The Protrusive Guidance subscription is a paid subscription for all this premium stuff, but the teamwork really hard to put this together.

And let me tell you, if you love the podcast, you’re gonna love our premium subscription and the PDF transcripts, the premium notes, and the ability to get CPD just like you can for this episode. We are a PACE approved provider. If you feel that this episode has helped you and advanced you in your understanding of sleep disordered breathing, and what on earth you should do next, then please do send this to your practice.

Your WhatsApp group with the all your principals and associates and everything. Send it to them. This is something that I think the entire team should listen to. And you know what? We all know someone who’s affected by this in our lives. This could be a parent, a spouse, an uncle, or even like me.

My children have been affected by sleep disorder breathing. My eldest had his adenoids out, and my youngest is on the list to have his adenoids out. Honestly, cannot wait to have them out. So all these teams are very close to home for me. But of course, now that I’ve been developing in the airway space for a small amount of time, but I just want to share my experiences so far.

I hope you found that useful. Thank you again for listening to the end. I’ll catch you same time, same place next week. Bye for now. Oh, and make sure you comment below. Tell me what you thought.