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Open AirWaves Episode 1: The Power of Dentist/Phys ...
Open AirWaves Episode 1 (Video)
Open AirWaves Episode 1 (Video)
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Welcome to Open Airwaves, a podcast brought to you by the American Academy of Dental Sleep Medicine, where we have clinical discussions on dental sleep medicine-related topics. I'm your host, Dr. Vicki Cohn. After graduating from the State University of New York, I began my career as a general dentist, but once I learned and realized that I was working in an airway and about the role between dentistry and its critical medical interventions, I just couldn't focus on anything else. I threw myself into learning as much as I could. In 2016, I had the great fortune of buying the dental sleep medicine practice of a friend and mentor, and I've been practicing dental sleep medicine full-time in the Boston area since then. I couldn't have predicted this fork in my career path, but it's been a great fit for me. Sometimes luck just has its way of finding you and disrupting all your plans, and I have to tell you, it's been a great ride. Today, I'm delighted to have been invited to host this podcast, and I hope that all our listeners will be just as intrigued by the clinical cases and topics of discussions we will be showcasing as I am. Before we begin, I'd like to disclose that the AADSM does not endorse any services, products, devices, or appliances. The use, mention, or depiction of any service, product, device, or appliance should not be interpreted as an endorsement, recommendation, or preference by the AADSM. Any opinions expressed or communicated regarding any product, device, or appliance is solely the opinion of individuals expressing or communicating that opinion and not of the AADSM. Whenever possible, presentations should be supported by evidence. In instances where evidence is lacking, speakers have been asked to verbally disclose that their presentation is case-based or based on clinical experiences so that you can use independent clinical judgment to make decisions for your practice and patients. Today, I'm joined by two guests, Dr. Michelle Cantwell and Dr. Leon Swear. Dr. Cantwell completed her dental training and a three-year residency in prosthodontics at the University of Pittsburgh. Following dental school, she served in the U.S. Navy as a lieutenant commander. Thank you for your service, Dr. Cantwell. Demonstrating her devotion to the field of DSM, she served on many committees and the mastery faculty since its inception in 2017, and she is now the president-elect of the AADSM. Dr. Swear is currently the associate medical director of WellSpan Sleep Services in central Pennsylvania. As a board-certified pulmonologist and sleep specialist, he has been involved in clinical practice, research, and teaching sleep medicine for over 35 years. He was previously the medical director of the Penn State Hershey Sleep Center and is excited to be a member of WellSpan's multidisciplinary team that offers a number of options for treating sleep apnea patients. Doctors Cantwell and Swear have worked together since 2018 in the pulmonary and sleep medicine department of WellSpan Health in York, Pennsylvania. Dr. Cantwell tells us that Dr. Swear supported her from day one by introducing her as an equal to the residents on rounds. Recognizing the important role of oral appliances in treating OSA, Dr. Swear routinely takes advantage of having Dr. Cantwell's office right down the hall, something he describes as an ideal situation for patient outcomes. First of all, Dr. Cantwell, Dr. Swear, can I call you by your first name? Yes, please. Okay, terrific. Absolutely. So, now tell me what's going on. What have you brought to the table today? Let us know. I'm interested. Well, Vicki, thank you very much for having me here today and letting me share this case because this case, I think the overall take home message would be most cases are not going to be straightforward and this one definitely isn't. There's a lot of twists and turns. And the other point I just wanted to share is that we cannot punctuate enough the importance of communication from one colleague on the team to another. So, to dive in, Dr. Swear and I are in the ... Leon, sorry, I can't break that habit. It's Dr. Leon. I'll just call you Dr. Leon. There you go. How's that? We work in the same hallway and so there's just a very natural flow. He had a patient in the office that day and was kind enough to let me come in to kind of see if there was something we could do to help him. So, this case involves a 72-year-old man who happens to be a retired physician. Very intelligent, very pleasant person, and very interested in being involved in every treatment modality, every treatment option. So, very intelligent person. He was there that day to see Dr. Swear and happened to mention ... He has a very long history. I should mention that too. He's got about a 15-year history of obstructive sleep apnea. On that day, he had asked Dr. Swear if he had any recommendations, I believe it was, on getting a new oral appliance. He had had one made several years earlier, outside of our hospital system, and I believe he just wanted it for travel purposes. Does that sound right, Leon? Yeah, that's right. He's looking to have alternatives to what he eventually found out to be a very reasonable treatment option with his bi-level positive airway pressure, a BiPAP machine, and we'll discuss that. But patients sometimes get tired of one modality, and they want to be mobile, and they want to travel. So, when he first walked into the office, Dr. Swear, I may even call you Dr. Swear, it looked like a straightforward case. Is that correct? Well, no. Not to me. As Michelle mentioned, this patient has been through 15 years of having sleep apnea uncovered and treated in a couple of different ways, which we could get into, but he most recently was on this BiPAP machine, which he had some success with, but mentioned that in the past, with his oral appliance, he thought he maybe did even better, and I think we're going to find that there was a problem he thought happened with some tooth movement at the time. So, I wouldn't say it was straightforward. I just had been seeing him for about a year out of these 15 years, the first time being about a year ago, and he was moderately satisfied, to some degree, with BiPAP, but he needed some fine-tuning. Okay. So, Michelle, you walk into the office, and what do you find? What are you thinking? Well, again, he was very pleasant, very knowledgeable. The type of device that he had, I could tell by this initial visit, he was going to be fastidious with home care, and that's always nice to see, that he would be cooperative in that. He had a device that has anterior anchorage to it, and although it was several years old, it was in excellent condition. He did, and again, this was a brief, very brief interaction. This wasn't a full consult at this point, but he mentioned that one of his concerns was occlusal changes, and so I asked him to demonstrate, you know, can you share a little bit more about what you experienced, and he said that he is now edge to edge, and when he bit down, and just, again, without any instruments or gloves, just kind of taking a peek, you could tell that appearance that I think we've almost all seen, where they're edge to edge, and there's just an ever so slight posterior bilateral open bite, but he wasn't bothered by that. I mean, he was aware of it, but it didn't bother him to the extent that he didn't close the door on oral appliance therapy as an option. And had he been using, was he continuing to intermittently use his appliance? It was my understanding it was when he traveled, and he had another trip coming up with family that he was preparing for. We talked about it at almost every visit. Okay. So, what was your next step, Michelle? Well, Dr. Swearer put in a referral, and so we could get him into the electronic medical record and get everything in order. We scheduled a consult, which I believe was about a month and a half later, and that's where we started gathering all the information. As you know, there's a lot to put together. And so, he expressed again that his chief concern was he wanted to minimize any potential for tooth movement, and that he was concerned about fatigue, he was still kind of having some fragmented sleep on occasion, and that he felt a little foggy, I think is the way that he articulated it. He explained that he really did like this device, but that he was open-minded and wanted to see what some of the other devices out there would be. He did note that his weight had fluctuated from originally being around 187 at his initial study, which was, I believe, back in 2009. And currently, he was hovering right around 200 pounds, which was understandable. He also had some surgical procedures that had left him a little sore and unable to always sleep in the ideal position. When we started looking into his dental history, he did have a history of sleep ruxism. He did express that at times he would wake up feeling his mouth was very dry in the morning. Of concern was the fact that he had childhood and adult orthodontics. And we went into a bit of a discussion about that, and that as a child, if you'd had orthodontics, and later as an adult are using an oral appliance, you would have about a 40% chance of minor tooth movement, versus adults, I said 100%, something's going to shift. Your previous dentist probably did an excellent job, but you were prone to that movement. And I can't guarantee it's not going to happen again moving forward. Okay. So at this point, you're just trying to make him an appliance to use as an alternative for travel. That's right. What are you trying to do in your office for him? I'm trying to optimize his treatment with his BiPAP device. And I'll give you my take on this gentleman in the fact that he is very meticulous, but also very astute, and can recognize when his treatment is not optimal. His sleep apnea would be considered in the mild to moderate range, and his apnea hypopnea index was around 10 back in 2009, as I recall, and more recently, something in the range of 15 or 16. And I will tell you that many patients with those relatively low numbers do not subjectively notice that they're sleepy or have any sleep problem. In fact, many patients with much higher numbers don't exhibit subjective daytime sleepiness, and almost have to be forced into the lab, sometimes by spouses or friends who can't take it anymore, the snoring and the breath-holding at night. But this is somebody who does snore without therapy and does have some sleep apnea, but he, I am convinced, is symptomatic from it. And this just goes to the individual nature of the disorder. But when he gets appropriate and complete therapy with six or seven hours of sleep, he does feel much better and doesn't have that sleep attack almost, and very drowsy period during the afternoon, which I think is his main thing. So by adjusting his bi-level machine, based on a previous bi-level study that he had in the laboratory, and based on some information from the machine, my goal was to get him treated the best way I could on that device, hoping that Michelle would be able to come up with a good solution with an oral appliance. So now you've proceeded to make him an oral appliance, Michelle. How did that go? It was very cooperative. And again, the patient had no perio-history, no missing teeth, I don't think he even had more than one or two minor restorations, so it was really, on the dental side, that was a treat. We looked at a series of devices, because as you know, there's no one perfect device, and it really comes down to trying to match up an FDA-cleared, titratable, custom-made device to your patient. But otherwise, I reassured him that they would all have equal efficiency. So his goal was that he also, he wanted this to be pretty durable. He does grind his teeth, but he felt that that was questionable. I mean, I could see some wear facets, but he felt that that was in the past, so it wasn't a big issue for him. So essentially, he wanted something that he could maintain easily. He did want to know about the warranty, and he decided, looking at all the devices, he wanted one that was made of nylon. He felt that that was going to be the thinnest, and I agreed with him. And so, yeah, we ended up going with a nylon device. And I didn't feel the need to be overly aggressive. So when we completed the digital scans and then went to record the bite using a gauge, I had him starting out probably around 55% of that range. I have a question, actually. I have a question, just because we all want to get clinical tips, right? Sure. Did you look at his old device and see where the position was in his old device? I tried. And I'm actually kind of glad, Vicki, that you brought that up, because again, it speaks to things to come. But I was not, you know, past Michelle wasn't as smart, and I didn't pick up on this, but I did ask to see the setting on his device, which he said he changes on a regular basis. Okay. All right. Because oftentimes, right, if I have a patient that's been in therapy and it's been successful, please bring me the device. I'm going to take the measurements. So now you have a device where you can't really use the measurements because he's been changing them all the time. Yes. Okay. So you're starting from the beginning. Yep, absolutely. So we ordered the device, sent everything out, double-checked our scans, and we had his device back within the month. I was really happy about that, and tried everything in, everything seated beautifully. I was really cautiously optimistic at this point. And I asked him if it would be okay to just stay at that initial setting until his follow-up visit. Now, this is another question I'd be curious to see if you have any thoughts on this, but some patients I can wait a month. Oh my God. And other patients, if I knew where they lived, I'd be stopping by their house on the way home of the delivery, but we had set him for a week. So I don't know if you follow a week or a month. I do a month. Yeah. Some of them you can, and some even longer, but he was definitely a one week. And this particular device comes with little rods. You know the one I mean? Yes, I do. Okay. So little straps that are going to change the position of his mandible. And we gave him the entire box because it's, you know, I don't work at Home Depot. I don't have stacks of shelving around to store these things. So everything's... I do the same thing. They go home with it. So he takes it and when he comes back in, Vicki, he hands it to me and I go to set it on the counter and it sounds like a snow globe in there. All of the rods have been pulled out and everything is just kind of in the bottom of the box. Needless to say, he was having fun changing the settings and... I have to say I just want to interrupt because that's incredible that it was only one week and he had gone through most of the rods. Oh yeah. Because I have to tell you we've talked about this a little bit and on that that's the particular appliance when I use patient... I can't even get them to change the rods by themselves. No, no. It was kind of funny but again he's got an inquisitive mind. He's a health care provider. Right. And I told him if retirement wasn't working out for him I'd bring him on. But the problem was that he expressed he had had a little bit of muscle pain and we had a conversation about being patient with oneself and listening to your body and that there was no prize at that finish line and that more is not better. I mean I'm sure you've had a million patients that think, you know... This is what I say. I say my job isn't that... The reason this job isn't easy is your sleep apnea does not always get better the farther you move your jaw out. Boy would it be easy if that's what it was. Absolutely. Right. Absolutely. But that's a hard concept for patients to understand. It's intuitive to think if a little bit is good then you know all the way to the farthest protrusive range would be better. But I mean we know it's not. But then he asked an interesting question and again I had to go back to Dr. Swearer for guidance. Okay. About when to order a repeat sleep study. This is definitely a data-driven person. This is one week into it? He was already asking me. He's one week into it asking. All right so I want to let you know he's a physician and I see physicians and engineers. That rarely happens to me with physicians. That happens all the time with engineers. Yeah. And I couldn't blame him. I like data too. It's kind of nice. You can work with them. They're data-driven. They can give you points. But he was very very anxious to get a result very very fast. And we had a conversation about waiting just a little bit longer and just making sure that we've nailed down any muscle tenderness and that we would order that study with the appliance in place and then send that over to Dr. Swearer for his impressions on it. All right so Dr. Swearer tell us what what happened at this point between you and the patient and what advice did you give and how did you add to all of this? Well from my standpoint around the time that Michelle was working with him after the appliance was made I was still pretty much working around that time to get him on optimal settings and mask fitting on his BiPAP. That started before Michelle came into the picture but continued throughout. And it's interesting that you mentioned that he changes his oral appliance pieces because he also changes his BiPAP settings relatively frequently as well thinking on a night-to-night basis that he could tell if he feels better and he might be able to. But also there's the added information that he can look at his machine data every night and say well I had two respiratory events an hour or three respiratory events per hour or six respiratory events per hour all of which by the way are probably clinically insignificant. But this is the kind of person he is. He's compulsive like you want a good physician to be. Very compulsive like you might want a good dermatologist to be which is what he is and makes it very difficult to settle on anything. But I was able to convince him over time that these variations in numbers of breathing events night to night whether it's two, three, four, five, six, eight are not necessarily meaningful in any way and we can get into that. And also the majority of his device of his episodes are central apnea events at least as read by his machine and we will get into that topic I'm sure a little bit later. But I also found it sometimes challenging to convince him that central events were important and have even less meaning most of the time than obstructive events because if they don't cause sleep disruption or any kind of oxygen desaturation we generally don't treat them and chase them at least in my opinion we don't. So my goal again was to get him on adequate BiPAP settings and when I finally was seeing him this year and towards the end of last year I think he was relatively happy with where he was with that. We sent him to the sleep lab not for another study but for a mask session in which he got a lot of education and fitting techniques and trying some other masks as well and finally decided that the kind of mask he had was the best for him. It's what we call a hybrid mask it covers his mouth and under his nose and it's most more comfortable for most patients than a full face mask. He I think from history could not do well with a nasal mask because his mouth would tend to pop open that's a frequent problem especially in patients that are not particularly obese which he isn't and maybe have his relatively thin facial structure at least that's what I think as a non professional of the bone structure but he is the type of person that would tend to open his mouth with any pressure in the nose. So with all those maneuvers he was finally getting settled in and his main goal was to try to get an alternative. So I'm going to make a couple of observations here. Number one you are you are both in the most ideal situation because it is not difficult at all for you to communicate you have instant communication. For those of us that don't have our sleep physicians in the same building and in the same practice it does take a little bit more effort but it's certainly worthwhile. I hope everybody has their sleep physicians emails that you can send off an email and let everybody know what's going on. Number two I imagine because this has happened to me that it can be quite challenging trying to calibrate and titrate BiPAP or some type of PAP at the same time you're trying to try to calibrate an oral appliance and that it it does become difficult if the patient's going back and forth. You're absolutely right but again our goal is we want to take the best care of our patients and also to make them happy whenever possible. You know if it's a Venn diagram great it doesn't always happen that way but he was very happy to see this moving along and again he's a traveler and he made it clear what his goals were. So in October of that year we reached the point that we were ready to repeat a sleep study and the type of home test that our facility uses is called a watch pat. At this point the patient's weight was right around 200 and remember the initial study was at 187 and I received the results which obviously have to be interpreted by a board certified physician and Dr. Swear was again helping with this so I guess it would probably be better to have Dr. Swear explain the watch pat and the findings with the appliance. So number one I'm going to let you do that and I'm looking forward to you doing that Dr. Swear but I also want to point out that this could be really interesting to a lot of our members because on one of our major Facebook discussion groups watch pat and that type of technology has been discussed a lot because people are using it dentists are using it for calibration before they send their their appliances back to their doctors and they feel like it's showing an overestimation of what's going on and they're getting frustrated with it. So with that note please let us know what's going on with this pat technology Dr. Swear and what you found. Well first let me say that the reason it's widely used is because it's easy to use. It just requires a patient to wear basically a fat watch you know on their wrist hook up a probe on their finger which does more than one thing other than oximetry it measures arterial tone and a little sticky probe on the front of their chest. It doesn't get much easier than that for a device that purports to measure a lot of things to be able to determine if there's sleep apnea. Anything else at home requires some sort of couple of chest belts plethysmography and or probes on cannula under the nose to measure airflow also an oximeter and any other variation of devices such as a microphone to measure snoring a body position sensor. So the body position is measured with the arterial tomography device on the chest chest motion is supposedly recorded there and snoring is recorded there so it gets easy which is why most people use it. But I think it's very very important to understand the principle behind it which I'm going to explain a little bit. And if you're not watching this on a video right now I'm going to refer to figure B which you can look at a little bit later. On the figure that I've depicted this is an experimental recording so bear with me with the details because I think it's important that everybody understand why a watch pad or any arterial tomography device works to record respiratory events. Notice that when I describe the signals I didn't say that there was anything measuring airflow or breathing or chest excursion or anything else. So in this figure which is an experimental recording from a lab this shows with a time axis on the bottom you can see 30 seconds this shows you what happens with three successive apneas. You can see on the bottom graph called airflow that there is no airflow for the three devices there and you can see how there's cyclic apnea and desaturation going up and down. The important thing to notice here is that at the end of an apnea after the patient has been holding their breath for a while, this particular subject, there's an increase in heart rate, an increase in blood pressure which really peaks sort of as the apnea breaks or ends, and an increase in sympathetic nervous system activity. And the cool thing about this study is it actually measured sympathetic nervous system activity with a little tiny microelectrode placed into a nerve in the leg. This is called microneurography and it's a technique developed over the past 20 or 30 years experimentally. It's very hard to do but also very interesting. So we know that sympathetic activity in the nervous system increases as an apnea progresses, reaches a peak, and then drops which corresponds to blood pressure changes and velocity of blood changes you can see there in the limb. And without worrying too much more about the details, the WATCHPAT or PAT technology relies on this. So it relies on the fact that when there's a respiratory event, whether it's an apnea, complete breathing cessation, or hypopnea, struggling to breathe but still some airflow, that all these changes occur. So the finger probe measures arterial tone which compresses as the apnea progresses. It measures heart rate, it measures oxygen saturation, and we have an oximeter, not only the oximeter, but we have all the signals you need with respiratory motion here to determine if there appears to be respiratory motion, if there isn't airflow, and if there's a vent. Now you notice this is very indirect. So it requires, to call something a respiratory event, it requires all these things to happen. Well you could probably think of 10 examples of where that might not happen. Let's say for example somebody has a pacemaker and their heart is fixed at a regular rhythm. Well their heart rate's not going to increase when they have an apnea event. Let's say somebody is on blood pressure medication. It might be that their blood pressure hasn't changed very much. Let's say that an older individual has very stiff blood vessels, that people with atherosclerotic cardiovascular disease have very stiff blood vessels. Is their arterial tone going to change significantly if their vessels are calcified and that doesn't happen? And there are many other examples. So does that also mean if someone has cardiac arrhythmias this is not a good test for them? Well when you say good, good is relative. Depends on the arrhythmia. But the heart rate's not going to vary. It's let's say less good, you know. And there is really not, there is a correlation you would say between the outcome of this test and the outcome of a laboratory polysomnogram. But that doesn't mean when you have a correlation, doesn't mean that for every patient that it is, that it tracks. So there's a wide variation between results especially at the low end. So we use this test a lot, but we have to place it in the clinical context. If you have somebody who obviously has severe or moderate to severe disorder whose oxygens are fluctuating, we can see these tracings when we look at the report. You can go by that, that they do have significant sleep disordered breathing. But down in the low range, we will very often not consider that test too heavily if they have a very strong clinical picture, for example, for instructive sleep apnea. So I'm a little bit leery of, go ahead. Maybe you were going to say it. I was just going to ask if it is less able to detect sleep disordered breathing in mild sleep apnea or does it overestimate in mild sleep apnea? Or am I completely off with those questions? And that's a complicated one because it kind of depends on the criteria they use for scoring. So my general feeling is that it tends to, if anything, underestimate it in those patients that present with sleep complaints that seem like sleep apnea. But there's another aspect to this in that it depends on how much desaturation you call a respiratory event. So there's another issue in sleep medicine that we could discuss further in a little while regarding the scoring criteria that you use to score respiratory events. And your audience may be well aware of that as they're educated in this, that you can score a respiratory event based on 4% oxygen desaturation or 3% oxygen desaturation. Now, the 3% criteria technically is not just 3%, but it's 3% or an arousal from sleep. But in this particular test, we can't measure arousal from sleep. So it just becomes 3% versus 4%. And the feeling is that with 3%, you could overestimate a little and 4%, you could underestimate it a little, but I don't really think there's a consistent trend there. I think that gets into like a whole other podcast about the definitions of sleep apnea, because there's 3%, 4%, ODI, REI, R-E-I, and that's a bit of a problem. But the bottom line- I think that there's a- No, go ahead. I think if there's a take-home point to this is that this type of technology is not a direct measurement of respiratory events and needs to be taken very strongly in the clinical setting and interpreted in the clinical setting and context of what's going on with the patient. It is not easy to use this to decide if somebody has a difference of five or six events per hour with any sort of therapy, or especially in this case with an oral appliance. Okay. So now you've- have you explained everything you want to about this PET technology, Dr. Swearer? I think so. Okay. So let's go back to the case. So he had his overnight with his PAT technology. What were the outcomes, Dr. Cantwell? I have to share this with you because I forgot about it, but it just paints the picture, and I think you'll appreciate this. So what triggered the actual order, we had planned on ordering it, but one of the components that I kind of forgot about was that he had sent an in-basket message to me, the patient that is, saying that he was very concerned because he now wears nocturnal pulse oximetry, and that he saw that it was giving him readings below 90 for 2.7% of the time. And this to him, you know, we had a discussion, you want to be respectful, but just share with him this is not a hospital grade, you know, oximetry, but that's what triggered getting the sleep study at that exact time. So now there's some urgency because the patient who's a physician is very concerned that his oxygen levels are desaturating, 2.7% of the time, right? So now as a sleep medicine provider, I'm going to kind of ask some questions of Dr. Swear because this is what I get in my reports. Some of my reports are less than 90%, how much time do they spend less than 90%, some are less than 89%, some are less than 88%. So that has made me have the assumption that sleep doctor physicians really don't get upset about this unless it's below 88% because most of them just report below 88%. Please help me out, Dr. Swear, what is actually really significant in terms of oxygen levels during the night? Well, first of all, the reason that 88% is there, it's less than or equal to 88% is because the Medicare criteria for getting home oxygen, which has really nothing to do with this at all in this case, is that you have to have at least five minutes of saturation less than 89% to even think about qualifying for oxygen, but you have to have a medical condition such as COPD or interstitial lung disease or something that would need to be treated as well. In these particular cases where people have minor degrees of desaturation, and in this case far less than five minutes anyway, it may be totally, it's usually, I feel, totally clinically insignificant if it's just a very specific period and the patient's saturations are normal otherwise, then you can't prove that you're helping anything to treat that at all. Now, could it be an indication of sleep disordered breathing that's more significant? Well, not in this case because we have a lot of evidence to know that he doesn't have really severe or moderate sleep disordered breathing, but that 89% figure is there because simply of Medicare criteria. Obviously, the lower saturations that exist at night have a lot of physiologic consequences, but the oxygen content of your blood is actually quite good at levels of 89 or 90% or better because of the oxygen desaturation curve that you learned about way back in dental school or whatever school you went to. So I never get concerned of about a minute or two of low saturations below 88 or 89% or lower for that matter, because I can't prove that they're harmful if they're short periods. Okay. Thank you. I never knew the history behind the 88 or 89%. So now, Michelle, let's go into the fact that he was using an over-the-counter non-medical grade pulse oximeter to do this. That's a little problematic because it has not been tested to understand or know that it is accurately recording that, correct? Absolutely. Absolutely. But again, I really like this patient. I really do. And I'm sure you've heard that phrase that people aren't going to remember what you say. They're going to remember how you made them feel. And I knew that if I said no, if I downplayed it, he would walk away feeling like he had not been hurt. So he wanted data, and there's nothing wrong with that as long as he was comfortable repeating it. So again, recurring theme, I reached out to Dr. Swear and asked him to review the results. This was completed then in April of this year. And it showed that it had decreased. His AHI at 4% had decreased from, I want to say it was like 16, 16.2, down to 6.7. And I'd be like, victory. Yeah. I mean, again, he has a BiPAP. He just wants this as a backup. But yeah, I was kind of happy. I mean, I'm going to put a little stop on it just to explain that. I would say victory in terms of numbers, that is different than in terms of symptomatic relief, all right? Exactly. You nailed it. So I want to be clear about that. But in terms of numbers, that's what I would be thinking. But you're right, you have to listen to what a patient says. And I always thank patients when they are trying to participate in their treatment. Because so many patients just come in and go, just help me. And they don't do the work. So this guy is doing all the work. And he's making all the effort. Absolutely, absolutely. And as you alluded to, the numbers looked good. But he was concerned that it wasn't below 5. So how did you deal with this? What was the outcome? What did you do? I have a secret. And I'm going to share it with you and your listeners. I referred him over to Dr. Swearer. Excellent. Okay. And it works every time. It does. And you know what? You have such an ideal situation. You know, Dr. Swearer, you might not understand that so many of our dental medicine sleep practitioners don't have a good relationship with their physicians. I mean, I do. My physicians are great. They've been doing oral appliances for longer than I have in this area. So they're receptive. But we have a lot of dentists that are afraid to send their patient back unless everything looks exactly perfect on the follow-up sleep study. I understand that. And I'm also told that dentists are shooting for perfection. Yes, that's what we do. I've been told that by more than one dentist. And I'm very happy about that when I go to the dentist, which I've unfortunately attended many times in the last few months, unfortunately. But when it comes to this numbers game and low levels of sleep apnea, it's important to realize, and this is true in I think many aspects of medicine, that the enemy of good is perfect. So let's just say that this patient has six events per hour with 4% desaturation, and I'm going to emphasize because you have to compare apples to apples. Before this year, they were all measured at 4%. Now we measure 3% and 4%, which is more of a criteria for the Academy of Sleep Medicine and to be accredited as a sleep facility. And that's fine. But everything has to be taken in context with understanding. So yes, the numbers were better. And am I going to be concerned about six events per hour and somebody that's feeling great? No, not at all. Because the threshold for sleep apnea is five events per hour. And all these thresholds are arbitrary. They're set by a group of people sitting around a room who've been doing things for a long time and have published a lot of papers in our universities. And we'll say, well, we'll say it's five. And then it's 15, but if you've got more than 15, it's moderate sleep apnea. You get more than 30, it's severe. But that's all arbitrary, but it gets you into trouble, but you have to use it if you're comparing study to study and apples to apples. So no, I have no problem. Right. And if you're using insurance, insurance is looking many times for that. Exactly. And that's even a worse problem. But I would explain to him, first of all, that six events per hour is great, but mostly go by how he's feeling. I also noticed in that study, however, which was in the previous studies, that his numbers are worse when he's on his back, when he's in the supine position than he is when he's on his side. So that's another maneuver that he should adhere to. He has trouble with that, I think, because he gets aches and pains like many of us get in one position. But if he can spend more time off of his back, it's also better. So I would use that to reassure him. But that doesn't necessarily, in this particular guy, help a lot because he still has the tendency to look at the numbers when he's on BiPAP and think about it. And he's going to change things. But I think we've made significant progress between the two of us of getting him to realize, stop and take a deep breath and stop worrying about these small changes in numbers. Absolutely. Dr. Swearer, I was always curious, and I've always meant to ask you, what do you look for when someone expresses chronic fatigue? And is fatigue the same thing as sleepy? Are those interchangeable? That's a good question. I try to separate them initially. So a typical patient will come in and say, I'm tired. And when they say that, I say, what do you mean you're tired? He says, I'm just tired all the time. I try to ask, are you tired in the sense that if you're sitting around during the day, you just don't feel like you have any energy and you want to get up and do anything that you feel drained, like as if you had the flu or something, or you just have no desire to get up and move because you might get weak or feel achy or something? Or are you tired in the sense that if you're sitting there reading a book, you fall asleep? Or if you're watching TV, you might fall asleep during the day. Or if you're driving, you feel drowsy. And I try to separate sleepiness from fatigue. And sleepiness, if it's verified and it's really sleepiness, you can always do something about that, depending on the disorder that there is, sleep apnea or something else, whether it takes therapy or medication or scheduling or whatever. Fatigue is a harder nut to crack. There are patients with various levels of chronic fatigue. Now can you have fatigue from having sleep apnea? Yes, sure. And I've had patients say, I'm just fatigued and it does improve. But more likely, sleepiness indicates a sleep disorder. And fatigue has many, many, many causes, as you know. Interesting. But I will tell you that as I was training, and I haven't heard this for a long time, but as I was training for this, it was always brought up that men tend to be more sleepy and women tend to explain it more as fatigue. Is there a gender difference between that, that you've seen or that? I might say yes, if I think about that. I never thought about that, but I think either could, it may be true. But if you pin them down, you can separate them. Initially, a person might come in and say, I'm fatigued. But if you ask specific questions in specific settings, like using the Epworth Sleepiness Scale, for example, you might uncover that they're sleepy. And by the way, they might've told 10 other doctors they're tired and they're getting workups for fatigue with blood counts and thyroid and looking for other things, when the reality is they're sleepy. And if you can figure that out, it's a whole different pathway. Now, you can be both, obviously. It's not always so clear cut, obviously, you can be both. When you say sleepy, you're trying to figure out if it's the chemical drive, like orexin, things like that going on that are creating the sleepiness. There's a lot of reason, but simply speaking, the desire to fall, the pressure to fall asleep. And that comes down to an algorithm of, I don't know if we wanted to get into it, but there's only five general things that make people sleepy. Of course, in the US, it's not enough sleep. Crazy schedule, medication, then you're down to, if you don't have a crazy schedule and it's not medication and it's not just insufficient sleep. And by crazy schedule, I'm thinking shift workers and whatnot, or anybody that has a crazy schedule for their job or anything else. Then you're talking about things going on at night that make you sleepy, that interrupt your sleep, such as sleep apnea, or a brain disorder such as narcolepsy. So that, but when you're talking about fatigue, it's a much broader group of conditions that often necessitate a big workup and often are chronic and sometimes not much you can do. Right. I suppose there are some environmental problems as well as people that live in cities or households that are noisy and that can be more difficult to figure out for your patients. That falls under things messing up your sleep. Yeah. If you live at the end of the runway at O'Hara Airport in Chicago, you're going to wake up every couple of minutes. That's another thing that, there's a long list of things that mess up your sleep, including your spout snoring and caused for sleep fragmentation, we would say. So where did you end up with this patient? What's going on now? Well. Well, go ahead, Michelle. On the oral appliance side, much to my chagrin, I didn't realize that he had also kind of played around with the settings because it wasn't what we recorded. Right. So every time he came in, it was a different setting. But ultimately, we left him, and I'm not going to tell him this, I probably should, but I'm not going to, that he was actually right. The setting that he had chosen was the best one and it had maximized. That's great. Yeah. That's great. So he figured it out. So I'm feeling that you are amazing. You are there for your patients. You're trying to do the best you can and make them feel good, but you were also under it a little frustrated that he wasn't following your instructions, right? So that was part of the challenge for you. Is that correct? Yeah, absolutely. And I mean, even though I've been doing this for, well, it doesn't matter how many years, many years, it doesn't get any easier. I'm a prosthodontist. We are so used to measuring success in fractions of a millimeter. You were a microsurgeon. Yep. And that's where it is incredibly reassuring to work with a provider like Dr. Swear because I present the data to him and he helps take very, very complicated components and boil it down and reassure. And that reassurance, he even came into the room with the patient when I was there to let him know, listen, this is actually quite good. You're going to be fine. This is for travel all as well. And then the patient seemed to be, he found that to be very reassuring, I think. Okay. So Michelle, you got to the point where now your patient is happy with his oral appliance and you're happy with the efficacy of treatment based on the sleep study. And now where's he going on vacation? Well, the long awaited vacation is actually to Colorado. So as far as I know, he may be there right now. Oh my God. So I am so excited that's where he's going because I always write myself like little questions if I have questions about what's going on with sleep apnea and treatment and sleep disorder breathing. And one of my questions is, number one, like Dr. Swear, he's going to high altitude. Like isn't that going to increase his chances of having central sleep apneas? It certainly is. And that's why I'm totally thrilled and glad that he's not going with his BiPAP unit. Because if he would go with his BiPAP unit, and that has happened, I think with him before and other patients, he will keep looking at those numbers and notice that he probably will have a significant increase in the number of central events he has. He may even have symptoms of poor sleep quality from that because as you know, altitude is one of the causes of central sleep apnea. So in the case of this oral appliance and the last study we have on him, whichever setting he was using, he did not have central sleep apnea, but he does have that tendency. So let me get this right. are you glad he's using his oral appliance at altitude because he won't know that he's getting central sleep apneas or because oral appliance would be a better treatment for him at altitude? Well, to be honest, I'm sort of happy that he doesn't know that he's having maybe some central sleep apnea because you, I, or anybody else, if it's measured carefully and the higher the altitude, the more we'll have, we'll have central sleep apnea. So I think we could use this opportunity right now to talk about central sleep apnea and maybe treatment-emergent central sleep apnea. And if you look at your show notes, I did put in a couple, a bullet point slide about central sleep apnea. Central sleep apnea, it's a term that's bantered around a lot. Just like, oh, obstructive sleep apnea, but he doesn't have that, he has central, this patient has central sleep apnea. Well, there is really no such thing as central sleep apnea as a syndrome. There are many causes of central sleep apnea. And if you look at figure D in the show notes, that makes the point that central sleep, obstructive sleep apnea is a syndrome, but central sleep apnea is caused by several different circumstances. One of the most common is in a patient with heart failure in which there is chained stokes breathing or accelerating breathing and then decelerating breathing to an apnea. And by definition, there's no obstruction involved. It's just the absence of effort to breathe. And this is a very common scenario. If somebody wakes up from sleep for any reason, by the way, if you're sleeping soundly and all of a sudden there's a noise and you arouse from sleep, maybe not even consciously, and take a couple of breaths and go back to sleep, you may have a central apnea because when you take a couple of breaths, you blow down your carbon dioxide level, which drives breathing, and you will pause in your breathing for a while. That's physiologic. And a lot of times, for example, patients on CPAP or BiPAP may wake up a little bit just from the mask, and they'll have some post-arousal central events, which are physiologic. And anything that causes an arousal can cause these post-arousal central events, such as leg movements. So a lot of times people end up chasing these central events on their results from their CPAP or BiPAP downloads. And the answer to do that is you gotta figure out why they're having them. It may not be one thing. People at high altitude get central sleep apnea. And then there's this thing called treatment emergent central sleep apnea, which refers to individuals that are placed on CPAP or BiPAP for obstructive sleep apnea that then develop treatment emergent central sleep apnea. And that's for a variety of reasons. A lot of them are not that well understood, I think, but the higher the pressure, the more likely that is to happen. And to make matters even more complicated, I know from previous trials of his CPAP that this patient tends to do that, but he isn't doing it very much as long as the pressures are low. And he wasn't doing that, having treatment emergent central sleep apnea with his oral appliance. Patients that take respiratory depression, such as opiates, oral morphine, oxycodone, they will have central sleep apnea. And sometimes people just have cyclic breathing like if they're at altitude. So it's not one thing. And now, if he goes to altitude and he gets it and he's symptomatic from it, the typical maneuvers we recommend for those kinds of patients are gradual ascent to altitude so that you can acclimate or usually the pill for high altitude sickness, which is acetazolamide or Diamox, is you pre-treat with that to prevent some of that. That was my question I put to myself in my notes. I look at it every day when I open up my computer. Should patients that are going to high altitude use Diamox if they are being treated for sleep apnea? Is that something that should be done preventively? I would have to say as a general rule, if there is a general rule, it wouldn't be a bad idea if there's not any other contraindication to it, if there's not kidney disease and other reasons to or other drug interactions to do that. The best advice is to try to ascend gradually, but that doesn't usually happen. Now, it's not that this guy, he's going up to what I remember was like 8,000 feet. But certainly people can get sleep disturbances and periodic breathing and central apnea at 8,000 feet. The other question I have about central sleep apnea is when I see central sleep apnea scored on a home sleep test, I pretty much ignore them because it really could just be that the piezo belts weren't on tight enough, something was going on. I really only trust it if it was scored during an in-lab PSG. Is that a correct assumption? I think that's an astute observation. It may or may not be there, but the techniques we use to measure chest effort, it's called effort, but we're not really measuring effort. We're just measuring excursion of the chest some way or another. And especially with the PAT technology, one little electrode that has an accelerometer on it that measures motion on the chest is a very, very poor indicator for multiple reasons of chest effort or chest excursion. And I usually take it with a grain of salt, unless it's in the clinical context of one of these conditions that I've seen or the pattern fits. But all those patients who you have a serious concern about, I agree, they should be studied in the sleep lab. Right, okay. And so did you finally get this patient to a point where you feel like he's well-treated on a BiPAP and why did he end up using a BiPAP versus a CPAP versus a PAP at a steady pressure? That was before he came to see us. I think in his case, it was just more comfortable for him. And it isn't for some patients. And I have another diagram that is going to be in your notes, figure A, just for those that are unfamiliar with the difference. CPAP is continuous positive airway pressure and just basically splints the airway open with a constant pressure. And that's the first line of, these are pressure recordings with these various modalities. And the goal of CPAP is to keep a constant positive airway pressure to splint the airway open through the entire cycle of breathing. A little modification that most people have now on their machines is called expiratory pressure relief or EPR. And you could see that on exhalation, this little drop in pressure, usually it's two or three centimeters, which makes it a little bit more comfortable. If you can imagine you're not exhaling against the fixed pressure, it makes it a little more comfortable. BiPAP takes that a step further in that on inspiration, the pressure is one level high, one level, which is what you set to the IPAP and the lower level as EPAP. And so the reason that works is that patients need a higher pressure on inspiration to keep the airway open than they do on expiration. On expiration, all you have to do at the end of expiration is splint the airway open so that the machine will sense when there's going to be an inspiration. Then during inspiration, the airway has a tendency to collapse in sleep apnea because of the negative pressure. The machine responds and senses the effort to breathe and moves up to the IPAP level. And many patients find it much more comfortable to have this machine rising when they're breathing in and falling when they're breathing out. Not everybody, but many people do. So that's the rationale for BiPAP, which allows the expiratory pressure often to be significantly lower than you'd have to have if you were just using CPAP. That's the difference. And he ended up on it for a comfort reason. And when he actually had a BiPAP trial a couple of years ago, it was found that as he got up to higher pressures in the laboratory, he did have more and more central sleep apnea. So that's what treatment-emergent central sleep apnea is. Sometimes it just gets better by itself and sometimes it doesn't. Which highlights that CPAP is not easily used for many people. If you just say, here's your CPAP, try it. Yeah, that's a disaster. Yeah, it really has to have a lot of oversight, which unfortunately I think a lot of patients don't really get. I agree. It has really to have the best outcome. And if you do have proper education, maybe a proper mask fitting, ideally a mask fitting and a CPAP trial in the laboratory, but if not, at least a good education, several masks tried, the patient's allowed to get comfortable with them. And then even so, if they get sent home with out-of-set CPAP where the machine sets itself, that can have a pretty good outcome too. But a lot of times none of that is done and the machine is just sort of dropped off or with very little education. And so when people say they fail CPAP or they fail BiPAP, you have to ask how it was instituted. Correct. So in the end, have both of you been... Actually, there's three people involved. Mine escaped. There's the patient first. We're all here for the patient. Is the patient duly satisfied with his treatment now and are both of you satisfied with his treatment? I believe so. I think so. I mean, yeah. That's great. So just- I'm sure he'll have some observations when he comes back from Colorado. Well, and knowing him, if he's having a problem, one of you or both of you are gonna hear about it while he's there. Because he's, of course, anyone can do this, but he'll start Googling high altitude and problems. Which is fine. I'm not a... I'm a fan of patients having more information than less. So I think it's very helpful. So Michelle, this has been a really great discussion. I've enjoyed talking about this. It's so much fun for us to have these discussions. We're all basically in our little offices by ourself, working every day. Maybe we get together once a year and have some discussions. So it's a real treat to be able to be amongst other practitioners and going back and forth with this. So in the end, why did you feel like this case was a success? What were the... There were some obvious challenges and it wasn't a straight line. So there's a reason you've picked this case. Can you give us a summary of why this stood out? Yeah, I especially wanted to share this case because I learned a lot from it. And it's cases like this that keep it interesting. There's just when you think things are getting routine, there's so much to learn. And we realized that we really need to reach out to our colleagues. And I think I've been guilty of this where I'm afraid to ask questions. You just want people to assume that you kind of know and no, there's no place for that. And that's why I'm so grateful to have a colleague like Dr. Swear where I can just admit, I don't know where to go with this or guide me. So don't be afraid to be vulnerable like that and to ask questions would be kind of the take home that I wanted people to get from this case. I think that's a great point because in the end, we're all humans. And I know one thing for sure, we're all here because we're interested in helping patients. My physician is interested in doing the best thing for their patient and so are we. And sometimes it seems like there's not enough cooperation. In your case, there's lots of cooperation. But for practitioners that feel a little isolated from their physicians, get to know them. You're gonna find out they went into, there were lots of professions they could have gone into. They could have gone into the stock market. They didn't. They went in to help people. And that's why we're there also. Yeah, it is very, I would say it's very difficult to recreate the kind of environment we have because we both learn. It's she, I mean, I don't know anything about dentistry and I'm sure I thought not too long ago, well, the more forward you move the jaw, the better. And you just can't stop when you get to the point where they can't take it anymore. And I learned a lot that way, but we're just, both of us are privileged to work in an environment where we have multiple modalities in this healthcare system. But besides this, we have access now to hypoglossal nerve stimulation with Inspire. We have access to people getting bariatric surgery. We have access to people that use the new weight loss GLP drugs. And all of these are complimentary towards treating any given patient with obstructive sleep apnea. And I'm sure there's something I've left out, but it's hard to recreate that in some communities. You can, but you'd realize people are taking their time. Some 25 years ago, I was in a community where I actually was able to put together a group of an otolaryngologist, a maxillofacial surgeon, but not a dentist, although of course they are dentists, but maxillofacial surgeon and our sleep team. And we did have conferences on patients, but it is very, very, very hard to do that. So Leon, great case. I really enjoyed talking to you and with both of you. Leon, what are your- I enjoyed it too. Great. What are your takeaway points for this case? Well, there were a lot of points that we made, but if I would emphasize a couple of things as it pertains to this particular patient. Number one, again, the enemy of good is perfect. And I would urge everybody when they're looking at test results, whether they be lab tests or home tests, not to focus on very small numbers, very small apnea, hypopnea indices, for example, or a minimal oxygen desaturation indices if the patient is doing well. Specifically, if somebody is in the mild sleep apnea range, certainly under 10 events per hour and they're doing great and they feel like they're sleeping well and they're alert during the day, leave it alone. You can only mess it up if you try to make changes from there based on a number. Thank you. I think the other thing I would say in general is that a dentist in the community who's doing sleep-related dentistry, sleep medicine, dental sleep medicine, should really try to develop a close relationship with a sleep specialist or two so that you could speak frequently and not be afraid to ask questions back and forth and not be afraid to show ignorance because there's ignorance on both sides, trust me. And also, you'll get familiar with what that particular provider is using in terms of testing equipment. I know a lot of dentists want to get at least a home testing device that they can use in their office. And I think it's a good idea because you don't wanna have to refer people to sleep centers all the time to do what they wanna do when you're trying to make adjustments with patients. But it'd be nice if you would have a good understanding of the device and even preferably use the type of devices that are being used by the sleep physician so you could discuss them. So communication is important there. Thank you. How about you, Michelle? Any final words? I couldn't agree more with what Dr. Swearer said about collaboration and looking for resources. Nobody's operating in a vacuum here. We really need each other to make these cases come together. And I think the other point would be to understand that what we're looking for is individualized to the patient. We should always be striving for the right treatment for the right patient at the right time. And that's gonna evolve. It's not gonna be a solid line. People and numbers change and we gain and lose weight. And so don't be afraid to say, I think I need help. I think the patient needs surgical intervention or can we revisit maybe CPAP desensitization or co-therapy. Just understand that it's very fluid and we need to stay on top of what the patient needs in that moment. Couldn't have been said better. Thank you both. It's been great. My pleasure. Thank you for having me, Becky. Thanks for inviting me. It's been a pleasure. Oh, you're welcome. It's been terrific. I wanna give a big thanks for all of our listeners. I hope you enjoyed this podcast and the discussion of this case as much as I did. If you have any suggestions for topics in the future, please send them to the AADSM. There will be a specific email to use in your show notes. And we look forward to continuing these conversations in dental sleep medicine in the future. Take care.
Video Summary
In this podcast episode, Dr. Vicki Cohn hosts a discussion with Dr. Michelle Cantwell and Dr. Leon Swear on the clinical case of a patient with sleep apnea. They discuss the patient's journey from using a Bipap machine to trying out an oral appliance for travel. The case highlights the importance of collaboration between dental and sleep medicine practitioners to provide individualized treatment for each patient. Dr. Swear emphasizes the need to focus on patient outcomes rather than being fixated on numbers, especially for mild cases of sleep apnea. Dr. Cantwell stresses the importance of asking questions, seeking resources, and adapting treatment plans as needed to best serve the patient's needs. Through their discussion, they showcase the complexities of managing sleep-related disorders and the significance of continuous learning and communication in providing quality care.
Keywords
sleep apnea
Bipap machine
oral appliance
travel
dental practitioners
sleep medicine
individualized treatment
patient outcomes
mild sleep apnea
continuous learning
quality care
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