Welcome to Open Airways, a podcast brought to you by the American Academy of Dental Sleep Medicine, where we discuss clinical topics related to dental sleep medicine. I'm your host, Dr. Vicki Cohn, and I'm joined today by two guests, Dr. Nadia Afzal and Dr. Shehzad Malik. Dr. Nadia Afzal is a dentist and diplomate of the American Board of Dental Sleep Medicine. Her current practice is in Bethlehem, Pennsylvania. It's a practice dedicated to treating patients using an integrative approach. For her, successful patient management may include many modalities, including pap therapy, surgical interventions, oral appliance therapy, myofunctional therapy, and tongue-tie release, all depending upon the patient's needs. In addition to running this busy practice, she's an affiliate in training with the Breathe Institute, also a fellow with the American Laser Study Club, and a recurring speaker at the Temple University of Medicine at St. Luke's Teaching Hospital. Her passion for treating the airway, as it relates to overall health, has placed her at the forefront of bringing about a collaborative care model in the Lehigh Valley. Dr. Shehzad Malik is a board-certified cardiologist in a private practice at the Heart Care Group in Allentown, Pennsylvania. This is an outpatient cardiac care practice that prioritizes well-being by offering preventive and non-invasive care. He is so dedicated to the importance of good sleep as a cornerstone to cardiac health that he also serves on the board for the Foundation for Airway Health. Like Dr. Afzal, Dr. Malik also emphasizes an integrative approach to patient management and frequently incorporates airway testing and treatment as part of a patient's cardiac treatment plan. His passion for his patient's wellness drives his willingness to pursue solutions beyond the scope of traditional cardiology and leads him to collaborate with other specialists as needed for each individual. Doctors Afzal and Malik, welcome. Thank you, Vicki. Thank you for having us here today. Thank you so much, Vicki. It's an honor. It's a pleasure, Shehzad. Let's dive right in and talk about what you two bring to the table because I know this is going to be a really interesting conversation. So, Nadia, can you just tell me how you first got interested in dental sleep medicine? Yeah, it was sort of a fluke. I am a Dawson trained scholar and they had sent me a flyer that they were having an airway symposium and I was at that point kind of toying with the idea of getting into sleep, but I didn't really know if I necessarily wanted to go through the oral appliance route directly or just kind of get a better understanding of how sleep affects people in general and how we can approach it as dentists. So I figured, well, I've been through Dawson, so why don't I attend their airway symposium? And it happened to be in Florida. And at that time, I said to Shehzad, our kids were young, I said, why don't we make a trip out of this? But I don't want you to just come with me. I actually want you to join me at this conference and, you know, let's just see what it's like, you know? Okay, so hold on a minute, spoiler alert, right? Because we haven't told everyone listening yet that you two are actually married. Yes. Yeah. I guess we didn't say that. Yes, we are. We've been married for, man, a really long time now. 16 years. No, actually longer, I think, 17. Almost 17. That's right. Okay. You're in trouble, Shehzad. But anyways, we'll deal with that afterwards. Yeah. 17 years. So it was kind of an interesting approach that the symposium took because it was a presentation with physicians and dentists. And I thought this would be something interesting for Shehzad as well since he had kind of talked about sleep on occasion. So I'm like, why don't we attend this together? So Shehzad, were you like, yes, let's go? What happened? Not at all. Not at all. I actually remember the day she asked me, I was putting my white coat on like I do every day at that time. I was working in the hospital a lot those days and just thinking of the day. And she literally came and said, you know, I'm really thinking about wanting to basically change the scope of my practice and enter into sleep. I honestly had no idea what she was talking about or why a dentist was that interested in a topic, which I felt I was a master in because that's what cardiologists think. We're a master of all things, right, when it comes to- Wait a minute. You're a cardiologist and you felt like you were a master of sleep. Well, I wouldn't say a master of sleep, but I knew in my mind I had a thought of what it was. And I can tell you after her introducing me to sleep from her perspective, so using it through her lens, I didn't actually truly appreciate or realize how it would completely change the scope of my own personal practice even to this day. I also think though, I don't think, I think we both kind of just went in with, I kind of went in with just low expectations to this symposium, just thinking, okay, I'll get an understanding of how to treat patients with sleep apnea and oral pines therapy and that's it. Like it could be just a part of my practice on some level, like a tool in my toolbox. And I think as we were sitting there and listening to them speak, it's almost like you're watching like a horror movie. Like you're just kind of like, oh my goodness, I can't unsee this now. And I didn't realize how much of this is prevalent in not just my patient pool, but I mean, I think where it hit home for us is that at some point they were talking about kids and we were having some issues with our, at that time, five-year-old. And we knew something was off, but we just couldn't pick, we just couldn't put our finger on it. And we're just like, are they, are they talking about our kid? Because that's what it seems like, all the signs and symptoms of sleep disordered breathing. So I think that kind of created this, just opened this Pandora's box for us. An urgency, right? Yeah, definitely. It definitely became an urgency because I couldn't understand, I couldn't wrap my head around why this wasn't more of a prevalent topic in our community. I think it's very interesting that you used the word, I can't unsee that, which I think is a really great way to describe it because we as dentists, at least when I trained, no one mentioned, nor did I understand that I was working in an airway. Yeah, a hundred percent, right? Like you see so many signs and symptoms of it and we're treating the symptoms, but we're not really understanding like what led to that, right? So yeah. Right. Nor were we, we were just looking at it at a cursory level. Yeah, you're on this med, you're on this med. Okay. Too bad. Sorry you have so many problems. Let's look at your teeth. Yeah. Right. I agree. And that training creates a whole different viewpoint of what you're looking at with your patients. So let's jump back to this moment in Florida where you dragged Shahzad, right? He didn't really want to go. And then so Nadia, you had an aha moment where it became an urgency. And then Shahzad, you went from, hey, I really think I understand this to, oh my gosh, I think I need to learn more, correct? I think I realized I didn't understand it on many levels. As a cardiologist, I pride myself on knowing things about changing people's diet, telling him to exercise, managing stress. And I knew something was always missing. And in the back of my mind, I knew sleep was important, but again, in a completely different patient profile and phenotype. I mean, large men, not really even women for whatever reason, it was men. Old fat men, right? That's what you're looking for. You know what I mean? The proverbial football player, truck driver, thick neck. When I saw pictures of what they were demonstrating at the Dawson Academy, I was pretty floored. At that time, I had very little understanding, of course, of oral anatomy. It's not something that's discussed really at all in any medical school training program. Understanding what it meant to have a crowded oropharynx, crowded teeth, a narrow upper palate, tongue posture, all these concepts at that time were completely foreign to me, but have, like Nadia said, opened up a whole different way of thinking for me that has completely and utterly drastically changed my practice and scope of patient care. So it was definitely a multiple of aha moments at that time, but only to be later realized now in the last few years. Right. And so let's go back to this situation that was occurring with your daughter. Describe what was going on with your daughter and how that intrigued you, and how maybe you've resolved that. Yeah. So she was a really poor sleeper, disrupted sleep, not getting into deep sleep, constantly tired, fatigued, not having the energy levels that you would expect of a normal, typical five-year-old. She looked tired, like dark circles under her eyes. Just a typical presentation about many of us probably see now in our own practices, but may just kind of like not really delve into it. So because when we would approach other healthcare providers, physicians in the area, I realized like there just wasn't sort of this integrative understanding, kind of like everyone's siloed in their approach. And so I felt, for me at least, I kind of became obsessed. I felt I had to advocate for her, but in a sense, I felt like I had to advocate for my own patients. And that was through the means of just understanding different educational pursuits, and what those philosophies are, and how they kind of come together. So going through the ADSM, getting my diploma, going through other modalities, and seeing how that all comes together, and being able to then speak on behalf of my patients to other medical members in our community. And I think we've been pretty fortunate. I think through the years, we've been able to create a team, albeit not a huge one, but it's growing, of where different providers of different disciplines, not all allopathic or osteopathic or dentists, but other disciplines as well, kind of have come to a better understanding of how we can all support and work together towards getting these better outcomes for our patients. That's great. And Shahzad, did this reinvigorate your medicine practice, your quest for knowledge? Yeah, 100%. I think Nadia, she's pushed me into this direction, initially somewhat probably unintentionally. And she says that she got obsessed with it. It's an understatement when you compare it to my situation. I got to a point where it was literally an opening in my thought. As a cardiologist, we're trying to make sense of patients. That's what we're trying to do. A good doctor is trying to make sense of your care, meaning they're looking at all of these basic parameters, whether it's diet, exercise, stress, what have you, in order to figure out why the patient presents in the way they do. But there was something missing, and the sleep thing has completely altered my entire scope because we now realize that there is such a huge link now between cardiovascular disease and sleep that if the average practitioner does not address sleep, then you're not making sense of your patient. And if you can't make sense of your patient in medicine, and I'm sure the listening audience will appreciate this, is that we tend to over-test, we tend to over-prescribe because we're guessing more than actually understanding. And it's really now through the sleep paradigm that I see patients through that is completely altering my approach and my management and my outcomes, so 100%. Right, because you're looking for more of a root cause of what's going on. Correct. Right. So now you both went for further training, right? And then how did that change the way you both started working together? Actually, let me ask this first. Before this, were you working together at all? You both went to your offices, you came back at home, and you worked together as a family, but you never intersected professionally, is that correct? Not really. Pretty much. No, no. We didn't talk about work hardly. No. Okay. And you never referred a patient back and forth. There wasn't... Unless I had a patient who was like, hey, doc, I'm looking for a dentist. And he's like, oh, my wife's a dentist. Here's her card, or something like that. Yeah, no. So how did that change? So that change didn't happen overnight. Because again, I was still pursuing my own education in all this to become more confident in being able to make the appropriate referrals. But as I was seeing patients who had a slew of issues in their medical history that were really not being managed in a cohesive manner, at least per my understanding, maybe never even having discussed a sleep study by their physicians, whatnot, I would say to them, hey, this is something I think we need to look into. You can talk to your primary care physician. But if these things are not being managed, then maybe you can see someone like my husband or someone who thinks like him. So I'm going to interrupt you for just a minute, because I think it's really important for the people, the doctors listening that are newer at this. Yeah. So I know when I was in general practice and I was doing general practice and dental sleep medicine, one of the key things that I would notice was really just looking at their health history and what medications they were on. So if they were on multiple medications to control their high blood pressure, if they had cardiac problems, if they were on insomnia medications, and maybe to some point even some depression, anxiety things. For me, that would be a clue that maybe something else is being missed about sleep. So were those the things you were looking at, Nadia, when you were referring to that? So before I started looking at sleep, you would see all these things, and obviously you would discuss them with the patient, but I never attributed it to sleep. Right. Because I just didn't have that understanding. I would just see these patients getting sicker, and I would see that they're on a kajillion things, and you're just kind of like, well, what's happening here, right? And I want to backtrack a little bit, too, because me working with Shehzad, like I said, wasn't overnight. It also involved working with other professionals in the community and understanding what their scopes were and what they can bring to the care of the patient that was able to facilitate me then being like, okay, I think these are the right people for you to go. This is what I'm encouraging. These are the conversations to have. So to equip the patient with an understanding as well, because sometimes, as we all know, we bring up these discussions with our patients. They go to their primary care doctor and say, hey, my dentist was like, maybe I should get a sleep study or have a discussion with you because they see all these things and all these meds, and they're just like, what are you talking about, right? So... Or sometimes I would hear, my doctor said the cure is worse than the disease. Yeah. Yeah. Right. I think we project our, like, oftentimes we project our own views or feelings on these things without giving the patient the opportunity to explore. And, you know, now there's so many ways to treat things to see, like, what works best for them. Yeah. So, yeah. So that's kind of how that started. And I think when you started kind of delving into patient's health a little bit more, you realize that some of these patients aren't being really seen by any primary care doctors. Like, maybe two years ago, they're on the same meds, and they're still kind of dealing with these issues of blood pressure and et cetera, et cetera. They have a family history. So for me, it became a lot easier to be like, maybe you need to go see someone like my husband. Doesn't have to be him. And then from there, once he started seeing them, we started exploring, or I don't want to say exploring, but understanding how that collaboration was actually for the benefit of their patients. Because it wasn't like I just let him go and then never saw them again. Like, we were actually, like, seeing results, right? And working back and forth. Yeah. And then when you see that, that then all the more makes you more assertive in a good way when speaking to other providers as well. Like, hey, this is what we're seeing. I can speak to this. These are the cases. What do you think? So would you refer a patient to your husband even when they weren't a strictly what you would have thought of as a cardiac patient, but you knew they had multiple medical problems and you suspected a sleep problem? Or would you use a different provider for that? Honestly, it really depended. If a patient had a rapport with an established provider, I had no issues being like, I think you need to go speak to your, you know, if you have a cardiologist or if you already have a primary care doctor, family doctor, speak to these things. But if they were kind of, if I got the sense that they were just not being really seen in a cohesive manner and they were looking for something a little bit more where they didn't have to re-explain themselves every time or go to someone and say, hey, why do you need the sleep study? Then I would say, I think this might be an easy approach. So then Shahzad, you started accepting patients through Nadia that weren't the typical cardiology patients then, correct? Which is, I assume, maybe I'm incorrect, right? But my assumption would be that you would get a referral from a GP or some other practitioner that said, this person has a problem. I think they have a cardiac arrhythmia. They have, you know, some type of cardiac disease and then they got you because of that. But now you have a practitioner that's referring to you because they're worried about their cardiac health because they have other things going on and potential sleep apnea or sleep disorder breathing. Is that correct? Correct. That's exactly right. I mean, we are very aggressive when it comes to sleep because when we get patients from Nadia or from whoever regarding sleep, we are very quick to tell patients that you are here because you have an established risk factor for cardiovascular disease. And the sooner we talk about it, 30, 35, 40, and address it in the most thorough way we know how, using a sleep specialist, using an airway dentist, using oral myofunctional therapy, weight loss therapy, the better your outcome will be. So that's usually the framework behind it. And in cardiology, we've, you know, we've, you know, cardiologists love to learn. That's how we are. You'll find it probably more in us than most medical specialties. We like to learn what we may not know because we kind of want to know it. And the reason is because we know it's all tied to the cardiovascular system at the end of the day. So high blood pressure management, which used to be a family doctor endeavor, cardiology. High cholesterol, cardiology. Diabetes now, cardiology. Sleep, becoming cardiology. So that actually changes my perception of actually the type of patients you were seeing in the past because I assumed, as I just said, oh, if they have an arrhythmia or if they have congestive heart failure, we're going to send it to the cardiologist. But no, I didn't realize that cardiologists are now seeing patients more preventively for high blood pressure and all of those things that you just said. So you've just added- About a third of my practice is like that, yeah. And is yours a unique practice like that or is that typical of a cardiology practice? I say, I would say at this point, I'm probably somewhat unique. I'm probably what they call an early adopter when it comes to pure preventative care. Although you have to understand, I see patients who are extremely sick. People are waiting for transplant. People are having complex arrhythmias. People who need ablations. We see all of that. But my passion, my interest lies in having to address all the things before those things arise. Before that happens, right. So it's a lot more fun talking to people who can talk back to you and feel good about it rather than really, really sick people. But we also deal with very sick patients, as you know. That's great. So give me an example of just a straightforward, like your first case together or one that stands out or something you want to tell us about. Yeah. Nadja. So I'm just going to preface this by saying that the cases that we're going to talk about, we can definitely share these perfect cases. Like perfect in terms of HIs, below five outcomes, et cetera, et cetera. But we intentionally selected these cases because we felt they were interesting and kind of more relevant to, I also think, what Shahzad sees and has to deal with. So they may not be perfect in the mind of a dentist. All right. But that's really, really important, Nadja, and I'm glad you brought that up because guess what? We often don't perfectly optimize treatment. We often have to do as best we can and then sometimes try to add other things to make it better. But yeah, I'm glad you pointed that out. It's not all about AHI and it's absolutely not all about getting it perfect. So give us a case. So we had this patient, I had a patient, a dental patient, Sean. He's a machinist, very active guy, a hunter, and he had a history of just, he had a family history of heart disease, but he also had just high blood pressure, uncontrolled. And he would tell me that he sleeps in a recliner in his living room. That's a red flag, right? And that when he snores, his wife tells him it's like a train driving through their house and that he hasn't been in the same bed as his wife for I don't know how many number of years. And his daughter actually works with me. She works for me. And so she was like, Dad, I think we really need to get this looked at. So he brought this up with me and I actually was like, I think you need to get a sleep study so you can speak to your primary care provider. And because you also have this crazy issue with your blood pressure and his family history, maybe you want to see someone like my husband. But he actually didn't end up going directly to my husband because what ended up happening, he inadvertently ended up happening because he had an episode, right, Shahzad? He ended up in the ER, yeah. He went to the emergency room because he had uncontrolled atrial fibrillation. And was this his first episode of AFib? Yeah, yeah. Correct, correct. Uncontrolled atrial fibrillation with a dilated cardiomyopathy, which means his ventricle burned out from the rapid AFib injection fraction less than 40%. Can that happen just from that one episode that the dilation could occur? It doesn't happen overnight. It probably takes a couple of weeks. Yeah. Oh, a couple of weeks. So it was going on. I didn't get just clarification of interest to me, right? Absolutely, yeah. Yeah. Yeah. Absolutely. OK. Keep going. He ended up in the ER. He went to the ER and, you know, he was treated as you would treat a patient with atrial fibrillation. We're going to control your heart rate. We're not going to ask why you're having AFib per se. This is where Nadia and I's way of thinking starts, you know, we start going into that root cause issues. But, you know, let's control the heart rate and go back and see your cardiologist. Now what's interesting about this is that the first cardiologist that he saw did not address which probably, you know, the topic at hand, which is sleep apnea. And what we need to appreciate is that this rarely happens. I mean, most cardiologists are seeing patients, most medical practitioners when they see people like this, they're unfortunately still not talking about potential sleep apnea and its consequences related to this atrial fibrillation. That's what makes this case very interesting to me because it's a very on-the-ground case. This happens all the time, by the way, all over the country. So he comes to see a cardiologist. The cardiologist says, we have to convert your heart back to normal. It's called a cardioversion. We don't want you living in atrial fibrillation because you're only in your 50s and this is going to cause you great problems in the future, stroke, you know, stroke issues, issues regarding congestive heart failure, early death. So he gets a cardioversion. But guess what happens after he gets the cardioversion after a couple of weeks? He goes back into AFib. Why? Because of, you know... So isn't there documented research that shows that if you have untreated sleep apnea, your cardioversion and ablation are unlikely, or let me state it correctly, are less likely to succeed. There is. There is, right? There is. For decades now. Correct. Yes. Okay. So he had untreated sleep apnea. His cardioversion reverted. He went back into AFib. So that's the question. So he has sleep apnea, historically speaking. So we needed to do a sleep study, which we sent him for. And I waited until he was back in a normal rhythm, ideally. So we actually had to send him again, establish it somewhat of a normal rhythm, quickly do that sleep study. And then we had the sleep study, which basically showed an RDI in the 19s range. So moderate-level sleep apnea. His lowest oxygen level that night was 73%. There was evidence of snoring. And he had all the other features. So daytime fatigue. Can I ask you... And large liquor. I'm going to stop you again to ask you a question. So for that study, you used PAT technology, right? Correct. So was that the reason you had to wait for him to go back to normal rhythm? Because that technology for a sleep test is less accurate if they're not in a normal rhythm? Or you waited for a normal rhythm for other reasons? It's a good point. So if you ask the company, they'll say, well, we have literature substantiating accurate diagnoses of obstructive sleep apnea using PAT technology and AFib. I tended to disagree. I feel like when I test patients who have atrial fibrillation with a watch PAT, or any PAT device, I feel like it's being under-detected. So I personally prefer when they're in sinus. I don't know if it's related to the beat-to-beat variation. Because I know the sleep image ring has the same issue. If they're not in normal rhythm, it will not be accurate. All right. In those patients, if I was going to be aggressive and test them while they're in AFib, then I'll probably use the nasal flow methods, the classic methods, or send them to the hospital. So we were fortunate enough to get him back in normal rhythm, maintain it. They actually put him on an anti-rhythmic drug, which can be highly toxic, but this is what it took to bring him in a normal rhythm, and test him. Can you tell us what that medication is, just so we all have an idea of what- Dofetilide. Dofetilide. Okay. Thank you. It's our enemy sometimes in the hospital. Sometimes patients go into cardiac arrest, and they're like, oh, crap, he's on dofetilide. We should- Got it. Let's go figure it out. But that was the only way you could get him into rhythm, apparently. That would keep him in rhythm, knowing that we haven't treated a substrate like the AFib at this point. But that's after the fact. Okay. All right. Great. Yeah. Great. So, he had pretty low oxygen levels. Right? Right. Let me just look at that. And he stayed down. How long did he stay down with low oxygen levels? Right? So, what- So, the report, it gives you ... This report's not going to tell you duration. It's going to tell you an absolute. So, his average oxygenation was not terrible at night. This is as low as he goes, 73%. But his oxygen desaturation index, which is the measure of desaturation below 88%, was 16, which falls into a moderate range. Right. Okay. So, again, and I think you had brought this point up in past, Vicky, that just because he scored a 19 RDI on day one doesn't mean he won't be 25 or 30 on day two. Right. So, the sleep study is just corroborating what we already know, pre-test probability wise. He's got obstructive sleep apnea. But then the interesting thing was he said, he immediately told me, on a personal one-to-one, I don't want to wear a CPAP. He was quite frank about that. Which is pretty interesting for someone to say that, to have that reaction when they've just been in the hospital for a serious cardiac problem. Yeah. Right? So, he's the type of guy who has a cabin up in the Poconos with no electricity, no nothing. He goes for the weekends, and he was just like, I'm not wearing a CPAP. Right. Which, yeah, I am not anti-CPAP whatsoever, right? But you have to respect a patient's thoughts and desires, because they have to be complicit with this and willing to do it. Yeah. And they have to wear it, right, to make it work. Right. Right. Exactly. So, if they're not compliant, and they're telling you that, I mean, you can't say, I'm not going to treat you. Then you have to see, okay, well, what's another option? Right. So then where'd you go from there? So then, she referred him back to me for an oral appliance, and we fitted him with an oral appliance. And once we got him titrated, where he felt subjectively much better, he got retested. But immediately, even in that process, before he even got tested, he was coming in telling us, I feel great. I can sleep in my bed. I can sleep on my back. I'm not sleeping in the recliner. That's huge, right? Yeah. I can go to work. I don't have to have my third coffee or second coffee or whatever to keep me going. I'm so energetic. I'm keeping up with the younger guys. He's like, I feel like a different person. So with a patient without cardiac problems, I say that's a slam dunk, right? Like if you're symptomatically better. Patients like him who have cardiac problems, then I also go, okay, now we're looking at the fine details, right? Yes. Right? So then he went back for a follow-up sleep. And also, some of our AFib patients always know when they're going into AFib. Was he having any bouts of AFib, or you had him so stable on medications that before he started using his oral appliance, he wasn't going in AFib, or he didn't know he was going in AFib? He didn't realize he was in atrial fibrillation by the time he presented to the hospital. So he was somebody who couldn't tell. Because sometimes my patients with AFib know it. And when they start treating him, they go, I haven't had an episode. Or they're monitoring it every day with their iPhone, or their iWatch. He was wearing, I think, one of those cardiac jackets or something, right? I think so, yeah. His presentation was more fatigue, low energy. And that's when he presented with that high heart rate, yeah. So he responded really well to the oral appliance. It was what I call comfortable slash tolerable than Nadia, correct? Yeah. Yeah. He was happy. He was like, I wear it all night. And he went into work like everyone at work that they need to get tested. He was literally like, if you want someone to market your oral appliance, he was the guy. He was that guy. And so then, Shahzad, I presume you did a follow-up sleep study to see what was going on. We did test. And his RDI wasn't perfect, but it fell by about 50%. His oxygen desaturation at times could still drop, but not as low as it did before. I mean, he still needs, so when I look at him, is he considered treatment success? From the standpoint of reducing severity of sleep apnea, the answer is yes. From the standpoint of reducing cardiovascular risk, personally, yes. You've gone from moderate to mild. From the standpoint of quality of life, oh, heck yeah. He brags about it now. He wants to show it off. I mean, he's also, yeah. Sorry to cut you, Shahzad, but at the last meeting we had in New Orleans, the ATSA meeting, I mean, Danny Eckert talked about phenotypes, right? And just like, so you still have the patient who's got this wide girth of a neck, sleeps on his back, wearing this oral appliance. So yeah, it'll improve, but he's not like on his side. He's not losing weight, you know. What's his, just for kicks, what was his BMI? Sean's BMI was between 27 and 30. So not horrible. Not horrible. But again, a typical cardiac patient. He has an enlarged neck girth, I mean. So he's going to have a residually elevated RDI. Having his tongue come forward is one method to reduce his collapse, but he's got other, like Nadia said, there's now we realize so much expressions of apnea, and the phenotypes are varying. We're discovering new ones. I feel like every year or two there's like new phenotypes we're discovering with sleep apnea. So he, you know. But again, at the same time, it's considered a treatment success in this case for me. Absolutely. Great. Yeah. You've changed. Good job, Nadia. Good job. You've changed lives. You've changed lives, right? One for oral appliance therapy. You've changed his life. And I'm the big CPAP guy. Right? Shazad's a big CPAP person. He is. He is. He has pretty good compliance with his patients for CPAP as well. But you know, a bow hunter, I'm not going to fight him over whether or not he should wear CPAP or not. And I always have maintained that for some people, their road to CPAP can be failure of oral appliance therapy. So Nadia and Shazad, but Nadia, you've just done a great explanation of how you're now collaborating with other physicians or how you first started mainly with Shazad, right? But I suspect it's a little easier for you because you're married to a physician, right? So let's give our listeners some advice or how would you give them some advice, how to create that relationship within their community? Because they may not have as close of a relationship with a physician as you do. Give them some insight. How can they do that? Yeah. I appreciate that question because that does come up a lot. I think for me personally, it helped to understand where Shazad was coming from, right? So not to make assumptions that doctors don't care, they're just rushing through their patients and bubble box. I think sometimes we do think that. I do, right? I agree. And the more I get to know my physician colleagues, the more I know they really care. They do really care. That's because they could have been stockbrokers, they could have been business owners, but they're there because like us, they have the same quest to do something meaningful and to help people. They're very conscientious, right, about recommendations. And I think for the most part, most of our physician colleagues are very thoughtful or at least try to be intentional about what they're recommending for their patients. So I think it's quick for us or someone like me to make an assumption or a judgment, but we don't know what they're looking at. So I think having that understanding of what their viewpoint is helps to have a conversation with physician colleagues. One thing that I did, I could appreciate more as well was that physicians are really big about outcomes, right? So approaching a physician colleague, whether it's a sleep doctor, whether it's an ENT or a pulmonologist, and discussing outcomes for their patients and how you can help support their outcomes and be just another means to do that, I think definitely opens up that conversation because now they're not looking at you as you trying to come in and being like a quid pro quo, right? Like we're like tit for tat, like I send you patients, you send me patients and oral appliance here, oral appliance that. It's really like, no, let's do really good patient selection and let's see how we can help and I'm here to support you and vice versa. So I think for me on that end, that allowed a greater opening for dialogue and referrals from other medical colleagues, sleep physician colleagues, because I think once they understood that I'm not here just showing them my oral appliances and being like, I can make these, you just send me your patients, but to be really like, no, I'm here to help support what you have in plan for them, made a huge difference. How can we, we can help you create a better outcome for your patient, right? And to be, and to be communicative. Like so I think physicians also can't stand when they don't, they send you a patient and they have no idea what's happening, right? Like I've sent you a patient, like they come to you, did you see them, and they're lost and then you fitted them with an appliance and like now what, like what's happening, right? So I think also like to be constantly in communication with them to have good systems in place. And then also from my perspective, when I started speaking to my sleep colleagues about just what outcomes look like for us and what's realistic and not to say, well, you know, this is definitely going to, you know, with the CPAP, we know we can get them down to like 0.1 or one or zero, whatnot, HI, but an oral appliance, yeah, oral appliance is like a work in progress and it may not get to that number, that HI that you're looking at, but we're also looking at other measures of success as well. And is this okay with you? So they can understand that we're also very intentional about our approach, that we're just not looking to put an oral appliance in and say, Hey, the patient's done. But what was our reasoning for saying like, I think this patient's good to go on your end. Can you check them out? And this is where we're at. You know, so that I think has been really helpful for me and taking the pressure off of me when I'm treating a patient, because I think then the sleep doctor understands like where I'm coming from when I'm approaching them as well, right? Right. And I'm going to guess that when you talk to a sleep physician about treating a patient, you're probably also communicating that you're not giving an oral appliance and going, Hey, that's the best we could do, sorry, because it doesn't end there. I'm just guessing that when you get a patient back and if oral appliance therapy doesn't fully optimize the patient's treatment, you're going to continue to work with them, whether it's one of your modalities that you happen to work with, or whether it's referral for something else, or even a referral back, like I was talking about last time about, Hey, for you, I really think you need to have a CPAP trial. And this is what I say. It's not a marriage. A CPAP trial is not a marriage. Just try it. You still get to kick it out of the bedroom if you don't like it. You know, a hundred percent. I remember hearing someone once say like when they come, when a patient comes to you for a consultation or an evaluation, it's not necessarily for an oral appliance per se. It could be maybe what brought them to you, but you're really just going over all their options with oral appliance, perhaps being one of the primary options, or maybe not, and helping them come to a decision. Like that's my role, right? So if I have other tools in my toolbox that can help, and oral appliance therapy still may be part of that, but maybe to help enhance the oral appliance therapy, whether it's myofunctional therapy, whether it's seeing the ENT to evaluate their adenoids has helped establish better nasal breathing, whether it's looking at airway space in the mouth and are they candidates for expansion? You know, like we want to have that whole conversation, right? So that patients understand that like, okay, you are here and I can maybe bring you here, but if we do all these other things, maybe we can bring you here. So where do you want to be? What do you want to do? What are you able to do? And then that helps then guide the plan, right? So in my consultations, I also do a great deal of education about sleep apnea. And I always get, wow, the sleep doctor never explained that to me. I just go, well, that's why they sent you here. Yeah, yeah. I get that a lot too. I'm like, so do you have an understanding of what sleep is and what sleep stages are? And they're like, no, not really. I was just told I have sleep apnea. I was like, okay, let's have a discussion then, right? So yeah, yeah, 100%. So I think that's kind of what's worked for me. And to be honest, I feel like as dentists, we're so much more than just appliance makers, right? Absolutely. Yeah. You almost don't even need to take a course to make an appliance, right? I mean, it's making a piece of plastic after taking impressions. At the end of the day, as one of my mentors says, James and Spencer, it's a piece of plastic. But it's not about the plastic. It's about what you do with it and all the other things that come with it. Absolutely. Yeah. And I think there's at least one study now to validate that dentists that have training, you know, significant training in dental sleep medicine get better outcomes than those that went to a weekend course or, you know. Yeah, because your understanding is much more broader. You could even just even how to interpret a sleep test becomes different, right? You two have some really interesting cases, I'm sure, that you've done together. Let's go into another case. Yeah. So let's talk about Jay because I think this is an interesting case. It's not a typical case. Jay came to see me and he's in his 40s, leads a life full of high stress. Again, a little bit of a heavier neck, very into holistic alternative therapies and uncontrolled blood pressure, has poor sleep, and an established mouth breather per his history. We offer or myofunctional therapy and we offer, you know, tongue tie releases. And so, which I'd like to speak to about in a second. So he came to me because of his wife, because they thought maybe him just getting, you know, correcting his tongue posture. So they found you on the internet or something? They found me and they brought him in. They're like, he needs an assessment for his sleep. We want to just see what's going on. What are some root causes? They're very big into root causes, right? And so that opened up a whole conversation for me about his breathing, you know. So he's unable to breathe effectively through his nose. And so, but we needed to establish a baseline with him as well, because I didn't really know where he's at. And so because of his preference to being seen not through a hospital system per se, but through private practice, wanting to get someone who has more of an integrative approach, he went to go see Chazotte. So can you... I don't think I heard exactly what his symptoms were. Just tell me. I know you figured out he can't breathe through his nose. Yeah. So he had uncontrolled blood pressure for a 40-year-old. He wasn't on any meds or anything actually at that moment. He... Was he heavy, thin, like just not worthy? So his BMI probably was in the upper 20s, I want to say. So not doable. Yeah. Yeah. But he has a heavy neck. Like he played athlete in school, like kind of like a football player-esque type of build. And just very anxious, tired, reported being fatigued. So he was... That was his... Yeah. That was his sleep... Yeah. That was his sleep symptom, tired, fatigued. Yeah. So... And he snored. Okay. So his wife brought him in. So he came in because his wife asked him to come in to see me because they wanted to explore others. So was this a case where the wife started looking things up on the internet and said, I think this might be what's going on? Yeah. And then like this dentist kind of maybe will have a different approach, so why don't you go see her? So that's what ended up happening. And so he went to Shahzad and I'll let Shahzad discuss that part of that case. Yeah. Okay. So Jay presented to me with his wife, who by the way, she's an architect and she decided to give up her career as being an architect to just devote her life towards making sure her family is healthy and happy. So she has a couple of kids who actually now see Nadia too for other things. So he presented to me actually with those complaints that Nadia has addressed along with chest pain and palpitations, which likely were related to some high blood pressure. But then the question is, where's the blood pressure coming from? Is it coming from stress? Is it coming from sleep apnea? So his pretest likelihood for sleep apnea was high because of him being male, being someone who snored, having a neck girth over 17 inches in circumference, witnessed apneas, mouth breathing. He did play sports, I believe football. So he had a deviated nasal septum from a prior injury. So very difficult for him to breathe through his nose and daytime fatigue and symptoms. So he got tested for sleep apnea and he failed miserably. His RDI was 33, his HI was 27, his ODI was 11. His lowest oxygenation level, not terrible, it's interesting. We talk about, again, phenotypes of sleep apnea and looking at this in a very multivariate way. Eighty-seven percent, not terrible, but the frequency of hypopnea and apnea was concerning enough and enough to explain that, you know, you got sleep apnea. His wife knew it all along. And so Jay, you know, I did say, you know, CPAP is an option. But in my mind I felt, how is this gentleman, and again, this is what I think should, the way we should be thinking. We should be thinking before we just apply some of the CPAP on their face, it makes us feel good to supply CPAP. Is it really going to be successful in this gentleman who can't even breathe through his nose? Simple question. The answer is compliance is horrible for that. We know it. So he'll try it because he respects my opinion and his wife thinks, okay, you know, but, and he'll come back noncompliant. So Nadia, I think, I believe I, Nadia's the one who gave me the idea of, you know what, I think you really need to send Jay to our colleague in ear, nose, and throat. Why don't you just work on him breathing through his nose and just leave it at that? And I'm thinking, yeah, but he's got severe sleep apnea, understood, but let's take this approach to heart, this integrative approach that we're trying to establish and really give him the option. So he said, oh yeah, I totally want to look at this from a root cause perspective. My whole life I've known I cannot breathe through this, but I want to, I want to get this done. So he went for a septoplasty. And what was interesting was he was capable of breathing through his nose in an improved fashion by about 50%, but not 100, particularly at night, which is interesting, particularly at nighttime, he was unable. And Nadia and Shahzad, do you work with also like over-the-counter nasal dilators with these people? Do you try to add whatever? Yeah. I discuss a lot of nasal hygiene with patients too, but in his case it wasn't successful. But post-surgery, where he still couldn't breathe 100% through his nose. But he still was a habituated mouth breather, right, even though he had the ability to breathe better through his nose. So again, he comes back and this is, I can breathe better, but I still feel like I am habitually breathing through my mouth. I wake up, I think he was more of a back sleeper as well. My tongue falls back. I can't get my tongue up. So we discuss or myofunctional therapy with him. And that was a route he wanted to explore. And he went through oral myofunctional therapy. And he found that through the therapy, he was unable to position his tongue up or to complete or to be able to fulfill the exercises, noting a functional restriction. So he came back to me for a lingual cranioplasty, which we did. And then he continued his therapy. And after his therapy was done, then we consider like that part of his treatment to be complete. He came back to me to say, I feel like I'm sleeping much, much better now. Like him subjectively saying this, I don't have any objective data at this point. Anything from his wife though, wasn't it? Oh, yeah. His wife was like, he's not snoring. He's like not choking in his sleep, etc. And he himself said, I also feel less anxious during the day. Like I feel more at rest. And this guy leads a pretty high stressful life. So he went back to Shahzad to get tested. Now mind you, and I want to caveat this because having attended enough meetings at the Academy, I also know this can be a little bit of a, what's the word I'm looking for? Sensitive subject about, or am I a functional therapy and tongue tie releases? And what does this mean? And there's not enough research, etc, etc. So I want to speak to that for a second because I think it's important because I know this is going out to the Academy. Research is coming. There is new, new research, right? And we have to be willing to look at things for what they are and understand their limitations as well. Am I coming in, are we coming in and saying to every single patient, you need a phrenectomy, you need a tongue tie release? No. It's going to be a miracle, right? It's going to be a miracle. No, don't say that. No. Am I treating every patient with that? 100% no. Okay. Am I suggesting to a lot of patients about tongue posture or am I a functional therapy? I am suggesting that to a lot of my patients. Yes. Why? Because I see there's benefit in that. It's a muscle. Let's get that tongue out of the back of our throat. Let's get it up, right? Now, do they have to do it? No. Is that going to change other steps of their treatment? No. But should they be aware of it? Yes. Why not? Why am I taking that choice away from them? So patients go through, or am I a functional therapy, if a phrenectomy is indicated, which it is not always indicated. It's a means to help support the therapy, not the other way around. And I think, and I want to be really clear about this because I know this is like a bone of contention for a lot of people, is that there's this sense that people are getting phrenectomies left and right, that these dentists are just doing them. And I think that's further from the truth. My dental colleagues who have actually accommodating this therapy in their practice have gone through a lot of training and rigor to understand where it's applicable. Where I see it being done actually left and right without any other thought in place is actually from my physician colleagues because I see those outcomes. Oh, really? Yeah. What physicians are doing it now? ENTs, ENTs, pediatricians, et cetera, where people get these tongue tie releases done because they see it online, they go to their ENT. And I'm not trying to like, you know, I'm not bad mouthing it. I'm just saying this is what I'm seeing, okay? But there's no sense of like, we need to retrain this muscle. So they don't know what to do. Their tongue's just still lying low. So what was the benefit in that? So I think what I'm trying to say is that there's a lot of consideration that goes into this treatment. And I want to be really clear about that. Or let's say, I'm going to restate it. Done properly, there should be a lot of consideration into this treatment. It needs to be coordinated with myofunctional therapy before and myofunctional therapy after. And I'm going to make the assumption that the patient has to be dedicated to some type of continued myofunctional therapy. Yes. So when I speak to my sleep colleagues, I do bring this up with them. I do bring this up that in my office, when your patients come and see me, if I feel like they have low tongue posture or they're habituated open mouth breathers, but they can establish good nasal breathing, I am going to bring this up to them. And they've all received it very well. Because that's not a conversation that they have the time or bandwidth to have with that patient. Right. So if you're going to help that patient at a root cause level, why not? And I also want to be clear, too. I'm not saying that or myofunctional therapy or frenectomy, et cetera, et cetera, is going to take away a severe sleep apnea. But can it bring it down? Definitely so. And does that make that an easier patient to manage? I think so. 100%. And that's the case here with Jay. And I know I kind of like word vomited a lot right now. I just wanted to- No, that's all right. I mean, the bottom line is absolutely no harm with myofunctional therapy. How can you harm anyone with myofunctional therapy? So I want Shahzad to speak to Jay now because he saw him again then after all of this was done. Excellent. Yeah. So keep vomiting, Nadia. Keep vomiting that information. And usually I'm the one who word vomits a lot on her. That was a lot. I'm sorry. No, Nadia, I think it was completely appropriate. 100%. 100%. No, I love it. And I don't do tongue-tie. I just don't do that. And not because I don't believe in it, but frankly, I'm at the end of my career. I'm not adding that. My practice isn't set up for that. I don't even have a suction. But you don't have to do it, Vicki, but you can send patients out for it. Absolutely. Right? So my message is I truly believe it's helpful for certain people. We don't exactly know who yet, and hopefully that research will come out, but it absolutely can be helpful for certain people. And you as a practicing ... Well, you don't really do the myofunctional therapy yourself. You have somebody who does it for you or that you refer to. You do the tongue-ties. So you probably clinically have a better idea of who it might help. Yes. Yeah. Definitely. Well, it certainly helped Jay, I think, because Jay came back and after a few months, and like Nadia said, he underwent the therapy, had the phrenectomy, went for more therapy, almost to the extent that he would say, I don't know what's going on, but my tongue is perpetually stuck to the roof of my mouth now. I'm like, that's kind of what you want, Jay, to help you sleep, because it's a feeling that he's never experienced before. But anyway, it's now led him to become, I would say, a more semi-permanent nasal breather at night. We did end up retesting him for apnea. Before I get into the testing, his symptoms actually, interestingly, were improving. So quality of sleep improved, wife was complaining less, chest pain palpitations were beginning to subside. His stress levels were still ... It's seasonally related, the way his job works. So there's stresses that affect him in different parts of the year. So the stress was still there, but certainly his symptoms had improved. We retested him, and his test was interesting. This is someone now who's undergone a nasal septal deviation surgery with therapy through Nadia, and the RDI went from an average of 33 down to 21. The ODI went from 11 down to less than 5. So the ODI actually normalized, which I thought was pretty interesting. But his RDI was still high, and one would say, well, is that, again, is it a treatment success? What do we define as success? This is going to be the question. But we're not done treating him, though, Shislav, right? So ... We're not. Yeah. I mean, so he's, at this point, I think he's ready to do the oral appliance therapy, right? Yeah. We're not done. Yeah. We're not done yet. We're not done yet. Look, the bottom line is, there's multiple modalities that need to be used to help our patients. And there's a reason why sleep apnea is difficult to treat, because we're not always getting to all of the modalities, or we're not always finding the right treatment for the patient. So it has to do with patient resources. How much time do they have? How much do they want to put into it? It has to do with their physiology, their anatomy. And so each practitioner is going to come at it differently, and each patient's going to come at you differently. Definitely. I mean, if this patient had come to me and said, you know, I have sleep apnea, and I just want an oral appliance, we would have done the oral appliance. Right. But he came to me and said, I want to understand if there's other ways I can also approach this just to get at a root cause level. What are those treatments? Then I owe it to him to go into that and to be able to say, OK, I think this can work for you, or at least lessen the burden of what you have right now, so that when we do approach it at that next level, whether it's oral appliance therapy or CPAP, you can respond that much better. Absolutely. As long as we're all trying to get at the same goal, just like in general dentistry, we all have our own techniques of doing the same thing, right? And so in dental sleep medicine, you really need more than one tool of just an oral appliance or just a CPAP. You're going to lead a lot of patients untreated and unsatisfied or less optimally treated than if you have more tools in your toolbox. In medicine, we pride ourselves on individualized patient care. It's a buzzword we're taught in medical school, but it does not happen in practice. And when you take an integrative approach like this, like the way we've been doing that for some years now, it automatically becomes individualized. And you don't see that in any better way, actually, than in sleep, because sleep is, by definition, multifaceted. It's more than just your breathing. They say it's your hygiene as well. It's the quality. It's duration. And so there's so many components of sleep that force it to be integrative, and that's why it's, for me as a cardiologist, it's sort of, like I said, it's sort of that platform of beginning the integrative discussion. It'll happen through sleep more than anything. So here's a bottom line, right? So we've all had, so number one, gaining nasal patency. Surgery isn't always the answer. It can be. And so that is a difficult thing because a lot of my ENTs will say, yeah, you've got a deviated septum, not really sure if you're going to gain anything from having the surgery. So it's an unknown, but if a patient's willing to do it, that's one of the steps. If the surgeon thinks it's going to make it better, that's one of the steps. But there are other ways to do it, and then I've also had patients, and I know you have, this is the one we're talking about, you've created really good nasal breathing, but they still can't stop being a mouth breather, right? So that should be a real red flag for all of us, that if that's happening, then maybe they're having some tongue function issues, right? Yeah, or like tongue posture issues or habitual open mouth, like so we have to retrain that, you know, et cetera. So yeah, it's not an overnight, they didn't overnight get there. And or certainly one of the ways that I would, one of the first ways I would try to treat it in my practice is, have you ever considered mouth taping? Let's just see if mouth taping, maybe mouth taping will solve it, maybe it won't. I have patients that love it. I have patients that don't even want to try it, but you just have to have a lot in your toolbox to work with. Yeah, yeah, definitely. And I think dentists, I think we're really unique in our practice because we do so many things, like for many of us who were regular dentists before becoming sleep dentists, think about all the different types of treatments we offer or procedures we offer in our office, especially if you're a general dentist, right? We do so much. And then we're looking at so many things, we're looking at pathologies, we're looking at like materials, we're looking at steps of treatment, you know, all of that. And we micromanage because we're dealing with like fractions of millimeters. So I think for us to have this type of perspective when it comes to sleep outside of just traditional oral appliance therapy, which, you know, I still support, of course, but I think I also kind of see there's other modalities, I think that's just a very natural progression of who we are as practitioners. And yeah, so for me, I don't think that's a reach, I really don't. I agree. So now you've got this patient breathing well. He's got his tongue on the roof of his mouth. We've seen a decrease in his sleep disorder breathing. And now, Nadja, did you say that you're getting ready to maybe try an oral appliance on him now as well? Yeah. So he's sleeping a lot better, he's feeling a lot better, but obviously his apnea is still there, much significantly less, of course, but still there. So we want to treat that. And so now he's ready for the oral appliance therapy. And the bottom line is, another positive for this case might be, and I have no way to prove this, right, but it might be that now when you do treat him with oral appliance therapy, he'll need less protrusion. I hope so. Yes. Right? Yes. So we'll see. So, you know, a lot of interesting cases, so maybe if you ever have us back on, we can tell you that to be continued. Well, unfortunately, there'll never be a before and after, what is protrusion, what have been before and what it might be afterwards, right? To be continued on Jay, like what happens to Jay? All right. Well, we'll do that in another episode, all right? Like how has working with Shahzad changed your professional life? We will go into how it's changed your personal life, that's... There's more conversations at the dinner table regarding work. Yeah. That could be a good thing or a bad thing, right? Well, the kids are like, oh, not sleep again. Not sleep again. Yeah. But how has it changed professionally for you, Nadja? I think just going back to being more of a dental sleep medicine practitioner, it's encouraged me or facilitated me to be more integrated with other fields of medicine. And you know, integrated medicine is such a buzzword too, right? Yes. You have people coming in and like, I want an integrative provider, et cetera, or all these courses to become an integrative provider. But I kind of find it funny a little bit because I think by default, we just are. You just have to be open to it. Aren't you supposed to be doing that anyway? Yeah. You're supposed to be doing it anyway. So it's like, when someone asks like, well, how did you get into this or how are you doing this? Just speak to it. Look at it and look at it comprehensively and be able to have a handle of that knowledge to speak to it and know where to make the appropriate referrals, right? Because you're not obviously managing these things, but that's where the integration part comes and having those relationships with the other people. So for me, this has really enriched my practice on a professional level and on a personal level as well of where I'm at in my life. So I think it's really rewarding, yeah. Do you do general dentistry at all anymore? I do, I still do general dentistry a few days a week. However, as my focus has shifted more and more into dental sleep medicine, I think it won't be long before I just 100% just go into this, yeah. And so in your dental sleep medicine practice, do you have any idea what your percentage of different modalities that you use? Do you always, are they always combined or are you sometimes just use an oral appliance and that's it, do you? So like you said, when we have that consultation with the patient, you're looking at a lot of factors, you're looking at like where they are at in their life, like how old are they, like what's their phenotype, at least what my understanding of their phenotype is and what makes sense. Finances oftentimes also do play a role, so you'll wanna be cognizant of that, like I can bring it up, but how much am I going to emphasize on something also may play a role into that. But oral appliance therapy is still the default for what I'm working with, but I want that oral appliance therapy to succeed. So I'm looking at these other modalities as a way to help with that. And this is like for my adult patients. So obviously I see kids as well and teens as well who are dealing with sleep issues and we're not fitting them with oral appliances, we're talking about some of these other modalities where I'm emphasizing more because that's where they are at in life. We can do a little bit more of that. So yeah, I mean, and then as we find like this next case that we're gonna discuss, where the integrative came into this, like there was actually no oral appliance and oral appliance therapy is actually not even in the cards for this patient who came to me from Shahzad. She was not a referral from me to him, it was a referral from him to me. So I can, Shahzad, do you wanna speak about Kate or? Yeah, Kate, when she saw me at that time, this was some years ago, she was 70, spry. She's a young 70, Kate, from Scotland. She had a bioprosthetic aortic valve or what they call an artificial aortic valve, high blood pressure and she snored and was tired and fatigued. Looking back at my notes, there was very little notes from me in regards to sleep because I was just learning. I just seeing my note just says snoring, fatigued. So I sent her for a sleep study and she tested moderate on her sleep study. Her lowest oxygen desaturation was 76%. So I felt she had moderate levels of sleep apnea. I did standard of care, which is CPAP, not realizing in hindsight, she was a mouth breather. So CPAP became very difficult for obvious reasons. Being a mouth breather, I just find it very, very difficult for these patients to maintain good compliance. So again, I didn't tell you this, but part of my journey in all this was Nadia telling me, I think you should start looking into people's mouths and I was a little bit uncomfortable with that because certainly it's not part of our scope. So I started actually looking at pallet width and molybdenum potty, we were used to, we knew that from our days of anesthesia training, advanced molybdenum potty in Kate's case, but she had a prominent tie. She was actually quite restricted, which was again, fascinating to me, like, oh, that's what I saw at the course. Like, is that what they're talking about? Is that what they're referring to? And then later on, I'd realize like they're all tied. It's crazy. In my practice, like they're all tied. It's bizarre. But anyway, so she was restricted. So I said, I'm sending you to Nadia. So she came, we didn't eval. We had her go through Oromia functional therapy. Hold on one minute. So did you check her nasal breathing first? You already knew her. So I'm sorry, you said she was not a nasal breather. She was a mouth breather. She was a mouth breather. She was having a hard time adapting to her CPAP. So I'm just wondering why you didn't go to look for, did you feel like there was no nasal obstruction? Is that why you didn't go down that road? No, I personally didn't feel, no, she never complained. That's why you didn't go through that road. Okay, thank you. And she was also, did you say, she also was not very tolerant on her CPAP. She wanted to be compliant, but she was hard for her. Hard for her, correct. Yeah, so. So she would take it off at night, things like that. Yeah, and she came to me and we decided to, let's see, have her go through Oromia functional therapy to help support her CPAP, to not have her tongue fall in the back of her throat and sleep and get a better position forward and up. So she went through the therapy and we did do a pronectomy on her, again, with the idea, the intent, to better support her CPAP compliance. So we did that. She continued her therapy, maintaining her CPAP, and she came back stating that she was able to tolerate her CPAP all night, didn't have to take it off, became much more compliant. And as a result, I mean, Shahzad, I guess you would say, like, she was a successful outcome for you from a cardiac perspective, being able to manage that sleep component, right? For sure, her post-pronectomy, now using nasal CPAP, her RDI went from 18 down to three. Her lowest oxygen saturation pre-treatment, like I said, was in the 70s%, and then it went, the lowest is now 87%. So from our perspective, it was a really good result. And yeah, I would say a treatment success, less fatigue, less snoring, naturally. So as a physician, how much are you paying attention to their, not just their ODI, but how much time they're spending underneath? 90%, 88%. So in our last podcast, I learned why the 88% was there, because, you know, I just assumed it was different sleep center's software, and someone's reasoning why some of the reports say less than 90%, some say less than 88%, some say less than 89%. So it's always difficult for me to sometimes do apples to apples, because sometimes the reports don't have the same metric that they're using. But nevertheless, how much are you paying attention as a cardiologist, not to just their RDI or their AHI, or their number of events, but how long the events are, number one, and how much time they're spending underneath 90% or 89% or 88%. And by the way, what I did learn in our last concept, our last podcast, is 88% is there, because that has to do with a pulmonary function. Correct. That's a pulmonary function criteria. It is. I mean, all of the parameters are important, but then there are certain nuances, and certainly oxygenation for us is, wouldn't say it's the most important thing. They're all important, but in a hierarchy, I would look at it and say oxygenation, of course, has to play a role. Dr. Redline out of Harvard did studies on oxygenation, deoxygenation burden and its effects on patients in terms of cardiovascular disease. So there's a lot of evidence to suggest that people who deoxygenate for longer periods of times, and more often, they're the ones that I think we should be paying attention more to, at least from my perspective as a cardiologist. So yeah, it's definitely an important parameter. I have patients whose RDIs are in the 20s, but their oxygen desaturation index is five or six. They're not, interestingly, they're not, they don't present in the way that I would think they present, and maybe it's because they don't deoxygenate all that much. And vice versa, I have patients whose RDIs are 15, and the ODI is 12, and they're extremely tired and fatigued, and that may have potential cardiovascular consequences. I think this is a fascinating field, because there's just so much we don't know, and so much we can learn. And our discussion today reminds me of an interaction I had with an ENT sleep physician from Long Island when I was in, I don't even know what course I was in, I don't even know what it was, I don't even remember. And throughout the course, she was next to me, she kept saying in my ear, REM sleep, REM sleep is when the nasal valves collapse. She just kept going, it's their nose, it's their nose. If they're having more sleep disorder breathing when they're in REM, her belief was it's nasal valve collapse. So it kind of, interesting, it's all tied in. So look for that in the future. See if you see a correlation in your patients with higher REM values. That's interesting. I mean, nasal breathing itself, just on its own, we know the importance of it. Which maybe makes sense, interestingly enough, because a group of physicians I work with around here, I'm lucky to work with a lot of Harvard physicians, all right, truly believe that if there's residual apnea left in REM sleep, one of the ways, one of the additives, and Danny Eckert does as well in Australia and also Wells here at Brigham and Women's, that adding oxygen, supplemental oxygen, right, can be helpful, and maybe that's helping to get through the nasal valve during collapse. Doctor, I think someone spoke to that at the last conference too, Dr. Long. They did, and then there was another dentist that was getting up and talking about, I'm still having, I don't know, it's difficult to get patients on supplemental oxygen, even when I've got some physicians that are willing to try it, and I shouldn't say willing, because some of my physicians are the ones that have been using it for a while, but it's difficult because insurance doesn't, it's really hard to get them covered for it. Well, you have to make criteria for requiring oxygenation, it has to be under a day, right? During the day, it has to be like, right? Well, during ambulation or at rest, right, or at night, if you demonstrate low oxygenation during a sleep study, then you can go for then later a pulse oximetry test that's supposed to demonstrate low oxygenation, but it's not that simple. Yeah, I guess, and like everything else, it's different for every insurer, but here's the other thing that we as dentists are much better at, I think, than physicians, and we know that some patients are willing to pay for something out of pocket, regardless of what their insurance will pay for. Yes, physicians don't like talking about any of that. They don't, and I understand, because their training comes from a different place. Correct me if I'm wrong, Shahzad, but my understanding- Talk to the manager about the price of that. I mean, we're not sitting here- Also because I really- But it's important. But I also believe that philosophically, physicians through medical school kind of grow up with and learn that there's this whole public health thing and to try to keep costs down for patients and try to work within insurance, and so I think it comes from a good place, but you just aren't as used to, as dentists, we're used to dealing out of pocket all the time, so we know it's what the patient values, and just like Nadja was saying, here you're, you've got this choice, this choice, this choice, this choice, pros and cons, and this is the fee for this and this and this. I can't predict what you're gonna wanna do, and as a physician, that's not a conversation you're used to having. We're not, but I'll be honest with you, and it's good that you're bringing this point, as my practice has become more integrative and we're offering different modalities and we're involving all these providers within our circle and tangential providers, as we call them. I'm surprised when patients say, oh, $200 for that? Yeah. And I'm thinking, oh, because we're just not used to bringing these things up, and $200 for some of my patients is, it is a lot of money, and so you have to, and I think being part, in the modern age, being a good physician is understanding costs. The whole picture, right? Yes. Yeah, but I also think, I find that when you're working in a true integrative collaborative model and you have other colleagues that have the same understanding of the goal that you're trying to get to, but from their perspective, the treatment becomes a lot more efficient, right? Because everyone has an understanding of what the other person is doing, and we're all supporting one another, but doing what we do best, ourselves. Right. So I think, and I could be wrong, but I feel that in the long run, financially speaking, it's actually better for the patient to be in a model like that, that's much more efficient, versus being in a model where the therapy and treatments are just being dragged on and on and on, right? Because we do see that a lot. I see that a lot. I see that a lot with, I treat babies and kids for anectomies, infants I treat as well, and I see how long it takes for parents to get to me because there was just different understandings of different treatments, and they've gone through this whole slew of avenues of treatments and just spent so much money where it didn't have to be that way. So, I mean, I do understand that, and I'm respective of that because everyone's different, and just like I said, $200 is a lot of money for a lot of people, a lot of people. I also think, though, if we can get towards, if we can work towards establishing a model that can help facilitate this better collaboration, understanding between different providers so there isn't a lot of double speak, a lot of double work, things being retested, redone, we can, in effect, do better by the patient. Yeah, be more efficient. I think that's a great point. And I think Jay's case speaks to that. I mean, how many times are you gonna have a patient where it goes from someone like Nadia, then to myself, and then back to OMT, and then ENT, which, for a layperson, you can say, well, I don't understand that. What is, you're just referring, no, we're referring for the intent of this outcome. As opposed, if you did not take that approach, I can tell you what would happen in the traditional medical system. He would come see me, and we would do a stress test after echo, after monitor, after scan. He would go see GI. GI would scope him. Mind you, he doesn't have health insurance. And then they would maybe find gastritis, because he's stressed out, right? So they'll put him on a medication for that. No talk of sleep, no talk of tongue posture, no talk of really anything that would be actually really root cause related. And he would come back to see me in a year, and say, I still have chest pain and palpitations. Why don't we retest you? So we'll do another stress test, and another echo, because I might have missed something. An abnormal stress test gets reported. He goes for a cardiac cath, which is not a benign procedure. I mean, this happens everywhere. If you took the integrative approach, like she said, you get from A to Z in a very, very, actually direct manner, and the outcomes. But there has to be intent behind it. There has to be intent behind it. And I think we have to study, and I think we have to study these results long-term so we can establish protocols. So I mean, I want to just go back to Kate, because this is my favorite case. We didn't finish Kate yet. You ended up retesting her again, Shahzad. Why did you retest her again for the third time? So Kate came back, and routine visit. And like a lot of my patients, after a while, they're like, I don't want to wear CPAP anymore. And I'm like, okay, well, why? He goes, I just, it's getting just cumbersome. I just don't want to deal with the mask, and with the recall, unfortunately, that happened in the last two, two and a half years, have changed a lot of people's perceptions of treatment, falsely or not. So she says, I don't want to deal with it. So I said, I have a question for you, which is a question that I ended up researching on. I said, is your mouth opener closed when you sleep? And she looked at me, and she's like, closed? And I'm thinking, okay, great. I'm going to retest you. And we test her, and her RDI is like less than three without a CPAP. She's just normal now. I can't figure it out, but she's good. I'm like, I'm not treating you for anything. Just keep your mouth closed when you sleep. It's incredible. But again, a lot of that had to do with going through the process. In hindsight, probably the biggest intervention was a combination of the OMT and the frenectomy to allow her to become a nose breather, which again, we're all discussing, including you, Vicky, about just the literal importance of keeping your mouth closed at night when sleeping. But yeah, that was definitely a bonus. I did not expect that. And one of the pearls I can tell other dentists and physicians, whatever, is communication, communication, communication. If you're doing a referral, if you're getting a referral, get your other doctor's emails, right? That's a really easy one. So you can just, hey, saw so-and-so today. This is what's going on. I have a concern about this or this, or I have to tell you they're as good as they can get. I think there's some residual stuff going on. Let's see what we can do, or they're getting tired of whatever it is. Just go back and forth. Because if you just send someone back without instructions or without a narrative of what's going on, they're not gonna be looking for the right thing. Yeah, I agree. And you know, we love educational seminars. So we like it if the dentists come in with their equipment, with their toys, with their literature. Remember, in dentistry, they have their own whole entire body of literature supporting this. We like to learn, and we wanna know. We wanna know what the outcomes potentially could be for our patients. Yeah, we like to be fed, too. Bring goodies when you come to our office. Ha ha ha, that's so funny. Even the cardiologist's office likes cookies and bagels at times. Okay, I guess that's the biggest take from this podcast. There you go. Bring food items. Watch out, though. It can't be over a certain amount of dollars. That's true. Otherwise, it gets into some federal issue. So bring a little, not too much. Don't go crazy, right? Don't go crazy, that's right. Just go with the cheap stuff, yeah. Just go with the cheap stuff. High-quality cheap, right? Know your laws. Right, exactly. Okay, well, this is, I think this has been a really great discussion. I've enjoyed it. I love doing these podcasts. I always learn something new. And I think it's gonna be really helpful for other people. Individualized care, yes, it's a moniker. It's something that's being talked about, but it just really just has to be done. Integrative medicine. I mean, you've got a person in front of you. You should be looking at the whole picture anyways. And there's lots of modalities that can be used to help your patients. It's good to be curious, Vicki, right? It is good to be curious. And you can always be learning. And trust me, in our lifetimes, we will not figure this out. It will always be, there's lots of reasons why people's airways are collapsing during the night. And trying to figure them all out is challenging and trying to figure out how to keep them all open and keep them feeling well, because also sometimes even stopping the collapse, they're still having sleep problems. And so there's a lot to be challenged by. For dentists that are just getting into this, it's a whole new paradigm, because as surgeons, as microsurgeons, we are used to very exacting and knowing results, right? I think you have to learn to be gentle with yourself in this process, which was a hard thing for me to learn. Yeah, that's what makes it so hard. Right, as microsurgeons, we are in control of everything and we know if we do a good job, it's done right. And I know that just like you, Shahzad, when you first went to your first course with Nadja, you start getting, as a dentist, you start getting, anyways, I would start getting angst when I started learning about sleep apnea and dental sleep medicine, because my angst was, it might not work, it might not work. What am I doing? How do I deal with this? How do I deal with this? And you absolutely have to learn with, guess what? It's not gonna work for everybody, but what this podcast is teaching us is keep going, keep learning, try other things to help your patient to get better outcomes, and guess what? They're not all optimal, but they're gonna be a lot better than where the patient started. Yes, definitely. Thank you so much. This has been amazing. I really enjoyed this. I appreciate it, Vicki. Thank you, and it's an honor for me to share the platform with you. Oh, stop it, Shahzad. Nadja and Shahzad, thank you so much for coming and spending the time with us. It's been incredible. I learned a lot. I know our listeners have learned a lot. I really appreciate the practice that you have and how you're helping people and how you are willing to share that to help others do the same thing. So thank you very much for our listeners. We'll see you in the next episode.

Open Airways

Dr. Vicki Cohn

Dr. Nadia Afzal

dental sleep medicine

Dr. Shehzad Malik

cardiology

integrated approach

sleep disorders

myofunctional therapy

tongue-tie release

sleep apnea

patient-centered care

collaborative care