[02:30] How did you get started in dental sleep medicine?
[13:00] How do you define success with oral appliance therapy?
[24:00] What is the timetable for oral appliance adjustments and healing?
[31:00] What are the other adjustments that dentists need to be thinking about besides the protrusion?
[44:00] What can you discuss with a patient to give confidence that OAT will work for them?
[49:00] What is the correct tongue placement when wearing a oral appliance?
[52:00] Do you give patients tongue instructions or exercises?
Dr. James Metz. I’m so glad to see you.
Thank you Barry.
I’m looking over some of your resume highlights and I decided not to take 30 minutes describing all your background so is it okay if I just go through a couple of things?
Whatever you think is important. I put it all there just so you would know.
Okay. So the main thing I want to talk about is that, are you a Buckeye?
Yes. I was actually the team dentist for Woody Hayes.
Really? Really, team dentist for Woody Hayes?
You graduated in 1973. A lot of activity here, American Dental Association, Scientific Investigative Committee workshop, you’ve also been involved in the Scientific Investigation Committee of the American Academy of Restorative Dentistry, for sleep dentistry. Also a part of the American Academy of Dental Sleep Medicine Board of Directors and of course Development Committee, public relations, chair and vice chair of various program offerings of the AADSM. You also founded, this one is very interesting, if you want to comment on it later on please bring it into the conversation, the Dental Interest group of American Thoracic Society. That’s very encouraging.
That is the most important one.
And then American Academy of Restorative Dentistry, International Academy of Gnathology, and also involved as you said…
You just have to get old Barry.
Is that what the secret is?
You’re also doing some work, as you’ve mentioned previously, in the Republic of China, and you’ve also got ideas cooking for some research projects and I don’t want to forget that you’re very interested in this whole area of Wilcodontics for accelerated osteogenic orthodontic procedures.
So much to talk about, we could go on for hours, we’ve got plenty of time. So make sure that you give us all the stuff you think we need to hear and I think the first place is how did you get started in sleep dental medicine? If that’s a good topic?
It’s interesting ever since I’ve been in dentistry I’ve been interested in crown and bridge advanced restorative materials. When I was in the army everybody let me do that because nobody else wanted to do it, you know, and so I got to do the hard stuff. And what that led to was an understanding of temporomandibular disorders, and because we used to think that the occlusion was principle to causing joint pain, headaches and whatever. And so you get a reconstruction or a lot of crowns you didn’t want to create a problem so I got very good at controlling the occlusion of the bite and as I moved along I began to realize that it was not the bite, it wasn’t the way the teeth fit together that was the problem. It was something else I didn’t know what it was, and then I got into this sleep medicine and realized that we clench our teeth just to protect our airway, and there’s some if’s, and’s or but’s to talk about, but that’s kind of the middle ground.
So with that I started studying sleep and it just opened up a wonderful world, I mean I, it’s the most exciting thing I’ve ever gotten involved in. It’s really all I think about anymore, it’s about all I work on and I’m driving myself harder now than I ever have in my life – and I’ll be seventy in September. So I really enjoy this whole area of sleep dentistry, sleep medicine and I think a lot of dentists are making a mistake, with trying to do this on their own, this needs to be done with a physician because we have moved as a dentist into medicine. It’s not medicine moves into dentistry, it’s dentistry moves into medicine, and we’re under the same guidance and criteria of other practitioners within the field of medicine, and so we need to learn to work together
Dentists are lone wolves a lot of the time, that seems to be the principle characteristic of dentistry because we work by ourselves in our office always, we’re not used to a hospital situation. But we need a cardiologist, we need a gastroenterologist, we need ENT, we need sleep especially because we get into things that honestly dentistry should not be handling. But we’ve got this great method of doing it and we can do the method but we need the medical help to assure that the patient has a good outcome.
Let’s talk about that for a minute because I have a small disagreement with you on it. I put a post up at HST America just a couple of weeks ago, I don’t know if you had a chance to read it. It’s one of the ones where I mention the Metz Group and your organization in Columbus Ohio.
I feel very strongly that because dentists spend so much time examining the oral airway that it’s not just that dentists are invading the medical space. I think the sleep doctors have a tremendous amount to learn from the dentists and I don’t think it’s unreasonable for the dentist to eventually see themselves as primary sleep providers. Because we both know that not everybody is going to be able to use a PAP machine and there’s plenty of people who might benefit from a dental device first. And because the dentists do so much in their exams of the oral airway I see it more as a natural fit and in a way I’d like to think that doctors are going to want to collaborate with the dentist. Not just the dentists have to go around begging doctors, you know, to work with them.
I think the dentists, and I’ve always said this actually ever since I met Tom Meade in Albuquerque back in the 1980’s, that dentists have tremendous amount to offer to this field, and they should not see themselves in what I would call a defensive posture. Although you are correct, there are certain areas that medically and legally we all have to be careful.
I couldn’t agree with you more. You’re exactly right. There’s no disagreement between us there. The only thing that I would say that I have noticed is that it’s hard for a dentist to move into the area where the patient’s health is actually critical to their survival. We’ve always been in an area where we fix a cavity, we fix a crown, you make them look better. But all of a sudden now a properly titrated oral appliance can possibly add years of life to someone that wouldn’t otherwise live that long.
We did a study at Ohio State, with an oral appliance we fitted 25 out of 25 patients that were mildly diabetic and brought them back to normal blood sugars, with an oral appliance. And it’s never been published, it bothers me that it hasn’t, it was actually the first study I was ever involved with Dr. McGowan at Ohio State. It amazed me that we could actually go after the physiology of the body, so profoundly with an oral appliance.
Dentists have always thought you know keep people happy, so their wives don’t elbow them you know from snoring, or you know they feel a little bit better in the morning when they wake up, and they’re not tired. But this goes so far beyond that.
The idea I heard you speaking before we came on, about inflammation. Inflammation you know is set up by cortisol and, in the body, and it could very well be controlled by an oral appliance very, very well, and so all of a sudden the inflammatory processes may actually be under our control, to a higher degree than we’ve thought in the past.
Jim, are you referring to that when you treat a sleep breathing condition we expect to see a decrease in the inflammatory response in the airway? Or you’re referring to something more systemic now?
In the airway, because I think the inflammation in the airway mainly comes from a reflux problem, and as we keep the airway open the reflux, and we teach them positions, you know how to sleep. The reflux decreases so the airway is the first inflammation to go away. But then what we’ve noticed is that we’ve been able to control the heart rate very well with an oral appliance because decreasing the fight-flight response. And with that decrease in the fight-flight response it appears, and there’s been some papers that show this, but the numbers have been very low and they actually haven’t been very well done. That shows the inflammation of the body decreases with the oral appliance, systemically.
So then similar to when somebody uses a, you know, a PAP device and some of the research that’s been published looks at endothelial dysfunction, the lining of the blood vessel and showing that there is improvement, clearly would go along with that theory.
How is that test done? I’m not familiar with the EndoPat?
Yes, it’s used mainly for research, it’s not really used clinically. What it is, is you put little blood pressure cuffs on the same finger on both hands, their little tiny things, and very similar to the WatchPat. It’s the same company, Itamar.
And what it is you also put a blood pressure cuff on one arm, and you go for seven minutes and you measure the blood flow to fingers. Then you pump up the blood pressure cuff and completely occlude it for another seven minutes and you continue to record the opposing hand, and after seven minutes you release it and you measure how long it takes the arm that was occluded to return to normal and that’s a measure the internal resistance of the vessels. Which is a measure of endothelial health. It’s worked out pretty well.
That sounds very interesting, and it gets into an area that is so important, which I know you have a lot of opinion on and ideas and experience, and that is how do we define success when people are trying to use OAT? Because obviously many sleep doctors, and obviously many dentists when they are comparing between CPAP and an oral appliance mandibular advancement device, there’s always the question of what is the, what is the true benefit of each one and how do they compare. Obviously one of the biggest issues that comes up in all these discussions is well if you don’t use your PAP machine, but you will use your dental device then obviously the dental device is superior, and there’s no argument there because if you can’t use a PAP machine then we want treatment, we don’t want NO treatment.
That’s right. Well that’s a big subject. The oral device is not mechanical, that’s the one downfall of it. Like if you put a CPAP on somebody and you splint the airway it’s open, you know, and their breathing that night. It’s pretty remarkable what a CPAP does.
The oral appliance is very different. It sets up conditions for healing, is what I say, more than it really resolves it quickly. One problem with the oral device is the change of occlusion, and change of the bite, and it’s interesting you read through my resume first, and I’ve been in Gnathology which means the study of teeth. Of all the disciplines of dentistry it’s probably the most involved with the bite, and I spent 25 years learning that, and knowing it, and lecturing on it and whatever. The first thing I did when I put a mandibular advancement device in, as I always said I blew up the occlusion, I blew up the bite. And it’s really something because all of a sudden all the things I thought I shouldn’t do I was doing, and I was changing the bite.
What I realized is for every millimeter you move the jaw forward you put 127 grams of force on the teeth, so the less far you move the jaw forward, the less dental, dental morbidity that you have. But the early appliances that I worked with really pulled the jaw out a mile. I mean the patients; their jaw was in the next room to get a decent outcome. So what I started doing, was playing around with the appliances, and actually making them thinner, smaller, less intrusive onto the oral cavity volume, and as I did we started not having to advance the jaw so far. So now we’ve come up to an average of between six and a half and seven millimeters of mandibular advancement, will clear most people and we’re just completing the study, we actually got 68.9 percent if I remember correctly of the patients to less than five and only took them out less than seven millimeters. So the dental morbidity doesn’t really kick in very strongly there.
And that was helpful, but to do more you have to get rid of the inflammation in the airway, which we talked early, and the first key to all this came from a ENT that I work with still today; as an example, when I got the patient out to about seven millimeters on one occasion he gave them a steroid dose pack and that really relieved the inflammation in the airway, and all of a sudden my oximetry readings and everything just got 100 percent better.
And so I realized I didn’t have to move the jaw completely forward to get the airway clear. I needed some help with managing the inflammation in the airway, and a less of a protrusion, and with that, I got a remarkable outcome and found as long as someone continues to wear the oral appliance then the inflammation does not seem to return and we’ve measured up to a year after that one instance of giving one round of the medication and the inflammation hasn’t returned. Which I think, we haven’t reported that, but I see that.
So the CPAP is very mechanical and works every time if somebody will wear it, it just does the job. The oral appliance is like tuning a Ferrari or something. It’s not mechanical, you’re moving the jaw forward, but the body doesn’t think it’s there, and so consequently the, it doesn’t trip any of the responses that I think CPAP may trip too. So CPAP has a benefit there.
But the body has to heal over time, and the first time I ever realized this was an older patient of mine, he’s actually, and he’s allowed me to use his name so I, he says, “Use it Jim, cause I want this to get out as an information.” You won’t know it but his name’s Pete Dawson, and Pete is the most, probably the most influential dentist in the United States today. I’ve known Pete most of my life, and about four five years ago I made him an oral appliance, his apnea index was off the charts, he was extremely severe. And what scared me, and the reason why you’ve got to be careful about this, is I put the oral appliance in but he did not want to work with a sleep physician, and that made me extremely nervous. I didn’t like it because he was, he was extremely severe.
Well I put the oral appliance in and I tested him, and then I tested him again about three months later and he was in pretty severe Cheyne Stokes respiration. He was really, the SpO2 was just up and down, up and down, up and down, you know uncontrolled. I thought Pete, I said, “this is beyond me, we really need to get someone else involved here.” He said, “No I’m not going to do that, I’m feeling better than I’ve felt in ten years and I don’t, I’m fine.” So I let it go, and I thought, oh I wanted to have a success with him.
This is a man I hold in probably the highest esteem I can imagine, of another dentist. I mean he’s been remarkable to me, and I’ve learned a ton from him. He practices in St Pete and so the next Christmas I went down and met with Pete and I did my adjustments and everything that I do, and I use a lateral ceph, which is unusual. I even had a hard time finding Lateral Cephalometric x ray machine in St Pete, we tried to use cone beam and that doesn’t work, but anyway. I finally found this old ceph and everything’s fine and he said, “Jim would you please give me a pulse oximeter my grandson needs to be checked, I think he has the same problem.”
So about a week later I got it back in the mail and I downloaded it, an apnea index of about eight, you know some d-sats, the SpO2 wasn’t real stable, and the heart rate wasn’t perfect. And I thought well it looks like a young Pete, is what it looks like, and I thought well this 20 year old not going to want to wear an oral appliance or have CPAP or anything, what am I going to say, and I always want to please Pete. I mean I always want to give him the right answer, and so I called him up and I said, “Pete I got your grandsons pulse oximetry downloaded.” And he says, “What do you mean my grandson’s?” And I said, “Well I gave you the oximeter for him.” He says, “Oh Jim he wouldn’t do it, that was mine.” And he went through Cheyne Stokes, I mean all the way through from severe sleep apnea to Cheyne Stokes to relatively normal, you know, he was about an eight AHI, but all the Cheyne Stokes had resolved.
It amazed me how with that, it tells me the oral appliance takes time to heal, so somebody that thinks an oral appliance in two weeks is going to knock it out of the park, is really wrong on these severe patients. If you’re working on a 20 or 30 year old patient maybe that’s true, but not on a, not on the severe apnea patient, or the ones that are, that have had it for considerable time. So you need to set up, I think the oral appliance does is sets up conditions for healing and you got to let the body go, and that’s the reason why you need to work with a gastroenterologist if you’re having trouble with GERD. I also wanted him to see a cardiologist, I wanted to work with a sleep physician. It was way out of my league I felt. Because I get to thinking that what I did was very similar to what the ASV units do. I know the problems that have been there, and I don’t know whether I created the same situation as a ASV unit or not, so, it made me worry.
There has been at least one published case report of somebody developing central apneas after starting with an oral appliance. I don’t remember the pathological explanation mechanism that they were describing. Let ask you when you talk about this timetable, remember with PAP therapy as we’ve published on numerous occasions, you don’t just get the perfect pressures the first time you do a titration. There is as you say healing and other adaptation issues until over time people return for re-titrations, the pressures are adjusted. In terms of the dental device, what are some of the ways in which adjustments occur and over what timetable based on this idea you’re talking about, regarding the healing?
The protrusion is the major one that everybody talks about. The how far forward you move the jaw, how far forward you move the mandible. But patients can only tolerate a certain amount of forward movement, then they get sore, they go into TMJ pain they suffer all these things.
I think the reason why I’ve been so successful with this; I’m very comfortable with managing TMJ. If I get them into a TMJ problem, I can get them out of a TMJ problem. And so that is not an issue, you know I can, sometimes it’s a fine balance, of playing with it to get them kind of over the hump with their TMJ issue, you know to get the oral appliance to work correctly. And so, I go through that, and that’s a first principle from what I’ve found…
Excuse me, but when you do the original protrusion then, are you saying that is done in a graduated fashion? In other words you don’t go to seven right away?
Right, some people can tolerate that but not many. We’ve found that you usually can get by with going half way forward, in other words to three and a half.
Usually you can go on to seven after that, after about three or four weeks, and have the adjustment pretty well completed. But that’s not true for some people. I’ve found that there’s a group of people that works for, and that’s probably about 80 percent of the patients, but there’s about 20 percent of the patients that have this whole other bag of problems, that are not related to the protrusion. What we’ve found is the vertical, in other words the one that goes up and down between the teeth becomes very important too and a lot of the appliances are so big and so thick that their actually taken, what’s called the vertical dimension beyond the range of tolerability of most patients to start with.
We’ve found that most patients want a fairly mild amount of vertical, and that helps. Then you get into that, the GERD is the third big issue. Then you get into breakage of the appliance, you need to have a robust appliance, but it can’t be big and heavy and thick. It’s got to be strong but now bulky, and a lot of the appliances are bulky.
then it gets into the patient, it gets into the patients and their habits. One of the problems with an oral appliance that you don’t have quite as much with CPAP is alcohol and drugs. Because alcohol will absolutely knock the efficacy of an oral appliance out the window. If they get bombed, I mean oral appliances don’t work well. So people that are severe alcoholics, or even always have a drink right before they go to bed at night, are not going to do well on an oral appliance. You’re never going to get their numbers down where they should be.
Then you get into the allergies, and dogs and cats sleeping in the bed, and all those kinds of things are an issue as well. We just bought a really fancy new CBCT, it’s an extremely low dose Planmeca, that we can actually scan the nasal cavity pretty well. We’ve referred more people to ENT in the last four months, than anybody, into this one very large healthcare system. They think that I, they think that I’m wonderful. I’ve sent them patient after patient after patient, and what’s really interesting is, is you, the nasal problem is always there in the beginning with an oral appliance, because I think the GERD may acidify the air and it goes into the nose and causes swelling. As you get the oral appliance straightened around and get it adjusted and more toward the normal titration it’s seem like that goes away. And people turn back into nasal breathers after a while.
But there’s a group of them that absolutely do not, you know they have the deviated septums and the enlarged turbinates. We had those, we’ve had those taken care of, and that has dropped peoples Apnea-Hypopnea Index dramatically, along with the oral appliance.
Right, we use the ear, nose and throat doctors religiously as well. One of the things we’ve been noticing over the last several years is there’s not just the GERD but there’s a lot of nonallergic rhinitis in these patients. Some of it could be provoked by the GERD, some of it is it’s own independent process. So we’ve been surprised how many patients respond to the non-steroid nasal sprays, for example the Azelastine antihistamine spray, or the Ipratropium Atrovent spray. And many of those patients will see some calming down, and so that’s, that is so important you know, that many of these people do see ear, nose and throat doctors and sometimes it’s allergists and both.
But do you want to comment now on some of the more intricate ways that you said come into play beyond the protrusion? You mentioned the vertical, and the vertical is very important. I think you and I have actually had conversations about this before, where I mentioned that one of the things that can occur is if you can have too much vertical you literally get a bit of a jaw drop and the tongue will start falling backwards. So that’s why I’ve been concerned about it and that’s what the last time that we met I asked you about it. What do you think of the devices that allow the tongue to slide forward and actually have the space, versus the type that the tongue runs up against the barrier of the dental arch created by the dental device? So any specifics there that you think dentists who are listening to our program, they would probably have a better appreciation for this than I would. But I’m curious if without revealing too many of your secrets, if you have some ideas on what are the other adjustments or manipulations that dentists need to be thinking about besides the protrusion?
It’s interesting, if I see a normal dental device I take a, what’s called a carbide burr in dentistry, I have one called the Terminator, which is highly, highly aggressive. I go after that appliance like crazy getting rid of excess of plastic. The technicians tend to make them too big, too bulky, too thick because they don’t want them to break. But it’s interesting when you make them big, bulky like that they are the ones that tend to break. Because you’re infringing on the tongue too much. So I always uncover and let the tongue come out through the front.
There are still many devices that don’t do that.
Tons of them, and see there’s no real consensus on even what’s called oral cavity volume. You know the idea, I always, always am trying to maximize how much room there is inside the mouth, that’s what my goal is you know, within a reason. You brought it up with the vertical. But the, so if you’ve got a little bit of plastic there I always say the tongue will take advantage of any space that it has, and if you get two cells out of the throat and into the mouth, cause the tongue can only be in the throat or in the mouth, one of the two places. If you can give it five more cells in there you’re doing, the patient is better off. But the interesting thing is, is the only way you can really evaluate an oral appliance, and one of the controversies right now, is with dentists using pulse oximetry, or any kind of monitoring device to titrate or to adjust the appliance.
In the beginning everything is a guess with an oral appliance, so what we do is we set it to a certain amount of vertical, we set it to a certain amount of horizontal, and then we get it in and what I consider to normal ranges and every appliance has a different normal range. There’s no normal, every appliance has like it’s own fingerprint. If you have more plastic in the palate, the advancement will not be six and a half to seven; it’ll be eight to nine, or ten. Or if it’s thinner or it’s not there at all, maybe it’ll be a five, but I haven’t figured out how to make it not there at all. So really, depending on the bulk, it sets the horizontal.
But the interesting thing about this is as you get out to the normal ranges, and this patient is worse, or not feeling better, or you know, and so you look at the pulse oximeter report so what do you do? Normally a dentist cranks them forward more, and they get even worse and more uncomfortable and they don’t like it, and they complain a lot.
So what we had to do was put an extra step in there, and what we use is the lateral cephalometric film, that’s been used by orthodontists since probably back in the 30’s. And it shows a lateral view of the head like this, and the beauty of it is, is that can be taken in an instantaneous basis, you can just, you can catch it. So we take it, the patient, there’s a little bit of protocol to it, and anyone that’s listening to this that wants this protocol I’d be glad to email it to them. But you breathe out, all the way to the bottom of the breath. You’re standing up straight, teeth together, and you take an x-ray, and it’s taken in a split second, and you can’t do that with a CBCT.
What that does is shows the oral, what the oral pharynx looks like with the oral appliance in place.
We have one of those to start, and we have one at say six and a half, if they’re not doing well. Now did we make that airway bigger or did we make it smaller? It’s all relative. I realize the patient is awake and standing up, and all that stuff, but it’s relative. If I make it relatively bigger, their probably bigger. And so what I found is, is by varying the vertical, the maximum vertical we ever use, and we define it by the pre-molar area, right here over the bicuspids, that’s where we define vertical.
The maximum we’ve ever done on a patient was six millimeters, and many, many of the appliances come in thicker than that from the laboratory for even small women. Small women have a, I always say they’re like a Swiss watch compared to a grandfather clock on a 6’5 guy. But anyway, you change the vertical by a millimeter and sometimes you’ll open up the airway space by, as much as two millimeters. So you adjust the horizontal to get into normal ranges and then you start playing with the vertical, open and closing it and see what makes that airway bigger. And so that is our second data point.
Our first data point was the pulse oximeter telling us whether we were good or not good. The other data point shows us what the airway actually looks like in an instantaneous point in time. And then we start playing with that, with the horizontal and the vertical till we get somebody straightened around.
I like the fine practical steps that a patient can try, that might convince them of why they would go down this pathway. For years I will have patients put their teeth, their lower teeth in a forward position, and then go back and forth, you know if I say, “Put your mouth out like that but don’t get all this tension, just hold your teeth forward, then put them back.” And most people who do that will say, “Oh I noticed that I can breathe better through my nose when my teeth are forward.”
And I’m wondering, do you ever use tools like that with a patient? And if so is there anything about this vertical that can be used in that way, where a patient would be able to try it, and be able to sense, because it seems like there’s got to be some… I don’t know how quantitative it is, but qualitatively, it’s been so consistent when people thrust their jaw forward, without tension, just hold it into a thrusted position. Most people will say, “I can breathe better, I can breathe better through my nose.”
That’s absolutely correct, and we do, do that Barry, that’s the quickest trick that I know of. A lot of dentists though are going down a path that I don’t think works, and that’s using temporary appliances, and saying that their similar to the custom made appliance. They just absolutely are not, they bear no resemblance to a custom made appliance. And people are selling that pretty hard, because you don’t vary the vertical, the horizontal…
It sometimes turns people off, that could be fixed with an oral appliance but don’t think they can be. I know some of the insurance companies are starting to use that as well, before they will pay for a mandibular advancement device. But what I liked about it is, I’m really proud of these numbers, we did 101 consecutive patients and we haven’t – we’ll soon publish this – of that group 69.8 percent we got to less than five breathing events with an average age baseline high of around 29. We had high BMI’s too, the median was over a 30. So they weren’t fit people, and they were all, everybody was 85 percent CPAP intolerant, that we took care of. We didn’t get first crack at anybody hardly.
But what I really liked, less than five is pretty strict criteria, but that’s what we want to go for. But for less than ten, we got 78 percent of the people to less than ten, with the oral appliance. But the one that I really liked, that I thought, you can tell people pretty predictably. We got 98 people out of 101 to have a greater than 50 percent improvement.
And so the idea that oral appliances work, but you have to work with the ENT, you’ve got to control alcohol, you have to demand something of the patient. If I go back to Pete Dawson, he was, he’s a unique man, he has always said that if you’re going to evaluate my technique you must do it exactly as I say, or don’t say that you are evaluating my technique. You know you have to reproduce it. He has been incredible on getting the bite correct and how he goes about doing all this, it’s really masterful work. Well, when I asked him to start wearing the appliance he said, “Yes”. He has never gone without that appliance in four years, never.
You get a compliance out of a patient like that and so it’s led us to realize that there’s three groups of patients, I call them our A-listers, our B-listers, our C-listers. And the A-listers do exactly what you tell them, they come in for their appointments, they allow you to actually treat them. The B’s they come in sometimes, sometimes they don’t. The C’s you sell them an appliance and you know the success rate is totally haphazard. It’s relatively predictable with the ones that come in now and again. But to get real true success with an oral appliance you need to be, you need them to be the A-lister, and come in.
When we were going through this, and I do have an answer for this when I get all done. But when we went through this, we had an average of 17 nights of study on each of these people in this 101 group. Well what it did, it caused several people to drop out because they wouldn’t get a clearing PSG, they wouldn’t get a clearing HST on the end; they basically did what they wanted to do so they weren’t part of the trial. You know so we lost this group of people who were relatively noncompliant, that’s one of the reasons why our numbers were so good. Because they wouldn’t, they just wouldn’t cooperate with the trial.
And so, anyway, if you get a compliant patient and they’ll work with you, you can have, same way as CPAP, you can have really wonderful outcomes with that group of patients. So we tried to tell them that, we had them call other patients to tell them what their success rate was if they’re not doing well. We have created almost like a little support group for people with oral appliances, and through that means we’ve gotten good outcomes.
What I tell people is, if you work with us, you’re going to have a success, and if you don’t work with us I don’t know. So you know, what’s your feeling?
That very much parallels PAP therapy, you have to be able to use the PAP in order to get the benefit. Now any other points though on that idea of anything the patient can do just in the very beginning phases? You mentioned that you don’t like the idea of those temporary devices, is there anything else a patient can do? Besides practicing the jaw thrust, that will give them not only an indication, but some confidence of, oh I think I want to do this because I get the feeling this is going to work for me. You mentioned you do the jaw thrust. Anything else?
The other thing is positional therapy. You know, sleeping with about 14 to 16 inches of elevation on their head, and on their left side. That really helps because there’s less GERD on the left side than there is on the right side, because of the position of the stomach. That seems to make people feel better too. And if they start doing better with therapy like that, that’s a big help. The other thing is some people will come in and they have dental devices and a patient will be told, “You got to wear your denture every night.” And so their wearing their denture every night to bed. So what I did is I said, “Okay, wear three nights,” and I always do three nights to screen out changes in night to night variability, and anyway they wore their upper denture for three nights, and three nights they didn’t. So which way were they the best? By far the best without the denture.
Now that may be different for other people, everybody that we’ve tested is better without their denture, than with their denture. Another thing is, oh golly what else do we do, I guess positional therapy and then sometimes getting people off their stomach is a big help because they get so much hypoventilation laying on their stomach at night. We can tell so much, but you know I think the best thing, you know coming back to it I hadn’t thought of that question for awhile.
The very best thing we do is we take that lateral ceph and we show the patient their airway, and I put my thumb over top of it and I say, “You know your airway should be the size of my thumb, and it’s the size of a tiny soda straw or anything at all.” And then I show them where the hyoid bone is and I show them what we’re going to do is move the jaw forward and there’s a muscle that attaches the two, so we’re going to pull that jaw forward for about six millimeters or seven millimeters, or eight. So your airway is going to get bigger and that’s, I show them that.
That’s very motivating.
It is, and you know the interesting thing, I got in trouble on this, this was funny, cause that jaw thrust I took a lateral… Now our x-ray machine is extremely low dose, I mean it’s the newest of the new, that, but what I did is I had the patient thrust their jaw forward, and I took another lateral ceph to show them the difference in the airway. Well the airway gets massive, I mean it gets the size of a garden hose, but what’s interesting is, if you put an oral appliance in and you pull it forward the same seven millimeters say, what happens is, is you don’t have the activity of the muscles like you do when somebody thrusts their jaw forward. Like this.
What happens is you pull the jaw forward and all that tongue tissue gets pushed up into the back of the throat and so that’s the reason why we’ve found we had to have vertical to be able to work with these. You have to put that tongue somewhere, is what I’m saying is, “Where we going to put it?” You know, you know sometimes you know you can’t open the vertical too much because they, their jaw angle is very high and it swings back against the back of the throat and collapses it like you were saying.
Sometimes you can only get by with two millimeters, or a millimeter and a half, is all you can. And then other times you can get five to seven, or six not seven, I’ve never gotten seven. It’s kind of like playing around, I hate to say it.
But you know what kind of comes down to it that’s what you doing with these.
When I went to my first Dental Sleep Meeting Society which was almost 25 years ago, I remembered that’s where I learned at the time, tell me if this is still valid? That the natural resting place for the tongue should be on the roof of the mouth.
And so I’ve always wondered then how does that play out with, going back to an earlier question I had for you, how does that play out with the dental device? Where on the one hand if it’s too bulky it probably can’t get to the roof of the mouth, if its got a hole in the space between the two arches then it can actually slide forward, is there an ideal place for the tongue where it should be slid forward or should it actually be on the roof of the mouth and does that depend on the type of dental device?
It does depend on the type of dental device and how thick it is and everything. You hit on my absolutely favorite topic, it’s this tongue thing. I do like this. What it is, when people, this gets into the scalloping of the tongue, when the tongue is scalloped their holding the tongue in the floor in the floor of their mouth so they can breathe through their mouth, because they’re not nasal breathers, they can’t breathe through their nose so they breathe through their mouth and that’s the reason why it’s scalloped. It’s interesting and you know we’ve brought up China a little bit, in the traditional Chinese medicine when you see the scalloped tongue, they say there’s an absence of, I think they pronounce it Qi, Q-I. And what that means the life energy has been evacuated from the body.
Just a, Qi, is that how you say it?
It’s the absence of the body energy, and so you’re not getting the benefits of nasal breathing, and with nasal breathing you get the nitric oxide which is, you know, which is a signaling device to lower blood pressure, it causes red blood cells to release more oxygen. And you also sterilize the airway more completely and you know for bacteria and whatever. So the best place for the tongue is not in the throat, you know, it’s in the mouth or in the oral cavity, wherever you can find a place to put it. There’s more nerve tissue in the tongue than there is in the bottom half of the body, so the tongue, why does it have all that nerve tissue? It has it all so it knows what to do, you know, it can contort itself to any shape, that’s the reason why you get the little scalloping on the side of the tongue. The tongue is trying to shove every little cell away from the back of the throat. So the idea if the tongue is up and forward it’s taking up the least amount of room in the airway, and that’s what I look for.
Okay, and so is that a regularly occurring issue with a patient? For example when you have a patient fitted for OAT do you have to give them, let’s call them tongue exercises or tongue instructions, where you say, “I want you to be thinking about trying to place the tongue in this position to see if you can get comfortable in this position”?
You ask the greatest questions. It’s so basic, we don’t tell them anything. We’ve tried it both ways and what’s really interesting is you get the airway open so they can breathe through their nose and they establish nasal breathing, that tongue comes right up and forward. It does exactly what you want it to do, they don’t need to exercise it. Now there’s a lot of controversy on that, cause then it gets into the myofunctional therapies.
And all those things that people talk about, and that may be very helpful and it may make it occur more quickly. But the fact of the matter is that most of our patients once they were nasal breathers when they got done, which I was amazed at, without any instruction. So I have a very good friend, he’s the only person that I know that’s kept data on this, and he puts a little dot on the appliance and tells the patient to hold their tongue up against this, and he’s gotten remarkable results by having patients do exercises. So that may be very valid, I, but I don’t do that. Could I say one more thing before we move on?
This is so cool, I love when something ancient works.
Cause we just didn’t land on this planet and have an iPhone in our hand you know. There was a study done in Sweden about three or four years ago, I forget the author, I should know it, I quote it all the time and I can’t remember the author’s name right now.
But anyway, what he found is that if you hum, you produce 15 times the amount of nitric oxide as you do normally. So what do the Buddhist monks sit there and do hours on end? That they do their ooooms, and so what is that going to do, you’re getting 15 times more nitric oxide, you’re going to lower your blood pressure, you’re going to get more oxygenation and you are going to get the enlightenment that they’re looking for. I find it extremely interesting by nasal breathing they can actually change you know the heart rate, and they said that’s the meditation, you can change heart rate with meditation. I believe that because you establish nasal breathing, and you’re using the nitric oxide to do that with. So I find it very interesting cause you know people had sleep apnea for a lot longer than you and I’ve been around, and they found ways of doing it, but we’ve lost a lot of the traditional ways.
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