Protrusive Dental Podcast
Dentists Prescribing Home Sleep Tests? – Our Role in Airway Screening and Management – PDP243
Can and should Dentists carry out home sleep testing?
It’s actually super easy and I have been doing it for 18 months!
What happens after you screen them—do you know what to do next? This episode will teach you!
Dr. Jaz Gulati shares his personal journey into incorporating sleep testing in practice—after 1.5 years of doing it, the impact has been nothing short of game-changing.
https://youtu.be/H4rTkIuOHWI Watch PDP243 on YoutubeJoined by clinical sleep scientist Max Thomas in this jam-packed episode, they deep dive into what it really means to go beyond awareness of sleep-disordered breathing. He breaks down the practical steps for dentists who want to do more than just refer—and start making a difference in their patients’ lives.
You’ll learn how to bridge the gap between theory and action, how to screen effectively, and why you play a pivotal role in the patient’s journey to better sleep, more energy, and a healthier life.
Protrusive Dental Pearl: If a patient has been seen gasping, choking, or stopping breathing during sleep — that’s pathognomonic for sleep-disordered breathing.
???? Don’t ignore it — they likely need a sleep study. Ask this in every history!
Need to Read it? Check out the Full Episode Transcript below!
Key Takeaways:
- Understanding obstructive sleep apnea is crucial for dentists.
- Dentists are in a unique position to screen for sleep disorders.
- The Malampati score is an easy tool for assessing airway obstruction.
- Sleep disorder breathing can significantly affect quality of life.
- Patient history is vital in diagnosing sleep apnea.
- Quality of sleep is more important than quantity.
- Dentists should ask specific questions to identify sleep issues. Sleep position can significantly affect sleep quality.
- Screening tools like Stop Bang and Epworth are essential for identifying sleep disorders.
- NHS sleep testing can vary greatly in wait times depending on location.
- Snoring is often a precursor to more serious sleep disorders.
- Dentists can play a crucial role in sleep disorder management.
- CPAP is the gold standard for treating sleep apnea.
- Understanding the legalities of sleep screening is vital for dental professionals. Remote monitoring became essential during COVID-19, shifting paradigms in sleep medicine..
- Remote monitoring helps ensure patients are truthful about their usage of devices.
- Mandibular advancement devices may be more effective for certain patient profiles.
- Patient compliance is crucial, with many struggling to adapt to CPAP.
Highlights of this episode:
- 00:00 Teaser
Resources for Screening Sleep Apnea
Screening Tools
- The Acupebble Device
- WatchPAT as an alternative
- Send your sleep test for reporting to Max Thomas – excellent service and affordable
- Max Thomas’ LinkedIn
If you loved this episode, don’t miss Sleep Disordered Breathing and Dentistry – PDP139
#PDPMainEpisodes
This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.
This episode meets GDC Outcomes A, C, and D.
AGD Subject Code: 730 ORAL MEDICINE, ORAL DIAGNOSIS, ORAL PATHOLOGY (Sleep Medicine)
Aim: This episode is aimed at empowering general dentists with the knowledge and practical steps to actively participate in the screening and co-management of sleep-disordered breathing through the integration of home sleep testing in their clinical practice.
Dentists will be able to –
Understand the role of general dentists in identifying signs and symptoms of sleep-disordered breathing, particularly obstructive sleep apnea (OSA). Identify when and how to refer appropriately to sleep physicians or medical specialists after screening. Explore collaborative workflows between dentists, sleep scientists, and GPs to ensure effective patient management. Click below for full episode transcript:Teaser: When you think about the number they have per hour, less than five is normal, right? Less than five of these breath holds is normal. Between five and 15 is your mild category. 15 to 30 is moderate, and above 30 is severe. You see patients that have what we call an AHI Apnea-Hypopnea Index of 60, and sometimes these breath holds can be 30 seconds.
Teaser:
You end up looking at these studies and there’s actually more time spent not breathing than there is breathing. In some areas, you are six weeks away from a test because they’re not only on top of their list, but their numbers are lower. In other areas, you’ve got high population density and low service output.
So you know, I have seen sleep departments that have got 60 week wait list just for the initial diagnostic tests. You already got the suspicion that they have obstructive sleep apnea. They’re already telling you that they’re struggling, and then they’re told to-
Sleep apnea is one of those things that a patient may need to report and they may need to report it in the case where they have moderate or severe obstructive sleep apnea with sleepiness.
And it’s really important that with sleepiness part is the main focus of the DVLA guidance. ’cause the sleepiness is the symptom that affects safety on the road. If the patient has sleep apnea, but they don’t wake up frequently from their breath holds, they don’t have the interruption to sleep, they don’t have the reduced cognitive function in the day. That sleepiness is what? This is all contingent on.
Jaz’s Introduction:
Protruserati, I think this is one of the most profound episodes we’ve done to date. You see, the problem is that everyone’s telling us that sleep apnea is this huge thing and that as dentists we ought to know about it. And there’s plenty of podcasts now out there. Plenty of content out there, plenty of courses out there that are kind of filling that gap of knowledge.
The issue is we’re still hungry. I’ll tell you what we’re hungry for. We’re hungry for the following. Okay, so now you know what sleep apnea is. Now you’ve asked your patient, you’ve done some screening questions to your patient, but then what?
What happens then? Because if you’re not already actively in this space and you kind of refer and you lose that patient forever, what if you as a dentist want to do the sleep test? That’s what I do. I’ve incorporated sleep testing into my clinic for about 15 months now and it’s amazing the results we come back.
Now, I just wanna start by saying that we as dentists, we cannot diagnose sleep disorder breathing. Okay, let me repeat. We as dentists cannot diagnose sleep disorder breathing, but we can screen and we play a pivotal role in its management. So what this episode will do is we’ll bridge that gap between actually knowing about sleep apnea and actually doing something about it as a dentist.
And that is only achieved by those who are testing in their clinic. And let me tell you, it’s not mega expensive. It can be very convenient for your patients. And hey, even if you don’t start testing yourself, you ought to find someone near you or a center near you that can get your patient tested for sleep disorder breathing, such as obstructive sleep apnea.
And correctly reported so that you can genuinely help your patients, help them live a healthier life with more energy, less dozing off during the day ’cause of sleepiness, better quality of sleep for them and their partners, and adding quality life to their years.
Hello Protruserati. I’m Jaz Gulati and welcome back to your favorite dental podcast. If you’re new to the podcast, welcome, you picked a great one, and of course, if you’re a returner, thank you so much. Really means a lot. Your time is important to me, so I’m gonna make sure we absolutely smash it in this episode.
This episode is a bit longer than usual, but let me tell you, it is full of gold, full of protrusive pearls when it comes to sleep apnea and actually doing something about it as a GDP being proactive, rather than just screening and then leaving it there and doing a big tick. Like, oh yeah, I’ve screened, I’ve done my job, actually helping your patients get the correct treatment.
And the person who’s helping me today is a clinical sleep scientist. His name’s Max Thomas, and he’s such a knowledgeable guy and he explains things really well. The funny thing about this episode is we’re talking about sleep here, right? And I was recording this like 10:00 PM after my evening shift at clinic, and Max said this just come from Japan, suffering the most major jet lag ever.
Yet, I still think we’ve created a piece of art, which I hope you will love and you may wish to listen to again as a reference. But most importantly, I think this is the one where the penny drops and things actually make sense in terms of how you can play a role to help and serve your patients. Let me tell you, the done for you notes of this episode are absolutely brilliant.
You’re gonna absolutely love them because our premium notes, what we do with our premium notes is we ensure that you can actually retain the information. Look, I listen to podcasts, I listen to audio books. Sometimes you get home, you sleep and you forget so much of it. When you actually read a handout, that literally takes about 10 minutes to read.
It really cements and reinforces your learning and it helps you take the next actions. So if you wanna download the premium notes, please head over to the Protrusive Guidance app. It’s all there for you. Head over to the Protrusive Guidance app. It’s all there for you in the Protrusive Vault section.
It’s also under each episode we’ve got the transcript and the premium notes, which are like the done for you, revision notes. And yes, this episode is eligible for CE or CPD. We are a PACE approved provider.
Dental Pearl
Every PDP episode I give you a Protrusive Dental Pearl and this one’s very relevant to airway and sleep and it is the following. If in your patient’s history they have elicited that someone has observed them stop breathing or gasping or choking in their sleep, and that is pathognomonic, I hope I’m saying it right, pathognomonic. Let me just make sure I get that right pathognomonic, there we are. I said it correctly.
Now what that means is that if someone says that they’ve been choking or they’ve been observed holding their breath or gasping in their sleep, that means they’ve pretty much have a sleep disorder breathing.
You can, with a high degree of certainty, screen them as positive and probably will benefit from a sleep test. So it’s a helpful question to ask in your history. Now, of course, we cover that in good detail, but we cover about all the different questions we should be asking, all the different signs and symptoms and how exactly am I testing my patients and how Max report these, and then what happens when we get the patients some sort of treatment.
This could be them having a CPAP. This could be a mandibular advancement splint, or a mandibular advancement device. So I hope you
enjoy this deep dive and I’ll catch you in the outro.
Main Episode:
Max Thomas, welcome. A very warm welcome to the Protrusive Dental Podcast, my friend. I like to start the podcast in terms of how I came under someone’s radar or how I met someone virtually, or how someone came into my universe and it’s Mahmoud, right? My brother from another mother, Mahmoud, we’re both occlusion enthusiasts. We do courses together. We teach together, and he was like, oh, you know what?
I play basketball and there’s this guy called Max, man. He’s really into the sleep stuff. I was like, man, I need a sleep guy. Put me in touch and I’m so, so glad that, I don’t know, a couple of years ago that he put us in touch. Man, it’s been so nice to learn from you to sort of manage these cases together, man, you’ve been pivotal in that.
And so what I really want to do is today I want this to be the most tangible piece of content that dentists hear while they’re on the train, while they’re driving, whatever they’re doing on the treadmill, so that they can actually feel like, you know what?
I’m actually gonna do something about sleep disordered breathing, because most lectures and most content you get out there is like, either come on my course or it’s like the basics and overview, but that nitty gritty detail of what do I actually do? Okay. Which you’ve helped me massively with. So Max, please tell us about yourself, my friend.
[Max]
Thank you for the introduction. Yeah, so we met when I was still working up in Birmingham, actually. We haven’t met in person yet, but yeah, our link was Mahmoud. I’ve still got him saved as Mahmoud ‘Dent Baller’ because I never knew his surname. So shout out to Mahmoud.
[Jaz]
Well, he’s still saved on my phone as Mahmoud Occlusion still.
[Max]
Yeah, fair enough. I mean, I did that with all of my contacts, how I remember them. But yeah, so, I’d actually heard your podcast before I met you ’cause my wife is a, she’s a big fan, so shout out to Beth.
She was playing one on a drive up between Birmingham and Bryson. And in order for me to get a Spurs podcast on, she also had to have a dental podcast. And it was a really nice episode. Where you had a physiotherapist on, and I still got something you mentioned tangible. I still got something that I use in my day-to-day practice from that, which is the best posture is the next posture.
Keep moving around, particularly if you’ve got issues. And man, that stuck with me, so I appreciate the sort of yeah, keeping it tangible, making it, sure there’s nuggets to take away.
[Jaz]
Excellent. And that episode, Sam, he actually came on again recently to talk about some more, the current concepts and the different types of loops that we have. So man, I’m so glad. That was a long time ago. That was like 270 episodes ago, so, wow. Like, we connected years ago, but tell us about you professionally. Like how do you define you? Because when Mahmoud was trying to explain your role, he was struggling.
[Max]
Yeah, yeah, yeah. So-
[Jaz]
He’s some sleep dude.
[Max]
Some sleep dude, I get called sleep man at some of the talks I do. I’m fine with either. I’m a clinical scientist that practices in clinical physiology and that is essentially the measurement of either lung function or sleep. And obstructive sleep apnea is where those things overlap.
The airways and sleep and breathing is kind of our forte is measuring breathing whilst people are sleeping, looking at interruptions to those breath. And so our job really is about the diagnosis and management of conditions relevant to our practice. So for me, that’s obstructive sleep apnea, that’s insomnia and used to be a lot more sort of narcolepsy, really complex sort of sleep stuff.
When we were first introduced, we’re in a big lab in Birmingham. Now I’m a smaller lab, but I deal more with obstructive sleep apnea, so probably, still doing quite a bit in the field that we were introduced in. I haven’t had any referrals from you recently.
[Jaz]
Yeah, well I had my pneumothorax and that kind stuff. But, I get the same conversation with my lab technicians, right. It’s like, for me it’s like buses. Like patients, when they come to me, it is like two, three a pop and then suddenly nothing for a while. And very much, it depends on how many conversations I’m having with patients.
So it really can vary week to week. But we’ll talk about, how I started to send my cases to you for reporting. ‘Cause I think that’s what dentists want to hear. How do you get started in your journey?
And when you talk about, just a little bit about you, about your day-to-day work, does that mean that you’re literally watching people sleep and you’ve got like, your clipboard or you’re just ticking things off and you are clicking things? Like do you do any element of that?
[Max]
Yeah, so when you have these full polysomnograph where you’re doing, you’re measuring everything throughout a night’s sleep. You have them in as an inpatient, well, we don’t have that kind of lab anymore where I’m at actually, we had that in my old site. But you would have someone who was there observing them overnight, just making sure that all the readings were occurring.
And if there was any issues, you’d be there to help. But the main job of a sleep scientist is to go through those data the next day and try and look at all of these different channels and work out what’s going on under the hood. If you’ve got a patient that’s complaining about the fact that they’re sleepy, well, you’re looking at the quality of their sleep overnight.
You’re looking to see if there’s any interruptions that might be related to breathing, and if there are, you count how many of those sort of interruptions there are. We get this hourly rate out the other end.
[Jaz]
Don’t you get the AI to do that though? You know what? There’s a list of jobs of where AI is gonna take over your job. Are you dangerously close to losing a job?
[Max]
Yeah. So do you know what? I would say-
[Jaz]
Sorry if I touched the nerve.
[Max]
I would say no, you’re not, I would like it to be able to support us. ‘Cause a lot of the stuff with AI and healthcare is, we’re actually better with the device having some form of AI.
But it’s to support clinicians and AI on its own can’t literally do the job and actually quite often need pointing in the right direction. But sometimes, people go to on holiday to Japan and then their body clock is the other side up and you’ve just got an AI to point you in the right direction and you kind of, it’s symbiotic in that sense.
There’s a lot of work in the world of respiratory moving towards like automated interpretation of lung function tests and things like that. But actually in the world of sleep, we’re not quite there yet. We have assisted scoring, but then we go through and check it. We make sure it’s right. There’s quite a lot of nuance to the things that we do.
And the traces are these tiny little squiggles and after years of experience you can interpret those squiggles, but quite often these interpretation algorithms, they get some of the big decisions wrong.
So we’re at a point, the only thing I’d say on the back of that is the uptake of technology in healthcare systems is so slow. We might have these AI technologies about, but then they’re not gonna be uptaken at a rate that will see me before I’m retired. I think.
[Jaz]
Good, your job is safe then. And that makes me happy because guys, the way me and Max have been working together is, I screen my patients and we’ll talk about that, which questions I ask.
And Max has been instrumental in helping me and I just wanna just go through his journey with you all and explore, okay, how did I detect, the first ever patient I sent you was like severe off the scale. I dunno if you remember this actually over a year ago.
And so it’s amazing, man, for me as a dentist, at dental school, they taught me that I can save someone’s life if I diagnose oral cancer or I see like lots of evidence of acid in the mouth and therefore they could have a Barrett’s esophagus and therefore.
That’s a very indirect way. But no one mentioned at that stage, dental school, they didn’t say, we have a important role to play in the airway ’cause that’s another way to save someone’s life.
And some of the studying I’ve done, some of the courses I’ve been on, were much like, we can add 10 quality years, not just 10 years, but 10 quality years in someone’s life. If you make such a diagnosis, if you help these patients. And you said something earlier that dentists are in the best position to do so. So just tell us why are we in such a great position to be able to help screen? Because we cannot diagnose, but we can screen and assist patients.
[Max]
Yeah. So you are in a great position. You’re in a great position for a lot of reasons. The first reason is you are genuinely, truly general practitioners. As in everyone will come to a dentist and see you. Whereas actually at GPs, they have this sort of sample bias of people turning up when they’re super duper ill and they’ve got one thing that they need to talk about and that’s all they get.
And sometimes GPs will catch other stuff and sometimes people will go to their GP saying that I’m very sleepy, my partner says I snore. That sort of thing. Whereas you kind of see everyone and you get this opportunity to have them sat in a chair and be still for a bit. And that’s when you start noticing symptoms.
Another person who’s having a conversation with them might not. You’re in a very unique position, not only because of that, but also because you are looking, as you said at the start of the airway. And the main crux, or the main point that causes an issue in obstructed sleep apnea is the upper airway back of the throat, crowding at the back of the throat, causes obstructions when they go to sleep, and all those muscles relax and everything collapses across.
[Jaz]
When you say crowding dentist, think teeth being crowded, right? So, no, you’re right. But see, so let’s spell it out for a younger colleague. ‘Cause I know what you’re talking about now, but there was a stage where I’d be like, wait, crowding at the back of the mouth? Like posterior crossbites? What do you mean by crowding back of my, what are we looking at?
[Max]
Yeah, so that, I mean it’s almost all the structures in the jaw and the upper airway, the soft palate, the tissues at the back, all of that can contribute to crowding. So what you tend to see, your classic obstructive sleep apnea patient is someone that’s overweight, very thick neck, all the tissues that are in the back of their throat, there’s a lot of fat mass.
And that’s taking up a lot of space whilst they’re awake and they’re operating their upper airways, muscles, the airway’s perfectly patient. It’s the moment they go to sleep. And when they get into the deeper stages of sleep, such as REM and all those muscles have really relaxed, they start getting obstructions that can’t be overcome by just trying to breathe in.
And what they have to do is they have to wake themselves up periodically in order to be able to breathe. And they don’t always fully wake up, but they are having interruption to their sleep. It affects their sleep architecture and the next day they feel rotten. So you can see all those structures in the mouth.
You could see retrognathia, you can see in a large tongue. You can see the soft palate is almost covering the entirety of the back. You can’t even see to the back of the throat. I don’t, I don’t dunno-
[Jaz]
Let’s talk about that The Mallampati score. Let’s talk about-
[Max]
That’s what I was about to say.
[Jaz]
So it’s good. So let’s talk about that ’cause I do that as part of my assessment, especially for my TMD patients. When I ask my series of questions, I’ll get the patient to open really big, as big as they can go and stick their tongue out all the way and just have a look. And there’s degrading from zero, is it zero or one? I forget the first.
[Max]
I think it’s one to four.
[Jaz]
Yeah, one to four.
[Max]
It’s four different grades.
[Jaz]
Mm. And so I think it was named after an anesthetist. Is that right?
[Max]
The history of its loss to me. Sorry, I could have done some Googling.
[Jaz]
But anyway, the anesthetists, they are looking at, they are giving the score a lot because it is important for them for what they do, but actually for the dentist it’s important.
But I won’t steal your thunder. You are the man of the knowledge. Please tell us about how easy it is for us to test Mallampati. I kind of gave a description of how to do it, but then how do you score it, and more importantly, what is the significance of that?
[Max]
Yeah, so you actually knocked a memory loose when you said it was about anesthetist. ‘Cause it was talking about the risk of in, or the need of intubation or the difficulty intubating as a result of the crowding at the back of the airway. And actually I think the evidence was a little less clear for that than it is for obstructive sleep apnea.
The higher your grade, the more sort of obstructed that area is the back of the throat. And for every step up in grading of the Mallampati, and I’ll talk about that in a second, but for every step up in grading, you almost double the risk of obstructed sleep apnea.
And the severity increase as it goes. And that’s sort of essentially those soft tissues contributing towards obstruction of the upper airway. A grade one, and now you’re testing me up. I should have had this up for me to look at, but a grade one is-
[Jaz]
I mean, grade one you can see everything, right?
[Max]
Yeah, you can see right through to the back. You can see beyond the uvula. The soft palate is way up and it’s all sort of in place. Grade two, you start getting the soft palate coming down.
The uvula is still visible, but you can just about see through to the back of the throat. Grade three, it might be at the point where the uvula is even just. Sort of hiding behind the back of the tongue down, and then grade four, you literally can’t see beyond the soft palate. And yeah, it correlates quite well with the risk of obstructive sleep apnea.
So your dental population are out there who are looking into the back of the throat, so their patient, you can spot this quite easily. You can see it without even telling them that I want to do an assessment here. You just pick this up as you’re going through your assessment.
[Jaz]
But what I wouldn’t want people to do is just, fair enough. Some people, this might be the one thing that they take from this podcast. They might doing it. Yeah. But it’s just one piece of the puzzle. You also need the history. You also need the sleepiness, which we’ll get into obviously. But that is one important point. I’m glad we start with something quite actionable for dentists.
Okay. So they actually realize, okay. There’s something to measure here, right? Dentist’s like to measure. So there’s something to measure. We like indices and scoring. So a Mallampati is such an easy one. I’ll just put you a word of caution actually for dentists is our patients with reduced mouth opening, right?
They will bias towards a higher Mallampati score. But that would be a false positive, right? So my patient’s got TMD and they can only open 35, okay, on that day. And so I’m giving them a grade three, a grade four on the Mallampati, but actually they’re grade one, two because could they open 45, 47, right?
They used to be that. So just take that with caution. But a really cool thing I like to ask my patients who are like, got normal mouth opening, but they’re still a Mallampati four is like, how did you find taking COVID tests? And they’re like, no, I can’t do COVID tests. I just never could get the damn swab to my tonsils. Have you thought about that?
[Max]
Well, I dunno. So you say that and I think because their gag reflexes so much, I don’t think that is in any way related, or you might be telling me different, but I haven’t correlated that with our patients. Mainly because COVID absolutely slammed sleep as a medical science because obstructive sleep apnea is the coldest of things.
It’s the last thing you sort out. If a patient’s got raring type two respiratory failure and all these other things going on, those services keep running lung cancer. Yeah, we’re gonna keep our two week weights going, but sleep was the first thing to get knocked on the head and yeah, it’s sort of been still recovering since, if I’m perfectly honest.
There’s a lot of sleep services, the sleep service that in the department I joined recently that was absolutely, yeah, it was shut down. Its diagnostics are only just picking back up. We’re talking four years later.
[Jaz]
I mean, everything’s been so slow, Max, and this is one of the reasons why I really wanted to just start helping my patients. So I started to do my own sleep tests and that that’s where you played such a huge role. And so we’ll talk about that. And I think we’ve jumped the gun. I mean, I’m so glad we talked about Mallampati score because most dentists that I speak to don’t know about it. They don’t look at it, they don’t know about it.
And so I think it’s good that we covered that. But I know we’ve done it in previous podcasts, but this might be the first podcast someone might be listening to Protrusive. So what is sleep disorder breathing? What actually is sleep apnea? And you’ve kind of said that, yes, crowding in the back of the mouth will predispose someone. But as a condition, how do you define it?
[Max]
Yeah, so obstructive sleep apnea or sleep disorder breathing, we should start with is about interruptions to respiratory function during sleep, quite simply. Now, the majority of cases we’ll see, or the majority of cases we are talking about here, are those where the upper airway is obstructed, usually by those soft tissues and crowding at the back of the mouth or enlarged tongue or something like that.
They interrupt the airway. You can have other forms of sleep disorder breathing that are related to the central system, the drive to breathe, which can be affected by damage at the brain stem, brain damage affecting respiratory function, but also some heart disease can cause altered chemo sensitivity and they start breathing funny when they’re asleep.
But putting that aside, ’cause that’s definitely outside of the remit of dentistry, the upper airway, you’ve got your obstructive sleep apnea. Now they have these breath hold events when they go to sleep, more common on their back often because of the way in which gravity affects those structures in the airway and they obstruct that airway during sleep, the more frequent these breath holds occur, which can be up to about, I’ve seen patients who have breath holds up to about a minute.
A minute and a half. When they have, yeah, exactly. When you think about the number they have per hour, less than five is normal, right? Less than five of these breath holds is normal. Between five and 15 is your mild category. 15 to 30 is moderate and above 30 is severe. You see patients that have what we call an AHI, Apnea Hypopnea Index of 60, and sometimes these breath holds can be 30 seconds. You end up looking at these studies and there’s actually more time spent not breathing than there is breathing.
[Jaz]
I’m trying to interject, but I just wanna just add a story and add some context into this. One of the reasons Max, I dunno if you know this, actually, I dunno if I may told you. One of the reasons that, you told me before we hit recording that oh, Jaz, you are quite proactive, whereas other people don’t care.
You were proactive, but maybe it’s because my children were affected by this. So my 5-year-old had to have his tonsils. Was it? No, he had his adenoids. It’s not his tonsils, just his adenoids removed because he was diagnosed with sleep apnea. He had a sleep test. We had to literally tell him, he was like two and a half and we had to tell him, look, we’re gonna pretend to be Iron Man and we’re gonna put this like stuff up.
I’ve got the video of him pretending to be Iron Man while he is kited up with his sleep stuff as a home sleep study. And so they found that, yeah, also the amazing thing is when I spoke to the surgeon afterwards, he said that, yeah, we removed this fat pad of adenoids, right? And we drained his ears and so much fluid came out. And so the next day I switched on the kettle and he was like, whoa, what is that sound?
[Max]
No way.
[Jaz]
And so like no wonder his speech was delayed. Like and I look back, he was always into Spider-Man since is like 18 months. But he would never say Spider-Man. He’d say Berman. He’d say Berman. And so we thought that was cute, but actually it’s because he wasn’t hearing properly.
Okay. And so that made sense. Now that was my first born, right now he sleeps well it’s awesome that’s fine. My now nearly 2-year-old has it worse. So he also had a sleep test ’cause I pushed for it. ‘Cause I knew what I was looking for now. And he came back with a moderate sleep apnea. And so this actually took the doctors by surprise because a 1-year-old to get a diagnosis of moderate sleep apnea is almost like usually children with down syndrome or syndromic patients have this.
So that was very concerning for me and my wife actually. Right. But anyway, so, he is a terrible sleeper. My almost 2-year-old. Okay. I talk about this regularly on the podcast, like, yeah. I had to get milk this many times to comfort him. I have to go get milk at night and he will hold his back to the main story.
He holds his breath so much. He constantly is gasping in the middle of the night. He’s constantly like sleeping and suddenly you go and then he’ll wake up. And so just very distressing to see your child do this, but this is what adults are doing and they’re holding their breath.
And these are the apnea hypopnea indices. The AHI. And so how well does that correlate that score? Like for example, you just made a really good example. You said someone could hold their breath for 60 seconds. That would come down as one event. Now someone doing that for one minute, 15 times as a AHI of 15. Right? But someone could be doing it shorter 45. Who’s gonna be worse off?
[Max]
Yeah. So the minimum time that breath hold has got to be counted is 10 seconds. But you’re right, that number that we use at the other end, the AHI, breath holds per hour. It doesn’t always fully explain what’s going on under the hood. Those people with really long breath holds.
They’re gonna have a large hypoxic burden. During those breath holds, obviously they’re not exchanging gases ’cause they’re holding their breath so their oxygen levels drop. It has a massive consequence physiologically down the line, and we think it’s associated, or that hypoxic burden is associated with later development of heart disease, high blood pressure, a whole profile of metabolic issues.
Yeah. And to some degree cognitive function and all these things. So, the number that you get about severity is more about how frequently they’re holding their breath. But actually there’s other variables that you can get from more complex sleep studies that give you a bit more about, well, this kind of explains other aspects of their physiology. This explains the memory loss and all these things.
[Jaz]
The reason I mention this is because I was always taught by someone, Jamison Spencer in the US who’s done some of the courses I’ve done is that, just ’cause someone’s AHI is 30 and someone else is 60 doesn’t mean that 31 is necessarily gonna be better in all the other metrics.
Feeling less sleepy, et cetera doesn’t mean someone who’s in the moderate category can sometimes be really hit hard, right? Whereas someone could have an AHI of 80 and not really feel it as much. It was really, really fascinating when I was learning about how people’s physiology responds and you know you, that’s exactly what you study really.
[Max]
Yeah. Yeah. So another concept that we talk about is how quickly they react to these breath holds, something called loop gain. So some people can tolerate these breath holds and that their internal sort of regulatory systems don’t put them into action as quickly as somebody else. There’s some people that might not even reach that ten second threshold for breath hold, but it will cause an arousal, which is our term for waking up.
And these arousals are what’s associated with your sort of interruption to your sleep quality. But some patients who desaturate, they don’t reach that arousal until it’s the point where you know, it is time to wake up. And often that could be the partner sticking an elbow in saying, you’ve held your breath for a minute now.
Just like you were saying you were distressed, looking at the breath hold of your child. We often have patients that come into the lab. And they’re not bothered about their snoring. They’re not bothered about this. They’re bothered about it, my partner says that I hold my breath and I’m disturbing her.
Is there anything we can do about that? And this is where the history taking and the conversation with the patient comes into it really, because what they want out of it isn’t always, fix my sleep apnea. I’m worried about my health. I’m snoring and it’s annoying my wife.
[Jaz]
This is where AI hasn’t got shit on you, mate. You can see the whole patient, right? So, screw you, AI, Max is gonna keep his job. He’s gonna see the patient as a whole, listen to their concerns, yada, yada, yada. Dude, there’s so much to cover in this podcast. We’re just literally getting started here.
Okay. So this is awesome so far. So, we talked a little bit about what sleep apnea is and there’s so many other dental lectures people can go to, but I actually wanna really get into okay, what our role is and how we can actually get started.
So what kind of questions should we be asking our patients? So you said, yeah, no examination. We look into their mouth and we do a soft tissue exam anyway, so at that point I’ll do my Mallampati check. Okay. But a little bit before then I kind of look at ’em as they walk through. They look tired and sleepy.
That first patient I ever picked up and my first sleep study I did using the AcuPebble device and I sent to you that the reason I sent it through, he was a TMD patient, but he literally yawned like eight times in a one hour consultation. And I was like, again, that is not to say that, I had another patient who yawned at similar times and I sent her a steep test view and she came back as normal.
But for me there was a lot of things going on here. And I think with our, I dunno quote unquote my positive screening rate in terms of your clients, I think it’s good to get the data to help us to choose the best care for the patient.
[Max]
I should have kept numbers on that. We could have seen what your hit rate was, but you are right. Do you know what it starts even before they walk in the room. ‘Cause you go out to the waiting area, don’t you? And you look at them sat in the chair and I mean, we’re in a sleep service so I see like, I see a lot of it, but the patients who are literally asleep when you go to get them and they’ve only been there 10.
They think that’s normal though. Their whole life has been like that. And so sometimes when you’re asking questions, you say, look, do you feel sleepy? They’re like, ah, you know, I’ll sleep when I go home after work when I’m watching the television, and then I’ll be awake for a couple hours and I’ll go to sleep pretty much all night.
And the questions you really need to ask are not so much about, do you feel sleepy? Do you wake feeling refreshed when you wake in the morning? Do you feel like you’ve had a good night’s sleep? And this can help lead the conversation to somewhere else that makes you think, ah, this is sleep apnea. Because sometimes I say, well, not in the morning, but when I sleep in the afternoon, I have a lovely sleep. And you say, okay, why is that? And that’s-
[Jaz]
Someone said that to me literally yesterday, right? And she’s someone, I really strongly suggested a steep test and I’m not the first person. An ENT doctor in India also told her to get a steep test, but she never actioned it. And now I’m said, look. We can really help you.
I’m convinced like she’s got Mallampati four TMD, which is obviously associated linked, but like, just exactly what you said, she struggles to sleep and then she has poor quality sleep. And every day when she has that nap at about 5:00 PM then she feels great.
[Max]
Yeah. So, and where is that nap?
[Jaz]
It can be anywhere from what I asked her, like the kind of questions I ask as well is sofa or something. And then when you’re watching telly, do you those off?
[Max]
That’s it. Yeah. So why I mention that is ’cause I always ask, the nap feels good, right? So your night sleep is in bed, where’s the nap? And they say, oh, it’s on a sofa.
And that means they’re either set up right and they’ve fallen asleep like that and had a really good, their airway is not being obstructed by gravity or they’re on a sofa where they can’t turn on their back. And you’ve got somebody who probably has supine-predominant obstructive sleep apnea. It’s worse on their back.
And then when they’re stuck on their side on a sofa, they do much better. So that exact situation has happened to you. That’s brilliant to hear. I’ve had plenty of patients like that who say, look, actually, I sleep all night on a sofa now because I get better sleep. And that I really just like to follow them up and see them afterwards and just say, look, are you now sleeping in your bed more comfortably now that you’ve got CPAP from us?
[Jaz]
But as a dentist, we can do this as well. The beautiful thing is that yes, we’re greatly, so I can tell you some stories, right? Whereby some patients, they couldn’t afford the sleep test that I usually send to you, for example, right? And therefore I send ’em to their GP, right? NHS GP and the GPs actually where I work, they’re pretty good.
And like I kind of tell my patients what to say and whatnot. And they managed to get the steep test from the NHS and then they managed to get the CPAP from the NHS ’cause my suspicion was correct. And they come back and there’s one particular lady, she says that i’m dreaming again. I can now remember my dreams.
I’m actually dreaming Jaz and so I thought about it for a minute, so correct me if I’m wrong, she’s dreaming because actually now she’s getting a better quality sleep and now she’s actually entering a proper REM cycle for her to actually get sleep. Am I right in my thinking with sleep?
[Max]
Yeah. Well, it is possible to dream at any stage of sleep. You just have more vivid, probably emotional dreams in REM and they tend to stick with you. You can do, because I mean, sleepwalking happens in non-REM sleep and you can often remember what you’re doing in non-REM. But yeah, REM is your main sort of having highly emotional dreams that really stick with you.
And you’re right, that’s the one that’s probably most interrupted as is slow wave sleep with obstructive sleep apnea. You sometimes get patients who present, actually they present with sleepwalking. And actually they have obstructive sleep apnea that’s causing the sleepwalking. And that’s because you’re not really supposed to wake straight up from deep sleep.
You’re supposed to work your way down from light sleep to slightly deeper, but still light sleep into deep sleep and then REM to awake. If you wake up straight in the middle of slow wave sleep, you are likely to trigger or more likely to trigger a sleepwalking event. So you might have all sorts of what we call parasomnias behaviors during sleep that are actually related to obstructive sleep apnea. Yeah. Your group are in a fabulous position to try and not only identify it, but yeah, as you say, treat it, diagnoses the issue.
[Jaz]
And follow up and diagnosing and yeah, managing, but then also the ability to follow up. ‘Cause like you said, sometimes you don’t get that follow up, right. You guys have managed it and then you go and get to see them again maybe.
Whereas we, every six months we see them. So it’s so rewarding to be able to be, I mean, sleep is a small percentage of my practice as you know, Max. I love my restorative dentistry. But I’m so glad I added sleep to my diagnosis set, my screening set, because I feel like I’m really helping these patients.
I feel great about it. Whether I get a negative diagnosis or positive diagnosis, at the end of it, I feel happy that I screened, I help, and those who get a positive diagnosis and I’m able to get them a better quality of sleep. And I’m thinking, wow, I just might have added 10 years. Quality is this patient’s life that makes me feel so good.
And so again, the whole follow up thing. I’ll tell you another story. Ricky, one of the dentists, one of the good buddies, he came to me because he won’t mind me saying this ’cause he was gonna post a video on Instagram about it. So I don’t think he’ll mind saying this Snoring, snoring is an issue. Okay? So he gets the elbow in the rib, right?
So he said, Jaz, you gotta help me, you gotta save my marriage, et cetera, et cetera. Okay? So he comes to see me, I’m make a typical dentist. I listen, just skip the tea sleep test. Just sort me out mate. Okay? All like, fine, let’s just quickly do a mandibular advance splint. I think for him, I made a ProSomnus.
And the cool thing is literally the next day, right, he sends me a screenshot from his phone. ‘Cause what I love nowadays, everyone’s got Apple watch, right? And so he send me a photo. Well done, or congrats. Your blood oxygen was 4% higher than ever recorded before last night.
[Max]
Good stuff, man. In action.
[Jaz]
More importantly, I did save his marriage.
[Max]
Yeah. Nice. Yeah, yeah. Like we honestly see patients in clinic who say, well, I haven’t been able to share a bed for the last 30 years. And if you are in a position to fix that and see them, you’re right about our follow up situation. It is a bit awkward.
We would like to be able to see every patient every year as a minimum. We try and follow people up after we set them up on treatment, but trying to get patients back in year on, year out with the fact that once patients get on our list. They never go off. I suppose that’s true of dentists as well, actually.
I’ve never really thought about that outside of sleep apnea services. But our services grow and grow and grow and grow and grow. And if healthcare leaders don’t allow us to add more staff, we have to either get AI to do some of the work, but we already know how that’s gonna go or, we have to be a bit more efficient in how we see them.
[Jaz]
So I just wanted to share those stories obviously, of patients and how we get to follow up. But again, there are lots of resources out there, like for example, indices or tests or screenings that we can do. So STOP-Bang, Epworth Sleepiness Scale, but for the general dentist who’s busy, like, but we also care about implementing this into our into actual service and care.
Yes. You said the clinical exam, Mallampati, and then talking about are they sleeping in the waiting room? Ask ’em about their sleep quality. Are they a sleepy person? Do they wake up refreshed? All these questions are important, but where can we find some structure? Where can we find checklist? So yes, STOP-Bang is one, is that highly rated?
[Max]
I think STOP-Bang is the best for identifying the risk of sleep apnea. Epworth is more about having a quantitative measure of how sleepy they are during the day, and it’s important if you think you’re diagnosing, obstruct sleep apnea, to ask the Epworth, you need this quantitative assessment because this conversation that then happens later on around driving and sleepiness the DVLA.
Now this can be, there’s nothing that is more of a rapport killer than telling somebody that your condition may affect your ability to drive or you might need to be monitored a bit more closely.
[Jaz]
I mean, I definitely wanna talk about this Max, but this is one of my last questions because there’s so much I wanna cover before we get to that. And yes, we’re gonna talk about the DVLA, ’cause it is obviously linked to Epworth. But what we should be checking for is STOP-Bang, Epworth. Do you think as dentists we should be asking for this or not?
[Max]
Yeah, well mainly because most of the stuff that you’re gonna do for your sleep studies will have incorporated questionnaires that you can stick in. So-
[Jaz]
But it’s more about figuring out, for example, I’m in practice, right? And so I’m using AcuPebble , I have a fee for that. That fee, or outta that fee, I also pay your fee for the report, for example, right? And so it needs to work in care, so you gotta be in an ideal world, yeah, everyone should get screened.
[Max]
Oh, I see.
[Jaz]
It’s a wonderful health thing to do, but how do we pick it so that it’s a good worthwhile punt. So how do we pick the patient that, okay, actually this patient, I think the patient, I think you will actually benefit. I’m hoping it’s negative, but you might actually come up with a positive. How do we pick the patients who are gonna spend money? Do you see what I mean?
[Max]
Yeah. So I think that you have some very high risk stuff that you see on clinical history. If somebody tells you that they have been observed holding their breath, witness apnea, do whatever questionnaires you need to do, get ’em the sleep study, because that’s quite uncommon, that’s limited almost exclusively to sleep apnea, sleep disorder breathing.
If they tell you they wake choking and gasping regularly. So not everyone has a bed partner to see, but if they say they wake up choking and gasping, and then still quite high risk, but less specific is unrefreshing sleep. Now if you’ve got any of those things, add a STOP-Bang. And if that’s even slightly towards the end of the scale, give them the information.
Just say, look, I suspect that it may be worth screening you for obstructive sleep apnea. Now these new screening technologies are quite uninvasive. We give you this thing to take home, you slap it on, you either have an app on your phone or you bring the device back and it gets downloaded and that is analyzed for you and we come and sit back and have a conversation with you about the results.
I think if you’ve got any of those high risk symptoms or you’ve got real suspicions based on their sleepiness, their neck size, they look like there’s crowding, bruxism is something.
[Jaz]
So you mentioned neck size. So basically the form that I really like to use right, is there’s a lab in the US, S4S Solutions for snoring. Good lab. I know the guys that own it really well and they have a fantastic form on their website, which I really like and all my delegates on my TMD course, I said listen for airway screening, use this form for your patients because for those who come as high risk, it’s actually got a pre-written letter to send to the GP.
Like it’s just done all the work for the dentist for them. And I love this form, so I’ll put it in the show notes. I’m sure S4S will be very happy about that, but essentially it does Epworth, it does questions about like do you fall asleep? How sleepy did you get during driving?
How sleepy did you get sat on the house, how likely you go sleep while you’re sat on the sofa. Got really great questions in there. And also the impact on their life. Like because of this snoring, are you sleeping in a different room? Like you get to understand that aspect as well in that form. And then Flemon’s, it gets the patient to actually measure their neck circumference. So how significant you think Flemon’s score is to all this?
[Max]
I don’t think I’ve ever heard that phrase before.
[Jaz]
Well, on the form, so Flemon’s basically is that you measure the neck circumference and you measure it. So it’s like, 43 centimeters or whatever. And there’s a certain, I think it is 43 or 48, there’s a certain cutoff, which puts you more high risk, low risk.
[Max]
Yeah. So is that 17 inches? ‘Cause the STOP-Bang is very US-centric. Actually a lot of our sleep medicine is because we follow the guidance of the AASM, the American academy for sleep medicine. So a lot of it is sort of, yeah, more US-centric. 17 inches, I think the one. So what’s that conversion probably about.
[Jaz]
Alright, lemme do it right now. Right. So on the podcast, just doing this guy 17 inch, good old Google, 17 inch to cm, 43. There we are. 43 centimeters.
[Max]
Yeah. So yeah, that, I mean, that’s just the cutoff for adding a point on that STOP-Bang. But it makes sense. So this doesn’t have to just be fat mass. We have rugby players. Enormous thick necks, muscle and fat both still obstruct the airways when they’re fully relaxed. And that’s what happens when you sleep.
[Jaz]
I didn’t appreciate that. I just thought it was fat. But no, if it is muscle. That’s interesting.
[Max]
Yeah, we have a lot of rugby players that have, I think there’s screening in, at least in the, I dunno, anything about positions in rugby, but where the larger players play, they screen those chaps ’cause they just have enormous mass in the neck. And so when they go to sleep, that just relaxes and contributes to obstruction of that upper airway.
[Jaz]
Now you said you’re a Spurs fan, so firstly I’m very sorry about that. Secondly, like some of these, documentaries that you see, like for example, like, not that I’d ever watch such a rude thing, but the whole documentary on Man City and their successes and whatnot. And how I know, right?
So how every athlete, like they have their, each player will have their special drink with their special formulations specifically for their biology. I wonder. And maybe if you know this, do these professional level highest football teams, do they do sleep screening for all and sleep tests? I just think why wouldn’t you? Why wouldn’t you for the highest performing athletes?
[Max]
Yeah. So in general, it’s all about marginal gains at that sort of level. Everyone’s elite, right? So how do you get that extra 1%? Cycling was the first sport to do that, and they did everything. And they started having people take maybe their own mattress, but, or a mattress they know that they get very good night’s sleep on.
When they go and do the Tour de France, they take this around. They have teams that are responsible for that. I mean, I’ve gone and done a talk for a premier league football club. I did one for knocking Forest and that was at the start of last season.
[Jaz]
So they’re having a cracking season this year.
[Max]
Ah, I’m not gonna say it’s cause and effect, but I think what they were doing is they were no way, I can’t say that, but what they doing-
[Jaz]
The Max effect.
[Max]
Yeah, the Max effect. I came in bush, but what they were doing is that they were demonstrating that they were an organization that is concerned with marginal gains and sleep is one of those. They do a lot of going on the road. They do a lot of late games and the recovery benefit from a good night’s sleep. You have patients who have been woken up by their own airways 30 times an hour for their entire life. Their entire adult life as much as they remember. Imagine how grumpy you’d be if you were poked awake 30 times an hour every night.
[Jaz]
Totally.
[Max]
You’d be really grumpy, you’d be forgetful. You would be really, really not your best self. And then I have patients come back to me in clinic and they’re like, this has absolutely changed my life. And you know your listeners can be part of that process. They can be the people that do that on the-
[Jaz]
It’s magic.
[Max]
Honestly, when you find a patient who is really badly affected and they don’t realize quite how badly affected they were, and they start treatment, that is a very special feeling when they come back in and they’re like, you have saved my marriage. I can actually remember the things that are happening to me in the day time. It’s remarkable how important sleep is.
[Jaz]
I think what this episode’s gonna do is that, we’ve set the scene in terms of trying to find that patient, that winning horse, if you like, so that you know it’s worth it for them. Because you can’t just sleep test everyone. The healthcare facility is just, that’s not how healthcare works. You’ve gotta no have a suspicion, a hypothesis or preliminary diagnosis or a screening that okay, this patient would benefit from screening. So that’s what we’re talking about. But I just wanted to mention this.
As a parent of two young kids, one who just does not like sleeping, ’cause you’ve got moderate sleep apnea, like sometimes you have to really look at their entire history and don’t think that someone is not sleeping well because sleep quality is not good because of sleep apnea. It could be that their baby’s crying every hour and waking up.
So you really look at that social history, like I sleep tested myself as well, right? Using the AcuPebble as well as one of the first patients. I did my own self, right? Just to test the tech out. And I was really curious ’cause obviously I wasn’t sleeping very much. I felt like not very good at all. But I was thinking, hmm, is it because I’ve actually got a small mandible. I have actually got retrognathia-
[Max]
Hidden behind.
[Jaz]
Exactly that. Why do you think I have such a voluptuous beard is to make me look class one and normal, right? So anyway, so I thought, wait, what if I do right? And no, I didn’t. My AHI was like two or something, right? So I’m golden in that regard, but it’s because I’m not getting great steep ’cause of the kids.
So you gotta really look at a patient’s social history. So we talked about, you mentioned some great things there. I’ll attach the form so that people can start using this form with their patients. And then, so now we’re getting into the real meat and potatoes of it, right? Okay, so we’ve just identified a patient who would likely benefit, and you’ve already said what you could say to a patient that, look, it’s a non-invasive thing to do.
You can have it done and if you’re in private practice like me and your patient can’t afford it, whatever, that’s fine. You fill in that form like S4S one and send ’em to their GP and maybe even a cover letter and some GPs will hopefully help. The problem is there’s big waiting lists in the an chest.
Now you are probably in a great position to tell us about that. Obviously this podcast goes out around the world, but for those in the UK, how long do you think that they’re waiting typically to get assessed and then seen?
[Max]
So the unfortunate answer to this question is that that is essentially a postcode lottery. It depends on where you are. It honestly depends on where you are. In some areas you are six weeks away from a test because they’re not only on top of their list, but their numbers are lower. In other areas, you’ve got high population density and low service output. So, I have seen sleep departments that have got 60 week wait lists just for the initial diagnostic tests.
You already got the suspicion that they have obstructive sleep apnea. They’re already telling you that they’re struggling and then they’re told they’re gonna have to wait a year for a test that, at the moment can be in the range of just over a hundred quid. Most people would pay for that level of diagnostics.
I wish they didn’t have to, to be honest. But I think we’re in a situation where the options now are for people to be diagnosed that in the community, in the comfort of their own home
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