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Episode 101 - Dr. Whitney Mostafiz-Levinson - The AGGA Controversy

1:06

Hey everyone, it’s Emma Cooksey here and I'm your host.

So today is quite a controversial topic.

So some of you might have seen that CBS News did an investigation into the agar oral Appliance.

1:22

So Agra a GGA which stands for anterior growth.

Guidance Appliance is a fixed and dental Appliance dentists who were using this claim that it cures mild to moderate.

Sleep apnea by growing the jaw forward.

1:39

So it sort of falls into the same category as the crows at or the alpha pliant.

So you might have heard of some of those.

So, at the moment, there's a lawsuit for over 20 people suing the inventor of the Agra saying that it caused permanent damage, like they lost teeth and they, you know, they're their teeth were pushed over like where their bones were and became on.

2:05

Stable and yes pretty grim.

And so I've linked the CBS investigation in the show notes, so you guys have you haven't seen anything about this.

You can go and watch it and but it's really heartbreaking to see some of these cases and I really understand how it happens.

2:24

Like I feel as though as soon as this lawsuit was out there, you know, I saw dentists on LinkedIn saying, why would a patient ever, you know, like Like go down the route of using an appliance and that's not FDA approved for the treatment of sleep apnea.

2:43

And the answer to that is because highly credentialed experience dental professionals.

Are telling them that it treat sleep apnea, right?

And there really isn't any peer reviewed data to support that.

So today, I'm joined by dr.

3:00

Whitney moskovitz Levinson and Dr.

Whitney is a board certified Orthodontist in New York City.

She's also an adjunct clinical assistant professor in the department of Orthodontics at NYU.

She's a long island native, and she studied human biology and Visual Arts at Brown University.

3:22

And then dental school at Harvard School of Dental Medicine where she graduated with honors.

Then she completed her Orthodontics residency at the historic University of Illinois.

Chicago were her research led to a master's degree during her training dr.

3:39

Whitney was fortunate to travel to Sydney Australia twice to perform and publish award-winning research on obstructive, sleep apnea an oral Appliance therapy.

There's the research was published in peer-reviewed journals, like chaste and the American Journal of Orthodontics and dental facial Orthopedics.

3:58

So I'm so grateful to dr.

Whitney for taking on so many controversial topics, right?

And I think it's really easy and these situations to just kind of say nothing, but there's so much Nuance to this discussion like that.

4:14

I really feel like it's going to be helpful to a lot of people.

So without further Ado, here is my conversation with dr.

Whitney.

Most of its Levinson Okay, so thank you so much for joining me.

4:33

Yeah, thank you for having me here.

This is such an important, you know conversation?

Yeah.

So I first learned about you because I saw you do a webinar a few years ago about women and absurd to sleep.

Apnea and I was totally blown away, and I was like, wow, I have to have her on my podcast at some point.

4:56

So here we are coming and so recently there was a CBS and And news story all about this case, involving the Agra AGG a fixed.

5:12

Appliance that some dentists have been using to grow people's jobs, expand pallets, that kind of thing.

And so I feel as though these are the stories that like I've known about but they've never really captured national news attention and I think it just highlights It's how much patients are struggling to navigate this whole pal expansion, whether that can help with sleep, apnea, like which appliances are FDA-approved, what they should do.

5:46

So I'm hoping today, we can just get your take on all of it and try and clear up some confusion and frustration among people.

So let's dive in.

So do you want to start off by just explaining?

6:03

Saying, like I hear from people a lot who are working with like either an airway dentist or an orthodontist, who is encouraging them to do, like, either an owl Appliance or crows at or Agra all these different things.

6:25

And when that story broke on CBS, there was a lot of posts like, especially on LinkedIn.

I saw lots of Dentist who were doing oral Appliance therapy saying, oh my word like why would a patient go with an appliance?

6:41

That's not FDA approved for sleep apnea?

And you know, and I was kind of like, oh wow, yeah, because there's a whole bunch of people who were, you know, like Professionals in dentistry and Orthodontics who are recommending these.

So I guess, can you just explain a little bit about this group of appliances?

7:03

What?

We know about them like is there a legitimate use for them that they're just being used off-label as sleep apnea Appliance or just clear it all up for me, right?

So that she can, it's very complicated.

Yeah, I mean it really, you know, opened up early important conversation and awareness so that Agra I've heard about some also, you know, some I guess they're like Facebook pages, like sleep supportive, tongue-tie groups, things like that and I started hearing about these Mine's is an artisan orthodontist actually never heard of them.

7:36

Until like I joined some of these support groups and I looked them up, I went on their websites and the part that was concerning to me was that there were no data supporting or evidence-based clinical trials in regards to these appliances and I was like, you know, I never learned that in my residency.

7:54

I was kind of curious about them because I like to consider myself, are we mindful?

So the Agra is here.

Grows the guide And so clients.

Want that one does, it's fixed and it actually doesn't expand in the transverse.

8:10

It, it moves in the what we call like a p Dimensions.

So if you look at your face from a profile kind of forward, so if you saw in that CBS or by transfer, she mean I word be more outward like DNA Appliance does expansion.

8:26

This one does AP movement for forward.

Also some more forward moving.

So if you saw in that They the people that were showing pictures of their teeth flaring out, like as there is literally moving the seat outside of the Bony enclosure.

Basically, there's a physiological and biological women to how much our teeth can move, especially in non groaning adults.

8:50

So, I think that's, you know, the distinguishment that I think is important that I think dentists in general, and probably, even the founder of that Appliance and some of, you know, I don't think they want to hurt people, write in a knowingly, I think.

They truly think they're helping their patients and I think what was lacking is that critical questioning of wait, where's the data behind this?

9:12

Where's the research and support?

And I guess the big question goes back to that FDA approval question to which I think CBS did a follow-up and asking that question and they were able to I guess not need FDA approval because they they claimed that their Appliance wasn't moving things enough to Ends FDA approval that such minor movements although they claims major movement they didn't like that minor in like yeah in the court case.

9:44

Yeah so I actually worked really hard at trying to find some unbiased literature on all of these appliances and I found one study that came out in 2022.

That compared a lot of these appliances and I could send you the name of that article, I'd love that was the tricky.

10:03

The thing is the copy that I had scenes in French.

So if you know anyone that's fluent in French, we can you know, translate the whole an interesting in this study so they were comparing.

I know I'm jumping ahead like the mark p which is, you know, another expander uses minion plans and then they were looking at DNA and I gotta Alf and I think they're comparing it to dome which I had never done with this.

10:28

Yeah, that's more like I call it surgery.

Yeah.

Intense as a Sarpy procedure, but, you know, it does involve visually opening the Powell suture and in that study, I will notice a sizes small and I think it was 16 appliances that were non-surgical, and one of them showed on CB CT Imaging, actual opening of the McCallum suture.

10:55

So very determined that all of the movements were tipping.

So we called it Denzil movement moving.

Rather than the actual I wasn't going movement or skeletal moving.

So it's really more just Dental compensation and it goes back to there's a limit to that.

11:13

So maybe, you know, in some patients that are being monitored carefully, you can stay within that physiological or biological women and, you know, not, you know, creates an image as shown in the CBS, you know, examples do that was quite extensive movement.

11:29

Like the chief just kind of flapping in the wind.

It almost looks like so.

And I've seen personally a patient that one through one of these appliances as well with, you know, I guess a holistic, dentist, that kind of thing.

And same thing, the front teeth were flared.

11:45

The back teeth were pushed back.

They were outside of the body housing as well.

And I referred her to a Perignon us, who think determined that some of the teeth have to go.

So, it's, you know, I think they promised also because of, that 18 movement, that it will unlock the mandible and the mandibles.

12:03

Gonna jump forward and you don't need to do draw advancement surgery, right?

Most people that I talked to who are considering these kind of like I think sometimes patients are they're just in a difficult position, right?

Because they're desperate to most people are desperate to sleep.

12:21

So they're kind of and they're struggling with whether it's CPAP or an oral Appliance, or whatever they've tried.

And so we get to the point where we're desperate for something that will help.

And if one of the these like dentist is saying like it just it kind of almost sounds too good to be true, but when you're in that situation, you're more likely to think.

12:45

Well, if I can do that and it can help me.

I won't have to have double jaw surgery, which is extremely invasive and expensive and all of that.

So I guess, I just, as a patient, see, it from that perspective, that like, I just feel for people, you know, like, they're in that situation.

13:03

So, a little bit of a scary update, the CVS, you know, report added a follow-up report that they found that is now under a new name being marketed as the Osteo restoration, Appliance?

13:19

Okay, how are you spelling you Osteo is OSS.

EO Dash restoration clients So that's the same thing as the Agra appliance that we talked about like the lawsuit, the beginning, okay.

13:36

It's just a tough time to be a patient and navigate all the stuff, but actually, you know, it's great that they exposed this because now as forces patients as well as clinicians, they're asking, you know, questions and being more critical, not just taking everything for face value or trusting the guru that's selling this device.

13:58

Great.

So I think it's going to you know lead to more more evidence, you know.

Yeah.

I hope so.

Yeah I think so.

Yeah.

And I think studies are going to continue coming out because it's like as a hot topic now so we write it was really good timing.

14:15

I had a message last night from a mother of a teenager who was I think 17.

And she said she was getting so frustrated because she had been Into multiple different orthodontists and dentists and she was being told by the dentist that her child could do the DNA, appliance, which is a vivos appliance.

14:41

It's a removable expander.

Yes.

So, which I know about it because I, we can get into my whole thing in a minute and but she was saying like that dentist said, yes yes, your 17 year old could do really well with this DNA, appliance which is removable And then she was going to multiple orthodontist, who were looking at her son and saying, no, because the palatal sutures starts to fuse later into the teen years and early adulthood.

15:15

So we're they were recommending more of a surgical like a star P or Mar pure a messy.

One of these things to actually surgically and split open.

Open the palatal suture to get more expansion than they thought would be possible any other way.

15:35

So can you I feel like this whole thing is so like there's so many people saying different things to patients, right?

There's there's some people saying, you know absolutely the Powell sutures fuses and any you know exactly what you just said?

15:55

Any movement would be the teeth and not a All proper expansion thing.

And then there's other people saying that's old thinking and as long as and, you know, they're pointing to the fact that there's it's living tissue and even though, you know, they're just basically saying there is some movement is possible, even in adults.

16:20

So what is your take on that?

So it's interesting you mention this because I as I did a literature review, I did find some more recent studies.

We have discovered that the paddle suture fuses later than previously thought and really the only way to you know, quantitatively know is taking Imaging like a cbct as well as you can to see if the the suture has fused.

16:44

So previously in originally, we've, you know, been taught and know that the paddles suture tends to fuse in the early adolescence.

So, let's say you just 12 to 14 and females may be a little bit later in males.

So, You can, you know, see some older teens as candidates.

17:02

So this study that came out, I think at this point maybe four years ago, showed that there are some patients in their 20s about almost 20 percent still had open sutures and I say 24/7, you know, it's like it's a significant number that's not 1%, you know, right?

17:18

So and males in general might have them open longer just biologically speaking.

So you know that can really Determine what candidate of treatment you know, obviously a patient doesn't want to undergo an invasive Sarpy procedure.

17:35

If they, you know, the center is open and they don't mean surgery.

So I think, you know, doing the Imaging which is sometimes a required component for Marquis or MSC treatment planning anyway.

So you can get the Imaging determine, you know, the sutures open or it's starting.

17:51

So you can see that.

So of course it depends on you know the detail of Imaging so different scanners have different definitions you know so I think you know based on that study like a clinician could you know look at their methodology or machines were used and you know this is so new so that's right.

18:12

That's why there's so many opinions.

So a lot of this is really cutting edge like some of these appliances.

Like MSC Marquis are, you know just a couple of years old.

Yeah, the public.

Mission data.

And so I think Mark be is maybe less than 10 years old, so, you know, it takes years of gathering the data and Publications, take, you know, a few years before they come out.

18:35

So a lot of this news is, you know, pretty cutting-edge.

I know that the American Association of orthodontists is updating in 2019.

They also had What's called the white paper that was I don't know if you've heard.

Yeah, I read that.

Just take a sleep apnea so they are updating.

18:52

It's okay.

Everything you know is changing so rapidly.

So I think that, you know, I've surprised myself with older patients, that problem Sanders.

You know, do open and you'll see a midline diastema, that's suggestive of Orthopedic movement but again, there's always that trade-off.

19:10

So the trade-off is how much true skeletal movement?

Are we getting versus?

How much Dental tipping and compensation?

Are we getting?

So in all these cases, they definitely need to be closely monitored in terms of the And a appliances.

I know that's a popular one now, I think was FDA-approved, so I think that that one, the biggest trade off also is time, so, it's a removable clients Orthodontics.

19:37

Ideally is slow, continuous pressures that are constant, which is why, you know, when I talk about tone, you know, tongues are savage or that kind of thing that to me is a orthodontic Force.

It's like constant.

Yeah.

And then I don't segueing a little bit but we've talked about that too.

19:53

But basically, the DNA my concern with that one, is that it's removable.

So there's that compliance component.

They say that you only need to wear it at night.

So that's what we would call instrument in our interrupted with them explores.

So that's just going to take longer.

20:08

So I would, you know, guess that it takes years before someone might even see like an actual difference and then they probably, you know, if they're an airway patient or have sleep disorder breathing chance, Are they also have a malocclusion and crowding and you know, they're welcome small as are expanding.

20:28

So you know, if you're using that Appliance or a couple of years and then you have another couple of years of orthodontic, it's just a long road of treatment before you actually see anything and then study, that study came out showing that there was no Orthopedic expansion.

Anyway so I think that yeah like so so high.

20:47

Like anybody listening to the podcast going to be like we know because they've already listened to all the stuff.

But just to fill you and so I had I essentially would probably be a good candidate for MMA surgery but I don't want to do that surgery and I'm also on CPAP and it's not perfect but it's, you know, keeping my hi low and all the things.

21:13

So I don't think I'm one of those people.

I know people who are looking into these things because they can't find a treatment.

That's the fact of it all for And so I'm in a different situation but I certainly had all the you know, things that would make me a good candidate for some sort of palatal expansion.

21:34

Just because I have all the classic, you know, like high really Arch palette and you know like super narrow and all the things.

And and so essentially like I signed up to do the Vivas thing.

21:53

And there was a dentist, I actually knew who had just trained in it.

So that's kind of a red flag.

You might want someone that knows, you know, about sleep apnea and but so I basically did a DNA Appliance for think nine months, and then after that did an end mRNA appliance, which is also got a mandibular advancement device attachment.

22:18

So they're both expanders but the DNA one like the MRNA, And had FDA approval because they looked at the fact that it wasn't a mandibular advancement device.

So they weren't actually seeing to the FDA and this Appliance like were applying to say because of the pal expansion, it treat sleep apnea.

22:41

They were essentially piggybacking on the fact that it was the mandibular advancement device.

So that was the one I did S.

I did the the DNA first and and my experience.

So I Was wearing it.

Just like you said I was doing about 15 hours every 24 hours, and I went for 15 months and I did see like what you're talking about, like a gap between my two front teeth and and tiny, tiny movements.

23:13

And, but it didn't help my sleep apnea.

So, I kind of and also, the other thing that was kind of, like, the final straw for me was My teeth at the front does start for shooting forwards more than I was comfortable with and I just abandoned that point.

23:32

So for me, it didn't work and then I didn't do any sort of.

I didn't do like a retainer and thing.

So there wasn't any permanent like as soon as I stopped wearing those appliances everything.

23:50

You know, you can see went back to Where it was before, right?

But I know so many people like I'm in all the communities and I've made lots of friends.

Like I know it's really weird but like all of the patients trying to figure this out kind of like stick together and there are people who are exactly what you said like doing a very long-term.

24:15

Like I know people that have been using these kind of appliances for like two years and they're gradually seeing an improvement.

And there's like that, me.

I like their sleep studies are showing like a lower rate shy, and they're starting to feel a bit better and all that.

24:31

So, I think that the thing I would say to people listening is that it's not like, well my you can tell me exactly what you think about it, but it's not so much that I think that it can never work, right?

I just think we don't know like how people are so different in their background and their, you know, physiology and yeah.

24:52

And like there.

Anatomy.

And I don't think we have enough data to show this.

Reliably treat sleep apnea, you know, in most people it's like, you know, they've kind of actually, I don't know if there really is.

Any, do you know?

25:08

No, there's no, I mean, like, what was?

So I don't know if you can kind of explain to people but from what I read that that how the DNA was given FDA clearance was patient.

Almost like case studies, like so they kind of followed a certain number of patients when were able to show in those individual cases that they did improve their sleep apnea.

25:34

Am I understanding that right?

Maybe not.

So that was one, you know, thing that troubled me when looking up that Appliance there are some studies, however, they're done in house on probably studying the really controversial right now.

I know this whole thing is really controversial but patients are just really struggling with it because they can Can you know, if navigate through it.

25:55

So if you look closely at some of the published Studies have sample size of one, so take a single case report.

So yes you might find success in one patient but and they were done.

If you look at the author's author One, the main author or one of the author's is the person who found that the appliance.

26:13

So this is units, you know, an unbiased studying but it's not.

I think people just average patients don't really think much about it but if thing Like peer-reviewed studies are really like the standard, right?

26:28

The the has actually been reviewed, right, on so that an unbiased exactly like kind of the Nuance of getting at.

So the literature that's out there is maybe not high, you're high quality literature.

And then another thing that concerned me is a, you know, eyebrows some websites and they all show the same cases, like same pictures before and afters before.

26:51

And after of the airway changes, And I was like, so, these aren't your personal cases, so that kind of concerns me when people on our websites when they're trying to explain it applying us, show, some generic image, that is probably from the company, you know what I mean?

Yeah.

So so I think with all of this, from a patient perspective, it's really difficult because it's not like going, you know, to somebody who doesn't have an interest in you signing up to do.

27:23

The treatment.

So it's really hard.

It's not that, I mean, and I think that, you know, the dentist I went to, I think is a really good dentist in really ethical, but it just is one of those things where you really don't, you're in a position where you're being marketed to.

27:41

Yeah, so that makes it really hard.

So the next thing was, oh yeah, well, I really want to talk to you as well.

About is how Orthodontics or kind of evolving like, I feel like back in the day like, it was very common for people to have like teeth extracted and pretty were attractive braces and it's obvious through all that.

28:08

So originally, it was generally a non extraction treatment and this woman orthodontist that started working and then, you know, turn of the century and 20th centuries.

Dr. Tweedie have you heard of that guy?

Yeah.

So he, you know, for people listening who were like was stupid on this, that was, you know, pretty prominent and was trying to create, you know, balanced occlusions and you know, was looking at what he called facial balance or be equation, is the bite, right?

28:40

And then he was looking at some fish.

Ooh, particularly orthodontist like to look at the Facebook profile view, looking at, you know, soft tissue and the nose, and where the lips and the chin meet and he just was having trouble.

Having you know what he called a balanced result.

28:56

And he ended up extracting for first premolars.

And he did several cases with those extractions was able to retract the teeth that he thought were flaring.

So, there are not felt great.

And inside the bone, particularly he would do a measurement looking at the angle of the mandible and then the lower incisors would be a certain position to have a favorable or what he called aesthetic, facial profile.

29:22

So right now, We're orthodontic extraction treatment became a thing, and another principle that he had was called Anchorage.

So to really prevent anything or anterior movement, he wanted to hold back the drawers.

29:37

And that's, you know, again, wear headgear came in which was extra facial Anchorage.

So that Appliance really talking about.

Heck, you're pushing things back almost or nothing back.

Its that it's restraining.

29:53

In growth, so that your crates like a posterior for Senate, restrains, the skeletal growth.

So that's used a lot in what we call a class, to my Illusions, where the upper jaw is more forward, although, and a lot of those cases, it might be that the Orbiter has actually small and a lower jaw is really small.

30:10

So it's always like a relative relationship but that's kind of where attractive we could call it Orthodontics, kind of developed.

And that was really in like a 1960s or so.

And they had literally Place like a line from the nose to the chin.

30:26

And look at where the lips are like there were certain proportions and angles of the teeth and and that, I guess we could call another trade off.

Sometimes not an extraction Orthodontics.

We'd so what we call camouflaging or dental compensation and the teeth might look a little flared and some people, you know, but he's bit World.

30:45

Some people are paying a lot of money to have Fuller lips, and Fuller features, but yeah, people don't like it or even, I guess, you know, No Trends have changed or even ideologies, or perceptions of what is beautiful have cheated and you know, in the 70s and 80s so forth, a lot of attractions were done.

31:04

And then as we saw, those patients age, there were some unfavorable facial changes, sold teeth, had you know, less support on the lips.

So, some people would say that, as people age, they looked more like a, which even these were kind of people come in almost.

31:20

Yeah.

Exactly how Canyon and then the nose and the And look, big relative to the lip or the lower face because everything is pulled in.

So, some some people then started noticing what we would call unfavorable facial changes.

So then there were, you know, philosophy is like, oh, we can open up those extraction spaces and reopen, you know, everything.

31:43

And I guess that goes to, I know you initially mentioned, dr.

Hang and yeah.

So so dr.

Hang and kind of coined this term.

Action retraction regret syndrome because he was seeing a lot of those patients who were feeling that there was this link between having had these pre molar extractions and were attractive braces and usually had your two and like, how they, how, well they were breathing later.

32:15

So this is kind of where the sleep apnea part of it comes in and I know.

And so one of the reasons it's so controversial is That there's a lot of things that go into sleep apnea, right?

Like like, I definitely had.

I actually only had to, I had the upper premolars removed and then braces, and I didn't have had gear, but also going into that is worth saying I was a mouth breather.

32:44

Since, you know, I was a baby and I had horrendous allergies and just thumb sucker.

But we really poor, I just had everything not going for me.

So I think that in this kind of debate, I think that you meet a lot of patients who say, you know, that they really noticed that the the extractions and the braces, you know, like they almost felt like they were fine before and then this happened to them and then they had the negative outcomes whereas I don't really feel like I'm in that camp.

33:19

I feel like it was almost like the cherry on top of Life.

Yeah.

That's what I think is is tricky with the attraction on expressions of weed.

It's not like we want to say extractions cause sleep apnea is no way to truly prove that.

It's a problem.

That that patient already had risk factors and that's probably why they also had so much crowding because they didn't have enough, you know, skeletal growth because the maybe lack of tongue pressures during the formative years and we can talk about that too.

33:47

So these patients had severe government favorite subject Why, why why?

35:55

I think, you know, looking at some things from a really young age and you know, we preventative and I think that's also where Orthodontics comes in from a world of prevention.

And so I don't think one treatment or the lack of one treatment can necessarily definitively cause because as we discussed sleep apnea, I always call her a multifactorial four dimensional because there's Anatomy, there's collapsibility of the airway, then there's brain.

36:22

So some people have sleep apnea and it's not even And it's not wrong.

It's just, you know, just nervous system related.

Sophia was just so an imposter, even sleeping posture.

There's just so many contribute sins that you know, can lead to sleep apnea.

36:38

So it's hard to, you know, pick one thing like old extractions or what did it.

So right, you know like you said the cherry on top.

I think it's like a whole constellation of certain signs and symptoms that I think you know, these recent years I've become more and more, you know, clinicians or more.

36:55

Aware and they're asking the right questions or, you know, I don't know if every dentist or even primary care physician is the checking, the airway, you know.

Or that's I think another we need for sure.

I think that's another tricky thing to like in my own personal example.

37:11

Like I had a daughter I guess he almost a year and a half ago and they're like oh she's like I saw something going on with all the tiles like looking at them, the doctor in the hospital, the primary, I knew there was one, so I got it released, and I think it really needs to start that early because if you don't address the tongue and it lacks Mobility, then how are we going to have growth in the air or the oral cavity, really?

37:45

But I also wonder what you think to this idea of Orthodontics, starting a bit earlier because I know Like most dentists are kind of saying, like, you know, take them for a consult when they're 12 unless they have something really crazy going on.

38:05

Do you think we just need to look at starting a lot earlier?

Like, especially for the kids, the don't seem to have enough room, right?

So actually, like, are always our guidelines are the American Association of orthodontists.

Guidelines are just start.

You know, as young as six or seven with just an initial evaluation.

38:23

It doesn't mean we're doing treatment, but yeah.

Yeah, looking for risk factors and I'm, you know, a strong supporter of what we call a phase 1 or Interventional or intercept enhancement.

Yeah, well that Onyx and you know you're not doing a full set of phrases with a lot of times I could be a palatal expander and a limited set of braces the Hawaiian things or some people have severe crowding and they need to do an intervention to get some even baby teeth in.

38:51

So I do think there is an important place for early.

Treatment and, you know, it's not for every orthodontist.

Oh, there's somewhere, that honest, that do want to wait until all the adult teeth are in before they treat.

And but that doesn't mean that's all orthodontist.

39:07

So I think finding, you know, orthodontist that have that mindset.

There's some offices that treat as young as three years old.

An expander.

So I think a selection is also important not every three-year-old.

Yeah.

Expanding its ready but I do think that there are you know, really initial Airway evaluations and There's a lot of kids that are let's say this diagnosis sleep, not sleeping ADHD, right?

39:30

A lot of Behavioral consequences or developmental delays moodiness or headaches like be City.

So there are you know, other symptoms that, you know, or you know, diagnosis.

We might give to kids and then there's an underlying Airway disorder, I think people are and becoming more and more aware of this.

39:50

Yeah, I really think it's what you said going back to what you said earlier is.

Tree.

Like I would love to see, you know, right what from when a kids born like all of the pediatric dentists and pediatricians looking for some of these signs, you know, like my breathing and just just that their jaws.

40:13

There's so many things they could do early.

I think, what do you think about my functional therapy and like, teaching kids to breathe through their nose and keep their lips closed and that kind of thing, you get another eye.

Wearing a lot to my own functional therapist, whether patients will go or not and you know here.

40:30

Yeah coloring but you know II again especially young children that's kind of the thing.

It's like.

Yeah.

So and I jog on my maybe I can be like a higher proportion of patients was um ties or not, isn't it time restrictive movement other time?

40:46

Yeah.

So I could give you my little Mantra and what I like to tell people to do and in a lot of my consoles I always offer a piece of mouths to feed.

I don't know if you probably Melty.

Yeah, yeah, yeah, interview.

James Nestor, so, like we talked all about that.

Yeah, so so I like to talk a little bit about, you know, how are resting posture?

41:06

Like, physiologically should be, you know, if your teeth are together that's Paradox, little, that's considered clenching or grinding and, you know, grinding will be flying off, you know, a blocked Airway.

So teeth should be ideally apart, lips are sealed together and that also helps ensure nasal breathing and I like to have a tongue.

41:25

I'm resting.

I called like the end position.

So if you mentally stay the letter n and your tongue is resting on the palate, that's, you know, more physiological position versus resting on the front teeth, which a lot of people with the tongue for us are open by Clarity that seems to be a more popular resting position in a lot of those patients that have an open by it or a tongue for us.

41:49

Often have a restricted tongue and you know it's one of those chicken or eggs in areas where it's like what caused the Yeah, those growing young, really young growing gauges, they, you know, develop this growth pattern, the high vaulted, narrow pallid and then it contributes to mouth breathing which leads to more inflammation in the airway.

42:09

So it all kind of, you know, yeah.

A deadly.

No balls.

Exactly.

So patients have trouble.

They put their tone up on the roof of the mouth and are Lulu's.

Not easy.

Like one study notes of the four percent of kids can have As you know, these sleep concerns and I'm guessing that number is actually a low estimate probably higher.

42:32

So I think a lot of parents even need to be aware of their kids snoring at all.

That's already a red flag.

Like, does he know some parents like that's a stress response in the body.

So another interesting fact is, you know, bedwetting is another risk factor of sleep disorder, reading that people always aware of And I always like to explain the physiology is, why it's like kind of scary and interesting.

43:00

At the same time, I really want to know.

So little basically a bladder control, you know, you know, it's important but it's not vital for survival.

So in, you know, a sleep disorder breathing episode or apnea episode, we kind of are sympathetic nervous.

43:17

System goes into drive and that's our fight/flight response and, you know, we're really fighting for life in those that are Gene in those examples.

And, you know, in those cases the body determines holding bladder control is not important.

So that's why a lot of those people will, you know, police or if you think of a examples when people are scared and they feed themselves or they're in an accident or some violent situation in the you know haven't added because again is that they lose the bodies you know in that fight flight mode is like what do I need to do right now to survive.

43:49

And if you think about your child like that is not how you want them to be.

Weeping.

They're supposed to be relaxed and rest and digest not like ready to run from a bear, right?

44:04

So that's what's scary.

Especially, you know, you're a size that are you know, 34 like this is happening many times throughout the night that you and that's what leads to the, you know, hypertension down the road like these definitely, you know how you feel too.

44:20

So a lot of these, you know, patients definitely feel foggy or Retired not feeling good.

Yeah, upbeat or thoughts.

And that's what I think is interesting too.

I think so many especially adult patients.

Like that's what their Baseline like.

They don't know, otherwise, how they could feel like once they have treatments like, oh, I could have felt like my whole life like this.

44:40

Yeah, you know, I know, I Think It's Tricky difference for sure, but I do think, you know, even oral appliances or CPAP they're coming denzil's side effects to.

And I think that's, you know, from an orthodontic perspective of cannot Andromeda mind.

44:56

Well, you know, because I don't know if you've heard, how long-term, you could develop more in class, 3, kind of.

Yeah, so you're talking about with an oral Appliance because it's moving your lower jaw forward, it can affect the way that your teeth I kind and but to me because I've had some orthodontist AP an orthodontist like Wiley.

45:21

How can you accept that?

It's like, well, they're alive, they're healthy, they feel better.

Like, you know, they have these off.

I like need a lot of times you joke, but you know, you don't die from a cross button push.

Yeah.

Or like, you know, pages that have an open bite and their well-nourished, like, you know, you can still need and function, but, you know, if you have, you know, Airway occlusion like that.

45:43

I think people underestimate just the health impacts of untreated sleep apnea, like it's really serious.

And so, it is that trade-off where, and, like, I've read a little bit about some of the things that happen to people's B long term if they're using oral appliances.

46:04

Like, but also, like, if you're getting restful sleep and you're not at that higher risk for a stroke.

Heart attack and all those other things.

I just tend to look more at the bigger picture for your overall health.

Yeah.

Exactly.

That's why things like there's a trade-off but I think in the grander scheme of one's whole life, I think it's worth it.

46:25

You know that.

So I did want to ask you a little bit about pregnant women because I feel as though I've done a couple of episodes on sleep apnea and pregnancy but I feel like we need a ton more research.

46:44

But for me like there's not enough attention being paid to that because I feel as though a lot of women, I talk to are going to their OB-GYN and the OBGYN obviously has a lot to cover during that time.

Like in there 10 minutes or whatever.

47:00

They get, they're complaining at.

Yeah, exactly.

Like six minutes actually in the room and so the woman's like complaining of daytime sleepiness and and all different symptoms of sleep apnea.

But there's this difficult thing where women often don't sleep as well during pregnancy.

47:20

So it's like the doctors kind of saying, oh, that sounds quite normal for pregnancy but actually the woman has sleep apnea.

So do we need to do a better job of screening for sleep apnea during pregnancy like War.

What's your take on it?

Yeah, no that's actually a good point.

47:36

I know he years ago.

I think when I was pregnant I did a literature review and there were studies that show that there is an increased Risk of sleep apnea during pregnancy.

You don't often goes hand in hand with the same patients that are at an elevated risk for diabetes as well.

Yeah.

So I do think that there needs to be more education or communication across communication.

47:57

I think that's a missing a lot in healthcare, especially previous special multicast.

I feel asleep and sleep.

Apnea particularly is, is just so like desperate for people to talk to each other, you know, because it's like You're going to the OBGYN because you're pregnant, so they know a ton about that, but I feel like, just at least some education about this.

48:22

Increased risk of sleep apnea could really help spot along people.

Yes.

So that is true.

There is a higher risk.

I don't know how aware will be Czar of that data, but study that now and you know, it is important.

48:39

I think screening is definitely an important And Tool, but it is and it's funny because maybe that is part of the reason why I like pregnancy is associated with poor.

So he maybe that's like right behind the scenes.

And so it is a good distinction that, you know, I have a feeling that these are not communicating at time with.

49:02

Yeah, you know, world.

I mean, I'm always like really cognizant of, you know, like all the doctors happy, like, I know that they can't be an And every single thing, but I just think especially pregnancy.

And also menopause, I think there's a lot of women going on diagnosed with sleep apnea that, you know, have all the symptoms, but it seems like those phases.

49:28

They're kind of like, you know, up until this point, we've just kind of said, oh, there's sleep problems with with this normal, you know.

And, and it makes me worry about the number needs to be like it, even starting from the beginning.

It's so cute.

Find smart and cute.

49:44

And I like, even in adults that I'm just like this.

I think that mine sent me says shift where, you know, there's for disrupted sleep.

That means something you know very sad like accepting it as a baseline, right?

Yes, not great.

I think it's going to shift it.

50:01

Even another fun factoid.

The American Board of Orthodontics, used to require an extraction case for becoming board certified.

And a few years ago, they actually removed Requirement.

So I didn't know that I'm swinging.

50:16

So I hope when it's like a glimmer of good news.

I think the pendulum swinging I think.

Yeah you are becoming aware of these things so you know, takes time.

But it does say time I think it's coming to light those.

I think the mindset will continue to shift but for awesome and so to wrap up and I think what you're saying is, would you say that your take is on?

50:42

Only go with FDA approved appliances.

Would that be?

Well, I wouldn't even submitting but then in clinical use.

51:00

So I would say only use appliances that there is evidence based data behind bright.

That's really important.

The thing asking those questions and you know, see In the study seeing cases that are not just from a generic website, that the companies providing Clinic very well, I think, showing that there's real work and not sample sizes of one in a study like real studies, you know, so you're this is what you're saying, real studies you're talking about peer reviewed and in a journal of like I don't even know what the orthodontic or dental and I guess that's tricky too, because, you know, a lot of these are novel techniques.

51:42

And so they won't necessarily be those studies yet.

So I think there's going to have to be, you know, some trust as well.

And you know, I think asking questions like, why are you doing this?

And, you know what's, you know, looking at past research to, you know, give rationale for why current methods are being utilized.

52:04

But I think, yeah, there it's not a, you know, black and white answer.

So it doesn't have to be that element of trust as well.

And I do think most dentists and orthodontists mean well and I want to definitely so yeah it just feels it feels as a patient a little bit like the wild west at the moment.

52:27

I don't like it's just maybe is this period where until lots more.

We have lots more you know cases and evidence is just needs to be really difficult for patients navigate but I Appreciate you helping us today.

52:45

And actually extend, thank you for having me and I'm gonna, you know, also put everything that we discussed into paper and I'll be a lot more detail so that could be a useful resource as well that will be awesome.

Yeah, they should definitely do that.

Thank you so much for your time.


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