Barriers to OSA Treatment in OMFS

All right, hello and welcome again to another downfraction podcast, a podcast for talking jaws downfraction podcast at gmail.com. Please continue to send us the emails. We do appreciate the feedback. We got some feedback this week. Maybe that our visuals when we have it visual based stuff. Sam, it's we're not describing it well enough. Yeah, yeah, I think it's probably one of the problems of posting this on some different media outlets, I would say. So sorry about that. For some of the more picture based topics, maybe we'll save those for YouTube and not post them. What do you think? It doesn't hurt to post them. You know, like some people like watching on YouTube, some people like to listen on YouTube, some people like to listen on different things. We're figuring it out. But yeah, thanks for the feedback. This week we are not multimedia heavy, correct? Like we're just, no, I think it's just going to be a couple guys talking about some jaws. That's beauty. It's good to see you. Anything going on? No, had fun week last week. How was yours? I was good. Yeah, it's kind of getting into the new year. So yeah, I think we came up with this topic. It's barriers to sleep apnea treatment because of a lecture you're giving you got an upcoming lecture. Tell me about that. Don't we always have some kind of lecture? Yeah, I think so. I need to learn. I need to learn to say no sometimes, but I do try to help. And yeah, so given a lecture coming up, I don't need to go into the specifics. But you know, one of the topics to talk about is, you know, OSA and one of the things that is part of the lecture is the fact that I, or the fact, the point that I was bringing up is we have to be able to monitor our patients, you know, from a general dentist perspective or another, you know, general practice medicine, your primary care position, maybe such as your wife, although I know she doesn't really practice in that regard. But like we tend to refer to solve problems sometimes. Like I don't mean it in a negative way, but like, hey, I've got this patient with condition A. I'm going to refer them to specialist B. And then in our mind, sometimes we look at that as, okay, I've solved that problem. I've checked that box. That patient is now on that pathway. I've done my, my part in solving this problem. But I think in our world, the risks that we see patients, you know, you and I in our practices, see as patients then go down a pathway of sometimes that sleep medicine. They don't tolerate CPAP or don't want to try CPAP, then they'd have been an E and T office who then recommend soft tissue surgeries and spire or both, or sometimes they enter the pathway from the dental world. And they get told about appliances, sometimes expansion or tonic treatment. And so to the patient, they kind of just whenever they get plugged into the system, they can kind of go down one of these directions. And maybe that's not necessarily treating or giving the patient the best treatment for their specific condition. And I, so that was the aspect that I was lecturing on and why I was, you and I kind of got started talking about this and thought, Hey, we're supposed to record a podcast in five minutes. Why don't we just talk about this on the air? Yeah. No, I like it. I mean, so you're giving it to a dental audience on just kind of like the care pathway of sleep management or just general medical disorders. Predominantly orthodontic audience is my understanding. Yeah. And it's one component of this lecture. But you know, my point in you and I were talking right before we hit record about the similarities to TMJ and that it's again, sometimes patients just get on a path that cannot necessarily be the best one for them. But as a patient and you're trying to navigate this, it's challenging because it all put up the other slide, you know, that we had that I had up when we were starting talking about this is, you know, there's so many different kind of things that can go on into the patient. They're seeing the quote-unquote expert or someone who's a health care provider who's giving them health care advice. And if we, and I don't mean to point fingers, I include myself and our profession in this too, Sam, but you know, if we're guilty of this too, but we can do the old, you have conditioned a eye-treat condition A, so you're the right patient for me to do what I do for your condition instead of, you know, the old, when you're a hammer, everything's a nail. And I think it can be a problem. And especially from a patient perspective, right? Because you don't, you don't know. You're kind of at the mercy of the providers that you're seeing and you trust them or you probably wouldn't be there in that office. And you kind of kind of go down some different pathways. Yeah, to sleep apnea treatment, I would say I like the similarities to team day treatment. Because once you get into practice, I was pretty surprised by people who show up for, let's say, sleep apnea surgery, the different routes they get there, right? Absolutely. Because there's the route for patients that it's self-driven. They get an diagnosis, they're having trouble with, because I mean, in large, in many ways, people who are suspicious or go to their primary care doctor for the suspicion of sleep apnea, get a sleep test, they're offered path therapy. If there's the dental pathway and there's the dental manifestations of sleep apnea, which I think dentistry is better about picking up these days, certainly on like a 20 year timeline, probably a lot better in a 10 year timeline, that you commonly end up on more of a dental treatment pathway of like an oral appliance or something, right? So patients can find their own way to see your for surgery because of online research or because of chat groups or just, you know, a well-motivated person, which is pretty different than coming from, let's say, an orthodontist who it seems to be as a, they've picked up on the sleep trouble and they have a skeletal malocclusion or they have a skeletal discrepancy and how they get set up. For management, that skeletal discrepancy is pretty different if we're going to be attacking from a sleep standpoint, you know what I mean? And sleep medicine, if it's coming from them, it's very much like end-of-the-line treatment, like everything else worked, didn't work, so, you know, they don't want to trake, so why don't we try an MMA? And then ENT is somewhere in the middle of that. And I don't know, at least from my perspective of seeing these different patients have come to appreciate, you know, the different patterns. And from a patient side, that seems, that seems pretty arbitrary. Yeah, I mean, in you just saying that I have it elsewhere in my presentation, but something we should put on our list or added this list before we forget, and it's something we've talked about in different contexts before, but treatment fatigue, like you talk about seeing this patients and nothing else has worked or going down, we're talking about going down these pathways, but sometimes that's an absolute barrier to them getting treatment of, hey, I've tried utriple P, I had tongue reduction, you know, I had high-oid suspension, I had inspire, I've had expansion, like I'm done, like I just can't go through this anymore. Yeah, that absolutely is a barrier to some people getting treatment fatigue, for sure. The thing that I like to remind myself of when it comes to management of sleep apnea is that sleep medicine as a field is new. It's only been around since the 70s. And so the management strategies is still an unknown. It's an open question in a lot of ways. Do you ever do the Stanford Protocol for sleep? Did I ever, did I ever do it or was I ever, did you ever practice in that way? Never. Is one of phase two surgery or stage one stage two? No, I was very much on board. I can't remember, I don't want to give myself too much credit, but I mean, I can remember when I would encounter that in practice, very much being like, that's not a good way to go about this. And I don't want to give myself too much credit, so it may have been around the time that we were kind of realizing that, but you kind of have to do it for a while before you realize it's not the right way to do that. Yeah, I mean, because initially people were just, because there weren't that many interventions at the beginning, you know, like in the 80s, 90s. And they were trying to figure it out, right? So trying out you triple P as an initial intervention. And if it didn't get better, you tried MMA, not that that's the exacting. But I mean, it's slightly more complicated than that, but not dramatically. I mean, it was a lot more stiff than the heart issue. Yeah, a lot more steps to get to MMA, like that was the problem that I viewed it as. And of course, we have our own bias coming from the jostardry viewpoint. Oh, sure. Yeah, and I mean, it's still that when it comes to non-surgical treatment, right? Like it's still pap therapy as initial offering. Sure. And then if that's not managed, I mean, nowadays, even like the weight loss drugs and that sort of thing seem to be more of a primary management strategy. So it's not like that's the absolute best for everybody, right? And it's very much just a, it depends on how the patient starts their process. And so yeah, absolutely. You know, it's, we don't, not saying that you and I know the answers to this. It's just, it's kind of an interesting clinical phenomenon, seeing patients for surgical consults, for sleep management on how different they are based off of where they come from. So, right. I mean, what you're saying about the stages of, of the Stanford sleep management and that sort of thing is very much like TMD is still now like you try authors and thesis and if that doesn't get better, you do scope. And if that doesn't get better, you do an open art to plastic. And then sorry to make this more of a team-jick discussion that it should be, but it's very much seen is that and talking to non-surgical providers, their perception of surgery is very similar to our perception of, of non-surgery, right? Like, I mean, honestly, I have superficial knowledge of PAP and the different settings and different masks, but same thing with oral appliances. I don't know that much about them. I know the general concept behind it, I defer to those guys when it comes to that. So, yeah, I think my biggest thing up on him where I get kind of worked up sometimes is to me, I pride myself and my practice and even my staff on we, if a patient, if we're seeing a TMD or an OSA patient because I completely agree with you, I see so many similarities between these patient populations. We see them first and they haven't been diagnosed or they haven't tried any treatment. We are very good about telling them every option and even then providing them a referral, so they don't have to go search on their own, you know, hey, we work with Dr. Sons of Down the Street who does a lot of inspire, go see him here, what he has to say, you may love what he has to say, you may hate it, go here directly from him or these people do a lot of sleep appliances go talk to them and see what you think. If they want those things, but we'd absolutely tell them about all of their treatment options or say, hey, we don't have enough information to really know what the best treatment for you is, like we don't have a sleep study or we don't have an MRI or we don't have a dice. And again, we have a lot of shortcomings and we don't, we're not perfect, but we're really good about that, but what I don't like is I feel like I'm in the minority, like I don't feel like that's standard practice for other people. Yeah, and I mean, because everyone's busy, right? And I understand the mentality of someone's coming in and talking to you about surgery and you look at MSA, you know, that's, you shouldn't start with surgery, you should start with CPAP, so you should try that out. Or if you have a different spin, which is let's just talk about surgery then, right? It's just hard based off of the limitations of no one knows everything and then also there's not unlimited time to go through the whole lowdown. But I mean, generally speaking in my world, if someone's coming in because they did self-directed kind of referral, I just want to make sure that we're doing surgery for the right reasons. Because generally, jaw surgery for sleep is going to be expansion of the arches or advancement of the arches. On occasion, there's some oddball stuff like tour eye or chin work or something. But for us to put them through a skeletal surgery, we kind of want to be doing it for the right reasons. And when it comes to sleep, I like a couple of reasons to do it, right? Like, you have sleep trouble, but your teeth also don't fit or you have sleep trouble and maybe there's some aesthetic things you would like to be different, right? I mean, if it's, because when it comes to sleep, it's kind of a, it's hard on the individual to talk success rate. You know, the data for success, when it comes to these things, I think is messy. And I think that's, I guess that's not one of your bullet points on your slide, but I think kind of sorting through the, I mean, honestly, BS data is hard. I find that hard as a provider. Yeah, absolutely. And again, another parallel between the TMJ world, right? Exactly. And, you know, it's just trying to sift through it as a patient, because it's got to be a nightmare, because it's tough enough as a provider to do it. But, you know, I guess the point I was trying to make and I agree with you, the best patients are the ones that have a skeletal malocclusion to know, say, because like, those you feel good about, like, the treatment to me is very clear as what's the ideal treatment for those people. But, you know, I guess for me, I get what I would say is the thing that bothers me about that is we know MMA for the, for the best information that we have MMA and TMJ surgery for arthritis, TMJ disorders. We know those, or what we know tells us that those are our best options for patients. Like, those get the best outcomes from them for the winners. There's definitely some clear people that should be offered jaw surgery or, yeah, just like, you know, we're people that should be offered other things. You know, that if you read any text book or you pull it up on AI, which I know you spend a lot of time with these days, you know, what's what's the best treatment? What's the best treatment for OSA short of a trick? It's always MMA. And, you know, now is it for everyone? No, should we offer that or make, you know, kind of force everyone into that? No, should everyone choose that? No. But like, the fact that the best treatment isn't even discussed with patients bothers me. Like, again, they may have reasons not to choose it. They may not be good candidates for a whole host of reasons. But man, I just always envision the scenario. I probably brought it out on here many times. What are my children had a disease, a condition, an ailment? And I went and saw the expert. And the best treatment option wasn't even discussed with me. I would absolutely lose my shit. Like, I may not choose that option, but they should know it. That seems aggressive. But I mean, I agree. I mean, because that's what's gone away from the phases of surgery or the stages of surgery. It's, you know, it's anatomy, driven treatment, you know, low mal and potty score, big tonsils, take tonsils out, right? Small jaw, big over bite, advanced the jaw. And I think on ENT world and in jaw surgery, world people who do this sort of thing, I feel like we're all pretty aligned on that stuff. I mean, be in my high, you know, do it. You can't cut that thing down, right? Because I mean, you're always going to be fighting those things no matter what you're doing. I mean, it's harder to wear CPAP if you have a small lower jaw, right? I mean, it's, if your nose is unable to get air pass through it, it's just going to be difficult nasal breathing. And so, you know, like doing the anatomic interventions on the surgical side, I feel like people are pretty good about. But, I don't know, it's definitely prone to things where, you know, what office they show up in. Do you do multidisciplinary care? Like, be honest, how often are you involved in multidisciplinary treatment? What do you mean by that in this context? Not like you work with a referring doctor that sent them over, like you're a three or four person, like one of three or four providers on an individual patient working together. Working together? I would say that at the same time that doesn't happen often. What's that? Like cleft, let's say, you know, you've been on cleft teams. Yeah. I mean, because, you know, like I think getting everyone together is difficult in real world because of the different systems, the different EMRs, the different schedules. And it just is difficult to have everyone pow-wow when it comes to that. Sure, sure. There are teams of that. There's, I'm actually part of this. We do some pediatric sleep on it. It's more of like a community cleft clinic. And it's always nice whenever we're talking about a sleep topic, just to have different people weigh in on real time. Because it's just, it's interesting seeing everyone's different view on it because they all keep up with, you know, like ortho keeps up with the ortho literature. And, you know, sleep medicine keeps up with sleep medicine. We keep up with jaw surgery or ENT, right? And hearing from those guys is always great. And so it would be great to do more multidisciplinary talk. And I think that's on our to do this year in terms of providers that have on the podcast, which would be good. But honestly, I think it's just like a just practical nature. It's hard to really carry that out. Even though I'm pretty suspicious. There's two or three reasons for most people sleep at me, like at least. Do you think there's ever a button to hit to make it go away? Yeah. And that's to understand your question. I would say that in most people's situation, they should have a few providers looking at her. Oh, yeah. Or for sleep, you mean? For sleep. Oh, yeah. Yeah, I mean, if we could design like the perfect healthcare system, it's always a few things, right? Like it's always like, you know, yeah, this is a surgical intervention to improve nasal breathing. But, you know, maybe being my reduction is a good idea. Yeah, I mean, I think your your cleft team analogy or even maybe not quite as good of one, but in our world and the OMS world, you know, a tumor, tumor board, you know, just even even a group reviewing the case of the patient together. Yeah. So you're getting, you know, because we too can get in rabbit holes like we can we can see a patient, and you know, again, we do jaw surgery, hammer, nail. And it probably all keeps it keeps everyone honest like it kind of keeps you remembering, okay, there are other treatments. You know, you're recommending jaw surgery. This might work too. The patient should be provided both options or multiple options, which again is kind of what I'm going back to that I think is is a frustrating aspect because I'm starting to see I'm sure you are to more and more people who have had inspire. And it's either they hate it or it's not sufficient. And so I think we're going to in our world, we're just going to see more and more of that because those things are going in like crazy. Oh, yeah. I mean, because there's commercials about those sort of things. And I mean, the other part is people who generally get care for sleep apnea are the people who are symptomatic, right? I mean, there are people that, you know, they have heart disease or they're managing their hypertension. And part of that is their primary care docs says to work up your sleep apnea, but people who are like symptomatically sleepy and are unable to get managed in other ways. They're pretty motivated to get treatment. And so the first reasonable option in many ways is is a good one because I don't know about you, but it takes a long time to get seen by people. And so if it's like six months or eight months to get a sleep study and your your at homes, you know, device, whatever you're wearing like your apple watch or whatever it's telling you have a terrible sleep, trying to manage to that seems to be a common pathway that people try. And so I think people end up, you know, going down inspire or going down other routes like jaw surgery or something. And so there's very much like the practical nature of the world. Anyway, I think the insurance part, we haven't really talked much about that. That's a real barrier. And insurance has seemed to be worse. What do you think? Insurance is getting worse. Yeah. Well, wait, because I would have almost said the opposite. Really? Yeah. I would say in terms of surgery coverage, approval and difficulty of getting those sort of coverages. You think it's I would have I would have said the opposite. Huh. I mean, in terms of the process to get approval seems to be more burdensome than it was before. But you don't have that feel. No, I mean, I can remember when I first came out in practice, you know, 10, 11 years ago, not six, seven. But 10, 11 years ago at this point, the criteria and maybe it's a state thing. I mean, I guess since I've moved states that that could be part of a geography could play a role in this and insurance in different areas. But I mean, I remember there being very specific criteria to get jaw surgery covered for OSA. That was, you know, you know, even mild to moderate, but I used to have a tough time getting it covered. It was pretty much had to be modern at a minimum or severe. And then there was clear numerical criteria of 60, 90, 120, 180 days of CPAP trial without it, patient being able to tolerate it or other barriers to that not being successful. And like, that was the bare minimum to get it approved. Is that still, since I've moved states, is that still kind of what you mostly encounter? Oh, yeah. Moderna is just a beer sleep avenue. YPAP therapy isn't useful. Why other interventions aren't being applied. Like, you have to spell out the reasons for why an oil appliance isn't helpful in that situation. Yeah. I mean, I think, I think you have to clearly indicate why you're doing the interview or recommending the intervention. But I find that I have less and less of those specific, like, hey, you got to try CPAP for 180 days and get a note from a sleep visit. You're the patient's sleep position saying they're in taller. Like, I remember used to have to go through all those who said, I don't feel like I have to do that as much anymore. But from, uh, from an insurance side, there's also the fact that we're working with other people. So let's say dental insurance and medical insurance, right? So sleep medicine doctors in general live in the world of everyone's in network with medical insurance. And if it's not covered with medical insurance, people aren't going to do it. Do you think? I mean, I think there's that, I think there's that bias for sure. It skews that way. And then in dental world, like orthodontics or general dentistry, it's like, dental insurance doesn't cover this and just kind of push it in the unknown in the medical insurance side. And so from a from our, you know, unique spot between dentistry and medicine, I think we encounter insurance barriers to referral based off of just how those different sides of the world behave with insurance, right? Yeah. So I think it's our practice, but it's also just like patients experience with it. So yeah, I mean, so I mean, do you still run into that? I mean, you feel like you're from an insurance perspective, it's as difficult. They're more difficult for me getting pre-authorization. Yeah, I feel like it is, it is not less difficult. It is the same or more difficult. Yeah, because see, I feel like I frequently have patients now who we submit for it, who haven't, like, tried world appliance therapy. Some of them haven't really even tried PAP, and it will sometimes get approved. And I found that genoplasty or, you know, surgery on the chin to help with the airway and, or aesthetics and conjunction with it, more and more frequently is getting covered. Like my standard line for that was always, hey, genoplasty is a static optional, so it's never going to be covered. But I've found recently some of that, even that is being covered as part of, yeah. I mean, when it comes to things like MMA, right? Like the cost reduction on the insurance side, they should cover it, especially for young people. I mean, it shouldn't be the end-stage for a 55-year-old guy with terrible sleep apnea, because the cost savings, if everyone, you know, if, from the life of the patient side, the cost savings, they have these for the different interventions, by the way, inspire as a reasonable paper on, you know, the company that makes inspired, on the cost savings through successful treatment, the cost savings from, you know, the secondary medical problems minimized, and then the savings from CPAP cost, there's ways that they figure that out. And the reality of MMA is that there isn't a company selling it, it's much the individuals that are performing the operation. And without like institutional payment, you know, it doesn't. There's not really a driver for that sort of paper, but it's still the premise holds true, which is helping people when they're younger avoid medical problems is more cost savings to the, to the pair. So from a philosophy, they should make it easier. I just wonder a little bit on your experience of it being easier is that your practice has been more focused on this. And so your staff are more, like, accustomed to doing those things. Whereas if you've not as accustomed to it, it's a little bit more of an effort. Yeah, I mean, I absolutely think that could be a huge part of it. I mean, I think you just learn sometimes what they what they want. Yeah. And if you have a patient who meets those criteria, just clearly making that available to the insurance company. And I do think we do a better job at that. But I mean, I would even throw in the young people thing, like I think just clearly outlining that, you know, one of the criteria that I see listed now from the insurance companies, you know, it used to be purely does not tolerate CPAP. And again, you had to have a certain time parameter to that. I see now on their checkboxes on some of their criteria, instead of just intolerant to CPAP, or the other option now is patient refuses. It used to be you had to try it and be quote unquote intolerant to it. One of those checkboxes now is patient refuses to try, because I and I think that comes from younger people. The fact that we're treating younger and younger people who were just flat out going to say, Hey, I'm I'm 22 years old, I'm single. I'm not going to try. Well, because I feel like this is generally right. Last time I looked at this was a number of years ago, but it was just something to the nature of about a half people decline pap use, like when you offered pap therapy, they just decline it for every reason, like they don't want to do it, you know, they they're a claustrophobic, they just they don't do it. And then of the half that'll that want to try it out, only about half or truly like Medicare criteria compliant with the intervention. And I mean, that's that might be a little bit different nowadays with different devices and all that sort of thing. But I think generally that holds true, right? And so you are missing an opportunity to treat a large number of people with different interventions. And it's good that we have different interventions now. But I would say that we can keep getting better on kind of like applying the right pay treatment of people. When people show up, like I said, I run into trouble with expansion, right? Like getting expansion covered. So dome or good lined distraction of the manual. I almost never try to be honest. You try for for just sleep reasons. It's hard. It's much harder than I have a may. Yeah. Well, that I mean, part of it is I maybe this isn't true anymore. Maybe you can tell me your experience. But the problem I had historically was getting insurance to cover both expansion, which typically is 21142 CPT. This civil fine modifier. Yeah. Exactly. And so you're trying to get that same CPT code or that same family of CPT code then covered for the MMA and then they would refuse. So like we kind of developed a strategy years ago when I was in Seattle is like, hey, you might need both or if you need both or both as a plan, we want the MMA to be covered. That's more expensive. That might involve a hospital stay. So we don't even want to submit for the expansion from an insurance perspective because if it does get covered, we may end up shooting ourselves in the foot. Plus we can do expansion in the office pretty easily. Well, I would say that's definitely a difference in skeletal sleep management than it was like five years ago and certainly 10 years ago is that there's a lot more interest. And I meet a lot more patients who have done expansion therapy as a primary or want to do expansion therapy as a primary. And insurance is just one part of that, right? I mean, I don't think there's clear protocols that are out there because this is relatively new thing in the scheme of sleep medicine of what it, where does expansion play a role here. And I think, you know, dome, there's a reasonable data with that on improving nasal breathing, reduction of sleep avian numbers, how that fits into the overall picture. I mean, I can't tell you I meet people who the jaws are small, right? Like I feel like they had a U-triple P in the past, you know, like you shouldn't have necessarily like looking back on it's obviously easier to say, but you're trying expansion when you should have advancement, you know what it means. Yeah, and that does even circling back to the insurance thing is like you're saying there's not clear data protocols where that fits. And so it can create that problem of, you know, historically, if someone had U-triple P and it failed or it wasn't adequate, getting job surgery wasn't a problem. But if they fail expansion, where does that fit in from an insurance standpoint? They may, again, you get that pushback of, hey, I've already paid for a piece of the fort. Yeah, and I think the new or patients shown up with some trouble with expansion, whether it's asymmetric expansion, whether it's still residual sleep avian after expansion, whether, you know, it's malocclusion after expansion, not that everyone has troubles with it, but there does seem to be higher rates of expansion going on as a primary offering before they show up to our clinics, but that does complicate the whole scenario, right? I mean, it's, it's a different, different management. And I, it's always, I don't know, I find it a little bit hard to, to artfully navigate that world, right? Because maybe with my eyes, advancement makes more sense. And so, you know, we're always, you like to think that you're always right, but that might not be the case. And working on expansion is a reasonable thing for a lot of people. It's just, I do think there's probably a little bit over over treatment there in the expansion world. I'm 100% and I mean, I would, I would lump inspire into that too, although, I mean, I guess over, saying over treatment or whatever, like you only find out it doesn't work when you've tried it and it doesn't work. Yeah, and we're not in it. It had worked way. Yeah, if it had worked, and here's the other problem for our biases, like we don't see it when it works, right? So, like our perception bias comes into play here, but I would echo your sentiments of, I can certainly in the last five years of practice, there's been a drastic uptick in seeing people who have had hyperglossal nerve stimulators and or expansion, who now need treatment. And it's compounds the problems and the difficulty navigating their treatment and insurance. Yeah, financial. And I mean, I think that, you know, we can still do a better job. I think generally oral surgery, we can do a better job of advocating for MMA because it doesn't do that. How do we do that? How do we do that? I mean, how do we break down these pathways of A, they went to, you know, they went to sleep medicine. Now they went to E&T. Why didn't they go to home a fast? Like, how do we, how do we deal with that? I mean, I don't know. We just get out there and talk about it. I feel like I was talking about it to some extent now. I mean, us doing this is helpful. I mean, when it comes to MMA from the from the sleep medicine side or from the medicine side of things, MMA seems like the most horribly invasive surgery ever. Right? Yeah. I mean, I think that's that's their perception of that. And I think from a patient side, it seems crazy too. I do. Yeah. So I mean, why do you think self in videos? You're like breaking jaws and, you know, there's wires and plates and just seems terrible. I mean, it's easy to forget that. But what? No, I think if you look at it from the prevention itself, like if you had to show the patient videos of all the surgeries or all the options, I see that perspective. But I guess I look at it at the flip side as I tend to harp on and linger on is like, man, I would want to know the best treatment options. And there's just so much data out there now. Kind of I was going to bring this up earlier when you talked about some of this. But, you know, we had a there's a recent paper, maybe within the last two years in Joms. And, you know, it kind of echoes the same sentiment of when you were talking about CPAP compliance, they tested or they had subjective and objective criteria. Maybe I should have put that on our PowerPoints. People can look at it. Subjective and objective criteria for four interventions, CPAP, applied, mandibular appliance, hypoglossal nerve stimulators and MMA in both surgical options consistently outperformed both non surgical options. You know, part of it is compliance and tolerance of these things. And then MMA, of course, was the both subjective and objective criteria when they repeat, sleep study them and everything like that, that best outcomes, patient tolerance, patient satisfaction, everything was higher in both surgical groups. And MMA was more so than hypoglossal nerve stimulators. So, I mean, I think to me, it's just weird that we tend to ignore that data like, hey, patients subjectively end up liking it the best, objectively gets the best outcomes. That's why I feel like how do we not break through to the sleep medicine pathway a little bit? Yeah, so I mean, I would say I see the invasiveness ever perceived invasiveness of it. I mean, it is a big surgery, by the way. It is the same as what we use to treat teeth that don't fit. Which I mean, I see both sides of that seems sometimes a little bit like a big surgery for that indication. You know, I obviously do that surgery for that indication, but we also use it for face change. Those, you know, let's say more of a cosmetic surgery. I don't know. I think from that view, it becomes a little bit less of a thing to go through. And certainly our perspective of the surgery, it's not, it's a safe thing to go through. It's a less recovery than what you would think. In many ways, I don't know, I find the pathway for patients going through it, and it may be much more straightforward than expansion. I mean, expansion of the arches, especially if they do both arches, is a long haul. That's a long treatment. Oh, man, yeah. And I mean, to get to the point where you're really appreciate the breathing, it's a long thing. But the other problem, which is it's still a problem, is there's not enough providers offering them a day. And so the invasiveness of it, it's seen as there's only a few people in town that do it anyway, right? And it's hard to see them, or they're not a network of your insurance. And so you should go try and inspire. Because that's, you know, not to hate on inspire, but, you know, you should go try, you, whatever, highway suspension. No, I think you definitely write about the in-network provider thing. And that being a very big barrier, because again, I agree with your sentiment that there's a large chunk of providers and patients who pay the jaw surgeries, the people, it's hard to find someone in network, who does this and does it consistently and does it well. I think that's, that's a real problem. But also just kind of the, even if you skip over the financial part, just the people who do a lot of it, there's not that many providers that do a lot of it. And I mean, not that I'm trying to talk people out of like referring for them in May, but like, honestly, the things that we can control on our little surgery side would fall into the camp of advocacy, you know, practice, trying to work as multi-disciplinary field, those sort of things are always great. You know, we, we, we largely, a specialist, you know, the referral patterns or big aspect of practice. What I find odd is, you know, if I'm working with an orthodontist or a dentist or whomever, and I sent them a lot of patients, generally you work together, they send patients back, you know, right? Like, hey, I, like, sent me a blah, blah, blah case. I like working with Mike. I'm going to send him my, their mullers or my implants or my, I do not find that in sleep. Like, I think of the number of people I refer for sleep studies in the amount of referrals I give. Well, that's not the medicine side, though. Yeah. But the medical referral patterns are just a little bit different. Just because, you know, they're more, I don't know, this is obviously any generalized term is, is going to be incorrect. But I feel like on the medicine side, they're more interested that you can do it well, right? Like they're, they're like, well, that was going to be my next on doing this surgery, or, you know, the person to do MMA that I've worked with is this person, right? Like they're more interested in competency. That, that was going to be my next point, though, is like, not only do I send, you know, it would be an odd week that we didn't send at least one patient for sleep study, you know, and then we send them back happy to get follow-up sleep studies to test the result. And so they're seeing, well, at least in my world, you know, again, not everyone, not every patient, but they're seeing us in tune with this world of, you know, sleep disorder breathing. Yeah. Getting sleep studies, doing an intervention, patients going back with significant improvement after that intervention. And generally, I find mostly patients are pleased with their outcomes, right? Like they had a problem. It's improved. Is it always perfect? No. Is it always cured? No. But like I would think to me, to my brain, man, I'm seeing a lot of patients from Dr. So-and-So, who had a problem. He intervened. They're now better. Maybe I should consider this as an option, even if they're not referring to me, like I should be considering MMA or other jaw surgery as an avenue, but that doesn't seem to happen in my world. Yeah. And I think that's probably time. We'll get better with that one. When I used to be employed in the medical group up here, I would go into the the sleep medicine group meetings. So they had like monthly meetings, I think. And I would attend those just because I mean it's great to network and just see the other side of it. And they are a group of practitioners that are busy. They see a lot of people. And I can imagine that you know, a win like someone's sleep avenue goes away or is dramatically improved is just in the sea of wins that day, right? Like, I mean, you can't get too high or too low in practice. And if those guys, and I don't know how many people they're seeing every day in clinic, but I do know that special TVB overworks. And I think there is the part of just the meat grinder of medicine. That it's hard. So I think I think that's just where they are busy, man. Like sometimes it's months just to get in to see him, like you were saying. So I don't know, are you doing anything to help circumvent this problem? Uh, you know, I like to think I am, but it's just like anything. I probably drift away from actively over seeing that in terms of promoting it. I tried to network with people. And I'm always open to talking about different things. And I'd just still like sending people in other directions. So like sending people to your nose and throat and sending them to dentistry or sending them to orthodontics. That's always a good practice builder. So I still do those things. I try to get out there and talk as much as I can. It's just, you know, we could all probably be doing something a little bit more. Oh yeah, doubt and no doubt. Have you tried the at home sleep study option? That's something we've been toying with recently is to avoid them going down certain pathways. Um, part of it is again, knowing that I personally would offer them all the options. Um, like so we'll sometimes when patients call the schedule, if they haven't had a sleep study wall, say, hey, go to this website and get an at home one. I mean, that just sounds a little bit like you're doing non-surgical TMJ management. Exactly. I mean, I, we kind of have to do that too. But TMJ surgery, um, sorry, we're probably catching people off guard in the similarity. But TMJ surgical practice is so much better once you create thresholds of referral, right? Like once you get them passed, like you have to try certain interventions or you have to get MRI that shows something like there's some pathology, you know, like there's some screening criteria to get people on the door. Do you start treating undifferentiated sleep trouble? The likelihood of them being in a main candidates is, is very low. Because there has to be a very small percent of this is helpful. I don't think it's one percent, but I feel like you'll be kind of managing a lot more than you want to. Well, that was my, that was kind of my point is if they call them, they haven't seen anybody, we can say, hey, get the head home, sleep study. If it's positive, call us back. Sure. And give us the result. And that, that is one of the ways we've screened people. I would throw out there as the inverse of what you're saying or to be devil's advocate is the patient who calls it jaw surgery office. Yeah, actually is interested in jaw surgery or calls a TMJ surgery office, a generally interesting TMJ surgery. That doesn't mean they've been appropriately diagnosed or they've tried other interventions. But they probably have some information that makes them think they're jaw surgery and they have no chin or, you know, like, and they're interested in it, right? Like, you don't call it if you're like, man, I'm, you know, so many of those patients, like you're saying, I'm not doing surgery. We don't call surgery office if you're in that, that subgroup of patients. Yeah, that's totally true. So yeah, I agree with that. So I think that offering those sort of things is nice. You know, there's a whole world of people getting sleep tests and offering those sort of things outside of the normal medicine pathway, which I mean, you know, it's good and bad. So I think getting people to care, they need is important. And so that, that area is definitely evolving. So, yeah, we need to, we need to wrap this episode up. I had it up. Maybe we can put a little reminder somewhere because I wanted to bring up the opposite problem that I'm sure you're probably singing your practice is seeing a subset of patients who come to you with perception of airway issues that then don't have a diagnosis or when you test them, they then don't have clear sleep disorder breathing OSA. Yeah, I mean, that's navigating that population is difficult. Yeah, well, it's a hard group to, please, to get better. Yeah, I mean, because it's in surgery, it's always nice to have, you know, ankleosis, like you're taking out a joint. You have severe sleep apnea, HI is 100. And, you know, SNB is like 61. Yeah, that combination's great, because I feel like I can move B point two centimeters. I feel like I can release in ankleosis. Like, I don't have enough space for my tongue is is a subjective measure, just like sleepiness is subjective. And outcomes when it comes to sleep intervention in terms of HI reduction or, you know, lowest O2 desaturation, date is a lot better on that than it is on subjective sleepiness improvement. So that's a tough one. I feel like it's, it's just a hard, you just got to be careful of it. I mean, I've learned that through practice, it's just I want to offer surgery to help, but I don't know to what degree to move to, right? Right. Right. That patient population with maybe minor snoring or perceptions of snoring or waking up for whatever reason, but no true diagnosis of obstructive sleep apnea or it's, you know, six, eight, already, I have six or whatever. And no skeletal abnormality. Yeah, that's a, that's a tough one. Like, if you said, hey, you've got a class two occlusion or even a class three occlusion or you've got transverse discrepancy, like we have a, we have a clear reason to intervene with orthagnetic surgery. And while we're in there, we'll advance things to improve the airway or expand or both. Like that makes it a lot easier. But the patient who is not a skeletal discrepancy that end that is indicative of needing orthagnetic surgery and is saying that they have sleep disorder breathing. And they're certain of it. You know, I've had thyroid vitamin D. I've had all these tests. I'm certain it's my sleep. I'm seeing that more and more. And it's a tough population to please. Well, because there's certainly more depth to sleep studies than just the HI, right? And, you know, REM dependent, position dependent, different phases of people live, you know, how does hygiene fit into that? There's, there's daytime aspect of breathing. So, obviously there's a lot more to this. But I do find subjective sleepiness to be hard to manage. Because the hard one is it's like just, just idiopathic sleep disorders. And, you know, they want to try anything to feel better. And they're like, hey, I'd try sleep abney. Or I'd try joss surgery if it helped me out. And I just have a hard time knowing if that's going to help them, right? And so, you know, trying things like oral appliance or, you know, that sort of intervention can be helpful. That's a tough, tough crowd. Because you want to, I don't know, I just, I want to help out. But I want to have a pretty good plan. So if they have a skeletal issue, it's always a lot better. Right. You know, and the answer is right? No. Some of those peptides that Gabby was talking about. Yeah, I don't know. Maybe I think wellness stuff is great. You know, we should get more on the wellness topic. So, I don't know. I think a lot of barriers to treatment, trying to come up with some solutions here by talking about it's always nice. So maybe someone hears this and finds a new path. Yeah, I think this is a topic that probably all of us in the joss surgery world have different, but very similar difficulties navigating this. So I'd be interested to hear from some of the listeners. As always, if they found answers or ways to circumvent some of these things and yeah, I think that's a good place to stop before we just ramble incessantly. All right, man. Yeah, it's a good topic. I think we didn't talk about eight coms. Eight coms coming up three weeks. I assume everyone's already got their tickets. So I didn't need to remind you at the beginning. So I heard the telluride ski strike is off. So they're back to skiing. Did you know about that? I did not know. Oh, it's better not you know. Yeah, it's known. Okay. Don't know anything about it then. It doesn't matter, but yeah, so actually look forward to seeing you there. What days are you going to be there? You know, I'm not going to put that out in the world. Okay, this this whole super start and thing is kind of offline, but look forward to seeing a person. Yeah, I don't think all that ruckus at the airport and the signs and yeah, I understand. All right, man. Well, yeah, thanks for talking today. Yeah, that's great. That's a good downpriced podcast to podcasts for talking jaws downpriced podcast at gmail.com. See you next time. Sounds good.