The Orthodontist’s Role in Sleep Apnea w/Anil Rama

You have to open up our minds and realize, we are a very small part of a much bigger puzzle. For those of you out there who are doing a lot of airway and sleep, I beg you, be responsible with the way you do this, be responsible with the way you talk about it online. Don't make promises, not found in science, because everybody in Earth always watching. Hello there, everybody. Welcome to another episode of the Earth Produce Podcast. So today, I know I'm gonna ruffle some feathers. This is gonna be a good one. And I just ask everybody, as we go through this podcast episode today, I want you to approach this with the same way I approach the topic we're gonna talk about, which was an open mind. Whatever your predisposition is, whatever your prejudices are in the sleep and airway field, I want you to set them aside. You can be the most proactive in your mind, sleep and airway focused or thought on us, or you can be somebody who thinks it's an absolute sham and people are stealing money from others. But today, we're gonna talk about science as much as we can. We're gonna talk about the literature as much as we can. We're gonna talk about a broader picture as much as we can. And I guarantee you, you're gonna get an insight into the airway and sleep disorder breathing world that is so much bigger than what orthodontics looks at. 'Cause I wanna give you scale and scope. And if you're not used to this world, you don't know anything about it, today's a really good place to start. And if you wanna learn more, talk to me. I'll try to guide you in the right direction of resources. But before you go any further, let me introduce our guest today. It's Dr. Anil Ramo, who's an amazing person. He is both a neurologist and a Stanford board certified Stanford sleep medicine physician. Welcome, Anil. And thank you for being here. - Thanks, Glenn. Looking forward to the discussion today. - Yeah, it's gonna be fun. I think we open ourselves up to be a little bit of punching bags from time to time. But I really look forward to this conversation today. And let's start here if it's okay. If you don't mind telling everybody a little bit about who you are and what you do every day for the most part. And then we can lead in from there a little bit more. - Well, I'm a neurologist, and did my training as Stanford, and then following my neurology residency, I did a fellowship in sleep medicine at Stanford. And then I've been in the sleep world ever since. That was 25 years ago. I spent my time partly in academics, and I got on my own private practice called sleep and brain. And what do I do all day? I pretty much play quarterback for most people. I give people guidance and recommendations. And I send people to see orthodontists, ENT doctors, allergists, maxillofacial surgeons, metabolic specialists, different things, all in an effort to treat sleep apnea. So I have a unique practice in that. I have great relationships with people from many different fields. - Yeah, and what I wanna get across to people listening, 'cause the vast majority are gonna be orthodontists. Maybe they'll share this with other members of their team, hopefully, but orthodontists, I want you to understand what he just said, right? You're gonna, let's start by saying, and the Nile Univ's spoken about this, you know, in the conversations we've had as friends and the past we've talked, there are some bad actors out there, right? There were people out there who were in this to make a quick buck. There were people out there who all they do is expand, expand, expand, expand, right? They never bring a sleep physician into it. They never bring an neurologist into it. They never bring any ENT or an oral surgeon. And all their social media posts are about expansion and breathing and airway. And, you know, they tend to do it alone, whether they're orthodontists or general dentists. And I think there's a lot of people out there as we start talking today, who are gonna be a bit shell shocked because of those people. But again, everybody listening, put those people out of your mind. Put the bad actors out of your mind. Put the sensationalistic claims you've heard out of your mind as we go through this. Because Nile, would you say you've got in some great education from some orthodontists along the way about what we do for a living and how we treat patients? - Oh, and what have I learned from orthodontists? Well, would you say, just in a broader context, would you say that you've interacted a great deal with the orthodontist, that when we talk about the orthodontist role, you understand it pretty well. - I do. And I'm still learning, but quite well. And it's fascinating. It's not a plug and play, meaning that each orthodontist does it a little differently also. So each one has their own style. So this is not something that people learn in orthodontic school, if you wanna call that, or in the other school. This is something that they're pretty much learning outside of academia on their own. And yeah, and it's interesting. They arrive at the same outcome, but they arrive at it in different ways. Some use direct skeletal expansion, some use SFOT, some use other, mechanisms, it wither without. And it's interesting. And it's some redentists that are doing it. And so some have a whole team, a network that they work with. It's pretty impressive. They have their own surgeon, ENT, Maxwell, Facial Surgeon, and my functional therapist, and others are just doing it by themselves. So I think perhaps that variability, that you kind of alluded to, may explain why some people are reticent about even approaching the subject. - Yeah, I think you hit two really good points there. One, it's nuanced. It is not a cookbook. You know, if you speak to orthodontist about what we call class two correction, right? How do we correct overbytes? Right? There's a famous saying that I think your mentor, and many ways in sleeping airway, my mentor, Dr. Christian Gimigno, right, the father, potentially. We could call him the father of modern airway, and sleep disorder breathing, why was lucky enough to learn from, at Stanford when I took a team there, and who is one of your big teachers and mentors. I think he would agree with Dr. Morton Amsterdam, who's the father of modern dental, periodontal prosthetic reconstruction, who said, "For every patient, there are multiple treatment modalities, but only one correct diagnosis." And it sort of underscores what you were saying. And we learned about that in dentistry, is that we can treat differently, but the diagnosis needs to remain the diagnosis, right? And I think all too often in today's day and age, there are people out to chase a quick buck, or who are getting a little lazy in the diagnostic phase, and they just see a kid come in who might be snowing, go, "Good, expander." Right, get expander, right? And would you agree that, that as long as we diagnose it the right way, we can treat it any number of different ways, right? Well, there's correct, and each is part of the solution, and not one thing will be the solution. - Right, and I say that to patients who are out there searching online, if you go to anyone who says, "I can solve your problem by myself, run," right? Right, because again, as a preface to everybody, as we go through this conversation, I've gone to the Stanford team twice, I brought the RD group went three times over the years, once I couldn't make it, but I brought, at my expense, my ENT, my oral surgeon, my myofunctional therapist, pediatric dentist, general dentist, brought them with me, so that we could do the dance together when we get home, because none of us can solve this alone. So for all your orthodontist listening out there, if you're reticent about becoming somebody's focused much more on airway and sleep, sort of breathing, and you're all alone, that can be a reasonable reason to say, "Hey, wait a minute here, I'm a little bit nervous," because I don't have a myofunctional therapist who's likely going to be getting involved. I don't have an ENT who understands and does more than just wants to give drops, which the vast majority of ENTs, here are some drops, they'll solve your problem, which they don't. And so, let's agree on something that me and Anil have spoken about in the past, and that's a Dr. Christian Gimignot. He had said that the orthodontist should be in charge of the upper airway, correct? Correct. Well, I think he said, "Be essentially your first slian." People will see you first. Yeah, and we were talking about the literature a little bit earlier off camera. And there's a study from 1993. The author's first name is, "I know people are gonna look, his name is Ali, "is the first name." But up to 3% of kids around age five have sleep apnea. That means in a class of 30 kids, or if you're seeing 30 kids in a day, odds would say that one or more kids that you're seeing every day have sleep apnea. And we can choose to ignore it and say, "You know what, not my place, I'm not getting involved." Or we can choose to at least be gatekeepers for these kids and guide them to the right people. And again, you'll notice I'm not saying you're saying, we should expand all kids. We'll get to that in a little bit. But if someone out there was listening right now, Anil, and they're not really that involved in airway, or they're a skeptic, right? What advice would you give them about the way to dip their toe in the water the right way, as a role as a gatekeeper, so to speak? - As an orthodontist? - Yes, sir. - Well, I think the question you have to ask yourself is what role do you want to play? Do you want to be the quarterback, meaning that you see this child, you will be in charge of expansion, You will be in trouble. you're getting the sleep study, you will be in charge of referring to ENT for the tonsils or adenoids, so you'll be responsible for sending them to the allergies. Or do you want your role to be more as to be one of the adjunctive cares? Hey, I'll focus on improving this child's airway, but I want someone else to quarterback the care. And so that really depends on your scalp, and the treating doctors around you. And so, yeah, if it doesn't have to stay the same, it can change over time. Your role can be just an adjunct and over time. I have orthodontists that quarterback everything, and orthodontists that just do the expansion or what not, airway management regarding the upper airway, and that's it, nothing else. Yeah, and for me, I like being the quarterback only because we're the experts in cranial facial growth, and my ENT, my oral surgeon, my myofunctional therapist, they all look at me and say, Glenn, you're the one who's going to implement this process in most kids. In adults, you know, it's a little different story. Me and my oral surgeon tend to be the quarterbacks together because he's going to do if there's a scalability. But it's become a very large part of my practice without even advertising a whole lot of it because this is one of those things out there, folks, that's gaining traction outside of orthodontics. And I've been saying for five years, and you can go back and listen to the podcast. I've been saying it. That as we, as orthodontists, don't follow what Dr. Giminyo said, if we don't become sort of the experts at leading the charge to help these kids and adults, someone else is going to take it on. And a lot of dentists have taken it on who don't understand cranial facial growth, who don't understand what we do about the skeletal change and what have you. And there is, there are crazy ideas floating out there and crazy appliances that are really actually causing great harm to patients. And that void is being filled because orthodontists have not taken the lead on this. Would you agree with that to some extent? And have you seen some crazy stuff out there? Well, there's things that don't work and they are being pushed out there. But it's, as you said, for some reason, this is not coming out of academia. Stanford is not doing the research on expansions per se, um, near the medical centers really are. It's all being done in the private world where research maybe is more clinical than research. And so there's, it's hard to hang your hat on research backing this stuff when the institutions are so slow. And part of that reasons because it's not insurance reimbursed, you know, for a lot of these things. So if it's not insurance reimbursed, institutions can't do it. And so it's, so it's, if you're waiting for the data to come from the institutions, you're going to be left behind. Yeah. And right now, one of the things that frustrates me more than anything, and I've shared my frustration with you. See, folks, I want to, I just want to give him some props here for a second. He's an neurologist and a sleep medicine physician and granted being in Stanford doesn't mean, I mean, there are Harvard attorneys who don't practice good law, right? There's MIT engineers, I suspect, to get it wrong from time to time. But Stanford is the leading institution for airway and sleep disorder breathing in the world. You've got some of yours who's a board certified medicine physician, okay? There's some credibility here, not infallibility, but credibility here. And when we don't bring these people into the discussion, and this is where my frustration comes in, there's this whole heated debate thing in ortho today, where there are these people speaking publicly about expansion, expansion, expansion, expansion, both for and against. And without having a sleep physician in the room, without having an neurologist in the room, without having an ENT or an oral surgeon or a myelotel therapist in the debate, everybody wants to claim superiority in these debates and they don't seem to realize it's like watching a room full of general dentists debate orthodontics without having an orthodontist in the room, right? And it's folly. Would you agree with this statement? I'd love to hear you talk a little bit about it about orthodontics is great as a prescriptive thing in the sleep medicine world, but we rely on the diagnosis from so many other places, then just, hey, this kid has a narrow palate, let's expand them, right? I think everyone is missing and not just the orthodontists, but the maxillofacial surgeons, the ENT surgeons, what everyone is missing, everyone, and at least you're pointing out the fact that orthodontists are dentists and what everyone is missing is that sleep apnea is really just a symptom of something else. And we don't know what that is. It might be your anatomy. And sure, why wouldn't you want to optimize that? That's your role. You're seeing this kid in front of you. Why wouldn't you want to optimize that part? It could be a metabolic syndrome. Does a kid have liver fat? How many kids are walking around with fatty liver right now? Is it metabolic inflammation that's causing the turbanist to be inflamed and what not? No one's asking you to look into that. You do your part. The orthodontist does their part. Don't screw that up. Make sure the airway is okay. If you're going to fix the teeth, fix it right. Fix it with an airway in mind. But then there's so much more. The maxillofacial surgeon will tell you, if I bring your job forward, we can cure you 90% of the time. Focus. Go out and look at the numbers. Almost everyone after MMA still has sleep apnea. Still uses CPAP. Just look at the numbers. Almost everybody's back on that darn machine because they looked at it as in through their lens, I'm going to fix it. And it's wrong. No one should think of that. The orthodontist shouldn't think they're going to be. They should be humble. I'm not going to fix this. I'm going to do my part. The surgeon will say, Hey, I'm going to bring adequate, fringial space. The ENT will say, I'll reduce the turbanist right now. The symptom. I'll do my part. And maybe there's fatty liver. Maybe these kids have to go in GLP one or metformin or something. Does that make sense? Hey, that person will do their part. And that's the key. Sleep apnea is a symptom. And even if you're not, you don't have to task yourself with figuring out what the cause is exactly, but do your part. You know? Exactly. You nailed it. It's beautiful to hear you say that because again, I will be the first to admit in my practice. If I have a child come in who's got a narrow palate, they're six or seven years old. Mom says they snore. Right. They're a growing individual. They snore or I always say this to people or they wet the bed or they have night terrors. Right? Or they're any sort of parasymia. Right? Or any other symptoms. It doesn't have to be all of them, folks. The studies are very clear. I think I think it was a churvin. I think it was in 2000. And again, in 2007, I think out of University of Michigan, the studies on, they said that the questionnaire in kids is as effective as a sleep study at home in terms of diagnosing sleep apnea in these kids. And so when I have a kid who's like that, and they got a narrow palate. And for functional reasons, I want to have a parasymia in my diet. I'm not going to necessarily, well, actually I will. I'll bring the, if I see a tongue issue or a tongue tie, we'll bring the ENT and for turbinets. They're not going to accept them on a six-year-old. But the turbinets, adenoids, tonsils, you know, you can make the counter-argument. People do, by the way, you may not know this a mill. The kids are going to outgrow it because lymphoid tissue reaches its peak at, you know, six, seven, eight years of age. They'll outgrow it. Right? What's your take on that one, by the way? I see large adenoids right now, right? Big, big fat adenoids. They take a beautiful, foringial space and narrow it out really badly. And somebody says, you shouldn't operate this. These kids, in the next two, three, four years, that lymphoid tissue will shrink and they'll have a great airway. I know my answer. I'd love to hear yours. I mean, most, you know, what they say, 60% of your face to else by age four, 90% by age 12. So, I mean, the damage is ongoing just because they shrink. It doesn't mean the damage isn't already done. And as soon as you take it out, ideally, you change that trajectory of growth. So, yeah, my opinion, you want to take it out as early as possible, even 18 months, if you can. Yeah. And if you look back, if you look back on these kids at 12 or 13, and it hasn't shrunk, and you've done them such a huge disservice by not it, you can't look forward and guess what's going to happen. And again, when we expand these kids, who let's just say I see a cues seven years old, they've got huge adenoids, huge tonsils, you know, the breath things that classic, horrible smell coming from their mouth. There's sick a lot. I have no problem expanding that child as a part like you said it best. I'm doing my part, but that's not where it ends. They're seeing the ENT, right? Maybe they're seeing an allergist. They're seeing them, I a functional therapist if I feel the tongue is playing the role here. And to me, that's the best part of it. And for ortho honest, who've gotten so hung up on the concept of expansion, I try to remind them, and I'm not going to mention names of a very, very well respected ortho honest. Who said if you expand the maxilla, the mandible will grow out from underneath it. It's for functional reasons, for better bites. So ortho has no problem expanding for bite reasons, but for some reason, they think of it as over treatment to do it for breathing reasons. Again, I don't understand it. I can't wrap my head around. Where does it come from for you? What do you think? - Well, I just want to back up a little bit and give an example of how different specialties when you work with them, they really make you think differently. Like we have a wonderful Brett specialist. I'm gonna say top three in the world, name is Lisa Kush. She works with that. She's out in Canada, but remote's in for our patients. But she's a Brett specialist. She's a Brett specialist. So we measure CO2 levels in all patients and a lot of people with small airways end up over breathing, hyperventilating, which causes a separate problem. But what she says is how your born makes a difference when you're born by C-section versus vaginal delivery, vaginal delivery squeezes everything out of your lungs. So then you start breathing properly from the first day of life. When you're born by C-section, you got all this gunk in your lungs and you never breathe right from the day one. It makes you think, it's very beginning. If she talks about adenoids, she'll say, oh, because you're breathing through the nose, that increases resistance. If you're a mouth breather, your body compensates and grows the adenoids. And then that actually acts as resistance that your nose should have created. And that helps to raise the CO2 to compensate your over breathing to some degree. So it's fascinating when you talk to different specialties, wow, is that true? Is that not true? But it's a different take on how they work and it makes you humble. And you have to keep being humble because you keep learning. It makes you humble if you keep an open mind. Because right now, I will guarantee you, Anel, that right now there's a huge number of people here when you talk about a breath specialist and go, you lost me. This is garbage. There's no science why I'm this. You're going to tell me that what happens at birth is going to follow a kid the rest of their life, that because they were vaginal burping, everything was squeezed out, that they're long-for-gift. Like, what do you want from me? But you know, Glenn, all I would say to those people is get a capnography, which is a CO2 measure, hook up the next 10 kids you've seen in your office, 35 to 45 is a normal CO2 level. I'm going to guarantee at least 40% of them are below 35. How do you guarantee? What do you do with these kids who are below 45? Well, it's breathing is natural, but you just like your heartbeat, but you can overtake it cognitively, right? And if you're, because it provides some type of benefit for you in your mind, maybe it gives you a sense of control who knows. But number one, you want to fix the airway, number two, you want to retrain them and how to breathe properly. So I am like a myofunctional therapist would help a child speak better after a tongue release, let's say. A breath specialist is going to help a child or an adult learn to breathe effectively to maximize the oxygen and reduce the carbon dioxide. Or like what's the oldest, oldest treatment for anxiety, which a lot of kids have a lot of adults have, what's the oldest, like most primitive treatment, the cheapest one, it's a brown paper bag. And what does that do? It raises your CO2 levels. It's truly amazing to me. And again, for those out there who get into the big arguments and debates and discussions among orthodontists only and think we know everything, the more you humble yourself before others who know so much more than we do, the more you realize that these debates within orthodontics about airway and sleep are so off target because it's like, I always joke with my team and whenever I argue with somebody, like it's too monkeys fighting over a coconut, right? When you watch orthodontist argue over it, if you know the broader literature, you just realize the argument is so based on nothingness. They're fighting over a mechanical expansion or not to, for instance, in ill, I'll give you another example. You and I have spoken in the past about the idea that, let's agree on that. I want people to hear you and I agree on this. If I do skeletal expansion on a child, right? If I put four mini screws into a child in their palate, the thickness of paper clips, and I expand them using a skeletal expander in, let's say, an eight-year-old versus a boneborn expander in an eight-year-old, a toothborn expander an eight-year-old, I will get far better expansion, superior and posterior and less alveolar bending and just a way better result. Is that a debate or would we agree that that is true? - I mean, every time I do a combing CT, that's exactly what I see. The basal bone, everything is much wider with the alveolar expansion. - But again, first of all, with the skeletal expansion. - I know you were going with it. I know you had it. But the problem is orthodontist, in the lead-up of things, you and I have talked about the fact that you would sometimes rather not do an expander in a four or five-year-old that's toothborn and wait till maybe there's a tiny drop older and do a boneborn expander because you know you're going to get a way better result with that. And we've had that conversation about that. - I mean, I have, there's descent even among the orthodontist I work with, some say, oh no, you're impacting them now. You need to relieve it as soon as possible. And it's true, I think a sleep apnea, like a traumatic brain injury, every drop in oxygen or a rousal, it's like a little mini concussion to the brain and it can degrade the brain as soon when you fix it the better. But I'm also recognizing that I've got 30, 40, 50, 60, 70 year olds after a double MMA, triple MMA, nasal surgery, expansion, everything. And they still got it. So then I pause and I say, okay, well, got it, if I wait two or three years and I do it right, like get the optimal expansion versus doing it early, even my own team, the people I work with, disagree some of them on that, right? But it's just, I think I don't think they see people like I do over decades. - And if you're looking for the science on this folks, there isn't, right? And the challenge is if you tell a parent at age four, I want to do an expanded on your child, which by the way, in ill, there's many orthodontist who say you're out of your mind to do an expanded on a four or five year old, even though the literature is very clear that some of them are sleeping apnea, many of them narrow palettes because maybe the tongue is tied and they're not swallowing the way they should or whole variety of reasons. But if you tell a mom, I'm doing an expanded on your five year old and then two years, three years later, you want to do a bone-borne expanded because now the bone's a little bit more rigid, you can get many screws in there easier. They'll lose the, the parents will never say yes twice. And number two, orthodontist go crazy at the idea of a mini screw a supported expanded in kids and I don't understand why. I have a reason, and I'll tell you what it is. Number one, orthodontist want to be the center of the attention, so to speak, in that there are so many courses teaching how to do a piezo cut. So orthodontist placed their own implants, you know, mini screws place their own marpees or if they're going slower, it's not a marpie anymore, right? It's something different. We want to get into that. But they like to place their own, put their own little mini screws in, do a piezo if they need to, and avoid the idea of sending to a surgeon like I do. I don't ever, I place the, the expander and I let my surgeon place the mini screws and I let him do an apex procedure which gets a cut that day, it's not a dome. And I think knowing that eight year olds are going to get a marpie which is way less invasive, way less invasive than serial extractions, which people never had a problem with, way less invasive than four by Cuspid Extraction, which people don't have a problem with. But the fact of the matter is asking them, if they say, well, I placed my own mini screws, well, I wouldn't place four mini screws in an eight year old. My surgeon would in a heartbeat in five minutes or less and it's not traumatic to the kid, they're going to do great with it and they're going to breathe better. So I'm trying to figure out why orthodontists give so much pushback when we know the literature is clear in many cases that bone, I saw a while moon talk about it over a decade ago that mini screw supported expanders are going to give better expansion throughout the whole nasal maxillary complex than a tooth-borne. I'm not saying you do that, folks. I'm just saying don't be so resistant to it and treat it as if you're telling me we'll do an MMA on an eight year old, right? Sorry, I'm gonna get off my soapbox here a little for a second. Your thoughts on this one, have you seen, what are you telling orthodontists who thinks you're crazy for recommending a skeletal-born expander? Well, I think no one's out there trying to do harm. No one's out there to necessarily be negative for the sake of being negative. It's what their experience is. I think for me, I don't need the research because for the last 10 years, I've just seen positive outcome after positive outcome with proper expansion in children. I think it goes back to it. Once I said sleep apnea is a symptom, I think most specialties, not just orthodontics work in a silo, you know, they're endocrinologists, hypothyroidism, and they treat their diabetes. They don't get, there's no like, you know, like people getting together and having discussion groups and what not between doctors ever, right? But this disorder is a little different. Sleep apnea, like I said, is a symptom. It's not a, I know it's considered a diagnosis, but it's actually just a symptom and it requires you to almost in whatever relationship you want, partial or major relationship, to be as part of a group of people treating this symptom. And, yeah, I think I wouldn't want to be with the Northodontist that doesn't do a proper expansion because that makes my job harder. You know, if you take out four teeth, you know, implode the maxilla and then hand them back to me. Okay, I have other levers, you know, but you've taken out one lever, you know, and, and, and, and that's, that's what I would say. And then I always go back to my favorite author's Oscar Wilde. He said, a sign of brilliance in his opinion is that people can pivot. And maybe he said that at that time because he was gay and a huge Victorian society. And maybe, you know, it was hard to change your attitude at that time. But I'm not saying this is like that. But, you know, you can go from I'm against it to I'm for it. But you're on tolerant of it. You doesn't even have to be on for tolerant of it. I'm tolerant of it. I understand why you're speaking about this. I may not agree with you in this particular or I may be uncomfortable with what we're talking about. But I understand where you're coming from as opposed to let's attack the person. Let's, let's call them crazy. And you didn't mention something. And by the way, there's so many great topics running through my head right now. Like my head is going to explode because Peter Dawson, who again, is one of the best educators in the dental world that many orthodontists have never even heard of. But he was one of the greatest teachers. He's had a great statement because he knew so much and talked so much about occlusion and bites and what have you. He taught it really was fundamental of the Panky Institute in Florida for years. And he always used to say, when you quote me, date me, because it was important for him to make it clear that just because he believed in this at this time, it didn't mean that a year or two later he didn't change his mind. So if you were going to quote his research and his literature, he just wanted you to make sure that, oh, Peter Dawson said this in this year, but five years later, he said this. And it's exactly what you say. It's okay to pivot. It's okay to change. It's okay to look at things through a different lens than the one we're looking at it right now. And that's why I love that. I'll quote. Yeah, there's people out there who do the same procedure, even though I won't say names and I won't say what the procedure is, but they're out there pushing it still to this day. Doesn't work, causes a bunch of harm. It's outdated, but that's what they push. And they have harbor degrees, what not, and I just shake my head thinking, God, I feel bad for the patients to see you. They're still pushing the VHS cassette. You know, and everyone stopped using that, but they're the, you know, they're the horse and buggy. It's a shame that that's out there. And so for people out there who say, okay, Glenn, Anil, you got my attention. I'm willing to learn more. Where would you suggest this? Actually, you know, let me go one more thing I want to talk about. You know, you and I have had the chance to talk about mind mapping a little bit. And I would love it if you would just share with people before we get into the concept of where can people learn more? Talk a little bit about mind mapping because I've had two kids who've gone through it for other reasons. And, you know, what is a Tiamat? Right? Tiamat is an M, not an N, right? T, T, trans magnetic stimulation. Right. I have a two kids who've been through TMS for reasons unrelated to airway and what have you. But you mind talking a little bit about mind mapping and TMS. And when we get in there after that, I do want to talk a little bit about the rhino-monometry as well. Because again, they're worth it on a thing they know everything, right? Expansion, expansion, no folks. Expansion is such a small piece of this picture. Well, I think we can back up and say, you know, like we say sleep apnea is a symptom. I'm not sure I keep saying of a broader condition of some type, right? But the reality is people with sleep apnea, if you consider a diagnosis, a lot of them have anxiety, depression, ADHD, and you see that in the kids all the time. A quantitative EEG and EEGs where you measure the brain ways of the brain. And because you have 80 billion neurons, they're all firing at different speeds. And EEG measures that. A quantitative EEG just takes that information and puts it through a software so you can kind of see. It's like taking all this data and then formulating in a way that you can understand it, right? And that's what a brain map or mind map is. And as I said earlier, sleep apnea is like a traumatic brain injury. Every drop in oxygen, every arousal is like a little mini concussion to the brain. In my opinion, you can see that on this quantitative EEG. And so therefore, if someone has mild apnea, borderline apnea, the standard doctor, in fact 99% of doctors, 99.9% of doctors will say, "I'll leave it alone." But if you see the brain map or the quantitative EEG, and it shows that it's completely degraded, and there's no other cause, they're not smoking pot, they're not doing concussions for it, they're not low in hormones, there's no other reason for it, right? They're otherwise clean. You would say, "Hey, there's a super narrow palette. The sleep apnea is there, but gosh, that brain is degraded. Maybe it's having an outsized effect on the brain." And so it helps, you try to rank everything. What's the exam like? What's the cone beam CT look like on the inside? What's the brain map look like? What's the sleep study look like? What's the rhino-menometry look like, right? And like you said, not everyone has every symptom of sleep apnea. Not everyone of those tests will be correlating with each other. And I think that also throws the more tests you do, the better picture you have with that person. So yeah, then your goal is to ideally stop what's damaging the brain, which I think in this case would be the sleep apnea for a lot of us, right? But the second thing is if possible, we try to restore the brain. Going back to something you meant earlier, I think the best way to get involved in this, the best way to really get involved is you could do a denovo. You can just try to teach yourself and try it. But I think the best way is to find a good mentor. You know, like one person that, and it may, and there may not be local, you may have to fly out to take a class, but someone you can keep in touch with, bounce questions off. Like I know Eric Phelps, he's wonderful out here in Osgato, in San Jose, he has a course that he does for expansion. I, I can't remember what the course is called, but his name is Eric Phelps, P-H-E-L-P-S. He does a great job. And he's so kind with this time. And all I know, I don't know what the cost is, the courses, but I can tell you that he puts just a ton of time, mentoring people. And I think you know him too, right, Glenn? Well, I met you through Eric because like Eric and I, for folks, I'm going to throw out their steward frost, who's, again, you may not know Stuart and L, but he's a very well-respected lecturer and clinician in the Earth of World. I would call him one of the top clinicians in North-Earn today. And he's an innovator. He was giving a presentation to our Earth, producer RD Group, our mastermind in New York in December. And he mentioned how he'd spend time with Eric. And when Stuart tells me he really respects somebody a ton, the next thing I do is pick up the phone. So I reached out to Eric and he was so generous, gave me time. We got on a Zoom call. We started chatting. I learned about Danes analysis, which I'm not going to give away now. But he went through hundreds of about thousands of CBCTs and identified some commonalities relative to the mandibular width. And I don't want to steal his thunder because it's his thunder. But you know, we started meeting probably at every two weeks. We just get on an hour's Zoom during his lunch. And we just talk, airway, and he said, "Oh, there's this great sleep physician out of Stanford. I really want you to meet." His name's Emil Ramay and I was like, "Okay." And he said, "And there's this Hawaiian practice that's. " "Once you realize how little you know, which is what I'll say." And I've been down this rabbit hole now for about nine years. Once you realize, wait a minute, folks. I've been thinking baseball as a center of all sports. And then you realize it's not baseball. It's the word sports that matters. And you've been playing baseball and you think you're an all-start baseball. And little do you know in the next stadium over there playing hockey. And then the next one over there's playing football. And then there's cricket and there's soccer and there's field hockey, etc., etc. And you realize how little you know compared to the broader world. That's when it becomes really fun if you really are about learning the science and really are about wanting to treat you better. Because if you're in it for a buck, you focus only on ortho. And yeah, sorry, that's just my. You know, it's interesting like how I operate is that I meet all these different practices. And I really am curious on what they do. Like, "Hey Glenn, what do you do? How do you measure this? Who do you use? What do you do?" And you know, at the beginning, it's all new. Everything is new. And you just want to. And with the point of making this, I added to my practice. I add anything new to my practice that I feel is relevant. And anything that I'm already doing, if someone else is doing it better, I ask myself, "Hey, that's better. Let me change what I do and add that instead." Right? And it's not stealing or anything like that. It's just. It's learned. And it's just learning. And so there's like I said earlier, wow, I work with a lot of amazing orthodontists, but they all do it differently. And in fact, sometimes when I coach my patients, hey, I based on geography, but I'm like, okay, this orthodontist does it this way, this one does it this way, and this one does it this way. And the patient's like, amazing, I can kind of like tell how each one does it. And then they want to say, well, I don't know if I like that, I think I like that better. Yeah, it's like it's like a chocolate chip cookie recipe. There's no two that are identical, but the cookies taste great at the end. And as long as you're doing the right intake and understanding how to do it properly, it works out great. And like, you've got new things. Let me give you an example in my practice, because I'm online in a lot of groups, I have people who reach out to me from all over the world. I have I had a consult with a guy from Sweden last week through Zoom. Not because I necessarily expect to treat him, but he has no providers near him, who know I'd read a CVCT properly related to airway and orthodontics. He doesn't have an ENT near him. I can be his guide to some really cool resources to help him. And that's the world we live in. And so now when someone comes to me for any sleep or airway consultation part, and I do charge for folks orthodontist, I do get away free exams for my kids and what have you. And if it's sleep in our way, I charge for it because included in it is a watchpad, right? That's something new that I've started instituting because of Eric. And do you want to tell people a little bit about the watchpad and what it is and how it can make a difference? Because I see that as a great place for people to say, I really don't know much about this. I don't know which of my adult, I don't know about kids as much as adults. I'd love you to talk about that. But I don't know which of my adults have sleep issues and how I should treat or what I should do or what even the diagnosis is, a watchpad in my opinion is a really good place to dip your toe in the pool and play around a little bit in helping these people. Yeah. I probably read for about 25 orthodontist and dentist all over the nation. The watchpad is super simple, disposable unit. The watchpad 1 is for 65 pounds and over. As a 1 in 200 failure rate, gives you a nice report. It's easy to use. It's uploaded into the cloud. You have access to the reports anywhere in the world, along Jeff, Wi-Fi access or internet access. And none of the groups I've worked with have gone and said, I want to use a different product. Nobody has come back and said that. It's a little more expensive than some of the rings out there, things like that. But it's just a wealth of information that's better. I think I agree with what Glenn said. If you have any desire to incorporate that into your practice, once you get that result staring at you, hey, my patient has sleep apnea crap. You got to do something about it. So that's when you're going to say, hey, I need to find an ENT to work with. I need to find an allergist to work with. I need to find my functional therapist to work with. Hey, I need to get my skills better. What am I going to do for this patient? So it is good to get into, but it does open up this whole can of worms, which I enjoy. And not everyone's going to enjoy that. So ask yourself, who are you? Do you want to open up that can of worms? Do you want to be that person? Yeah. And for people listening out there, in my practice, I don't treat every kid for aerobic sleep disorder breathing. When a new child comes into my practice, I don't need to give them a full pediatric sleep questionnaire in my opinion. I just ask, Mom, how I look at the kid. I listen to the kid. You want to do a favor for your patients, folks. If you don't know anything about sleep, airwear, whenever you have them in the chair, reclined like they are when they're sleeping. And you're doing your exam. Just listen. Just listen while you're examining them. You'll sometimes hear the, you'll hear them laboring breathing, just sitting there in the chair. And I'll pause. I'm behind them. So mom and dad, I'll point to them and they'll be like, I point to my ear. And everybody in the room is quiet as I'm doing my exam or supposedly, and they'll hear it. And I said, how do they sleep at night? Right? And you can answer those basic questions. And if you don't know what to do with it, go to your EMT. And I pray you don't have an EMT who just gives them drops because they invariably, right? Like, I asked my EMT. And you can, please, you go. No, it's interesting what you said. It's like many orthodontists don't like to engage in this. You just can't send a sleep apnea patient to a standard EMT because they're not airway focused. And you know, I sometimes I would send a kid with sleep apnea or an adult with sleep apnea to like, if I send her to 10 EMTs, eight of them will do nothing. Like they'll just say, go home, you don't even have sleep apnea. They'll look at the RDI and say, they're going to look at an RDI. You don't even, they'll tell the patient the opposite of what I said. You don't even have sleep apnea. They'll tell the patient. The patient comes back to me. The EMT said, I don't have it. And then that's what I realized. Oh, wow, you know, it's, it's, and it's that they're not the once again, they're not evil, they're not trying to do harm. They just don't know. They haven't seen that treating that RDI makes that kid better, happy, calmer, more focused and sleep better and, and, and, and be more energetic during the day. They haven't seen it. And so in their eyes, they learn sleep apnea is an AHI. They must have oxygen drops. It must be relatively severe. Otherwise, we don't do anything. Yeah. And I, when I was in Stanford, like I said, with my EMT side by side with me, while we watch Zaggy in order, Yun and Stanley Lou and all these great speakers, I said to my EMT, I said, why do the vast majority of patients who come into me who came from an EMT? Why are they always pushing drops? Why are they not just doing a simple, you know, adnoidec to be or turbanectomy or whatever it might be? And he said, honestly, the overwhelming majority of them were never trained at operate properly. I go, what do you mean? They're EMTs. He goes, that's not the focus of most EMT training. It's not operating. It's managing symptoms and dealing with stuff. And if they don't go to the OR at some, they're not going to be comfortable going to the OR at some. And he goes, so, so he says, that's number one. I think insurance reimbursement is so low for these things people. You know, he showed me how much he gets paid for adnoinec to me or a tonsillectomy. You would be shocked to see how little they often get for these. And so my surgeon, Dr. Dale Aimer, who I'll give a shout out to out of Dallas, he'll do this stuff. But if you saw what a lot of these people are getting paid, they're not incentivized to go in and treat these kids. They look at you go, I'm for a few hundred dollars. Because I'm not going to risk treating this kid for next to nothing. And I can't say I blame them, but that doesn't. And the sad thing is what you said earlier. Now that I have my own CBCT and I scan patients after adnoidectomy, I realize, oh, wow, I can see which surgeons can operate and which surgeons can't. Because the mom will say, I say, oh, it's the tonsils and the adenoids are here. They're just taking out two weeks to go, Dr. Rahma. I said two weeks to go and I try to cover it up a little bit. I say, oh, maybe they're much larger before. I have no idea, but there's still people. They're still there, right? And so I, and then what do I do? I don't say anything. I just fade away. So my network goes to people where that doesn't happen. Yeah, exactly. And I always tell parents what's happened in the past certainly helps tell the story, but I'm focused on the future. I'm focused on what we're going to do moving forward because what we've done up until this point has gotten us here, but you're here for a reason. So let's, you know, and most of the time this is a seven year old kid who's coming for their first exam with me. And you know, I'll go back to the watchpad real quick. It's just because you, to be clear, the watchpad is a watch with a pulse oxymeter attached to it. So they put it on their finger. They wear it on their wrist. And it has a wire that's probably about three feet long that has a microphone on it that they attach up by the jugular notch area. So while they sleep for one night, they punch in a pin coat as an app on their phone. It's a single use item though. It's a shame because it's a really well built thing. They start their test. They go to sleep and when they wake up in the morning, they end the test. And it's automatically uploaded to a sleep physician. In my case, it's a nil. He reads the report. And I'm going to show them real quickly here if you don't mind just to get an idea of what a report looks like. If you're watching this, you'll see the report that's been generated. I took the patient's name out of it. But hopefully you can, they can see this. Can you see the nil? Yep, I can see it. Yeah, so it's basically a report with a diagnosis. I'm not getting into the details about this. It goes to all the other things related to it. And then you'll start seeing the numbers, right? And again, total sleep time and all the events. Again, the goal here is not to get into this in a big way. I just, it's going to, it's going to monitor body position and snoring by body position, oxygen saturation. So when we talk about treating people, when I show you something on this report, Glenn, where do you look at this report? Go to the AHAI RDI. See this is something that a lot of ENTs would call normal. The AHAI 3% is 3.8. It's under five. Oh, that's normal. You don't have sleep apnea. So look at the RDI. It's 12.5. The American Academy, the ICSD International Classification Sleep Disloaders 3rd Edition says that if you have an RDI greater than 5 with symptoms, it's sleep apnea. So the RDI is a very important part of the treatment. So this was formerly called Upper Area Resistance Syndrome, AHI, less than five, RDI greater than five. But here's the thing, scroll down now. So this, most ENT surgeons will call this normal. Scroll down, scroll down, now stop there. Look at that hypnogram right there on the bottom, at the very bottom, look at that hypnogram. Look at how many times that person is waking up, wake up, wake up, wake up, wake up, wake up, wake up. Look out, every time that line goes to the top, that means that person woke up. And it should be no more than once or twice during the night. Look how fragmented that sleep is. And so that's the whole point. Maybe they're not gonna get a hard attack or stroke or anything like that, but they're gonna be miserable. - Yeah, the pulse rate rising numerous times around night, snoring by body position, you can see. So what I'm getting out of your focus is-- - But if you look, if you overlay this snoring, you'll see that on the snoring, wherever the snoring is, look how fragmented that sleep is. That's where the rousals were occurring. The awakenings were occurring. Do you see the snoring? Look down now, all the way to the where the awakenings are all the way down. You see that, the three awakenings there? Now look at the next cluster, sloring. The second cluster, you look at that, you see that? And then look at the next cluster. And then like the final cluster, you see that, they kind of overlay, does that make sense? And so, the watchpad's a beautiful test because it kind of, you get good at it. I've got a video on YouTube that says how to read 10 watchpads. And you can, you know, someone can always watch it. They can become an expert at it. - It's a great video. It takes 10 consecutive watchpads and shows you how to read them. Or how he reads them. And so you're getting a report with each one. I know people want to know how do they order one? Do they just do it through you? Do they do it through somebody else? I know how I get mine through you. And I buy them in boxes of 12. - Yeah, there's different ways of doing it. They can get it through us. Boxes of 12, case of 48. They can get it on their own from the company. And I can just read for them too if they want, right? Most people, about 80% get it through us, 20% get it on their own. We don't care. You know, like, you know, whatever it works for them. And then I'm licensed in like 20 states or so. And if not licensed in your state, I'll get licensed in your state. But I'd like to think that I act more than just, I read your studies. They can call me. They ask me questions here. They're not very often. But you know, like I said, find a mentor, find people that you can interact with and ask questions for. Right? Hey, hey, Nia, I got this patient. It was moaning. I made an oral appliance for them. They're still moaning. Try CPAP. (laughing) I mean, you know, it could be a simple, see see, it could be simple questions that come my way, right? And, and, yeah. And, and, and just, as we start wrapping some of this, I know you've been so generous with your time. I just want to tell people a quick, two quick stories. Number one was my daughter. I was an ortho residency and before ortho residency, I started, well, it's, it's kind of a fun story. Before ortho residency, I had been introduced to the concept of sleep disorder breathing in airway. We were talking 15 years ago. And, I didn't really listen. You know, I thought it was BS. I was the most ardent, non-believer in this. And, I was a general dentist at the time. And, I, this is garbage. I saw Jeff Rouse speak at the American Academy across the, a, a, a, a, I think it was, oh no, American Academy of Restorted Dentistry. On the triad of, Bruxism, sleep, and I figured what the third one was. It was Bruxism and sleep disorder breathing, the third thing that, and maybe wear of teeth. I don't remember what it was. But, I like, this is garbage. This isn't real. Then, when I was an ortho residency, he came to speak at the Panky Institute. And, he said, "Hey, Glenn, what, this night, why don't you bring your residents with you after I'm done with my lectures? We'll meet at my place. I'll repeat this for everybody, and I'll go through all the sleep literature for you." So, I asked all 21 of my residents and my faculty if they wanted to come and be that night for free. Just to sit with a guy who really knows the literature. Two people showed up with me. Two. And then, I still didn't buy into it. And then, I moved to Dallas after I graduated in 2014. And, shortly thereafter, there was an airway symposium here in Dallas, run by Jeff Rouse. And, I went to it. And, for the whole day, I listened to all the lectures and I still didn't buy into it. So, if there are people out there who don't buy into this stuff, I was there, folks. And then, one day, one day, Rebecca Bach, I'm my mentor now, who was my associate in practice at the time. She had said to me, "Glenn, just shut up and do this stuff. Just don't learn it. Watch the impact you make in these kids' lives. You've been on the fence with this now. You've been sort of like the old saying is, "How do you give a message to a person who has two black eyes?" You don't. They've already been told twice. I was already told three times that this was scientifically voweled. And, three times, I ignored it. And, if it wasn't for my good friend, Becca, a decade ago to say, "Glenn, shut up and start doing this. I did it. I never look back." And, the second part of it I want to share with people is, when I was going through the process, I bought into a little bit kind of, so my daughter, who was snoring, and wasn't really herself when she woke up in the morning, I said to my wife, "Well, I went to residency, I said, take her to an ENT." And, we got the name of the quote, unquote, "best ENT" in the Miami area. So, I come home from school, my wife is there with our daughter, and my wife says, "E-N-T looked at her, said she's fine." I said, "I know she's not my hearing snoring, I know it's an issue." So, we found a second ENT that was recommended to us, and she took it to the second ENT. Well, when I came over and worked at, from school that day, now she was pissed. She was angry at me. "Glenn, you're wasting her time. I went to a second ENT, and they said she's totally fine. If you want to take her to a third person, you take her yourself 'cause I'm done." And I took it to a third surgeon, by that point, I moved to Dallas. I took it to the ENT myself. Dale looked at her, the surgeon I worked with looked at her in a third, because it goes to Adenoids or Massive. We need to remove these. Remove them, it changed your life overnight, and it illustrates the fact that not only are orthodontists not on this journey, but the, the AHN, the American Academy of Head and Nex Surgeons, changed their protocols, what, like five years ago, it used to be you couldn't do an adenoid, A-N-T, a T-N-A, unless they had like seven, you know, bouts of 101 over a three year period, and then they suddenly changed it, and put in the words, "Or for airway." And that changed everything. And there's something that, you know, medical fatigue is real, Glenn. Like you, like, if you do this incorrectly, like one of the reasons why I like doing dental expansions, age five and six, and then what's gonna happen, they're gonna need a skeletal expansion later. But if you subject them to too many office visits, too many procedures, you're using up your capital, and you need to save it, you need to be like a, you can't send them to a bunch of doctors that don't do it correctly, or at least, you know, not the way that you wanted them to do it, right? You have to really like, this is what I want you to do, A, B, C, that's it, and each person does their part, and then what happens is, hey, they're on the same page, the patient gets whatever treatment, they start seeing the results, and then it's a win. It kinda, and you got, you maintain your ammunition for if they ever need MMA surgery or something. - Exactly. And so, we're not gonna get into run-on-monometry, which is really cool. - Yeah. - And once you learn how to read run-on-monometry, it's amazing. Do you mind just taking two seconds and explaining the different brainwaves that people have when they sleep and what they mean? 'Cause when you explain that to me, again, it just illustrates how little we know as orthodontist, 'cause we don't get taught this stuff. - Oh, okay, well, you got, right? - Like theta, like theta. - When you close your, well, you got 80 billion neurons, they're all firing at different speeds, like just like cars in the road, different speeds. The neurons that fire the slowest, the EEG picks those up as delta waves, that's what you see in delta-sleep, slow-wave sleep. The neurons are firing a little faster, make theta waves, that's what you see when you're drowsy and attentive, zoned out daydreaming. The neurons that fire the fastest, make theta and gamma, that's when you're problem solving, thinking, concentrating. But the ones in the middle, that's when you're awake, calm, alert, eyes closed, that's when you're meditating, that's alpha. And so, you're not thinking like beta and gamma, you're not sleeping like theta and delta, you're just being in alpha. And so, I always tell patients, hey, you want, you kind of want to be, you want, you know, you want the sun in the day and the moon at night, you want alpha during the day and delta at night. And if you deeply ate from that, sorry, my dog is barking to get in the room. If you deeply ate from that, then it can, it can sometimes leave the problem. - Yeah, and what people don't realize is that sleep happening at night is often, and more often than not, problematic breathing during the day. And these, this, right, so, we talk about, oh, I have a night appliance, I wear. Well, that's great. What are you doing during the day? You don't have to be laying on your back, necessarily to experience reduced air flow, desaturated oxygen, right? All these things that go along. And so, before I let you go, I want to tell everybody out here, first of all, thank you, and Neil, for being here. From the bottom of my heart. - Thank you, Glenn. You're amazing. - Amazing show. - No, no. - Content. - I'm, I'm, I'm, I'm so, I'll be the first to admit that everybody here, how little I know, and I've been doing this for a decade. We have to be humble about this, folks. We have to open up our minds and realize, we are a very small part of a much bigger puzzle. There are so many voices out there, some you can agree with, some you can disagree with, but we need to have a humility to understand that we are just part of a team. Don't make promises that are grandiose or unachievable or ridiculous or not found in science because everybody in Earth was watching. And they tell me, "Oh, did you see someone's host today? That's why I don't do this." And so for those of you who see those posts and say, "That's why I don't do it," I call BS, all right? Just because you don't like the way someone acted doesn't mean you should close down to the science. And if you're really close-minded, you'll find a hundred things that me and Anil spoke about. That you'll have a problem with. And you'll turn into problems that don't exist. But if you really, really, really get people of science, if you really want to help the children that we know for a fact you're seeing every day, if you really want to help the adults who are begging for solutions in your practice, but don't know how to ask, just get started with this. And if people out there are interested in it, you know, I've been poignant the idea of having another airway meeting that I would or not an Amarpe meeting, not an Expandor meeting, but to understand to bring people like you and Anil into the conversation so they can learn, "Where do I start? What are the modern modalities?" I did it in 2019 for my summit. And if enough people hit me up on DM and say they want another one, I will run another meeting that I will beg you to speak at Anil. Oh, my pleasure. So, just anything I say there that you disagree with or you agree with before I let you go? No, no, wonderful test. I think my dog is trying to break down the door. Okay. Well, it sounds like your dog's airway is really functionally well, which is a good thing. Yeah, I said, take a giant fluffy samosa. I love samosa. Don't get me started. But I just want to say to everybody out there, keep an open mind. Let's not debate this alone. Let's debate. When I said, you know, you're earlier, but I think we need that others in it. Let's get others in this conversation. And please reach out to me. If you think the idea of wanting to learn more is what you want, I will put something together. And Anil, I'll let you go rumble for the dog breaks down the door. Okay. And I'll just say that if anyone wants to contact me, my phone number and email are on, you can just put it www.sleepandbrain.com, and my info is under contact. That's the view I want to reach out. We'll make sure it's shown as well, and that everybody will be able to get a hold of you. And again, Anil, thank you for the time. They really appreciate you. And I'm always here if you need anything. Thanks, Glenn. All right.