Episode 39: Dental Solutions for Snoring and Sleep Apnea

Eon Engelbrecht E-Radio (0:04 – 0:52)

Hello and welcome to Save Your Money, Save Your Teeth. It’s the go-to podcast where curiosity beats dentistry, and we’re joined as always by the expert Dr Clifford Yudelman from OptiSmile. He is helping us to take a deep dive into the world of dental care from a consumer’s perspective.

So, if you’re looking to brighten your smile or protect your wallet, we have got you covered with practical tips, practical advice and the latest insights in this podcast. So do stay with us as we uncover the secrets to maintaining both your dental health and also your finances. From last week’s podcast, in which we spoke about sleep apnea, today we continue with part two.

Dr. Yudelman, welcome back.

Dr Clifford Yudelman – OptiSmile (0:53 – 1:14)

Thank you very much, and I hope you had a great week, and it is good to be back. Thanks very much. The official title for today’s podcast is Dental Solutions for Snoring and Sleep Apnea, more than just a good night’s sleep.

So hopefully, that’s catchy and that’s how people found us for today’s podcast.

Eon Engelbrecht E-Radio (1:14 – 1:24)

Great, I like it. And I want to ask you, Dr. Yudelman, how do dentists actually get involved in diagnosing and managing sleep apnea and snoring?

Dr Clifford Yudelman – OptiSmile (1:25 – 4:03)

Yeah, look, dentists are often the first to notice oral signs of sleep apnea. To be honest, since I got diagnosed with sleep apnea when I was 48, 16 years ago, since then, I’ve done a number of courses and I’ve actually put a question on my medical and dental history. It just says, do you snore or has anyone noticed that you stopped breathing during the night?

So that’s the easiest is just to ask people, do you snore? You ask everybody, do you snore or get complaints of snoring? Has anyone noticed that you stopped breathing when you sleep?

But we sometimes, if someone hasn’t answered that, anytime anyone complains of teeth grinding or I see where people have been grinding their teeth or bruxism as it’s called and their teeth are wearing down, I will often refer them for a sleep study to check for sleep apnea and severe snoring. And there’s other things like dry mouth. And so dentists are also involved because they can refer patients for a sleep study.

So I’m actually recording this podcast from the practise today and I just saw the lady from the sleep clinic, Melissa from Farina Associates. She comes in sometimes on a Thursday or Friday to do sleep studies for patients that have contacted us or for patients of the practise that have this problem. And they don’t come and sleep here at the practise.

These are home sleep studies. So that’s what we’re talking about. And so based on signs like if we look at a patient’s throat and they’ve got very swollen tonsils or a large tongue, sometimes scalloping of the tongue, if their jaw alignment or their arches are very narrow, like from orthodontic problems, we can spot some of these signs and ask them further.

And then dentists are also the only ones that can provide proper oral appliances, something called MAD or M-A-S, which a lot of people prefer these days because MAD doesn’t sound very good. So mandibular advancement device is a MAD or mandibular advancement splint, which is the same thing, but that’s M-A-S. And you can use that to manage mild to moderate sleep apnea.

So severe sleep apnea, a CPAP machine is still the answer.

Eon Engelbrecht E-Radio (4:04 – 4:12)

Okay. And what role do mandibular advancement splints play in treating sleep apnea?

Dr Clifford Yudelman – OptiSmile (4:13 – 5:23)

So they’re very, very effective. What they do is they help to keep the lower jaw forward, which pulls the tongue away from the back of the throat. So if you’re lying on your back and your jaw, your mouth drops open, your tongue falls back and it blocks your throat.

So that’s really where most sleep, almost all sleep apnea or obstructive airway disorder or disease comes from. It’s not from having a crooked nose or having sinus problems or your uvula. It’s the tongue falling back.

And funnily enough, your tongue, the main attachment, your tongue is just a muscle and that’s actually behind your lower front teeth. That’s where your tongue originates. And so by pulling the jaw forward and stopping it from dropping back, that stops the tongue from blocking the airway.

And they use as a comfortable and a less intrusive alternative to a CPAP or an APAP machine, especially for people with mild to moderate sleep apnea. And they’re adjustable and customised to the patient’s mouth, making it a convenient solution for long-term use.

Eon Engelbrecht E-Radio (5:24 – 5:34)

Okay. And then Dr. Yudelman, let’s talk about oral appliances. How do they work for sleep apnea and exactly how effective are they?

Dr Clifford Yudelman – OptiSmile (5:35 – 6:58)

So the main oral appliance is the one we’re talking about, this mandibular advancement splint. There is another oral device that I did buy one online once. It’s called a TRD or a tongue retention device.

And it looks like a mediaeval torture instrument. It’s like a suction cup that goes on your tongue and it pulls your tongue out of the back of your throat. You sort of suction cup this on and it then pulls.

It’s like a baby’s dummy in reverse. But basically, back to mandibular advancement splints or devices, they’ve been very, very well studied. They reduce snoring.

They improve sleep quality. The compliance rate is generally higher than for CPAP machines and they’re comfortable and they’re portable. It’s just like a bite plate that you use to stop you from grinding.

It fits in a little box. You can wear it on the aeroplane. So people don’t think that the engines are failing.

If you do fall asleep on the plane and you start snoring. I use a CPAP machine and one of these devices depending on where I am and so on. But on an aeroplane, you can’t really use a CPAP.

So people with sleep apnea really suffer when they travel.

Eon Engelbrecht E-Radio (6:59 – 7:10)

Yeah, that was quite funny about the engines. But anyway, how do dental devices compare to these CPAP machines, Doctor, in terms of comfort and efficacy?

Dr Clifford Yudelman – OptiSmile (7:11 – 9:31)

Comfort we already spoke about. There’s no need for a mask or a machine that you have to plug in and a hose. I don’t want to bad mouth CPAP machines because of the efficacy, the CPAP.

So CPAP stands for continuous positive airway pressure. They’re no longer actually CPAP. Some people use a CPAP, but now it’s APAP, which is automated positive airway pressure where instead of continuous, there’s a computer in the device, and it changes the amount of pressure.

But they’re still the gold standard for severe sleep apnea. But more and more in the U.S. and other countries, oral appliances are becoming the go-to, especially for mild sleep apnea. If someone’s got mild sleep apnea, or sometimes we have patients with very little sleep apnea, but severe snoring, that works really well for that.

Then, the cutoff, the international cutoff for mild, is between 5 and 15 times an hour that you’re not breathing. And 5 or less is normal. And then 15 to 30 is moderate, and then over 30 is severe.

And we actually, when I work with Melissa from Furrian Associates, we agree that anyone who has an AHI or apnea hypopnea index under 25 will probably benefit from a mandibular advancement device. And people over 25 and definitely over 30 should always try to use a CPAP as their first go-to. But there are patients who just cannot tolerate CPAP, and they’ve got AHRs that are a lot more serious.

And rather than not doing anything, they get a lot of all the health benefits from a mandibular advancement device. Even though it’s not as effective, it does reduce the sleep apnea to a point where the sleep apnea won’t affect their health as badly. And the compliance of these devices tends to be better according to research and from what I’ve seen.

Eon Engelbrecht E-Radio (9:32 – 9:45)

Just a quick question on the CPAP machines. In terms of your partner, are those machines noisy? Will they disturb your partner when you sleep with one of those machines?

Or is it less disruptive than snoring?

Dr Clifford Yudelman – OptiSmile (9:46 – 10:46)

No, no, it’s much less. So I’ve had three machines in the last 14, sorry, 16 years. And the first machines that came out were quite noisy.

They sounded a bit like a Darth Vader. You could hear the air going through the machine. That’s quite scary.

But maybe I’m going a bit deaf. In fact, I am going a bit deaf. But when the machine is on, I don’t even know it’s on.

I’ve got to lift up the mask just to check that there’s air coming through. But I don’t hear it at all. And my wife doesn’t complain.

And also, it’s way less noise than any snoring. And I want to say that the machines are getting quieter and quieter. So it’s less noisy than if you’ve got an aircon on.

You’ve got some white noise or background noise. And it’s got a continuous like a whooshing sound. But you don’t hear that breathing, that sort of hollow Darth Vader noise anymore.

Eon Engelbrecht E-Radio (10:46 – 10:47)

That’s very scary.

Dr Clifford Yudelman – OptiSmile (10:48 – 10:48)

Yeah.

Eon Engelbrecht E-Radio (10:49 – 10:54)

Thank goodness they’ve done away with that because that could be quite scary, you know, in the dark.

Dr Clifford Yudelman – OptiSmile (10:56 – 11:03)

Luke, I’m your father. There are more Star Wars fans out there.

Eon Engelbrecht E-Radio (11:03 – 11:16)

Oh, that’s funny. Okay. So, Doctor, also, you know, for those concerned, any risks or complications associated with the mandibular advancement splints?

Dr Clifford Yudelman – OptiSmile (11:16 – 13:41)

There used to be a lot more problems. Most of the complications that we see now are very mild, if at all. I don’t really see too many complications.

If we have a patient who has TMJ problems or temporomandibular disorder, we will often send them to the physio. We have a special physio in Cape Town that specialises in treating this. Her name is Trish Lang.

She’s in Bree Street. And she often sorts people out in three visits. If we’re going to make someone a bite plate or they’re going to get Invisalign or they’re going to get a mandibular advancement splint, we’ll send them to Trish first.

But even patients who’ve never had jaw problems, they can complain in the first few weeks that their jaw is a bit stiff in the morning because it’s being held forward. We don’t force it all the way forward. In fact, the device, we measure your teeth, your jaw in a backward position and a forward position, and then we set about 60%.

And then the devices that we make are all what’s called titratable, which means we can adjust them forwards or back. So we adjust your jaw forward if it’s working, but not as effective as it could be. And we adjust it back if your jaw is bothering you.

And we notice every millimetre, you can move it back a millimetre and the wife can complain of snoring, but your jaw feels better. Or you go home with it, there’s no jaw problem, but there’s still some snoring or apneas. And then we move it forward even one millimetre and that can get rid of the problem.

But the devices that we make, we’re able to move backwards and forwards four or five millimetres either way. If for some reason we didn’t scan you in the right position. It used to be a big problem with the teeth fitting together, bite changes, people could, their whole bite could shift.

But these days we make them with a digital scan. We use our iTero or Invisalign scanner and they’re super, super accurate. So they actually keep the teeth in place.

If you had Invisalign or orthodontics and you could use one of these instead of your retainers to keep your teeth from shifting. So the complications we used to see in the past, we just don’t see anymore.

Eon Engelbrecht E-Radio (13:41 – 13:42)

That’s good.

Dr Clifford Yudelman – OptiSmile (13:43 – 13:52)

And certainly nothing like the complications of having untreated sleep apnea, even if it’s moderate or severe, there’s so many bad things that can happen.

Eon Engelbrecht E-Radio (13:53 – 14:00)

I was wondering, can a dentist actually tell if you have sleep apnea just by examining your mouth and your teeth?

Dr Clifford Yudelman – OptiSmile (14:01 – 16:18)

Yeah. So like I said earlier, you can’t diagnose sleep apnea from looking in someone’s mouth, but certainly by asking them about snoring and then looking in their mouth will often see signs of teeth grinding, worn away teeth, the narrow airways. There’s something called a melampaticore and I’ll try and spell it.

You can Google it. It’s M-A-L-L-A-M-P-A-T-T-R, something like that. And it’s when you look at the back of someone’s airway, if they go, ah, and they stick their tongue out and you can see everything, the uvula and the tonsils and everything, that’s a score of one.

But if someone opens their mouth and sticks their tongue out and goes, ah, and all you see is tongue and you can’t see any airway, that’s a score of four. But that’s also makes you a lot more suspicious of, like if I haven’t asked anyone about snoring or they didn’t mark it and I’m looking in their mouth and I always check their tongue in the back of their throat and if I can’t see the back of their throat, I ask them, oh, does your wife complain about a bit of snoring every now and again? And then like we said last week, oh, only when I drink red wine.

Oh, how often do you drink red wine? Oh, every night. Okay.

Well, there’s your answer. So the other thing is large tonsils and that little uvula, that little dangly thing that hangs from the back of your throat. If you’re making vuvuzela sounds all night, it’s that little uvula that’s working overtime that’s dangling at the back of your throat and that can get very elongated and very inflamed.

And so dentists’ main role is screening patients and raising awareness about potential sleep issues. Sadly in South Africa, it’s becoming more and more, there’s more and more awareness. I’m on a few WhatsApp groups and there’s a South African Association for Dental Sleep Medicine.

I’m on the WhatsApp group. I’m not a formal member. I don’t attend any of the latest webinars or anything to follow them.

And I believe that’s what it’s called. I can post some further information in the show notes.

Eon Engelbrecht E-Radio (16:19 – 16:30)

Okay. Yeah, that will be great. And Dr. Tellers, what should patients expect when they come to you at OptiSmile for a consultation about snoring or sleep apnea?

Dr Clifford Yudelman – OptiSmile (16:31 – 18:41)

Actually, we used to get the patient in and check their teeth and check all the things that we spoke about. But to diagnose it fully, you need a sleep study to confirm it and also to develop a treatment plan and to know what the AHI is. So when patients call OptiSmile or we’ve got another website called Apnea Sleep and also on our main OptiSmile website, we’ve got a section under problems for snoring, the apnea sleep information.

Basically, we always give the patients Melissa’s number and they go up to Millerton Sleep Clinic and get a machine for a home sleep study. Or I just waved to Melissa now. She was leaving with a patient.

I’ve never seen that patient before. It’s somebody who must have contacted the practise and said, my wife complains about snoring. And my receptionist would have given them Melissa’s number.

So I will see, a lot of them have their own dentist. They’re not looking for a dentist. They’re looking for a snoring cure and or treatment.

So we just kindly give them Melissa’s information. We don’t charge people for that or we don’t charge Melissa to use our rooms. She sends a patient home with this home sleep study computer that they rig up.

She shows them. It’s very straightforward. You take it home.

You sleep with it. You put it back in the little bag and you bring it back here and she picks it up on her way home the next day and puts it in the computer. She sends you a report, your doctor report, and we get a report as well.

And a doctor, a physician that specialises in sleep medicine has to read that report and make a recommendation for a mandibular advancement splint or for a CPAP or says that it’s nothing, it’s just snoring and your airways are fine. And then in those cases, like I said, mandibular advancement splint will work very well.

Eon Engelbrecht E-Radio (18:42 – 18:51)

Okay. And then can dental appliances be used alongside other treatments like CPAP? How do they work together if possible?

Dr Clifford Yudelman – OptiSmile (18:56 – 21:11)

Most of the time, it’s people who are severely obese. You don’t have to be obese to have sleep apnea, but if somebody is very, very heavy and a really large diameter neck and they have an AHR upwards of 40 or 50 or 60, it means the airways, as soon as they lie on their back, the tongue is so big and the airway is full of basically adipose tissue or fat, that the airways become very, very tiny. The CPAP machine adjusts the pressure automatically.

And in a case like that, the CPAP might have to pump out a very high pressure, like 20 millimetres of water or mercury. I’m sure it’s water. The pressure is 20.

For example, my airway isn’t that bad and I’ve set my CPAP to go between four and nine and I cut it off because if for some reason the pressure starts going higher, if you haven’t set it properly, you start getting a leak in the mask because the pressure is so great and it gets uncomfortable. So those types of patients can benefit from having a mandibular advancement splint and then a CPAP machine on top of it. But I think that’s more in the States.

I can’t remember any time that I’ve made a mandibular advancement device or splint for someone who’s on a CPAP to use together. But a lot of patients on CPAPs want a mandibular advancement device or splint to use when they travel or they’re just tired of wearing it or they find that it gets in the way and a splint, they didn’t know it was even available. Some of them have mild or moderate sleep apnea and somebody sold them a CPAP or prescribed a CPAP and didn’t even tell them about a mandibular advancement splint.

So that’s when people end up with both.

Eon Engelbrecht E-Radio (21:12 – 21:20)

Okay. And can you take us through the process of getting fitted for a mandibular advancement splint?

Dr Clifford Yudelman – OptiSmile (21:21 – 27:15)

Yeah. So once we’ve got your sleep study and let’s just take it for granted. You’ve got a dentist.

You’re not coming to us for your teeth. Your teeth are in good shape. We do check with you whether you are due to have any implants or crowns or bridges, anything that would significantly change the shape of your teeth before we scan you with our special scanner.

Because if you get one of these devices made and then you go and you get a new bridge or you get an implant or you have a missing tooth replaced, the device obviously won’t fit. So we do get into that a little bit with a patient. We have a look around your mouth just to check that there’s nothing, no loose crowns or big fillings that are broken, but it’s not a full exam like what we’ve discussed in our previous podcasts.

And we then give you all the information. We’ve got an informed consent form that tells you about the sore jaw and shifting teeth and things that could go wrong. It’s just a legal thing and we discuss that.

But the main part of the appointment is we scan your upper teeth and your lower teeth as if we’re going to scan you for Invisalign. But then instead of scanning you with your teeth together and your normal bites, we used to use something called the George gauge that is a special device for measuring how far back the jaw is and then how far forward. We now use every day one of those little flat wooden sticks called the tongue depressor that the Doctor would use when he looks in the back of your throat.

And we use two or three or four of those to adjust the height of how far open we need your mouth because we need space for the device to fit over your teeth. And then we have you move your jaw backwards and forwards and we listen to the, we get you to go sing the national anthem a few times with your jaw forward and back and especially some of the Afrikaans bits, you know, that I use. And if you try and with your jaw all the way forward, you’ll sound like an American that’s trying to speak Afrikaans.

The rolling your G’s just doesn’t happen. And so that’s like a bit of a hack that we’ve been doing for a number of years and it works well. I learned that from a fellow South African dentist that co-presented with me on a webinar that I did.

So I’ve been doing it that way. So thanks very much. I think it was Everett Berger that taught me that technique, but we do that.

And then we lock your bite in place with a quick setting silicon in that position. And we check with you that it’s comfortable. And then we scan the top and bottom together.

And then it actually records your jaw in that exact position. And then we use, I actually order the devices that I make at the moment are from Germany called OptiSleep. If you Google OptiSleep, not OptiSmile.

Funnily enough, I actually sold them the German company OptiSleep.com and .net because I named my apnea sleep business originally or the sleep apnea clinic, which is now called apnea sleep. I named it OptiSleep and I went to Germany and there was a huge company called Sycat, S-I-C-A-T. And they were launching this OptiSleep device, but I had the .com and the .net.

Anyway, just a little story there. Yeah, that was when I first came back to South Africa. So that’s almost 10 years ago.

So I’ve been making those. There was a period where during COVID and after where it was a real hassle to get them and they were getting held up in customs. But now that’s my favourite one.

There are some South African devices. I even developed one myself with my lab, but I have gone to making mainly these OptiSleep devices. They just make differently and they work beautifully.

We make adjustments when it comes back. That’s a perfect fit. They either fit or they don’t.

They click in. There’s a little connector. In the case of the OptiSleep, it’s a little nylon connector that pops on and off and they come in different sizes.

So usually it’ll come with a size four or five, which means that it’s 14 or 15 millimetres long. And then I’ll check that your mouth is in the right position. We send you home for a couple of weeks.

And then after two weeks, you come back, we get you to record any snoring sounds with that app called SnoreLab. And that’s good indication. It’s better than asking the husband or the wife.

And then we can adjust it forward or backwards as needed. And you’re supposed to get a follow-up sleep study with that device in your mouth, but it’s not very often that patients do that. If somebody’s got severe sleep apnea and they’re not using a CPAP and we make them a device and they’ve got heart problems and diabetes, then I would insist that they do a follow-up sleep study with the device in their mouth because you’re now talking about severe or very dangerous medical conditions and you don’t want to make one of these devices for someone and then they have a heart attack or something in their sleep because they’re getting apneas and the device is not working. But for the mild and the moderate that we spoke about, I don’t get too many patients have follow-up studies.

I do recommend it, but they don’t.

Eon Engelbrecht E-Radio (27:16 – 27:30)

Okay. And then our final question for today’s session, how do dentists monitor the success of sleep apnea treatment after a patient starts using a mandibular advancement splint, for example?

Dr Clifford Yudelman – OptiSmile (27:32 – 27:37)

Well, the first thing is the wife goes on Google and gives us a five-star review on Google.

Eon Engelbrecht E-Radio (27:37 – 27:39)

Okay, good one.

Dr Clifford Yudelman – OptiSmile (27:41 – 29:40)

When they come back two weeks later, they’ve got a big smile on their face. They look much more rested. They tell us that they’re no longer sleeping on the couch, that they’re back in the bedroom, and life is amazing.

A lot of the time, the snoring or the apnea doesn’t bother them. It bothers their partner. Obviously, the severe cases, those people, we don’t see a lot of those, to be honest.

Those patients have got so many other medical problems. They’re probably getting diagnosed when they have an operation or by an anaesthetist because it’s very dangerous if you get a general anaesthetic and you’ve got sleep apnea. So the anaesthetist, they can tell when they knock you out and they know that they can see you have a very small airway.

But basically, they’ve got a lot more energy, like I said. We use that SnoreLab app a lot. They come back with their app and they show me.

I get them to sometimes if they think or the wife says it’s not working to do one night. We like to do a week with it and then to leave it out for one night and to record and then we can listen to the recordings. To listen to the whole recording, you have to have the paid version of the app.

Like I mentioned, in some cases, another sleep study may be recommended to ensure that it’s effectively reducing the sleep apnea events, but that doesn’t happen very often. But yeah, great questions. Thanks very much.

I know next week, we’re going to do our final, final episode on snoring and sleep apnea. So if we’re putting you to sleep and you’re not interested in this, then don’t tune in next week. Otherwise, see you next week.

Eon Engelbrecht E-Radio (29:41 – 29:50)

Sounds good. And that’s a wrap for another episode. Thank you as always to you, Dr. Jeroen for sharing all this interesting stuff with us. We really appreciate it.

Dr Clifford Yudelman – OptiSmile (29:50 – 29:51)

Pleasure.

Eon Engelbrecht E-Radio (29:52 – 30:22)

And then until next time, and also just remember while we strive to provide valuable insights with this podcast, you must always consult with your own dental professional or any medical professional for advice tailored to your personal health. Do subscribe to the podcast for more enlightening discussions. Join us again next week as we continue to explore the fascinating intersection of dental health and financial savvy.

But until then, keep smiling and taking great care of your teeth.

OptiSmile Announcer (30:43 – 31:28)

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