2009

A new year… 2009!  This promises not to be a normal year for most people.  We are on a train that is heading into a recession that has not been seen in this generation.  I live in Houston, which historically has been guarded against downturns in economy because of the oil industry.  When it does get hit with recession, it is usually delayed six months to a year.  The year is up and I am certain that this recession will definitely hit Houston this year.

 

My observation is that the baby boomer generation grew up with the depression generation.  We heard all the stories, we heard about how to live with it, we heard what people did to deal with it, and we heard the effects it had on our parents as they try to live with the prosperity of our generation.  Growing up, I have thought it was a bunch of baloney because I cannot understand how it could possibly be a reality.  This was affirmed during most of my working career until just a few months ago.  Now, all of a sudden everything my parents said about the depression has come to mine as I am trying to think of strategies to adapt to this economic downturn.

 

The generation that will be hit the hardest of course will be the generation after us.  They are in their 20s and 30s now and they have never known what is like to be in a recession and they have never even heard the stories from their parents like we have. They are at a complete loss as to what to do.

 

The reason why I have mentioned this is because one of the things I have been thinking about in response to this recession is the amount of stress that is going to be generated among my patients.  The stress is one of the major contributing factors to a TMD and facial pain with headaches.  Therefore, I am expecting a large increase in patients in the next few years.  What will add to this stress and to their misery is the fact that they will not be able to afford any type of health care.  That will be the health care provider’s challenge in the next couple of years.  How to compassionately deliver the health care needed to people who do not have the money or resources to enter into that type of care.

 

So, that is the type of environment we enter into 2009 as we face some of these challenges.

 

God Bless,

Dr. Ron Prehn

CPAP Failure

The CPAP machine that people have to wear at night, is a box that goes by the bedside and blows air down the hose into the mask on the face.  The purpose of the CPAP machine is to open up the collapsing airway while the patient sleeps.  Compliance with the CPAP nationwide is approximately 52%.  The main reasons for noncompliance are leaky masks and discomfort with the straps.  There are many other reasons too numerous to mention here.  The main point is that 48% of people who need to have their airway open at night do not and are slowly dying from lack of oxygenation and pressures on the heart from the collapsing airway.

 

Dental Sleep Medicine is the leader in sleep disordered breathing.  A dental sleep specialist such as myself can offer several different options to open up the airway at night.  I start with a mandibular advancement splint.  This advances the mandible (lower jaw), which also advances the tongue and thereby opening up the airway as the base of the tongue moves forward.  These are extremely effective and even more effective when compliance is considered, than a CPAP machine.  There are side effects from this mask that need to be considered, which I can deal with because I am also a board certified orofacial pain specialist, but any dentist who is qualified to do these appliances can also deal with the side effects.

 

Because of the side effects, some times mandibular advancement splint cannot be used.  Then we have another option available and that would be to make a nose pillow interface where we are able to attach nasal pillows to the oral appliance so that the CPAP machine can be effective in opening up the airway.  The CPAP machine is connected to the nasal pillows via the hose. All the obstacles of the CPAP machine are eliminated because now we have an interface that does not have a mask, does not leak, and does not have straps.  It is secure and the patient is able to move about at night without leakage of the mask.  These are very comfortable and my patients are grateful for this option.

 

Sometimes if the pressures are too high because the person has a very collapsible and very small airway, the nasal pillows cause leakage to the mouth.  Because of the collapsing of the airway, the pressure will go out the mouth and thereby causing the pillow interface not to be effective.  I also have an answer for that.  We make a custom mask based on a face impression.  We make a mask that molds to the face and then that mask is connected to the oral appliance.  Now we have a custom mask that fits the face perfectly and does not move or shift.  There are also no straps with this so that the compliance is close to 100%.  This is the ultimate solution for a collapsing airway.

 

The final solution for a small airway and sleep disordered breathing is orthognathic surgery.  This is the only “cure” for sleep disordered breathing.  Orthognathic surgery entails advancing the mandible and the maxilla by cutting the bone and advancing the jaw and securing it together again.  This permanently opens up the airway because as the mandible is advanced, the tongue comes with it.  This is a drastic solution; however, there is an application for this, for example, a 25-year-old with sleep disordered breathing.  Why should he have to wear a CPAP or mandibular advancement appliance the rest of his life when this problem can be cured with surgery?

 

Therefore, the dental sleep specialist is able to solve any obstacle that comes in the way of a collapsing airway at night.  We can take it from the very simple oral appliance all way up to the custom mask and then beyond to surgery.  Only the dentist can offer all these options to the patient.  A caveat to all this is that only a physician can diagnose obstructive sleep apnea, which requires the team of a dentist and a physician in treating this complicated disorder.

 

God Bless,

Dr Ron Prehn