As many of you who have been following me for the past couple of years know that I have been helping Dr. Keith Thornton on developing the custom CPAP mask.  The hours spent without any compensation are immeasurable.  I credit my staff for putting in many unpaid hours and helping us to figure out how to make this mask a viable option for dental sleep doctors and their patients.  Dr. Thornton just recently got this mask FDA approved so that we can start teaching it to Dentists.  We have also been able to work out and streamline the procedures so that it can be delivered at a fee that the patient can afford as well as the Dentist and his staff is able to deliver.

Having said that, with the availability of this custom mask to obstructive sleep apnea patients to the nation and possibly worldwide, this will completely revolutionized sleep medicine.  The biggest obstacle to CPAP machine as many of you know, is the mask.  With this custom mask, all these obstacles are eliminated.  There are no straps and no leakage.  These were two main problems with the current CPAP mask situation.  Check  my website for more information concerning these masks and look for educational opportunities for those of you who are Dentists.

I have previously commented on information source for medical professionals and how it should be taken from journals of various professions who have editorial boards and follow strict guidelines.  This source of information can be scarce when it comes to an emerging medical profession such as sleep medicine.  There are many universities and treatment centers currently doing studies in sleep medicine; however, the profession is expanding so fast it is hard to keep up. The relationship of sleep disorders to many medical conditions is emerging everyday.  It has influence on the entire body and on almost every pathology the body has.  There are not enough treatment centers and universities to keep up with how fast this profession is emerging.  So where does a medical professional go for information?

This is the second emerging field that I have been involved with in my carrier.  The first was Orofacial pain.  My observations are that in any emerging field, evidence based scientifically validated studies are difficult to come by.  Therefore a medical professional has to take the knowledge base that he has secured to this point and apply it to the information as it is coming in from several different sources.  He attends seminars with leaders in the field who are just starting to observe conditions that are related to sleep medicine.  He takes the known information that has been validated and apply to the new information, as well as what he has experienced, and what is known to determine if this is something he can use clinically.  I know for myself, I am involved in several studies in order to validate ideas and relationships in sleep medicine for current and future professionals.  People like me all over the United States doing these things and bringing them to seminars and lectures to the rest of the profession as the science is emerging.

The difficulty comes with an emerging science like this when faced with clinical decisions.  Medical professional wants these decisions based on fax and validated science so as not to do harm to the patient.  A medical professional must be very careful when interpreting signs and symptoms and run it through the filter of what is known to apply it to what the treatment will be.  Reason is because what is known is scarce.  Therefore it comes down to care, skill, and judgment of the medical professional as he makes his decisions as to how to treat the patient.  My only suggestion at this point to a medical professional is to make sure that one does not make conclusions of fact based on what is known.

 An example of this would be when it comes to imaging the airway.  With the new Cone Beam technology we are able to see the airway in great detail.  A patient may have a very very large airway and the logical conclusion would be that this person does not have an airway collapsing problem.  However, my experience has shown that just because the image is large they can still have a very collapsing airway.  This is because I know that the x-ray is a static image and sleep disordered breathing or a collapsing airway is a dynamic process.

I also know from experience that if the x-ray shows that the airway is very small, they have extremely high probability of having a collapsing airway at night.  Therefore when I make decisions as to what treatment should be done my next order of therapy would be to obtain a nocturnal polysomnogram to verify that indeed the airway is collapsing.  I will not use the image to tell the patient they actually have obstructive sleep apnea.  I will say that the image suggests that he does.  That is the way to use emerging technology in a new profession.

  Ronald S. Prehn, D.D.S.

The Internet has become the main stay of source of information in society today.  The plethora of information is mind boggling, but also without any type of standardization.  This is great for patients who are looking for answers to the medical problems as they read through as much information as they can.  It is difficult for patients when the information is contradictory or false or even worse yet…deceitful.  I am a big fan of information and I appreciate it when the patients do research on their medical condition when they come to my office.  Then I can engage them at that level and guide them into correct information and help them understand their condition.

However when it comes to research by medical professionals, the Internet is not a good place to go.  Most of the information on the Internet is antidotal at best and speculative and fantacy at worse.  There is some information that can be had on the Internet for a medical professional; however, it must be viewed with a jaundiced eye.  The source of information for medical professional should be in the literature, which is in the medical journals of various professions.  Medical journals have an editorial board and they filter out studies that are not valid and do not follow the scientific method.  The studies must be outcome based and follow a certain procedure and validation requirements in order to be printed in their journals.  Yes, there are many journals that are online and can be a great source for a medical professional and they know where these are.  Look for future blogs as I comment on source of information for emerging science.

 Ronald S. Prehn, D.D.S.

Normally this term talks about the type of speaking a speaker does.  However, when I am referring to this term in this blog, I am referring to what motivates a speaker.  I just had the incredible opportunity to speak at the national sleep meeting in Seattle June 2009.  I was able to see many speakers and learn as they spoke and afterwards as to what motivates them.  I saw many different motivations for speaking.  I saw people who were speaking simply to convey information, I saw people who spoke in order to pride fully showoff or pride fully present their research.  I also saw speakers who were speaking in order to get a name for themselves.  I am not certain if they are trying to pursue a professional speaking career or if they were just looking for acceptance and prestige among the peers.  Then I saw some speakers who I admire who were speaking simply to enhance and grow the knowledge and skills of his fellow colleagues.  These speakers were motivated enough not by pride or prestige rather than by a desire to not only help the profession, but to connect with the audience in order that they may respond by becoming better dentists and health care providers for their patients.  These speakers are the ones who I admire as I watch them present.  I also watch them after the presentation as they interacted with the audience and/or interested individuals on a one to one basis.  These speakers were accessible, friendly, and very helpful to those who were seeking what he knows. These speakers are the ones that motivate change.

God Bless,

Dr. Prehn

Rumors can be a deadly thing.  Rumors not only destroy people and destroy relationships, but they also can affect a person’s well being.  The rumor that I have in my mind is the rumor that TMJ treatment is expensive.  I cannot tell you how many times I have heard that just as a person going to the stores and meeting people.  People hear these rumors and they decide not even pursue treatment because it is “too expensive.”  They decide to suffer with it or they decide to go to the drug stores and sport stores and buy mouth guards and never even consider actually getting a proper diagnosis.

 This rumor will have an adverse effect on their overall health.  TMJ disorder, if it is related to the joint itself, is a degenerative disease that will continue to destroy the joint unless intervention is considered.  The longer a person waits, the more expensive the treatment will become.  The longer person waits, the less effect of the treatment will be.  So in reality the greatest value of TMJ treatment is to catch it early because the money spent for treatment will have the greatest effect on dealing with the problem.

 Therefore, the rumor that TMJ treatment is expensive is not only detrimental to the health, but is also very costly to the patient.  I suppose that pertains to any type of degenerative disease that patient can possibly have.  The longer they wait to get properly diagnosed, less effective the treatment will be.  That is an adverbial truth and there is no way to get around it.  Because of that, I would encourage anybody who has got any type of TMJ disorder to get properly diagnosed and to make investment of time and money early on in disorder, and start to get the most effect and benefit from the least amount of financial investment.

God bless,

Dr. Ron Prehn

I have decided to open up an office in the galleria area of Houston.  This is in the close proximity to the medical center downtown.  There is a huge need for a sleep dentist in that area and there are some excellent sleep doctors in the downtown area who are treating patients at a very high level.  If you are reading this and in that area please call the office for more information. 

 The reason I am doing this is because I believe that the Dentist can offer many options for the patient who has been diagnosed with obstructive sleep apnea.  The Physician is able to do the proper diagnosis and to manage the disorder at many different levels; however, the only physical way they are able to treat collapsing airway is with CPAP machine.  A great addition to a sleep physician’s team would be a Dentist such as myself that could open the door to many other options to treat a collapsing airway to include a mandibular advancement appliance and combination therapy.  It is a Dentist such as myself that has actually many more tools to be able to get the patient to compliance to resolve the issue of a small or collapsing airway. 

 The advantage of having a dental sleep professional on a team of sleep disorders clinic is the number of options that a Dentist has available.  We are highly trained in the head and neck area and especially the airway.  It is something we deal with every single day and our knowledge of the anatomy and structure of the mandible and airway is what we are trained to do and able to apply to any situation concerning pathology of this area.  To open up an airway for a Dentist is something that can easily be accomplished because we are able to use the dentition as anchors for various appliances.  This is something that a medical doctor is unable to do.  Therefore it takes a team approach to this problem because many times the airway alone is not the only sleep concern.  The other factors such as restless legs syndrome, periodic leg movements, and fragmented sleep by other causes that must be addressed by the sleep physician.  A Dentist working with the Physician is the best way of treating the total sleep disorder patient.

  God Bless,

Ronald S. Prehn, D.D.S.

I had mentioned in previous blogs how the only way to properly diagnose sleep-disordered breathing is to have a nocturnal polysomnograph (NPSG).  This is because sleep-disordered breathing is a dynamic process that can only be recorded while the pathology occurs.  Examination and history alone has been shown by various studies to be unpredictable in diagnosing obstructive sleep apnea.  The only way to properly diagnose is with an NPSG.

 With that information as a medical fact then treating sleep-disordered breathing such as snoring needs to have a NPSG in order to be treated properly.  The reason for this is because often times there is what they call central apneic events, which have nothing to do with sleep-disordered breathing.  Sleep-disordered breathing is a situation where the patient cannot breathe; however, central sleep apnea is a situation where the patient will not breathe.  There are some pathological, physiological events that occur that decrease the desire to breathe causing cessation of breathing.  This usually has to do with CO₂ levels in the blood and the monitoring of the CO₂ level by the brain.  The point is that if the patient is being treated for snoring or obstructive sleep apnea without an NPSG, these hidden central apneic events may be undiagnosed and untreated.

God bless,

Dr. Ron Prehn

The more a medical practitioner learns about sleep-disordered breathing.  The more her or she has to learn about the effects of this disorder.  It is the effects of this disorder that is often the clue that the problem exists at all.  Most of the sleep-disordered breathing is very subtle and difficult to diagnose.  Therefore, it is incumbent upon the investigator to look at all the effects of sleep-disordered breathing and accumulate the evidence.  The evidence will come from multisystem examination and history.  Because each of the systems investigated has its own possibility of pathology; however, it is the complete picture that will bring to bear upon the sleep-disordered breathing problem.

 For example, sleep-disordered breathing can cause an increase in high blood pressure, nocturia (going to the bathroom at night), type 2 diabetes or blood sugars problems, TIAs, hyperactivity, fatigue, drowsiness, weight gain, GERD, and other pulmonary disorders.  When asking the history of a patient, he can explain that each of these problems he has, has its own clause within its own system; however, when stacking up the evidence it is apparent that the sleep-disordered breathing is affecting all the systems or many different systems, then the evidence starts to pile up that there is a sleep-disordered breathing problem.

The issue is that often times this sleep-disordered breathing is very subtle and not apparent.  The patient does not know this is occurring because he does not actually wake up.  It occurs in the sleep stages of deep sleep and light sleep; however, the arousals from the deep sleep and the light sleep is causing many of these problems as is the pressures in the thoracic cavity due to the closing of the airway.  Therefore, it is incumbent upon the investigating medical practitioner to learn as many of the effects of sleep-disordered breathing so that he can accumulate the evidence to provide a diagnosis or at least a clinical impression of a sleep-disordered breathing problem.  The actual problem cannot be diagnosed without a sleep study because it is a dynamic problem and not a static problem.  That is a subject of another blog.

The more I learn of sleep disordered breathing and its consequences, the more I realize what a profound effect it has on all the systems of the body.  It affects the heart, the brain, the blood chemistry, the lungs, gastrointestinal, and urinary system.  It affects the general overall feeling of a person and the fatigue levels and it even puts a person in danger as the person’s ability to concentrate and stay focused is decreased with the sleep breathing disorders.  When a person goes to doctors for particular issues on an individual basis, it seems that each of the systems that could be explained the way as its own pathology.  However, when you start putting the pieces together and accumulating the evidence, there seems to be a common cause and that is sleeping disordered breathing.

When I talk to patients about their medical conditions, they all seem to explain away the medical problems they have by saying that it is either age-related or natural causes, but when we start accumulating evidence and checking out different systems, it seems to have a common causative factor and that can very well be sleep disordered breathing.

Therefore, it is imperative for a medical practitioner involved in sleep medicine to learn the effects of sleep on all the systems of the body so that he or she can start putting together the evidence of this problem.  This would allow the medical practitioner to not only convince the patient of this problem by presenting the evidence, but also to help the practitioner to actually treat these patients at a much more profound and life saving level.

When starting to understand sleep-disordered breathing, it is imperative that the medical practitioner understands that this is a dynamic problem.  The collapsing of the airway at night is a problem that occurs with changes in the pressures of the esophagus.  This is not something that can be imaged, although imaging does suggest a narrow airway and the possibility of this happening.  There is no exam for this problem that can be done without invasive techniques.  The medical problem can be brought to light by history and examination of the various effects of sleep-disordered breathing.  Once the case has been made, then the only way to diagnose this dynamic situation is with a nocturnal polysomnograph (NPSG).  This sleep study would then measure the various parameters of sleep-disordered breathing such as airflow and effort to come up with a proper diagnosis of sleep-disordered breathing.

Therefore, the examination process is basically good enough evidence that this problem exists to the point, which a NPSG will be ordered.  The goal-up of this evidence may have several purposes one of which might be to convince the patient that this problem actually exists.  The other purpose is to determine the severity.

It is impossible to guess the severity of sleep-disordered breathing by the examination history alone.

God bless,

Ron Prehn