Dr. Madan Kandula is a pioneer in new techniques for treating nasal airway obstruction, snoring, and sleep apnea issues. Read about his solutions built around addressing anatomical problems at multiple levels.
By Madan Kandula, MD
Obstructive Sleep Apnea (OSA) is the Rodney Dangerfield of medical conditions. It gets no respect, and it gets mistreated more often than it gets appropriately treated.
It’s no wonder that 80% of Americans who suffer with OSA aren’t being diagnosed. And, the 20% who are diagnosed are likely to be shoved into a one-size-fits-all box they’re not meant to fit in.
And do you know who’s doing the shoving?
The reality for all these patients is that their throats are too narrow for their bodies 100% of the time.
You (dental), me (ENT), and the man behind the tree (sleep medicine).
The current standard of care for OSA patients is a one-size-fits-none approach.
If an OSA patient walks into a sleep center, they will be walking out with a CPAP machine (probably with a full facemask) – guaranteed.
If an OSA patient walks into a dental sleep practice, there is a high probability they will walk out with an oral appliance.
If an OSA patient walks into a typical ENT practice, they will walk out with a head buzzing full of information, and a body still suffering with a broken airway.
The reality for all these patients is that their throats are too narrow for their bodies 100% of the time. 70-80% of these same patients have noses that aren’t adequately patent during sleep.
No oral appliance or CPAP machine can work properly and efficiently without a well-functioning nose. Yet how many dental sleep and sleep med docs properly evaluate and correct nasal airway obstruction prior to placing a patient into a treatment modality?
I think we all know the true answer.
Why is this?
OSA is an ENT issue that is seldom adequately addressed by an ENT. Because of medical turf battles and ENT apathy, OSA has been almost abandoned by the ENT community at large.
Who suffers? Certainly, dentists and sleep med docs looking to collaborate. Sadly, those who suffer the most are patients who are being sent down a one-way street to frustration and failure.
To put it bluntly: if a patient is tossed an oral appliance or CPAP machine and wished, “good luck,” they either learn to live with the frustration of the device or the misery of their OSA. With a malfunctioning nasal airway, they are destined to fail. This is a band-aid approach, not a root cause solution. What’s worse, patients are left feeling dismissed and hopeless. Like they’re the failure.
But there’s something even bigger at play here. Bigger than quality of life issues — I’m talking about years of life left to live. OSA is like a ticking time bomb. Every time you brush off another patient by providing them a remedy not primed for success, you’re nudging them one step closer to detonation.
Every mistreated case is one more daughter who loses her father to a heart attack before he gets to walk her down the aisle. It’s one more grandchild who will never know his grandmother because she died from a stroke before he was born. It’s one more parent who loses their battle with diabetes before their kids even graduate from high school.
Tick. We’re failing our patients.
Tick. They’re paying the price.
Tick. Because the solution is all too often doomed to fail.
Millions of people are suffering and dying from OSA and its comorbidities, but dental sleep, sleep physicians, and ENTs are so caught up in their own ways of thinking that they’ve got blinders on. They’re unwilling to give up a little ground in order to bring to light a better way.
…dental sleep, sleep physicians, and ENTs are so caught up in their own ways of thinking that they’ve got blinders on…
As dentists, you literally stare into the broken airway abyss all day long. I commend your willingness to step in and help, but you must understand the true nature of each individual’s issue to treat it properly and effectively.
Many dentists, maybe even you, think of ENTs as the “throat surgery guys” yet it’s unlikely you have a firm grasp on the clinical aspects of what we now offer to OSA patients. And it’s even more unlikely you have a productive partnership with anyone in our field.
At ADVENT, a practice I founded in 2004, we’ve pioneered a much different model than the typical ENT practice that you grew up with. In fact, throat surgery is what we do the least. Our paradigm starts with getting the nose working properly first, most often with simple, in-office procedures. Only then do we clear a patient to move into an oral appliance or other OSA treatment.
As ENTs and sleep dentists, we must make a shift and approach OSA more holistically on behalf of our patients, together. Rather than treating a singular part of the issue — the collapsing airway — with our limited resources, let’s instead focus on solving the upstream issue, the obstructed nose, prior to treating the throat issue. Let’s put the murky animosity between our two professions to bed and focus on healing our patients.
Put yourself in your patient’s shoes and imagine the ruthless cycle of getting poor sleep every night: waking up day after day with a sore throat or throbbing headache, battling insomnia, irritability, and depression. Consider, the emotional and psychological strain it can put on you and your relationships because your partner is dealing with the same lack of rest due to your OSA. Meanwhile, all your symptoms are leading to the hidden, ticking time bomb underneath — hypertension, heart disease, erectile dysfunction, diabetes, and anxiety to name a few.
Imagine this is your daily life, and the only options for treatment are just as uncomfortable and have lousy success rates. It’s not just the misery of OSA we are up against… it’s this!
The dental track is too often broken. The ENT track is broken. The sleep med track is undoubtedly broken. All solutions too often lead to despair and an inability of getting patients over the goal line. Our patients are stuck in this broken system and frankly it’s our fault.
Until all participants acknowledge the limitations of the tools in our toolboxes, we will continue to fail … and our patients will continue to feel the brunt of it.
This is not to say that oral appliances and CPAPs never work — I’m not writing them off at all. It’s just that they’re working against an issue that remains often unidentified and massively untreated. You cannot address an airway problem downstream with an oral appliance or CPAP if upstream the airway is restricted.
The bottom line is this: oral appliances cannot work adequately if nasal airway obstruction is not addressed first. Solutions must be built around addressing the anatomical problems at multiple levels. This problem will continue to be unidentified and undertreated if there is a lack of communication and coordination between dentists and ENT surgeons.
It must be our mission to treat OSA in a way that works for the patient. Appliances can be a highly effective solution when coupled with a properly working nose. Let’s use our power together to change the trajectory of this highly mistreated disease and deliver an undeniable improved quality of life to the people that desperately need it.
Including dental airway obstruction is an important addition to a total diagnosis for a DSM practice. The specialty continues to evolve. Read Dr. Warren Schlott’s article “The Changing World of Dental Sleep Medicine” to find out more. https://dentalsleeppractice.com/the-changing-world-of-dental-sleep-medicine/