Richard Jacobs:  Hello, this is Richard Jacobs with the future tech and future tech health podcast and I have Mark A. Cruz, D.D.S. We are talking about the Inspiratory Flow Limitation, its effects on sleep and breathing and wellness. So, we’ll get into the details of that but Mark thanks for coming, how are you doing?

Mark A. Cruz:  I’m doing great. Thanks for having me.

Richard Jacobs:  Yeah so, what is IFL? What’s the theme of that?

Mark A. Cruz:  So, you know it’s a term that stands for Inspiratory Flow Limitation used in, pulmonology and sleep medicine. More often refers to Upper Airway Resistance Syndrome, which is its own logic definition within the sleep disorder’s breathing spectrum. So, a lot of people think of obstructive sleep apnea syndrome as breathing or sleeping problems. And yet that’s really to an end-stage diagnosis of a whole spectrum that has a number of different conditions or neurotheologies.

Richard Jacobs:  Yeah, I’ve heard that apnea is defined as stopping breathing for 10 seconds or more, a certain number of times in an hour. It’s a certain number of times in a sleep cycle as well, or sleep period. But you know, do you have a more formal definition of apnea or is that close enough?

Mark A. Cruz:  Actually, the definition of apnea is stopping your breathing for 10 seconds or more accompanied by a drop in oxygen saturation of greater than four percentage points. The number of times that happen for hours, it gives you the index.

Richard Jacobs:  Is that hypopnea index?

Mark A. Cruz:  No, the apnea-hypopnea index. So the apnea-hypopnea index includes apneas and hypopneas. Hypopnea is another major event and there are a number of different definitions, but, the more common one is a drop in airflow through 30 to 50% for 10 seconds or more again, accompanied with a drop in oxygen saturation greater than 4%. So, you have apnea and hypopnea, the number of those that are counted within an hour gives you the apnea-hypopnea index. The respiratory disturbance index is the apnea-hypopnea index plus this smaller event called RERAS or respiratory effort related arousals. So that’s defined as a drop in oxygen saturation, between 2 and 4%.

Richard Jacobs:  Yeah, I have observed that. We’ve seen it in movies and you know, I’ve seen it with my parents and all that you know, they kind of snore and they seem to wake up partially and then go back to sleep. You know, in the movies they’ll do that like let’s say they trying to take someone’s keys without them waking up and they’ll move and you know, murmur or something like that. Is that an arousal or an example of one?

Mark A. Cruz:  Well that certainly is arousal, whether you would define it as a RERA is another case because RERAS are typical, you have an EEG, that is that you could see beyond just actigraphy, you know, the movement if you will. If you’re using high-resolution pulse oximetry, you have an algorithm that will define a RERA, effort related arousal that does it have an EEG associated with it, but it’s associated with the change in the heart rate, if you will, that you could pick up on the pulse oximeter. So, but yes, an arousal and inspiratory flow limitation can cause an arousal and why it’s important is that obstructive sleep apnea syndrome, is really the tip of the iceberg if you will, of the sleep disorders and people are now starting to recognize the much more common form of it, in the form of upper airway resistance syndrome that can happen to a teenager, a young healthy female in large numbers. And yet it’s not too much recognized by the third party payer and that’s part of the problem. So, seeking care for it, you know, from or benefit from your medical insurance for it is a little bit of a fly in the ointment, if you will.

Richard Jacobs:  Let’s say, I wake up every day tired and I have all these symptoms and I go and my doctor sends me to do a sleep study and for some reason, I had like 29 second apnea or something, nothing was 10 seconds or longer, for instance, would they just say, oh, you’re fine, have a nice day and insurance would not pay for anything?

Mark A. Cruz:  Right. That’s just one example. It could be an ODI-4 event which is defined as an event, greater than 3 seconds, less than 10 and those are very very common and they would never be scored so you can have somebody that ends up having a respiratory disturbance index of two or zero. That is very fragmented in sleep and they’re rather symptomatic and stick. They have what’s called the functional somatic syndromes, TMD, muscle aches, irritable bowel syndrome, anxiety, depression, etc so all those symptoms and so I would not send them for a sleep study. That’s why I screen them with high-resolution pulse oximetry. I learned many years ago that if I send them to a sleep study, it makes the problem even worse because now they have a physician that said, you don’t have a sleep problem when they’re thinking of a sleep problem being obstructive sleep apnea, they may be true in that regard, that they do have a sleep problem, a sleep breathing problem and I’ll be more specific and say they have a breathing problem that’s resulting in fragmented sleep. And why that’s important is that we now know there are studies that show there’s causation for serious conditions such as cancers, metabolic dysregulation, cardiovascular remodeling, even if you don’t have obstructive sleep apnea. And with children, it’s especially critical because just having sleep fragmentation for whatever reason is enough to cause inflammation in the brain and increases in inflammatory markers like IL 6 and Alpha-2 necrosis factor and specific C reactive protein that really has adverse effects on children from failure to thrive to cognitive problems, anxiety, ADD/ADHD etc. So there are some serious conditions just to sleep fragmentation.

Richard Jacobs:  So, alright. Let’s define a little bit more, so a sleep fragmentation, one example could be, the adults or the child doesn’t sleep through the whole night, they’ll wake up one, two, three, four, five, ten times, even if it’s only for a few seconds and go back to sleep.

Mark A. Cruz:  No, the sleep fragmentation would be they sleep all night but they don’t necessarily have to even wake up. They are just pulled out prematurely from N-3 sleep or REM sleep and why that’s important, the recent studies that just came out only a few months ago from Europe, their pediatric journals showing that you can have a failure to thrive when you have that. So what would be the reason? And that’s let’s say for mouth breathing, it’s because the hypothalamus releases the metabolic hormones and growth hormone during N-3 sleep in short periods of time. So, if every time you go into that deep sleep, which is when the airway is more vulnerable to collapse, tip the mere threat to collapse from the autonomic nervous system in the brain stem is enough to pull you out of that sleep into a shallower sleep. So you may never wake up, but you just don’t get that full healthy sleep architecture. You sleep for 10 hours, you wake up very tired and fatigued and it could happen 30 times in an hour.

Richard Jacobs:  So, how do you evaluate someone that has this problem with him won’t even know it? I guess someone like this would present to you and say “Hey doc, I sleep 10 hours a night, but I still wake up and I feel like I haven’t slept” If they say something like that, for instance, what would you do?

Mark A. Cruz:  Yeah I deal those patients every day, in fact, they come in from all over the country and they’ve been previously chronicle diagnosed or ruled out for Lyme disease or molds. They know they have fatigue and no one could figure it out. If they are primary care physicians and specialists and they’re still tired, no one could figure it out, but no one’s asking about sleep quality, let alone quantity, but sleep quality. And so the way we look at it is we do a very specific, airway examination, looking at nine different areas within the assessment, like Sherman’s pediatric sleep questionnaire as an example, so that’s qualitative, and then we get quantitative data with, let’s say a high-resolution pulse oximeter. So we can actually see quantitatively what’s happening. Not so much looking at the apnea-hypopnea index or the respiratory disturbance index, but looking at the cardiovascular modulation as it presents with the heart rate. So you’ll see these heart rates that are 50 to 60 beats per minute. But then throughout the nights are getting these huge spikes up to 110 and 120 beats per minute, they crunch down immediately and yeah that’s happening all night long.

Richard Jacobs:  Yeah I guess that cycling of the heart rate, because of stress on their whole body, it disturbs them.

Mark A. Cruz:  I wouldn’t call it cycling because that’s a very specific term. But it’s heart rate variability.

Richard Jacobs:  Okay. Gotcha. Alright. So, you’ll run these tests on the person and then what kinds of things do you find that they’re addressable, what can you do? What kinds of things are common that people like this have? What kind of problems with their airway or what can you do about it?

Mark A. Cruz:  So what we look at is, once you do a thorough assessment looking at structure, function, and behavior, we have an algorithm that we teach. They basically say the first thing we need to do is unfragment sleep. So to prove our chronicle hypothesis, if we can unfragment the sleep, then we’ve shown that it’s related to their breathing and sleep. So, for example, a kid that’s wetting the bed all the time and getting up with night terrors and they snore or an adult that has similar symptoms, they have nocturia. They have daytime fatigue versus sleepiness, two different things. If we can go ahead and use either a trial oral appliance or a trial CPAP and, then second two weeks later, redo the high resolution pulse oximetry after we titrate either of those two approaches and then look at their changes in their clinical signs where, let’s say their fatigue severity scale shows at baseline that it’s severe, moderate to severe and then after a week they come back and it’s half of that they know that they’re sleeping better. But it’s not just about the device it’s also looking at, sleep hygiene. Are they on their iPad, right before they go to sleep, are they eating an hour before they fall asleep? We also look at breathing function. So, we look at five competencies and we believe that there are five things that every human being should have and there’s good evidence to support the physiology. One is they need to be able to breathe through their nose exchange gas through their nose efficiently. 90% of the time very easily with minimal effort. Number two is they need to be able to maintain a lip seal so they have lips confidence with their tongue on the roof of the mouth, which is the third competence and that’s driven by the fifth cranial nerve. The fourth is a non-collapsing interference to sleep and the fifth is diaphragmatic breathing. If any of those competencies, things that should happen equally day to day, moment to moment are threatened, then you have compensation. And those compensations are what results in the science and the symptoms that the clinician sees when they come into the office. All the things that we list in the airway exam. And so we want to reestablish those competencies and kind of unraveled the compensation. And then that’s how we know that we are successful. We’re measuring outcomes that are based on the patient versus the provider outcome and so we document that. There are any of a number of things you could do from just therapy from addressing breathing behavior with a capnometer to myofunctional therapy to creating tongue space or oral volume.

Richard Jacobs:  Can you re-step through the possible remedies and what does that mean? What’s myofunctional therapy?

Mark A. Cruz:  Right. So, one of the confusion that’s out there in our disease management health care system is the care is very siloed and so if you see a surgeon, they do surgery. If you see, an internist is a pharmaceutical intervention, if you see a therapist, it’s just, manipulations or therapy and you’re not getting the integration of care where people are addressing the three things that are required to have consistent, reliable, predictable outcomes. And it’s addressing the structure, the function, and the behavior. So the structure would be, for example, where an individual has a cross-by high parallel valve, a deviated Septum, swollen turbinates, they can’t breathe through their nose, by-maxillary retrusion, their face did not develop enough, they have adenoid faces, as an example. So those are structural risk factors that could be addressed turgidity and non-turgidity. As far as function, you’re going to have compensation, the swallow, how they swallow, how they breathe? Where they keep the tongue? Are they mouth breathing are they nose breeding? So those are functional issues that could be addressed with what’s called myofunctional therapy. It’s nothing new. It’s something that the rest of the world is ahead of the United States and doing with many studies and a lot of evidence to show that you can re-pattern the oral posture, the tongue being on the roof of the mouth, which is where it should be.

Richard Jacobs:  Quick thing. So I’ve done probably over a hundred interviews of sleep professionals and it took me until literally, number 98, 99, 100 to run into three people now that talk about this myofunctional therapy. Until then, even I never ran into it and I’m actively looking and interviewing people like you. So, I think it probably pretty rare that anyone gets to the point where they just say, you need CPAP, alright you need a sleep study, and alright you needed a dental appliance to advance your jaw. I mean, I know this is the world you live in and everything, but, I would guess just based on my experience, which is again focused in this area lately, is that it’s rare that most people will be aware of this and it’s rare that most people’s doctors will be aware of. This is just my experience.

Mark A. Cruz:  Right. So I’ll just say that the problem is, that in a disease management health care system, it’s not recognized because you’re treating signs and symptoms. So, it is nothing and in my world, yes, it’s a self-selected population. It’s known. People know that this is what they have to do. Brazil has done studies now, a P.H.D level studies, systematic reviews, and Meta-analysis, and original studies actually showing this. It’s being recognized now at Stanford School of Medicine. There are studies regarding the use of digital to increase muscle strength in the pharynx. That actually re-patterns the brain. So it’s not just the muscles, it’s actually changing the neural connections at the level of the cerebellum that function to give us our respiratory, our reflexes and breathing mechanics. So yeah, the problem is that people aren’t addressing that and to prove it, now the evidence is very strong. And so I’ll just say something that I think that’s even less understood. So, that’s structure, that’s function. The third thing is breathing behavior using a capnometer. So that’s an issue that every one of these patients has disordered breathing at night. That’s why it’s called sleep disorder breathing, also have disordered breathing during the day. So it’s how they ventilate. So, their chest’s breathing, they’re not moving to full oral title volume and they’re in a chronic state, a respiratory alkalosis. So they’ve blown off too much Co2 and that stimulates a sympathetic drive. All these individuals are in this low state of sympathetic drive. It’s causing a lot of signs and symptoms. In-fact. It’s what’s making them sick and they’re not aware of it because that’s all they know. So anybody who has taken yoga understands how they feel, they feel relaxed. Why do they feel relaxed because essentially they’ve been able to take an hour to pull themselves back into parasympathetic coherence, which is the way every mammal is supposed to function. But as soon as they leave the gym and they stick their keys in the ignition car, they’re back into that sympathetic drive that disordered breathing because they have this respiratory pattern because they have what’s called low-end title Co2 and you can measure that with the cap-nominator and there’s lots of science to support its use. And so that’s one of the things we also measure is their entitled Co2 and their breathing pattern.

Richard Jacobs:  So what do you call them if someone’s looking for, you know, some of them sleep problems, they’re waking up tired or you know, any of others, normally people would say, I need a sleep doctor, but is that what you’re called or how would people even find practitioners like you that look at all these things?

Mark A. Cruz:  Well, I say that disordered sleep is just a symptom. It’s treated as its own entity, like type two diabetes treated as its own disease, is actually a symptom of which fragmented sleep is a major risk factor. So I would say that I’m addressing breathing problems, people come in with breathing problems of which fragmented sleep is only one of the symptoms.

Richard Jacobs:  If I have a problem, I think, okay, you know, I can think of a couple of things. I can think, oh, I’ll just go to my primary care doctor and then he’ll help me. And the primary care may say, you need a sleep doctor or maybe you need a pulmonologist, or maybe you need an ear, nose, and throat. How do people identify that they need you? I mean, you know, so you’re listed as a DDS, which is dentist right?

Mark A. Cruz:  Well, right. And so that’s why we train dentists, actually, we train physicians and allied health professionals as well. I work with well-known sleep physicians, pulmonologists and ENTs that this is their world. And they agree with, you know, what we’re teaching, what we’re saying. The average physician knows very little about it. They get one hour of sleep science and medical school. So when people come to me, what we as dentists, what we’re actually seeing are the signs of disordered breathing and sleep. And so we have to start recognizing and I’m working with the ADA right now. We’re actually changing the way we think and the way we train in regarding that. So when people come to me, its how you talk to them about it. I ask questions, we do screenings and we get data and then we put it all together. So, now I’m getting people who come in, and, and they’ve seen the ENT and the sleep physicians, the pulmonologists and the system has failed. They know these now have this problem. They know they don’t have Lyme disease, they know they have fatigue and this fragmented sleep and they don’t want to a CPAP or even an oral appliance. Those are interim management tools. I think it’s necessary to manage the problem first. So if someone presents with a femoral artery that’s ruptured, you have to put a tourniquet on to save their life. And that’s what I see CPAP and oral appliances to do, but eventually, you want to get into definitive care to address the underlying etiology. And that’s basically what we trained for. What could we do to get them off of that and to cure the problem? So medicine can manage and they must manage it. Dentistry can cure it.

Richard Jacobs:  Okay. No, that’s great. So how would you, you know, I interrupted you and took you off track on all of the things you look at, but you’re also saying them in a technical way. Can we restate the things that you would look at just in the plainest language possible? Maybe the language that you would use with a patient. So you may want to say we want to look at the size and the dimensions of your airways, your nose, and your mouth, etc. to see if, you know, that’s creating a blockage or, how could we restate the things that you will look at and, like I said, very plain terms.

Mark A. Cruz:  So, usually patients when they come in at a dental office, they already have signs and symptoms and complaints, whether it’s temporomandibular joint dysfunction or disorders, or they’d have, you know, fractured teeth and lost teeth. So they have dental signs that you know, as a trained airway focused dentist, that they’re related to the airway function. So your job is to communicate it in a clear, simple way that the patient gets it and they do. Once you explain it, they do understand that the teeth are the canaries in the coal mine, so to speak. They’re just kind of a victim of a bigger problem. And so I always talk to them and address them by saying, we have to address, you know, the hardware, the software, and the operating system. So the hardware would be the structure, the software would be the function. And the operating system is the behavior and behavior is physiology in action. And so they get that. And I’ll give you an example, so, let’s say a patient comes in and how I started connecting these dots many years ago is in my demographic, pretty, privileged, socioeconomic area educated people. I was blown away as to how many of these patients were on anxiolytics and antidepressants. Why would you be on those medications when life is good? So let me give you an example of how I would talk to a patient about it from a dental point of view. So I have these three different caliber straws and I would give them a large straw and I’d say, Mr. Jones, I want you to breathe through this large straw. And while you’re breathing through this straw in your mouth, pinching your nose, I want you to imagine that your head is underwater just under the surface. And I’m going to you how you consciously feel as you’re breathing from the straw. And my guess is that as you’re breathing, you’re feeling, okay, you’re getting enough air pretty easily. Is that correct? And they shake their head and they say, yeah, I could do that. Okay. Maybe it’s not a snorkel, but they could breathe well enough and they could imagine there’s no threat there. So I’ll take that away from them and I’ll give them that regular straw that you use to suck up a malt or a milkshake. And I’ll ask them how are you feeling? Now again, breathing through that with your nose pinched underwater. My guess is that if you were doing that for a few minutes, you’d start maybe having some anxiety, right? And then I’ll have them the little coffee straw and say, well, how do you feel now? They don’t even put it in their mouth. They’re already anxious just thinking about it. So I tried to make a distinction between psychological anxiety and physiologic anxiety. If people conflate the two, they don’t make the difference. They think it’s their wife, they think it’s the traffic, it’s their husband, it’s the school, you know, etc. Those are just, that’s what we call life. That just exacerbates that language for it. So you could understand that but the autonomic nervous system or the brain-stem does not have language. You just have that limbic response, that feeling of anxiety and when you threaten it in any way, it’s a survival mechanism. So, if you have a small airway, inadequate structure, and the soft tissue compensations, you can imagine how that anxiety that results in these functional somatic symptoms can result in that and they understand that intuitively. Oftentimes they start crying in the chair saying, ”Oh my God, I knew that’s what it was”. And so our job then is to address structural and functional issues to where you can predictably get them feeling well and we do. CPAP is not going to address that very effectively. The way the physicians are dealing with it, it’s given them an anxiolytic. They don’t recognize the problem for what it is. I could get delve into all the research having to do with the effect of chronic intermittent hypoxia on the brain and how it actually destroys the white matter causing depression. A high correlation with depression. Same thing with anxiety. The well-known Australian Deloitte study in 2011 actually showed the effect that it had on those symptoms on the gross national product. So it’s a huge economic problem as well. So we could go on and talk about all those correlations. All they’re doing is they’re treating symptoms and I just say, let’s step back and take a more global approach to what’s actually happening rather than chasing signs and symptoms. Let’s see what’s happening with the entire organism from a global point of view.

Richard Jacobs:  I guess the big point here is that just because someone’s a child, 5, 10, 15 years old doesn’t mean that they’re immune from any of these things.

Mark A. Cruz:  No, that’s when it starts. In fact, there are studies to show it starts in the third month in Utero and we actually have a fetal and maternal initiative that’s actually screening moms during that third trimester because there’s a high percentage of those moms that are suffering from sleep-disordered breathing that has a downstream consequences to the fetus and create risk of Preeclampsia, gestational diabetes, small-for-gestational-age birth outcomes. That data’s already out there. That’s where it starts and then postnatal looking at their swallowing reflexes, primitive reflexes. And so we go from that point all the way through by the time you get into, you know, a 20 or 30-year-old, they’ve already been suffering from this for a long time. It just wasn’t recognized for what it was. And the data is super strong. I mean, this isn’t anything I’m making up, it’s just, not being integrated.

Richard Jacobs:  Oh. So what are some of the interventions you’ve done as examples for people and what was their experience once you did them? Maybe pick a couple, the most common or most deleterious things that you’ve seen. And maybe just comment on a couple.

Mark A. Cruz:  Okay. So, on one end of the spectrum from the most invasive that someone has sleep apnea, a maxillomandibular telescopic orthognathic surgery in combination with myofunctional therapy and breathing re-patterning on one end of the scale, those people are predictably cured from the problem as measured by the gold standard and their reported signs and symptoms. It changes their life. They turn into a different human being and they’ll tell you that, I have dozens and dozens, I can tell you the interviews, I could show the outcomes, we measure everything. On the other end of the scale, nine months old. I would work with a knowledgeable airway focused fleet and language pathologists that understands the primitive reflexes. The deep rotation patterns are manifesting because they can’t breathe through their nose well or because there’s lipping competence to in between, what I call, the skinny woman syndrome. The 22-year-old college Grad that is suffering from mood swings and anxiety and irritable bowel syndrome and TMD and Bruxis. Something like that, the first thing we do is we stabilize sleep and then we address structure, function, and behavior. And it may be that we do orthopedic remodeling to address the mid-face efficiency, in combination with repairing the tongue myofunctional therapy and doing breeding re-patterning. So there are so many tools that dentists have at their disposal to address that beyond surgeries, medications, and devices. We’re just using surgery, medications, and devices because that’s all we know and how we were trained. And yet there are all these validated approaches that are very very effective. And in fact, we go through monthly case reviews, our team does. We have an interdisciplinary team where we go through these case reviews on a regular basis and we actually teach that and we have web-based meetings where we train the clinician to present the examination profile and their treatment sequencing and then we all work as a team from the pulmonologist point of view, from the otolaryngology, orthodontic, myofunctional therapy, physical therapy, craniosacral osteopathic point of view. All have a stake in understanding what’s going on with the patient. It’s not just one person and that’s what makes it difficult.

Richard Jacobs:  So what happens if, I know you can’t see everyone in the world, what happens if people are not local to you?

Mark A. Cruz:  Well, I have people flying and driving from all over the country and internationally now. My greatest efforts right now are to train other people and we actually have a health care model called the BeeWell collaborative where we’re setting up these interdisciplinary facilities all over the country, following our specific algorithm where the patient is evaluated by the seat position, the Otolaryngologists, the orthodontist, the restorative dentist, and the therapist. And they could go in and a lot of it is web-based. So we have telemedicine, teleMyo, telebreathing, we’re establishing teleradiology so we can actually get data from South Africa or from Malaysia and we can actually, as a team look at it and say, okay, here are the things that we would do. We’re in a digital world, so there’s a lot that we could do. Everything’s planned digitally as well using Colombian Tomography, using digital scanning, so we have a lot of technology that allows us to really evaluate these patients anywhere in the world. And, it’s just putting the pieces together in treatment sequencing, you know, where the challenge is depending on what you work, where you are, with all it. A lot of people will fly in. But my hope is that we could do this as a standard of care everywhere and that’s where I see us in the future going right now. It’s exploding worldwide. So it’s interesting that you say that you’ve been interviewing a lot of people and you’ve only heard a few talks about Myo, in my world, I’m connected to a global network that is very well aware of this and there are international conferences looking just at myofunctional therapy and AASM is one of them, IIOM, AOMT and I could give you a lot of organizations and it all comes down to connecting. And so your efforts in interviewing individuals is part of, I think, the intellectual infrastructure that’s going to make it happen. You’re connecting people from a lot of different disciplines and understandings to really address what I call knowledge void. And that’s what we have to address right now. The information’s out there. It’s just getting it all connected and then integrating it.

Richard Jacobs:  Yeah. I mean, talking to you is like, I’m speaking to someone that brings up, you know, you brought up all these things that, and I’ve only heard a little bit about and a lot of them are new and it sounds like you’re like, of course, there’s all these things you can do. And I’m telling you, most people have no clue about any of these things. They may not even know what a CPAP is.

Mark A. Cruz:  Right, right. So from your point of view, you’re interviewing a lot of people but you know, if you get into the context of where we are, I mean you’re dancing around the mainstream and the mainstream is kind of mixed a lot of, because it’s all about disease management and what we teach the first number of hours is how we think is part of the problem. Our education gets in the way of our learning. And so, we could go through many many hours of discussions on what the problem is. The problem is really how we see the problem. And yeah, I mean we could spend a lot of time and it is,

Richard Jacobs:  Yeah, I don’t want to, I mean, again, I’m just one person, one family, but I’ve been to the dentist, they don’t say a word like, my daughter has been to the orthodontists, nothing, you know, my wife has been to the dentist, nothing. My friends, I’ve never heard any of this. From anyone, at all.

Mark A. Cruz:  Yeah, there’s a big grass-roots effort. If you want to look up, you could Google documenting hope as an example. Beth Lambert, looking at children. So this is the first generation of kids that’s going to not live as long as their parents. We have an entire population in the United States of kids that is sick, not just a little sick, but they’re really really sick. More autism, more ADD/ADHD, more metabolic dysregulation. So you have to ask the question, what’s going on with our species? And ultimately one of the underpinnings of what we teach is that it’s our environment since the industrial revolution that is making us sick. So if you look at the data from the World Health Organization, worldwide you’re finding that more people worldwide are dying from diseases and conditions that didn’t exist a hundred years ago, didn’t even exist 50 years ago. They were dying of infections, tuberculosis, and dysentery. That’s pretty much under control. We’re now dying from conditions that we’ve created in our modern environment that we did not evolve from for Ian that we can’t cope very well with, from lack of sleep to what we eat to we breathe. So we can get into the whole topic of epigenetics. But you know, with the time it just mentioning the word, that’s really where the problem is. And so it’s affecting our kids. And so the United States ranked number 50 in the world in its population health. And yet we spend more than twice of any other country. In 2011, we stopped $2.7 trillion. It’s unsustainable. It’s going to take us down. We cannot continue to do what we’re doing unless we change our healthcare system in whole. And, I can give you so many references and organizations that understand that and so that’s a whole other discussion. So yeah.

Richard Jacobs:  Oh that’s great, that’s fantastic. Just a couple more questions. You gave the example earlier about, you know, one of the most invasive ways that you may have to intervene to help someone. What are some of the less invasive ways? Maybe like two examples.

Mark A. Cruz:  Oh, myofunctional therapy. You could have a myofunctional therapist that could be a hygienist who’s gone through the proper training to a physical therapist that has gone through the proper training, to re-pattern, the swallow and the oral posture and faster nasal breathing 90% of the time. But it does require work from the patient it’s not a magic pill. You’re not going to take a pill a day and you’re going to be fine. You actually have to do some work to change what got you sick, to begin with, the poor sleep and breathing to begin with. Another example would be perhaps craniosacral therapy from an osteopath or creating a craniosacral therapist that addresses those issues that are related to the cranial structures that are also potentially a problem. You could do the breathing re-patterning with behavioral capnometry. A masters level therapists that understands the physiology and the chemical axis of, from under-breathing or over-breathing. You know, we all know that overeating is not healthy. Well, over breathing is also not healthy. It’s just as bad and most of our population is over-breathing. It’s what’s causing that sympathetic up-regulated drive that leads to adrenal fatigue that could be re-patterned by behavioral capnometry in just a few weeks.

Richard Jacobs:  What is over-breathing or under-breathing by the way, what’s an example of that? How does someone over-breathe or under-breathe?

Mark A. Cruz:  High percentage of our entire population is definitely doing that. It’s kind of like hyperventilating, but it’s more nuance. You just don’t know you’re hyperventilating. So if you had capnometer, it’s what’s used to check someone who was under general anesthesia. So, medical capnometry is well validated medical instrumentation looking at end-tidal Co2, which is the amount of carbon dioxide reserved in your lungs and everybody should have a minimum of 35 millimeters of mercury, of pressure within their lungs. And that could be measured, but a lot don’t because they’re over-ventilating. And why that’s important is that hemoglobin releases oxygen, the brain or the muscle or the organs, as a function of the Co2 gradient. And if you’re over-breathing all the time, it’s going to cause disordered breathing and you’re going to over-ventilate and that’s going to stimulate the sympathetic drive at the level of the brain-stem. Well, you can re-pattern that with instrumentation and find out from the patient why they have that behavior. It could be that every time they’re in an interaction with let’s say, somebody that threatened them, they start, you know, becoming fight-or-flight sympathetic and every time they were in a situation similar to that, they have this behavior that they’re doing that and they don’t even know it and it’s eventually making them sick and they think that it’s the traffic or their workload, as an example. So they have these triggers that stimulate that over-breathing and then they try to sleep at night and they can’t fall asleep because they have too much norepinephrine or adrenaline in their system. And so by the time they fall asleep, the alarm’s going off and then they start the cycle all over again, what do they do? They reach for a venti Starbucks and they end up waiting till happy hour and they want to talk themselves off the ledge, how do they do that? With happy. A beer or chardonnay. Now don’t get me wrong, I’m not saying that you should do that, but it’s a way that they kind of try to chemically get themselves into that sweet spot to feel okay, but they’re not well. We have a whole population. That’s what’s making us sick. Read the book, Robert Sapolsky, why zebras don’t get ulcers. The very well-known neuroendocrinologist that he’s read about, he’s written a lot about that. He studied baboons for decades in out Africa, looking at the stress response. You can read Daniel Liebermann who wrote the story of the human body. He’s a very well-known anthropologist from Harvard. He wrote that book, as well as the evolution of the human head, talks about exactly the same thing. “Read well, be well” by Robert Freed, he talks about how 60% of emergency room visits in large cities are a result of dysfunctional breathing. So, there’s a lot that’s been written about, it’s just that people are going to the primary care physician and they’re having their symptoms, they sure are treated with the medication and no one’s really looking at the underlying problem. And you know what, there’s this grass-roots effort that a lot of people are getting frustrated with the current disease management health care system. There’s a chemical solution for every symptom. And so we could go on into what the problems, what the broken system in disease management is, but you kind of get the meaning of what I’m trying to say here, hopefully.

Richard Jacobs:  Oh yeah. I mean, for instance, just for listeners, I did a Google search for myofunctional therapy as I was talking to you just to pull it up and I see ads it’s just a person there can’t sleep, take this pill and yeah it’s everywhere. I understand. The WebMD and all these things had been invaded by this. It’s all over TV and everywhere. I totally agree. You know, and
it’s a far inferior way than finding the root causes and facing them. So yeah, I got it.

Mark A. Cruz:  A lot of the population that listens to you, you say, they may not know about myofunctional therapy, but they know about the problem that we just described. And I think that’s the start. They just don’t know where to go and I think education, like with everything is the big part of the solution.

Richard Jacobs: Yeah, definitely. Well, this has been great. Really really great interview. If people are local to you, you’re in what, Orange County, California?

Mark A. Cruz:  I’m in Orange County you know they could go to markacruzdds.com and in there I’ve got a tab called airway focused dentistry and on the main website with probably 50 educational videos from a lot of different perspectives. And for me, I’m not necessarily about getting the referrals, I have a very very busy practice. I’m about getting the word out and educating people like yourself. And I’m going to die and I’m going to be going somewhere else. Like my dad would say to the big molar in the sky at some point in time, the problem remains. So if we can leave the place a little bit better than we found by educating, then I think we’ve done our job so, they can go onto my website to learn more. If they want to contact me, the information’s there I’m more than happy really to promulgate this knowledge and really to help, like you, you know, getting out there and doing our part in trying to help healthier US public and beyond.

Richard Jacobs:  Yeah, no problem and if people either go to your website, is there a place where they can find practitioners that are trained as you have been trained or are you not at that point yet?

Mark A. Cruz:  Yeah, I have a whole network of practitioners I’ve trained from all over the world, that’s gone through our rigorous program and that continued to, we have a big group coming from Europe and South Africa and Asia this next fall. So we have people from all over and I’m happy to connect so they can contact us and I’ll try to, find somebody near them or help them find out where they can go to get the answers that they need.

Richard Jacobs:  Okay, cool. Excellent. Well, thank you again for coming. I really really appreciate it.

Mark A. Cruz:  It’s absolutely my pleasure and good luck in everything you’re doing. Thank you for what you’re doing.

Richard Jacobs: Oh, no problem.