Richard Jacobs: Hello. This is Richard Jacobs with the future tech and future tech health podcast. I have Dr. Mark Burhenne. We have been talking about his book, “The Eight-hour Sleep Paradox” that we’re sleeping away fatigue. Dr. Mark is the bestselling author in the family and sleeps medicine dentist. He’s been in private practice for about 30 years. We’ll just see on the patient-centered and preventative dental health care. Well, he sees people from all over the world. And he’s got many accolades and he has been around the block many times. I’m sure. So Dr. Mark. Thanks for coming.

Mark Burhenne: Oh, Richard, thanks for having me on the show.

Richard Jacobs: Yeah. So where did your book come from? What was the inspiration for writing it and why is it called the eight-hour sleep paradox?

Mark Burhenne: It’s a personal experience. How often do you hear that about authors, right? I discovered I had sleep apnea and my wife as well. And you know, we were healthy, doing well, exercising, we weren’t too overweight. We were functioning in a very stressful environment in Silicon Valley, both working, raising three kids. And then in our, let’s say mid-forties we dropped off our first daughter to college and of course, that put us all in the same hotel room and woke up with my three daughters have thrown pills at me going, dad, you sounded like a freight train last night. And I’ll say, oh, okay, well that’s interesting. I remember my parents snoring and my mom a little bit, but my dad a lot I tell that’s interesting. And you know, back then snoring to me was just, it was almost funny. It was like seeing Bambi swore in the Disney cartoon, right. Or Popeye or all those kinds of things. But anyway, so to make a very long story shorter we had to navigate that whole process of fixing our sleep and we’re both health care professionals and we just found it to be very frustrating, difficult to navigate, confusing for the layperson, even for us. And so that’s originally what prompted, I told my daughter who helps me with our website. I said, God, this is a frustrating process. There’s so much I’ve learned. How do I get that out to other people? And she said we’ll write a book. And that’s how we wrote the book together. And it was a one year process, a lot of research and study and personal experiences and then trying to make that more universal for other people in other countries. And so it really was treating my sleep apnea, my wife’s sleep apnea. And I have to say, I wouldn’t have been able to write the book if I hadn’t been able to treat my sleep apnea because I started feeling much better. I only had mild sleep apnea, 12 interruptions per hour at night while sleeping. And my treatment went quicker than my wife’s, I was able to become more alert, wake up earlier, feel better, focus longer. And that was doing a lot of research and reading. What I hadn’t noticed over the years is that I love reading mostly nonfiction research of course. But what I had noticed is that I couldn’t focus as much as long. I remember after I started sleeping better and the next morning being able to sit down and reading for an hour straight with no interruption, no thought of standing up or going to surgery later or that kind of thing. I realized that’s the way it was when I was younger, so it was great on all fronts. But I did want to share that with as many people as possible and well beyond my patients in my private practice.

Richard Jacobs: My family’s had experience with it too. My dad had it. I don’t know. Doesn’t want to do anything about it. I’m sure I had it on my back and you know, does it seem like it on my sides? But once I lost some weight than seem to get there. But yeah, it would read and fall asleep and I couldn’t read more than like a page and I would just constantly fall asleep doing that. I’m sure people have suffered many more things from sleep apnea. It’s pretty pervasive. Is any stats available have it at certain ages?

Mark Burhenne: It’s probably, it depends on who you talk to. And so generally the numbers are 19, 20%. In my practice, it’s 30%. I mean, I’ve literally, you know, out of 5,000 patients, I’ve looked at that number and studied it and I’m not sure why it’s a little bit higher there. I think it’s just because I’m better at diagnosing it. I see it earlier. Perhaps dentists can see sleep apnea decades before a physician can because we look at different things. We’ve been trained and well it’s the oral signs and symptoms that alert us to that.

Richard Jacobs: What do you see this, the physician wouldn’t see what happens in the mouth?

Mark Burhenne: I have a list. That is in the book. Actually the list is cotton longer, but that a checklist that I go through and it’s got at least 50, 60 items on it. Scallops tongue, the tongue sits high and the four of the mouth and narrow arch. In other words, the roundness of your lower arch, upper arch of teeth as narrow or v-shaped. Height to the palate, the narrowness of the Palates, position of the tongue, tongue-tie, tonsils are swollen. But mostly in kids. We see a lot of kids not breathing well and suffering and you know, their tonsils and adenoids are very large and large. Facial structure. That’s a big one. When I go to a cocktail party, again I’m dating myself. When I see people out in the open, it’s so evident to me who is suffering just based on the facial type, a profile, a frontal view, side view, developmental, the lower jaw. I mean and there, are other factors. And of course I throw in all the medical, but the medical doctors look for older comorbidities of sleep apnea and that’s my second list. I’ve separated into two. And then I started seeing all those dental warnings of sleep apnea. And then I see, oh my God, you know, this patient’s going to the bathroom a lot in the middle of the night. That’s not diarrhea, he’s got high blood pressure, and he has a fib. He complains of daytime sleepiness and he’s depressed. I mean, then I throw in all the other medical stuff and Winton 15, 20 minutes of conversing with a new patient, it’s pretty clear even to what degree the sleep apnea is. And that’s when I don’t diagnose sleep apnea. Dentists aren’t allowed to do that, but I screen for it. That’s when I make the referral and I make the referral to a sleep specialist and MD. I work across the street from one. If they’re not part of that medical system, then I make sure that they’re on their way. And usually they’ve read the book and they understand the process and that’s where it gets complicated. That’s where you start getting pushback, although that seems to be a little bit less than it was when I wrote the book three or four years ago. So yeah. There are lots of things in the mouth that make it clear to me. And even outside of the mouth facial structures I mentioned that make it clear to me that this person has an issue with chapped lips, the shape of the nose, sniffling. I mean it goes on and on. And I’ve been around it for so long and yeah, I just, I can make a quick kind of assumption of that person’s ability to breathe within minutes.

Richard Jacobs: What about the world of remedies? Seems like there are two big camps, CPAP camp and then the oral appliance.

Mark Burhenne: Yeah, those are the two big ones. Surgeries, kind of behind all that. We can talk about that. So CPAP. It’s a positive pressure machine, everyone knows, everyone fears that machine. They’ve heard about it. They’ve seen a friend or a loved one or a family member use it, travel with it or they’ve seen them use it and then throw it away or give it away. It’s a little box with a tube that somehow you connect your airway to the nose, to the mouth. It’s something that you have to strap to your face and head and it basically blows you up like a balloon. It prevents that airway from collapsing. There’s enough positive pressure being pushed down inside of your esophagus, towards the lungs and pass the airway that that airway will not collapse and you will not wake up because your body does not think you’re suffocating. Your appliance, which has been around, well, the APAP has an automatic, CPAP is the continued pressure device. That’s was I think, amended late, the early sixties, maybe 65. The oral appliance actually has been around a little bit longer than that, but it was more of an orthodontic device and now it has come back into favor for while there are a lot of positions and even dentists thought it was causing TMJ and that it wasn’t really working. But now we have studies that support the fact that these oral appliances can be very handy, especially if the CPAP compliance is very low, which it is about 30% of people hang in there with their c-pap after the first year. And there’s usually no follow-up. It’s very frustrating to see that where they’ve gotten the diagnosis, they’ve got through it, they’ve got the solution. And then after a year or six weeks or eight weeks, it does not matter. They’re running for the next decade or two with nothing. Oral appliance compliance is, it depends on if you’re the seventies, 80% even I’ve seen as high as 90 depending on who’s making them. And all that. So why is it so low? Well, I mean, think about having a tube stuck to your mouth or nose and blowing air into your lungs and dries you out. It can predispose you to lung infections, dry mouth, and higher cavity rate. If you don’t use the humidifier, it’s bulky, it’s cumbersome, it’s noisy, it’s noisy to your sleep partner, you have to get used to the noise. But they keep improving them. I always encourage people, even though I’m doing an oral appliance for the patient, I always encourage them to hang in there, keep working with it. Make sure you have a great provider that the people that dispense these machines that they’re working with them on getting the right face mask. I even make recommendations for face masks because I know what works and what doesn’t work. I’ve seen people struggle and I’ve gone on the web and at the back of my book, we have this great reference that people love. It’s a URL to a kind of a user’s group of CPAP users. And actually they’re the experts. It’s not the people that dispense these units. It’s not the doctors, it’s not even the dentist. It’s the people that are using them that have successfully used them. And so I steer people there. I scan that late at night myself, even though I’ve really don’t wear a CPAP, but my wife did. And it’s just good information. So again, cumbersome, difficult if you don’t have insurance, expensive. And it’s something that you have to get used to. And a lot of people, especially if they’re tired, don’t have the patience to really sit down and be very detailed and analytical and when they’re tired, they’re tired to make this mask that properly. The good news is that there are some great advances coming in sleep. Speaking of the future there’s the next door to me. I mean, in the valley we’ve got a company that’s going to scan people’s faces and 3D print the masks so that they fit better. One of the problems with these masks that cause alterations and blisters. They don’t fit properly. The air blows past it into your eye, dries out your eye. So that’s cool. There is a company called carbon and they’ve been doing shoes. You can scan your foot. I mean, they’re gonna scan just about every part of the body that has something attached to it. You know, it could be prosthetic joints. Because I mean, let’s face it, there’s so much variability when you’re dealing with the human body. And so it’s great technology. You’re also going to see a lot of, part of the problem with sleep, and I wrote about this in a book, is that diagnosing it is difficult that that sleep study is the threshold that I referred to earlier. I guess it’s expensive and a lot of people don’t like sleeping in some weird, strange room and people are coming in and out and making sure everything’s glued to your face and head and chest. These leads and these wires that are glued to you, so just come in and sleep. No, people are very particular about their sleep, especially people that are very tired. They locked the door, they have a maybe alights on. I mean sleep is a very individual thing and we all kind of have our little phobias about sleep. And so that’s where the revolution is going to come. We’re going to get, instead of a $3,000 sleep test that’s done in some weird clinic or hospital, we’re going to be barraged soon and it’s already starting with these 100 to $300 tests that we can just slip on our finger, stick in our ear, wrap around our foreheads, stick to our forehead, glued to our upper chest, little dispatches. I mean, that’s coming. And these tests are going to be as good in many ways, not better than the gold standard. And that is this PSG, the polysomnography, And that will be wonderful because Richard, there are about 80, 90% of us out there that have sleep apnea that has not been diagnosed or don’t even know we have it. We’re driving or flying planes with surgeons. We’re bus drivers. I mean, we drive our own vehicles between one and five o’clock in the afternoon. That’s when we’re, you know, people that don’t sleep well are very dangerous on the road, on these two-way roads. So it would be nice. I can’t wait till that wave of diagnostics. And then everyone will be able to sleep study. So everyone will be able to get a sleep study and everyone will be able to not only diagnose what their situation is at any age, but we’ll be able to continually verify our asleep based on, you know, if we can wait to get older, sleep gets worse.

Richard Jacobs: Since you, bailiwick seems to be the oral appliance. Let’s talk about that more. So what is it doing to like a mouth guard you’re biting in that advances your lower jaw pulls it forward. Is that how it works?

Mark Burhenne: Well, I look at it as kind of a two-stage process. When they sleep, especially on a back but even on a sliding side, our jaw falls backward and that’s for a variety of reasons. Gravity, the lower jaw is very dense. The mandible is like a piece of granite. It’s got the tongue attached to it. So when the muscles relax, as you approach deep sleep, which they all do except the diaphragm in the heart of course, the jaw falls downwards into the pillow and with it goes the tongue and as do the muscles of the airway, they become very flaccid and they lose their tone and all of that contributes to an airway that when you breathe in will collapse. It will like a balloon. When you draw air through a collapsible airway, the Bernoulli effects, it will suck itself closed. And then that could happen. You could have a cloth stairway for 30, 40, 50, even 60 seconds, and then your body thinks, oh my God, we’re suffocating. We can’t let this happen. And it wakes you up. Then that can happen up to 70, even a hundred times an hour. Imagine someone waking up. For me, it was 12 times an hour. Imagine someone waking up 12 times an hour. How would you feel? You’d be pretty frustrated and angry in the morning, anxious. They will not have rested. Your brain will not have healed. So the oral appliance basically reverses all that. The first stage is you don’t necessarily have to advance the device. It’s an upper and lower night guard. Everyone knows what a nightguard is or a retainer that can be very thin. They can do a little thicker, they can be thermal plastic, they can adjust to body temperature, and they can have metal pieces in it. It can be all plastic or acrylic. It comes in so many different versions and forms. And then the devices are connected together via struts or bands. And when you lie down and the muscles let go of the mandible, the lower jaw, and you’re relaxing and you’re going into a deep sleep, the jaw doesn’t fall back because it’s being suspended or pushed back, pushed upwards with these struts or suspended by the straps. And so that’s the first stage. In other words, I have a lot of patients that, they may only have five or eight interruptions per hour or healthier and they want to sleep better. So what we do is we just support the jaw. We don’t advance them. Those devices can be advanced, which makes it a little bit more complicated. But for those people that are borderline, all we do is give them this device. We deliver it, we take impressions, we scan their teeth we have to adjust it may be a few times and then they wear this at night and every time they go to sleep, the jaw stays where it is. It doesn’t fall back. The more radical, the more classical way these things work is that we actually advanced the patient. So they may have an obstruction just in a normal job position. And by advancing the mandible forward or upwards of you’re lying on your back the tongue gets out of the way and typically we’ll keep that airway open without blowing a lot of air inside the patient. And then sometimes we do an oral appliance with the C-PAP. That’s actually one of my favorite therapies because the C-PAP can be turned way down. The oral appliance doesn’t need to be advanced that great. So you’re taking advantage of both technologies but you’re not pushing the limits on each of those devices or technologies. And that sometimes works very well for people. So oral appliance basically is a stent towards it basically keeps your arteries from collapsing in your heart, your coronary arteries. It’s that kind of concept. Pretty cool.

Richard Jacobs: Is it because are you biting it or it just sits in your mouth like?

Mark Burhenne: No, we definitely don’t want to do that because if that was the case then when you went to sleep you would become paralyzed and your muscles stop working and so it would work. No, you can snap it into place. I put mine in the dark. I think nothing of it. It’s like putting on a pair of sandals, you know, flip flops. It’s just an automatic thing. It takes a second to do and maybe two seconds to remove and it’s very comfortable once you get used to it. I mean, most people, if they’ve worn a retainer or night guard, which a lot of people have, and this is very second nature, it’s not a problem. For people that haven’t worn anything in their mouth and they’re breathing to their mouth. They can’t breathe through their nose. They have a gag reflex. It can be difficult at first because of the bulk and the material that’s in there. But it’s a very relaxed passive thing. Once you snap it in, your upper and lower arches have snapped into these little night guards, these little U shaped devices and you’ve got disrupt there and you just basically let go of your face. You just kind of relax and the jaw does not fall back. So it’s a very passive state.

Richard Jacobs: Can you breathe through tour mouth with these mouth guard pieces or do you have to breathe through your nose?

Mark Burhenne: Well, that’s a really good question actually. So I mean, the short answer is we want people to breathe through the nose, but let me explain. So you can make a device that is open in front that has a little cannula or an airway or a tube, or the patient’s mouth will fall open and they can breathe through their mouth. Yes and that is a necessity because I have a lot of patients that can’t breathe through their nose. However, for the patients that can’t breathe through their nose, I’m actively getting them to fix that because the c-pap or an oral appliance or both the efficacy of those therapies, those modalities are much higher if the patient can breathe through the nose. So I ask patients if they can breathe through the nose to tape their lips shut for a sequel or oral pints in, their jaw slightly forward or it’s being supported then, and this is what I do. Then I tape my lips closed again very passively. If I were to open, the tape would peel off and that forces me to breathe through my nose, which actually, and I can measure this using wearable’s. I have an O ring, but I can other devices pick up on this too, especially the pulse ox is the ones that measure oxygen in your blood. I can literally see the difference between my mouths being taped all night long and not being taped, even though I’m a good nose for either, my mouth will inevitably fall open at night. My device in there and my breathing rate and my respiratory rate and my resting heart rate will slightly go up. And that’s not what you want when you’re sleeping. We want everything to, although staff to drop, you want sure heart rate variability to go up, you want your buddy temperature to drop. So breathing through the nose is crucial. Whether or not you wear a device, whether or not you have an oral client or CPAP. But your question, it’s interesting because a lot of people that need the device, it will help them, the oral appliance, but their nose is blocked. Well temporarily I would say that’s okay, let’s get you the device, let’s get you breathing with your mouth open. But to really optimize things, you have to refer that patient to an ear, nose, and throat and get them able to breathe through the nose. It may just be malfunctional therapy. It could be many things, but typically it’s a surgery that has to be done. So, you can talk about these things in place. It’s kind of like the British bulldog kind of talk and you can take medication, you can drink water. It, depending on the device, some are kind of locked in front. I don’t like those devices where you can’t move your mandible, you’re kind of locked into position. You can yawn, you can yell out, you can talk in your sleep with these devices and you can breathe through your mouth if you want.

Richard Jacobs: Over time if they’re advancing your jaw or even holding it in place, when did that change the structure of your face as your muscles are put into different positions for eight hours a day or a night?

Mark Burhenne: Yeah, so that is both the c-pap and the oral appliance have side effects. It wouldn’t necessarily change the shape of your face unless you had like a very retro Knaflic face. Again, remember I think I told you earlier that this device was around much earlier than the CPAP, that it was around as an orthodontic device was designed to pull the jaw forward downwards to help to development facial development of a child. So again, an orthodontic device was called the Herbst appliance. What it does is it could change your bite. Sometimes they can improve it. I mean, I had a class two-bite, which is a slightly retro ethic. We see that you know, Chin and it actually improved my profile. And sometimes patients will wake up with their bite, their bite will be off in the morning. What we’re essentially doing is, and one thing I did mention earlier is that most people, one of the early signs, dental signs of sleep apnea is grinding or Bruxism is not clearly understood. And at least in 50, 60% of the cases patients, I think it’s greater than that. But patients that grind their teeth, brush their teeth, sleep bruxism, it’s called now grinding at night. That’s a sign that they’re struggling for air at night and their airway is collapsing. Those people have also mild facial issues, morning headaches, their muscles of mastication are worn out. They can’t keep their mouth open for a long period of time. The muscles are so tired, grinding all night. These are all signs that we look for. The device is undoing decades of grinding. So you can’t get into that tight position with the muscle. The master muscle closes tightly because of the device as you move forward. So we’re undoing a lot of hypertrophy adhesions in the muscle. And it’s almost like you’re stretching out your calf muscle kind of thing. It doesn’t change facial structure, but it does change the mechanics of chewing for a short period of time in the morning. But if you wear this thing long enough, and the majority of us, I do wear these devices once we’re used to it. We basically have two positions. We go back and forth between the two positions that four position at night, in the morning, within minutes we’re back to our centric receded position where teeth meet properly and we can choose. So, but some people don’t. Some people stay in that zone where they love their device, they’re addicted to it, they can’t sleep without it.

They won’t wear an APAP or CPAP and then their bite is kind of off until noon or even two o’clock. And I went through that in the early phases of wearing my device. And it doesn’t happen to me anymore. Occasionally it will if I sleep more than seven or eight hours. I usually sleep under seven hours and so that’s a problem. But the good news with that I find, and this is just a personal reflection on it, is that with intermittent testing, I don’t, I try and narrow my eating window now so I don’t eat till noon anyway. So it works. It’s fine. I don’t need to, I don’t need to be able to have a tight bite until noon. So, I eat lunch, big lunch, like dinner before six and I’m done. So, that works in that regard. It doesn’t solve the problem for everyone of course, but yeah, you can. There are muscular changes, some bite changes, sometimes permanent, nothing serious. And the other thing that people ask about is TMJ. You know what if I have TMJ, TMD you know, that’s clicking and pain in the joint to dislocate a kind of damage to the Meniscus, the pad that allows us to move properly that jaw joint and dislocate the jaw. It’s one of the few, it’s the only jaw on the body where we can literally just pop it out and move it forward. That’s why we’re able to keep it slide forwards for sleep. That’s a complicated mechanism. And often they can go wrong. Most of the time it will go wrong if someone’s grinding their whole life because of sleep apnea. And so in a nutshell, if you have TMJ, TMD, don’t think that you can get an oral appliance. Sometimes, actually often in oral plants, we’ll undo that and take away a lot of the pain that the patient’s experiencing with TMJ.

Richard Jacobs: So, when patients come to see you, are they having sleep problems and therefore they come see you. I mean, do people think a dentist can help them with sleep problems? You’re only a sleep doctor or do people come for normal checkups and you say, yeah, wait a minute, this is going on.

Mark Burhenne: Yeah. Well, I mean back in the early days, that wasn’t the case now. I mean, I have people come from all over the world. I have positions that come see me in their backyard, in their own university, they’ve got a sleep clinic. And so I’m handling a lot of very difficult cases, cases that haven’t responded. And so I get those patients now and that’s a lot of fun, very challenging. And it makes it very interesting. But the bulk of my practice, I’m still a general dentist. Everyone gets screened. Last month, actually, last two months we had over 30 new patients. Every single one of those patients, even though one and two-year-olds and the four-year-olds and the eight-year-olds, they all get screened for sleep apnea. That’s just the way I’ve set up my practice. Because you know, 10, 12 years ago I realized, Gosh, you know, I can see this, I can do something about it. And I’m just shocked. Back then I was shocked at how many people didn’t know they have sleep apnea and they’re seeing their physicians. I mean they’re seeing other dentists. They even know that they’re tired. They’d been told that they snore. But so I’m still a general dentist. People come in for a cavity and or they need a crown or a root canal. And then on that day, typically when I first see them, it’s like they also know that they have sleep apnea. No, some of them are really bummed and I even have patients tell me, you know, my longtime patients, they give me a hard time. In fact, this happened last month. I got a referral of a family from another family that we’ve known for a while and they were very pleased and we went through a lot and of course lot of them had sleep apnea and then she kind of looked at me and said, you know what, the people that the family that referred us, they said that everyone has sleep apnea in your practice. And I laughed. My staff did too because it’s 30%. It’s about 30%. It seems that way because we are very focused on this. We are screening everyone. We don’t want anyone not to have a chance to fix their sleep if there’s a problem. So I hope that answers the question.

Richard Jacobs: Well, the question is, do people think I’d better go see a dentist because I’m tired all the time and as daytime sleepiness, where did they think, oh, I need to go see a sleep doctor?

Mark Burhenne: It’s a good question. I think back 10 years ago, no one thought to see their dentist. I think today it’s changing. A lot of dentists like me are talking about this and treating it and, and we’ve got organizations like the American Academy of Dental Sleep Medicine, which is a group of doctors and dentists that are collaborating on this and working together as a team, which is the way it should be. But here’s the thing. Okay, so people now are thinking maybe I will go see my dentists. But yeah, the important thing to remember is who do you see? Most people in this country see their dentist twice, maybe three or four times a year. How often do you see your primary care physician? And so we have this great opportunity as dentists because we have loyal patients. We see them more often. We have so many opportunities to give them nutritional advice, sleep advice, kind of that overall systemic what happens in the mouth, happens in the body. Oral microbiome, feeding the gut microbiome. I mean these are all the new frontiers, a functional medicine including sleep. And we have a great opportunity here if we’re trained properly to not take over the physicians. We’re not, trying to do that, but people use their dental insurance more often than they do their medical insurance. So deductibles are way lower. People wait until it’s too late to see their position sometimes where they’ve been seeing their dentist on a regular basis. So instead of just filling in, filling and doing those kinds of things, we really, as a profession, dentistry, we really have this great opportunity now and in the future to be so much more than just a drill and fill, you know, kind of tooth carpenter. We’ve heard all those terms. Right. So that’s the thing. I think patients now are seeing dentists as more of an all-rounder in terms of health care. So she ain’t asleep. I think you’ll see more of that with the gut microbiome. Dysbiosis and analysis are all new terms or posture, facial development, getting our kids to grow up properly so they don’t have airway issues. There’s a lot more going on in dentistry. It’s very, very exciting. So I think patients are getting it, but the frustration is that not all dentists are up to speed, so the patients get frustrated. It’s like, which dentists can do this. And so I feel a lot of that, so.

Richard Jacobs: Okay. How does someone end up with a CPAP versus an oral appliance or vice versa? I mean, is it just lucky the Irish? If I go to you, you say, oh, it looks like sleep apnea. You can’t diagnose. You got to go do a sleep study. They go do it. Then what, you know, how do I get pushing one item or another head of who makes right decisions?

Mark Burhenne: Yeah. It’s not arbitrary and it’s not up to me to make that decision. Although I’ve already made that decision to some extent, as a dentist, I always refer to the sleep doc. That’s very important. And if they have severe sleep apnea, there are three categories. There’s mild, moderate and severe, mild and moderate. Typically, we’ve all been trained physicians in a dentist that an oral appliance may work. Although even for me, that’s not enough information. I can get into that later if you want. But if it’s severe sleep apnea, let’s see if you have more than like 25 or 30 interruptions per hour. There’s no sleep doc that’s going to write a prescription for sleep for an oral appliance. I have treated people that have given completely given up on the c-pap. And so I have treated people that have AHI of 70 or 80. We’ve gotten them down to 19, and then my ploy there is to get them back onto an APAP. Because I remember I mentioned earlier that the two together seemed to work very well and that has worked well. But that’s something where you have to have the patient sign the treatment records saying, listen, you know, you’ve said that you’re not going to wear an oral or a c-pap. We’re going to try the oral appliance, but it is not the end-all. And it’s usually hopefully heading to wearing both together. So it’s not arbitrary. There are things that I look for. I like to do what’s called a modified Mueller’s maneuver. That’s where the ENT sends a camera down through the nose into the airway, above the airway. And I like to preview what that thrusting of the jaw does. If the airway opens in that movement, then we know that the constriction of the airway is high up a nasal pharynx, oral pharynx. But if it doesn’t, if that thrusting doesn’t do anything to that little airway, which is sometimes the size of a tapioca straw, I mean, that’s the diameter of the airway. It’s frightening when you think about it. If it doesn’t change anything, then I don’t want to waste the patient’s time, have them go through all the adjustment phases of the world clients and sometimes have to pay out of pocket now three, $4,000 from oral appliance if it’s not going to work. So it’s not arbitrary. It’s not either this or that and we don’t want the patient to choose because they always choose the oral appliance over the CPAP and that’s not necessarily a good thing. So there is kind of rules and parameters and protocols that guide us into where this patient should be or how they should be treated.

Richard Jacobs: I just wondered again how someone makes those decisions. OK. That makes more sense. Well, very good. So what’s the best way for people to get your book? Is it on Amazon? Is available everywhere and then if they want to see you, how do they see you?

Mark Burhenne: Well I would start with the book. And because it’s just a four and a half hour, five-hour read. It is designed for people that are tired to read. Lots of bullet points and easy, just a quick way to make an assessment, a self-assessment of whether you should get a sleep study or not. So that’s on Amazon. Just type in my last name or type in eight-hour sleep paradox. Give it a quick read and I will recommend, you know, read it, read it once, read it twice, maybe take a, make a copy of the bullet list that you’ve checked off and then give it to someone else that you think needs that. And then you can always find me and send me an email if you want, if you by going to our website and that is askthedentist.com and there you’ll find lots of information on sleep references to the book links to the book and also lots of other dental stuff, lots of exciting stuff that’s coming. New sleeps tests. The whole oral microbiome, how it connects to the gut microbiome, which is getting its final do. It’s a lot of attention now to how that affects our overall health. And then the mouth is tied into that just completely and totally. It’s amazing. So just those two, Amazon Burhenne, type in Burhenne to get the book and then the website askthedentist.com.

Richard Jacobs: Alright. Very good. Dr. Mark thank you for coming on the podcast. I appreciate it.

Mark Burhenne: Right. Great. Thank you. Thanks for having me on the show. I enjoyed it.