Autobiology with Jennifer Little-Fleck

How Dr. Nicole Chenet is Fixing Sleep Apnea, Snoring, and Marriages Without CPAP

November 02, 2023 Jennifer Little-Fleck Season 3 Episode 49
Autobiology with Jennifer Little-Fleck
How Dr. Nicole Chenet is Fixing Sleep Apnea, Snoring, and Marriages Without CPAP
Show Notes Transcript Chapter Markers

In an eye-opening conversation with Dr. Nicole Chenet, a sleep apnea dental expert, we unpack the ins and outs of sleep apnea treatment, illuminating her unique approach to this sleep disorder that is more than just a nuisance, but a serious health concern. Dr. Chenet's journey from regular dentistry practice to sleep apnea specialization is not only intriguing but has been a game changer for me and my husband. We delve into the personal side of things as we share our experience under her care, revealing how sleep apnea doesn't only affect the person suffering from it, but can also take a toll on their relationships.

Ever thought orthodontics was just about perfecting your teeth? Our conversation with Dr. Chenet turns that notion on its head. We explore how orthodontics play a crucial role in treating sleep apnea, by increasing the upper airway nasal volume and guiding the lower jaw forward to open up the airway. Dr. Chenet shares how she tells a patient's 'mouth story' to reveal if they've been breathing correctly since childhood, underscoring the need for multi-disciplinary collaboration to fully assess a patient's needs.

From discussing the use of advanced technology, such as medical-grade materials and artificial intelligence in sleep apnea treatment, to success stories of patients who've seen incredible changes, our conversation with Dr. Chenet is full of practical advice and inspiration. We talk about a range of treatment options including CPAP machines, oral appliances, septal surgery, and sleep rings, and address the impact of factors like menopause on sleep apnea. So, join us in this enlightening episode with Dr. Chenet to better understand sleep apnea and its treatment.

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Speaker 1:

Hello everyone and welcome to another episode of Autobiology, and today I have with me Dr Nicole Chenay. She is with the Sleep Apnea Dental Center of well here in Pittsburgh, and what's really awesome about Dr Chenay is she is currently helping my husband andI and I'm going to let her go ahead and introduce herself and tell you what people call her as well. Dr Chenay, welcome to the show.

Speaker 2:

Oh thank you. Thank you so much for having me, Jen. It's an honor to be here. My name is Nicole Chenay. I am a practicing dentist who solely focuses on treating sleep apnea snoring for patients. I no longer do dentistry in my practice and we are passionate about treating sleep.

Speaker 1:

Now, when I first met you, I came to the appointment with my husband, actually because I had just read this fascinating book that had no idea about jaw and jaw development. I love evolutionary biology as you know, I'm a biologist and they were talking about sleep apnea in the first chapter of the book and I was like why did I buy a book on sleep apnea? I don't understand why they're talking about this. And it was fascinating. And then, lo and behold, my husband comes home from an ENT appointment because he's getting his deviated septum surgically fixed next month and they said, by the way, you need to see this woman, dr Nicole Chenay, about treating your jaw. And I flipped out and I was like what I have to come to this appointment. And that was how I met you and you told me at that appointment that they call you sometimes the marriage doctor.

Speaker 2:

Well, think about it. You have A, the person who has sleep apnea, who is not getting great rest every single night, and then you have B, the spouse, who is also not getting great rest because of the noise due to snoring, choking, gasping, tossing, turning, moving around, waking up their spouse. And so what does that do? I mean you're both exhausted and tired. We don't behave like our normal selves when we're exhausted, we're tired. We're not getting that good, reparative, deep and REM sleep every single night, and it is a game changer.

Speaker 2:

I mean, thank God you guys have a beautiful, wonderful, healthy relationship. You can see that out from the start and you really care about your husband's overall health. I think I said we're birds of a feather because we want to know the why, we want to dig deeper and we want to have everybody who we know and love be the best version of themselves. If I will tell you, I have patients who literally say my husband or my wife is going to divorce me if I don't get this under control and I'm like, okay, let's get going, let's get you back to your own, like yourself. You know, yeah, yeah, no.

Speaker 1:

I mean, I haven't said that, but I'm sure that my behavior some mornings probably says that. But yeah, now, before we get to talking about myself and my husband, jim, what I thought was super well, I want to back up a little bit like how in the world did you switch from regular dentistry into getting into such a specialized?

Speaker 2:

form. I love everything that dentistry has to offer. I love education and early on in my dental career I took a wing towards orthodontics and, of course, my children my first two were toddlers, babies at the time and that's segue training on orthodontics the way I was trained by Dr J Gerber. Basically, if we don't have a good airway, if children are not breathing well meaning huge tonsils and adenoids, bad allergies, et cetera then they are mouth breathing and as they sleep all their teeth, everything, their palate, everything's collapsing in and then that's making their sleep disorder breathing worse. So in the child from day one, as I was trained, we had to form those relationships with our ear, nose and throat physicians to coordinate care to get these children breathing better. So that segueed me into then evolving under doing a sleep mini residency with Dr Dennis Bailey, who was based out of UCLA at the time but actually brought his whole mini residency program over here to the East Coast, which worked out great for me at the time because I was pregnant with my third son, rocco. So the other thing that happened too is that my own dental patients were saying to me hey, I've tried the CPAP, I can't wear it, and you just made me one of these oral appliances I'm reading about, and after I had about four or five of those patients say that to me and this was back in like 2011,. This was about 13, 14 years ago I felt I had to do this for my patients.

Speaker 2:

The other thing is is there's not a lot of us providers that do do this and at the time, there's only one other dentist in the Pittsburgh region who is doing this, and I always wanted to specialize and I just said you know what, if he can do it, I can do it, but I have to do it with the right board, certifications and credentials, et cetera.

Speaker 2:

And so we took the journey and worked really hard and developed all these relationships with not just sleep providers but ear, nose and throat sleep, pulmonary, the list goes on. I'm involved with neurologists, cardiologists, because obstructive sleep apnea really affects every aspect of the patient's overall health. It got to the point where, nine years ago, one of our main hospital systems here in Pittsburgh asked me to become like the dental sleep medicine provider for their sleep medicine department at Allegheny Health Network, and when that happened, I just knew in my heart of hearts it was really difficult for me to close the doors on the relationships I have with my patients in my regular dental practice. But I needed to serve this need that was in our community to take on the volume of patients we have that need this appliance. So at that time that's when I say I hung up my handpiece, I retired from regular dentistry and then really had all the time, effort and energy to focus on oral appliances to treat obstructive sleep apnea.

Speaker 1:

One of the reasons that I was so excited to talk to you and that I've been telling everybody about this interview oh my God you have no idea is the collaboration between different specialists. I so rarely see that and that was one of the main things that stood out to you. The whole reason that we found you was because Dr Seuss, who's doing gym surgery, referred you to us. But you two have worked together and really built this great program and camaraderie that I just really hope to see in other places and other types of specialties. But this problem is so pervasive.

Speaker 1:

I love that you talked about the pediatric side of things, because one of the first thoughts that I had after reading that book and then and then talking to you was my kids, because they're both in braces and I thought all of a sudden, should I not have them in braces? Should I be doing something else to deal with their jaw issues? I know I have one mouth breather that is taking after gym and but you assured me that there the the orthodontist that we go to, specifically good orthodontics that they have a good reputation, understand what you understand and they address that. What are some of the things if people are looking for, or good orthodontist for their children who understand what you do Like. What are the some of the things that they should look for in an orthodontist who understands this?

Speaker 2:

So a lot of the orthodontists are really reputable in our area and the concepts of what they're doing.

Speaker 2:

It's not when we do orthodontics on children, you're doing everything right. That's one of the big major steps, especially in your son who's mouth breathing. So when orthodontics are performed, it's not just about the teeth looking pretty right, it's about arch with alignment. So with them using braces and wires or, if they choose to use like a clear align or like invisible line product is to create room on the on the upper palate, on the upper arch, so that the teeth are able to line up properly. But it's not just so that the teeth are straight, it's so that their upper palate isn't narrow and pushing up into their nose and sinus area. So when this think of it as a TP tent, so it's like this and then and then we're rounding it out, bring your hand fingers down and it's coming down. So you're increasing your upper airway nasal volume space by doing that. So that's on the upper arch, right, okay, so say then, orthodontically, you have the patient who is mouth breathing, right.

Speaker 1:

Right.

Speaker 2:

Mm-hmm, I love our bath. Uh-huh, all right, and they're look, their lower jaw is pushed back right. So we are then guiding once. Once there's the room on the top, now the lower teeth can unravel, create, create a nice open arch with. So the tongue has room, okay, and then we're gonna guide that jaw in the blade To where the lower teeth are just behind the upper teeth. And what's that doing? When we posture our lower jaw forward to its appropriate position, the tongue is attached to the lower jaw and the tongue then postures forward with it. When the tongue postures forward, the, the soft palate, the back of the throat, and the tongue posture forward, and then that opens that airway. So then, when that airway is open, your nose can take the breath in. It's not blocked, you're taking that breath in and it's going into your lungs, where it needs to go, and that's how we get oxygenated, right, right, okay. So it all comes together and that's what the orthodont, that's the orthodontist role in that.

Speaker 2:

The thing that's very important is that the orthodontist also needs to have coordination of care within ear, nose and throat. Now, a lot of orthodontists do feel and believe that if they create that room in the mouth and With the jaw position coming forward to where it needs to come to, that the patient then has room for the tonsils and adenoids. I personally feel, and in my practice, the way I approached that was I wanted the ear, nose and throat doctor to make that determination Not me, okay, right. And traveling both ends, I think is critically important. So, for instance, in your son's situation, if he's coming towards the tail end of his orthodontic correction, right. If that's coming towards the tail end and he's still mouth breathing, two things I would suggest a, you need to talk to the orthodontist about that, and b, you need to go see Dr Seuss, you know, and have him Take a little camera, go inside the nose, go inside the adenoid area and the tonsils and determine does he really need something to be addressed or not? Genetics play a role.

Speaker 1:

Yes, right, you were very into genetics. Yeah, I can't remember if we talked about that or not. So that's interesting because I bet you, a lot of families don't understand why, when they go in for an orthodontic consultation, why they do take x-rays of the airway and they point that out. I did not at first understand and they they did point out to me your son does have a narrow airway and we need to to watch that. I had no idea, I mean. Obviously now I totally get it, but you know, I just I'm so wanting to get this information out to people who have no understanding that it's a much larger problem than just, like you said, making your teeth look pretty like there's. You know it's. It impacts everything Oxygen. We need oxygen, um, all right.

Speaker 1:

So now let's transition a little bit, because you did something else in the appointment with Jim that I absolutely loved and I almost wish I could have videotaped it because it was so amazing. You opened up his mouth and you looked at his teeth and you said oh, jim, your mouth tells me such a story. Let me tell you the story that your mouth Is telling me and you went through and you described the state of not only his teeth, but of his mouth, and how you could see that he had not been breathing correctly since he was a child. You could see that in his mouth. Can you explain to the audience, like, how you're able to decipher that story?

Speaker 2:

Sure, so you just hit the nail on it. I say every mouth tells me a story. So what do we see in evidence of sleep disorder, breathing? Number one we see the person who, as a child, was mouth breathing and so they had Upper palatal collapse. And I explain it to the patient like your, your upper palate looks like a tp tent rather than a, rather than like a, just a nice rounded Oval conic. You know, I mean, it's a tp tent, it's very narrow, and then the teeth are so crowded in. Well, they didn't just do that on their own, they did that because when the somebody's sleeping, your tongue is supposed to be up In your upper palate.

Speaker 2:

Taking Shaping your upper palate as a developing child and baby. So what step one I could see? Oh, he never. He never breathed through his nose since he was a kid. He has significant palatal collapse, his teeth are crowded. So then what do we start to see? Then we start to see on the teeth, we start to see pretty heavy wear, facets, you know, worn down teeth, crack, tea, chipped porcelain on crowns. And then so why do we do that? So when the, when the body is fighting for air, the your, your own body goes into fight or flight and says breathe, gym breathe. And so after he has had that collapse, no breath, 10 seconds or longer. So his body is naturally going to thrust lower jaw forward. I call it nature CPR. So with the clenching and the grinding and the thrusting the jaw forward overnight, what you're doing is your body is naturally doing CPR To open that airway.

Speaker 1:

I love that nature's CPR. That's a great.

Speaker 2:

CPR. So so what? Who takes the beating? For nature? Cpr the teeth, right, right. The other way that that pressure and damage manifests is it could be wear on the teeth, it could be Gum recession. So how many people listening to this say I don't understand why I have gum recession? Okay, they're not taking a toothbrush and scrubbing the heck out of their teeth like this. Maybe some people are. The reality is that when you have this constant force and pressure of the upper and lower teeth, that force has to come out somewhere. So what happens is it'll happen at the weakest spot, and that might be that a little bone is pulling away from the front of that tooth and with the bone pulling away, so does the gum that the bone receipts.

Speaker 1:

Oh my gosh, I'm sure that you just forced an aha moment out of so many people right now with that explanation. Yeah, yeah, like, why do people have receding gums? And the other thing that always perplexed me was gum tissue is a living tissue, so it can grow back, so why isn't it? Why is it consistently receding? Why is it so, which would suggest that there's an ongoing problem, right, if it's not coming back, right?

Speaker 2:

Well. And two, it has to be connected to bone. So it's not that tissue could regenerate, but the bone isn't there. So once that bone is gone, the bone can't come back. Around the root of that tooth there's bone and there's what's called a periodontal ligament and there's a teeny little ligament between the bone and the root of the tooth. And once that gets kind of, I say, melts away, it can't come back.

Speaker 2:

And the other thing that can happen is it's all how that mouth manifests the stress and pressure of the clenching and grinding is that we can actually grow extra bone inside, and it's mainly mostly on the lower jaw where the tongue is. And so the clenching and the grinding it's like okay, so you had a two by four and you have a hammer and you have a nail and you're pounding that nail in Right. Well, that two by four, that wood is going to splinter somewhere. So how that particular patient manifests it is, they start to grow bone and grow bone. Well, guess what? Those little extra bones at the floor of your mouth. They're blocking where your tongue needs to lay down. So then the tongue comes up and back and towards the back of the throat.

Speaker 1:

So is that where all those little bumps are. Like you know, because I have them, because I used to grind my teeth really bad at night, like just you know, and you're lower, and you're lower jaw, you can feel them around below your tongue, those little bumps. So that's what that is, yeah, from.

Speaker 2:

Yep, that's what it is. So so often patients will go oh, my mom and dad had those. Those are just genetic and I go. Well, your mom and dad probably have some type of obstructive airway breathing, which is genetic. So you know all these other symptoms. Yeah, you did get it, but it's not like you just had it. It came, it arose because of the obstructed airway breathing and they were really stressed, probably maybe. And the body is stressed. Yeah, the body is stressed, right. So that's the other thing. People go. Well, I'm stressed out. I'm not sleeping well because I'm stressed out, which happens it happens to me it happens to you.

Speaker 1:

Yeah, it happens to everybody but, like I said, I don't think that people understand the what your mouth goes through as a result of all of this stress or poor jaw development. Not only do you specialize in sleep apnea and the devices, but you took it a step further, because you recognize that the standard device that people are starting to use to fix this might not be the best device, and you continue to research this. Could you tell us a little about your research and what you've done to help educate others in your field?

Speaker 2:

Well, actually, jen, there's like over 120 FDA approved devices for our yeah, wow, yeah, yeah. Like this has been going on this our Academy of Dental Sleep Medicine started about 35 years ago and it wasn't known. It's taken hundreds and hundreds of studies and finally really getting collaboration with our medical colleagues to accept this as a means of treatment. What I've done personally is that, like I personally only work with the best, and what I mean by that is that the one device that I put James into it's not just this company. They put a ton of their money back into research and funding and what that has done is then proved the efficacy. That's actually even better because we're using.

Speaker 2:

The materials we're using now are so much different than what we were using 10 years ago. 10 years ago, we were relying on traditional, like dental acrylics materials we normally use in dentistry and we were using mechanisms like metal arms and stuff that would help like gently bring the jaw forward, et cetera. Now, like with the appliance I gave Jim, is that is a medical grade device and what that means is the material is medical grade. It looks like a clear, kind of like a plastic. It's not plastic, it's called MG6. And it is the most biocompatible material that we could have a patient wear inside their mouth.

Speaker 2:

Why is that so important to me? Just like you, you always want to know each ingredient that goes into everything. Right, I make my own hand soap, I mean, not that that's hard, because I'm not like I don't have time to do a lot of stuff at my house, but I want to know the ingredients in my detergent, in my makeup. I want to know that everything that I put into a patient's mouth is the healthiest material that I can have there. It's inside their mouth.

Speaker 2:

They have saliva, you know. I mean everything is in there. They swallow saliva, so there's no with that biocap compatible material. There's no micro leakage, so there's no absorption. There's no porosity of the material, meaning it won't absorb bacteria, viruses, staining, et cetera. So it stays very clean with simple cleaning techniques and stuff like that. So that's, I opt to do that. And the other thing is is that now these appliances are now 3D printed. Artificial intelligence helps make them. The way we take our impressions when you're in our office is it's all technology. So there's digital scanning of the mouth, which the accuracy is just so much better than when we used to do traditional Gooby impressions that a lot of patients get anxious about because yeah, that's really cool watching you do that.

Speaker 1:

You just like wave a wand like around the mouth and it just magically appears like on the screen. It's a 3D image of his mouth. It was crazy.

Speaker 2:

Right. So all of those things add up to better materials, better fit. The lovely thing is that if a patient loses, say, they're upper tray or they're lower tray, or dog eats it, or whatever may happen, it's in a cloud and literally I send in a request to my lab, they push a button, it gets milled out, shipped out and it's back in the patient's mouth within like two weeks. Oh so the technology is soaring with it, all right.

Speaker 1:

So let's talk about Jim. Okay, I'm sure he appreciates this.

Speaker 1:

Yeah, yeah, oh, trust me, I'm sure he does. Like, if I can, I'm going to try and beg him to, like, kind of you know, insert a little testimonial of you know. We'll see what happens. I don't know what I have to do to get that out of him, but okay, Okay, Okay, Take away.

Speaker 1:

He went to Dr Seuss. Dr Seuss said you absolutely have to see Dr Chennai. In the meantime, we're going to do a sleep apnea study. What we found with his sleep apnea study was when he was sleeping on his back, he stopped breathing. It was crazy. What was it like? 150 or 300 times an hour. It was insane. I'm out. I can't remember exactly what the number was. I remember it was over 100, but he literally stopped breathing every hour that many times. And then it started to make sense to me of why he sounded the way he sounded when he was asleep or was attempting to sleep. And so when we came in to see you, you explained that it's not just one device but a series of devices. And can you go into the detail of the process that happens when somebody comes to see you and they go through the scanning, and then what do they get in the mail, and what does that process look like over the course of four to six weeks?

Speaker 2:

Okay. So when the patient first comes in, we obviously do a nice big digital x-ray. We want to make sure the teeth are healthy, the bone that's holding the teeth is healthy, the jaw joint, and we also look at the nasal septal in the sinus area as well, and then we do a full, comprehensive exam and then I tell the story of their mouth and what I think has happened over the years and why we need the oral appliance and the soft tissue, like what's going on with their soft palate and their tongue and what I call it the back of the throat for layman's terms, and help the patient understand. Body position while we sleep is such a critical factor, and one of the big things I do like in Jim's situation is explain look at your sleep apnea score on your sleeping on your side versus sleeping on your back, and when the patient sees that information it's eye-opening to them and so, out of the gate, one of the very first things I say is we've got to get you off of your back right Now. You do have some patients who have had back, neck trauma, et cetera. It might be hard for them to sleep on their side. Whatever the case may be, hips, hip replacements knee replacements make it difficult for patients. So I say, okay, do we have a way to elevate your head so that you're not flat and at least you're elevated in that circumstance? So we figure out what's gonna be best for the patient.

Speaker 2:

After I've done my full exam, what I use is I use all these little sets of just different measurement gauges and, laying the patient back, I will have them put all these different little measurement gauges inside their mouth, on their front teeth, and determine which one makes it easier for them to breathe through their nose, which makes which position makes it hardest for them to snore. And based on that specific measurement, I know that's the position I'm going to start their oral appliance therapy in. They've gotten their digital scans ready and then we're gonna schedule the patient in three weeks. Nothing gets shipped to the patient in the mail. This is all I have to assure that when the patient comes back in for their next appointment, that things fit properly, not things painful or uncomfortable, and that they're gonna be able to wear it. And I really say to the patient don't I need you to tell me the truth, don't? Some people are afraid to speak up and I say this is your appliance. This isn't my appliance. You gotta make sure it feels right to you and we get, and typically most of the time they fit. Great things are good. They also were gonna get in his situation.

Speaker 2:

In that design, which is probably the one main appliance I use the most right now because it works for pretty much everybody, you actually get multiple upper and lower trays and each one of those with the little side wing that holds the jaw forward has a specific measurement, and so each time you change it, it's just bringing the jaw forward by one millimeter. But one millimeter in the front relates to four times the amount of volume space in the back. Oh, I didn't know that. Yeah, and so if it doesn't take much to, okay To then posture the tongue open and open up that airway space in the back for them to breathe.

Speaker 2:

Well. So here's the thing our physiology and anatomy changes in our sleep versus our awake time, like people say to me well, why don't you have trouble breathing and have sleep apnea during the day? Because our brain is functioning differently, our anatomy is functioning differently and we're not laying down right and as we go into deeper stages of sleep and I don't know if you know this or if your audience knows this, but when we go into our REM sleep, our whole body paralyzes. Yes, everything paralyzes, and that sounds like a scary thing, doesn't it? But it's not.

Speaker 1:

It's not, it's very necessary, right Cause that's when our lymphatic system empties out the waste products basically from our brain, and when it opens that up, we can't be moving. It's a very, actually dangerous time for us, and so the body temporarily paralyzes itself so that you can't move while that happens. So I did know that and that's crazy awesome, and we've only known that for like 10 or 15 years that that happens.

Speaker 2:

Well, and it connects all the docs for everything, right? So when somebody's laying down and their body's paralyzed and they have a tendency towards structures that are cutting off their airway in REM sleep, that can get significantly worse. So that's why I have so many patients that'll say to me I'm up every hour and a half, I'm up every hour and a half. So if they're in lighter stages of sleep they're not as obstructive, right, right, your body is trying to go into REM and it really. Then the airway collapses because everything's paralyzed. So then guess what the body says Wake up, wake up, you're not breathing. Okay, so the goal of therapy for me is open the airway, get them that good, delicious, wonderful body repairing deep in REM sleep that they need.

Speaker 1:

All right. So we also learned that Jim doesn't have sleep happening, and nearly as bad when he's on his side. So, to your point, the body positioning makes all the difference in the world. So one of the first things we did with him, at your behest, was make sure he started sleeping on his side, and there's actually all kinds of devices you can buy on Amazon that you turned us on to that, while we're kind of retraining him to sleep on his side, it makes it kind of impossible for him to roll over on his back. So that was one really cool thing that we learned.

Speaker 2:

Would you like me to mention? Yeah, yeah, go ahead, one of my new favorites on Amazon. If you type in magnetic ball for side sleeping, now the thing. That's a funny question that I have to ask, like my mail opens. Mostly not, I mean, I treat a lot of males and females equally, but a lot of men don't sleep with an undershirt. So I have to say to them I'm not asking you this weird question, but do you sleep with or without an undershirt? And if you do sleep with an undershirt, this, it's on Amazon $25 a mat.

Speaker 2:

I didn't come up with the idea and the ball splits in half and there's a magnet on either side and you put the one half of the ball inside the undershirt, you know, on midway in your back, and you put and then you connect the other half of the ball onto the outside of the undershirt. So it's there. I call it kind of like a sleep trainer, like we would do with our babies, right, yeah, and so if the patient lands on their back, they're like, oh, that hurts. Let me get to my other side. It's $25.

Speaker 2:

It's a very simple solution, even for somebody who's in the process of maybe. Hey, they're scheduled for that sleep doctor, they're waiting for their home sleep tests or they're like why do I feel so terrible in the mornings? Just keep you know tonight, take a body pillow, take something, put it behind you. You could just say somebody doesn't wear an undershirt at night or they sleep without any clothes, potentially so maybe taking a sock and putting some golf balls or tennis balls in it and pinning it to the sheet so that if they land on it they're going to get to their other side, right?

Speaker 1:

Yeah, that was something that Dr Seuss had suggested. Yeah, I like your method better. So, and to your point, he would wake me up probably six times within the first hour and a half. We would go to bed snoring, and not just snoring, but like I mean choking for breath. So that was a really big deal.

Speaker 1:

Yeah, so we got his devices and we started with the smallest one, and one of the things that I thought was interesting was when you were fitting him for these and you were doing the measurements, even in your office, when you laid him down on his back and you had him put something in his mouth and close his mouth and you were taking measurements, it was hard for him to breathe through his nose and it was very obvious that he has barely ever done that. And one of the things that you had said was make sure you try and clean out your nasal passages and stuff before you go to bed, because we're basically going to start forcing your body to breathe through its nose. We need it to be open and accessible, and so that was interesting. So the first night he did it, he was. It was funny in the morning because he was like I didn't.

Speaker 1:

You know I drink a lot of water at night and I wasn't sure how to drink water. And then, you know, I keep having these dreams that I'm chewing on something and I break up and he's like I got this thing in my mouth, I can't open my mouth and I forgot, and you know it was, it was interesting the first week. But then he was telling me, you know, and showing me that after you wake up in the morning you use kind of a second little thing for five minutes just to reset the jaw for the day. Can you talk a little bit about that as well?

Speaker 2:

So we spend a third of our life in sleep, right? So if we're using an oral appliance that's bringing the jaw forward conservatively, but it feels like a bigger deal inside the mouth, your brain starts to think, oh, you want me to move forward, almost like as if you were doing some type of orthodontic movement, right, right? So by making the little morning we call it like a morning realignment bite, and so we make that when the patient's there in our office and it molds to the teeth and they bite on the front teeth with it. And what we want to do is we want to make sure that the patient is biting on their back teeth and back molars into their natural bite. So what we're doing is number one, we're reminding the teeth where they belong the jaw, the lower jaw, where it belongs. Number two, it's actually sending what's called a proprioceptive reflex to the brain and when the upper and lower teeth actually touch, there's a little, there's a little nerve endings in there and that says, oh, that's where we belong, no problem, and we get back there. Yeah, some people need to wear it 15 minutes, some people need to wear it for 30 seconds. Oh, really, okay, yes, everybody's different, everybody's different. But we do say whether you think you need it or not, we require that you do it Just because I have some patients that you know they're like I feel fine, I feel my back molars, I'm like I know you do. But it's such a subtle change that can happen over the years and once you start wearing an oral appliance, you're wearing an oral appliance till we move on to the next life, right? So so we got to make sure that we maintain that, that nice posture where they people are chewing and biting efficiently.

Speaker 2:

One of the potential side effects is that people's bite can change over the years and especially if they're not very compliant with doing that morning realignment bite and the patient's well aware of that that that can potentially happen. But again, some patients don't even you know I have a different, every patient's different. So some patients might feel like, hey, I'm fine, I didn't even notice that my bite changed, I'm chewing efficiently, I have no pain, no discomfort, et cetera, and they're like I'm willing to take that slight side effect versus not getting up four times a night to go to the bathroom, choking, gasping, feeling like terrible throughout the day. And then others are like it really bothers me that I can't chew efficiently, you know. And then we work. We work with them to to get their bite back into place or determine what we need to do next for those people. But that's after those. Those are patients that have been wearing their device for a long time.

Speaker 1:

Most patients do well, most patients if they're compliant with wearing their morning realignment bite, their bite gets back into place and they're okay, yeah, yeah, he's had no problems at all and it is interesting, though, you know, every week when you have him just move another millimeter, you know he can really feel that, even though he he said he was really surprised that you could feel that just tiny, tiny little shift, but it makes such a huge difference. So, in full confession, like we were not even sleeping in the same room most of the time, because it was just that it was that bad. You know, I'm one of those people that I I have to get at least eight hours of sleep or I just can't function. And, like I said, he was waking me up six times in the first hour hour and a half. So we waited for about three weeks with the device and then we did the great sleep in bed experiment.

Speaker 2:

And you didn't want to have a night where you had a terrible night yet.

Speaker 1:

Well yeah, I mean, yeah, I mean we, you know we have little kids and I have a business and you know it's just a lot, a lot of stuff. And you know I was expecting that it would be less, that he wouldn't be doing the, the choke. But when the first night came and went and he did not wake me up a single time, I couldn't believe it. Dr Chenay, I was floored and you know he knew that I was, you know, going to be interviewing you. So I knew probably that was making him more compliant, but I was, you know. I was like we really got to follow through on this because I want to know, you know, and I and other people need to know this, you know, does this really work?

Speaker 1:

And so far he has not looking me up from snoring. In fact I haven't even heard him. I can't, I don't hear anything anymore. He sleeps on his side. He doesn't. He hasn't reverted to sleeping on his back at all. So, you know, it is, in my opinion, a wildly huge success. You know, and I just can't thank you enough. I'm like you are, you know, you are a marriage doctor, in my opinion, but I guess the thing that just floors me is how few people know about this. I mean this is like wait, this is a joke, like almost, I bet you, 90% of married couples over the age of 45 have this problem.

Speaker 2:

I would say I agree, I agree and we're trying to make more awareness. We are very lucky in our Pittsburgh region I have to brag, I feel it's one of the best places in the country as far as being treated with sleep medicine and the coordination of care between yes, yeah, where we all yes, it's not like one, you know, it's one thing or the other, it's what's going to work best for this particular patient. They're multi-level. You know what did Dr Seuss said? Dr Seuss says, yeah, we got to. We got to treat that nasal septum finally. But he also wants to see how the nose behaves when we get the sleep apnea under control with the oral appliance, right, the other thing that does is that it gets his nose. Even with having the bony obstruction from the deviated septum, it gets it behaving a lot better than it did without being treated. So all of this has to come together, but it just. It fascinates me that every single day patients will go. Why didn't I know about this four years ago?

Speaker 1:

when.

Speaker 2:

I first got diagnosed? Yes, that's exactly my question. I mean, I've always the thing that's super important to me is always maintaining professionalism but there's this part of me that wants to like put big billboards up and say you know, there's another option, you know, there's options. There's CPAP, there's oral appliances, there's nasal septal surgery. There's options for you. And I think so many patients don't even get diagnosed because they think that the only choice they have is to wear a CPAP mask on their face. And that's what really saddens me is that then everything starts to decline. They're on blood pressure medication, they're becoming three diabetic, their weight starts to increase because their hormones are so out of whack because of the poor sleep, they're increasing the risks of Alzheimer's and dementia. You know, I mean, the list continues to go on and on. Just because they're like I don't want to wear that mask on my face. But they have no idea the choices that they have.

Speaker 1:

And I think that is a huge part of it. You know, if you would have asked me, I just would have said well, I just think there's CPAP, like I didn't know. You know that there were other things. I think there is also now implantable devices, right, that kind of like cooks you to take a breath, or you know, I'm not really familiar with those devices, but yeah, yeah please go ahead.

Speaker 2:

So that's called inspire therapy. But what inspire has done? They spent. I think last year they spent $200 and some million dollars on advertising and you would think, oh, that's not good for you. I actually call it marketing for me, because now these patients go to my ENT sleep specialist here in Pittsburgh saying I couldn't wear CPAP, I want to be evaluated for inspire, and my ENT colleagues say listen, we're going to try an oral appliance with you first, before we implant anything inside your body. Not only that, surgeons are not there to just do surgery, it's to do no harm. So if the patient can be treated conservatively and get their sleep apnea under control with an oral appliance, that's what they're going to do.

Speaker 2:

And as far as being approved to be a surgical candidate, you have to have failed CPAP and you have to have failing, meaning we can't get their sleep apnea under control with an oral appliance. Or it could be that the patient simply couldn't tolerate the advanced position that their jaw needs to be in in order to get, maybe, their severe sleep apnea under control. But what else are we coaching that patient on? At that time we're going to say, hey, if you lose 10% of your overall body weight. Your sleep apnea score is going to improve by 25 to 30%. That being said, how is that patient with moderate or severe sleep apnea who's not sleeping, how are they going to lose that weight if we don't get the sleep well controlled, where they have energy, when you get good sleep, you're actually everything changes with your body.

Speaker 2:

Cravings, like the types of food you crave, the amount of food you want to eat. Those are controlled by ghrelin and leptin, and those hormones are out of control when somebody gets horrible sleep. So another little thing, anecdotally, that a lot of patients will say to me is that I've lost my appetite or I'm not as ravenously hungry as I was before I started treatment. So they recognize it regulates, they self-regulate and they feel full appropriately. But they also kind of change their eating patterns because they're not craving comfort foods, like when we're sick.

Speaker 2:

I'm Italian. What would I want since I was a kid? Pastina, I want the comforts of what was given to me as a child. Right, and that's what we go back to, what we know, the comfort, and what we find is that people don't need that anymore. So these person who thinks, oh, I'm gonna go and get the surgery Well, it's not as simple as we think it is. There's a lot of mitigating factors, so again, it's this collaborative effort and most times an oral appliance gets the patient well-controlled with their sleep apnea where they don't need to do that surgery.

Speaker 1:

That's incredible, and just talking about the whole deep sleep thing. But Jim and I, well, we were, you know, oral sleep rings, and well he did, and he stopped because he was getting so pissed off, because I would consistently like it, you know, whoo-hoo, you headed out of the park you're an awesome sleeper, you know. And they would be like are you even trying to sleep? You know, really awful, awful sleep scores, and you know we were doing like all the things and we could not get his sleep scores up like no matter.

Speaker 1:

You know what we did and I just had no idea how much this apnea was contributing to the fact that, you know, he wasn't sleeping. His brain was never at that rest level that he needed to, you know, repair himself. And the more I read was how much that then contributes to cardiovascular disease and issues with that, and I was like, oh my gosh, we need to get this fixed, which is, you know, the whole cascade of events kicked off, you know, and you know we came to see you. But that was, you know, really, for me it was more about mitigating cardiovascular issues as we get older than correcting his sleep. But now I realize, oh, that's why he wasn't sleeping, you know. So after we we're gonna, we're gonna do our own little fun or a ring study after everything's been done, just to see okay, well, how's your sleep? Now, you know, can you hit those normal sleep score ranges.

Speaker 2:

So I'm looking forward to that. Yeah, I mean, and what'll be neat for in his circumstance is doing it now wearing his oral appliance.

Speaker 1:

Oh, yeah, I'm sure.

Speaker 2:

And then doing it again about eight weeks after his surgery.

Speaker 2:

You know, in just comparison. A note about all these wearables I think they're a wonderful tool and, again, a simple way for your patients to say is my sleep concerning. The wearables are not as accurate as a home sleep test. They do not give us the level of detail of a home sleep test, but I gotta tell you they do give us a lot of information. And if somebody you know goes to their doctor and say hey, I'm wearing my Fitbit and it's telling me, you know, I'm having this terrible sleep score and this is how I feel in the morning, you know, that's another level of proof that this needs to be addressed Now.

Speaker 2:

Let's flip over. Now we have the patient who's been treated with an oral appliance. Sleep apnea is well controlled, your numbers are well controlled. Patient sleeping well. Then I have patients come in and go.

Speaker 2:

Well, my Fitbit told me I had a terrible when I had to sleep on Saturday night and blah, blah, blah. And I'm like well, guess what? Every there's night to night variability. So once it gets to the point where things are controlled, we're consistent spouses saying we're quiet, you know. Or if we have a person who's living independently without somebody sleeping in the room with them, maybe from time to time they wanna wear that Fitbit. But then once and I have some patients they love their data, they love the nitty gritty and I say time to take it off. If you sleep great every night, take it off, you know, because what'll happen is you might go to bed, have a great night of sleep, but for whatever the reason your ordering is saying you did terrible last night. So then it gets in your head and you think, oh my God, I had a terrible night of sleep.

Speaker 1:

Yeah, that does. That does. I'm not gonna lie, that does happen. To bring up the point about the home sleep study and I literally had this conversation with a girlfriend of mine yesterday was I was telling her about you. She was like well, do you have to go and do those? You know, still like get it and sleep someplace weird. And I was like no, they send you all the stuff to your house and you do it at your house and you don't have to go anywhere. And it was amazing. It was awesome, it was so easy to do the home sleep study.

Speaker 2:

I was like wow, that was not what I expected, it was very, very easy 90% of the diagnostic testing for patients is done with the home test to get an accurate description of what's going on with their sleep. Some patients will be asked to go into a sleep lab if we think there's another sleep disorder.

Speaker 1:

Okay.

Speaker 2:

Or if they have several comorbidities, and what a comorbidity is is if we're concerned about like things like obesity, hyperventilation syndrome, or does the patient have narcolepsy or, you know, have they had a past history of strokes, heart attacks, et cetera. But overall, pretty much, to get a diagnosis, you're given a home sleep test at first and then you're given the choice Do you wanna try a CPAP or do you wanna do an oral appliance? At this stage in 2023, the physician should be going over the choices and saying which one do you think you'll be willing to be more compliant with and go from there Right, we do encourage people who have severe sleep apnea to try a CPAP. Try it, see how they do, but some people just aren't able to, you know.

Speaker 1:

Yeah, I know, and I'm just so happy that there's other choices and that you are there to guide them through the oral appliance journey, because this is something that I'm just super excited about and I just I'm so grateful. I'm so grateful to you and everybody at your office. Your office staff is so awesome, they're so nice, and so we're pretty much out of time here. If people want to learn more about this, you know, let's say they're not in Pittsburgh and they want to bring something like this to the attention. They're a physician. What should they do? How can they go about that?

Speaker 2:

We have a wonderful there's a couple academies, but our main academy is called the American Academy of Dental Sleep Medicine and you could type that in on your web browser and what's great about that is they have a lot of resources for patients and it'll say for patients. And the other thing that's really awesome is that you can type in your zip code and find out what dentists are providing this service in your area or region and you can do that. You know, as a, you know 25 miles, 50 miles, 100 miles, depending on where you are in the United States, and the thing that's important is that you could see the provider's level of education so it'll show you if somebody's like boarded where they became board certified, which means it. You know it was required. We do a volume of patients. We have to hit certain levels of education and take a board exam in order to pass it, to become a diplomat of the American Academy of Dental Sleep Medicine.

Speaker 2:

Other ones who have really wonderful credentials are ones that are trained in what we call craniophacial pain and TMJ, and they have. They have a really deep understanding of how it all connects with jaw pain and head and neck pain and obstructive sleep apnea, because it all goes hand in hand. I would say that is your best resource to connect you to somebody within your region and to also maybe even print out a little bit of literature. If you have a medical provider who maybe doesn't think or know of the resource, at least within a decent driving distance of them. To refer to Right.

Speaker 1:

Now, I know we found you through, obviously, referral, through an ENT, but do people here in Pittsburgh, can they make an appointment with you directly and start with you?

Speaker 2:

I can. Only I only will treat the patient after they've had a sleep study. So patients do schedule with me directly, but they've already been diagnosed, they've already had a sleep study. So let me say I will also treat patients who don't have sleep apnea, but they have all the symptoms of sleep apnea. So they may not have sleep apnea but they snore, they wake up, they get up to go to the bathroom, they have headaches in the mornings and they just don't feel good. But medical insurance only covers patients for the oral appliance who have a diagnosis of obstructive sleep apnea. When somebody doesn't have a diagnosis it is an out of pocket cost and we go over all of that with the patient.

Speaker 1:

Okay, but you can diagnose sleep apnea from a sleep study, or do they have to go through an ENT first?

Speaker 2:

They can get a home sleep study and a diagnosis through their primary care. Okay, ENT, neurology, psychology, cardiology all of those physicians are ordering home sleep tests to get the patient diagnosed. A boarded sleep physician has to read the sleep study to get an appropriate diagnosis that can be submitted to insurance. As a sleep dentist, I do not order a sleep test and get that person diagnosed. Does that make sense?

Speaker 1:

Yep, that makes sense All right. So you kind of come in once that diagnosis has been established. Or if they don't have the diagnosis, they can still come to you, but the insurance plays a factor with those patients.

Speaker 2:

It does. But I couldn't stress and reiterate I don't have sleep apnea and I wear an oral appliance every single night and so does my husband. You can see, I have a teeny little jaw. I have a tiny little jaw. I look like everybody in my family. By bringing my lower jaw forward, it just postures my airway open, just enough that I don't have a little bit of sleep interruption. I don't toss and turn at night.

Speaker 2:

What else is happening? I'm approaching 50. We're in perimenopause. I mean you and I could go on and on and maybe we'll do this another time. The hormonal changes affect the tissue quality and our tissues become a little more floppy when we lose progesterone and estrogen in females. In males the testosterone change affects that as well. So I might not have sleep apnea now. Give me five to seven or eight years and I might tip in to having a little mild sleep apnea and you would think that's not a big deal. But it impacts the patient greatly. Who knows what healthy, good quality sleep is? And then now they don't get it and they're blaming everything on menopause. I highly encourage that female patient to go and get a home sleep test and find out what is actually menopause and what is actually obstructive sleep, which can also make you have nights, sweats, et cetera. We can help them put those to sleep.

Speaker 1:

Wow, wow, this is really interesting. It's funny because you were talking about the oar ring and not always relying on that for your sleep, but I rely on it to track my temperature because, being in perimenopause.

Speaker 1:

I feel like I have no idea what is going on with me and I'm like it has been really eye-opening watching my temperature change over the course of time and it's not super cyclical anymore and then all of a sudden it is, and I just think I love data. So this is truly interesting to me. But I'd never heard about the sleep apnea and menopause thing. So yeah, that might be another whole other discussion. All right, I have taken up way too much of your time. This has been an amazing discussion and again, I just can't thank you enough. You've really made my bedroom more interesting and probably saved my husband's cardiovascular health as well. So thank you so much, dr Nicole Chenet. It was great having you. Thank you, thank you so much, thank you.

Sleep Apnea Treatment and Specialist Collaboration
Orthodontics and Breathing/Airway Improvement
Advancements in Sleep Apnea Treatment
Oral Appliances for Sleep Apnea
Options and Treatment for Sleep Apnea
Discussion on OAR Ring and Menopause