Dr Harry Ball: SleepWise – Snoring, Sleep Apnea & Sleep Problems

What exactly does a good night's sleep entail? How significant is it? Well, to know more about it then tune in to this episode. Today, we will be exploring the topic of sleep with Dr Harry Ball.

Dr Ball is the immediate past chairperson of the dental sleep medicine council of the Australasian Sleep Association. He has restricted his practice to dental sleep medicine. He is one of the most experienced practitioners in the world, establishing Sleepwise Clinic which has treated over 14,000 patients with oral appliance therapy.

Dr Ball has organised and presented training programs for dentists throughout Australia and New Zealand as well as in the United Kingdom, Holland, Belgium, Singapore, and Malaysia. He has presented on sleep to GPs, sleep physicians, and on behalf of the Australian Dental Association, the Australian Orthodontic society, and Dental Health Services of Victoria.

Join me as we talk about snoring, sleep apnoea, insomnia, and so much more.

Dr Harry Ball: SleepWise – Snoring, Sleep Apnea & Sleep Problems Introduction

Well, today, we are exploring sleep. Actually, we’re exploring the problem of poor sleep, which includes not breathing well while you’re asleep.

As we’ve said many times, a consistently good night’s sleep is a function of both quantity for 90% of the population or more. That’s getting seven to nine hours of sleep at night consistently, and putting your head on the pillow is not enough. It’s also a question of quality. That means breathing well while you’re asleep, and let’s remind ourselves that sleep is all about enabling you to rebuild physically, mentally and emotionally, and poor sleep affects every aspect of your sleep. And this is a very sobering statistic that 80 to 90% of people with sleep disordered breathing problems go undiagnosed.

Well, my guest today is Dr Harry Ball. Harry is one of the most experienced practitioners in the world, establishing the Sleep Wise Clinic, which has treated over 14,000 patients with oral appliance therapy.

And we talk a lot about that today. Harry is also the immediate past chairperson of the Dental Sleep Medicine Council of the Australasian Sleep Association, and he has restricted his entire practice to dental sleep medicine in Melbourne and in Geelong, in Victoria. Harry has provided training programs for dentists throughout Australia and New Zealand, as well as the United Kingdom, Holland, Belgium, Singapore, and Malaysia.

And he has presented on sleep-disordered breathing problems to GPs and sleep physicians, as well as the Australian Dental Association, the Australian Orthodontic Society in Dental Health Services of Victoria. Look, Harry knows a great deal about this issue, about how best to treat it. I hope you enjoy this conversation I had with Dr Harry Ball.

Podcast Transcript

[00:00:00] Dr Ron Ehrlich: I’d like to acknowledge the traditional custodians of the land on which I’m recording this podcast, the Gadigal people of the Eora Nation, and pay my respects to their elders past, present, and emerging. Hello, and welcome to Unstress. My name is Dr. Ron Ehrlich. Well, today, we are exploring sleep. Actually, we’re exploring the problem of poor sleep, which includes not breathing well while you’re asleep.

[00:00:27] As we’ve said many times, a consistently good night’s sleep is a function of both quantity for 90% of the population or more. That’s getting seven to nine hours of sleep at night consistently, and putting your head on the pillow is not enough. It’s also a question of quality. That means breathing well while you’re asleep, and let’s remind ourselves that sleep is all about enabling you to rebuild physically, mentally and emotionally, and poor sleep affects every aspect of your sleep. And this is a very sobering statistic that 80 to 90% of people with sleep disordered breathing problems go undiagnosed.

[00:01:10] Well, my guest today is Dr Harry Ball. Harry is one of the most experienced practitioners in the world establishing the Sleep Wise Clinic, which has treated over 14,000 patients with oral appliance therapy.

[00:01:24] And we talk a lot about that today. Harry is also the immediate past chairperson of the Dental Sleep Medicine Council of the Australasian Sleep Association, and he has restricted his entire practice to dental sleep medicine in Melbourne and in Geelong, in Victoria. Harry has provided training programs for dentists throughout Australia and New Zealand, as well as the United Kingdom, Holland, Belgium, Singapore, and Malaysia.

[00:01:55] And he has presented on sleep disordered breathing problems to GPs and sleep physicians, as well as the Australian Dental Association, the Australian Orthodontic Society in Dental Health Services of Victoria. Look, Harry knows a great deal about this issue, about how best to treat it. I hope you enjoy this conversation I had with Dr Harry Ball. Welcome to the show, Harry.

[00:02:22] Dr Harry Ball: Thanks, Ron. Great to be here.

[00:02:24] Dr Ron Ehrlich: Harry, I’ve heard about your work in the sleep field, and you are a world leader. I would happily acknowledge that, and we hear a lot about sleep problems, but how, what are those problems, and how common are they in the population?

[00:02:42] Dr Harry Ball: Yeah, there’s a number of different sleep disorders. Probably the most common disorder is insomnia, where a lot of the population has suffered from insomnia, depending on what the definition is. But basically, it’s problems either falling asleep or staying asleep, that is, you know, incredibly prevalent. You know, it could be 20, 30, 40% of the population have insomnia. And insomnia is complex because it can be due to medical conditions, it can be due to sleep apnea, to other sleep disorders as well.

[00:03:12] And, then you’ve got what’s called sleep disordered breathing, which is snoring and sleep apnea. So that’s also a very common disorder and it’s kind of estimated up to 30 or 40% of the adult population have got some degree of problems with snoring and sleep apnea. I mean, not everyone who snores has sleep apnea, but if you snore loudly, if you snore chronically most nights, and it’s loud enough, there’s probably got about a 90% chance of having a degree of sleep apnea.

[00:03:43] And, then you’ve got and by the way, children can have it as well. it’s often related to, to tonsils and craniofacial morphology. and often they grow out of it as well, but it can be a real problem in children. And then you’ve got other sleep disorders, you know, to do with sleep-walking, sleep-talking, you know, nightmares & restless leg is, a common sleep disorder as well where people get movements and twitchiness when they start to fall asleep. and that can have a real impact on the quality of sleep and tiredness.

[00:04:16] So it is very common, and I think a real trap for dentists is that probably the sleep physicians tell us about 50% of the population have more than one sleep disorder. So it’s easy to think you’re just treating sleep apnea, but that person can easily be suffering from, say, restless leg syndrome, more insomnia as well.

[00:04:37] Dr Ron Ehrlich: And those issues about sleep-walking and sleep-talking are a reflection of breathing, poor breathing while you’re asleep, whether they’re diagnosed as a clinical problem. Are they reflective of breathing issues?

[00:04:52] Dr Harry Ball: I don’t think there’s a strong correlation, at least amongst the medical fraternity. So, generally, they’ll be treating them with medication, hypnotherapy, counseling, et cetera. But, my view is, and maybe it’s because I’m biased, but a lot of the people that we see that come in with sort of multiple sleep problems, like I’ve got insomnia, restless leg, and maybe Sleep-walking/talking – they’ve got an underlying sleep apnea problem, and that disrupts the quality of sleep. And they’re tired of sleep yet. And, once you fix that, you know, once they start to breathe, and they’ll sleep better. And it tends to clear up a lot of the other problems as well.

[00:05:37] When I first started out, you’d see patients come in and they had insomnia. They could barely sleep, but they clearly had sleep apnea as well, and you feel as if, well you should maybe be referring them out first to deal with their insomnia, send them to a sleep psychologist. But, you know, for a long time now, just basically treat their sleep apnea, all of a sudden they’re sleeping better & they’re more confident with sleep. Sleep’s not a, you know, an anxiety producing time and then insomnia clears up. That happens a lot of the time.

[00:06:12] Dr Ron Ehrlich: People get told how important sleep is, and it’s a kind of a chicken and egg thing, and they lie in bed and think, Oh my God, this is so important to my life.

[00:06:22] Yeah. And I’m not sleeping well. I think rest is another one that’s underestimated what, you know, people who just rest. What do you think of that as a concept?

[00:06:37] Dr Harry Ball: Eah. I think that rest is really important. I actually did a study with a friend of mine who’s a psychologist, this is going back about 15 years ago. And we went into a company and we made an audio recording of it’s like a muscle relaxation, maybe 10 minutes. and this was with the insurance company, double ami.

[00:07:03] So they got a lot of their, their workers there to stop three or four times during the day and just do this relaxation. And it really had an impact in their quality of life and taking those short breaks of, you call it rest meditation, however, it’s different to sleep, and that’s something that, you know, I’ve discovered that if you’re deprived of sleep,  you really need to have a certain amount of REM sleep.

[00:07:32] Non REM sleep architecture’s important. So there’s no substitute. And, I think rest certainly helps a lot. You might need less sleep. And I think definitely it’s one of the big treatments now for insomnia. So one of the sleep physicians we work closely with, he, he had David Cunnington.

[00:07:52] He’s kind of a world expert in insomnia and non-drug approaches too. And he’s very much focused on not just what happens when people go to bed, but what they do from the time they wake up, keeping that arousal down so that by the time they get to bed to sleep, they’re not kind of hyped up, stressed out from their day.

[00:08:09] So they’re resting, they’re dealing with things that might cause this arousal. So to try and prevent a situation where they go to bed, and they’re really stressed and hyped up from the day, You and they’re trying to sleep, then

[00:08:24] Dr Ron Ehrlich: Mm. I mean, You mentioned insomnia. I’m gonna go onto the sleep disordered breathing problems, but sticking with the insomnia part of it because it’s such a common problem and also related to how well we sleep.

[00:08:38] What do you think about, our relationship with light? Because on the one hand we are told, be careful of the sun. It’s very dangerous. And on the other hand, here we are sitting in front of our computers with blue light streaming.

[00:08:52] What role do you think the relationship with light has in, in this issue?

[00:08:58] Dr Harry Ball: I think light’s pretty important from insomnia point of view. So light at the wrong times can change the circadian rhythm and the kind of pressure to fall asleep. So I think it’s generally acknowledged that you don’t want to be.

[00:09:13] On computer screens until late at night and subjecting yourself to light at that point in time. But in terms of having light at the right time in the morning, that helps set the clock. So if you’re. I mean, one of the best ways to get over jet lag, for example, is to when you get to a place, you go outdoors and you subject yourself to light and then that starts to change your body clock.

[00:09:42] So light is important from that point of view, but then, you know, too much sunlight can cause. other problems. So light therapy is used a lot to regulate the circadian rhythms that people who are out of phase, especially, you know, teenagers are sleeping in for long hours in the morning and that mucks up their whole circadian kind of rhythm.

[00:10:03] They can’t fall asleep at the right time at night. So lights used for that. But  I was just reading a Facebook post from actually David Cunnington this morning, and he is talking about the fact that he showed an article where this person was realized how much she’s having problems with insomnia and, and so she’s cut out computer screens, et cetera beyond about 7:00 PM But in the article that talks about the fact that she has six cups of coffee a day as well and the impact that that has on sleep.

[00:10:30] So, you know if he sees someone with insomnia, he’ll spend an hour just looking at all the different sort of factors and lifestyle stress etc. that goes into it.

[00:10:43] Dr Ron Ehrlich: Before we dive into what the problems are what does just remind us of what a good night’s sleep should be?

[00:10:53] Dr Harry Ball: Well, it’s more in an ideal situation. You would take about 15 minutes to fall. And you should be ideally going to sleep when that, when that circadian rhythm’s there, for most people, it’s gonna be, you know, somewhere between maybe 10 and 12:00 PM and then if it’s taking you a lot quicker to fall asleep, then that’s a sign that you’re over tired.

[00:11:17] So we have patients come in, they boast, and they say, well I’m a really good sleeper, I fall asleep the minute my head hits the pillow. And, you know, they’re excessively tired and that’s a problem, but they actually boast about it. And then obviously the other side of it, if it’s taking more than half an hour or so to fall asleep or longer and you’re frustrated by it, that’s insomnia.

[00:11:35] But for most people it’s that seven hours. You know, and you get people who boast, you know, like people like Trump boasted, he gets three or four hours sleep a night, and anyone in the sleep industry knows that is a real red flag for difficulty functioning and making decisions and etc. So it’s not a good thing for the majority of the population to be getting a lot less than seven hours sleep.

[00:12:00] So, and there’s, there’s research that shows that getting five, six hours sleep has a massive impact on immune system health. Much more likely to get cancer, heart disease, and shift work. I mean, are you aware of these stats on shift work?

[00:12:15] Dr Ron Ehrlich: I am, but it’d be good for you to share it with our listeners.

[00:12:19] Dr Harry Ball: Yeah, so you you see the stats on particularly shift work, where that shift is changing all the time. Your probability of getting serious illness like cancer and dying early is something like 40-50% more than general population. Like having seen the stats, I wouldn’t dream of doing any shift work, you know, unless you are paid some an amount danger money or whatever. So Yeah, that’s a real problem.

[00:12:47] And also oversleeping. So the research shows if you’re sleeping more than, say nine hours or so, you’re at risk as well. Bu t everyone’s different. There are a few people that can get by with less sleep, but the majority of people need around that seven as an adult.

[00:13:06] Dr Ron Ehrlich: And tell me if somebody has, is wanting to explore that, you know, that they have a sleep problem or not, I know there’s a whole process they should go through. what, Just give us a sort of an overview of what that process looks like in your practice. Cause I know it’s very focused on sleep disorders. So tell us what that process is…

[00:13:29] Dr Harry Ball: Well, it depends what the sleep problem is, you know. If it’s pure insomnia, so in, in our clinic, our receptionists are trained when, when, I mean about half our patients are referred in by sleep physicians or GPs, etc. And then half the patients just come in from word of mouth or they’ve seen an ad or something like that.

[00:13:54] And our receptionist are trained to be able to screen those, those patients as to whether they’re a suitable patient for us because we are Dentists and we just, we specialize in treating sleep disordered breathing, snoring, and sleep apnea. And what we don’t wanna do is, our initial consultations 45 minutes, we don’t want to have our books filled with patients who come in and, and they haven’t got that problem, and we’ve got to then refer them out.

[00:14:20] So, If someone rings up and it’s clear that they’ve got insomnia, for example. So our receptionists are really good at listening and, and asking some questions and ascertaining. In other words, they’re doing a screening and if it’s insomnia and let’s say they don’t snore at all, so someone doesn’t snore, it’s not that likely they’ve got sleep disordered breathing, so we’ll recommend they go and see a sleep physician, you know and, and that might be a good place to go. If they’ve got just – to answer your question, there’s some really good online cognitive behavioral therapy type programs, which are validated so people can do that online for insomnia for example.

[00:15:02] if it’s, I mean, the thing is though, if you speak to sleep physicians speak to anyone in the sleep industry, they’ll say most patients come because of snoring. They don’t come because they’ve got sleep apnea because most people don’t know, most people who have got sleep apnea don’t know they’ve got it, you know, in the population.

[00:15:21] And so they, it’s a snoring problem. And so they come in for that and then we, we will manage that.

[00:15:28] Dr Ron Ehrlich: And then they will do a sleep study. Or what, how would you move on from there?

[00:15:37] Dr Harry Ball: So you’re talking about how we, how we manage a patient when they come in? Yeah, So patient have come in and they’ve already been, I mean we’ve gone over the years to, we’ve made a big effort to put a lot of information on our website. So most patients looking through our website will recognize that, yes, I’ve got sleep apnea.

[00:15:57] That sleep apnea, it’s not hard to recognize, like once you’ve been treating patients for a while, you just ask them like, if anyone chronically snores for example, and it’s allowed enough to disturb people and then also saying they wake up a little bit unrefreshed despite getting at least six, seven hours sleep, you can almost guarantee that they’re gonna have sleep apnea.

[00:16:16] So, you know, you speak to the sleep physicians and they’ll say you don’t really need a sleep study to work out whether someone’s got sleep apnea. I mean, what you don’t know. Mm-hmm. is the level of severity and that’s important because the level of severity will dictate the type of treatment. So that’s something we tell patients that, because often patients will say, Look, do I really need a sleep study?

[00:16:38] Because like, I know I’ve got sleep apnea, people see me stop breathing and et cetera. Mm-hmm. , but you know we explain to them, yes, I agree with you that things highly likely you’ve got sleep apnea. But we don’t know the degree of it. Becaus we have people who come in and you swear they’ve got really severe sleep apnea.

[00:16:54] You know, I can barely stay awake. People see them stop breathing all the time, and it comes back mild, and in other people, we are really surprised we’ll have someone come in, they’re younger, they’re not overweight at all, they’re snoring. They’re not tired or sleepy, and you talk them into a sleep study, and it’s really severe, you know, and so you just can’t know for sure that individual patient, that level of severity. So we do wanna do a sleep study at there’s sort of a different bar for us as Dentists. So with, speaking to couple of sleep physicians recently, and there’s a trend now not to do a sleep study. Like if someone snores regularly and they’ll do a medical, they’re basically medically fit.

[00:17:37] They’re not tired or sleepy. The research tends to show that an oral appliance would be fine for someone like that without having to go to a sleep study. But and that’s something that’s changed over time. But as dentist, we can’t do that assessment. And based on the kind of guidelines that we have, we really should be doing a sleep study on, on everyone. On anyone that snores. Because what I say, snoring is a sign of obstruction. So if someone snores regularly, they’re obstructed. And so you wanna do a sleep study on them.

[00:18:09] So, to answer your question, a patient comes in, we will speak to them, we’ll confirm their symptoms, and then we’ll educate them.

[00:18:17] Cause that’s all part of the process. They need to understand why they would do a sleep study and what sleep apnea is. and, and you have to do that because a lot of times I come in just for snoring and that they’re not really, that either don’t know about sleep apnea or they’re not interested in it.

[00:18:33] And we and our job is to try and get them interested because you want them to do a sleep study. So, that’s the challenge, you know, when those people come in.

[00:18:44] Dr Ron Ehrlich: What do you think of? I mean, I’ve done a sleep study, I’m sure you have too. And you are hooked up with all these different tubes and wires, and I know if I go to bed with my watch, it irritates me, and I don’t get what I would call a normal night’s sleep.

[00:18:58] And yet with all this hardware on what, what’s the view either personally or across the profession of the, of the accuracy of those kind of tests?

[00:19:08] Dr Harry Ball: Yeah, look, it’s a good question. And when I started out, all there was, was the overnight sleep study in a hospital. And patients had no confidence in the results of that cuz they got a bad night’s sleep, they’re all wired up, and they can only sleep on their back, and they’re in a foreign bed, and there’s noise all over the place in the hospital, et cetera.

[00:19:27] So that, that was an issue. And then home sleep studies came into affect probably about 10, 12 years ago, and they’ve got more and more unobtrusive. So I think most people can do a home sleep study without too many problems. And the ones we are using now, we’ve got, with a couple of sleep physicians, we’ve set up a diagnostic service for dentists, and it’s based on an instrument called the Watch Pad.

[00:19:55] Have you heard of that at all, right? Mm-hmm. , I have The watch pad. So that’s simply, it’s just like, well, you’ve gotta at least wear a watch.You’re saying you have trouble with a watch, but yes. No,

[00:20:06] Dr Ron Ehrlich: But that’s relatively minor in comparison to what…

[00:20:09] Dr Harry Ball: yeah. Yeah, it is.

[00:20:11] Dr Ron Ehrlich: What do you think of those?

[00:20:12] I’ve just recently been exploring, well, obviously I’m wearing my aura ring and I’ve tried wearing a whoop band, and there is small lab and there’s all these different apps. What do you think of that? Even sleep image is something that’s a little more recent that I’ve been looking at. What do you think of those as a way of assessing or giving us a snapshot of our sleep quality?

[00:20:33] Dr Harry Ball: Look, I think it’s, you know I’m only just talking about feedback that I get from sleep physicians. They kind of feel it’s not quite there yet. I mean, it’s definitely something that’s, that it’s going to be, and, you know, the Apple watches, et cetera can assess sleep to an extent. But I think that for us as dentists, I’m not sure what, how it’ll help us.

[00:20:55] Because we need to do a sleep study, we’re a sleep physician involved, so we’re not gonna go ahead and make an appliance based on, on that data. And so I think something like the watch pad is that simple to use. You got a sleep physician doing a report on it. I would just do that.

[00:21:14] And then basically most of the patients we see, they’ve got mild to moderate sleep apnea. If they’ve got severe sleep apnea, then you’ll kind of monitor it differently. But let’s say mild to moderate sleep apnea. Then you’re mostly treating their symptoms, you’re treating their snoring and their tiredness, et cetera.

[00:21:33] And, and that’s what you’re targeting. And more sleep physicians are not even ordering like a second sleep test. For people with mild to moderate sleep apnea as long as, they’re feeling good and not snoring. Mm-hmm. , they’re kind of happy with the treatment. I think it can be overkilled to start using oxymetry and doing all these assessments for people.

[00:21:53] And I’ve spoken to sleep physicians that they don’t really want us as dentists to be doing those things because if we start doing those things, we, the patients then get reassured that they think they’re being looked after and they’re a lot less likely to go to a sleep physician afterwards. So the sleep physician feel as if they’re not the patient, are not getting the proper assessment.

[00:22:13] So, if they’re severe then they really need to go back to the sleep physician and do another sleep study while they’re, say wearing the appliance, for example, if they’re miBld to moderate. Then most of the time they don’t need to do another sleep study. And I just think you can get a bit obsessive by looking at the technology.

[00:22:32] And you asked about things like Snor lab, and I made this mistake about four years ago. I love Snore Lab. I thought it was great, and I was using it a bit, and I thought I’ll write a blog on my website, all about lab and send it to our database of, I know, 15,000 patients, and all these patients started using Snore Lab and say, Oh, the Snore lab is showing, you know, that I’m still snoring and stuff like that.

[00:22:56] And would say, Well, is your partner? Ha yeah, my partner is happy. I feel good. But this is what the this nor Lab’s showing so people can get really obsessed by it. Yeah. I think Snore Lab’s really, I mean it will use it. So, for example, if someone hasn’t got a partner at all but they’ve got sleep apnea, the Snore lab’s good to cause it.

[00:23:17] If the person snoring is improved, then we feel as if we’re heading in the right direction. They haven’t got a partner to give feedback. So I think there are indications for it, but, you know, I just think that there’s a lot of, that technology can trigger people who start to get a bit obsessive about, about their, about their health.

[00:23:35] Dr Ron Ehrlich: Yeah, no, I think obsessive is the right word because having worn an Oura ring myself when my wake up in the morning and my wife says, Oh, did you sleep? Well, last night, when I first got it, I’d have to say, Hang on, I’m just gonna check that’s right. And she said, Okay, you’re not allowed to get out of bed.

[00:23:51] When I ask you that question, just answer it, you know, because you can get very, very obsessed with it. You mentioned different appliances and you mentioned the fact that you’ve either got mild, well, you’re snoring, you can snore and not have obstructive sleep apnea. You could snore and have mild, moderate, or severe.

[00:24:12] What you mentioned appliances. Let’s talk a little bit about what those appliances do and when they’re appropriate to use.

[00:24:20] Dr Harry Ball: So you’re talking about Mandibular advancement splints.

[00:24:24] Dr Ron Ehrlich: Yep. So but I know what that is. I know. Let’s not assume. Let’s not assume. Okay.

[00:24:29] Dr Harry Ball: So basically, it’s an upper and lower device that goes over the teeth, and it’s got a mechanism for holding the lower jaw forward.

[00:24:40] And because the tongue is attached in the midline to the mandible anteriorly, if you bring the jaw forward, you kind of open the airway, you tighten the muscles, et cetera. So it has a positive impact on increasing airway size. And so it’s a, very effective if you’re looking at just snoring itself….  we’ve done a study on a hundred of our, patients, and we’ve found, around 96 out of a hundred, we’re very happy with the results for snoring. So it’s a very effective treatment for snoring and, and in my seminars like I’ll and I might have a sleep physician involved, and, I make the assertion that as dentists we have got the best treatment for snoring.

[00:25:25] So you go online, and there’s a million different treatments out there, but I’d ask the sleep physician to name a more effective treatment for snoring. And there isn’t. So that’s not known by dentist. You’ve got massive amounts of people who are concerned about their snoring. They’re looking for cures for their snoring.

[00:25:42] There’s so many shonky treatments out there for snoring, yet we, as dentists, have got the only thing that it’s got 96% chance of working. So, you know, you’ve got sprays and pillows, and you’ve got all sorts of things. CPAP machine will get rid of snoring, but it’s really overkill. No one’s gonna use it, you know, just for snoring, surgery I mean, most people are not gonna wanna have surgery for their snoring, and it doesn’t work great unless you speak to an ENT and they’ll tell you how great it is.

[00:26:17] Dr Ron Ehrlich: It’s actually an interesting point. This isn’t it, that depending on the patients or the person, let’s say person’s entrance point here will determine what they are offered. Oh yeah. As an alternative. Because if it comes via the doctor through a sleep physician, whether it’s snoring mild/moderate/obstructive, they will almost invariably be offered a CPAP machine like that.

[00:26:43] Is that your experience Harry?

[00:26:47] Dr Harry Ball: When I first started out over 20 years ago, like apply, they just didn’t know about appliances. Like it was just Mickey Mouse type thing.And here I’m wanting to conduct a dental sleep medicine practice, and I’d have patients come in, I’d take impressions, I’d speak to a sleep physician and say, don’t bother with an appliance, you know, So I was to go, I used to send sleep physicians literature and go around, but the evidence wasn’t that great.

[00:27:18] But over the last and by the way, I mean CPAP was discovered as you know, in Sydney by a sleep physician there, Colin Sullivan. And it’s now around the world and there’s, and it was, and there’s companies on the stock exchange selling CPAP machines and it’s massive business, but especially in Australia, which is the home of CPAP, all the sleep physicians are trained. It’s all CPAP. So that was the only treatment, especially when I started out.

[00:27:47] So really had my work cut out with oral appliances, but that started to change. And probably, I’d say, you know this studies started coming out validating oral appliances. And the group in Sydney and Peter Sistoulie and others did crossover studies with groups of patients in the severe group who had CPAP.

[00:28:08] Then they changed to oral appliances to an oral appliance, and then they did all sorts. They not just looked at their apnea index, but also looked at all these quality of life measures, et cetera. And they found there wasn’t a lot of difference between CPAP and oral appliances for most patients and the reason is that the average CPAP uses three or four hours per night. You know, so we can talk about compliance of CPAP, but you know, we are very lucky as dentists that we’ve got an opposition. Because there’s only two treatments for sleep apnea, two main treatments, and that’s like CPAP or oral appliance.

[00:28:44] Dr Ron Ehrlich: And just for a second, becuase we’ve used that expression a few times, CPAP and again, I know what it means, but just give us CPAP 101, very high level.

[00:28:53] Dr Harry Ball: It stands for continuous positive airway pressure.

[00:28:57] So it’s a mask & a hose attached to a machine which blows air through the airway. Keeping the airway open mechanically. So it’s just to stop the collapse of the airway. So someone who’s got more, more mild sleep apnoea the air pressure required to keep the airway open, is not as great. And someone with severe sleep apnea, the air pressure’s a lot higher and it’s harder to use. But essentially you’ve gotta sleep with a mask and a hose blowing air through the airway. And CPAP come a long way, you know, they’re not noisy. They humidify the air and they’re really computerized machines now that can actually measure the degree of sleep apnea. But the end of the day compliance is still, is still poor.

[00:29:39] Dr Ron Ehrlich: What is that? What does the literature tell us about compliance for CPAP? Meaning how likely people are to actually use what they’ve been given?

[00:29:47] Dr Harry Ball: So I can talk a lot about that because it’s been an interest area of mine.

[00:29:53] Dr Ron Ehrlich: I’m sure it was. I wanted to ask you…

[00:29:55] Dr Harry Ball: Well, so there’s a couple of different ways to look at it.

[00:29:58] A major study came out recently, of 4,000 patients and it was a multicenter study, which all the sleep physicians were very interested in. It was, look, it was looking at whether CPAP was gonna prevent mortality or deaths. But one of the main issues that came out, the average CPAP use was 3.3 hours per night.

[00:30:20] You know, so lots of studies are showing it’s around the four hour mark, four, five hours. Because what happens is obviously the people with sleep apnoea out there are pretty tired and sleepy. They can fall, a lot of them can fall asleep with the CPAP on, but then they’ll wake up after a couple of hours, say, to go to the loo. They’re not quite as tired anymore, and you’ve got this machine blowing air through – they can’t go back to sleep with it. So they’ll just leave it off. They won’t travel with it. And so average use is low.

[00:30:47] And so like if you’re not using the CPAP for three or four hours a night, and yet you’re stopping breathing 20, 30, 40 times an hour, that’s a lot of time that you are getting obstructions and all the health implications of it.

[00:31:02] So CPAP use is a problem. And there are companies that sell CPAP and I’ve seen some of their stats and so, That they’ll have patients referred to them for a CPAP trial and about a third of the people, when they look at what it is, they say, no way!

[00:31:23] And, I get patients saying this all the time, I’d rather die eight years younger than use that machine. Right. That’s what they say. And so they actually refuse outright. So that’s about a third.

[00:31:37] And then that leaves two thirds that give it a, a trial of about a month and of that two thirds about half just say, “Look, I can’t use it”. You know, because it leaks or they can’t get the right mask, or it irritates their cheek. There’s a whole lot of things that can happen.

[00:31:53] And then you’ve got the remainer, you know, what is it a half of, of two thirds who,  will use it, but then they’re using it not all the time as well.

[00:32:06] So they’re the stats. and when I speak in the past, I’ve spoken to sleep physicians and I tell ’em all this and they say, Oh no, but my patients use it, you know, 90% of the time.

[00:32:15] I spoke to a sleep physician recently and I really like the way he operates. So basically, and this answers your other question. More and more the sleep physicians now are deciding which patients really need the CPAP and which will need, who needs an oral appliance. And they refer out a lot to oral appliances now, so I can talk, especially in Victoria, where almost everyone who is in the mild to moderate range now they’ll mention an oral appliance.

[00:32:46] And are you aware of the American Academy of Sleep Medicine guidelines now?

[00:32:52] The American Academy of Sleep Medicine they’re like the peak body in the field. They changed their guidelines recently and they’ve said that every sleep physician needs to include an oral appliance as well as CPAP. So it becomes like a choice for the patient.

[00:33:08] Because what happens in the past, the sleep physician would just recommend CPAP and when the patient fails CPAP, they then think there’s nothing else for them. becuase the oral appliance hasn’t even been mentioned. But now the, the guidelines say they need to, at least that they might say if they’re in a severe group, they might say recommend CPAP in the first instance.

[00:33:29] And if they’re intolerant of CPAP, then an oral appliances.

[00:33:33] But for the mild to moderate it’ll be, they’ll say – it’s patient’s choice. And so the sleep physicians now that I speak with and work with, if, if the patients are in that subgroup where, where a CPAP machine is really indicated – so there’s no question that there are people where CPAP is, is definitely their best option, you know, by a long way too. But you’re only talking about a small group of people.

[00:33:58] So you’re talking about people with really severe sleep apnea. Their sleep apnea is just as bad on their side or on their back. They’re overweight. Let’s say they’ve got blood pressure, heart problems, diabetes. Those people should be given every opportunity to use CPAP, and the sleep physicians. We’ll recognize a patient like that and they will educate them and motivate ’em. And those patients will often do really well with CPAP because they know they should be using it.

[00:34:25] And if they’re educated properly and motivated, then it’s true. Like if you just, just refer that group out and they’re educated and I’ve got a good CPAP therapist that works with them, yeah, 95% will use it. But that those stats that you see in the literature is when sleep physicians are referring off everyone for CPAP  and people who are mild or they’re just not gonna be interested.

[00:34:49] And anyone who’s not symptomatic, there’s no way they just don’t use CPAP even though they could be severe.

[00:34:56] Dr Ron Ehrlich: Yeah, because they, you know, I can relate to people who say I’d rather die eight years earlier than wear a CPAP. But if the reality was you are going to die in the next eight years, there’s a motivation for using it.

[00:35:11] Mandibular advancement splints though, I mean, you mentioned that there’re 96% effective in terms of dealing with snoring, but what’s the compliance like for, for that form of treatment, you know, oral appliances?

[00:35:24] Dr Harry Ball: Yeah, it’s a really good question. Because, I mean, it’s interesting you got sleep apnea and, you know, everyone wants to take a magic pill or, or somehow prevent the problem.

[00:35:32] And deal with the cause. But the reality is that the two treatments are relatively intrusive. You got a machine or you put an upper and lower device in your mouth. So compliance is really, really important.

[00:35:46] It’s so with, with the oral appliances now, if they’re made properly and we, we made a transition in our clinic about four years ago to 3D printed nylon.

[00:35:56] And it is so thin, it’s just, we’ve got to the point where I think anyone who is serious can use it easily, you know, because… I mean the, the, just to backtrack a bit, there’s a lot of different appliances out on the market and I’ve got slides where from about five different manufacturers and they all say, we’ve got the gold standard, the best appliance, you know, and these are the top, these are companies on the stock exchange.

[00:36:24] And it’s just rubbish really because there’s been something like, I think it’s 12 or 13 studies back to back comparing appliances and there’s never a difference really shown.

[00:36:34] So the, the actual style design of the appliance really doesn’t matter. It’s,  to do with holding the jaw forward. So you hold the jaw forward, it does the job, you know, so…

[00:36:44] But what is really important are two things. One is how comfortable is the appliance? You know, how easy is it to use, How easy is it to titrate or to adjust and bring the jaw forward? And what about the side effects? So there’s a real different profile in side effects from the different appliances.

[00:37:06] So Yes. So that they do vary. So when we made the transition to nylon, we, we started to get no fractures at all. So fractures is a really bad side effect. So if you’re using acrylic.

[00:37:18] The research shows that if you’ve got sleep apnea, you’re probably twice as likely to have bruxism as the general population clench and grind.

[00:37:29] And everyone in practice sees that as well. And, you know, you can argue as to why that’s the case and there’s all theories, but the fact is that they do coexist. And so you find that you know, we went for 15 years doing all acrylic appliances, and I would say if someone wore an applianze for, say, at least eight years plus, probably 80% are going to fracture them, break them at some point.

[00:37:56] They might get a crack in it, and then over time, it’ll break off. And it’ll usually happen while they’re sleeping and they wake up with a bit of acrylic floating in the back of the mouth and they’re freaked out. And, you know in my seminars,  I show emails where they let people love their appliance and they wake up choking and they’re really nervous about wearing an appliance again.

[00:38:19] So it’s a really bad side effect to happen. A fracture.

[00:38:25] Dr Ron Ehrlich: No, no, I was gonna keep going, that’s one side it – breaking it.

[00:38:32] Dr Harry Ball: There’s been cases of patients, we’ve had patients swallow them and then swallow bits. But there was a dentist in Sydney who talked, the patient inhaled a bit, and that’s a really serious side effect.

[00:38:45] So acrylics, a brittle material.To stop it breaking you kind of make it a bit, you have to make it thicker and thicker, make it, you know, less comfortable. So, you know, the materials are really important. So there’s really three materials. It’s the hard, soft, laminate type materials and they’re really comfortable, but they, they tend to be quite flimsy, they’re more flimsy and they’re more likely to fracture and crack.

[00:39:07] The good thing about ’em is that they usually, bits don’t break off because the soft material keep, keeps it more intact. But with nylon, I mean, even the thinnest, our appliances go down to 0.2, 0.5 a millimeter and they just don’t break. I saw it in, in America at the American Academy of Dental Sleep Medicine meeting, and I couldn’t believe it.

[00:39:28] I came home and I got hold of some of the nylon appliance. I drove my car over it. I just couldn’t break it. You know,  I’ll show you the videos.

[00:39:39] Dr Ron Ehrlich: Patient wasn’t wearing it. Patient wasn’t wearing it at the time…

[00:39:41] Dr Harry Ball: Well, it was my appliance say,

[00:39:44] Dr Ron Ehrlich: Oh, okay. But listen, you mentioned titrateable and that means it’s adjustable, meaning that you put an appliance in and it stops snoring, but a few months later you need to adjust it, move the jaw slightly forward, which means titrateable, are those nylon appliances capable?

[00:40:02] Dr Harry Ball: Absolutely. Yeah. So they’ve got, they have a  method, a system of bringing the jaw forward. So they’ve got, there’s little tabs in the side and you just take one out and insert another one, and it just brings the jaw forward.

[00:40:15] Dr Ron Ehrlich: And nylon is also a little bit more flexible.

[00:40:19] Dr Harry Ball: It’s flexible, which is nice. It’s comfortable and one nice thing is it’s thermoplastic.

[00:40:25] So if you put it in boiling water, you know, if you dunk it in for 10 seconds, it actually softens. So if a patient has some restorations or if you wanna tighten it or whatever, you’ve got that sort of flexibility. So it’s a really nice material. We haven’t had no fractures, because in the old days before that, every day we would have two, three, four, five phone calls of people fracturing appliance.

[00:40:49] Dr Ron Ehrlich: Now another side effect cause I think these mandibular advancement splints have the potential to change people’s bite, doesn’t it? I mean, we used to, I think Harry, you probably were of that era too, where recapturing, clicking, correcting, clicking joints, jaw joints was something yes, we strived for.

[00:41:10] And the mandibular advancement splint can do that, but in the process it can change bites too, can’t it?

[00:41:16] Dr Harry Ball: Yeah. So we’re not talking about side effects. The majority of side effects are temporary. You know, you put in, put appliance, get a bit of extra saliva, teeth might be maybe bit tender.

[00:41:33] But if everything fits well, normally after three or four days, everything’s comfortable, et cetera. So the only two side effects percentage of patient will get TMD problems with it. It can…

[00:41:43] Dr Ron Ehrlich: Temperomandibular joint.

[00:41:45] Dr Harry Ball: Yep. Jaw joint. So maybe about 8% of patients will get that. And it’s usually only in the first two or three weeks.

[00:41:54] And they’re usually, people have never had a temperomandibular problem before. So that’s a whole other conversation. But the good news about that is that it’s normally pretty easy to deal with, resolve, and it’s, in my experience, it’s never a deal breaker. You get them through that period and then, then they’re fine.

[00:42:12] So that’s the temperomandibular situation.

[00:42:15] By the way, you have to educate doctors and sleep physicians about it because they think that, you know, it’s gonna cause arthritis of the joint and all these irreversible changes, etc. So that’s been part of what we’ve done. And I’ve sent newsletters to sleep physicians to educate from about side effects.

[00:42:34] But then you’ve got this other area of occlusal changes by changes. So that’s real. And it’ll happen to a large percentage of patients that will wear an appliance. It usually doesn’t happen in the first two years or so. It’s a very slow process if it happens in the first two years.

[00:42:53] And so by change will happen because there are very gentle forces on the teeth from an appliance. So even though you wear one and you don’t notice it, I mean I’ve worn for a long time, you don’t notice any forces. But they’re gentle enough to actually cause upper teeth, especially anterior teeth, to retract slightly lower anterior teeth to move more, bit more labially and you can get some bite changes over time.

[00:43:21] And so they start to,  if they happen in the first two years, the consensus is that they’re reversible is take out the appliance and it bounces back. And that’s been my experience as well. So if we have a patient who comes in and they’re vulnerable to bite changes, you know, for, they may have just had ortho, et cetera, we’ll get them in every three or four months and just check that first couple of years is important.

[00:43:45] Becuase if they are getting it, then they can choose maybe not to wear the appliance. You know you don’t want a situation where, and it does happen where you, you put an appliance in and you they know they should be coming back every 12 months or so. And you either Ron it says your just gone off the screen.

[00:44:09] Dr Ron Ehrlich: Oh look, that’s the beauty of this platform. Harry, you can just keep on talking and we are recording. No, no problem. As

[00:44:14] Dr Harry Ball: we speak. Yep. Yeah. So I was saying that yeah, what you don’t want and, unfortunately, it happens where you put the appliance in, you tell a patient that gotta come back every 12 months and you don’t see them again for eight years.

[00:44:29] And the reason you don’t see them is becuase they’re happy with that, everything’s going really well, but they’ve had a pretty big bite change. And the, you know, the bigger the bite change, the harder it is to deal with. And so you don’t want that. ,

[00:44:42] Dr Ron Ehrlich: Which, surprisingly Harry, in my experience, they’re not unhappy with either.

[00:44:46] Dr Harry Ball: That’s exactly right

[00:44:49] Dr Ron Ehrlich: I mean that’s what I find most remarkable about it. I kind of, it happens, but the patient themselves are going, Yeah, look, my bite feels different, but I’m not uncomfortable. Yeah. And I as a dentist, we kind of a little more concerned than they are.

[00:45:03] Dr Harry Ball: True. I mean, I’d have a patient come in like I’ve described.

[00:45:06] They came in, say after 10 years. And I say to them, How’s it all going? Oh, really good. Yeah. And they don’t mean, they don’t mention bite change. They open up and you have a look. And it’s my God, you know, and I’ve, I’ve got, I’ve got, I’m in Woodly, I’m going, My God. But I’m trying to act cool, you know? Yeah, yeah.

[00:45:22] Dr Ron Ehrlich: Stay calm. stay calm.

[00:45:23] Dr Harry Ball: And I say, Look, I noticed that your bites changed a little bit. And if you notice it?. Ah, yeah. It has a little bit. Is it worrying you? No. So you, you’re absolutely right. For the majority of people, it is not a problem at all. Even severe ones our biggest problem is other dentists. Right?

[00:45:41] So what’ll happen is the patient will get a bite change. It might be a small one, they’ll go to a dentist or, you know, they might change state, and the dentist will look in their mouth and the patient hasn’t even noticed a bite change. The dentist will go, Oh my God, what’s happened to your bite? Etc. We’ve gotta send you to an orthodontist.

[00:46:01] And then they go off to an orthodontist. Mm-hmm. And the orthodontist has a look and says, Well, got, we’ve gotta do surgery and braces etc. This happens. I can tell you. And, because everyone focused on ideal occlusions, ideal treatments. Yes. Yep. Yeah.

[00:46:18] So over the years, I’ve, patients will ring me. And they’ll be upset and they’ll say, You never told me about this bite change. You know, And I, and of course we do. Because it’s a really big part of informed consent, So mm-hmm. ,  I can’t overemphasize the importance of having signed informed consent. So when they say, You never told me, which just printed out and say, Well, you signed this and in it, so it’s good to have that for a start.

[00:46:47] And but most of the time I’ll get them to come in and we’ll chat and most of the time the bite changes as such that the, you know, the patients are happy with their appliance. I mean, you, you wouldn’t get a bite change un unless they’ve been wearing for a long time and no one wears it for a long time unless they’re getting good results. And so yes, they do wanna wear it, but they’re also not, not happy with the bite change.

[00:47:10] But look, most of the time I have a, a prosthedontist that I refer to and he might just do a bit of a ration here or there. So instead of having say, three teeth in contact, they might,  have four teeth on either side.

[00:47:26] They might still have an anterior open bite, for example. But all of a sudden it’s, mostly a functional problem. Oh, I can chew. They’re happy with that and, they another appliance. So, you know, like when they go down that pathway for the orthodontics, it’s all for perfect treatment. And but you know, having said that, there’s ways of minimizing bite changes now. So these sort of things don’t happen. So I dunno if you’re aware of some of those methods at all.

[00:47:58] Dr Ron Ehrlich: What? Like the morning, a morning appliance or some exercises to take the jaw back to where it was, you know?

[00:48:05] Dr Harry Ball: Yeah. So like, we’ll make up a, it’s a thermoplastic material where it’s like a little anterior jig where they’ll bite into their centric occlusion before they get the appliance, and then every morning they will bite into that.

[00:48:19] Yep. And, and also they’ll know if there’s any change as well. And then there’s a few other strategies that we’ll use to, to minimize bite changes as well.

[00:48:30] Dr Ron Ehrlich: It’s so interesting though, Harry, isn’t it? And that is that for a lot of dentists focused on the minutiae of what goes on in the mouth. Where we are talking down to microns, sometimes we lose sight of the fact that there’s a person attached to a respiratory system and a good night’s sleep is life altering.

[00:48:50] Dr Harry Ball: And that’s a really, really good point, Ron, because the dentist is just focusing on the occlusion and whether. The correct number of cusps are touching and the right fissures, but you, you step back a bit and the appliance is having a really big impact on their quality of life, their health and you know, I’m a dentist.

[00:49:13] I’ve got a,an edgeI’m really vulnerable to bite change. But my wife is a really light sleeper and if I wanted to be in the same bed or travel with her,I’d have to wear an wear an appliance. And I know there’s a lot of dentists like that okay if I get bite changes, so I get them.

[00:49:30] But the positives far, far outweigh, you know,

[00:49:34] Dr Ron Ehrlich: Harry, you’ve just described my whole life too, there I have an edge, I have  my teeth are edged to edge like that and was faced 20 years ago with the choice “Your snoring has become a problem. Either move out of the bedroom or do something about it.” And it was a revelation to both my wife and myself.

[00:49:52] That I finally did something about it, and both our health is improved as a result of it. I mean, I often say I have more energy now at the age of 67 than I had 40 years ago.

[00:50:01] Dr Harry Ball: How valuable is that? You know?

[00:50:04] Dr Ron Ehrlich: Absolutely. Listen, you do a lot of training for dentists and doctors and all of this I think I saw some statistic – there are a hundred thousand registered doctors in Australia, and I forget how many registered dentists there are you, do you know offhand?

[00:50:19] Dr Harry Ball: Dentist? I’m not sure. Yeah. I’m not 15 to 20,000, something like that. Yeah.

[00:50:24] Dr Ron Ehrlich: Yeah, and what percentage would you estimate are familiar with these issues of sleep disordered breathing and the dentist role in that?

[00:50:34] Dr Harry Ball: Yeah, so, and there’s been a couple of studies on it showing how much is covered in the undergraduate dental program in universities in Australia and New Zealand and it hasn’t changed. Something like two or three hours is devoted to dental sleep medicine and usually by a lecturers never really done or both operated in the field at all.

[00:50:55] So the dentists don’t get a lot of training whatsoever in the field. There is more and more interest in dental sleep medicine in Australia. It’s really taken off in the US. So in the US it’s really big there, there, there are a lot of companies training dentists all over America and the dentists are really kind of into it.

[00:51:13] And in fact the American Dental Association mm-hmm have now come up with guidelines that every dentist should be screening their patient for sleep disordered breathing. So it’s a recommendation because dentists are looking in mouths, they can see some of the telltale signs and we should be doing it. And so if you doing that, you might as well be treating them.

[00:51:34] But here I think there’s a growing interest. I mean, I’ve been doing training programs for maybe over 15 years or so, and there it’s one of these things that dentist either are really interested or they’re not. It’s one of these things I don’t, you have to have a bit of a, a real interest or passion in it. You can’t just do it for the money kind of thing.

[00:51:54] It’s this, because there is a learning curve, you’re bit out of your comfort. It’s different to any other area of dentistry where you can just go in there and do whatever you want to do. Like if you want to do a root canal or denture, whatever, you just go ahead and do it.

[00:52:07] But here it’s a medical issue, so you do have to work together to some degree with sleep. Physicians and dentists for their first say four or five appliances or cases, they’re out of their comfort zone and there’s a real barrier there and they don how to do. Mm-hmm. doing a sleep study is a real barrier in Australia for dentist.

[00:52:25] How do you organize that for your patients? There’s really big. Barriers through Medicare for that and it all becomes hard for dentist.

[00:52:32] So what we do in our training programs is very much break down those barriers and make it really simple to screen the patients becuase you know, in, if you’ve got 2000 patients, a lot of those are already had sleep studies and they’ve fail CPAP and they’ll be really good patients.

[00:52:49] So you should be screening your patients and then especially, and that’s what’s called a low hanging fruit, that patients who already had sleep studies and that they don’t, they don’t anything about oral appliances and you’ve got a good relationship with your patients. So, There’s patients there that would be, you know, ideal candidates and you’d be contributing a lot to their health and, and, and quality of life.

[00:53:11] Dr Ron Ehrlich: Absolutely.

[00:53:11] Dr Harry Ball: But to answer your question, there are these barriers. So we’ve set up a diagnostic service to help dentist, we do mentoring programs. And so there’s more and more, of an interest in the field because there’s a lot of patients you’d have without even doing any marketing at all.

[00:53:27] And it’s just, in our own practice in the city,  we have six dentists working part-time and all of them don’t like general dentistry, you know.  And they’re in their thirties mostly, and they’ve just had enough of general dentistry. They love this field, right. They love it. You know, Or you’d be aware, I know you work in the field.

[00:53:48] You can, you got Yeah, yeah. Yeah. It’s more interesting. There’s so much more interest. Satisfied patients. You know,  I never got patients telling me how great my margins were, kind of thing. , you know, .

[00:54:01] Dr Ron Ehrlich: Yeah. The edges of your fillings, How beautifully you polished a filling or anything. No. But change their life like that.

[00:54:07] Another one that dentists are always looking at, and a lot of patients are very aware of, is clenching and grinding of teeth. And I know that has changed our perception of what the cause of that is has changed over the last particularly 15 or 20 years. Can you about clenching grind that change?

[00:54:25] Like how it was viewed 15 or 20 years ago, how it’s viewed today. Well,

[00:54:30] Dr Harry Ball: You’d probably be aware was as dentists, you know, we, thought we had, the answer was to do with occlusion and, and the way the teeth fit together would cause bruxism now. But I mean we know that bruxism is what’s called centrally mediated, you know, it comes from the brain and, and yes it definitely when people are more stressed, they going to brux more.

[00:54:51] And the feedback I’ve got during COVID, you know, the high levels of stress in the population, the amount of bruxism, you know, you just hear that all the time. I’ve got a couple of patients who are psychiatrists and they’re telling me the degree of stress and tooth fractures and things like that. So stress is a part of it.

[00:55:09] I think bruxism is probably the most undertreated and managed sort of disease amongst dentists. Because, and it, I’m talking about, I mean, if we look at this, the effects of bruxism, yes it can cause TMD, but most of the time, people are pretty much asymptomatic. You know, they might get a slightly sore jaw, they might get the odd headache, but they’re getting wear on their teeth.

[00:55:33] They’re getting significant wear on their teeth and that those teeth should be protected. The easiest thing is just to wear an Occlusal splint, right? I’ve got a, I’ve got a 24 year old son. He’s already into Dentine in a few areas, and what’s he gonna be like mm-hmm. When he is 40. I mean, so the easiest thing is to wear just an occlusal splint.

[00:55:53] It’s underutilized greatly. Like if, I mean, dentist should be doing. I don’t know, two or three a day really if you look at the number of people that have. But I, I think the trap is, you know, and I’ve looked at why don’t dentist do them? And I think that, mm-hmm the, first of all, you’ve gotta educate the patient properly because these patients have, haven’t got symptoms.

[00:56:15] They’re coming into you and you are telling them they’ve got a problem. So you’ve gotta make sure they understand what that problem is. Use some visual method of patient education, but the splint’s gotta be super comfortable or they’re not gonna wear it. And that’s where nylon is, is really good for protecting teeth.

[00:56:34] They just click it in, barely know it’s there, and they’re likely to wear it longer term With acrylic, you know, my experience is they’re motivated to wear it for three or four months and they forget why they really need it. They start leaving it out and it’s all a bit much. So it’s got to be the splint’s, gotta be really unobtrusive, gotta educate the patient and show them models of their own teeth compared to.

[00:56:55] To unworn teeth. Use the intraoral cameras as well. And it’s a great service for patients to be doing that.

[00:57:04] Dr Ron Ehrlich: Mm-hmm. Yeah. Another quickly, we’ve almost finished. We’ve covered some territory here, Harry. And I just wanted to ask you very quickly, cause ever since James Nestor’s book came out, breath, you know, I’m sure you’re probably aware of it, and I know we had him on as a guest.

[00:57:19] And then he talked about mouth taping, putting tape on the mouth at night. What’s your view of that?

[00:57:26] Dr Harry Ball: Look, I think it’s a really good thing, but probably for maybe a different reason. Like I think there’s no doubt that nasal breathing is what we’re meant to be doing. We,  are using quite a bit of taping and I think we need to be doing more of it because the main appliance that we make it’s called an ADVANCE. It’s a nylon, it’s like a dorsal design appliance, but it, it’s an appliance where the upper, the upper and lower are not connected. So it’s really comfortable. A patient can open and close. And so there’s a lot of, I mean, every appliance has got pluses and minuses, and there’s a lot of pluses with that one.

[00:58:08] But the minus is that the jaw can drop down during the night while the patient’s sleeping and they breathe through their mouth.

[00:58:15] And so we all know that if the jaw can drop down, the appliance doesn’t work as well for that group of patients. Most patients sleep with their lips together, jaw, and the risk position.

[00:58:27] But if your jaws dropping down, and there are a lot of patients that will do that, the applies are not gonna work as well. So they’re coming back saying, I’m still snoring, even though they’ve advanced the jaw enough and taping the lips will stop, will prevent a lot of that happening and help them breathe through their nose as well.

[00:58:44] So I think it’s a really good thing to do. And I was just looking a study recently, which showed that the results were better when patients did that. So, I see it as a combination. There’s a lot of combination treatments that, of things that you do with an appliance that really help get successful outcomes.

[00:59:02] Yeah. Mm.

[00:59:04] Dr Ron Ehrlich: Yep. Well, Harry, thank you so much for joining us today and sharing your wisdom and knowledge with us and experience. And we will, of course, have links to your website so people can find what it is you’re doing and all the things going on. Great. Thank you so much.


[00:59:21] Well that’s every time I speak to one of my guests, I learn something new and I hope you do too.

[00:59:27] There was actually so much in that episode, and actually I thought was most interesting was a reminder of dentists. Dentists deal with such minutiae. I mean, we deal with an accuracy of fillings that is in the order of 10 microns. Now, to put that into perspective, A hair is 20 microns and dentists get very, very pedantic and particular, which is just as well, they do because it’s what defines  a successful filling or crown that things have to have to fit incredibly accurately.

[01:00:04] And that person’s bite is so sensitive that if it’s not quite right, they can pick up 10 microns as well. So if a filling is too high or a crown is too high, you will have a sore tooth or a teeth that is sensitive to temperature, particularly cold. So dentists get lost in the minutiae of the mouth.

[01:00:24] That’s one of the side effects of being a dentist. But taking a holistic view of dentistry reminds us that actually there is a whole patient attached to that that mouth, that tooth that we are so obsessed with. And that person has. A respiratory system. And it’s worth remembering as a dentist and as a patient too, and as a health practitioner, that the size and shape of your mouth determines the size and shape of your upper airway.

[01:00:55] And we’ve said this many times in this podcast that 95% of the population in our modern world do not have enough room for all 32 of the teeth that we have evolved as humans to have in our. That means you have crowded teeth or narrow jaws, and that means you have a narrow upper airway. And that means you don’t necessarily have enough room for your tongue in your mouth, and that means the likelihood of you snoring or having a sleep, disordered breathing is very high.

[01:01:29] And that means that as dentists, we need to take a step back from the minutiae of doing really good fillings and crowns and remind ourselves of the much bigger, arguably role we have to play in ensuring that our patients have a consistently good night’s sleep, which as we said at the beginning of this podcast, is a function of both quantity.

[01:01:52] Getting seven to nine hours sleep a night and quality breathing well while you are asleep. And that is the role that oral appliances and in the mouth, which are custom fitted appliances that support the jaw and the airway in a more balanced and healthy way. We’ll have links to Harry’s website and all of the great resources he has on there. I hope this finds you well. Until next time, this is Dr. Ron Ehrlich. Be well.



This podcast provides general information and discussion about medicine, health, and related subjects. The content is not intended and should not be construed as medical advice or as a substitute for care by a qualified medical practitioner. If you or any other person has a medical concern, he or she should consult with an appropriately qualified medical practitioner. Guests who speak in this podcast express their own opinions, experiences, and conclusions.