Dentists: Rivals or Collaborators

This week on ADVENTing, Dr. Kandula and Dr. Handler discuss the similarities and differences between ENTs and Dentists. Should they be seen as rivals or collaborators?

- Hey, Dr. Madan Kandula, founder here at ADVENT and your host of ADVENTing. Thank you for watching or listening to us again. I'm here with Dr. Ethan Handler. How are you doing?

- I'm doing well, I'm doing well, decided to dress up today.

- Yes, in clothes and pants.

- Ditched the scrubs in pants, yes, not pantless like last episode.

- Nah, we will have no pantsless episodes. Moving forward, we've been corrected by HR to never ever do pantsless again.

- Or the P metaphor?

- Nop, no, no.

- No bodily fluids.

- No bodily fluids.

- Yeah.

- No, Lackey... Well, that's a double naked. Yeah, we always will be clothed fully. From here, you have my promise to you dear viewers and listeners.

- So this episode will be PG or G?

- PG, G, yeah.

- Fair enough.

- If they even make G news anymore. Speaking of movies or shows any good views here in the pandemic lockdown crazy world?

- Yeah, I mean, you know, wife and I have watched a few but one new one that we started watching was "Avenue 5" You've heard of that one?

- No.

- So, it's the same writers that did "Veep," which we also found just hilarious.

- Okay.

- More just kinda... We needed some comedy in this time, time of the great pandemic. But anyway, so "Avenue 5" is like this space satire show. And the guy who was in "House," I'm trying to remember his name, the British actor?

- Oh, yeah.

- So he's kinda, he's the captain of the ship and then Josh Gad is like the commercial founder, billionaire that like created this like cruise line through space, and it is hilarious. Like, it's legitimately-

- What is it on?

- It's on HBO.

- Oh, yeah?

- Yeah, it's funny. It's worth checking out.

- I've never ever heard of this.

- You watch like two episodes, it's just, yeah, it's good. And Josh Gad is a talented.

- Who is Josh Gad? I know the name.

- Josh Gad, he's all off in "Frozen."

- Oh, that's right.

- Okay, but then he was also on Broadway, he was in the original "Book of Mormon" and he was like one elders, you know?

- Yeah, I gotcha.

- And just a talented singer and-

- Wait, there's not singing in this though, right?

- No.

- Thank God, okay. I can't do singing.

- No, there's no all off singing in this, but-

- No.

- He plays just a centric kind of. I mean, what you would imagine a billionaire in like 200 years from now, what'd be like.

- Nice.

- It's pretty, it's funny.

- Yeah, still I can't think of a... You know, there's something I just watched but I can't think of it. I mean, we talked about "Last Dance," I guess theoretically, I watched that.

- Yeah, that on Netflix now, it's transition, yeah?

- This is off of ESPN. But yeah, the most... This is pathetic but my, I got two sisters, my eldest sister recommended the show, "Indian Matchmaker."

- Hmm!

- Have you seen this? This is on Netflix.

- Did it relate to you?

- It did. Well, it didn't and it did. And it was sort of Indian people... So I'm Indian.

- What?

- Did you know that?

- No.

- This is breaking news!

- Are you from India?

- No, I'm actually born and raised in this country.

- Okay, very good.

- Thank you for your, your ethno, whatever fascism.

- Yeah.

- This "Indian Matchmaker" is, you know, it's basically about arranged marriages both in India and in this country. But it's just interesting.

- How common places it's still especially in this country?

- More common than you think. I mean, if you ask like the... If you stop the next Indian person you meet and ask them?

- Actually, it would be totally-

- Yeah, probably I wouldn't, huh!

- But I want you to do it-

- Unless I was with you and then it's cool.

- Nah, I'm not okay either.

- Okay, fair enough.

- How is it okay? No, it's interesting, it's just it's a whole... 'Cause the whole culture is very deep in arranged marriages and like when... And this is like my parents, they call an Indian culture, there's arranged marriages and then they call them love marriages, there's a two different. My parents are a love marriage and I am not married to somebody who's Indian, did you know that? Gwen's not Indian?

- I did know that, yeah. Did you know that? I don't know, how did you figure it out? DNA testing?

- Yes.

- But anyway, and so, I'm also in a love marriage

- That's good.

- So we've never dealt with the arrangement, and I've got, as I said, two sisters, no arranged marriages and so it's interesting kind of seeing the dyn... The dynamic in general, like looking back through time and then the dynamic in this 2020 day and age.

- I wonder, is the divorce rate any different between love marriages and arrangement marriages?

- It is, it's lower in arranged marriages.

- Interesting, right?

- Which then, it sort of calls in the question, this whole kinda Western concept of dating and yeah, how you like, you know, 'cause I mean, this is how I was told. Like you date so you know, tell like what you want, what you don't want in a partner and then, but then you look at divorce rates and it's... If success of a marriage is divorce or no divorce, then I'd say well, then this testing and trying doesn't seem to work as well as just show up, just here's the day, just show up, get on your horse or whatever you're gonna ride and just show up and ought to be good.

- Like literal horse?

- Literal horse.

- Okay.

- You don't have to. I didn't ride a horse, but

- Yeah.

- There are many people who ride horses to their

- No, I... Look, one of my best friends in college, so he married... I mean, she's also born in, you know, the United States, but her name is Diksha. Justine and he's, you know, Caucasian, tall, you know, if you're white guy and then in Diksha. And so, they had kind of a traditional marriage, traditional Western culture marriage and then they did the Indian ceremony right after and it was it's pretty cool kinda see both cultures blended.

- How many horses?

- I don't think a horse could hold him, he's like 6'6" pretty big.

- No horses, I don't think it counts. If there was not a horse there- It was a Clydesdale.

- There's no Indian portion of the way, it's automatically just...

- Yeah.

- It's invalid. So they might not actually be married.

- They maybe not.

- Without a horse.

- Yeah.

- Get a horse. I'd recommend it. Anyway.

- All right.

- There's no segway here but-

- Good show or not good show?

- It's all right. It was kind of a... It is a kinda reality TV kind of stuff, but it was, I don't know, it's hard to describe. I think it's worth watching just to kind of peer into a different culture, it's kinda that, 'cause it was almost, it was foreign for me even watching it even though I'm Indian, but I'm just saying like, I never really dealt with any of that stuff and it's kinda just interesting, I thought so.

- All right.

- Worth, I guess maybe worth of you. How do you go from horses in Indian marriages into?

- Dentistry?

- Yes.

- That's a fantast-

- Horses have teeth, how about this? Horses have teeth! and they have bridles in their teeth. Let's talk about bridles can be like headgear.

- Correct.

- And what does headgear do when people get headgear when they're young? Is they pull the maxilla, the top jaw-

- Nobody knows what you're talking about.

- Right?

- Nobody knows.

- Let's talk about-

- let's talk about our friends

- Yes,

- Our dear friends, dentists?

- Dentists.

- Right?

- Okay, yeah,

- 'Cause we're in a... So we are ENT physicians and surgeons and in the spectrum of medicine, there should be no two closer friends to dentistry... No, two closer friends than ENT and dentistry.

- Correct.

- Correct? And yet, I don't know that there's... We have and try to cultivate a nice relationship with dentists, but I don't know that that's it's certainly, it's not a universal thing.

- No.

- And that's too bad. It's too bad for patients who have, you know, how do you say it? Who have airway issues, which is mainly what we treat. Obviously, I think everybody's got dental issues or needs dental care, but I think there's things, there's a wall between those two things, which we've been trying to break down for a reason, why? Like, why, you know, how do those things interrelate? You know, why should? Why do dentist? Made this a question. Why do dentists seem to care more about ENT issues, meaning airway issues than ENTs do?

- That's a fantastic question. I mean, dentists obviously see all the downstream effects and see kids developing a certain way from lack of having a good airway, right? But they lack the ability or power to do something, especially nose related.

- Mm-hmm.

- So, I mean, but why don't ENTs pay more attention to that? I don't know whether it's in training, if we're more kind of focused on the breadth of what we do and undervalue the importance of nasal airway breathing could be, there's, this weird rivalry, I don't even know if it's a rivalry as much as dentists trying to get traction in ENT community and have help and not getting any of that. And honestly, if you're ENT physician and in like our practices, I mean, we're happy to collaborate. You know?

- Sure.

- And I don't wanna spend time doing stuff in the mouth or teeth, right, even you?

- No.

- It's not my specialty.

- Yeah, I think there is. I mean, I think and I don't feel this way, I've never felt this way but I know that, I'd say almost every ENT I know feels this way, is that they feel like if dentists and dentistry is... The crossover tends to be on sleep and airway, and if dentistry is getting involved in that, that there's somehow some sort of small pie, that that pie is now even smaller kind of a thing. When the reality is, is ENT is a specialty in general, we've done a horrible job taking care of the N and T part of that. You know, we've done a horrible job of, you know, really letting the public know what problems they might be experiencing and delivering solutions for those problems as a specialty. And so, we have nothing, no leg to stand on to say anything to anybody else who's looking to help and offer solutions, there's nothing you should be able to say if you aren't doing the same thing, and I'd say most ENTs are not doing anything to help those patients out there. And dentists are trying, they're trying from their vantage point to assist in any part of the assistant, assisting is identifying when they see somebody that might have an airway issue and putting that on their radar screen and pointing them, and, you know, the right direction. And there are things that dentists can do by themselves as far as expansion of the palate and kids, and they're starting to do some of that in adults. There's work that can be done to help. And really, one of the things we tend to use most often for our patients who are suffering with snoring or sleep apnea, or oral appliance, and so, appliances that somebody wears in their mouth when they're sleeping at night, to help to keep their mouth shut, but also pull the lower jaw forward. Oral appliances can work really well for a lot of folks who have snoring and sleep apnea issues. They don't work very well if your nose doesn't work, so it's kinda our sweet one, two punches, get somebody's nose working, and then getting them into oral appliance if that's appropriate. That works really well when you have that one-two punch, but if you only have one of those punches, it's tricky. So, if you're a dentist who can't impact somebody's nose, you're kinda out of luck and vice versa if we didn't have that option, many of our patients would be out of luck. So it's really that collaboration that it's optimal care for our mutual patients.

- Right, there's certainly a benefit to having a dentist who actually make something that's custom made for a patient's mouth.

- Mm-hmm.

- You know, 'cause, certainly what we find a lot when patients are coming in, and maybe they've tried some of these over-the-counter devices, or these ones, like suck your tongue forward and things like that, is they might work for a week, but they're insanely uncomfortable. And they end up being spit on the floor and just not used. And so, you know... So, okay, dentists can help make something that's gonna be custom made, the reality is, us getting a nose working is gonna help somebody keep something in their mouth with their mouth closed.

- Mm-hmm.

- And so, we optimize what dentists can do, but we still need dentists, I think, you know, could we make custom appliances? I guess we could, but again, that's not our wheelhouse, it's not what we wanna do, it's not our specialty,

- Correct.

- We can partner with dentists and make them more successful, but those oral appliances by getting their nose working first.

- And the reality is... And I'll make no bones about this, is that dentists are, they're looking in the mouths of the population, they are sitting on the perch that can and identify if they're sort of the scout looking in a forward direction, they can, especially if they, you know, with a little bit of extra training or interest, they can generally like, if you're staring down somebody's throat, you can point to, "Hey, this is, might be a problem, hey, this might not." And certainly, and they'll do well, and a lot of people, most people who have sleep apnea issues will also have some dental and/or TMJ issues that are, they're actually a combined issue. So, meaning that a dentist who is treating bruxism, which is grinding your teeth or TMJ issues, if they're not looking for airway issues, they're not doing their job and, you know, flip that around for us too, is if we are identifying an airway issue, but not making sure that somebody is, you know, kinda following through from a dental side of the equation, then we're really not doing our job completely. At the end of the day is, when you get somebody's breathing properly when they're sleeping at night, so breathing properly is, nose working, mouth shut, that's what you should be doing. If you're doing that and you have any underlying TMJ potential or bruxism potential, it may not impact that but it likely will minimize that to whatever extent is possible. And so, it's sort of like this combined approach, but the unfortunate reality, we do work closely with dentists and we've got a dentist that is on site with us. And so, we're used to that and we're thankful for having that resource, but that's the exception to the rule rather than the rule itself. Most dentists are sitting in a silo by themselves and they can do and try to do whatever they can do to help these patients but they do need the assistance of ENT decent amount of time. And I'd say, on the flip side, I mean I don't know, I think our special aid, I don't even think we have our eye on the ball at all. But for those ENTs that do have their eye on the ball, then they too need a friend on the other side of this stupid fence has been, you know, built up over time to help out. And so, I think from a patient standpoint, you know, when we can deliver the best for our patients is when we can really freely collaborate. And I think there are patients that their noses maybe fine, and then maybe it's just really, let's get them in the appliance if they have that issue, and that's wonderful. But I think there's, I think when you're sitting on one side of that wall, or the other, that's a bad place to be when you're trying to, you know, get somebody a solution, I mean, it just doesn't help anybody. But, again, that's the norm, the norm is just on this mold of partition.

- Yeah, yeah, I know it's unfortunate, but I think that, you know, again, it's, comes down to collaboration, and doing what's best for patients. I mean, sleep apnea is a multi disciplinary issue, it starts with the nose that works and then it kinda goes from there.

- Yup.

- I think, you know, as head-neck surgeons, we are positioned to be the gatekeepers for sleep apnea. And we should be, but we need to collaborate. you know within a community.

- Yeah, absolutely. Yeah, I think, I mean even that statement, I think, you know, just looking around on social media and just in the world in general, I don't know that I've heard any ENT, we say it all the time so we kinda get sick of each other saying this and I've been saying as generally speaking, but I've not actually... I don't know if I've ever heard another ENT practice say that clearly with conviction and I've heard hundreds of dentists say that is which is talking about the importance of nasal airway and the importance of breathing through your nose and how paramount that is to everything down the line. ENTs, for whatever reason, and I think... I mean, I guess maybe I'll dwell or kinda touch on that is I don't, I guess I know why, I know why is because in my training, we've never ever ever talked about it, we just never did, we just sort of like assume, like, "Oh, someone's got a deviated septum, that's a problem." They'll let us know like the person with a deviated septum's supposed to magically know that, "Hey, I'm not breathing like I should." And so, you just wait until they come to you and then you're gonna straighten the septum and that's all good. But it's just, we just never, ever get the full story.

- I mean, we either. I mean something that simple, we just, we didn't either. I'm trying to think about when we thought about nose and breathing, I don't know.

- Uh-huh!

- Just didn't really go into detail about how important it was, or talked about the quality of life of the nose and what it means to breathe well through your nose, like never!

- Well, I mean, and then there's the literal, there's the impact both ways, meaning that, and this tends to be a kid growing up, who can't breathe through his nose or her nose, they drop their mouth opens, so they're mouth breathing, what happens when your mouth breathing is your dentition doesn't form normally. And so, when your mouth is open, your tongue is not sitting where it supposed to sit. And so, your jaws that should be pushed forward and basically open and out, are sitting there and kinda getting tucked back further and further and that literally strangles you. So, most of our patients who we treat, almost every adult patient we treat for sleep apnea, have had airway issues their whole life and that airway was likely a nose that wasn't working when they were a kid that led them to jaws that are too small, that led them to those jaws strangling them when they're trying to sleep at night. And then, we as ENTs are not... I don't think ENTs get... I know, I keep being trying to sort of be nice about it, but I'd say, I think if you went in and you point blank asked an ENT, "Tell me the story. Tell me that story I just said?" And they believe that story to be true, and that story has been sort of, it's not my story, that's a story for, through the dental literature. It's actually, you know, if you think through that and follow that, it makes absolute sense. But if you take a random ENT and say, "Hey, tell me about this?" I don't think they'd be willing to start.

- No.

- I don't think they would even go to square... I don't think they would make the connection whatsoever. If you can't even make that simple connection, there's no way you could, you know, build beyond that. And so, yeah, I mean, I think the reality is that dentists are seeing the byproduct of noses that aren't working, and they understand the importance, and then they say, "Gosh, why? Would it be great if we got people's noses working as adults? And Geez, it's really important in kids, and we really wanna do this, we really wanna talk about this and that." Unfortunately, they kinda, you know, stick their necks out and I think the people most likely to chop at those necks are people in our specialty, unfortunately. And it's just, I'm keep dwelling on the negative there. I think the positive is that there are solutions that there are... There are problems for which there are solutions to, it's a mutual, I mean, there's so many people who suffer with these issues, that it's not like there's this pie of that's limited, that's that small. It's like there's so many people who could benefit from that combined approach, there's so many people who could benefit from the awareness that they're helping to create, and the more that we can collab, we, me you, and ADVENT the more that we can collaborate with dentistry, the better for our patients. I think there's a specialty or specialties, more than ENT and dentistry we can collaborate, the better it is for all. It's sort of a... It's a infinite situation, I mean, it's a situation that needs to be rectified, but will only be rectified when we understand that we need to be working together.

- Great, agreed.

- Any other dental tidbits?

- No, I mean, I'll just say, you know, it's kind of a caution to patients is that, you know, there's a lot of devices that are made over the counter. Amazon's got gazillions listed and, you know, one of my talking kinda tracts with patients is that like, if a company is advertising and they're very good at marketing, you know, and so, and patients don't really understand kinda root cause and we talked about the collaboration with dentists, we need the nose that works, otherwise, how you gonna keep an appliance in your mouth and how you gonna, you know, tolerate that? And so, you know, I would just throw a little caution out there not to spend too much money on devices if, you know, really gotta understand it, that nose is working, otherwise, that thing's probably not gonna work for you and it's gonna end up being a waste of money. And so, you know, from a company perspective, if they sell 50% of them work and they sell them in millions of those devices, they're winning, you know?

- Yeah, and it is tricky. I mean, like on those over the counter oral appliances, which is what you're talking about, yeah, if your nose isn't working, and I hear this all the time, you know, I'm sure you I know you do too, is like, "Hey, I tried this thing and I spat it out 'cause, you know, it just wasn't working." Well, probably, it wasn't working 'cause you couldn't breathe through your nose and you shoves... You can't breathe through nose when you shove something-

- It's gonna be miserable.

- It's just not gonna work.

- Right.

- Now, even if your nose is working, the over the counter appliances, they could work and they sort of temporarily but there's a reason, if you think about, I don't think they do this much these days, but, you know, think about retainers and headgear, and all that sort of stuff, there's a reason where if you're putting something on your teeth and you're pulling that that's gonna create some issues every time. And so, part of having dentist involved in this process, is keeping an eye on that and making sure that, you know, the teeth are getting taken care of too. So you can't just constantly crank on the teeth and expect them to not sort of buckle at some point, and so, it's both. There's some degree of, yeah, over the counter oral appliances can work and they can on some degree of, yeah, but be really careful with them, you know, both as far as knowing cause and effect as far as if you can't tolerate it may not be because the appliance maybe cause your nose. And then if it's something that's good fit for you, that's fine, but likely, well, almost assuredly, if you have a over the counter appliance, the custom appliance is gonna be better for your teeth and better for the overall situation than the one size fits-all appliance.

- Right.

- Like pretty much by definition. So it's just something kind of stuff to be, kind of conscious of and be aware of. Yeah, no, I think, turning any other dental?

- No, I mean, you know, again, it's... As we expand, we're identifying dentists and communities that understand the airway the way we do, try to bring it to patients, every location that we have, and it matters and we're making a big effort to make sure that we can provide that service to patients everywhere we land.

- Right, and the other thing I'm just thinking about, I mean, I think there are, I know there are, there are advances happening these days in the dental aspect of sleep, that are really promising. So there's just stuff that's happening in that space that I feel like they're trying to push the ball forward and help and the flipside of what I was saying before is, if your kid who can't breathe through their nose and your jaws are not too small, and now you're an adult, there for a while now, I mean, surgeries where you can break the jaws and bring them forward, that's a big, big-

- Which is pretty aggressive?

- Right. And so, that's... There's people who go through that and it can be very, very successful, but it's a big, big, you know, big barriers to entry because it's pretty aggressive. On the flip side, I'd say there are minimal, sort of more elegant, minimally invasive ways to do similar sorts of things, you know, basically, releasing some of the bones there and instead of just, in one fell swoop moving them, releasing and using expansion in an adult to change somebody's airway, well, jaw and therefore airway. So, there's stuff like that I think that has some legs. And I think, though, that absolutely is gonna take collaboration between dentistry, and, you know, the rest of medicine. And so, I think that's what I'm looking forward to seeing how some of that stuff plays out, seeing how we can collaborate together, seeing how we can... I mean, really, the solutions that exist today, they're fine but we're always looking for better solutions on all fronts and I'd say this is an area where I'm at, fully expecting, and then, you know, as the next few years roll by, they're gonna have new options for our patients and we want those. And so, we wanna do everything we can to kinda help to facilitate that.

- Yup, yup, absolutely.

- So, yeah, I mean, I think more to come down the road on the dentistry topic. I mean, and really, I get an odd shoutout. Today we try to do a shoutout and choosing off a positive one. Our shoutout today is sort of, you know, shoutout to the land and the people of Lebanon in Beirut, and you saw what happened there?

- Yeah, crazy.

- Devastating explosion which happens to be about the 75th anniversary from the, you know, Hiroshima and Nagasaki.

- Yeah.

- Actually, when I saw the video, it looked to me, it was a mushroom cloud as far as everyone was seeing.

- I mean, when I heard about it, and then the video showed, like how big that explosion... Like did not in my mind reconcile what I thought like okay, but like something exploded, and then you see that you're like.

- Yeah, yeah, it's something. I guess the reason I'm saying it's an odd shoutout is 'cause they, you know, for those that don't know, but it's Lebanon in Beirut, have been through decades of this at this point of war, of the corruption, of this sort of... This was you know, an accident it sounds like, but bombings bombings as a result of the war, terrorism, Coronavirus, you know, all this sort of stuff that's been going on, and on, and on and I'd say, this is probably about as sad of a moment in time is there probably can be in one place. But I would say, they're in this desert, in this place that lacks hope that things will, you know, green will grow out in the desert. And the reason I'm saying this, I'm thinking back, back to Hiroshima specifically is my I took my family. My family and I, we went to there last year and it's a vibrant city at this point. I don't know that, I think... I don't know if Americans think about that, 'cause I think you think about the bomb, you think about what happened then, and I don't think people think but it's a thriving city at this point. And looking at the video and picture from what happened back then, I don't know that anybody would have thought anything would have been possible. And I'd say, looking at some of the pictures and videos coming out of Beirut today, I'd say, yeah, you see the devastation. I mean, when I see that, I don't even know. Like, even to me, my simple mind is like, I don't even know, where do you even start to clean up to rebuild?

- Or rebuild. like, where do you? Where's one even start? And I'd say, well, probably, one shovel, and one, you know what I mean like? And miraculously, if you have one little step over time can, you know, really make a big difference. So anyway, our thoughts are with you. And, you know, the future will be here probably before we know it. So, that's all I got, anything on your end now?

- No, that's wrap!

- Nothing too much? Okay, so really, that's all we got. If you are watching us, give us a like or a comment if you, you know, find the time. And, you know, keep watching, keep subscribing for those that haven't and for those who have, we thank you, and we will catch up with you next time, take care!

- See you next time.

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