Speaker 1: 0:00

Welcome, welcome everyone to our Friday night special. We are so excited to be over here with you guys on a Friday because we have some very, very, very special people with us. I am going to actually let everybody introduce themselves today. We have some questions. However, we would love this to be very interactive, so if you guys have any questions, please just put it in the comments In both places that we are live. Just send us some questions and I will read them and let us know in the chat where you're from, what's your specialty, what brings you here. But first of all, I wanted to start thanking Dr Shireen Lim. Thank you so much for working so hard and putting together such an incredible meeting that's coming up in Australia Inspiration by Integration. So, if you can, please introduce yourself to everybody and then talk about this wonderful meeting that's coming up soon.

Speaker 2: 1:04

Right, yeah, so my name is Shireen and I'm a general dentist from Perth in Western Australia, so really I started out with my airway journey looking at adult obstructive sleep apnea, but now my passion is how can we restore airway health for children as early as possible? So in my practice, I'm focused on tongue-tie management, orthodontic treatment for young children and tongue-tie management orthodontic treatment for young children and tongue-tie management and myofunctional therapy, and so the conference Inspiration by Integration really is about helping to promote more awareness of these issues and helping healthcare professionals be able to screen for them and understand what are their integrative treatment options, because it's never really just one specialty that has all the answers, and so I'm really excited to be bringing you guys along, all of us from our different professional backgrounds, to be able to introduce you guys to more Australian colleagues Plus, we have people traveling from different countries as well and really bring together professionals from different professions everything from lactation consultants to maxillofacial surgery to be able to have these discussions about integration and how we can help children get more care.

Speaker 1: 2:17

Welcome Stanley. Yes, that is wonderful. Well, jj, it is your turn to introduce yourself. Welcome, dr JJ. Hi Hi, renata Sh to introduce yourself.

Speaker 3: 2:26

Welcome Dr JJ, hi, hi Renata Shireen and hi Stanley.

Speaker 3: 2:32

Well, it's good to be here and good evening.

Speaker 3: 2:36

I'm an ENT surgeon and I've always been interested in the nose for the longest time and then somehow or other, got sort of roped into the sleep journey about a decade ago when I met CG and he was a sort of the key person that sort of made me open my eyes and start this journey.

Speaker 3: 2:54

And then, somehow or other, it's just been evolving, started as usual with sleep surgery and then started integrating practice somewhere around 2017 with dentists, then incorporated my functional therapy and then, as usual, it evolved and we realize now that we've got to catch patients as early as possible, and now we've even moved earlier. It's like what I'm looking at is create a healthy mom and dad before you even have to have the kid, because we now realize the influences start way earlier than that, right through pregnancy, the delivery and so on. So it's great that sharing has put up this program in melbourne next this month. Uh, it'll be my third trip to melbourne in four months, which is crazy, but uh, yeah, it's fun and I'm looking forward to meeting everybody there in person yay, it will be my first time, so I'm super excited to be in australia.

Speaker 1: 3:45

Uh, dr stanley, liu welcome. Do you mind introducing yourself to the crowd?

Speaker 4: 3:52

yeah, thanks, uh, renata, and and um great to to uh connect with the airway circle. Uh, audience again, I'm stanley, um and uh, uh. So coming up to about a decade now with um surgical focus, um in the treatment of patients, uh, patients with sleep disorder, breathing sleep apnea, um had amazing mentors, uh in Riley Powell, uh on the surgical side, cg and Dr Kushida uhida on the medical side. But more than anything else, you guys, you know, a couple of years ago, when we, you know, when Shireen hosted the Inspiration for Integration meeting I mean, getting all the different specialties together to talk about sleep apnea was kind of still relatively new, you know. I know a lot of meetings now have seen how much more awesome dynamic these meetings are when we bring everybody together. But I wouldn't say that's the norm. So, super excited about it.

Speaker 4: 4:58

I get to see JJ for I think, the 15th time this year. You know where did I mean thank you for hosting me? In Malaysia. Where did I see you again right after that? Oh, in New Orleans by way of Shireen's and the Airway Health Solutions Group meeting. So, and can't wait to see the, to see the post expansion Renata in person. Uh, so yeah, but um, one, just one thing I've always believed in, and you know, as a surgeon, the more, uh, probably the most important thing that I learned is that if we can capture these missed developmental milestones, we can do much less surgery and, you know, everybody would do a whole lot better as a result. So yeah, thanks for having me on.

Speaker 1: 5:53

Of course.

Speaker 2: 5:55

Renata, if you don't mind me just jumping in for a moment. A lot of people want to know how did I meet JJ and where did he come from, wants to replicate him and really, jj, we met in person for the first time when Stanley and I did the meeting four years ago the inspiration by integration, the first one and JJ was such an active participant, always putting his hand up and contributing to the discussions, and everybody just loved that. That really made the course um and so I thought he was a speaker he was a semi-speaker with everything that he contributed.

Speaker 2: 6:31

Yes, but that's the first time we met in person yeah, before the world shut down that that is true.

Speaker 1: 6:41

Right before all that happened, I was going to go a little bit through our schedule in Australia because I know a lot of people are curious to know what exactly we're going to be talking about. Of course, we cannot share everything with you guys tonight. You got to come to Australia to see us. However, your first topic, sharim, is about airway health and recognition of red flags in early childhood. Can you share with everybody just two red flags that we should be looking at on young children?

Speaker 2: 7:13

oh, how do I sum it up into two? Just pick two.

Speaker 1: 7:16

They don't have to be the most important ones. Just pick two, yeah well, teeth grinding.

Speaker 2: 7:21

Teeth grinding, I think, is very overlooked. A lot of people think that it's something that children will grow out of, even bedwetting as well Very common problems. A lot of people are under-recognizing it and we're failing to address that underlying airway issue and help that child have a better quality of life.

Speaker 1: 7:38

So how is bruxism related to airway?

Speaker 2: 7:44

Yeah, a lot of the times bruxism is a stress response to difficulties breathing. So when we have increased airway resistance, rather than having an obstructive sleep apnea like an adult may, a child has a more intact sympathetic nervous system and they can have an arousal from sleep which is accompanied by this jaw movement, and that helps open up the airway and so it's very protective against obstructive sleep apnea. They don't have deprivation of oxygen, but it does lead to very unrestorative sleep because a child can't enter the deeper phases of sleep.

Speaker 1: 8:19

And I think that one of the number one, the number one question that I get from parents is about bedwetting. My children are bedwetting, and how is that related also to airway, and then what can you do about it?

Speaker 2: 8:36

Okay, yeah, so it's a common thing. Do you know what I think it's? It does involve a whole hormone cascade when we have this increased resistance and these intrathoracic pressure changes and I'm going to see Stanley, do you reckon you can help answer this for me, Because I reckon I'm throwing you under the bus here. Stanley, Do you understand the whole hormone cascade that's involved? Because I'd love to be able to go deeper, but it's not something that's really ingrained in me go deeper, but it's not something that's really ingrained in me.

Speaker 4: 9:12

You know, we, we go back to the earliest. You know I still credit what was in 1974, right, when, when, when CG had to publish on the first nine kids right With with sleep apnea, right, it was still. I mean, you had to convince people that kids also can, can develop or, you know, can manifest. Um, one of the things that you know, he, he noted you know, two things, so, bedwetting being one of them. The other one is also that most of the kids were not overweight. I know that if you read a lot of papers now, they'll talk about obesity. They still talk about obesity when it comes to kids.

Speaker 4: 9:44

The thing is, by the time, obesity is a major contributor to sleep apnea in kids. You've way missed the boat, right, I mean, for this group here, you've really way missed it. And in the very beginning, in fact, most of those kids were underweight. They were not overweight, right, and so part of it is, beyond the growth hormone production in poor sleep and disruptive sleep in general. You have that ghrelin, and what's the other one?

Speaker 4: 10:10

Jj, the flip side of ghrelin, leptin, yeah, right, but what's complicated about it is, if you look at the literature there. It's not so simple like it just flips, you know. I mean, they're just like a whole lot of things. I think there is a time sensitive change to the severity of the hormonal disruption. So that's all I, that's all I really know. But I'll tell you, like today, even today, just in clinic, does that? You know, let's not use the word disaster, that's so negative, all right, but I just feel that way Cause I just feel terrible. Wait, are we sorry? I don't. Actually I don't want to take away from this discussion. We'll come back to this, you know, real life example later. Let's go back to Shreen's focus on hormonal imbalance and whatnot.

Speaker 1: 10:58

And the reason why I asked that is because I have heard different doctors explaining several different ways. And then, if JJ, you would, if you'd like, to add into this conversation. So the first time I ever heard about bedwetting being related, it was explained. I believe it was Dr Jeff Rouse and he was saying that when your body goes into your sympathetic system and fight or flight turns on because you are choking to death, you cannot breathe. There's an airway obstruction somewhere. You release everything that is not important and one of those things is urine. Just like when somebody has a heart attack, sometimes they will pee on themselves. When somebody has an extremely traumatic event, if they are robbed a gunpoint, they tend, you know, sometimes they'll also urinate. So that was the first explanation I have ever heard. And then the second.

Speaker 3: 11:51

It's actually a combination of a lot of things, and one of it is in sympathetic overdrive, you actually the sphincter gets relaxed. That's one, and the other one is the sensitivity to ADH, antidiuretic hormone, is also reduced. So they cannot the sensation of bladder fullness, they cannot hold it, so they pass on, and so it's a lot of combination. But you know, I think what we really need to get that message out there is the most subtle symptoms that we miss. You know, people parents still think that it's cute for a child to snore Grinding is okay but I think what we really need to get the message out there is the moment you see a child who's got an open mouth, with poor lip competence. I think that's the biggest warning sign that tells you that this child needs to be looked into Because, like Stanley said, we are missing the early subtle signs.

Speaker 3: 12:41

A child can have poor lip competence and not snore. So there are lots and lots of. We cannot say that one symptom is more important than the other. I think we need to have that whole lot of symptoms that parents need to be aware of, from restless sleep, open mouth posture, whether there are symptoms of colic atopy, you know, eczema all these early onset of eczema, very severe eczema. All this tells us that there's a potential for airway issues. I mean, we know now there's a lot more than that, and I think that's going to be a great when we come to Australia.

Speaker 1: 13:17

Oh my goodness, this is wonderful.

Speaker 4: 13:20

Sorry, since we're talking about peeing, can we talk a little bit more about peeing? Yeah, you know, we talk about kids, ok, and we're going to do this focus on, you know, this meeting upcoming, also on kids. But I think at least and Renata, at least with your group, you know we're getting, the folks are getting it. Now it's very important. Kids, we need to find treatment and you're beginning to even identify people who can take care of this. You know, a horribly, horribly missed group, entirely, of course, is women, and I say that because we know so little about the presentation of sleep disorder, breathing in women, although, again so the peeing example, it gets worse if, if not corrective, right Urologic symptoms is very bothersome to adults.

Speaker 4: 14:11

Now, when you're, you know, I still remember, you know, treating an adult post MMA did very well. Age I went from, you know, the high fifties to to the single digits. He feels better but he still has very poor sleep. Why? Because he still has to get up three to four times a night to pee and the thing is, by then it's really late. It's hard to retrain that function. But I go back to the women, because you have lady patients who in their, let's say, late 30s, early 40s, premenopausal by getting there and they now exhibit urinary symptoms or complaints during sleep. Okay, they almost look like kids, they almost look like the pediatric patients and even something like besides what JJ has mentioned with the ADH sensitivity just the negative pressure. So think upper airway resistance, taut upper airway, pulling down as you're breathing on this and pushing abdominal pressure right Down onto the bladder and then tricking the body into thinking you got to get up and pee.

Speaker 1: 15:17

That's the second one that I was going to talk about is the pressure.

Speaker 4: 15:21

So now, of course, you'll do every urologic exam and you know there's nothing, it doesn't appear like there is anything wrong. You know right that's causing this. And so once we're done talking about kids and I think we're almost getting there, not done, but you know, bring about that awareness. At some point we need to do this integration, inspiration meeting and focused on women's presentation about what I say. But anyway, that's it.

Speaker 1: 15:48

Yes, well, jj has studied a lot, researched a lot on women. Why don't you share a little bit with us? Because whenever we're talking about children, we have to talk about women and you know, usually our first line that we reach these people are through the moms. The moms are the ones that are trying to help their patients and often get overlooked. You know their own sleep issues because they're trying to take care of everybody else. Do you mind talking a little bit about women's sleep please?

Speaker 3: 16:17

So when I spoke to Kevin Boyd about this and now they're looking at intrauterine ultrasound that's showing poor mandibular growth because, uh, you know, the child is actually hypoxic I I would encourage every one of you to read this 1954 paper where it's called mount everest in utero. It's an amazing paper because it basically tells you that the fetus grows in an environment of a 32 000 feet, which is where your airplane flies, where it is not survivable, if you. And the beauty about it is the child grows in such a hypoxic environment but yet thrives very well and the oxygen that comes from this is competitive with the mother. So if the mother is not breathing well and I think even looking at upper airway resistance syndrome we are compartmentalizing this. And that's why I said, once we start looking at women with breathing dysfunction and this is where we really need to look at it, and in my work that I've actually looked at about a few hundred women the five cardinal symptoms that they have is musculoskeletal pain, so they get a lot of neck stiffness, shoulder tightness. They get a lot of GI symptoms, so like almost mimicking, ibs, bloating, burping. The third is what Stanley said the sensation of waking up, going to the bathroom in the middle of the night, so they wake up at least once or twice to go to the toilet. The fourth is mental health. They get a lot of anxiety, panic attacks, compulsive behavior. So it's a very sympathetic, system driven kind of a behavior. And the fifth is waking up early morning feeling tired. Now the problem why we have probably not picked it up is it's the type of sleep study that we are doing to pick up All these women are missed.

Speaker 3: 17:58

If you are doing a type three and above, you have to do a type two and a type one and you see a lot of movement issues as well. So they get a lot of bruxing and restless legs as well. And I think it gets more complicated because there is a hormonal influence and also the effect of anemia. So there's a whole lot of things going on in this and I still don't think there's enough work being done to look at this specifically and very simple, I'll put out a very controversial thing over here Somebody who has had bicuspid extraction and braces. We know that this restrictive or retractive auto is causing airway issues. Now, if we don't realize this, this is a high-risk woman for pregnancy and now they're looking at studies as we need to screen for sleep-disordered breathing in couples who are going for infertility workup. So we've moved way beyond.

Speaker 3: 18:49

You know, let's look for sleep apnea in hypertensive heart problems, stroke patients. I think this is like very, very obvious out there. But now we need to start looking at all these small little things that we are missing in the big picture. And once I started doing type 2 in these women, they all have sleep apnea, but the problem is they've got zero apneas and they're predominantly hypopneas.

Speaker 3: 19:11

And if you look at the new classification of hypopnea, which is a drop of 3% and above, they are all hypopnea and they show very definitive patterns where they are more obstructed during REM sleep. So they get short REM latency, they get increased REM and they are mainly obstructed during REM sleep. So there's a lot that we need to look at and it's getting bigger and bigger. So I just had the opportunity of presenting at our National Obstetrics and Gynecology meeting and they were shocked at the data that we were showing Increased risk of caesarean section. Shocked at the data that we were showing Increased risk of caesarean section, increased premature births, kids needing more airway attention, low APGAR scores if the mother has got sleep apnea during pregnancy. So it is downright scary.

Speaker 1: 19:56

Wow, I feel like we're missing so much, but together we are able to educate and to reach so many more professionals, so they can start looking at these things too. So thank you, jj. For my goodness, I'm sure that their minds were question in terms of your history and your, your careers, which I think I might leave that a little bit to the end. We had a couple questions come in. Uh, one of them it's specifically, I think, to dr stream limb. Um, somebody said I'm curious about methods for early intervention regarding deep bites. I have trouble finding providers willing to intervene in yet so many severe deep bites.

Speaker 2: 20:46

Yeah, so it's definitely a lot more easy to deal the younger a child is.

Speaker 2: 20:53

When I think of a deep bite where the top teeth and the bottom teeth have a very deep vertical overlap, I'm usually thinking it's related to low tongue posture, or the back of the tongue is quite low.

Speaker 2: 21:06

So if we get a person to open their mouth, what we'll tend to see is the front teeth are standing up like this and the back teeth are dipped back so they're kind of sunken down, and what's actually happening at rest or during sleep is the, rather than the tongue lightly suctioned to the roof of the mouth.

Speaker 2: 21:25

It is actually sitting low and resting. The back of the tongue is resting on those back teeth and then we get super eruption of the lower teeth so that actually traps the lower jaw, so the lower jaw is not able to grow forward. So in a very young child really, what I want to do is I want to get the back of the tongue working better, and so how I'm going to do that is usually to do some sort of expansion to restore that palate structure and then myofunctional therapy and many of the time with that deep bite there's going to be a posterior tongue side time, with that deep bite there's going to be a posterior tongue side, so I want to release that as well so that I can get those the the sides of the back of the tongue off those bottom teeth and back up into the mouth um, thank you so much for that.

Speaker 1: 22:12

Another question we had was how can each of your specialties help TMJ patients I? I thought that was a great question. Who would like to start?

Speaker 2: 22:27

I'm not a TMD expert, but what I do know is that anytime we have TMD, there's a disharmony between the muscles and the structures, and so I think that we can actually help minimize those problems if we intervene early to get the structures and the function optimized.

Speaker 1: 22:47

JJ, you're muted.

Speaker 3: 22:50

From an ENT perspective, when I see patients grinding and clenching, there are two things that I look for nasal obstruction and nutrition. So from a nutrition point of view, we check iron, magnesium and vitamin D as a routine. And nasal obstruction well, that's when you look at the whole craniofacial complex and you look at any, you know within the nose whether there's any issues like tympanate hypertrophy concavolosa and stuff like that. A lot of the times when you address the nasal obstruction it seems to help the grinding and clenching as well for some reason. But that's only one part of it. So maybe the dental part of it. We work together with the dentist, so we all have all our individual roles, but we want to optimize the patient as much as possible before we go on to other things as well.

Speaker 1: 23:37

Excuse me, Stanley things as well.

Speaker 4: 23:46

Excuse me, stanley, there's a lot there, but I'll highlight one top one that I see quite frequently and this is, you know, let's. This is usually, let's say, 11 to 13 years old, so sleep, breathing and TMJ. So next door to my clinic there's an oral facial pain clinic and they see patients with TM, joint pain and facial pain. What does a 13-year-old girl typically look like in this clinic being treated for bilateral joint pain? I walk in and you see whopping facial asymmetry. It's very evident. The face is this way and yawed, okay, and you know, long mid face. So mandible's kind of trying to come forward.

Speaker 4: 24:32

The orthodontist brings the incisors in because you've got a seemingly class two myoclusion. But now as the mandible tries to grow, I'm not quite sure where it can grow because it's just going to clock right into the incisors and so what's? Something is someone's going to have to give, and it's going to be the joints, and so in those patients then typically not asked because you know they're treated by TM, joint splint therapy and all of the sort, but a lot of times that facial asymmetry is associated with nasal obstruction, usually much worse on one side. So now you have this seeming asymmetry and what happens. Now, look, I'm exaggerating. If it's this off, we would know. So it's not that off, but it's off to the trained eye. You can see the maxillary cant. What does the mandible do? It's got to fit somehow right. So usually you just try to pull down the teeth a little bit on one side. The other side, the clocks in sooner.

Speaker 4: 25:34

That joint hurts first, and almost because this is a process that just got started with these kids, this is a process that just got started with these kids. So I can almost just ask the patient so, do you breathe worse from that side? Oh, yes. Or even like, oh, yeah, I do breathe poorly. He asked a mom about, you know, associated sleepiness symptoms. Then she goes, yeah, yeah, she doesn't sleep very, very well, et cetera. And then you say, well, it hurts on this side and it's going to click on the other side, right. Say, well, it hurts on this side and it's going to click on the other side, right. So I think now this phenomenon you can continue to see up until even, you know, 50, 60, some year olds, where you know you look at their complaint, you look at the history of their complaint and you trace it all the way back to. Did you breathe worse on the right side and did you have bad nasal allergies as a kid, and did you move somewhere when you were two years old? So, yeah, I would say the association of related symptoms to poor nasal breathing, particularly during sleep, and joint complaints highly correlated, joint complaints highly correlated.

Speaker 4: 26:48

The scary part, though, is I wonder how much we on the healthcare professional side is actually contributing to it, in the sense that by treating one, are we neglecting the other or sometimes hurting the other in the whole sort of bite, breathing beauty and if you want to call this bone joint whatever in this whole complex. But yeah, just go into any TMJ clinic and I feel like it really looks like an airway disaster zone. I mean, it is just wow. But you know, to their credit, I think a lot of our TM joint pain specialists are very open to learning and examining the airway and, by the same token, I know very little about the TM joint, having spent so much time focusing on the airway. But again, there's only one truth in the end, it's all going to converge, so at some point. Again, topic for the next, next meeting, although this one ties in better with the women. Anyway, that airway joint meeting is going to have to happen at some point.

Speaker 4: 27:52

So so you know, because otherwise right now what's happening is people are going to two different types of meetings and then you're going to have to go home and try to bring it together and it's kind of difficult.

Speaker 1: 28:04

I agree.

Speaker 1: 28:05

I'm not a TMD specialist by any means. However, of course, my side of the story is looking at the muscle. I am asking patients also about sleep positions to see if they have been sleeping for a long, long time on their face. I'm looking at chewing. They usually have a preferred side of chewing. Sometimes if somebody loses a tooth, they're going to, of course, avoid chewing over there. If they had a toothache for a long time on one side, they're going to start using more the other side and the other muscles and that can cause an imbalance in the TMJ. Also, most of the patients I'm looking at facial pattern, growth and facial types, and the brachycephalic patients are usually the ones that are way more likely to be Bruxers. I mean, look at those beautiful mewing masseters that people want to all have. So, being very aware of these facial types and what kind of exercises you're going to give to your patients, being able to tell you know if one masseter is bulkier or it's engaging first, you know there are some exercises that you're not going to give.

Speaker 1: 29:29

You're not going to ask them to close anything. You want to open, you want to stretch, you want to use heat and not cold, because anything cold is going to contract those muscles even more. I hear so many people giving cold stuff and asking them to to massage and massage the wrong way. Very important whenever you're massaging the masters for anybody who has any type of burksism, you never ask them to massage up. You never do, because that's the contraction of the muscle. It's going to get worse, so always go from here down. You have to go with the, the contraction of the muscle.

Speaker 1: 30:02

It's going to get worse, so always go from here down. You have to go with the fibers of that muscle, how they're moving. So you want it to open, so you go always from top to bottom. Also, if you just do round, it's also not going to do much for those patients. You have to elongate the muscle towards where the fiber is going to go. Um, whenever you're trying to stretch, we have somebody with their hand up. I'm not sure. If you want to unmute and ask your question, prair, let me see if I can. Okay, see if you can unmute and ask your question.

Speaker 3: 30:35

Before that, I just want to just chime in, and this is where I mean Stanley made a very wonderful point that a lot of us go to different meetings and we focus on different areas, but I think what we really need to see is we need to understand that the endpoint problem that we are looking at I mean, if you look at it this way, it's actually one major issue here and everything else is centered around the major issue. And I think that is where we don't realize that airway and breathing seems to be a big determinant for every other subsequent. And this is where I feel that the whole group of us at least in the core group of us, we're talking about this. We all need to come together medical, dental and we need to standardize terms. And I know, renata, in one of the questions that you put about it and I think this is something that I'm very passionate about that we talk, we use terms nasal breathing, mouth breathing but we don't realize that the physiology of breathing itself is such a complex mechanism and you know, no matter what kind of surgery that we do, what kind of myofunctional therapy that we do, the end point is to get the patient to breathe right. Because if you do surgery and this is what I see in the patients, even if I do a simple nasal surgery in a child who is nasally blocked and the moment after surgery, what the child ends up doing is the child ends up over breathing. So we are taking a rapid, shallow breather and making them breathe deeper and faster, which is now going to drive autonomic dysfunction even worse. And this is exactly what we see in women. They get more anxious, they get more worked up after treatment.

Speaker 3: 32:12

So a whole lot of breathing retraining has to go into this picture. We need to get them to slow down their breathing. We need to teach them how to use their diaphragm. All these things are very important. So that is why I love using the term dysfunctional breathing, and a lot of people disagree with me and they said there's no such thing as functional breathing. And I said at the end what we really want to do is we want to take patients who have adapted an aberrant physiology and get them back to normal physiology. Once we correct physiology in one place, everything else falls into picture. A person who is not breathing right is going to have autonomic dysfunction. A person who is not breathing right is going to have acid-base imbalance, you see. So the body is always going to try and compensate to make sure that you breathe right, and I think this is where we really need to focus and sort of get all these things.

Speaker 3: 33:07

We tend to be very, I mean, as disease care providers, as what I would like to say. Patients come to us with symptoms and we all look at trying to fix those symptoms, but now what I've actually evolved in is I try to look at the root cause analysis, what is the underlying cause which may not be seen to the patient, and tell them this is where you're getting your symptoms from, because you have changed your physiology here, and what I'm going to try and do is I'm going to correct that physiology, either by structural work or functional rehabilitation, and then see what happens to your symptoms and then refine things as we go along. So I think that's going to be a big change or shift in the way we're going to have to look at things. I don't know, this is just something that I always think about and I'm always challenging the norms, so that's why I'm always a very controversial figure. So, yeah, you know we're not going to go anywhere, just being nice and, you know, not opening up these discussions and challenging these ideas and concepts. So I totally agree that at one point we're going to have to have a meeting where we're going to look at all these things Nutrition airway you know, airway rehabilitation, breathing rehabilitation you know people do Wim Hof's Buteyko.

Speaker 3: 34:21

We heavy rehabilitation, breathing rehabilitation you know people do Wim Hof Buteyko we're all looking at it from different compartments and we are definitely I mean, we don't have an expert here, but we need to talk about bodywork and now even the Australian the consensus on tongue tie release. One of the things they insist on is you have to get bodywork done before tongue tie release. So where does all this fall in? How do we put this in perspective? Where do we prioritize? What do we do? You know all these things are so important and I think we are a long way from, you know, really understanding this whole process. Like I said, we're still in infantile stages. We've got a long, long way to go, although we have made progress, fantastic progress, in the last decade or so, thanks to people like Stanley and Shireen, and you know it's amazing where we are, but lots of things still yet to be done.

Speaker 1: 35:06

Thank you. Thank you, yes, I feel like everybody's holding their puzzle piece over here. We all have to bring them together in the middle because we all, you know body's so complex. If we put everything together, we're going to be able to help our patients better. We have a question, Hi. Thank you for the informative sharing. I would like to ask what is the pathophysiology of night sweats during sleep? Thank you, Stanley. You want to start?

Speaker 4: 35:38

I'm going to make the assumption that we're talking about sleep disorder, breathing, I mean, there are a lot of reasons for night sleep. We won't talk about all of that, you know. This is another. I would say yes, I'm sure you know, on a very basic level you go back to the autonomic control and the fight or flight response.

Speaker 4: 36:00

One of the things that is interesting is that in this one they studied more so specifically in the menopausal group is that the night sweats actually tend to occur during N2 stage sleep. So that is interesting to me. N3 are, you know, slow wave sleep, airway most stable, n2 highly unstable. So I think the you know the answer to that question is really going to have to come from sort of at what stage of sleep this is really occurring and then from there we may be able to tease out the physiology. But you know, if let's say we're looking at N2 sleep, night sweat type thing, then you know there's a very high degree of airway instability and we would know that. I don't know, jj, do you, do you have any other insight to that?

Speaker 3: 36:55

I think it's pretty much the autonomic nervous system when we are talking about sleep. But you know, like you rightfully said, there are lots of other things that you need to look at thyroid hormones, you know, pyrotoxicosis, even certain drugs, may even cause it. In Malaysia you tell night sweats. The first thing we'll think about is TB.

Speaker 1: 37:14

Brazil.

Speaker 3: 37:17

But I think it's basically in sleep. It's because of what you mentioned end-to-sleep and autonomic dysfunction.

Speaker 4: 37:26

That one is interesting, because that one we can actually study better these days because of the smart mattresses that we have now. Um, granted, I don't know if any of it really picks up night sweat, but I think that that's a really point. Um, you know Dr Tan who who raised that point, um, if, if we can correlate the timing of when the night sweats actually occur, um, I think we would know more. Um, yeah, cause otherwise I don't think in in, currently, in, currently in the literature, we we have anything more than these kind of you know the known sort of you know causes.

Speaker 1: 38:06

Shereen, do you mind going through a little bit? In the meeting in Australia, who else is speaking? Do people still have time to join us?

Speaker 2: 38:18

Yeah, absolutely. You know, I've done a few meetings and I know the rush comes in at the end, so definitely able to accommodate that. It's the four of us plus I have invited two local speakers Jim Papadopoulos, who is regarded as one of the leading sleep pediatric physicians, so he's from Sydney, as well as Dr Noor Taraf, so he's an orthodontist from Sydney and he does a lot of presentations on TAD expansion and he's completed his honors project in growth modification using TADs. We also have Dr Surush Laki, who I've invited on day one to present live online via Zoom on tongue tie diagnosis and management as well. So I think that was a really important topic to be able to cover.

Speaker 2: 39:05

Yeah, and so really, it's going to run over two days. The first day is more each of us giving our own talks about the screening and identification, what we're looking for, and day two is more about treatment and how we integrate our different pathways as well, and we do have a lot of people from various professions and some people have been in this field for a very long time. I think it's not just for beginners but also for those that are experienced, for the networking and just listening to you guys as you're talking there. It's so engaging, there's so much more to learn from you guys, and so I hope that other people will find the whole experience not just the course but those other discussions really enlightening.

Speaker 1: 39:46

All right, wonderful, and I also put in the chat box a link that you guys can go straight to that website I was just showing and also I'd like to offer anybody who is here if you'd like to become an Airway Circle member. We are an online airway study club, so we usually meet every Thursday night at 8 pm Eastern and it's free for everybody to watch live, because our mission is to just spread knowledge, get more professionals to join us, to listen in and to share their knowledge with us. Also, we have a directory of professionals that is global. We have about 3,000 visits to the directory every single month, so there are thousands of referrals coming from our directory. If you are treating airway doesn't matter what specialty, it's multidisciplinary please join our directory. It's also free. So if you'd like to become a member, you have access to hundreds of lectures that we have recorded in the past, a research folder, and you get to. You know, help with the management of these things and increase airway knowledge to everybody, patients and professionals alike. I'm going to leave a link right here in our Zoom for whoever is on Zoom only, you get $50 off forever. You're always grandfathered in the next.

Speaker 1: 41:06

Now I can ask the questions that I said I was going to ask you guys before. Okay, and there's the. I'm going to do the other one real quick. Um, the question that I wanted to ask you guys before I know dj has to go. Um, where is it at? Has there been? Can you share? Um, if you have had any life-changing patient or life-changing thing that has happened in your career that has really kind of shifted from how you started to where you are today. I'll start with you, shereen.

Speaker 2: 41:51

Sorry, the question is a life-changing patient.

Speaker 1: 41:54

Yes, so going from not treating airway to, all of a sudden, you want to look into these things. There's usually something that happens or a very you know a patient that that changed your trajectory in your career yeah, I think most people know the story about my husband snoring.

Speaker 2: 42:14

But you know, I think every day there's a story, like yesterday in particular, I saw a 12 year old boy who his mum came in and he, you know, he has a tongue tie that's been dismissed for a long time and he's got a very narrow v-shaped palate. And his mum's just like I just want to know my boy inside because he he he's keeps to himself, he has troubles regulating his emotions and difficulties with his speech, and it's hard for her to connect and engage with him. And sometimes he says he hates himself, he doesn't know why he's here. And, yeah, these are the things that actually make me feel very, quite passionate, because you look in the mouth and you see this tongue tie and it's never been working well and its mouth has never developed well and it's never had good sleep. And, yeah, I just every day there's a story that really inspires me to want to do more to help more people be able to identify these issues and not let them get dismissed so early all the time yeah, I know anything you'd like to share.

Speaker 1: 43:22

Maybe that has happened to you recently. Jj, you always have some great stories.

Speaker 3: 43:29

I. For me, I think it's it's not been life-changing, but for me it's been a journey since childhood and I sort of tick all the boxes in hindsight of airway dysfunction and I've been trying to fix myself from the time I've been a teenager and because of this I've explored all the various things that I've done, from body work to dental, to expansion, to nasal surgery which I've had six, by the way and I've even had a radio frequency of the palate. I've done everything and nothing worked. It worked for a while and then problem keeps coming back and then you keep asking. So I think for me, the patient that taught me the most was myself, and you know, knowing what I went through and knowing what works, what fails, I think it's sort of given me a better perspective, a bigger picture of the whole thing. As far as patient goes. Well, I'll put it in the middle. We have had patients who have had dramatic changes. We have also had patients where we have failed and you, you ask your questions why did we fail in these patients? So it's it's almost like bittersweet kind of a thing you win some, you lose some, and this is an area where we are so dependent on patient compliance and we have to work on a lot of the psychology of the patient. We have to have people who understand working with relationships, what kind of patients you get, how you want to approach these patients, how you win them over.

Speaker 3: 44:59

I used to be very dictative or very, you know, authoritative. You've got to do this, you must do this, you must get this done. And then now you sort of learn to win the patients over. I tell the kids, why are you doing this? Well, you know, to get better teeth. And I was like, oh, like, oh, really aren't you looking at improving your breathing? Maybe better oxygen to the brain? You think that might make you smarter. Or if you like playing games, you know you get better oxygenation, would that make you more? Endurance? Improves your endurance in sports and and the kid's face just lights up. And then you get parents coming and telling you dogs, can you advise him what to do? He seems to listen to you more than listen to me, and these are all things that you know. It's really life-changing in the sense that it motivates you, it drives you to improve and keep striving to do things better as we get, you know, more encouraging results. But, like I said, every day is a life-changing day.

Speaker 4: 45:53

I will share mine, and then Stanley will share.

Speaker 1: 45:55

And we have a couple other questions that came in before we go really quickly. I know, jj, whenever you have to go, just let us know my patient that I will. Well, he's not my patient, but I think that one of my inspirations and another reason why I'm so passionate about this, it's because of my father. My father has severe sleep apnea, so I grew up with him snoring so loud that we could hear from three rooms down the hall, and often I would remember that he would wake up in the middle of the night and had to run to the bathroom almost to throw up because it was choking so bad. But nobody in my household spoke about sleep apnea. Nobody talked about it.

Speaker 1: 46:34

Eventually, when I moved to the United States and then I started learning about this, I remember asking my mom and my dad like why are you guys not seeking help? Oh, he doesn't want to wear a CPAP. That's what I always heard. So finally, about five years ago, I went to Brazil and my father was telling me the same thing over and over and I was like, hmm, there is something going on there, but everybody trying to mask it, everybody trying to know it's. You know he's just yeah, he's going to a neurologist. A neurologist was giving him some antidepressant medication and doing some treatment for his brain, but nobody had requested a sleep study, no doctor. So I remember calling a sleep doctor from here and I said it doesn't matter what he does, just do a sleep study when he comes in.

Speaker 1: 47:22

So his HI was 49. His oxygen was dropping to the seventies and today my father had to stop working because he has Alzheimer's disease and it is so sad that he went through so many years of undiagnosed and untreated sleep apnea. So he just, you know, keeps me going. He's not my patient, unfortunately, but I wish I could help me help him more. Stanley, you can share about a patient if you'd like. And then I have two more questions. I'm going to ask them right now and then we'll answer them later. This is for Shereen Would people that cannot physically make it to Australia meeting be able to purchase sessions or view the meeting online? And the other question is I would like to ask if there's any relation of this topic with sleepwalking in kids. Stanley, you're patient.

Speaker 4: 48:27

Instead of just one patient. I think I want to let me share sort of one consistent thing and JJ, you alluded to that and thank you for sharing the story about yourself but it's really this missed opportunity thing. You know, I don't think there's any condition in the course of my training in maxillofacial surgery, in ENT sleep surgery, that where there's this like I wish this had happened, you know, this sort of mutual recognition. Oh yeah, you know, and then we're trying to play catch up, and so I would. You know, and you know, the motivating factor and inspiring factor that keeps, you know, me at least, in the field, is that yet, at the same time, we're addressing something so fundamental.

Speaker 4: 49:17

There's something so simple and challenging about the topic. We're talking about healthy breathing right During sleep, and it's almost like in the journey of a surgeon's development. You know, first you get excited by learning all. You know all the different operations I can operate on the nose, the palate, neural stimulation, skeletal surgery Wow, you know I, I can do so much. And then you realize, the less you do, uh, if there is some kind of a better timely intervention, the better off it is. So it's a real exercise in life and you get to meet some of the best colleagues in the world and, of course, some of the most, you know, frightening colleagues in the world. So it's a true. It's life, man. You know it's life itself and it couldn't. It's almost a pursuit of simplicity turns out to be the most challenging job.

Speaker 1: 50:08

Amazing JJ sleepwalking in kids.

Speaker 3: 50:11

Yes in kids. Yes, I think sleepwalking is is definitely, uh, some form of parasomnia and I think a lot of the times when that happens, I can I can tell you one thing there is always an airway component involved. It may not be the only component, but there will be an airway component. So I focus on the airway component and I work with either the neurologist or the pediatrician to look at the other aspect of the neurological aspects of it. I won't say that airway is purely the only thing, but it is something in that whole circle. Yes, so you will find things like REM sleep disorders or, you know, even in kids, sometimes we overlook things like night terrors. You know the child will be sleeping in the room, waking up at 2 am and then the next thing you know they're with their parents. So all these things are things that we look into.

Speaker 1: 51:04

All right. Last question how to screen pediatric airway issues as a dentist suggested by ENT doctor, and what are the steps to be taken by the dentist and ENT doctor to screen such kids and what treatment are suggested?

Speaker 2: 51:18

last question it's an Australian meeting yes let's leave it at that and and read, breathe, sleep and thrive 100% get Shireen's book.

Speaker 1: 51:30

This has been such a wonderful night, guys. Thank you so much for taking time out of your days to come hang out with Aerie Circle a little bit and share the meeting. Go ahead.

Speaker 2: 51:40

I might just answer that question about the online component. No, this meeting is not being recorded. Really, the value is in coming along, learning from other professionals, hearing it, discussing it with people. The term inspiration by integration it really was coined by Stanley when we did the first meeting last time. It just brought so much energy and I've discussed it with Stanley. We should try and do this in other countries, maybe in the US, maybe in Asia, but it's not happening in Australia for at least another few years. So if you are in Australia, you should really be looking to join this one.

Speaker 1: 52:13

That's going to be wonderful. Thank really be looking to join this one. That's going to be wonderful. Thank you everybody. Please share this with everybody. We hope to see you guys in Australia. If you have any other questions, just reach out to us.

Speaker 2: 52:23

Thank you Everybody have a wonderful weekend. Bye See you soon.