Dentistry Uncensored with Howard Farran

How to perform dentistry faster, easier, higher in quality and lower in cost. Subscribe to the podcast: https://podcasts.apple.com/us/podcast/dentistry-uncensored-with-howard-farran/id916907356

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Howard: It’s just an honor to be podcast interviewing Dr Madan Kandula he is a board-certified head neck Oh toll area laronologist and the founder and president and visionary of Advent the largest independent auteur oh my gosh help me say that word one time a little laryngologist okay I'm Larry ecology I'm so glad I'm a dentist just so I don't have to say that word every day the rest of my life his practices in Wisconsin he's skilled at all aspects of the iconoclastic practice of medicine strong business development professional with a track record of innovation and passion his board-certified American Board of Otolaryngology residency University of Oklahoma head neck surgery it just goes on and on but he was my gosh he was the first surgeon to perform balloon sinuplasty in Wisconsin Madonn leads especially as a pioneering and visionary otay tellurian ologist board-certified in specialty is known as Wisconsin's thought leader for breathing and snoring sleep apnea solutions patients traveled from throughout the state region and the world to seek his expertise he routinely treats patients who have had previous unsuccessful surgeries and is often able to deliver better results with less invasive procedures because of his track record of innovation medical device companies often consult with Dr Madan Kandula on new product development additionally dr. GU laws as substernal surgical skill set allows him to be an expert trainer for other surgeons in advanced tech needs whether innovating new treatments are redefining independent medical practice for the 21st century he has a philosophy of doing better today what was done yesterday he is personal life he and his wife dr. Gwen  Kandula audiologists see that's a much easier she should have been you should have been both audiologist they founded Advent in 2004 to establish a new benchmark in quality for independent medical practices with the goal of implementing state-of-the-art care and unbiased patient focused care they have grown Advent into southeastern Wisconsin's largest independent ENT practice dr. Ken doula is no stranger to sinus issues himself read about his personal sinus surgeries I mean he can talk about that later his residency was University of Oklahoma his MD was Drexel University Philadelphia Pennsylvania is bas and Duke University he's a licensed physician in Wisconsin I have to be honest with you when I got out of dental school in 1987 no one had even I'd never even heard the word sleep apnea and then it seems like I was out of school like all of a sudden like 10 years later it just it was this big Cambrian explosion of thought and and then it hit dentistry so what what made this from when I graduated 87 what what happened when did this really become everyone's on everyone's mind yeah 

Dr Madan Kandula: literally in the 80s like literally in 80 so so the diagnosis was first sort of kind of sort of started to be understood in the 70s but the 80s is where sleep studies came into play sort of the actual understanding of hey this is an issue I mean the actual medical issues been going on for you know probably the dawn of humanity but you know as far as from a medical standpoint understanding it and being able to diagnose it that's what they it's in the 80s and so you know at the same time when the diagnosis was being made that was also where they kind of backed into the CPAP machine and treating it and trying to figure that out so in the grand scheme of things it's this is still in my mind a very it's it's a newborn from a medical esteem we're still figuring this out we're still still figuring out sort of the science behind it the treatments for it and the mystery it's for and so it is it's literally that new I came out of med school in 98 in my training you know right around at the Millennium or the turn of the this new century and between then and now there's been massive understand when I came at when I came out of med school I mean I think with in dentistry and medicine I think there was some knowledge of sleep apnea but the lay public I don't think had any idea what that was I think now I would venture to say that most people have heard asleep at yeah many people you know know somebody either themselves or other people who are getting treated for it so it's it's  both the understanding has gotten much more in-depth and it's a really common issue well 

Howard: I'm really honored that you came on the show I mean I feel like I got the the smartest guy out there come on I'm serious because like anything new its controversial to be on dental town you know we have my gosh a couple hundred thousand members and the full distribution as some people all the way from if you treat someone from for grinding and brookson and you don't do a full sleep study workup it's malpractice all the way to the other end oh come on dude this is a fad this is this is something coming and going so I was so glad to get an authority on this show to just start you know the bottom line why does this seem like everyone has sleep apnea nowadays and what I want to know and I think you want to know too is it the cause of our baldness if we the beauty of science these days but no it is it's it

Dr Madan Kandula:  is it's very very common you know massively so and massively undertreated so as common as we think it is and as many people who get the diagnosis most people don't most people who haven't aren't getting the diagnosis and part of the issue is that there's a lot of mistreatment misinformation out there and so part of my reason or want to kind of get out and get the word out is that you know the actual core concepts are pretty simple it is the intersection between dentistry and medicine and that space is often I use sports analogies a lot but to me it's this pop up fly ball between the infielder and outfielder and dentistry I think you know it's calling the ball harder than medicine is and that's a good thing I think there's a lot of passion in the dental community and I don't see that same passion in the medical community and you know kudos kudos to dentistry for for pushing the envelope on this and and and you know we'll get into it as we you know kind of talk further but I think there's a it is literally when you think about sleep at being the cause for it wise why does it exist it's literally the fact that you know the the airway is that intersection between medicine and dentistry and you know as everybody who's gotten a third molars pulled out is our jaws are getting smaller our jars are getting smaller as we evolve over time therefore our Airways are getting smaller therefore we've got this issue that's sort of sit in front and center for us and

Howard:  I just want to say that I feel so fortunate to have a lecture around the world and when you leave your tribe born in here Americans see other tribes I I think the Soviet Union did it much better keeping dentistry as a branch of medicine there they become a stomatology and it just makes them work so much better on Ohio had the first dental school and then Baltimore had the first dental university it was like 1815 and I I think it was it was a mistake I I think that and I I think we got to get back on line like I was  in Israel last month and what was interesting there were so many Russians who had moved to Israel over the years that they their three largest dsos were all part of the hospital when talking to the dentist there it was so nice because if you're treating a little girl and you think my gosh does she have something going on you're in a hospital you're a doctor you're treating my mouth you didn't have someone come over and see if this little girl has leukemia or this or that and I I think this hundred and fifty year he'll work dentistry is 5% of the healthcare industry in America is measured by dollars it's been going out on this string I think we need to start varying it back to getting it back together and I also like the  fluidity of it because if you're a dentist in Russia and you lose your eye or you know dentists we all do surgery was 90 percent of the physicians are not doing surgery today and so if a dentist loses his eye hand coordination and she can't do surgery in Russia well so let's go do a residency in dermatology and she's just in another branch where's America they're like what do I do now I I can't be a surgeon and I'm not sure 90% of MDS are surgeons so so um so what so you know I have to say um what do you think today about the current system to evaluate and treat snoring and sleep apnea you always say it's broken why do you say it's broken 

Dr Madan Kandula:  it is broken because the the traditional medical model is a sort of I mean scams a hard word but the traditional medical model is railroading towards one option and blinding your eyes to the issue at hand what I mean by that is as most people have sleep apnea treated by a medical doctor or treated by a non ent so ents our wheelhouse is the throat I mean that's part of what we do if you have obstructive sleep apnea you have a throat issue 100% of the time so therefore in my opinion you should be seeing an ENT you to evaluate and figure out what pathway you need to go down versus if you have sleep apnea and you've got a throat issue and you're seeing a lung doctor for your throat issue it's it's a you know sort of one size fits all approach and that approach doesn't work the other thing you know the nuance here is that you know if you have sleep apnea you've got a throat issue 100% 100% of the time very often like 70 80 90 percent of the time you've also got a nose issue that's coexisting and if you don't treat the nose properly if you don't start it with somebody's airway open and working meaning of the nose then every other treatment option coming after the sleep app your snoring is going to be premised and so again I say it's not rocket science it's just sort of it's sitting there literally right in front of our faces and the challenge is is if somebody goes in again to say you went into your primary care doc and say I'm snoring I've heard about sleep apnea I think I might have it the likelihood for you get getting a successful outcome is really low like less than 30% which is abominable you know if for any other medical treatment if we were sort of left with those odds you would abandon those treatments and seek others and so this is where I feel like you know from a dental community with a variety of treatments it's not just oral appliances but certainly within the dental community oral appliances are a big part of how dentists help us treat folks who have sleep apnea there are other options they're released there are surgical options there are minimally invasive surgical options that will likely be the future of treatment for sleep apnea but they again fall on that in-between zone between you know medicine and dentistry and so we've got to break down that wall that exists between the two communities 

Howard: well the difference between a general practitioner family physician and a specialist is one treats what you have the other thinks you have what he treats and when I was when I got out of school in the eighties people that were storing really hard they would go to their ENT Appy straight from me and they would take a co2 laser and a roto Ruter of the back of their throat what do you what what does that look like now and with 20/20 vision um

Dr Madan Kandula:  you know I'd say you know sort of the their procedures in the back of the throats have existed do exist but you know in isolation I think it's a failed mission and you've seen that meaning that if if for us for instance there are approaches evaluating and understanding why does somebody have this issue the likelihood as far as if somebody has sleep apnea it's a throat issue like I said a hundred percent of the time it's more often than not actually a back of tongue issue it's not a pallet issue most of the time sometimes it is and so if somebody's got a tongue issue trimming it down you know theoretically it can help a little bit to open the airway but if we can pull that tongue out of their airway which is what an oral appliance does that tends to work a lot better so you know I would say you know CPAP machines work really well for the right you pool of candidates oral appliances work really well for the right pool of candidates surgery works really well for the right pool of candidates and there's an overlap there and it's definitely not one size fits all and that the common thread again this is my sort of soapbox I I stand on and I'll yell it from the rooftops is that none of those things can work if somebody's nose doesn't work it just it cannot happen and it shouldn't happen and again part of what we do is there's simple things that we can do nowadays to get somebody's nose working so it generally isn't going to surgery it's doing office based procedures getting somebody's nose working and then you know again it depending on why they have sleep apnea figuring out what the right treatment option is for them 

Howard: do you think that there really is because the country is suffering from an airway crisis I mean do you think it's a crisis in the United States and if so what are some of the ills that you think this is causing I'm trying to separate the hype and the mass media from I would say and I'm not one for hype 

Dr Madan Kandula: I'm really not one I would say this is an area where there is a crisis and the downstream is the deal here is the downstream effects of improper airway a poor airway sleep apnea is the most common issue that that you know that represents that are massive so when you look and there's been many studies that have been done looking at the downstream impacts and it's you know starting at the top of the less heart attacks and strokes nobody wants those depression nobody wants that diabetes nobody wants that erectile dysfunction nobody wants that you know but but behavioral issues you know this is where you know I don't think now let me please come back to the beginning here I don't think every you know the root of all evil lies in the airway but I do think there are a lot of folks walking around a lot of adults and a lot of kids walking around with areas where ways that are compromised that either are ticking time bombs or bombs that are going off and nobody's connecting the dot back to their airway which is a sin in my opinion I mean I think if you're an adult and you and if you're an adult armed with proper information and you do what you want with that information fine and if you choose not to do something fine if you're a kid who's armed with an airway that doesn't work and you know you're you're getting in trouble in school because you've got you've been labeled ADHD when in fact you're just trying to keep moving so you can stay awake that's not okay and that happens all the time and so yeah I think you do have to separate hype versus truth and reality but at the end of the day in my opinion if more people who have you have airway issues are treated the you know that population will be better off period you know and you know I don't know I guess the counter-argument would be you know okay it's overhyped this is there's there's sort of you know whatever you want to call it and I'd say yeah is that part is it possible is it is that in the realm of possibility it's possible I don't how do you say this I will stake my reputation on the fact that the opposite is true that that that it is under treated and and the part of this is is this in-between phase so you have a dental community that's very interested in it and they're trying to push the envelope forward the challenge is is for to really treat this properly it is an interplay between dentistry and medicine and in most communities there there is no communication there and in fact there's the opposite I'd say in most communities the the sort of attitude of medicine toward dentistry is demeaning and flip opposite I'd say you know for me personally like when I'm looking and finding trying to find champions on these issues it's-it's dentist you know the lining ups and trying to do the right thing and I feel bad because there aren't really great options to to to treat patients properly because it's collaborative and if you champion this you oftentimes are sort of you know you're putting yourself out an aisle into some extent from both communities from the dental community and the medical community and you know I think that's a scary place to be if you don't understand that there are other people on those islands that are fighting the same battles

Howard:  um dentists are you know like dental town so to tell you how important this is dental town has uh it has 50 categories you know root canals fillings and crowns it's got a quarter million dentists on this site I wish you would go number 50 is sleep apnea you know starting with ass and they're they're always running into late late today someone says can dentists administer sleep tests I mean so so since you're talking to dentists today how do you dentist fit in this dentist ent relationship can dentists administer sleep tests should they you know and and and should we is the goal to we'll just answer that content to start this whole process it's challenging because 

Dr Madan Kandula: I think part of that depends on sort of you know whatever state you're practicing and what the guidelines are they're part of it too is is is is medical insurance and how that interacts with dentistry which in in the reality is it interacts with interest to very very poorly and so if somebody but most of our patients you know really all of our patients would prefer to use their health insurance when they're getting easy issues treated and and we can do that and though health insurance is a pain in the ass to be dealing with as far as pre authorizations and those sorts of things and the problem is if you're a dentist that wants to champion this you can you know you kind of I think you have to pass is is finding a knee is finding somebody in the medical community that you can collaborate with and that's cool or sort of I can't they don't exist I'm gonna take this on my own and then at the end today then that needs to be from my understanding that really for the most part isn't gonna be going with you through health insurance and then it's a you know cash based endeavor which is okay it's just sort of it's challenging it prevent presents challenges for the patient and for the provider and so I think now back to the question Holmes sleep studies traditionally were done in a sleep lab that were administered by typically pulmonologist the technology is there where home sleep studies are very accurate very effective and that's only gonna get better and better and so the technology is there but there still is there there's nuance there as far as the sleep studies go and you know how do you say this I think to me where I've you dentists and how they can fit in is really I mean you guys are looking at Airways that's all you like every time you look at some of these mouths you're looking at their airway and there's and so I think it's it's once you start knowing what you're looking for it's pretty easy to start saying this looks like it's a problem here and then I think the challenge is I don't have a simple formula to say hey this is what you should do but it would say you know if somebody has either symptoms or anatomy that suggested for sleep suggestive of sleep apnea the right thing to do is to do a sleep study and but not just an isolation that needs to be part of an overall treatment plan of where what are you going to do with that information because you can do a study but if there's not an actual actionable next step then it you're kind of stuck in a blind alley there and I 

Howard: there's nobody in my opinion in the healthcare that could see this more often and more comment than a dentist because you know when to the physician my whole life and taking my four boys to the doctor now my grand five grandchildren to the doctor the the the physical is open up and he thinks the public say aw like okay dude I'm a dentist for 32 years what what did you just do I have no idea what that all thing did whereas our patients are laying down on their back Chenab open our side looking down well should the do you do you have a screen test that you could give to the dentists or or could you make an online seee course for dental town of how to bridge this dentist ent bridge make it more seamless yeah 

Dr Madan Kandula: well I I wish I could wave my wand and make it so because I think the challenge is it comes back to the community that you're in and practicing in there are certainly our screening tests there's there's scoring systems or just simple tests that you know you can give out and yeah I would imagine that you guys probably had all those those tools in your arsenal I think it's it's really the challenge is is trying to find to marry somewhere nice with the medical community that for the most part doesn't care about this issue is ill-equipped to deal with this issue and doesn't want anything to do with it and so in in most communities that's the way it is and so it's rare that you're going to find so it like really if you're gonna find it for if we're gonna find sort of a you know an optimal conduit between dentistry and traditional medicine it's in the ENT community so my community but my community is my community is looking for bright shiny objects not the the big massive issue that's staring as in the face which is sleep apnea and so my community generally falls down on the job with this so if you I mean you pick a city in the country and it's very rare that you're gonna find an ENT who who has awareness understanding and compassion for for patients who deal with these issues and is willing to do something with it and medicine is has changed massively in my career in a bad way medicine used to be very entrepreneurial and very much about individual impact on patients and doing the right thing because it's the right reason to do it medicine has become stay in your box because you know that's how you that that's how we want you so medicine nowadays is big healthcare systems owning doctors and telling doctors what to do and how to do it and the sad truth is it takes two to make that deal happen meaning that healthcare systems want that but then the sheep that our doctors want that too and they want to be they want to live in their little box and stay in that box and so the challenge is is you go to normal normal community and you've got doctors that are used to being told what to do and really what I'm asking the dental community to do is finding somebody who's willing to think outside the box and it's a challenge in this day and age and you know I guess my you know so it's easy to call that out and it's easy to say hey this is a problem that should something that should be done about it what I all that I can do is in my little piece of the world a little part of the world is is trying to do the right thing for our patients and so we absolutely collaborate with dentists here in Milwaukee and really throughout the Midwest at this point which is nice but that's unusual it's not usual to have those resources and and other than trying to grow what we're trying to do which is certainly what I'm trying to do and bridge that divide I don't have a good you know there isn't an easy solution for for somebody who's in a community without a door into the into the medical community 

Howard: oh my gosh it was only August of 2018 last year where the American Academy of Sleep Medicine and the American Medical Association advocated to block dentist from diagnosing obstructive sleep apnea agnya and argue that only licensed physicians you know the one that says open your mouth and are qualified to order and interpret home sleep apnea test I mean what in the world could have made them do that other than money's the answer what's the question right no I got you I mean I mean I mean when you say open up and say aw and you're trying to block the dentist and they're doing root canals on your molars and pulling wisdom teeth and in the back of your throat for decades I mean that was just that was just a key it was just like really your that gross yeah

Dr Madan Kandula: well yes I'd say those are I think it goes deeper and then maybe I don't want to take this in a bad place but I'd say the industry uncensored go buddy yeah would say I think there's you know that what you see on the surface there is just a surface representative representing what exists beneath that which is to me I think there's I think there is I think it's well I think it's more ignorance and I think it's more prejudiced against dentistry in the medical community because because there's no exposure there's no overlap there it's completely walled off if somebody is in in medicine general medicine gets zero exposure to to dentistry and the impact of it and even in ent so what the area of medicine that's gonna be the most habit that most overlap with dentistry and Izzie is ent and we get nothing we get nothing in our training we'll get a little oral surgery a little you know a little bit of that and you know we'll go through the occlusion you know categories and all that sort of stuff which is fine but it's very surface level and it's it's not with collegiality it's sort of with you know dismiss that's not but you know I mean I think it goes really deep and I think this this airway issue in the sea happy issues sort of bring it up to the surface and it just brings out passion more from the dental community I think dentists are passionate dentists who get airway issues and understand the impact are very passionate about it the passion doesn't exist in medicine and in medicine it's really more of a turf battle and you know let's let's make sure we're protecting our territory kind of a thing which is where you see some of those policies policy statements but the last thing we need in Airway sleep apnoea awareness I mean is is fighting over a confined space meaning there are so many people who would benefit from increased awareness increased diagnosing diagnosis an increased treatment that the pie is endless in my career I'll never it's in there's no way this job is gonna be done on my watch and I'm really just getting started as far as trying to try to really get out to the public and make sure we're getting this thing done and so I know that I know that for reality which is why from an organizational standpoint well we need to grow while we are growing but even if we grow as big as we can grow it's still not going to be enough to reach the the the people who suffer with these issues

Howard:  what are you doing you see your website is Advent knows Amy VNT Advent that's the period before Lent it's so it's a so it's Advent know so add and advanced ear nose throat nose that's your website ad nose calm water dentists gonna find when they go to Advent nose calm well I mean 

Dr Madan Kandula: it's really a consumer facing website so it's really it's about our practice and what we do there's a lot of information about airway issues at least this is everybody's biased I'm biased to this is coming from an ENT perspective we do have dentists that we collaborate with and so we're trying to actually amp that up that's one of my little sort of projects that I've been working on for the last couple years is figuring out how we can how we can integrate things more closely with still a work in progress but it's there so I think what you'll see in what you'll find is open arms to folks who are coming from a professional standpoint you know seeking to take care or help their patients out of everybody array issues and then you know really more specifically a beacon out to patients who are suffering from this issues with you know it's a lot of information unfortunately it's a lot of me talking and you'll see a lot of my stuff out there which is fine but you know it's really trying to put information out there tear down barriers and I think there are barriers that exist I mean the biggest barriers that exist in this space is between patients who from these issues and the treatments that exist those barriers need to be torn down a lot of people don't seek out treatment because they don't they've heard it's they've heard of hey my buddy was was went in and he got the you know the old you know stick out your tongue and say ah thing and they slapped a machine on him and he hates the machine and he stopped using machine I don't want that and they're right and so you know meaning that that's the typical approach which is not appropriate and so for us it's sort of calling a spade a spade which is what I just did and I'll do it until it no water needs to be called out and then trying to figure out well how do we you know what's a more rational approach and for us you know may not be the perfect approach but our rational approach starts as our website does starts with the nose takes us through that upper airway and figures out you know how do we treat somebody you know with these issues and do it in a manner that is that meshes with that individual so some people are fine with a CPAP machine and that's great many folks who have a CPAP machine would be just as well served in with an oral appliance but they never hear that option you'll never hear that option in a typical sleep center which is which is a shame and then even more remote but exists is some people would be perfect candidates for throat procedures but throat surgeries for the sleep apnea you're never in here that you know if you're not sitting in right in front of the right person so it's really trying to keep kind of cast our net wide make sure we're getting people in and then trying to do the best by them by you know but by walking down that road one step at a time 

Howard: so your so your company Advent knows it says Advent knows you want to be your best self we understand your inability to breathe freely and sleep well hinders your quality of life which is why we pioneered simple in-office sinus and snoring solutions to help you live the life you were meant to live schedule your appointment stop living in a pharmacy aisle and get back to your life so you can enjoy the big moments and small ones too and you have two locations you're in Milwaukee up the street from Laverne and Shirley right yeah and and you're also an oak creek wisconsin so so you're having a great day after last night after those Green Bay Green Bay delivered last night or yeah great that was a good game that was a good game yeah we've got not just on there you'll see but we've got six locations five in Wisconsin we've actually got a location over in Illinois now and so and that's you know that's sort of part of that mission I was talking about before as far as trying to trying to really push forward and meeting patients where they come from patients you know you said in my bio and it's fine and it's it is what it is but it's people come from all over the place not just to see me but to see our other Docs and just kind of get our treatment protocol which is great on one hand but it's a shame on the other hand because what we are doing should be available everywhere and there should be collaboration between the dental community and the community everywhere and so it's just sort of stating the obvious and putting action behind it that's what we do and and then you know the thing with that and it's rewarding to see patients sort of how do you say that taking you know when you go in to see any medical professional you're kind of going on a level that you're sort of saying yeah you know I've heard of you I was right you know somebody recommended do you meet to you whatever and you're going to see if they can you know they can take care of you and and that's a big charge that they just put on our shoulders and we don't take that lightly and but you know if you're doing things from the right or with the mine site and right mindset for the right reasons it generally works out okay 

Howard: well you you you said something very very interesting in that deal you said if you're living in the the Isle of Walgreens or CVS there's a lot of commercials advertising what I call b2c business to consumer um so what do what is your assessment of the of the American patient and 327 million people when they visit one of their 4,000 Walmart's and they see all these things for sleep what what are they seeing and what what do you think of all those products and commercials on television what you're seeing in the pharmacy aisle and what you're seeing with all the kind of the gimmicks that 

Dr Madan Kandula: you tend to hear about is a giant neon display of how broken things are you know when you walk down that pharmacy aisle either when you go to the C part but especially when you go down that that cold and sinus part you'll see hundreds of things that you know the efficacy for some of those components might be there but the the display on hand there is the pharmaceutical world telling everybody that that we don't know what we're doing here because you wouldn't see that that sort of display if there was a solution or a fix there and for us you know again I am biased don't get me wrong here so my bias from a medical standpoint is I don't want to take a medicine if I don't need to take a medicine and and so and and that's my bias and I think maybe there are folks that want it would rather take a medicine and rather use a band a than getting to the root cause you know how I'm wired now I want to be treated from a medical standpoint is if I need to take a medicine because it's the right thing to do and it's gonna help me find if there's something that can solve the problem I'd rather do that and then the reality is you know back to this the nose part which is kind of what we're talking about with the pharmacy how is it if somebody's got a nose issue they've either got an Anatomy issue or they've got a lining issue it's one of the two things where it's both of those things medications can't treat Anatomy and so you can you can sort of fool yourself and to feel like you're doing something but you know the secret sauce there is if somebody's got an Anatomy issue and a lining issue if you treat the Anatomy issue first you oftentimes don't need to do very much from a medication standpoint and that's a good thing in my opinion and you know again it's it's a biased opinion but it's if it's coming from a place of seeing patient after patient that when given a choice you know I guess I'm not that unusual in my mindset I guess is what I've seen over the over the years is that people tend to to seek solutions when they exist

Howard:  well you know ever since the book came out Origin of Species everybody knows that the the number-one goal of a species is to reproduce have offspring and so and you see that in dentistry I mean there's you know there's ten thousand eight hundred orthodontists mostly treating teenagers and if you cut orthodontist and a half the next half oral surgeons and parried on us to combine donee courts and I say in dentistry you'll do braces mom and dad will spend money on braces for their kids a hundred times before momma to have a nice smile makeover so the pediatric dentists are getting bombarded with this question a lot of them when they have their newborn baby someone is now coming in the hospital to help them learn how to nurse for the first time and they're suggesting oh that the the tongue is tied and then and now there's they're they're getting requests from the consumer that you should have have a laser and do this for and this lingual cut that and and then parents most sleep apnea questions to me in my office are really concerned moms and dads watching you know a four-year-old take a nap on the couch breathing clicking all that how do you so let's talk all things pedo yeah if you were just talking to pediatric dentist talk to them for a while what should they be thinking about

Dr Madan Kandula:  yeah I mean they are the front lines of identifying the issues and there are so many kids out there who suffer from these issues now this is the challenge does every every does every child that's born neither friend ulam clipped no they don't do more need that treatment than are actually getting that treatment in my opinion yeah it's true and so it's sort of there's a truth out there that's somewhere in between the medical community is the opposite is generally sort of you know that one specific thing is generally yeah leave it alone unless it's absolutely causing an issue the challenge is is you know that tongue and I'm kind of going a different direction but the tongue is crucial the tongue in a proper position is crucial for feeding crucial for speech obviously but crucial for the proper development of dentition period and so if your tongue is tied down to the bottom of your mouth it may not be a prominent issue it may be if it's a prominent issue it'll get addressed if it's more of a lower key issue it can create a domino effect that will harm the airway and so that's just one example but you know ideally an ideal world is every child would have their talk assessed to make sure that it is proper and it's sound it's harder it's easier sort of said than done that way but it's okay fine you have that but on down the line and you see the kid the kiddo who's you know 10 or 12 and is in braces is very much more likely to have an airway issue I mean this is where it kinda this got these dominoes that fall down that you're seeing you know somebody's got crooked teeth they very well very well may have started with an airway issue as a young kid that just was never identified and it just goes on and on and on and then you know I think to me there's many sins in the world but I'd say straightening teeth in a set of jaws that is too small is problematic so I think from a dental community a pediatric dental community and I don't know how controversial this is or isn't but I'd say at least from my outside perspective looking in there's a lot of kids that would do very well with expansion early on because you expand that air which is great but from my biased part of the world you expand that airway and then I'm live my bread and butter is on the roof of that airway meeting the nose and you expand that upper palate and all of a sudden you've given somebody who knows it works better and so flip that around for the adults that we treat many of them you know were kids that had airway issues that were not identified that led to an adult who's got an airway issue that's still not identified and then we have to pick up the pieces on the back end so I'd like to squeeze it from both sides you know I think for us in my practice we try to treat you know we will identify and treat as proactively as we can we tend to see mostly adults on the peds side the P side of things I think that is really the the dental community in the pediatric dental community is the right community to take that bull by the horns because that's that treatment is really more you know establishing proper airway and a growing child is really more about expansion of dentition and an upper and lower jaws and and that's not surgical the surgical that's with expanders for my knowledge and so it's there's so much work here that needs to be done that I can go on I'm just fifty but I'd say you know the more people out there doing the right thing the better and some 

Howard: so what would your message be for Dentist I mean should they try to become a Medicare sleep provider there's there's consults out there that can help them sign up for Medicare what what advice would you give them knowing that they're in a broken system where do you where do you what would you dentists where should we go from here yeah I guess and when when are you making the online seee course for dental tile maybe we'll make it happen but

Dr Madan Kandula:  I would say at the very to me the start of this for a dentist is just trying to establish understanding and understanding is educating yourself because maybe you guys get more education and your training than I imagined but I imagine that that's probably lacking like it is in the medical community so really trying to get the understanding you know yourself because you're kind of likely gonna need to seek this out on your own and then based off the understanding figure out do you believe this or not and if you don't but if you if you truly have the information and you say you know I don't really I don't think this is really that big of a problem or issue then don't do anything about it if you understand the issue then I think what you'll find is you're gonna see broken Airways every direction that you turn and then you're going to want to do something about it and this is where I feel like that's where the passion that there I see comes from is that you see people who get the understanding and you get and you guys are looking at in into Airways you know all the time and so once you start knowing what you're looking for you're gonna see it and then I don't have the simple answer I don't have because they don't have the simple like well once you have the awareness once you start seeing this what do you do and I think what you do is this is back to like they might cop out answer of figuring out you know a collaborative arrangement that you can that you can have with you know the medically made community if you can't do that then I would say then then you know if it is getting a credential with Medicare to take these issues on doing what needs to be done to you know make treatment possible so it's not a simple solution and and that by an if it by definition means that in order right now for somebody to take action they kind of have to you know they're going against the stream and the stream is really brisk and so you it's not for the light of heart or the faint of heart but it but I think once you start seeing these issues and understanding them as a human being and I'm a parent of kids and if you're a human being if you're a parent of kids you you will find a way that to to get something done 

Howard: the way you talk though you always kind of talk like the hospital is a dinosaur more to extinction yeah what do you mean by

Dr Madan Kandula:  that it is it the big in big-box healthcare that's what that's our term for it is a big Hospital it's the center of the universe where all that all of Medicine revolves around that is a relic from the 40s and 50s that has died and nobody's told it that has died yet because medicine most of medicine you know when you talk about the healthcare system that's broken and all these sorts of things most of the practice of medicine needs not a hospital a hospital you need rarely in your life you need a hospital when you need it and when you don't need it you stay the hell away from it you know if you for instance you if you need an outpatient surgical procedure that can be done in an ambulatory surgical center do it there do not do it in a hospital if you go to if you want to be sick go to a hospital you know that's where that's where bacteria you know if you want to get the craziest infections you can possibly get you'll get them at or you'll find them at hospital and so the challenges is hospitals are very powerful and they're very entrenched in the sort of medical industrial complex you know hand in hand with with a lot of things but you know hospitals are too big to fail but they need to fail in order for sort of health care to go where it needs to go it needs to be from the ground up it needs to be you know from a patient level up it can't be from the top down and that's just doesn't exist it well we're trying to fight that battle and I think dentistry is actually on the frontlines of that battle identifying an issue that needs to be treated that in the traditional model the traditional model can't treat that patient differential model fail somebody USA back Nia almost all the time and so and and yet the medicine is there the treatments exist if you lose properly disconnect between a system that's top-down birth system versus a system that's sort of more bottom-up which is a bottom-up person every day that week bottom is where the good is you know the good happens you know in your exam chair what happens from a dentist to a patient that's magic that's the best thing in the world you know I think evil exists when it it's sort of goes from the top down and looks at that as as a commodity it's not a commodity 

Howard:  when you talk like that like you said the word of military-industrial complex and you said top down and you said evil and it's just I mean we're both doctors it's so obvious but when you talk like that to people they see those almost like a conspiracy but I I agree completely I think that what Steve Jobs did when he plugged the internet into the phone in 2007 was the end of the 5000-year recorded history where the top religion government military police are converging down on the individual and that was the inflection point that started the inverse of coming right back out and I think this the fact that now humans are carrying a computer in their hand that's stronger than what Neil Armstrong had on the moon has started the inversion and I think 2007 Ford will be humans greatest century as they regain a new equilibrium with the top and so how can how can dentist you know be an advocate for themselves how do they regain their power in this broken system and how can they run a successful business with all these big box healthcare hospitals and the government I'm shoving Medicare and Medicaid down passing all these laws to handcuff us behind her back and the blatant attempt that where they were trying to block dentists from diagnosing obstructive sleep apnea that the dentist that that should have been the last straw for the dentist that that should have been those are fighting words we're no longer gonna be your your mindless lemmings marching off the

Dr Madan Kandula:  yeah I mean I I think understand that I would agree with you I mean I would agree that that knowledge is power and there's nothing more powerful like that the change that's happened in my lifetime we don't understand the impact of that because we're living in the moment but I would agree I mean the the access to information that this right now makes it impossible for top-down to to make any sense it just doesn't there used to be a time in place where you know colleges and universities held all the knowledge and if you wanted to go into a certain you know field and that's only way you literally you have more knowledge in your phone and then you know all the knowledge that's ever existed is sitting there in front of you the individual is is powerful and powerful with if we all use our voice and so I would say you know to that alone dentist that's out there is figuring out a way to use their voice just like you right now you're using your voice you you found a way to use your voice with a megaphone with the podcast and all that other stuff that you do I think the more that that's done the more that that sort of chips away at the bureaucracy is that need to fall down they're not gonna fall down easily and you don't even need to be consciously sort of chipping away at them I think the undermines some of what's out there as far as the broken systems that exist are creating systems that work and that do exist and that are made for humans by humans which is kind of what we're talking about you know really honestly what we're talking about right now are issues that affect many of us that are treatable you know without you know you don't need it this isn't like the Manhattan Project we have very simple effective solutions that exist right now common issues common solutions done on the ground level is where it's at and so you know again back to it's a lot of this sounds sort of jingoistic and and whatever but it's it is as simple as taking responsibility for the profession and professionalism that you have and doing the most you know for that and with that and and that's powerful I mean again I think people forget sometimes how powerful each individual voice is and especially in a profession dentistry a noble profession medicine a noble profession there there needs more voices out there that are championing you know what what needs to happen is what I'd say and

Howard:  that's exactly like the podcast like in 2007 the am when Jobs did that podcast started to explode and then they flattened out because people had this new Facebook app and these new social media apps and now social medias but that's part of the inversion now you see the big part of social movie is private groups private communities like  dental town is a private community you hear all these big people that are saying things that they don't like about the United States United States has been at war all but 20 years since 1776 I mean they're always at war and when you when you start asking about that they take down your communities on Facebook and Google and there so I think podcasts private communities like dental town per your own I'm so excited in fact I just wish I could live a hundred years from 2007 because I think it's gonna be their finest century ever with the inversion I know you're a busy man and you've given me an hour of your life and I'm so grateful but just a summarized real quick between the dentist doing sleep appliances and a CPAP I mean obviously it's a continuum they're both ideal at some level how should a dentist wrap their mind around that continuum 

Dr Madan Kandula: I would say between those two options understanding how and why both of those things work understanding the the role and a place for each of them and then you know and being agnostic which is challenging I know and I think from the dental community I think how you know how you will get knocked is if every patient that walks in your door is only given one option which is an appliance and oral appliance because there are there are many folks that may be better served with a machine now flip that around I'd say the opposite is more true there are more people walking around or using machines at night that would prefer an appliance and never hear about that option so it goes both ways but I would say coming at this space from with your own sort of knowledge base arsenal toolset and prejudice and understanding that you're prejudiced and understanding that there's a limitation when it appliance can do and can't do and flips that around there's a limitation of what a CPAP machine can do and can't do my bias starts with the nose and say I'd say from my bias perspective it's a you know if the number one reason for somebody to fail and an appliance whether it's an oral appliance the dental appliance or a CPAP appliance is because the nose doesn't work and so if there's no option to address that nose issue then you're you're gonna fight an uphill battle if there's an option to to partner with somebody you can get some of these nose working properly it's gonna be more of a downhill battle our sweetest one-two punch that we do here at our practices our practice for somebody else leave Apia is we get some of these nose working with office based procedures and then we'll have them sit down with our dentist and if appropriate you know she'll get them in an oral appliance and magically nose working appliance working it's the success where success rates are massive and you get a well treated patient who's also a happy patient who's also an advocate for a system that works now flip that around and I'd say well if somebody has anatomy and sleep numbers that suggest an appliance it's not going to be as this is the oral appliance is not going to be back a big enough punch then we ought to get that person and we ought to start with the approach that's most likely for success and maybe it's get their nose work and get them a CPAP machine and fall back to an oral appliance if necessary but to me I guess when I feel like I'm doing my best work is when I have all my options sitting in front of me and taking a patient and walking them through those options and figuring out the white right sequence for them where I feel like I'm doing my worst is if I feel like my options are limited and we are to walk somebody down a road that that's not ideal for them I just don't feel good about that and one more technical thing 

Howard: there's also the oral surgeons they're seeing a a spike in orthognathic surgery procedures yep for this so we're talking about from CPAP to appliances how do you view the market increase in oral surgeons surgically doing orthognathic surgery for sleep apnea what does that look like to you I think there's 

Dr Madan Kandula: I think there's a massive I think there's massive room for you say this for movement at space because I think at least my understanding and maybe it's outdated is my understanding is there's sort of the traditional surgeries in that space which tend to be pretty aggressive and pretty brutal but pretty effective so you know we when you bring some of these jaws forward you're gonna open their airway up but it's gonna work but you're also gonna create a pretty big you know it's kind of like it's a big situation that needs to be rectified from from a dentition standpoint my understanding is that there are more minimal procedures that can be done so maybe you're releasing sutures surgically and using an appliance in an adult to create the same effect without creating the same sort of trauma that traditional surgery creates I think there's I think that's a there's so much territory there to be understood and undertaken because I think at least when I talk to patients they're most patients are not interested in a massive surgery unless there's some sort of guarantee that that's going to you know be you know unicorns and rainbows which you can't really guarantee that and so people are looking for solutions and so in the nose and my space we've got we got pretty hardcore surgeries but we've also got very low-key elegant procedures and I think that's true in oral surgery but I don't hear I don't know that the public knows about sort of those in-between options and I don't know at least my sort of limited knowledge suggests that at least just conceptually theoretically I'd say boy that seems like that would work that should work and can work and I think there ought to be more of it I think there ought to be more understanding and more doing of those things but there needs to be more awareness and probably more refinement in those areas as well so

Howard:  final sentence final question is the independent practice of medicine and dentistry dead 

Dr Madan Kandula: no it is not it is not it is it is maybe we're a little bit down not for the count but I think we're down right now and I think you're gonna see back to this sort of empowering the individual I think gonna see a lot of groundswell little pockets of resistance and pockets of folks standing up for what they believe would be the right thing and that doesn't ever go out of style 

Howard: to the individual yes Mon man 2007 it's been 13 years Steve Jobs did an amazing thing and I and I I think he was you could tell by his Orwellian commercials that he I mean he knew exactly what he was on to which was disintermediating the middle man right like I could have never talked to anybody like this unless I would have been a guest on someone's you know the three major networks you know and now it's just the rise of user-generated content and it was just an honor to generate content with you today III if there's any I would I hope someday you might reach out to dental town and ask some questions there's a yeren Wisconsin and Chicago Chicago is ground zero for dentistry that's where the American Dental Association is okay on to eleven Chicago Avenue it's at 22 story marble building and when you drive by it I want you to say Oh Howard and your dues help pay to clean out all the asbestos and Nana make that a ground zero but thank you so much for coming on the show today it was just an honor to hear what you're doing I mean my gosh III got like say I couldn't have thought of a bigger expert to bring on the show on this issue and you said you would come on the show I you just made my day so thank you so much for coming on the show and talking to my homies day we all learned a lot thank you thank you appreciate this was fun and hopefully informative but I appreciate it a lot okay and go to his website Advent knows Advent knows just remember it's that holiday before Christmas Advent advanced EMT knows Advent knows calm thank you so much doc thank you thank you have a good day all right you too.