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The vast majority of Americans with sleep apnea are still undiagnosed. Dr. Avi Weisfogel explores, in depth, the care and support that every sleep dentistry patient needs in order to live happier.
Dr. Glassman's HOWARD SPEAKS podcast
Howard Farran: Hello. We’re in Las Vegas at the 2015 Townie meeting, 13th annual Townie meeting and I thought I had to interview Avi Weisfogel because whenever your last name starts with wise, I’m sure he was named for a very specific reason. Why did your mom and dad name you wise?
Avi Weisfogel: Yeah I think that name was kind of chosen for them on the other silent part, but the Weisfogel part came from a mixture of two names. There’s Weises, there’s Fogels. They put my family together and here we are.
Howard Farran: Well I’m glad you’re here.
Avi Weisfogel: Trying to live up the wise part.
Howard Farran: So you are in…so bottom line, am I’m 52, I got out of school 20 years ago and there was no word of sleep apnea, you never heard anything about it.
Avi Weisfogel: Yeah.
Howard Farran: So let me walk you through my journey. So when I…first it was snoring and the ear, nose and throats were buying these carbon dioxide lasers and they were boring out the back of the throat.
Avi Weisfogel: Absolutely.
Howard Farran: And every dentist had patients that did this back in the 80’s and they all said, my litmus test is, would you do this again and they all said no because it messed up their smell and taste.
Avi Weisfogel: Right
Howard Farran: I saw a patient today that said it’s like eating cardboard from having that done. So the tongue is not just taste, it’s the smell, the sinuses etc.
Avi Weisfogel: Exactly, and the pallet, that’s still part of it. Take away part of the palette and you lose part of the taste.
Howard Farran: Yeah, and that is a huge negative with an upper denture.
Avi Weisfogel: Yeah.
Howard Farran: I would say more people rant and rave about how much they love their upper…
Avi Weisfogel: Those little horse shoe dentures, yeah, those always work well.
Howard Farran: Yeah because they get the roof of their mouth back and that is huge for taste. So taste is a very complex system between tongue, nose, palette etc. So then sleep apnea started coming along and now it’s just rock star status. I mean you can’t throw a cat without finding a blog, a magazine, all over…you know when you go to the grocery store, you know a third of those magazines have something about sleep. Really famous people are talking about it a lot. So how did you get into sleep apnea and tell us your story?
Avi Weisfogel: So I will give you a bit of my story and I will give you a quick background on what you’re saying which is fascinatingly amazing. I mean we are talking sleep, you’re saying you hear it everywhere. So in 1992 there was a study done named by a guy called Young. He studied the entire population. How many people are there that are undiagnosed with sleep apnea? So this was back in 90’s. You said you graduated in the 80’s. I graduated in the 90’s, I also had zero sleep education in dental school, and Young said that 90% of the population that had sleep apnea was undiagnosed. Now there is all this information out there, you can’t see a television show without seeing somebody with a CPAP. People talk about sleep, dentists are talking about sleep and yet Young repeated his study two years ago and numbers were identical. 90% of the population still undiagnosed, and we’ll talk a bit as we go further as to why that is the case. I was a senior in dental school.
Howard Farran: What dental school is that?
Avi Weisfogel: I went to NYU. I was a senior in dental school and I have a friend who is a pulmonologist and she said to me, you’ve got to get involved in sleep apnea. It’s going to be real big. I said okay, I don’t know anything about it, there is nothing about it in school. I don’t have an instructor who knows anything about it, but if you think it is going to be big, I’m graduating, maybe that will be my niche. That will be what I start out with that makes me a little bit different that average Joe dentist. It just happened to be that weekend, Keith Thornton, the inventor of the TAP, everybody has heard of the TAP. Probably the second best selling mandibular advancement device or oral appliance next to the one from Glidewell, which name escapes me. Maybe you know it. It’s the Glidewell one is big, because it’s easy. It’s very easy for any dentist to do, but I took…Silent Night, there we go.
Howard Farran: Silent Night.
Avi Weisfogel: I don’t know were that came from. DiTolla knows his stuff too. We have had some good conversations. That weekend Keith Thornton, the inventor of the TAP, speaking right in New Jersey. How could…how big was that coincidence? I am a guy who believes in all that stuff, where if things are coming together at the right time it makes sense to do it. So I took that course and learnt how to do sleep. Week one, I come out of my general practice residency, I have a sleep patient on my doorstep and figured this was going to be a breeze. I got paid 2500 bucks, had no clue what I was doing but I repeated her sleep study six months later and her sleep apnea was gone so I guess the science part was not that hard. The doing of the appliance not that hard, so I figured this was going to be a great way, but as time went along I kind of slowed down a little bit in my life. The sleep part and I really wanted to do more.
Howard Farran: Okay I want to back you up a little bit for our viewers. These are downloaded on iTunes in every country on earth.
Avi Weisfogel: Beautiful.
Howard Farran: Talk to a dentist that’s sitting out there asking what is sleep apnea? What do I care? Explain to them why this is a disease, why this is a concern?
Avi Weisfogel: Will do. Okay so let’s talk about what sleep apnea is. Sleep apnea is a breathing disorder and it’s not a breathing disorder that occurs while you’re awake. It occurs while you’re sleeping only, hence sleep apnea. So you could have a guy who stops breathing 90 times an hour while he is sleeping, he is breathing no problem when he is awake. So what happens when you stop breathing? Why is that such a big deal and why does it even make a difference to dentists? Why are we involved in this process at all? We will get to that, but we are talking about, talking to people, talking to patients. I love talking to patients like they know nothing even if they know more about sleep apnea than I did, I would talk to them in English. You know I remember I was in dental school and we were each assigned a partner and we were supposed to do charting for the partner, and then you sit down and explain it to the patient and my partner says to her patient, she goes yeah, you need a mandibular amalgam on 15, and she’s looking at her like what? I said let’s talk English. Let’s break it down. So what happens during sleep? It’s an obstruction of your breathing. What happens when your breathing gets obstructed? Think of what happens when you run straight up a hill. You’re at the top of the hill, what happens? If you run straight up a hill, what are you feeling when you get up there?
Howard Farran: Weak, tired, exhausted.
Avi Weisfogel: Tough to catch your breath, heart pumping real fast. So your body has to compensate for the fact that you have just exhausted yourself. Your heart is beating real fast to get oxygen to the rest of your body. When you have sleep apnea, every time you stop breathing, your heart now has to make up for the fact that your body was lacking oxygen, starts beating faster. We don’t want our heart beating too fast, hence the number one correlator with obstructive sleep apnea and any kind of mortality is cardiovascular disease. The heart starts beating real fast. It accommodates for the lack of breath and it causes issues in the cardiovascular system. Now if my partner Barry was here he would talk for an hour about it, but I keep it simple and easy.
Howard Farran: And yeah so… so how do you…for a dentist who is, let’s talk to these dentists out there who have never done anything, tell them what is possible. So you’re saying that you will start with…how would you start a sleep apnea program?
Avi Weisfogel: Anybody who wants to start sleep, should take a level one course. Anyone who wants to do it.
Howard Farran: Names, courses, websites?
Avi Weisfogel: I’m going to be partials to my guy, Barry Glassman is the man when it comes to level one and sleep. You’ve interviewed him before, he’s speaking here, he’s spoken here before and he’s written articles for Dentaltown. In my opinion…
Howard Farran: He is probably the number one guru.
Avi Weisfogel: He is the guy to go to. He knows more about sleep than sleep doctors. He is amazing and Ken Smith who is also one of our partners, fantastic as well. John Tucker who lectures with Schein is fantastic.
Howard Farran: So how do they find the information about…?
Avi Weisfogel: So the easiest place to go, Dentaltown, online course. You’ve got level one that Barry recorded a couple of years ago. You got level two he just recorded this week. Fantastic online courses to get you going, but in the end Barry is going to tell you until you come to one of my courses you haven’t really leaned sleep. Learn it the right way so that way when you’re out there, you know how it is in almost any part of life, if you can talk about something and it flows off of you, you’re the master of that thing. If you don’t master your field and you sound a little funny, patients aren’t buying that you’re the guy who can do this. Doctors aren’t buying that you’re the one that they’re going to refer to. You’ve got to really know your stuff and I’ve must have heard Barry’s level one lecture 25 times already. Fantastic each time. It’s like something new each time. So really good stuff.
Howard Farran: Yeah Einstein said if you can’t explain it to a sixth grader you don’t know your subject.
Avi Weisfogel: Yeah exactly.
Howard Farran: So the first thing that dentists are thinking is probably, am I going to have to buy a $5000 laser or $100 000 3D X-ray or $150 000 CAD CAM? What does he have to buy?
Avi Weisfogel: You’ve got to know how take impression and how to take bite registrations, and that’s really it.
Howard Farran: So you don’t, so you’re saying you can do this without buying a take home sleep…?
Avi Weisfogel: Buy nothing and you can do this and everybody should be doing this. If just us dentists…if every dentist screens their patients for sleep apnea we could change the entire world of sleep. We are going to go into the difficulties that we may run into as we talk a little further here, but if every dentist screens their patient for sleep, we can make a dent in that 90%.
Howard Farran: And Americans see a dentist twice a year for every time they see a physician.
Avi Weisfogel: Twice a year, absolutely. I mean you go to the physician maybe if you have cold, and the last thing they’re going to ask you about is sleep.
Howard Farran: So how do you screen a patient for sleep apnea?
Avi Weisfogel: So there’s a couple of different ways of doing it. If we are screening right out of the dental office, best way of doing it, what’s called the adjusted neck circumference. Yeah, exactly, mine is good. Howard may have an issue. Mine is good. Any male size over 17 neck and any female over size 15 neck that correlates with snoring, you’re probably going to end up being a candidate for a sleep test. It does not mean that you’re going to test positive for sure, no, but you’re at least a candidate for it. And let’s talk by the way about snoring. It’s an issue. People don’t want their spouses to snore so that’s an issue in itself.
Howard Farran: What is the correlation between sleep apnea and snoring because more Americans, in all honesty, more American probably can’t stand their spouse snoring than worrying that they themselves have sleep apnea?
Avi Weisfogel: Right. That is probably half of my patients are sent because their spouses send them in.
Howard Farran: For snoring?
Avi Weisfogel: For snoring and or to check for sleep apnea.
Howard Farran: And what percent of load snorers probably have sleep apnea?
Avi Weisfogel: So I wouldn’t give you an answer on that per se, but I’ll tell you 100% of sleep apnics have snoring. Every single person with sleep apnea snores. Not every snorer has sleep apnea but let’s say anywhere between 30 to 50% of snorers, loud snorers have sleep apnea.
Howard Farran: I will tell you what, seriously. I’ve done a lot of missionary dental trips and I mean sometimes you’re in a room with eight dentists sleeping and you’re just like oh my God, snoring and kicking and jerking.
Avi Weisfogel: You ever hear those guys doing this (snort sound). That’s the signal to your brain that says hey buddy, we’re not sleeping. Get up. Get up, you’ve got to start breathing. So that is what it does.
Howard Farran: Do you write something on the chart or does the hygienist ask on recall or what specifically are you doing to screen for sleep apnea?
Avi Weisfogel: I’ll tell you my practice is different in that I am a sleep guy that is what I do. So patients…
Howard Farran: What percent of your practice is sleep?
Avi Weisfogel: 100%. I don’t really even do any of the dentistry anymore. I have dentists who work for me up and down the state of Jersey. All the way from Atlantic City all the way up to North Jersey which is right by the George Washington Bridge. Seven dentists working for me.
Howard Farran: So is Governor Chris Christie your patient?
Avi Weisfogel: I wish he was. I could help the guy but…he’s got to wear a CPAP I assume because he’s a big man.
Howard Farran: He’s morbidly obese and just had a gastro…
Avi Weisfogel: He did.
Howard Farran: So this is pure speculation, would a guy like that be a high candidate to have…?
Avi Weisfogel: High candidate to be a sleep apnea guy, high candidate to be a severe sleep apnea guy. So one of the things that I think keeps us valid as dentists always is knowing our limitations also, knowing what we can do and can’t do. Every mild to moderate patient that comes out…what makes a patient mild? They stop breathing five times an hour. Now to count as a stoppage of breath, it’s got to be at least 10 seconds. So a little bit of sleep 101 for you. If you stop breathing or have for 10 seconds or more, that’s called an apnea. If you have a disturbance of breath for 10 seconds or more it is a hypopnea. You add up the two and you divide them by them the amount of hours slept. So let’s say you have a hundred apneas and hypopneas and you have slept for 10 hours your apnea, hypopnea index or AHI would be ten. That would put you right in the mild range. 5-15 is mild, 15-30 is moderate, 30 and above is severe. As dentists, front line treatment, keeping things real, we treat mild to moderate first with an oral appliance and severe first with a CPAP. My programs are really strict. Six months into it we retest everyone and if they’re not being treated successfully according to AASM guidelines which are- they are what they are, they are not perfect but we got to go by something. So we consider the AASM to be the standard out there. If they are not successfully treated according to the guidelines, we try something else with them.
Howard Farran: And who is that organization, what is their website URL?
Avi Weisfogel: It’s AASM.org. American Academy of Sleep Medicine and then the dental part of American Academy of Dental Sleep Medicine and it’s dot org for those who are looking for it.
Howard Farran: Okay.
Avi Weisfogel: They are the go to place for sleep.
Howard Farran: Now are you mostly prescribing oral retainers or do you also get in to CPAP?
Avi Weisfogel: I’ve been involved with CPAP. For the average Joe dentist it is a huge headache.
Howard Farran: Explain to our viewers what a CPAP is.
Avi Weisfogel: Okay so let’s talk treatment for sleep apnea. That guy is not breathing, how are we going to get him to sleep? How are we going to get him to breathe while he is sleeping? Two ways, one is the CPAP, everybody’s seen a CPAP on television. It’s the mask that goes over your face, forces your airway open, kind of like if somebody was giving you CPR, we are forcing the airway to stay open by blowing air in. That is what a CPAP machine is. It’s yay big, they used to be like computers per se. So now you have a little machine that blows air into a mask, the mask is fit over your face and it goes out at a certain pressure. The pressure is determined either through a sleep study in a sleep lab or through an automatic CPAP which can read your breathing patterns while you are sleeping. The CPAP itself will force your airway to stay open via pressure. That’s one way of doing it. The average compliancy rate in a country, United States 43%. Meaning 43 percent of the patients who get CPAP wear it successfully. So there’s a whole load of patients out there, probably in the millions that were given CPAP and remain untreated to date because they were never given the option of oral appliance. Oral appliances is what we do, that’s the dental part. That is the part dentists can get excited about. A, it’s so rewarding to treat a patient with sleep. You’re talking about a life changing procedure. You’re also taking about, which is not disputed by far the biggest profit procedure there is in dentistry. So in New Jersey the average reimbursement rate this year was around $4900 hard costs are about $400-$500. Most of the work is done by your dental assistant. So it’s a pretty neat profitable procedure.
Howard Farran: I would argue that the most profitable procedure though is billing insurance for procedures that weren’t done. There’s just no time or money involved.
Avi Weisfogel: Yeah seriously.
Howard Farran: That was a joke.
Avi Weisfogel: Take it and run.
Howard Farran: So tell them what CPAP stands for?
Avi Weisfogel: It is continuous positive airway pressure.
Howard Farran: And the oral appliance is more by keeping the jaw open and advanced, you’re just trying to open up the back?
Avi Weisfogel: So typically the oral appliances are called MAD – mandibular advancement devices. Have you tried to snore with your jaw out here? It’s tough right, so the further your jaw is forward, the more open your airway is so think of the first thing you do when you give CPR?
Howard Farran: So 100 dentists out there instantly just thought what is this going to do to the TMJ? Are they going to be sore in the morning?
Avi Weisfogel: Usually not, no. I can tell you back in the day when I first started doing them I would develop…I had a handful of patients who developed TMJ issues. If patients follow instructions now, it’s not a big deal. They really don’t develop TMJ issues. You can develop a bite change for sure, and sure a bite change could then affect TMJ, but really these are patients who we’re treating for a medical condition so what are our choices here because I’ve had patients who had this exact problem. They can’t wear a CPAP because they hate it. They stop breathing 50 times and hour.
Howard Farran: So only 43% comply with CPAP?
Avi Weisfogel: Correct.
Howard Farran: And what percentage complies with a MAD?
Avi Weisfogel: So 85-90% comply, now if I could surely pick my cases I could tell you maybe we’d have 85-90% success rates, but the truth of the matter is probably somewhere between 60-75%. So here is the difference between CPAP and oral appliances.
Howard Farran: So basically one in four just don’t wear it?
Avi Weisfogel: Not that they don’t wear it. They may not be successful. Almost everyone can wear an appliance, the compliancy is not the issue. The issue is can we treat them well? Can we get these patients to a level that is considered a success? Now I ask you this question, if you didn’t know anything about sleep apnea, and you had two choices. Choice number one, try to force them to wear a CPAP, they hate it, they’re not going to like it. They’re not wearing it, or you give them an oral appliance and the times that they stop breathing goes from 50 times an hour to 15, would you consider that to be a success?
Howard Farran: I would.
Avi Weisfogel: Yeah, so that’s were the standards don’t always go perfect because that patient still technically has moderate sleep apnea, but we have just helped them where at least those 35 times an hour they’re doing better.
Howard Farran: I want to talk about something that’s taboo. You know they say when a marriage fails, it’s one third about sex, one third about money, one third about substance abuse. There’s just a lot of men and women who don’t want to crawl in bed with their lover with a Star Wars mask on their face, just like I don’t want to go to bed with boots on my feet.
Avi Weisfogel: Yeah I hear. So I think by the way you mentioned substance abuse, one of the biggest growing places that we go to for sleep apnea is pain management offices because people who are on narcotics tend to be sleep apnics. Something about the narcotics and the way you take them hinders the breathing.
Howard Farran: Because it suppresses your respiratory? That’s how you die from a narcotic overdose, you suppress your airway.
Avi Weisfogel: Correct so we’re treating patients who are on pain management the docs who get it, one of my partners is actually a pain management physician and he is big into saying, hey guys if we’re not treating their sleep we’re not giving them pain medication.
Howard Farran: So tell us more about…you are walking around Vegas right now, if you are walking down the strip, give us takeaways on who do you think is sleep apnics? I mean are they more…like TMJ, a lot of the TMJ experts say it’s 80% women. So is sleep apnea more women or men, is it more older or younger, is it more obese? If you are really obese…?
Avi Weisfogel: Obesity is a given.
Howard Farran: Obesity is a given?
Avi Weisfogel: Obesity is a given.
Howard Farran: And explain why that is.
Avi Weisfogel: Thick necks, narrow airways. You know if you open someone… you know the Mallampati classes, when you look in their mouth if you’re judging them pre surgery and you have them open and they have a thick tongue, thick tonsils. You can’t even see their uvula in the back. Those patients are likely to have obstructive breathing. So think about what happens when you’re sleeping. You’re looking up at the sky, your mouth drops the tongue and the tissues being that they’re attached to your jaw, drop back with it. Now how big is your airway? That big? You know you see the little tubes that go back there, they’re not particularly big. The tongue and the tissue slides right over the airway. If a patient goes ah, and you can’t see back there, that is a patient with sleep apnea.
Howard Farran: Now how crazy is it when you look back there and their tonsils and adenoids are so big. Have you ever recommended a tonsil and adenoid removal for this?
Avi Weisfogel: Sure, definitely have but not as treatment for their sleep apnea.
Howard Farran: Explain that more.
Avi Weisfogel: So there’s dangers in surgery and that’s why usually will try something else first. Now if someone’s tonsils or adenoids need to come out that is something we recommend, but we are going to recommend it usually in compliance with a CPAP. Surgical procedures done…the most popular one, you were talking about it before, it’s called the UPPP, it’s the uvulopalatopharyngoplasty, you’re cutting it out. Now all of a sudden that patient will be a perfect candidate if you looked in surgically. But what we found is at best it’ 50-60% successful and those 40-50% that are not successful, we now can’t treat them with a CPAP properly. It doesn’t seem to work as well. I am not sure why yet. The oral appliance certainly doesn’t seem to work as well post surgery. So we try everything before our surgery just to see if those will work first, conservative first and surgical last.
Howard Farran: Okay what about boy, girl, young old and ethnicity?
Avi Weisfogel: Women, older, heavier. So older women, you see it for sure. We do run across problems as dentists with edentulous patients. Out of our lab in Allenton we make, what I think is the only appliance that is out there that goes over many implants. For many implants on the upper, two on the lower and you can make an oral appliance for a patient. So it is great thing for a patient who hates CPAP, if you’re placing implants, fantastic way to use an oral appliance with it.
Howard Farran: Okay describe to this person who’s never seen what an oral appliance would look like. Is it something on the upper, the lowers, upper and lower?
Avi Weisfogel: Yes, it’s both. Think about what we’re doing here. We are bringing the lower jaw forward. We are going to use the maxilla, the upper jaw as the anchor. So think of two night guards. One is going over the top, usually custom made and one going over the bottom and they hook together. The top usually has a little connector with it that will allow the jaw to come forward. There is a hook typically that is attaching the top part to the lower part and we are going to bring that lower jaw forward. That is the most common form of mandibular advancement device where you use a hook to bring the lower jaw forward. There’s other ways where it can be done from the back, those are called dorsal appliances.
Howard Farran: So for three dimensional geometry, what is opening up the airway more? Opening up your mandible or moving the mandible forward?
Avi Weisfogel: The vertical component can take place if we’ve tried to bring them forward as we can and we can’t get them done. Then we’ll play around with vertical. Typically it’s just jaw advancement.
Howard Farran: So the mandible advancing is going to open up the back for the breathing?
Avi Weisfogel: It is.
Howard Farran: Not just opening your mouth?
Avi Weisfogel: You’re trying to avoid obstruction, specifically upper airway obstructions, we’re trying to avoid them. You pull the tongue and the tissues away from the back of the throat, you’re opening up the obstructions.
Howard Farran: So let’s go more holistic. Could a person with sleep apnea fix themselves wit out a CPAP or an oral appliance if they lost weight? I have read things that it’s people having three or four beers before they go to bed. Go through the unhealthy lifestyle that adds to this. How can you reverse sleep apnea?
Avi Weisfogel: If you want to hear a great course on this, Ken Smith gives a great course on what he calls sleep hygiene. You know the patient has got to take a role in this process as well. We don’t want patients drinking much before bed. The best way…
Howard Farran: Why is that, what’s the difference between alcohol and ice tea before bed?
Avi Weisfogel: Same difference along the lines of respiratory effects, you know slowing down the breathing so typically we’re talking about patients who are overweight can lose weight and may have their apnea go away. It has happened before. It is not a definite, but if you came in and you were 5”10, 180 pound athlete that looked fantastic and you had a sleep test and you were positive, you’re pretty much going to have to use one of the treatments, oral appliance or CPAP. Typically those appliances by the way are worn for life. This isn’t really a curing thing. There are a few interesting devices out there which, such as the DNA appliance or Perfect Start which is a new one that comes out, which is looking to expand the palette and bring the jaws forward in a different kind of manner. Have you heard of those at all? The pneumopedic devices per se?
Howard Farran: I have not.
Avi Weisfogel: Yeah it’s pretty interesting. There’s a couple of docs out there who use them exclusively. They think that they’re going to treat towards a cure. They’ve talked about taking patients who are really severe apnics and bringing their sleep apnea levels down to normal.
Howard Farran: And other low hanging…sleep hygiene?
Avi Weisfogel: It’s really about weight. It’s about getting the proper amount of sleep. It’s about exercise, it’s about everything that you think would be good in terms of living a good lifestyle that’s going to help your sleep process. All the not fun stuff, all that stuff.
Howard Farran: Is there any association with GIRD and sleep apnea? I mean we hear in GIRD that it takes four hours to empty the stomach and a lot of Americans skip breakfast, eat a huge dinner that makes them sleepy and they go to bed. Does a full stomach do you think make you snore or GIRD?
Avi Weisfogel: There definitely is something between GIRD and sleep apnea but it’s not known yet what that big something is. Bit if I was to go into a gastro office, 10-15% of the population would test positive for sleep as opposed to 4-10% of the regular population.
Howard Farran: Okay repeat that again.
Avi Weisfogel: Okay so this is kind of the fun stuff when you think about it and we’ll talk about how we even got into this part of it. I’ll take you through the little steps that happen that even led me to these findings. So here I am, this guy who wants to treat sleep patients. I’ve got at most eight patients a month, most I ever saw doing every Barry Glassman told me to do. This is the king, who knows more about sleep than Barry? He’s telling me this is what you’ve got to do, you’ve got to wine and dine the sleep docs. You’ve got to go to sleep labs. You’ve got to get your name out there. Join the hospitals, get on the board of the sleep labs and your relationships are going to become such that you become the guy. They guy that they go to. Now imagine I told you this. Howard, you know what, I’m a periodontist. You’re a regular general dentist, I’m not by the way. I’m giving a little hypothetical- and we all know that I’m going to do a better job on cleaning so how about you send all your cleanings to me? What would you say?
Howard Farran: No.
Avi Weisfogel: Yeah, take a hike right? Yeah I’m going to lose every single one of my patients on hygiene to you, where your hygienist is going to clean them as opposed to mine. A sleep doc, if they send you a patient, that patient is no longer their patient. That patient is being treated by a dentist. How many patients are you going to send to a dentist when you’re losing that patient? If you have 5000 patients and you send half of them to the dentist, you’d have 2500 patients left. It doesn’t make sense for the sleep docs, hence they’re biased towards CPAP. A CPAP patient is managed by a sleep doc, an oral appliance patient is managed by a dentist. Problem right? Why? Because we as dentists can’t diagnose sleep apnea in the country. So how are we supposed to get patients, we’re all relying on that sleep doc to send me patients and he doesn’t want to send them to me because he loses that patient, that’s his patient. So who does he send me? You know that list of about 50 horrible patients that you have in your office that you want to get rid of? There you go. You can have all these 50, I’m going to keep the other good ones for myself. Crazy stuff out there. But that’s the typical of what goes on in this country in terms of sleep is that the sleep doctor runs the process, we as dentists are left fighting for this tiny piece of the pie. 90% of the patients diagnosed with sleep apnea are give CPAP as first line therapy. 10% of the patients are being referred for oral appliances. Every year there’s more and more sleep dentists and yet, we’re all fighting over this tiny little piece of the pie. I started thinking about this process because I put so much time into it, and I said you know what, if I got eight crowns a month and I had to rely on somebody else for those eight crowns I would quit. I’d be done, I’m not doing that. There’s got to be a different way for me to get patients than going through the sleep doc. So I asked my sleep doc, what do I need to do to get more patients from you? She said you want more patients? Get me more patients. I had a little in. My dad is a cardiologist. I said how many are you getting from my dad? The answer was the typical, one to two per month. I said I’m going to fix that. My dad and I started looking into sleep. I told my dad I think that there’s something going on here because every patient I’m seeing has cardiovascular disease. We’ve got to look into cardiology and sleep a little bit more. My dad got so into it, he’s now a cardiologist who became the first cardiologist to be board certified in sleep in the country.
Howard Farran: And I saw him lecture in Vegas a week ago? Two weeks ago? He’s an amazing man.
Avi Weisfogel: Incredible right?
Howard Farran: Do you think you could ever get him to do a podcast with me or an online CE course?
Avi Weisfogel: 100%. He definitely would.
Howard Farran: I would really love that.
Avi Weisfogel: Yeah he would love it too.
Howard Farran: So what does your dad think is the connection between sleep apnea and cardiovascular disease?
Avi Weisfogel: Put it this way, you ask him now, if you’re a cardiologist and you don’t treat sleep, are you treating cardiovascular disease? He’ll say you’re missing the boat. What came first, chicken or the egg? Cardiovascular disease or sleep? Nine times out of ten it’s the sleep disorder that caused the cardiovascular disease and not vice versa. Amazing stuff? Remember we talked about it. That heart’s beating real fast because of the apnea. It causes stroke, it causes cardiovascular disease, congestive heart failure, hypertension you name it. So if you’re a cardiologist and you’re not screening for sleep, you’re not treating sleep. Plain and simple and he’ll argue that until he’s blue in the face and unfortunately docs don’t get it.
Howard Farran: So when he turns blue in the face, he would be hypoxic then?
Avi Weisfogel: Yes, he certainly would be. But we could treat it.
Howard Farran: So, yeah there’s just so many people that I’ve talked to that, I’m talking about dentists on Dentaltown, who are big fans of Barry Glassman that said that the one takeaway point so many dentists have said is you don’t know what a good night’s sleep is if you’ve never had one.
Avi Weisfogel: Oh no doubt.
Howard Farran: And there’s some of the biggest believers in sleep medicine that I know actually are the ones that had the disease and I mean they were tired their whole life, they were tired…a lot of them told me they were tired for a decade and you just think well, it’s just because you’re old or that’s just the way you feel when you’re 40, 50, 60, so talk more about that- age. Do pedo, do kids have sleep apnea?
Avi Weisfogel: We’re getting into that, by the way now. I just mentioned that Perfect Start, it’s the first thing that I know of that is somewhat of a treatment for peds and OSA. I’ve been in sleep for a long time now. I’ve opened up 27 sleep labs in the country, got them all accredited. I could not find one doc in the country who wanted to work on kids. I finally found a couple but it’s really just not that big out there. So it’s tough to find a pediatric sleep doc.
Howard Farran: So talk more about yourself, what do you mean you’ve opened up 27 sleep labs? These are all in New Jersey?
Avi Weisfogel: No. Across the country, so I’ll take you back a bit to when I said let me get my dad into this. My dad and I opened a sleep lab. We tested his whole patient population.
Howard Farran: Now is a sleep lab a place where a person goes and spends the night?
Avi Weisfogel: Correct. 17 different leads.
Howard Farran: I did that after I talked to Barry because I listened to that so I went and got checked out and they said you’re good.
Avi Weisfogel: Fantastic.
Howard Farran: So you opened up 27 places?
Avi Weisfogel: 27 different labs.
Howard Farran: You opened them?
Avi Weisfogel: I opened them, ran them, they were run by my company but they were built specifically for doctors. For cardiologists at the time, maybe there was one that wasn’t a cardiologist, but of the 27, 26 of them were cardiology labs.
Howard Farran: Now I’m in Phoenix Arizona, you did one in Flagstaff, Arizona didn’t you?
Avi Weisfogel: Flagstaff yeah and Henderson, Nevada right here in Vegas. That Flagstaff one was an amazing operation because the docs were not the best business guys so they hired a business guy and they let him run the show and he said this is the protocol, the protocol is we’re going to follow this and patients are going to go in and they’re going to get tested. That’s what’s going to happen. When that happens you have a fantastic result. Did you happen to hear the pain management doctor at my course when you were out there a few weeks ago?
Howard Farran: Which one?
Avi Weisfogel: His name is Dr. Didier Demesmin, big black guy. He’s my partner. He’s a pain management doctor. He gets it. We put in a system in his office, he follows it. Every doctor thinks that they may know better. If they were doing a good job screening sleep, they wouldn’t necessarily need me to come in and show them what to do. So let’s step back to those 27 for a second. Remember number one was my lab with my dad. We tested his whole patient population, this was a guy who was referring one to two patients a month. 81% of his patients tested positive. Incredible number right? We’re talking about 4000 people, 81% of his patient population tested positive for OSA and that’s when the lightbulb went on. Okay I think we just figured something else out here because I just introduced all these patients to the world of sleep that never would have been tested before. If I can constantly do this and constantly introduce patients to the world of sleep, rather than being the guy who the sleep doctor may send that one patient to, the sleep doctors are going to be looking to me for their patients and if they’re looking to me for their patients, you can be pretty sure they’re going to follow my rules which are, mild and moderate patients her treated with an appliance first. Now I don’t have to worry about whether patients are going to a sleep doctor or not. The rules are set up. We have it set so mild and moderates come straight to the dentist and that’s something that we’ve set up now in over 1600 doctor’s offices in the country and that’s more along the lines of home sleep testing which is the new rage. The sleep labs were big back in 2010 and 2011 when reimbursements were $4000 a night. Now for a sleep lab study you get maybe $600, $700 which means you’re making $20, $30 a study. It’s just not worth it.
Howard Farran: So you think the market’s moving to home sleep?
Avi Weisfogel: I don’t think it, it’s a fact at this point. Medicare demands first night be a home sleep test.
Howard Farran: So okay, talk specifics. My motto has always been no dentist should have to ever practice solo again. There’s many types of units, devices, what do you…name brands, websites, price?
Avi Weisfogel: I’m partial to the Watermark device. It’s Sleep Med.com. Their brand is, they bought the company names Watermark, the device is called the ARES. It’s a great unit.
Howard Farran: Spell Ares?
Avi Weisfogel: Ares. Like the God Ares.
Howard Farran: Isn’t there a casino here? Ares?
Avi Weisfogel: The Aria. Close enough.
Howard Farran: Oh that’s not the same. I was close.
Avi Weisfogel: Yeah we got two letters in there, we’re good.
Howard Farran: Tell them this machine, how many electrodes, how much is the cost? What’s the website? How many electrodes?
Avi Weisfogel: Back in the day when they first came out you had to buy the units. They were about $3000, $4000 each and then you were paying per test. Other companies started coming out with an unlimited testing program where you would lease the machine and you get as many tests and disposables as you wanted. It’s really where the marketplace is now, so start at the high end. There’s a company called Itamar which has a unit called the WatchPAT. It’s a fantastic unit. It goes right on your wrist and it has a little finger pulse. I believe it’s $370 a month for unlimited testing which is fantastic. The ARES, the Watermark unit is $300 a month for unlimited testing. If you want to go a little cheaper, maybe it doesn’t look as professional but gives you pretty good stuff, there’s a unit by the brand called ResMed. Their unit is called the ApneaLink Plus and that’s about $160.
Howard Farran: I’ve heard dentists tell me, when they’re talking about different systems, a lot of them focus on not so much the machine, it’s the software of loading the test up and being able to read it and all that kind of stuff. I guess intuitiveness of getting your patient, you walk back in, you drop off this machine, how long does it take you to load it up.
Avi Weisfogel: That stuff’s all great but let’s think about practicality. What’s the number one thing I want? I want the patient to wear this device all night long and I want it to be easy for them. It’s why I love Watermark and why I love WatchPAT. They’re two really easy devices. So typically, when we send a patient home with one of those, I know they’re coming back the next morning with data on it, whereas opposed to some of the other ones that are a little chunkier and maybe not look as professional looking, patient may get frustrated with it. They may bring it back and say I couldn’t sleep with this.
Howard Farran: So to have this Watermark machine would be a $300 a month lease?
Avi Weisfogel: $300 a month.
Howard Farran: And then if a dentist, so my doc’s got one hygienist who sees eight people a day. How would you recommend he would be screening those eight hygienists and theoretically, could he be sending someone home every night after hygiene?
Avi Weisfogel: Probably not. Let’s talk about the population out there. 4-10% of them are positive for sleep apnea.
Howard Farran: 4-10%.
Avi Weisfogel: 4-10%, in any store, in this casino, 4-10% maybe if you’re in McDonald’s it’s higher than that but 4-10%, that’s the regular amount. Now we talked a little bit before when I said if you’re in a gastro office, it’s 10-15% of the population. Go to an internal med doc, 35% of the population has obstructive sleep apnea. Go to a pain management doc, 40% of their office has obstructive sleep apnea. Go to a cardiologist, up to 60, 70, 80% of their patients have obstructive sleep apnea. So a regular dentist doc, let’s say you have 2000 patients and you’ve treated all of them maybe you’ve got 4-10%, maybe of them have sleep apnea and of those, maybe you could treat 40-50% of those. You’re not talking about massive numbers. You’re talking about a small piece of the pie again, but if you’re just a casual observer and you want to treat patients, there’s great easy ways of doing it. I wouldn’t suggest paying $300 a month for something you’re not going to use. You could go to our website which is DSM Elite.com. Our main website, Dental Sleep Masters.com is under construction so it’s not ready yet. But if you went on there, we’d be able to hook up your patient where we send them a device straight to their house and take care of the insurance and everything. It’s a pretty neat process.
Howard Farran: Your company would send the machine to the patient’s house?
Avi Weisfogel: Directly to the patient’s house.
Howard Farran: And then they…
Avi Weisfogel: Give them a return shipping label.
Howard Farran: And then the return shipping label would have the data?
Avi Weisfogel: Yup. They send back the machine with the data in it, we upload it to a computer and then we have it interpreted by a board certified doc in the state. So if you’re from Arizona, you need to doctor from Arizona to read your study. That goes for every state in the country. And the laws are becoming stricter and stricter. So when I first started there weren’t many laws on this stuff. There were laws but not many. As home sleep testing is becoming more and more popular, they’re going to make it more difficult for doctors to get reimbursed. The last thing Medicare wants to do is pay claims and what Medicare does, insurances jump on pretty soon.
Howard Farran: Right. So this doctor screens a patient, again more specifics. How does a dentist, I’m going to go in there Monday and I’ve got eight people on recall. How does this doc go from never getting into this, to diagnosing?
Avi Weisfogel: First of all, take the level one course.
Howard Farran: Or would you say this, is this advice valid: I think if you’re a dentist and you’re making a six figure income, you deserve elite medicine. You should test yourself. So I agree with you, they should log into Dentaltown and watch Barry Glassman but how could that doc listening there get a hold of you and you send the sleep test to him or her and let her find out, because I think the strongest believers are the ones who found out, I’ve had dentists tell me themselves, their spouse, I had one tell me his ADD, bat shit crazy teenage son was, it’s done wonders for him. I mean so how does this dentist, you send him a machine?
Avi Weisfogel: You can either go onto DSM Elite.com or email me email@example.com. If you send an email to Dental Sleep Masters @ Gmail, we’ll send you a packet back that’ll tell you everything you need to do in order to sign up to get home studies shipped to your patients. What’s really neat about the program is that we’re not just shipping units to your patients. We’re having your studies read by doctors who believe in oral appliances, so we’re going to follow the same Avi Weisfogel guidelines which say mild to moderate, you’re going to get a chance to treat. If they’re severe, we’re going to put them on a CPAP and we’ll hook them up with someone in your neighborhood who does what’s called DME, durable medical equipment. Those are the guys who do CPAP. So, but if you send an email to Dental Sleep Masters @ Gmail or go to DSM Elite.com we’ll send you a whole packet. It gives you everything you need, including the screener which is that adjusted neck circumference. There’s a little scoring table that goes with it and it’s real simple. It takes literally 30 seconds for the patient to fill it out, I think it’s five questions and it’s pretty predictable. So patients who screen positive, we’ll send the test to their house, have it read by a board certified sleep doc. If the patient is mild to moderate, you’re going to get a prescription to make an oral appliance for them.
Howard Farran: And what labs are making these prescriptions for you?
Avi Weisfogel: For the oral appliances? There’s tons of them out there. Obviously I’m going to say the best one is the Glassman lab in Allenton, Pennsylvania.
Howard Farran: So Barry Glassman has a lab?
Avi Weisfogel: Barry has a lab and he also inspects every single one before they go out. So you’re getting really the expert in dental sleep medicine looking at your devices before they go out to check them, quality control can’t be better. Every big lab has sleep devices now, Glidewell has them, Microdental has them, Keller has them I mean you name the big lab and they sell sleep appliances now. Space maintainers is a big one.
Howard Farran: So if you’re a Billy Joel fan and really like Allenton, that would be perfect.
Avi Weisfogel: I don’t think he shows up there much anymore but he’s looking a little hefty nowadays. He’s probably got sleep apnea. Yeah I heard his fiancée is pregnant.
Howard Farran: Is that right?
Avi Weisfogel: That’s correct.
Howard Farran: Well you’re from New Jersey so are you a Springsteen fan?
Avi Weisfogel: Jon Bon Jovi. I like Bon Jovi and I may be the only guy in Jersey who can’t stand Springsteen music.
Howard Farran: Really? Are you a Bon Jovi fan? You like Bon Jovi?
Avi Weisfogel: I like Bon Jovi. My dad was actually Mrs. Bongiovi’s doctor. His mom.
Howard Farran: Oh is that right?
Avi Weisfogel: Maybe that’s a HIPAA violation. I don’t think she’s alive anymore. Does that count?
Howard Farran: So to those viewers out there, those dentists, you said 4-10% of the general population would be…what do you predict for the Dentaltown podcast viewers? The Townies? I mean you were at a Townie convention, there was 1000 dentists here.
Avi Weisfogel: I would go a little higher, 8-12%.
Howard Farran: And why would dentists be higher than the general public?
Avi Weisfogel: Typically dentists, our jobs are sitting down. We’re not necessarily that active.
Howard Farran: So we’re more obese?
Avi Weisfogel: Definitely heavier. I don’t know, what do you think? You see them out there, it happens to be the Townie crowd is a little bit younger so that’s a good thing going in our favor but I’ve seen some guys out there who may be a little bigger and maybe likely to have sleep apnea.
Howard Farran: I have a friend who lost his white collar job during the recession and everything and he was so bummed and he ended up having to work construction in Phoenix. Oh my God, he went from 220 pound fat, now he’s like a ripped, shredded good looking…I’m like dude, you’re lucky! Trust me, you’re just lucky! So I’ve only got you for 10 more minutes. What low hanging fruit, because the bottom line is, this is what I believe, my belief is well it’s kind of like podcasts. It’s kind of like apps on your phone, it didn’t exist in 2010 and now it’ 2015 and now everybody has an app on their phone and right now we’re doing a podcast and I swear a year ago, you couldn’t find a dentist who had heard of a podcast and now they’re exploding, so sleep medicine is new. So I’m going to guesstimate that the vast majority of people listening to this, they’ve all heard about sleep, I mean God I was watching something the other night where some journalist was saying that the reason Bill Clinton said that a lot of his worst decisions he ever made including Monica was from exhaustion. Bad decision, up all night, irregular hours.
Avi Weisfogel: Do you buy it?
Howard Farran: I don’t know what it would be like being in the White House. It must be a crazy job, so they’re all hearing about it everywhere. Tell a more big picture from 30 000 feet, why should they get interested in getting into sleep medicine?
Avi Weisfogel: There’s two reasons. Let’s say it’s great, everybody wants to help out their patients. We all do, it’s a fantastic feeling. Let’s talk practicality. A, as I said it’s really profitable. You know some of our docs get reimbursed up to $11 000 per appliance.
Howard Farran: But that’s not from Delta, that’s not from dental insurance.
Avi Weisfogel: No it’s not dental insurance, it’s a medical insurance process.
Howard Farran: So that dentist listening out there, he’s never billed medical insurance once in his life.
Avi Weisfogel: Exactly. Again, check out Dental Sleep Masters.
Howard Farran: So you’re going to bill the medical for the doctor?
Avi Weisfogel: We do it for a really cheap price too. I think it’s the cheapest price that’s probably out there. About 6.99%. Ken Smith also has a great company for billing. He does a great job at it. The whole goal is once you know how to do it, it’s like anything else. I remember the night before I placed my first implant, I was pooping in my pants the night before. I was up all night, I was so nervous. This was a guided surgery, it was the easiest thing I had done. I said what was I staying up all night for? Before you do anything, it’s hard, it’s nerve wracking but once you do it, it’s alright.
Howard Farran: And you know a lot of dentists, they don’t want to join the American Dental Association, they want to save $1000. They don’t want to go to any state meetings or anything and look at the price, maybe if we were stronger in organized dentistry, Medicaid would reimburse for sleep medicine. I think the fastest growing oropharyngeal cancer is from human papillomavirus for young females and we’re not even allowed to give a HPV vaccine, but if I go into the hospital the nurse can. So a registered nurse can give it, but a DDS can’t and then the average American sees a dentist twice for every time they see a physician, yet I can’t give them a flu shot but if I go into Walgreens pharmacy, a pharmacy tech, they’re not even a pharmacist, can give me a flu shot. I’m sitting there like why can a tech give me a flu shot and I’ve got nine years of college and I can’t give one? And then you know, the general public says well you’re a dentist, you’re not a real doctor I always say well you know, Dr. Pepper is not a real doctor but I get asked my colleagues, this is the trade off of when you don’t get involved in organized dentistry. I mean it’s real easy to sit on the sideline and bitch about everything they don’t do right or whatever because we all know you’re perfect, you’re absolutely perfect but not the ADA. But you know if we were stronger, if we were stronger we could be giving flu shots, we could be Medicare, Medicaid could be getting reimbursed and what about Delta Dental? I mean oral cancer is exploding in young girls and they don’t ever cover an oral cancer exam? I mean how do you deal with a dental insurance company that doesn’t even reimburse you for a lethal disease of oral cancer which kills an American every hour, by the way this is April, this is oral cancer month, kills an American every hour and 50 000 a year dead. And we don’t even stand up to a dental insurance company that doesn’t even reimburse for an oral cancer exam?
Avi Weisfogel: It’s crazy stuff but that’s the business. Insurance is a business so the CEO of Blue Cross last year made what, 250 million dollars. It wasn’t because he paid every claim, it was because they deny, deny, deny. And this is not easy, medical billing. It takes time, it takes patience and typically, here’s a typical journey for a doctor who goes into sleep medicine. He goes to the AASM conference. The ADSM which is coming up in Seattle June 4th I think is when it is. Great conference, they learn all this brand new stuff, they’re given this whole bill of goods about how amazing it is. They go home, maybe they see one or two patients, they submit it to medical, they pay their lab bill and they get reimbursed zero and then do nothing with it ever again. That is the typical guy. You know every year they have about 800 people. 800 doctors at the ADSM and I believe 90% of them are new every year. Which means that people are going and they’re fading out. They’re not sticking around in the profession because it’s not easy. Building this stuff up took me years to build it up. It took me years to figure out how to build this up. I can tell you that just like you’re saying hey, we as dentists have got to stand up, we as dentists still can’t diagnose sleep apnea. We can’t diagnose it, we can give out a home sleep test but without a doctor saying this patient needs an oral appliance, I can’t do one. Same difference right?
Howard Farran: That’s right, so but you’re saying, what if a doctor is out there saying dude, I don’t want to learn how to bill medical insurance.
Avi Weisfogel: Don’t do it. That’s my advice. Don’t bill it, but use a place that does.
Howard Farran: And you could do that for them?
Avi Weisfogel: Absolutely. Yeah we bill them out for you. Dental Sleep Masters.
Howard Farran: Okay any by the way, for my podcast what I do is, I always send the transcript to have it transcribed so if you’re driving in your car now, you go onto Dentaltown after his podcast is the complete transcript and I do that because probably almost everybody that feeds back on this says the same thing. They say I live in a town of 3000, my office is 70 miles away in a town of 12 000 so I have a 71 mile drive each way and I love these podcasts. They put them on Bluetooth in their car because you think in an hour long commute it’s like across LA, but for every person driving across LA, there’s 10 in rural America with no traffic. So all these notes, will you also add other information?
Avi Weisfogel: Yeah there’s so much still that we haven’t covered. There’s so much in there that we haven’t covered. I’ll tell you what, I’m going to give you guys the best things that you can do. Email me, Avi Weisfogel @ Gmail, that’s an easy one to remember. You can email Barry, DRBGlass @ Gmail.com. We’re looking to really change the way sleep is done in this country. The average doc sees between two to four sleep patients a month. The highest I ever saw was 372 in one month. It’s an insanely large amount of patients. Over the years, my company has treated over 10 000 patients for sleep apnea which is just a fantastic thing. There’s so much you can do to get involved in this field. I love it and one of the coolest parts about it, let’s say you don’t want to do sleep only and you want to be a general dentist, you and I know 50% of the population does not have dental insurance right? Most of the patients that come to us tend to have dental insurance. So you’ve got one out of every two people without dental insurance, what are they doing for a dentist? Some of them go, most of them don’t. But they all have medical insurance so you now have this patient who comes into your office with no dentist, no attached dentist. You can believe pretty easily the majority of those patients end up becoming my patients as a dentist as well. The last year that I did general dentistry, I only treated patients who came in via sleep. I had no hygiene anymore, it was just doing sleep appliances and doing dentistry off of patients who came in from sleep. I still like doing full mouth rehab cases, they were fun for me. They were challenging, and did almost three million dollars in dentistry that year, just from patients that came in via sleep. They’re all in need of rehabs because their teeth are broken down, they haven’t seen a dentist in 10, 15 years so it’s a great way to not just build up a sleep practice, it’s a great way to build up a general practice with literally no competition.
Howard Farran: And I just want you to close on one thing, what percent of these people with sleep apnea that have got a MAD have their snoring reduced?
Avi Weisfogel: Almost everyone. You wear an oral appliance, your snoring is gone.
Howard Farran: Because I will have to vouch, well first of all I want to vouch for you and Barry as being just great, wonderful guys and everybody I know loves you and you’re just the real deal.
Avi Weisfogel: Our company by the way loves Howard and Dentaltown. You’ve been awesome to us since we started. So thank you.
Howard Farran: But on the street, the dentists that have got into this, they tell me the hottest thing is when all the women on Facebook find out that this dentist cured their husband’s snoring and snoring is a far bigger issue. I read an article in a psychology magazine that said one of the biggest taboos that no one will talk about or admit is that them and their spouse sleep in separate rooms because if you go to work and say oh yeah, my husband and I sleep in separate rooms, they think oh that’s weird.
Avi Weisfogel: They’re having problems.
Howard Farran: You’re having marriage problems and you’re not having sex and all that stuff and that when you’re snoring, it’s a huge stressful deal on a marriage and when one of the spouses are snoring and the word gets out that you’re the dentist that fixed the snoring, I mean I just think, I’ve always said that I think people want their teeth cleaned for mental health more than oral health. People want whiter, brighter sexier teeth, they don’t want to be free from gingivalis and I think more people want to stop snoring than want to lower their risk of sleep apnea.
Avi Weisfogel: It’s a huge deal. There’s nothing wrong with treating snoring. You’re saving a marriage possibly, you’re helping the person for sure. Yeah there’s a thing about this, quick little one. If you stop breathing 90 times for nine seconds each time, you don’t have sleep apnea but if you stop breathing five times for 10 seconds, you do. So it’s a real fine line as what defines you as sleep apnea or not. There’s a whole population of snorers that when you treat them with an oral appliance, they feel better. Even if they don’t have sleep apnea. You’re stopping them from snoring, everybody who wears a device, their snoring is reduced greatly first night. First night.
Howard Farran: Well we are out of time Avi, and you’re parents named you right as wise.
Avi Weisfogel: Thank you Howard.
Howard Farran: Thank you so much for an hour of your time.
Avi Weisfogel: I really appreciated it.
Howard Farran: Deliver your dad, I want to do one with your dad.
Avi Weisfogel: I’m going to bring him in. He would love to do it with you and for those of you listening, make sure you’re at the next Townie meeting. This place is fantastic.
Howard Farran: Thanks buddy. Good to see you buddy.
Avi Weisfogel: Always.