The new idea

I had these thoughts upon returning from Collaboration Cures, a joint meeting of the American Academy of Physiologic Medicine and Dentistry and the American Academy for Oral Systemic Health. Both groups began in the dental community, explicitly founded to promote cross-pollination of ideas within the complex world of airway-related health. I’ll simply say that I found it to be a most . . . refreshing environment. In my view, one of the most exciting developments in the field of Sleep Medicine in the last decade is the emergence of a new discipline within dentistry called Airway-Centered Dentistry. This is more than just a poster on the wall at your dentist’s office, with the possibility of fitting you with a mandibular advancement device to treat Sleep Apnea in-between cleanings. Airway Centered Dentistry is bigger than that. Airway Centered Dentistry understands Sleep Apnea to be more than just floppy tissues in the back of the throat; Sleep Apnea is a vastly complex combination of problems, one which has evolved since it was first described. Which, perhaps requires yet another digression. Cue harp glissando as time travels backward. . . In the 1830s, a young Charles Dickens wrote a newspaper serial that would become his first novel, The Posthumous Papers of the Pickwick Club [1]. See, it was Dickens who famously noted the phenotype that would later become the legend. In the story, there’s a character called Fat Joe, an unfortunate soul who snores while awake and falls asleep on his feet, the intended effect being comedy. Partway into the 20th century, though, the medical world wasn’t laughing. By mid-century, physicians had sniffed the signal that guys like Fat Joe collected medical problems, like heart failure and pulmonary hypertension. They eventually coined a name for the phenotype. They called it Pickwickian Syndrome [2]. In 1966, Henri Gastaut and his team employed a new technique called Polysomnography to study the Pickwickian Syndrome [3]. Gastaut’s team found that all of these obese, sleepy snorers suffered from severe sleep fragmentation caused by breathing interruptions. Sleep Apnea, nice to make your acquaintance! Place your mind into that space, back then, in 1966. These individuals, each a walking, talking version of our fictional friend Fat Joe, now had a possible explanation for their devastating daytime limitations, but there was also a stupidly obvious solution: Help them breathe, and you’ll help them get better! Of course, once the breathing limitations were recognized, the next step was to quantify them. Capture them. Study them. Give them names. See what they do. Henceforth, we see much lively discussion in the scientific literature about how these terms are defined: Central vs Obstructive; Apnea vs Hypopnea; Respiratory Effort-Related Arousals (RERAs) vs Upper Airway Resistance Syndrome (UARS). The debate about the “best” way to define these events continues to this day. The reason I’m blowing so much hot air about the semantics of bean-counting is to call attention to this seemingly small, but actually seismically important, fact: The diagnosis of Sleep Apnea can now be made merely by reaching a specific threshold number of events on a sleep study. The Pickwickian phenotype is no longer needed. I submit: (1) this small truth has rocked the world of Sleep Medicine into an existential crisis, and (2) the party’s only getting started. In the last century, we’ve seen the face of our human race change . . . literally. Our jawbones are smaller than they used to be, our faces narrower. Our nasal airspaces are collapsed, harder to breathe through. Don’t get me wrong. The Pickwickian phenotype has not gone away. Obese, snoring sleepy people are still out there. In fact, these are still the folks who are still most likely to benefit from using positive airway pressure therapy. It’s the most effective therapy we have. It’s just that, these days, Fat Joe is getting outnumbered by another phenotype—Thin Lizzy, perhaps? Slender, exhausted, narrow-faced folks with overdriven sympathetic nervous systems . . . nasally-congested, insomniac, brain-fogged, hypertensive, bruxing migraineurs, who seem to have an instinctive aversion to having anything on their faces. CRANIO®: THE JOURNAL OF CRANIOMANDIBULAR & SLEEP PRACTICE 2023, VOL. 41, NO. 1, 1–3 https://doi.org/10.1080/08869634.2022.2161768