Dr. Ronesh Sinha
Dr. Ronesh Sinha, author of The South Asian Health Solution and free Sleep and Fatigue e-book being used by Silicon Valley companies and readers worldwide, is an internal medicine physician and expert on insulin resistance and corporate wellness. His groundbreaking work in reversing diabetes and insulin resistance in diverse populations has been featured on the front cover of Fortune magazine and the LA times. He is a top rated speaker for companies like Google, Oracle, Cisco and more (read testimonials), and has been a guest on popular podcasts such as Peter Attia’s The Drive and Mark Hyman’s Broken Brain.
Dr. Mark Burhenne
Mark Burhenne, DDS, knows that the mouth is the gateway to health in the rest of the body. He is the author of the #1 best seller, The 8-Hour Sleep Paradox, and is a sleep medicine dentist in Sunnyvale, California. He also hosts the very popular website, askthedentist.com, an excellent resource on sleep, oral health, and overall health. Dr. Burhenne has been practicing dentistry in the greater San Francisco area for over 30 years. He is a TEDx speaker, and his advice regularly appears on media outlets like CNN, CBS, Yahoo! Health, the Huffington Post, Prevention, The Washington Post, and Men’s Health.
He received his degree from the Dugoni School of Dentistry in San Francisco and is a member of the American Academy of Dental Sleep Medicine (AADSM), Academy of General Dentistry (Chicago, IL), American Academy for Oral Systemic Health (AAOSH), and Dental Board of California.
Dr. Burhenne (affectionately dubbed “Dr. B” by patients and friends) is passionate about helping people understand the connection between oral and overall health. He also spends a lot of time educating patients and readers about the importance of healthy sleep.
Dr. Michael Gelb
Dr. Michael Gelb, DDS, MS is a world-renowned TMJ and Sleep Specialist with practices in both New York City and White Plains. He received his D.D.S. degree from Columbia University College of Dental Medicine and his M.S. from SUNY at Buffalo School of Dental Medicine. Dr. Gelb is the co-author of GASP: Airway Health- The Hidden Path to Wellness, and the co-founder of both The Foundation for Airway Health and The American Academy of Physiological Medicine and Dentistry.
The Gelb Center was founded over 30 years ago by Dr. Michael Gelb’s father, Dr. Harold Gelb. Since then, Dr. Michael has taken his father’s findings to the next level through his Airway Centric® integrated therapy. He invented the ACG™ Airway Centric® System with the help of ProSomnus Sleep Technologies. The ACG System is the first day and night dental appliance solution that offers an integrated approach to addressing airway issues. Dr. Michael Gelb is dedicated to improving his patients’ health by reducing pain, restoring refreshing sleep and transforming lives.
S (Ron) Well, it’s great to have you guys here, and I viewed Mark’s work long ago, but Dr. Gelb, I was looking over your work, and you’ve got some great resources too, so I think we can have a really unique discussion. We know sleep issues have been a problem for people for eons, but now I feel like the sleep issues are on steroids. Even for someone like me, who prioritizes sleep quite a bit, I’ve had my own share of sleep troubles through this time. So, I thought for this particular discussion (and I’m definitely not gonna pretend to be a podcast host, I’ve been asked to host podcasts and that’s the last thing I ever wanna do), we would start off and each of us will give a one-line intro about why they’re passionate about sleep, and how they got into this field. Dr. B, I’m gonna put you on the spot and start with you.
Dr. B (Mark) You’ve heard this story before, Ron, and if you’ve read my book, which I think you did, it’s the first chapter. Unbeknownst to me, I had sleep apnea. I was told one day, by my three daughters, that, “Dad, you sound like a freight train at night.” The funny thing was that it was really my wife. She was snoring, I was snoring, she had severe sleep apnea, I had mild sleep apnea. This was in our late s, a world completely not known to us at all. She’s in biotech and was a cardiac care nurse. We had no idea. It really was a personal story. By solving that and going through the system and learning of all its inadequacies, and how difficult it was, even as healthcare providers ourselves, I learned a lot about it.
Dr. B (Mark) That frustration led to my venting to a lot of people. One of them was my daughter and she said, “Dad, let’s write a book and solve this,” and of course, the connection between dentistry and sleep apnea is phenomenal. In one sentence, “Dentists can recognize sleep apnea decades before a physician can.” For me, that was a game-changer, and that’s why I really started treating sleep-apnea. Unfortunately, we cannot diagnose sleep apnea, but we can screen for sleep apnea. Every patient, as time went on got a screening for sleep apnea, even if it was a -year-old. That’s my story. I feel better now. In hindsight, if I had not fixed my sleep apnea I wouldn’t be here today. I’d be a wreck. I mean, and that’s just mild sleep apnea. So, personal experience has brought me to this whole world of sleep and now thank goodness it’s on fire. And dentistry and physicians are better collaborators and that’s important, and I’m sure we’ll talk more about that today.
Dr. S (Ron) Absolutely, thanks so much. Dr. G.
Dr. G (Michael) My first exposure was probably when I was teaching at UMDNJ in Newark. I didn’t really want anything to do with sleep, sleep apnea, or kids. Then when I went to NYU, when I started running the program there, [Dr.] John Parker came in, he’s a big sleep dentist from Minneapolis and [Dr.] Wayne Halstrom from Vancouver. After listening to them the light bulb went on. And I realized that in dentistry, we were perfectly poised. That was in , and then I guess around , I heard Karen Bonuck [Ph.D.] and she started talking about kids, and like what you were saying, Mark, I realized, first of all, that I’m a mouth breather. My mother was a myofunctional therapist, my dad treated TMJ. We were really, serendipitously, we’ve been opening the airway by bringing the jaw down and forward for years. Never realized really, what we were doing and then we had this thing, the cone beam CBCT, we could visualize the airway with imaging and then this home sleep testing came about.
Dr. G (Michael) So there’s a lot of good things that have come into the field of dentistry over the last to years, which have made a world of difference. And then I realized how we could transform lives. It was so much more profound working with sleep than it was even with TMJ, and TMJ was great, don’t get me wrong. Getting rid of headaches, giving people their lives back, getting rid of pain, that’s fantastic right?
Dr. B (Mark) Right.
Dr. G (Michael) But sleep trumps that, sleep is… Sleep’s the top in dentistry. I don’t know if you would agree, but a lot of us say that airway and sleep trumps everything else in dentistry.
Dr. G (Michael) I do agree, yeah.
Dr. G (Michael) Also in dentistry, we are responsible for, and most aware of, especially in our training, one of the major root causes of sleep apnea, that is facial development. I mean, physicians don’t get that training. And it’s been sitting literally under our noses all this time.
Dr. S (Ron) That was a very big revelation for me as I’ve been exposed to your work. So my background, I’m a physician, an MD surrounded here by dentists. I work for a large multi-specialty group and so I had a very regimented approach to addressing sleep and sleep apnea type issues. It’s very protocol-driven. I’ve only got a limited number of specialties I work with. But I found that sometimes the results and the outcomes were pretty sub-optimal in many of my patients. I treat diabetes and I work on preventing heart disease and one of my big approaches is I wanna catch diabetes and heart disease way, way before the glucose goes up. So I talk about catching pre-pre-diabetes and that’s what I love about both of your work is because you are catching this at the earliest stages where we can minimize the amount of invasive procedures we have to go through.
Dr. S (Ron) I also wanna expand upon what you guys have said, because not only are you guys experts in airway and sleep, you guys are both experts in general sleep. ‘Cause it’s not like you’re gonna close your ears when somebody asks you about melatonin, or insomnia, or waking up at in the morning. So for today’s discussion, I think that we all wanna elevate the discussion and enlighten our patients and our listeners about breathing issues, but also you guys have a very unique perspective on general sleep-type issues too. And I wanna jump into that actually right away. So we’re basically recording this during the COVID- pandemic. And I just wanted to talk to you each and ask you, there are probably some unique things that you’re seeing around sleep during this time and then maybe some of the more garden variety issues which are just becoming much more common. So, I’m gonna start with you this time, Dr. G., maybe can you highlight some of the unique types of things that you’re hearing during this time?
Dr. G (Michael) Yeah, so, insomnia seems to be really disturbed, fragmented sleep. The guys today that I was with playing golf, no one is sleeping well. Everyone’s worried. They’re worried about the economy. Personally, I’m not really stressed at all about getting the virus, maybe I should be. But economically, having to bring back my employees, am I gonna have another downturn, is [Governor] Cuomo gonna shut us down again once we reopen? We’re not even officially reopened yet. If you listen to everyone on TV, this could last to months. So people are not sleeping well, so we’re looking for aids and we’re looking for what people can do for insomnia. This is just the whole field of behavioral sleep, not even talking about airway and sleep apnea. The second one, that’s kind of interesting, is the number of men who I’m treating who are coming in with jaw pain and headaches and ear pain, because of the increased jaw clenching during COVID.
Dr. S (Ron) Oh, wow, that’s interesting. So this is new-onset TMJ type jaw issues in individuals that didn’t have it before?
Dr. G (Michael) New onset, typically it’s women, these are men who are being stressed out, it’s a once in a lifetime thing. It’s the worst stress that some of us have faced and these guys are presenting with this intermittent dull ear pain and jaw pain.
Dr. S (Ron) Wow, interesting. Dr. B.
Dr. B (Mark) Yeah, I don’t think you can really underestimate the amount of stress during this crisis. We’re all feeling it to different degrees. I think, one, we hear the horror stories of dying or not being able to breathe and then the stress of not being there for your loved ones if that does happen. And then, of course, the economic impact or ramifications, I mean, this will have multi-generational effects with families and small businesses, especially, and many dentists, typically, most dentists are small businesses. So this is huge.
Dr. B (Mark) So what I’m seeing is certainly insomnia but also people staying home, stressed, not sleeping well. How well you sleep impacts how you respond to insulin and then because you’re tired, the next day, you wake up and you’re making bad food choices that will affect your resting glucose levels. It’s just this multifactorial, spinning hamster cage wheel that has sped up, essentially. So all these metabolic things were happening, and then, as we gain weight, there’s the “COVID-” or , however you wanna call it, then our airways are impacted, our tongue gets bigger, our airway is more likely to collapse, because it’s bigger, you know, we can gain fat in the airway and the tongue, and then the stress, the cortisol levels are off at night, so all these things are actually affecting our sleep, which in turn makes it worse for us the next day when we open the refrigerator door, and which again then impacts our sleep.
DB I remember /. Michael, you were there, again, Ground Zero. That was a lot of stress. I was worried for my family. I remember literally having a patient at AM and at , we looked at each other, all three of us, at chairside and said, “We’re going home,” because it was all just unfolding on TV. I’d have to say that was a stressful moment for me. I was a Cold War child, I was always “Where’s the closest bomb shelter?” That’s how I grew up in San Francisco. I think this kind of brought a lot of that back. But COVID, it’s huge. I think by staying home, by not being able to see friends and family, not being able to practice, which a lot of us thrive on and love. As Michael was saying, I mean, we really feel good when we come home and have improved someone’s life, more than just filling a filling, but made them happy and made them thinner and, you know, healthier and improved their sleep and all that. So yeah, COVID has been a game-changer and I see this in my patients in so many different areas blood pressure, stress, their eyes, their hair, I mean, it’s very sad to see.
Dr. S (Ron) You know, I give talks on stress and you guys highlighted the key issues. I would use the analogy like this is kind of like being chased by a tiger looking at your phone. But now we don’t need analogies. This is actually scarier than being chased by a tiger. You know you’re being chased by a tiger. But now we’re facing our mortality and a fear of the unknown because every day is a different day. And Mark, I wanted to highlight the point that you’re right, the biometrics, I’m seeing blood pressure, glucose, out of control. The worst thing is our patients are not connected to their healthcare systems. Not only are they not connected, I’ve been doing a lot of telehealth visits, but even when we open back up, patients are scared as hell to even come into a lab, they’re not gonna be coming in, so their numbers are gonna keep getting worse, and the metabolics are gonna keep getting worse, too.
Dr. S (Ron) So I think at some point we really need to comfort our patients and not have them be so influenced by the media. Obviously, we wanna practice the precautions that we’re talking about, but as you know from the New York data, the international data, the three independent factors that really increase severity the most are diabetes, obesity, and hypertension. So we gotta be laser-focused on that, rather than, you know, how long should we be wearing this mask, or obsessing over hygiene. We gotta do all the basics. I think it’s time for us really to take control there.
Dr. S (Ron) The key point you brought about / is that at least on / we still had outlets. You could socially connect, you can go work out. Now, we’re faced with stress and we have very limited outlets right now because we’re sheltered at home. So, it is really a perfect storm. So have you guys figured out any sort of unique ways to support your family and your patients to mitigate the stress? Because you’re right, the stress is at toxic doses right now. Any unique approaches that you guys have helped people with friends, colleagues, patients as well?
Dr. B (Mark) I think teledentistry is a big thing. I mean, it really does work, just, I mean our patients rely on us and, you know, being in front of each other is one thing, but just hearing each other’s voices and reassurance. For example, what Michael was saying, “What is that pain here?”, you know, “Is that toothache? Is it just tooth sensitivity? Or is it really a cavity and what should I do, because I can’t come to see you, what should I be doing at home in terms of home care and diet?” So, I think teledentistry, I keep telling other dentists now is the time, if you haven’t already, add that avenue in your practice. It should be built into your scheduler, your software, where you can be at home helping your patients and you can bill for this. Of course, the COVID thing has made it easier because a lot of the regulations have been temporarily dropped. I hope that’s a continuing trend. It’s important.
Dr. G (Michael) So what we’re telling our patients is “This is the time to stockpile your reserves, to build up your immunity, to get outside, vitamin D, get outside in sunlight for at least an hour a day.” We are talking about getting at least steps in, if not more, as well as nutritional things to do such as Vitamin C, zinc and things like that, and to work on diet. Now’s the time to think about these things, this is the time to go back and reassess. Life is gonna be different after COVID, right? Some things we’re gonna change, hopefully, things will change for the better for some things. Teledentistry and telemedicine are both one of those things that may be here to stay.
Dr. G (Michael) I always say I like to palpate, I like to have my patients there, I like to look at the imaging, so I’m old school. I get something out of being there with the patient and laying on the hands, but you know, you can’t always do that. So we’ve been really limited in what we’ve been doing with teledentistry, but I talk to people around the country and I think that that’s a great idea. But again, it’s a good time to stockpile for yourself to build up your reserves. This could be a long siege, that’s the difficult part of this. We’re only two months in, most people are burning out now, most people can’t really take any more, this is what worries me.
Dr. G (Michael) We’ve been into this for two months, and it seems like it’s been six months. If you were to tell me that this is really gonna last until we get a vaccine or herd immunity, that this could last to months with this kind of attitude of fear, I just don’t know how we’re gonna hold up. I mean, it’s enough. Most people are saying, “I’ve gotta get back… I wanna get back to work.” You see the protests, no one really has the answer. Some colleges are opening up like Notre Dame, others like Cal State are going to do everything remotely. So I mean, there’s such confusion, and we don’t really know what’s gonna happen until we start opening up. So there are a lot of unknowns.
Dr. B (Mark) I agree, there is a silver lining. The silver lining is that first of all, we can’t go to restaurants. Let’s face it, when we go to a restaurant, we’re eating beyond our normal caloric intake, we’re eating richer food, maybe eating some industrial seed oils, so that’s gone. Also, it’s hard to get food now, we don’t shop as often, we’re not likely just to get in the car if we have a hankering for some ice cream or something, because it’s something we’ve been told not to do. So now is the time to really look at your diet and your habits, whether it’s home care for oral hygiene, or how much food do you eat, how much food do you put on the table, how closely to bedtime do you eat or drink alcohol. Of course, there are a lot of other silver linings in there as well. We’re connecting more with people, even though it may be a Zoom call. What I’m telling my patients is now is a time to work on that, but also on sleep.
Dr. B (Mark) Personally, I’ve been going to bed about an hour earlier because of this COVID thing, and I think it’s been helping. We know that sleep affects a lot of the things that, in turn, are comorbidities that are bad to have, if you are exposed or you get enough of a titer of this virus, and some people are doomed because of that. I know Ron has so nicely on his website spoken to “Covesity” but there are things that we have to face in our lives. If we’re overweight, if we have a little roll around our belly, I mean, these are all things that predispose us to infections like this, especially novel ones.
Dr. S (Ron) Yeah, absolutely. I think building up the internal reserves, I think is a great point, and what I love that you brought up getting outdoors, sunlight, and vitamin D, ’cause I’m having a lot of patients ask me, “Should I double up on my supplement dosage?” They want the magic pill basically to help them through this, but we all know after doing this for many years, there’s really no magic pill out there, it’s just the basics that we talked about. Vitamin D in particular is a really interesting one and I wanted to talk about that for a second and get your perspective, but I already have patients that are significantly vitamin D deficient. And now what’s happening is they were already sort of sheltered in during the winter because a lot of them are techies that don’t get out much.
Dr. S (Ron) And usually they sort of resurface in Feb. Except now they’re still indoors, so when they are getting tested they have single-digit vitamin D levels. I’m pretty concerned about that, so I try to get them to get it out and get the adequate sun dosage, and then if they need supplementation as well. But I wanna get both your perspectives, too, if there’s anything unique about vitamin D and sleep, or even the airway and dentistry issues that you’ve been talking about. So, Dr. B., I’m gonna start with you this time.
Dr. B (Mark) So vitamin D is very important. Whenever I hear of vitamin D, I always think of K and A, you gotta have all three onboard, it’s a triad. Dentists talk a lot about that triad when it comes to remineralization and teeth and bone density and development of the face and all that, and that has a lot to do with the airway, but getting out in the sun is also very important for the circadian rhythm. That’s another thing I’ve been telling patients, to get out in the sun before noon. This is something we didn’t have the opportunity to do when we were getting up before dark, commuting to work, being at work all day long, being under blue lights, and then coming back during the winter, and coming home to a dark artificially lit house, but really never seeing the sunlight.
Dr. B (Mark) That in itself affects sleep, because that circadian rhythm, you know, the adenosine drive, the sleep drive, and melatonin, all those hormonal factors set up our sleep properly and time it well, those don’t really do very well without sunlight. They don’t reset, and they don’t start at the right time if we don’t see that sunlight. So that advice that Michael’s giving is key, that one hour of good trunk exposure of sunlight. The morning is better because you’re not gonna get fried like midday. Also, it’s probably better to do it earlier and further away from your sleep time. So that’s important. D and COVID are being discussed a lot together. It seems that people that are low in D are more susceptible to the bug, although the CDC just came out with something saying that it’s not the case, but I think overall it is.
Dr. B (Mark) D is very important. Get your blood levels measured, especially in the winter, you have to take more D during the winter, obviously, than you do in the summer. And you can take… too much D, you can have too much D in your system, which can affect your sleep. I’ve had that problem, I actually was taking , iu for a time and I was tossing and turning a lot and I’ve dropped it down to about , iu, did the sunlight thing and that helped, so there is too much of a good thing. But D is crucial right now, it’s always important, but now it’s very important to know what your serum levels are of vitamin D, it’s a hormone.
Dr. G (Michael) Yeah, agreed and I would say just to add a little bit, I don’t know if you know [Dr.] Stasha Gominak, she’s a neurologist, and her program for sleep is built around vitamin D and B complex. It’s a great resource for both professionals and for the public.
Dr. B (Mark) She’s down in Texas and she’s great. You’re right, she was in the Bay Area, Ron, I don’t know if you knew, but she worked at Palo Alto Medical Center for a while.
Dr. G (Michael) In New York because of the way this hit in February and March, most every patient is low vitamin D, if they’re not supplementing, they’re low. At our latitude, where we are, most people are low in vitamin D, across the board. I don’t know what you would say, Ron and Mark, but between and , is that what you are looking at as optimal levels? Because they’re coming in at and some are in single digits. Is it between and , or do you look for a different number?
Dr. S (Ron) Good question. So in my practice, looking at all the data, there are some people who think that the higher the better. Some people say above , get to , but then when I’m looking at a lot of this data, I think about to is the sweet spot for most of my patients. And just to highlight one other thing, as much as I’m a big believer in Vitamin D, a lot of people have used vitamin D to explain the high incidence of severity in certain ethnic groups like African-Americans because they tend to have very low vitamin D. And although I think that’s playing a role, I do wanna say that I think it’s playing a minor role because we know African-Americans and South Asians, they have a very high incidence of hypertension, obesity, and diabetes.
Dr. S (Ron) So we wanna keep our eye on the ball, because a lot of my patients who are higher risk, they feel like if, “I take my vitamin D tablet, I don’t have to worry about diabetes and just everything else will fall in place,” but it’s part of more of a cohesive, comprehensive strategy. And the other risk is over-supplementing. If you’re looking at the news and you’re like, “I gotta triple my dose,” there is a risk of that calcification ending up in your coronary arteries if you’re not doing it properly. The last thing we wanna do is elevate your cardiovascular risk, which can increase your COVID severity risk as well too.
Dr. G (Michael) Yeah. I think people that are taking a lot of calcium and a lot of D, and they’re not taking K, I worry that that calcium in your blood is just not getting to where it should be going, and that is teeth and bones and calcified tissues, and you can even calcify your pineal gland if you have too much calcium. It’s pretty clear to me as a dentist, I have a lot of patients that take a lot of calcium, they have a terrible diet, they’re not getting any K from diet or as a supplement, and they’re getting a lot of tartar. Blood and saliva are essentially the same thing, minus the red blood cells, and you’ve got a lot of calcium in saliva, it’s there for a purpose, to help re-calcify teeth, remineralize teeth, but you can have too much and then if you’re a mouth breather and your mouth is continually dry, you’re gonna get a lot more build-up of tartar which can eventually lead to gum disease if it’s not removed.
Dr. S (Ron) You know, even mainstream doctors have taken our foot off the gas pedal for recommending calcium supplementation. Most studies show that it really doesn’t do a whole lot for bone health. Again, just thinking about lifestyle, get outside there and walk and do some weight training, do some exercises, and get vitamin D naturally and supplements if needed. There really is not much purpose for getting calcium through supplements for most patients, and most studies show that for osteoporosis prevention, it doesn’t do a whole lot. So totally agree with more of a natural approach to that, for sure.
Dr. S (Ron) The other thing I wanted to bring up is that I’m finding my patients are staying up a lot later. You brought this up as well Dr. B. People are just exposed to so much media. I had to actually go through a detox process. I had my Apple news, I’ve got a couple of WhatsApp chains, I’ve got old high school and college buddies sending me all types of COVID- jokes. I was getting so many streams of information. At the same time, my medical group is sending me about email updates per day. So I’ve had to actually implement some media detox strategies I call media distancing. Is that something you guys have been successfully doing or getting your patients to sort of adhere to? Because like you said, it can destroy our melatonin cycle in the evenings.
Dr. G (Michael) I think what’s happening is that you get into some of these Netflix shows and then it automatically goes to the next episode. Then you’re up to , midnight, where I normally would be asleep by , as an escape from the stress. And I think that’s great to escape the stress. But I think Mark’s right, we’re staying up later. I try to get more sleep and my patients say this is the time where they actually can get more sleep, but I think we gotta be mindful of not staying up and bingeing until in the morning.
Dr. B (Mark) Well, and listening to the news, as well. I just have a rule. I try not to look at a video version of the news, I listen to it or read it and then by noon or o’clock that’s done. I just don’t look at it again, I don’t wanna see anything stressful before I go to bed, because I think it does contribute to when you wake up, that’s maybe the first thing that pops in your mind and then it’s hard to get back to sleep.
Dr. B (Mark) But the blue light of staying up late and watching the next Netflix show and the next episode and that’s tough. It makes you feel good, but it can be very dangerous. That blue light just basically rewires your brain for the rest of the night. I’ve gotten to the point now where I have abused my sleep so long and so much that for the last years, I’ve been paranoid, and I’m trying to catch up if that’s possible. Some say it’s not. I’m just thinking of all the methylation and the damage I’ve done to my body from being up till a and then getting up at or a the next morning, and being able to do that, burning the candle at both ends.
Dr. B (Mark) I don’t get rigid about many things, but my family can tell you, my ring tells me when to go to sleep and I’m in bed. I set an alarm to go to sleep, not to wake up. I’m a little obsessed about sleep. And it’s worked, it really has changed my life. It’s made me crave carbs less, I gave up sugar years ago. It was much easier doing that after being able to sleep through the night. If there’s a night where if I get up in the middle of the night and go to the bathroom, to me, that is a catastrophe. That is a failure, I must have had some apneas that allowed that whole event to occur. So, thank goodness that’s very, very rare. There’s so much temptation out there, especially now, because we have more time at home. The refrigerator’s there, the TV’s there. It’s tough.
Dr. S (Ron) A lot of people get fixated on the concept of sleep duration. So I’ve got a lot of techies that go to bed at a and they get up at or a, they don’t have to commute to work and they brag to me that they’re getting eight hours of sleep. So I kinda wanted to talk about just phasing in bedtime too. From my perspective, it’s really key, that we get that first half of the night down, because we know in that first half of the night we’re getting more of that deep phase sleep, we’re releasing more growth hormone and glucose metabolism happens really well. So I tell people eight hours of sleep, like p to a is very different from a to a. I’m just kind of curious, and I’m gonna let you finish what you were saying Dr. G., but I was curious if there’s anything from an airway perspective, in terms of me getting eight hours from p to a versus a to a, maybe we can talk about that.
Dr. G (Michael) Well I can comment about the airway. I also wanted to talk some more later on about sleep testing, because I think this is the time to encourage our patients to get tested. I can talk about that in a bit. For me, the REM sleep occurs later in the night. REM sleep very often is when the muscles are paralyzed. We get more apneic events in REM sleep. I’ve even looked at people that talk about bi-phasic sleep, get four hours of sleep, get up, maybe read a little bit and then get your other four hours. I’m interested to hear your thoughts about whether p to a is different than a to a? That’s an interesting conversation. I hadn’t really thought about it too much. I’d like to hear what you guys have to say.
Dr. B (Mark) I focus more on the circadian rhythm. Every night I have a routine. I start running upstairs around p and my bedtime is p-p. It depends on sleep latency and all that, but then I wake up without an alarm and it’s amazing how I don’t even have to look at the clock. If I sleep well, my body has told me how long I have to sleep, I wake up within minutes of the same time every morning if I stick to that circadian rhythm. So my thinking is that by doing that and optimizing where I sleep and having the airway open (I wear an oral appliance), I test, I monitor with the Oura ring. So everything’s data-driven. I’m not worried about how long I sleep and my numbers tend to be very good. Unless I lose an hour of sleep by going to bed an hour later, then that makes the data not look as good.
Dr. B (Mark) So for me, it’s all about the circadian rhythm. Follow that to the minute, and everything else should fall in place, as long as you’re able to sleep, as long as your airway’s not collapsing. To me, that’s what drives how long I should sleep for and let my body decide, but I have to follow the rules and that is, go to sleep at exactly the same time.
Dr. G (Michael) So we’ve told the patients not to eat after p, so if I follow that rule then I would go to sleep around p, and I like your concept, totally agree with the circadian rhythm. From a glucose perspective, we don’t want them eating or drinking too late, we want no caffeine after either noon or p, and we’d want no eating past a certain time so that it doesn’t interfere with sleep. So from that perspective, I can see how it would affect insulin resistance and glucose. I’ve even talked about intermittent fasting a little bit with my patients.
Dr. S (Ron) Yeah, my patients that wear continuous glucose monitors, until they see that number in the morning as proof of the earlier bedtime, they don’t believe it. It’s funny because a lot of people think that they’re programmed to be late-nighters, but a lot of my techie friends, when we go camping, everybody gets to sleep at p right? Once we are back in nature, they realize that this is really the natural rhythm. But I definitely wanna transition into a little bit about breathing, because I think it’s so overlooked. In my clinics, people have overt snoring and daytime sleepiness where they’re falling asleep at the wheel. So I wanna make sure I have a chance to address that. Symptoms, early symptoms that we should look out for, and also, what is a good way while we’re evaluating the patient to maybe test for some of these things. Dr. B., would you like to start?
Dr. B (Mark) As Michael said, testing is very important and the question is, is the testing catching all cases of sleep disorder breathing? And I’ll answer that question, I’m sure Michael has a response to that as well. But essentially, sleep is a very complicated thing. It’s very broad and there are many different types of sleep disorders. And your airway doesn’t have to collapse, you don’t have to have low SpO (oxygen saturation) in your blood to have sleep apnea. You can be interrupted in many different ways Blood glucose levels, the dawn effect, it can be the dog that’s sleeping with you, it can be your sleep partner who’s snoring, it’s very, very complicated.
Dr. B (Mark) So testing is really, really important and I’m not % happy with the testing. Most of these apps don’t work, and then there’s resistance to testing, and there’s a lot of denial, especially with my male patients. Even though they are shown a recording of themselves snoring, and I guess I was in that boat as well. It’s such an insidious, gradual kind of disease or condition that you think it’s more just old age. That you’re not sleeping well, that you’re getting up in the middle of the night to go to the bathroom, that you’re kinda creaking a little bit in the morning and you’re tired during the day, and you have to take a nap. I took all of those things for granted as being normal. So when most people think of sleep apnea they think of breathing.
Dr. B (Mark) And we should probably start talking about that. But the airway is impacted by so many things. Again, dentistry is in the hot seat here or in the pole position because a lot of it has to do with how we develop, how our face develops. I always try and simplify this, because if you’re not a dentist it’s complicated. Michael, correct me if you think this is too simple, but there are three boxes that have to develop. There’s the mouth box, there’s the airway box, and there’s the nose box. And when we’re kids and come out of the womb and hopefully we’ve picked up a lot of mom’s vaginal microbiome and that’s all in place ’cause that has a lot to do with gum disease later. But being pushed through the canal, and then breastfeeding, and that sucking motion, and not having a tongue-tie, hopefully that’s a midline defect, all these things have to work really, really well so that we develop these boxes.
Dr. B (Mark) If the mouth box isn’t wide enough, then the ceiling of that, which is the floor of the sinus, doesn’t get wide enough, and then also the airway isn’t effective because we don’t get that forward-downward growth. So these boxes which all contribute to the patency of getting air in and expelling air, if they don’t grow to their full potential, then you’re guaranteed to have sleep apnea. So how do we test for that? Michael mentioned the CBT, the cone beams, they’re controversial. I think they’re great. It gives you some baseline even though patient’s not asleep when that image is being taken and they’re upright, but I think it’s all about testing. A, we have to understand how wide of an umbrella we have to throw, to cover all these sleep problems, and then we need better testing, and it has to be more available, it has to be cheaper, and insurance companies have to pay for it. And Ron, I have to say one more thing.
Dr. B (Mark) Not to you, but to your profession in general. And again, medicine and dentistry separated a long time ago, which has been very deleterious to our patients in general, back in, I think it was, . It’s less so now, but back about years ago, in the beginning when I referred a patient for a sleep study, the general or primary care physician would push back. They would say, “No, there’s no need.” I was sending patients who were thin and healthy but because dentists can see the oncoming sleep apnea, we can see UARS. We see it. When Michael goes to a cocktail party in New York, he can literally see UARS in the people he is surrounded by.
Dr. G (Michael) Right.
Dr. B (Mark) Anyway, I’ll give it over to Michael now, I’ve said enough.
Dr. S (Ron) And Michael, when you respond to this too, I just want to ask you, what percent of general dentists are looking for this? Are most dentists looking for this, or do you have to have some sort of special training? So maybe you can address that.
Dr. G (Michael) I think it’s important to realize that only % of these patients at most have been diagnosed, and then unfortunately in the United States, a lot of those have been put on CPAP, and maybe % are non-compliant. In Europe it’s much more equal with oral devices and CPAP. And in terms of mean disease alleviation, we know that oral devices work fairly well because they’re more comfortable and the compliance rate is higher, even though efficacy may only be %. So when we look at those people in the United States, we’re up to maybe million. [Dr.] Atul Malhotra who is down in San Diego, he’s done some great work. It was written up in CHEST. So the rates where we used to quote % and %, we’re up to % of the population. As obesity increases, as diabetes increases so do sleep disorders. So this brings us back to that inflammation. Everything is related to everything else, like you guys have been saying. If you look at the sheer numbers, and you look at our failure to diagnose in this country. And I always say, “Men are in denial, and women speak in code.”
Dr. G (Michael) A woman’s never gonna say there is a problem, she will say “I’m fine, I’m okay.” But the number one question that I ask is, if I say, “Are you tired?” “No, I’m not tired. Who’s tired? I’m not tired.” I say, “Could you be more refreshed?” Totally different question. And everyone says to me, that’s the number one complaint in New York City, “Doc, I’d like to be more refreshed. I’d like to feel like I felt when I was a kid.” I’m getting these executives coming in, and I’m getting thin women with big tongues. That UARS, that Upper Airway Resistance, and I totally agree with the three boxes concept. We wrote a book called GASP with Howard Hindin, and I love going back to kids ’cause we can see it at that stage. [Dr.] Kevin Boyd is a leader in this.
Dr. G (Michael) So Ron, most homo sapiens have this problem, because our faces have gotten narrowed. I have a long face from being a mouth-breather, our snouts have gotten pushed in. So we have flatter nasomaxillary complexes. Everything’s been pushed back. We don’t have the snout of a neanderthal man, we don’t have the face of a paleo man, we have the face of an industrialized homo sapien. And homo sapien is almost contiguous with sleep apnea. And if not sleep apnea, upper airway resistance. So one of the things that we look at, when we look at testing, we don’t always see it, and often we don’t see it with oximetry. We don’t see it with O desats, because it’s not apnea anymore, and it’s not hypopnea, it’s upper airway resistance syndrome, which results in fragmented or disturbed sleep.
Dr. G (Michael) And we’re getting a lot of fragmented and disturbed sleep. That’s what portends and predicts Alzheimer’s, dementia, and cognitive impairment. It’s that lack of slow-wave sleep, and something that’s not really talked about very often is that decrease in slow-wave sleep. I’m afraid that that’s some of the stuff that we’re seeing now. But they came up with WatchPAT ONE, which is a disposable test. So with COVID, it’s great. You mail it to the patient, it comes in through the iCloud, it doesn’t have to be mailed back.
Dr. G (Michael) That’ll give you an idea of the RDI. That will give you some idea of sleep disturbance. It’ll measure apnea and measure hypopnea. But just yesterday, a guy woke up to times during the night. Mark’s upset if he has to go to the bathroom once. This guy’s brain is waking up to times, and I could show him on the graph. It was very clear that even though he didn’t fully consciously wake up, his brain was coming right to the verge of wakefulness to times. This guy’s exhausted and no one knows why and everyone’s in denial.
Dr. G (Michael) So I think it’s time for people to recognize this. I was gonna say to you guys, we know that the comorbidities, we know that morbidity and mortality of COVID is directly related to obesity, diabetes, these other comorbidities. So isn’t this the time that we should really be addressing this. Is this what’s gonna motivate people to try to get rid of their diabetes now and get rid of their obesity now, so they’re not as susceptible to dying or getting really sick from this virus. I just put that out there. Now is the time for them to get tested.
Dr. B (Mark) The threshold for testing, the conventional test, the PSG, it’s really set too high for you to get a positive. Michael’s right. The classic example of this is a study out of Sweden where they took women that were very thin, very active, very healthy, very fit, no diagnosis of sleep apnea or anything, no complaint of any sleep issues. When they were tested, I think it was just shy of % had some form of sleep disorder breathing. So, how doesn’t that get picked up? Well, the PSG doesn’t pick up UARS necessarily. The home studies, which are great, some of them, I mean the WatchPAT is great, but home studies tend to under-report. So that one guy that Michael was talking about, it’s probably worse than what the home study indicated.
Dr. G (Michael) Exactly.
Dr. B (Mark) Again, we need to test more. I think, and I wrote this in my book, I think everyone should get a sleep study every five years. There are some countries that do that. Iceland and Italy try to do it. It’s an important test to have. Sleep is not guaranteed. It’s innate but it’s not guaranteed that you’re sleeping well. And especially because we’re not developing properly, our faces don’t allow us to breathe properly.
Dr. S (Ron) Yeah, one key thing I also want to mention is in the medical system we were trained that sleep apnea is more of an obstructive disease, so we automatically link it to obesity or morbid obesity. Both of you basically brought up the point that it’s really more of an inflammatory condition. I know in my practice, a lot of people with normal to lower body mass index individuals have sleep apnea. And I’m assuming that’s the same case that you’re seeing. I think, Dr. G., you mentioned you’ve got skinny, high-stress execs that are having it. So I think one thing I’d like to highlight to doctors and patients is, yeah, weight, plays a role, but it’s really more inflammation. If you’ve already got signs of inflammation from your symptoms, from your blood glucose, your blood pressure. Even if those are all fine, there’s not much downside to doing a test that is relatively non-invasive, you’re not getting exposed to radiation. I agree that most patients should fight for getting this test done as a baseline because aside from chronic disease, it’s about mood, it’s about well-being, it’s about productivity, it’s about energy and those things you just can’t put a price tag on.
Dr. B (Mark) Yeah, I think, Michael, you’ll agree that your most frequent patient for sleep apnea is a thin, very successful, very hyper female.
Dr. G (Michael) Yes.
Dr. B (Mark) It’s not the big neck, the big guy that’s snoring away.
Dr. G (Michael) It’s a narrow nose. They might have had a rhinoplasty… They have a little deviated septum, they have enlarged terminate. They’ve got a big tongue, they’ve got a narrow palate, very thin, they work out all the time and they’re exhausted.
Dr. B (Mark) Yep.
Dr. G (Michael) So these are my failures for years going back with my TMJ. These are the women that come back, they’ve got functional somatic syndromes, like [Dr.] Avram Gold wrote about, and like Dr. Christian Guilleminault writes about. They have irritable bowel, their nervous system is sensitized, they have low blood pressure, they get faint sometimes when they stand up. They have resisted breathing and these patients are missed and these are the ones that keep coming back. They’ve got tension headaches, they say they have migraine headaches, they clench every night, they can’t stop clenching, they bite through their bite guards and they do not have sleep apnea.
Dr. B (Mark) I’ve seen the orthostatic hypotension a lot in these young women that have sleep apnea. It’s very interesting that you mentioned that.
Dr. S (Ron) Really?
Dr. B (Mark) Yeah.
Dr. G (Michael) Oh, yes.
Dr. B (Mark) Yep.
Dr. G (Michael) Yes. And they have cold hands and cold feet.
Dr. B (Mark) Yes, Raynaud’s, yep.
Dr. S (Ron) Oh, my gosh, yeah, I did wanna ask you one thing. Because I know despite us having this discussion, some patients are just not gonna get the type of testing they need and everybody’s about sort of home monitoring apps, tools and devices. What are the best options? If somebody really wants to find out an easy sort of screen that they can do, now that they are sheltered in. Do you guys have some recommendations? Dr. B., Dr. G.?
Dr. B (Mark) Yeah, I mean… My recommendation is typically to stay away from most of these fit trackers and things that are based on data that you’re getting back that’s based on moving. My favorite apps are, the simple one would be a night recorder, something that just records you all night long and you can just playback only the sounds that the recorder recorded, in other words, snoring. That’s very enlightening. And the other one is the . I don’t have any affiliation with them. I just like seeing the data. It’s not % accurate, but it’s pretty close. But to be able to see that you did get your delta wave deep stage well before the REM set in and how much did you get, what time did you get up in the middle of the night. It shows you that. Then it tells you how long you slept and then it gives you a score. So, that’s a great place to start. But as soon as COVID is over if you think you have sleep apnea, I always recommend the PSG. Start with that.
Dr. B (Mark) If you score well on that and you’re still tired, then keep going. A lot of my patients will say, “Oh, I passed,” but they’re still tired and they still don’t sleep well. They have fragmented sleep. So, you can’t stop there, but that would be the first thing to do. Because the brainwave patterns are so important.
Dr. G (Michael) Yeah. I echo that. So, I think an app like SnoreLab. If it’s snoring and you’re in denial and you wanna figure out how many minutes and how loud it was. We’re not in favor of having electronics by the bed for various reasons, but for one night or every so often, either to monitor the efficacy of the treatment or to see how many minutes you were snoring during the night, that’s a great app. I think like what’s happening with certain other diagnostics where people can take their blood sugar or their blood pressure. By the way, during COVID, about six weeks ago, someone asked New York State, the ADSM asked New York State about whether dentists could deliver on a physician’s request, the home sleep tests, and the answer was no. So, just at the time where we think we should be improving access to care, it’s like what’s happening in our government. It’s a time where certain states, local governments, and certain boards are now saying, “No, we’re gonna limit access to care.”
Dr. G (Michael) So, I’m a big, big advocate for a patient being able to get their own diagnostics. They’ll be read by a physician. I’m great with that. But I want patients to know how important it is to be able to order. And if you go online, WatchPAT ONE, there are certain companies where they will send it to a board-certified physician, you’ll have a telemedicine visit, it’s even set up through insurance, and a patient doesn’t have to go through an MD or through a dentist. Because like a lot of people said if you’re a thin woman, first of all, it comes back we can’t help you. You’re not a candidate for CPAP. So, I do love working with physicians, but I also love the increased access to care and the ease to deliver a home sleep test. There are no obstacles in the way. They go home with it. They walk out of my office with a home sleep test, FedEx label, or even now it’s better because the iCloud’s gonna bring it back in.
Dr. S (Ron) That’s awesome. I’m gonna be respectful of your time ’cause I definitely wanna share a lot of the resources that you guys have talked about and we’ll set up a page for that. But I gotta ask you one question that’s come up over and over in the clinic and on my blog as well, is those darn a wakings, where people are getting up around a or so. I always get that question all the time and I just wanna get each of your perspectives. I’ll start with you, this time, Dr. G. Do you have any common causes? I’m assuming breathing can play a role with that. But if you guys had any unique experience with how to approach those a wakings, which I come across so much.
Dr. G (Michael) I think it’s a good time now to talk about sleep hygiene. You want that room to be cool. So, if I’m feeling hot, I gotta take the blankets off. If you’re sleeping with a partner that is going through perimenopause who keeps whipping the covers on and off. That affects sleep. Also a dark room. I was on a call with an Alzheimer’s group and one man is wearing a mask, an eye mask, and he said that made all the difference in terms of circadian rhythms, like you were saying, Mark. Just putting that eye mask on allowed him not to wake up a, allowed him to sleep through the night. Also, environmental noise is a big one as well as exercise. And I’m a big advocate for exercise. You can’t overestimate those benefits. If an hour of exercise will improve that and allow you to get through that a awakening, exercise, it cuts dementia by %, according to someone like Perlmutter. So, exercise can do that, sleep hygiene, nice blankets, maybe even a weighted blanket in a very cool room, degrees. No dogs or cats. Nothing that’s going to crawl on you. A bed partner who snores.
Dr. G (Michael) The guy is in denial or the woman in denial. Either you’re gonna treat it or get into a separate bedroom. The kids are out of the house, you’ve got two or three bedrooms to choose from. And that might be the difference between conquering your glucose levels or not conquering it. But if you have a bed partner that’s buzz sawing like at decibels, how do you expect that you’re not gonna wake up at a? And then maybe less water. Everyone wants to be hydrated. This angiotensin and we can talk about ACE- and it’s all kind of very interesting, but maybe not drinking right before bed. Drink all day, but don’t drink water after a certain amount of time. And certainly alcohol will dehydrate you. You’re gonna wake up at a all the time, you’ll fall asleep in a drunken stupor and then you’re up at a dehydrated and you gotta drink water and that won’t happen if you limit the alcohol and drink earlier in the day. I shouldn’t say it like that.
Dr. S (Ron) Those are actually really good points. I love that. I was actually told that Costco is selling more alcohol now than during the holidays, so I think people are really loading up on the alcohol now. So, Dr. B., do you have anything to add to that, the a waking?
Dr. B (Mark) Yeah, absolutely. All that is correct. I wear one of those masks. It’s huge. I used to make fun of people that used to wear those masks or wear those masks. But my three things, as I was hearing Michael talk, my three things are GERD, blood glucose levels, and alcohol. Those are the things that will wake up at a, other than the obvious, like a cat or a sleep partner or a truck driving by. There’s a study that says that people that live in a very busy area like New York, the study was out of Atlanta, and it depends on the neighborhood you live in. The poorer the neighborhood, the more likely you will not get a good night’s sleep, that you’ll have an interruption.
Dr. B (Mark) So, anyway, alcohol, Michael mentioned that. Obviously, I mean, it conks you out, you go right to sleep, but it has altering effects on brain physiology and it will wake you up at a, and then GERD. So you know, if you have apneas, GERD can wake you up. In a nutshell, apneas fool the body into thinking because of that pressure or the thoracic pressure from the apnea it fools the body into thinking that it needs to dump blood volume to lower blood pressure. And so, of course, the aldosterone and vasopressin and all that, the kidneys are working, they’re helping you fill up your bladder. Because you’re not sleeping well, you’re tossing and turning. And those apneas are causing that.
Dr. B (Mark) So, that’ll wake you up. Obviously, a full bladder will bring you right out of deep sleep, and then you get up, you may turn on a light, which is a mistake, and then it’s tough to get back to sleep. The GERD is, literally if you have apneas, it’s like a pump, a reverse pump. You’re pumping stomach acids right up into your mouth, your eustachian canals into your nasal passages. It’s amazing how quickly that can happen because you’re lying down, and then of course you know you’re gonna get esophageal cancer if that goes on too long, but that’ll wake you up. A lot of my patients have this complaint. I ask them, I say, “What actually wakes you up?” And we talk about it. “Is it a taste in your mouth? Is it dryness of the mouth? Is the mouth open?” And a lot of them will say, “My teeth are really sensitive when I breathe and I’ve got this burning kind of weird taste in my mouth.”
Dr. B (Mark) Sometimes they’ll express it as being, “It tastes like I vomited a little bit.” Those are all root causes of why someone wakes up at a. It could be a if you go to bed late, but assuming a regular schedule, there are a lot of things that can wake you up.
Dr. S (Ron) You know, I’d add to that that the glucose thing’s a big thing that I see in my practice and it can be either extreme, so some of my patients on very low-carb or ketogenic diets are going to bed in a sort of hypoglycemic state. And they can have a major, major drop around a or even a major spike at that time. Abrupt fluctuations in glucose can really get us out of deep base sleep. The other extreme is true too. A lot of us are baking like crazy during this pandemic and we’re snacking on muffins and cake at night time. Those insulin and glucose excursions can really send a signal to the adrenal gland and make you come out of sleep at a.
Dr. S (Ron) Some people actually have to starch shuffle a bit, other people probably need to starch back a little bit, but also you both mentioned intermittent fasting. We don’t wanna be digesting a huge, heavy meal during the night. So finishing that meal between or p can be really helpful for kind of curbing those in my experience, but I think this is a great list that came up together so I love everything people brought up there.
Dr. G (Michael) Wearing a CGM is a great idea. If you’re getting up in the middle of the night, you should get a CGM prescription from your physician. Because when you’re not sleeping well, it triples your fasting glucose, it decreases your insulin sensitivity by like -%. I mean, that’s big, it’s all tied into sleep. And then you know, what is it that’s waking you up? Is it poor sleep? But it could be the fact that your insulin isn’t right. Yeah, I mean, it’s all tied in together, but low sugar or high sugar can wake you up, but poor sleep, of course, aggravates that whole thing.
Dr. S (Ron) Yeah, you know, the battle is getting doctors to order CGMs as well, too. So I did a detailed blog post on how to get your doctor to order a CGM. So I’m gonna put down your guys’ resources and my resources on some of the things we talked about so we can have that info. But yeah, I would love, Dr. B., since I got to you here, can you maybe highlight some of your key resources? You brought up a lot of great information, but where can people find you? How can they reach out to you, order some of the resources you’d wanna highlight based on our discussion today?
Dr. B (Mark) Yeah, we’ve got the Facebook page, the Instagram account, we’ve got the website. If you’re concerned about sleep, I would just type in my last name, and Gelb as well, into Amazon, and read the books. I mean, I think the dental perspective on sleep apnea is very unique and it’s very interesting, and I think it’s very approachable by patients.
Dr. S (Ron) I would actually call it revolutionary.
Dr. B (Mark) Demystifying sleep.
Dr. S (Ron) I really think it’s revolutionary what you guys are doing, honestly.
Dr. B (Mark) Thank you.
Dr. S (Ron) We, as physicians, simply don’t have that perspective.
Dr. B (Mark) And then, and then one other thing, just go to our website, askthedentist.com. You’ll see lots of stuff on sleep and intermittent fasting and how that’s good for reversing cavities and all that stuff.
Dr. S (Ron) I love that site, absolutely. Dr. G.?
Dr. G (Michael) Yeah, so we started the foundation, Airway Health. It’s a good site, it’s for the public. There will be a lot of information about sleep and airway and then, if you wanna find a practitioner, we have a group of MDs, physicians, dentists, myofunctional therapists called the AAPMD, the American Academy of Physiological Medicine and Dentistry. You can find a provider there in any part of the country, and you can join, if you believe in the airway and you’re an airway advocate, it’s free to sign up if you’re a professional doing this kind of work. You guys should be on there too, and it doesn’t cost anything. Again, it’s so we can all have an equal seat at the table. There’s a lot of good information on that site, as well. And then, as you said, my book also, GASP, is on Amazon, it’s a good place to start. And then our websites, you know Mark’s website and my website gelbcenter.com or Dr. Michael Gelb, even better, with all the blogs on it, has some useful information. I think that’s a good place to start.
Dr. S (Ron) Fantastic, and for my research, you can go to culturalhealthsolutions.com, that’s where I blog. I’m also on Instagram @roneshsinhamd, so check out my resources there. This has been awesome. I learned a ton here and hopefully, this is gonna help support everyone’s sleep inside the pandemic and beyond the pandemic too. This is something we need to prioritize in every stage of our life. So, thanks, everyone, for listening.
