Dr. Keith Thornton has spent several decades challenging how dentistry thinks about sleep, breathing, and the airway. In this episode, he joins Jason Tierney and Dr. Erin Elliott to look back at the origins of his work and explain why he sees oral device therapy as much more than a dental treatment.

Dr. Thornton traces his approach to his early training in Navy anesthesia, where airway management meant understanding how the jaw, tongue, and surrounding anatomy influence airflow. That experience shaped the way he later approached sleep patients and eventually led him to view devices such as the TAP as tools for managing the airway rather than simply repositioning the teeth or jaw.

The conversation also explores nasal breathing, mouth position, CPAP leak, titration, long-term patient management, and the evolution of dental sleep medicine. Dr. Thornton shares his perspective on where the field has improved, where he believes it has fallen short, and why dentists should think beyond delivering an oral device and instead build systems that follow the patient over time.

What’s on the Menu

• How anesthesia shaped Dr. Thornton’s approach to airway management
• Why he sees oral devices as breathing and airway devices
• Nasal breathing, mouth position, and CPAP leak
• The importance of titration, testing, and follow-up
• Moving from appliance delivery to lifetime airway management

The Value Add

One of the clearest ideas in this conversation is that the device itself is only one part of treatment. Dr. Thornton repeatedly brings the discussion back to airway function, breathing, patient response, and what happens after the device is delivered.

His approach challenges clinicians to think beyond a single intervention and consider how oral devices, nasal breathing, CPAP, testing, follow-up, and collaboration with medical providers can fit into a broader system of care.

Clinical Concepts & Terminology

Airway Management
Dr. Thornton uses this term to describe maintaining or improving an open airway through attention to jaw position, tongue position, breathing, and other anatomical and functional factors.

Physiologic Breathing Device
Keith’s preferred framing for devices designed around breathing and airway function rather than traditional dental or orthodontic concepts alone.

Titration
The process of gradually adjusting an oral device and evaluating the patient’s response rather than assuming the initial position will provide the best outcome.

Mouth Shield
A component discussed by Dr. T that is intended to encourage nasal breathing and reduce mouth breathing while using an oral device.

CPAP Mask Leak
Dr. Thornton discusses both intentional and unintentional air leakage and argues that leakage should be considered when evaluating CPAP tolerance and breathing.

Professional Organizations & Collaboration

The conversation touches on the American Academy of Dental Sleep Medicine, the American Academy of Sleep Medicine, the American Dental Association, dental schools, ENTs, sleep physicians, and primary care providers.

Keith and Erin both emphasize the need to reduce professional silos and create more practical pathways for patients to receive appropriate evaluation, treatment, and follow-up.

Recommended Tools & Topics Mentioned

TAP and TAP-PAP
Devices discussed in relation to airway management, titration, and combining oral device therapy with positive airway pressure.

myTAP
Discussed as an accessible starting point for some patients and as part of a broader treatment pathway.

FlexTAP
Dr. T describes the FlexTAP as a breathing-focused device designed around tongue space, jaw position, and airway function.

Mouth Shield
Discussed as a way to encourage nasal breathing while managing mouth position.

AM Aligner
Discussed in relation to morning bite management after oral device use.

The Big Idea

Dr. Thornton’s central argument is that dental sleep medicine should not stop at delivering an oral device. He believes clinicians should focus on the airway, evaluate how the patient is actually breathing, titrate and test therapy, collaborate when additional treatment is needed, and continue managing the patient over time.

In his view, the goal is not simply to make an appliance. It is to build a system capable of managing the airway throughout the patient’s changing needs.

Sleep apnea, for sleep professionals, feels EASY to diagnose - but what about when it isn’t cut and dry? For patients who don't fit the stereotype, don't respond perfectly to CPAP, or need more than one provider involved in their care, the path can feel impossible.

Emma Cooksey spent roughly a decade living with undiagnosed obstructive sleep apnea. She was exhausted, waking with headaches, struggling to stay awake, and treating anxiety and depression without getting to the underlying problem. It wasn't until she fell asleep at the wheel with her newborn baby in the car that she finally received a referral to a sleep specialist and got diagnosed.

In this episode, Emma joins Jason Tierney and Dr. Erin Elliott to share how her experience eventually led to Sleep Apnea Stories and her advocacy work with Project Sleep. What started as a podcast became a much broader look at the gaps patients face, from insurance problems and disconnected providers to limited awareness of treatment options beyond CPAP.

They also get into one of the biggest disconnects in sleep care: what the numbers say versus how the patient actually feels. Emma explains why a great AHI or strong CPAP data doesn't necessarily mean the patient feels great, and why clinicians need to ask what outcome the patient is actually looking for instead of assuming the metric tells the whole story.

The bigger lesson is about creating a system that works for real people. That means breaking down silos between providers, making more treatment options accessible, educating primary care providers, listening to patient experiences, and ensuring people can see themselves represented in the sleep apnea conversation.

What's on the Menu

• Emma's 10-year journey with undiagnosed obstructive sleep apnea
• Why sleep symptoms can be mistaken for anxiety, depression, or personal failure
• What happens when patients need options beyond CPAP
• Why great sleep data doesn't always mean a great patient outcome
• The importance of asking patients what success actually looks like
• Breaking down silos between sleep physicians, dentists, and other providers
• How Project Sleep is working to challenge stereotypes and expand awareness

A Few Threads You'll Hear

Listen to the patient, not just the numbers. Emma spent years telling her sleep specialist that she was still significantly sleepy while being reassured that her CPAP data looked great. Her point is simple: good numbers matter, but the person sitting in front of you matters too.

Patients need more than one pathway. CPAP worked well enough for Emma to make a major difference, but it wasn't the end of her treatment journey. She explains how difficult it can be to coordinate multiple treatment options across providers, even when you have knowledge, resources, and connections.

Stop deciding who "looks like" they have sleep apnea. Emma's Sleep Apnea: Let's Face It campaign is built around breaking the stereotype of who gets the condition. Patients are still avoiding testing, and even being dismissed by providers, because they don't fit the expected profile.

Patient voices can change the system. Through Project Sleep, Emma has moved from sharing her own story to helping other patients speak up, educating providers, advocating for research and funding, and pushing for patients to have a seat at the table when sleep care is being shaped.

Resources & Links

• Emma Cooksey - sleep apnea patient advocate, creator of Sleep Apnea Stories, and staff member with Project Sleep
• Project Sleep - patient advocacy nonprofit supporting education, awareness, research advocacy, and programs for people living with sleep disorders
• Sleep Apnea: Let's Face It - Project Sleep awareness campaign focused on challenging stereotypes around who can have sleep apnea
• Sleep Apnea Squad & Coffee with Emma - free Project Sleep education and support resources for people navigating sleep apnea care

The Big Idea

Sleep apnea care can't stop at getting the diagnosis, handing someone a CPAP, or bringing their AHI down. The real question is whether the patient is getting the outcome they need.

Ask how they're functioning. Ask what they're still struggling with. Make sure they understand their options. Build relationships with other providers so patients aren't left to connect the dots on their own.

As Emma puts it: “This journey was hard enough for me, but for most people out there, it's impossible. So we have to do better.”

Dentists have a habit of making sleep harder than it needs to be. They get buried in medical insurance, device details, referrals, and clinical workflows before they've even figured out how to consistently get patients tested.

Dr. Tarun Agarwal has spent years building a successful sleep practice and teaching others how to add sleep into their general practice, and his approach is refreshingly direct: treat it like a real business inside your business. In this episode, he joins Jason Tierney and Dr. Erin Elliott to break down why so many dentists never get their sleep program off the runway.

For Tarun, success didn't happen in the first few months. It took six months, nine months, even a year before the program started gaining real traction. Instead of squeezing sleep between existing appointments, he funded it like a startup, gave a team member ownership, and built a process that could eventually run with very little intervention from him.

They also get into one of dentistry's biggest blind spots: money. Tarun explains why dentists shouldn't make financial decisions for their patients, why leading with insurance often creates unnecessary friction, and why understanding the patient's real reason for wanting treatment matters more than explaining every clinical detail.

The bigger lesson is about how dentists define success. You don't need to become a sleep-only practice or match the biggest names in the industry. Sometimes success is adding a few thousand dollars, stacking small wins, and building something sustainable over time.

What's on the Menu

• Why dentists overcomplicate sleep before they ever get started
• The runway most practices underestimate when building a sleep program
• Treating sleep like a startup inside your existing practice
• Why financing belongs in the treatment conversation
• The difference between a chief complaint and a chief disability
• Why your team shouldn't be asked to "sell" sleep devices
• The comma-not-decimal mindset for making better business decisions

A Few Threads You'll Hear

Give the program a real runway. Tarun didn't see meaningful success overnight. He explains why sleep needs time, resources, clear goals, and someone who actually owns the process, rather than trying to squeeze it between other responsibilities.

Stop making financial decisions for patients. Patients may have insurance and still choose to pay. Tarun's approach is to explain the benefit, present the price, offer monthly payment options, and let the patient decide what works for them.

Find the chief disability. The clinical details matter, but they're rarely what moves someone to act. Tarun explains why the better question is how sleep is affecting the patient's actual life, whether that's getting kicked out of the bedroom, feeling exhausted, or wanting to be around for their kids.

Think in commas, not decimals. Dentistry can get obsessed with saving a few dollars while missing much bigger opportunities. Tarun shares the mindset his father taught him: stop chasing home runs, stack smaller wins, and make decisions based on the bigger picture.

Resources & Links

• Dr. Tarun Agarwal - practicing dentist, practice owner, educator, and co-host of sleep apnea implementation training through 3D Dentists
• Dr. Erin Elliott - general dentist and dental sleep educator who teaches alongside Dr. Agarwal through 3D Dentists
• 3D Dentists - referenced throughout the episode for its sleep apnea training and business education
• Paul Homoly - credited by Dr. Agarwal for the concept of focusing on a patient's "chief disability" rather than only the traditional chief complaint

The Big Idea

Sleep doesn't fail because dentists can't learn the clinical side. It fails when they treat it as an occasional procedure rather than something that requires attention, ownership, and time.

Give it a runway. Put someone in charge. Get more patients tested. Understand what actually matters to them. Then let the process build.

As Tarun puts it: if you treat it like a stepchild in the practice, you will get stepchild results.

Press play.

Most dental sleep courses are built for sleep-only practices. So when a general dentist tries to copy that model, the workflow buckles, the team stalls, claims get denied, and less than 5% ever make it off the starting line.

Dr. Erin Elliott runs a thriving general practice and treats a lot of sleep. In this episode, she and Jason Tierney get into what actually works when you want to do both, and why the way most dentists start almost guarantees they'll quit.

Her first year? Three appliances. Then she stopped forcing the sleep-only playbook and built a process that fit a general practice. She talks through the long runway it takes, why leading with insurance is a trap, and how she went from three cases a year to blocking off whole days for sleep.

The turning point wasn't a system or a billing hack. It was getting out of her own way and handing the program to a sleep champion who owned it, plus a hard look at the small early mistakes that were quietly killing case acceptance.

If you want to treat more sleep patients without going all-in on sleep, this one's for you. And if you're weighing full-time sleep, you'll hear the other side of that argument too.

What's on the Menu

• Why less than 5% of practices ever get their sleep program off the ground
• The one thing to stop leading with, and what to lead with instead
• Building a workflow that fits general dentistry instead of fighting it
• The hire that changes everything, and where to find them
• The early mistake that was quietly killing her case acceptance
• Reading a sleep study so the patient has the light-bulb moment
• When medical insurance actually belongs in the picture

A Few Threads You'll Hear

Give it a long runway. Sleep isn't a graft class you implement the Monday after. Dr. Elliott explains why the practices that quit almost always quit right before it clicks.

Lead with value, not insurance. An oral appliance can look like a piece of plastic or like a life back. The difference is entirely in how the conversation is run, and that's a soft skill most dentists were never taught.

Make it team-led. The dentist can't be in every op at once. Hear how she got hygienists, assistants, and the front desk speaking about sleep with real confidence, starting with the team's own families in the chair.

Find your sleep champion. The single biggest unlock in her practice, usually someone promoted from within, given autonomy and the freedom to fail.

Resources & Links

• Dr. Erin Elliott — speaker, educator, and dental sleep bio: erinelliottdds.com
• Sleep Apnea Implementation Course (Dr. Elliott's hands-on training, via 3D Dentists): 3d-dentists.com/courses/sleep-apnea-implementation
• Dr. Tarun "T-Bone" Agarwal / 3D Dentists — credited for the "don't give away sleep studies" lesson, and a future guest: 3d-dentists.com
• Episode 18 with Dr. Mark Murphy — the communication and body-language conversation Dr. Elliott references: https://open.spotify.com/episode/1UiyHJMcTBgwMJ2rnwZCTA?si=6465280bef01484d

The Big Idea

You don't need a sleep-only practice to change lives. You need a reason to help, a realistic runway, and a team that owns it.

Even three to five cases a month is a handful of people who sleep better, and who tell everyone they know.

Dr. Elliott's challenge to every dentist on the fence: if not us, who?

Press play.