In this episode, Dr. Erin Elliott and Jason Tierney sit down with Dr. Madan Kandula to explore a part of airway care that too often gets overlooked: the nose.
Dr. Kandula is a board-certified ENT and the founder/CEO of ADVENT, an ENT practice built around treating airway concerns across what he calls the "breathing triangle." In just a few years, what started as a single location in Milwaukee has grown into 40 clinics across 6 states.
The conversation makes the case that nasal breathing is one of the foundations of successful sleep treatment. Dentists are often the first to notice nasal obstruction in their patients, but the field hasn't always given them a clear next step or a trusted ENT partner to hand it off to. Dr. Kandula explains how improving nasal function can help patients better tolerate and benefit from CPAP or oral appliance therapy, and how the right partnerships can close that gap.
This one is for anyone who has ever spotted an airway problem they weren't equipped to solve alone.
What's on the Menu
- Why nasal breathing is essential to airway health
- Understanding the breathing triangle
- Expanding access to nasal and oral appliance treatment
- Strengthening collaboration between dentists and ENTs
- Balancing clinical quality, growth, and mission
The Breathing Triangle
Dr. Kandula describes the breathing triangle as a simple framework for understanding the airway.
The two nostrils form the top points of the triangle, and the back of the throat forms the bottom point. Together, these areas represent the three passages through which a person can breathe.
Patients dealing with snoring, sleep apnea, nasal obstruction, or recurring sinus concerns may have problems in more than one part of this connected system. Treating the throat without evaluating the nose can leave an important part of the airway unaddressed.
The framework gives patients and providers a clearer way to see how the nose and throat work together.
Nasal Breathing as the Foundation
Dentists working in airway care already understand how much nasal breathing matters. What's often missing is a clear path for what to do once a concern is identified.
Without a trusted ENT who understands sleep, oral appliances, and collaborative care, a provider may have little choice but to note the obstruction and move forward with treatment.
Dr. Kandula argues that nasal breathing can play a major role in maximizing the effectiveness and tolerability of both CPAP and oral appliance therapy. His goal with ADVENT has been to provide patients access to effective outpatient nasal and sinus treatments while partnering with dentists who provide OAT.
Good breathing starts with nasal breathing.
Simple Solutions Before Bigger Surgery
One of ADVENT's central principles is to start with the simplest appropriate treatment.
Dr. Kandula explains that many nasal and sinus procedures can be performed in the office under local anesthesia. Depending on the patient, these may include turbinate reduction, treatment of the nasal swell body, or balloon sinuplasty.
The point isn't to claim every patient can avoid an operating room. It's to make sure patients have access to less invasive options before moving straight to more intensive surgery.
Dr. Kandula describes this as harvesting the low-hanging fruit first. Address the internal obstruction, evaluate the result, and move further up the treatment ladder only when necessary.
Nasal Collapse and Root Causes
The same principle applies when a patient experiences nasal sidewall or valve collapse.
External nasal dilators and similar products can provide relief in the right situation. But Dr. Kandula cautions against assuming the visible collapse is the only concern.
Internal narrowness may be increasing the effort required to breathe through the nose. Treating that internal obstruction first can reduce or eliminate the collapse without requiring additional treatment to the nasal valve.
When the valve still needs support, options may include radiofrequency treatment to stiffen the cartilage or a small dissolvable implant placed beneath the tissue.
The sequence matters: identify the root cause, begin with the simplest effective option, and escalate only when needed.
Oral Appliance Therapy and Access
Oral appliance therapy has an important place within ADVENT's breathing triangle approach.
Opening the nasal passages can improve breathing, but it doesn't automatically resolve the throat-related obstruction associated with sleep apnea. Patients may still need CPAP, an oral appliance, surgery, or another appropriate treatment.
As ADVENT expanded, partnering with local sleep-focused dentists became more complicated and difficult to scale. The availability and experience of potential partners varied from one market to the next.
That raised a bigger question: how can an organization consistently provide appropriate oral appliance therapy across dozens of locations without sacrificing quality?
Dr. Kandula doesn't claim to have the final answer. He describes it instead as an ongoing effort to expand access while continuing to work with capable clinicians, companies, and technologies.
The Direct-to-Consumer Debate
The conversation also takes on direct-to-consumer oral devices.
Dr. Kandula views these companies as attempts to solve a legitimate problem: many patients simply don't have access to oral appliance therapy. Their goal of expanding access has real value, even when providers disagree with how the service is currently delivered.
Jason adds an important distinction. The goal of delivering treatment at scale may be admirable, but some current models raise concerns about impressions, clinical oversight, fit, and the quality of care.
The challenge isn't choosing between access and quality. It's building a model capable of delivering both.
Collaboration Across ENT and Dentistry
Dr. Kandula believes sleep and breathing concerns give ENTs a real opportunity to make a difference in patients' lives. Yet many specialists stay focused on the narrower set of procedures they were trained on.
Dentists can find themselves in the same position, and for the same understandable reason.
A general dentist may be comfortable providing a familiar appliance, while sleep testing, airway evaluation, medical collaboration, and long-term follow-up sit outside the systems the practice was built around. That's a training and infrastructure gap, not a lack of ability.
Better airway care asks professionals on both sides to look beyond their own corner of the problem. Dentists need dependable partners for nasal and sinus concerns. ENTs need to recognize when a patient may benefit from oral appliance therapy or another sleep-focused intervention.
Patients do better when the providers responsible for the nose, throat, teeth, and sleep condition stop treating those areas as separate territories.
Retraining Mouth Breathing
Opening the nose doesn't automatically undo a long-standing mouth-breathing habit.
A patient may have relied on mouth breathing for years because nasal breathing was difficult or impossible. Once the obstruction is treated, the physical necessity may be gone, but the learned behavior can remain.
Myofunctional therapy can help patients retrain these patterns, though cost and limited insurance coverage can create barriers to participation.
Dr. Kandula also cautions against treating mouth taping as a universal solution. It shouldn't be used as a shortcut when nasal obstruction or untreated sleep apnea hasn't been properly evaluated.
Correcting the structure is a major step. Retraining the habit is often the rest of the job.
Mission Before Scale
After growing ADVENT from one location to 40 clinics, Dr. Kandula offers a direct warning about expansion: growth for the sake of growth is rarely enough.
His second location was hard. Copying a successful office across town didn't produce the same result.
The turning point came when he identified a larger purpose. Patients across the country lacked access to simple, effective airway treatments, and he believed he was in a position to help solve that problem.
The mission made the difficulty of expansion worth accepting.
Scale was never the original destination. It became a tool for increasing access.
The Fork in the Road
Dr. Kandula's central business advice is to make difficult decisions as binary as possible.
When you face a problem or an opportunity, reduce it to a fork in the road. Based on the information available, decide which direction to take.
This creates clarity and cuts down on the temptation to stay stuck in a victim mindset. It also forces healthcare professionals to acknowledge the trade-offs behind their choices.
Building a serious sleep program may mean giving up another part of the practice. Opening another location may mean accepting financial and operational risk. Pursuing one opportunity usually means declining another.
The easier path isn't always wrong, but it should be chosen on purpose. Anything worth building will involve uncertainty, sacrifice, and risk.
The Big Idea
Better sleep treatment begins with seeing the airway as one interconnected system.
The nose affects the throat. Nasal obstruction can shape the success of CPAP and oral appliance therapy. Long-standing mouth breathing can persist even after the physical obstruction is gone.
No single provider can address every part of that system alone, and none should be expected to.
Dentists, ENTs, sleep professionals, and myofunctional therapists each bring an essential piece of the solution. The goal isn't to protect professional territory. It's to give patients access to the right care without making the process more complicated or invasive than it needs to be.
Start with the foundation. Understand the entire breathing triangle. Choose the simplest effective treatment. Build partnerships capable of handling what comes next.
And when it's time to grow, make sure the mission is strong enough to justify the risk.