Sleep Apnea – Role of the General Dentist
Main article: Breathing Easier
Following a diagnosis from an accredited sleep study, and when appliance therapy is recommended by a sleep doctor and selected by the patient, the dentist will construct an oral appliance and manage patient follow-up care and treatment, in collaboration with the patient’s physician. According to Keith Thornton, DDS, a general dentist in Dallas and inventor of the Thornton Adjustable Positioner® (TAP®) oral appliance for sleep apnea, making an oral appliance to manage sleep apnea is similar to making a bite guard. The dentist takes an upper and lower impression and measures the protrusive range of motion, starting from where the teeth come together and then pushing the jaw forward as far as it can go. The patient must be comfortable in this position and the airway must be open.
Anatomical bite issues, range of motion in the joints, mobility of the teeth, small mouths, and recessed chins require evaluation to determine if the patient is a good candidate for appliance therapy. “Dentists can’t learn all of this in a few hours and be ready to hit the ground running,” cautions Dennis Bailey, DDS, FAGD, an AGD member in Colorado who specializes in the treatment of temporomandibular disorders (TMD) and the use of intraoral appliances to manage snoring and sleep apnea. “It takes a series of courses to get it right.” All dentists should be aware of and understand the effect of these oral appliances on the temporomandibular joints, adds Ronald Perkins, DDS, MS, a Dallas orthodontist who focuses on managing OSA with intraoral devices. A correctly fitted appliance for sleep apnea brings the jaw forward and supports the TMJ.
See also: Sleep Apnea – Studio Dentaire
Moisture Tolerant Sealant – Clinical Technique with Embrace Wetbond Pit and Fissure Sealant
Main Article: Moisture Tolerant Sealant
See also: Dental Sealant – Studio Dentaire
When using Embrace WetBond Pit and Fissure Sealant, etched enamel surfaces are lightly dried and left slightly moist during sealant placement. Although the clinical use of pit-and-fissure sealants is relatively straightforward, errors in technique can result in premature sealant failure. For Embrace WetBond, following the directions below will contribute to clinical success.
Examine and evaluate the occlusal surfaces to be considered. In the case shown (Fig. 4), sealants had been placed eight years previously. At evaluation, the mandibular first molar needed sealant reapplication, and the mandibular second molar required a preventive resin restoration because of caries on the distal surface. This technique will focus on the sealant placement for the first molar.
Isolate the field with a rubber dam. Other methods of isolation include the use of cotton rolls, which should be changed frequently to keep the area dry, and the use of an Isolite (Isolite Systems, Santa Barbara, CA), a combined bite prop-high velocity evacuator-oral illumination device. If using cotton rolls, consider the use of a Garmers cotton roll holder to stabilize the position of the cotton rolls.
After isolating the teeth, clean the tooth surfaces with a water-pumice paste with a disposable prophylaxis angle in a slow-speed handpiece. Other methods for cleaning teeth before sealant placement include using a non-fluoride, pumice prophylaxis paste and an air abrasion device.
After cleaning, rinse the teeth surfaces thoroughly with an air-water spray and then dry.
Etch the teeth for 15 seconds with a phosphoric acid etchant. In this case, Etch-Rite (Pulpdent Corporation) was used to etch the teeth (Fig. 5). Then rinse the etchant from the teeth with an air-water spray for 10 seconds, followed by very light drying of the treated surfaces. With Embrace WetBond, the typical dull, frosted appearance of the etched surface is not desired. Rather, the surface should be lightly dried and very slightly moist with a glossy appearance. To accomplish this, compressed air or a cotton pellet should be used to remove the excess moisture (Fig. 6). There should be no visible pooling or drops of water on the tooth surfaces.
Apply Embrace WetBond to the occlusal surface using the supplied applicator tip (Fig. 7). After dispensing, use a micro-brush applicator to place the sealant, covering all pits and fissures and extending onto the cusp ridges. The final sealant thickness upon application should be at least 0.3mm.
After application, light cure the sealant for 10 seconds, holding the light curing probe at right angles to the occlusal surface as close as possible using a high intensity LED curing light. In this case an Allegro (Den-Mat, Santa Maria, CA) light was used (Fig. 8).
Evaluate the sealant for retention, seal of the occlusal surfaces and occlusion (Fig. 9).
Although the most common practice is to apply the pit and fissure sealant directly to the etched enamel, various studies have evaluated the efficacy of using an intermediate adhesive resin before sealant placement. The use of an intermediate adhesive resin has the potential to increase sealant retention with traditional sealants, but the disadvantage with this procedure is that it increases the number of steps and adds cost in time and materials. It also increases the potential for contamination when treating a paediatric patient, possibly resulting in premature loss of the sealant.37 With Embrace WetBond Pit and Fissure Sealant adhesive bonding agents are not required. Although saliva contamination should be avoided whenever possible, it does not affect the bond of Embrace WetBond sealant.
Sleep Apnea – Children and OSA
Main article: Breathing Easier
Despite articles in the “Journal of Paediatrics” and the sleep literature, “we’re just starting to scratch the surface when it comes to children and OSA,” says Dennis Bailey, DDS, FAGD, and AGD member in Colorado who specializes in the treatment of temporomandibular disorders (TMD) and the use of intraoral appliances to manage snoring and sleep apnea. Sleep problems often occur in children because of congenital issues, but Dr. Bailey believes that children who are sleep-deprived need to be evaluated by both general dentists and paediatric dentists.
“No child should snore, in my opinion,” says Ronald Perkins, DDS, MS, a Dallas orthodontist who focuses on managing OSA with intraoral devices. “If they do, they should be evaluated by an ENT.” Yosh Jefferson, DMD, MAGD, a general dentist who has limited his practice to orthodontics, TMD therapy, and major oral rehabilitation cases, says that morning crankiness or behaviour problems at school could signal a warning for OSA; long, narrow faces may indicate sleep deprivation; and a bluish hue under the eyes can be a sign of allergies or oxygen deprivation. According to Dr. Jefferson, children who have sleep disturbances are often smaller because they lack vital growth hormone production during lesser stages or rapid eye movement (REM) sleep. Finally, Dr. Bailey notes that sleep deprivation can cause attention and behaviour problems and increase the risk of obesity.
See also: Sleep Apnea – Studio Dentaire
Sleep Apnea – The Future of Dentistry and OSA
Main article: Breathing Easier
Devices like the Remmers Sleep Recorder or the Watch-PAT could make it possible for dentists to play a larger role in treating OSA, says Yosh Jefferson, DMD, MAGD, a general dentist who has limited his practice to orthodontics, TMD therapy and major oral rehabilitation cases. Both of these are take-home devices that measure oxygen saturation in the patient’s blood as well as other indicators of sleep disturbances. Results can be sent electronically to the patient’s physician for review and to evaluate whether the oral appliance is doing its job to decrease the patient’s AHI rate.
“We’re not the definitive diagnosticians for sleep apnea yet,” says Dr. Davis. “No dental schools have said that this is an area of dental responsibility but in the future I think it will be.” “I’m convinced that the dental profession can save a lot of lives,” adds Dr Perkins.
“Dentists aren’t in this alone,” says Dr Shapira. “They can work as a team with other practitioners – ENTs, pulmonologists, and sleep centers – in the best possible way and in the best interest of the patient.
See also: Sleep Apnea – Studio Dentaire
Moisture Tolerant Sealant – Identifying Teeth that Need to be Sealed
Main Article: Moisture Tolerant Sealant
See also: Dental Sealant – Studio Dentaire
Based upon clinical studies, teeth can be classified as sound or incipient-at risk. Heller and colleagues compared teeth that were sound and at risk for caries progression by comparing sealed and unsealed teeth in the same mouth.9 Teeth that were initially sound had a caries rate of 13% at five years when unsealed and 8% when sealed. Teeth that were classified as incipient-at risk had a caries rate of 52% at five years when unsealed compared to only 11% when sealed. While the benefit of sealing sound teeth (a difference of 13% to 8%) may not be significant, there is no doubt that sealing teeth at risk has a substantial benefit.
Using a dental mirror and explorer during a clinical examination, a clinician makes the observation that there are pits, fissures and grooves on the surfaces of teeth. The diagnosis of carious pits and fissures, however, can often be daunting especially with recent changes in the diagnosis and treatment of caries. The concept of using a sharp explorer for the detection of pit and fissure caries has been discarded in favour of the visual appearance of enamel, radiographic diagnosis and new types of devices. Even with newer technologies for caries diagnosis, it is still difficult to chart the progression of the disease since considerable variation is noted when this type of caries is examined microscopically.
Pits and fissures can be classified according to their appearance in cross section, namely: V-type, U-type and I-type pits and fissures. In most cases the shape of the pit or fissure is such that it is impossible to clean. Food and bacteria become impacted into the invaginations of occlusal surfaces. This explains the high susceptibility of occlusal pits and fissures to dental caries when compared to the lower caries rate of buccal pits with the same morphology.
The earliest sealants were resin adhesives placed with an acid-etch technique that sealed caries-susceptible pits and fissures. Clinical research trials with sealants demonstrated their effectiveness. A four year clinical evaluation of sealant retention comparing sealed with non-sealed teeth demonstrated an overall 43% decrease in the prevalence of caries effectiveness with a significantly better sealant retention on premolars (84%) than molars (30%).21 A later, seven-year study by Mertz-Fair-hurst and co-workers reported 66% complete sealant retention and 14% partial retention. Sealant loss was 20% while there was a 55% reduction in caries rate for the sealed teeth versus the unsealed teeth. In a more comprehensive 10-year observation of over 8,000 sealants placed on permanent first molars, there was 41% complete sealant retention at 10 years and a 58-63% retention rate over seven to nine years.
Simonsen has reported on the retention and effectiveness of a single application of sealant to permanent first molars at both 10 and 15 years.24-25 The results indicated that at 10 years, 56.7% of sealants were completely retained and 20.8% were partially retained. In the sealed group, 84.4% of the pit and fissure surfaces of the first molars were caries free. Of the unsealed, matched-pair group, only 31.7% of the first molars were caries free. At 15 years, 27.6% of the teeth still had complete sealant retention with a further 35.4% maintaining partial retention. Of those teeth sealed, 68.7 were caries free when compared to the matched pair of unsealed first molars, of which only 17.2% were caries free. Also, sealant success is multifactoral. Technique, fissure morphology and the characteristics of the sealant contribute to clinical success.
A basic concept of 5-10% of sealant loss per year has been seen when one reviews published sealant data. This data reveals the importance of teeth with sealants having periodic revaluation and reapplication if necessary. If one were to find a negative aspect of sealants in the realm of dental prevention it would be the failure of clinicians to revaluate and reapply sealants when they are lost or failing. Table 1 lists considerations for early sealant failure. Based upon the data reported in the aforementioned clinical research reports, it is important that patients with sealants have periodic revaluations and reapplication of sealant if necessary. When a sealant needs to be repaired or reapplied, the tooth should be treated as if an initial sealant is being placed.
When sealants are placed on the occlusal surfaces of posterior teeth, they can interfere with the occlusion. For the child with a transitional dentition this is not problematic but for the adolescent and young adult with a fully erupted dentition it can be problematic for retention. In order to avoid any problems and to increase the retention of the sealant it is important that the following be done:
- For fully erupted dentitions, check the occlusion with articulating ribbon to evaluate any potential occlusal interferences. If the tooth has occlusion in the areas where the sealant placement and retention is desired, it is recommended that a fissurotomy be performed to create additional space for thickness of the sealant to increase retention.
- Sealant should be applied to cover the cusp ridges to a thickness of at least 0.3mm.
Sleep Apnea – Drawbacks to Oral Appliances
Main article: Breathing Easier
Oral appliances can alter the bite, change or move teeth, and cause the patient discomfort or even pain. Excessive salivation could discourage patients from using the devices. “Patients salivate like crazy when they first start lo wear the appliances,” Dr. Pancer says. “They should come in regularly for checkups, to circumvent problems. You might get dramatic changes in a short time, or it might take a long time for problems to develop.”
Bite changes are the most common drawback, says Dr. Bailey. Transient bite issues exist briefly, typically in the first half hour after the device is removed. Dr Thornton recommends a special oral exercise for patients to do after removing the appliance, in order to reset the joint. Dr. Perkins has modified the TAP to balance the bite in the back. “Most OSA patients clench their teeth,” he explains. “Balancing the device with two posterior pads alleviates some of that stress.”
Some patients have no problems at all with appliance therapy. If the apliance is balanced, tooth pain, joint pain, and bite changes should be minimal. “Once you’ve worked several cases, when a patient comes in with a problem, you’ll know what it is immediately.” says Dr Perkins.
A bite change is a minor issue, however, compared to the morbidity and mortality of sleep apnea, says Dr. Thornton. Patients must understand the follow-up care necessary to manage sleep apnea successfully with an oral appliance. Be sure that patients understand that if the appliance isn’t working, they need to see their physician and get CPAP instead.
Internet devices and products advertised to treat snoring are risky at best for treating OSA. “Snoring is a symptom but it isn’t sleep apnea,” says Dr Ash. A severe risk of using snoring devices to treat sleep apnea is that the device might silence a noisy apneic, perhaps forever, warns Dr Shapira. Oral appliances that aren’t custom made and do not fit well can become dislodged during the night and choke the wearer,” he says. Finally Dr Perkins says that sprays and pillows are a waste of money and are not indicated for OSA.
See also: Sleep Apnea – Studio Dentaire
Sleep Apnea – Treatment Options
Main article: Breathing Easier
Continuous positive airway pressure (CPAP) or surgery is the most commonly recommended course of action. CPAP works like an air splint forcing air pressure through a small nasal mask that the patient wears while sleeping, keeping the throat open so that the wearer can breathe normally, says Dr Pancer. CPAP has been shown to work for patients with moderate to severe OSA; however, some patients simply can’t tolerate the device and/or won’t wear it. Meanwhile, according to Dr. Ash, surgery often is too extreme to be the first line of treatment. “It’s like sending a patient with chest pain straight to the cardiovascular surgeon,” she says.
In cases where CPAP isn’t tolerated and surgery is too radical, oral appliances might be the answer. “CPAP can save and change lives,” says Dr. Ash, “and in the right patient population, oral appliances can do the same thing.”
An oral appliance designed to treat OSA gradually brings the jaw forward which opens the airway. Dr. Pancer says that in clinical trials, oral appliances have proven to be effective for patients with mild and moderate OSA and they are indicated for treatment if the patient prefers the oral appliance to CPAP. However, he emphasizes, dentists need to know which oral appliances are available for treating OSA and how and when to use them.
Dozens of appliances including the TAP, PM Positioner, Elastic Mandibular Advancement (EMA) and SomnoDent MAS, are specified for treating sleep apnea. However, devices advertised to silence snoring are not indicated for OSA.
Screw mechanisms on oral appliances move the jaw forward in quarter-millimetre increments, says Dr Thornton. During a series of follow-up visits, the dentist gradually adjusts the appliance and tests the fit, which has to be comfortable enough for the patient to wear all night. Dr. Shapira advises that patients should be forewarned because initially the bite will feel strange. Not wearing the appliance because of pain or discomfort will defeat the purpose and put the patient at risk, so close monitoring of appliance use is important.
The location of the adjustment mechanism varies from appliance to appliance. For example the adjustment mechanism for the TAP is located in the front of the appliance. “The TAP provides an easy way to position the jaw while the appliance is seated in the patient’s mouth, speeding up the titrating process,” explains Dr Pancer. “Most oral appliances must be removed to titrate the device”.
Dr. Thornton has adapted the TAP so that it can be used in combination with CPAP. “The custom mask treats patients who are on a ventilator,” says Dr Thornton. Among those for whom Dr. Thornton designed the PAP-TAP is a patient in an iron lung. Dr. Thornton receives referrals from all over the country and works closely with Joe Viroslav, MD, a pulmonologist.
See also: Sleep Apnea – Studio Dentaire
Moisture Tolerant Sealant – Overview
Main Article: Moisture Tolerant Sealant
See also: Dental Sealant – Studio Dentaire
Sealants are highly effective at preventing pit and fissure caries. The primary measure of sealant efficacy is their retention. Typically sealant retention is higher on occlusal surfaces than for buccal and lingual pits and fissures. Based upon clinical studies, the loss of sealant from occlusal surfaces averages 5-10% a year while the loss of sealant for buccal and lingual surfaces increases to 30% per year. Based upon the clinical evidence of sealant retention rates, it can be deduced that the occlusal surfaces of molars are easier to protect from caries than buccal/lingual surfaces.
The decision to place a sealant should be based on caries risk. Because the occlusal surfaces of permanent first and second molars are at the greatest risk of becoming carious, practitioners face a clinical dilemma in deciding the appropriate time to place a pit and fissure sealant. Although the optimal time to place a sealant is when an at-risk tooth erupts, there are anatomic limitations that make the placement of sealants less reliable at that time.
During the eruption process, permanent molars break through the gingival tissues leaving excess tissue, an operculum, over the distal surfaces that can interfere with the success of a sealant. The benchmark study that evaluated sealant retention on at-risk fully erupted teeth and partially erupted molars demonstrated a significant difference in resin sealant retention between the three distinct groups. Group 1 consisted of fully erupted molars. Group 2 consisted of molars with gingival tissue at the level of the distal marginal ridge. Group 3 were those molars that had gingival tissue over the distal marginal ridge.
The findings of this three-year study were that no sealant replacements were necessary for the fully-erupted, sealed teeth in Group 1. The molars in Group 2 that had a gingival tissue operculum at the level of the distal marginal ridge had a 26% sealant replacement rate. For group 3 with gingival tissue over the distal marginal ridge at the time of placement, the replacement rate rose to 54%. This study clearly demonstrates the importance of field isolation and access when making the decision to place a traditional resin-based sealant. In fact, the controversy whether to seal and not to seal clearly hinges on the retention potential of the sealant. A poorly placed sealant will have leakage, partial or complete sealant loss, and will contribute to pit and fissure caries on at-risk teeth.
Many published clinical studies demonstrate that sealants are highly effective in preventing caries. Dentists and dental hygienists want to provide patients with the most conservative, effective and minimally invasive treatment of pits and fissures. For caries prevention, it is advantageous to seal teeth as early as possible. Unfortunately, it is difficult or impossible to achieve isolation when the permanent teeth are first erupting, and traditional resin sealants require placement on a dry enamel surface. In order to ensure sealant success the clinician is inclined to wait until the tooth has more fully erupted and isolation can be achieved. Timing of sealant placement is critical, however, and often when the child returns for the next recall appointment, caries has invaded the unsealed, at-risk pits and fissures. The treatment then requires an invasive tooth preparation and placement of an adhesive composite resin restoration.
Traditional sealants typically used in dentistry are hydrophobic and require a dry field. Recently there has been a significant improvement in resin-based sealants with the development of a unique, moisture tolerant chemistry, Embrace WetBond Pit and Fissure Sealant (Pulpdent Corporation, Watertown, MA, USA). Embrace sealant is hydrophilic, taking advantage of the moisture that is ever-present in the mouth. It is acidic in the uncured state, but after light curing it has a neutral pH and has physical properties similar to other commercially available sealants.
Embrace WetBond Pit and Fissure Sealant contains no Bis-GMA and no Bisphenol A and uses a hydrophilic resin chemistry that is completely different from the typical hydrophobic Bis-GMA resins used in the current sealants. Embrace incorporates di-, tri- and multifunctional acrylate monomers into an advanced acid-integrating chemistry that is activated by moisture. When placed in the presence of moisture, Embrace WetBond spreads and forms an intimate association with tooth structure. No bonding agents are required. Enamel and dentin inherently contain water. A typical sealant will not spread over a moist tooth surface due to its hydrophobic nature (Fig. 1). The unique Embrace chemistry is miscible with water and flows into the moisture contained in etched enamel (Fig. 2).
When using Embrace, there is a change in clinical protocol from traditional sealants. The etched enamel surfaces of the teeth to be sealed with Embrace should be slightly moist during sealant placement. A practice based 4-6 year clinical research study in a paediatric dental practice evaluated this unique moisture tolerant, resin-based sealant in the prevention of occlusal pit and fissure caries. This long-term study evaluated 334 permanent first and second molars sealed on the occlusal surfaces with Embrace WetBond Pit and Fissure Sealant. Of the 334 teeth sealed with Embrace, sealants on 299 teeth remained intact after four to six years (89.5% retention over a period of 4-6 years). Thirty-two teeth in this study (9.5%) were re-sealed during routine recall examinations during the course of the study. Only three teeth (less than 1%) developed pit and fissure caries and needed to be restored with a composite resin. These long-term recalls, which are 99% caries-free, are evidence of excellent durability, sealing ability and cavity protection afforded by the Embrace WetBond sealant (Fig. 3).
Sleep Apnea – Working with Sleep Physicians
Main article: Breathing Easier
Dr Chediak believes that the intermingling of medical and dental treatment can be a complementary situation, where one’s success depends on the other. Care of OSA patients provides a great opportunity for dentists and sleep physicians to work together. “Dentists can be very valuable in the treatment of sleep apnea”, he says. As sleep physicians we know how to look at the health outcomes and evaluate if treatment is successful. But I don’t have the skill set to construct an oral appliance.”
However Dr Ash says that dentists are left out of the patient care because diagnosis and treatment of OSA hasn’t been a priority and a lot of physicians haven’t received adequate training for follow-up. “Some physicians are not familiar with the processes and the resources. It depends a lot on the physician’s frame of reference,” she explains. Thus the dentist might refer the patient to his or her physician for a follow-up but the process could stop right there if the doctor is unsure of how to obtain a diagnosis. “We all need more education,” says Dr. Ash.
Although the fear of litigation or learning a new aspect of the profession are genuine concerns they shouldn’t prevent dentists from being leaders in the field, says T. Bob Davis, DMD, FAGD, an AGD spokesperson and general dentist in Dallas, Texas. “Dentists should be aware of how sleep apnea presents itself and what the disorder can do to general health in addition to knowing how to design the treatment appliance,” he says, adding that dentists and sleep physicians have to work together to provide successful patient care.
“Sleep medicine is a wonderful field,” says Dr. Pancer. “It changed my life because we were able to find help for patients. You develop a different relationship with other physicians and help each other.”
“Patients with OSA can die, so we desperately need dentists to identify patients with sleep apnea and to learn to make the treatment appliances,” says Dr. Ash. “We also need medical doctors to reach out to dentists and embrace these methods to help patients.
See also: Sleep Apnea – Studio Dentaire
Moisture Tolerant Sealant – Discussion
Main Article: Moisture Tolerant Sealant
See also: Dental Sealant – Studio Dentaire
Clinically, a moisture-tolerant sealant makes sense. Unless a clinician is using a dental dam, the oral cavity is 100% humidity with a temperature that mimics the Amazon jungle. Typically, when a clinician places a dental mirror in a patient’s mouth, it fogs up due to the humidity within this closed system. This atmospheric moisture assures that even the driest tooth surfaces contain moisture. Also, because the permanent first molars are the teeth at greatest risk, it is desirable to seal them immediately upon eruption when isolation is the most difficult. A moisture-tolerant resin sealant is necessary to ensure the optimal chance for successful retention. Up to this point in time, the only moisture tolerant sealants were glass ionomers. Their mechanism of adhesion is ionic bonding, not micromechanical retention to an acid-etched enamel surface. In studies with glass ionomer sealants it has been reported that at three years retention was only 31%.38 Pardi and co-workers also reported low sealant retention rates with glass ionomers.
The available information at the present time suggests that the optimal characteristics for a pit and fissure sealant are a resin-based material that is moisture-tolerant, light-cured, and lightly filled with color so that sealant detection and evaluation at recall is possible.
The introduction of a moisture tolerant resin-based sealant (Embrace WetBond) will eliminate some of the problems seen in the past with typical, hydrophobic resin-based sealants. In a dental practice, pit and fissure sealants are best applied to high-risk populations by dentists or trained auxiliaries using an etch and rinse technique followed by placement of a moisture tolerant sealant. Practitioners will find that pit and fissure sealants can be more successful for caries prevention than ever before possible if they adhere to the technique described in this article.
