Sleep Apnea – Documenting your Concerns
Main article: Breathing Easier
Sleep apnea is considered a medical disorder. ”The dentist’s role in diagnosis lies in recognizing a patient who might be at risk for sleep apnea and in making the appropriate referral to the patient’s physician or to a sleep specialist,” says Dr Bailey, DDS, FAGD, an AGD member in Colorado who specializes in the treatment of temporo-mandibular disorders (TMD) and the use of intraoral appliances to manage snoring and sleep apnea.
When Dr. Bailey was in general dental practice he sent letters to patients’ physicians whenever he detected signs of a medical disorder including sleep apnea. This was unheard of at the time, he says, but these days, it’s medically and legally prudent to inform both patients and their physicians of your suspicions. “Anyone who has a license to practice health care is obligated to identify all medical conditions and to notify the patient,” he says. Reporting possible sleep apnea is no different than noting a suspicious looking mole on the face, signs of high blood pressure or indications of diabetes. Dentists also need to be diligent about follow- up. “Be sure to document everything,” says Dr Shapira.
That documentation could prove valuable from a legal standpoint, for some OSA patients sleep deprivation could compromise their immune system, which in turn could affect how they respond to dental treatment. In addition, notes Dr Ash, conscious sedation could impair the brain of a patient with OSA, and the brain might fail to jump start the breathing process in such a situation. “Dentists have to manage the treatment of patients with OSA differently,” she says.
See also: Sleep Apnea – Studio Dentaire
Sleep Apnea – Diagnosing OSA
Main article: Breathing Easier
If a patient complains about being tired and irritable all the time, it could be sleep apnea, says Eric Z. Shapira, DDS, MAGD, an AGD spokesperson in Montara, California. Patients frequently believe that they can’t have OSA, with many of them insisting that they don’t snore, he says. Patients typically view their symptoms as isolated conditions instead of recognizing that all of them combined could be the result of sleep apnea. They also tend to attribute a lack of sleep to external factors such as stress brought on by working long hours, having young children or worrying about the economy.
Look for bloodshot eyes, black circles around the eyes, and puffy eyes. Dentists also might see a coaling on the tongue from mouth breathing, or scalloping on the edges from clenched teeth says Dr Bailey, DDS, FAGD, an AGD member in Colorado who specializes in the treatment of temporo-mandibular disorders (TMD) and the use of intraoral appliances to manage snoring and sleep apnea. “Redness of the soft palate or an enlarged uvula or tongue also can be signs of OSA,” he adds.
Dr Shapira emphasizes the need to obtain a social history to understand the patient’s habits so that signs of other issues aren’t mistaken for OSA Excessive use of Listerine® for example, will dry out the mouth and could indicate a false positive. Breathing obstructions caused by smoking, alcohol use, or enlarged tonsils or adenoids also can be misleading. “It’s one thing lo note the signs, but you have to play detective and investigate causes too,” he says. “Dentists can get a lot of false positives which is why the social history is important.”
Keith Thornton, DDS, a general dentist in Dallas and inventor of the Thornton Adjustable Positioner” (TAP®) oral appliance for sleep apnea says that anecdotal reports rate the patient’s levels of daytime sleepiness which could predict signs of OSA. One such report is the Epworth Sleepiness Scale, introduced in 1991 by Dr. Murray Johns of Epworth Hospital in Melbourne, Australia. “The questionnaire draws an empirical correlation between the information collected on the questionnaire and other predictors, like the Mallampati Score, with the potential for detecting patients who could be at risk for OSA,” says Dr. Bailey.
OSA can include partial (hypopnea) or complete (apnea) closing of the pharynx while a person sleeps says Alejandro Chediak, MD, FACP, immediate past president of the American Academy of Sleep Medicine (AASM) and a Miami, Florida, board-certified specialist in internal medicine, pulmonary diseases arid sleep disorders. “The apnea hypopnea index (AHI) performed during a sleep study is currently the forerunner in the measurement of OSA severity.” AHI indicates the average number of apneas and hypopneas per sleep hour, measured in a sleep laboratory using polysomnography.
Dr. Pancer cautions that symptomology can be a real issue, adding that test results can be misleading. “I’ve seen patients with an AHI of 5, which is very low, yet they were symptomatic for OSA. My own AHI was 45, but I felt great even though my numbers indicated that I had severe OSA.”
Measuring adjusted neck circumference is another diagnostic tool that can be done in the office, a service Dr. Thornton offers in his practice. “The sleep test is a tool, but it is not the end-all” says Dr. Chediak. “It helps the medical doctor plan the best therapy”.
Dr Shapira favours using a conservative approach to rule out other causes such as craniofacial problems or allergies. He concedes that the problem may be sleep apnea but notes that treatments and sleep studies are costly and often are not covered by insurance. “Do your homework first and inform before you perform,” he says.
See also: Sleep Apnea – Studio Dentaire
Sleep Apnea – Physical Effects of OSA
Main article: Breathing Easier
The effects of OSA go beyond losing sleep for only one night. “We’ve become a society in which sleep is considered the one commodity that can be sacrificed to accomplish other tasks.” says Dr. Bailey, DDS, FAGD, an AGD member in Colorado who specializes in the treatment of temporo-mandibular disorders (TMD) and the use of intraoral appliances to manage snoring and sleep apnea. “But without restful sleep the body is in a constant state of fight or flight,” he adds. “It’s under stress.”
Going night after night without sleep wreaks havoc on the cardiovascular system. Studies show that patients with OSA are at increased risk for major cardiovascular disease such as heart attack and stroke. Sleep apnea also has been linked lo obesity, hypertension, diabetes, and joint problems. Dr. Ash, a pulmonologist and the medical director of the Sleep for Life Program, adds that sleep disorders are the cause of many common illnesses and can cause premature death. In addition, daytime sleepiness caused by sleep deprivation can lead to automobile accidents and other dangerous incidents.
See also: Sleep Apnea – Studio Dentaire
Sleep Apnea – Who is at Risk?
Main article: Breathing Easier
Obstructive sleep apnea (OSA) can and does occur at any age, but most victims fall into the middle and older age groups. In October 2003, the Journal of the American Medical Association (JAMA) reported that approximately one in five adults had at least mild OSA while one in 15 had moderate or severe OSA. The National Heart, Lung, and Blood Institute (NHLBI) division of the National Institutes of Health (NIH) reported in February 2006 that more than 12 million American adults had OSA. Other clinical estimates reach as high as 30 million. Despite the statistics, the disorder hasn’t reached a level of national awareness possibly because it often goes undiagnosed as a silent condition.
“The numbers regarding undiagnosed patients can be tricky,” says Dennis Bailey, DDS, FAGD, an AGD member in Colorado who specializes in the treatment of temporo-mandibular disorders (TMD) and the use of intraoral appliances to manage snoring and sleep apnea. Dr Bailey also teaches a university-based training program in dental sleep medicine at UCLA. “The bottom line suggests that there are a lot of people who have the symptoms and signs of sleep apnea, besides snoring, but have not been diagnosed.” Dr. Bailey estimates that when he was a practicing general dentist 10 years ago, roughly 40 percent of his patients showed some sign or symptom of sleep apnea.
Dentists are just as likely as the general public to develop OSA. For some, firsthand experience led them into the field of dental sleep medicine. “I had sleep apnea for almost 25 years and didn’t know it,” says Ronald Perkins. DDS, MS, a Dallas orthodontist who focuses on managing OSA with intraoral devices. Jeffrey Pancer, DDS, president of the American Academy of Dental Sleep Medicine (AADSM) in Ontario also has OSA.
See also: Sleep Apnea – Studio Dentaire
Sleep Apnea – What is OSA?
Main article: Breathing Easier
According to Carol Ash, a pulmonologist and the medical director of the Sleep for Life Program, there are about 80 sleep disorders including sleep apnea. “When you go to sleep, the dilator muscles in the throat relax, and that’s common,” she explains. But in sleep apnea, the airway starts to collapse. The tongue may sink to the back of the throat and create an obstruction. When the airway narrows, air turbulence develops and causes snoring. The uvula acts like a flag flapping in the wind. Negative pressure, caused by the pulling down of the diaphragm in an effort to breathe, can contribute to the airway collapse and cause desaturation (oxygen depletion in the blood).
Sleep apneas can be noisy or quiet, says Dr. Ash; some people with sleep apnea will snore, and others won’t. When the airway collapses, the brain senses the emergency and will yank unsuspecting sufferers out of their slumber in order to kick-start normal breathing again. As a result, the person might snort, choke, or gasp for air. Severe cases of these sleep-wake cycles may recur hundreds of times each night, often without the sufferer even being aware of them.
See also: Sleep Apnea – Studio Dentaire
Protocol for Porcelain Veneer Temporization
All too often, the importance of porcelain veneer temporization is overlooked. For the clinician to have a satisfying outcome, there are steps in sequential fashion that must be followed. The meticulous completion of the porcelain veneer temporization stage is paramount to insure clinical success. The benefits are many:
- Allowing for all involved to reduce errors;
- Visualize the end results;
- Make final appointments smoother.
Procedure
The preparations are carried out according to the dictates of the study models and the lab fabricated matrix guide. The preparations are then cleaned with sodium hypochlorite so that remnants of the impression material or smear layer are removed.
The preparations are then spot etched with phosphoric acid at the centre of each tooth. After 10-15 seconds the preparations are washed with copious amounts of water.
A clear matrix stent, which is formed from an impression of the diagnostic wax up, is then used as the template for the veneer temporaries. Using the desired shade, the matrix is filled with a flowable resin covering the buccal surfaces of all the prepared teeth and then set aside in a dark area.
The etched preparations are treated with an unfilled bonding resin at the spot etched position and around the margins. Each tooth is then cured for 30 seconds. The placement of the unfilled bonding resin at the body of the tooth aids in retention while the coating of the margins assists in reducing intra operative sensitivity. It is imperative to note that only unfilled bonding resin can be used for this technique. If a filled resin is substituted at this stage, the subsequent removal of the temporary veneers will become difficult and may result in potential damage to the teeth.
Once all teeth have been bonded, the stent containing the flowable resin is seated into position and cured from the buccal and the lingual for 30 seconds per side. Once curing is complete, the stent is removed and cured again. The clinician may notice small voids either at the surface of just below. Using a small burr they can be accessed, bonded and filled with the same flowable resin.
To remove the excess resin, a diamond tip aesthetic trimming burr can separate the flash from the legitimate margin. The procedure is done slowly by laying the tip of the burr almost parallel to the emergence profile as each margin is reduced. It is important to open the gingival embrasures so that they do not impinge the papilla and be easily cleansed. The body of the temporary veneer is developed and shaped. With the help of a football shaped diamond trimming burr, the lingual surface is contoured and smoothed. Though the temporary veneers are fabricated in one piece, embrasures are simulated on both the buccal and lingual surfaces.
To add additional characterization, diamond impregnated strips are used to soften corners and create incisal embrasures. The restorations are finally polished with a polishing paste to add luster to the temporary veneers prior to dismissal.
At this time the patient is encouraged to do warm salt water rinses twice a day, until the insertion appointment, to aid in gingival repair. The patient is also advised that, though the restorations are secure, they are placed with enough bond to hold them in place but not too much to prevent their easy removal at the permanent insertion appointment. As such, a soft diet is to be followed. In addition, because there is lack of a total seal at the margins, the patient may feel intra-treatment sensitivity.
See also: Dental Veneer
Source: Oral Health Journal
Update on Early Childhood Caries
Being a general dentist practicing in a family neighbourhood with lots of children, an article in the Oral Health magazine caught my eye. The article, which title was Your Health Care Team, Early Childhood Caries, and Dental Care Policy, was written by Dr Ross D. Anderson, Dr Peter Cooney, and Dr Carlos R. Quiňorez. Although I have rarely seen children suffering from early childhood caries, I understand it is still a widespread health problem among children, and it needs to be addressed.
Early childhood caries, also known as baby bottle caries, baby, is a syndrome characterized by severe tooth decay that develops on teeth shortly after they erupt into the mouth. The decay can be mostly noticed on the front teeth of young children. The risk factors, which mainly are the consumption of liquids containing sweets or carbohydrates, are present well before tooth eruption. Early childhood caries is a serious condition with many consequences. It is very painful, can lead to serious infection requiring hospitalization, eating difficulties and numerous other dental and social problems. The prevalence of this disease is not decreasing, and according to the article, it is now present in all strata of society, not just high risk socioeconomic groups.
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Some statistics for early childhood caries (ECC) in Canada |
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The article suggests stronger collaborations between paediatricians and paediatric dentists in the prevention and detection of caries, which already occurs in some parts of Canada and the United States.
Pulpal Diagnosis for Endodontic Treatment
| PULPAL DIAGNOSIS | CLINICAL FINDINGS | RADIOGRAPHIC FINDINGS | ENDODONTIC TREATEMENT ASSUMING TOOTH IS RESTORABLE |
| Normal pulp |
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| Reversible pulpitis |
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| Irreversible pulpitis |
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| Necrotic pulp |
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| Previously treated |
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