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It’s amazing to see in the petite women I see how many have had their premolars removed. If their petite women, usually their airway’s petite, too. This are his lower teeth, and you can see how V-shaped that is. If you notice, too, this is him open. His tongue falls right back.
Gag reflex. That’s our body’s way of keeping obstructions out of our throat. I have a couple of patients that are actually treated with CPAP, but every time I see their name on the schedule and I see x-rays, I say a little prayer for my hygienist because it’s really tough for them to get through that. Anytime I see a gagger, it raises a red flag. It’s not saying that they definitely have it, or they are diagnosed with it or anything. It’s just that all these clues can tell us something, and, again, we’re looking at airways all the time.
This is a nice airway. This is something we can see in adult patients as well as kid patients. Now, in our kid patients, when we I talk to the parents, I’ll talk to them about if they are 6 or 7 and still wetting the bed, if they have bags under their eyes, they’re called shiners. They fall asleep really easy because a lot of kids that are sleep deprived fall asleep really easy, but I’ll ask them, “Do they have restless sleep? Do they move around a lot? Are the sheets crumpled up in the bottom of the bed in the morning?” That’s telling me that they sleep about 8 or 9 hours, but they’re not getting good sleep. Because kids’ nervous systems are not matured yet, it’s like when I give my two kids Benadryl®. One gets higher and one gets real drowsy.
Because the nervous system isn’t really developed yet, when kids get tired, they can get wired. So, they are finding that ADD and ADHD are related to sleep. Again, in kids, the first thing we look at is airway. When I ask the parents to talk to their pediatricians, I tell them that we’re not looking at sore throats. We’re looking at the fact that they can’t breathe through their nose, and it’s affecting their sleep.
So, it’s really important when we talk about treatment options that there are more things than just CPAP or oral appliances. Sleep hygiene is really easy. That’s something to coach your patients on, going to bed at a normal time, getting up at a normal time. If they’re shift workers, try to keep them on that same schedule, keeping electronics out of the bedroom, keeping TVs out of the bedroom. If you do wake up, don’t go watch TV or get into your computer. Just do some nice quiet reading. These are all things that help get good quality sleep so we are well-rested in the morning.
We need 7.7 hours and 40% of the American population gets 5 hours or less. In addition, the use of electronics and video games has caused a lot of us to be night owls. I still go to bed at 9. In addition, if you are having trouble sleeping, going to sleep in a quiet room, dark room, even a little bit of light can affect our sleep and Circadian rhythm and melatonin release. One way to stimulate melatonin is to take a hot bath and get into a cold bed.
Lifestyle modifications. That includes exercising regularly but not too close to bedtime, no smoking, no alcohol. Alcohol actually relaxes the soft tissue so much that it can cause even more crowding of the airway, and some people even say they snore only when they drink. That’s because it relaxes the smooth muscle of the throat.
Positional therapy. Some patients only have closing off or obstruction when they’re on their back. So, keeping them on their side would be a good solution. The problem is getting patients to actually do it. We coach patients on it all the time, but they rarely follow through. One strategy is to install [45:29] on the back of their t-shirt and keep them off their back. I know a Canadian that actually use hockey puck and places them on a hose and places them right on his kidney. A bed wedge is really easy to use and successful. It’s really easy to use. It’s just a foam, wedge that you can place under your mattress to keep it on a slope so that you can sleep on your side.
Of course, we have surgery. It’s really important to have an ENT that you can work with, an oral surgeon that you can work with that get it. Again, with the children, we’re not looking for sore throat, strep throat. I want tonsils or adenoids out if it’s causing airway obstruction, and having an ENT that works with you is great. A lot of times, they want to work with you, too. They want somewhere to send their patients who aren’t surgical candidates. Of course, we have CPAP and oral appliances.
We’re going to get into surgery in a little bit here. Nasal obstructions. There’s a couple of ways to treat that. This is a deviated septum as well as a big turbine, and you can actually get these fixed and allow you to breathe through your nose again. This is radiofrequency, energy that is delivered beneath the surface of the turbine. The treated tissue is heated to coagulate, and over the next three to six weeks, the tissue shrinks.
So, a lot of times, we’re hesitant to send our patients for surgery, but there are some in-office procedures that can be done to help, especially since oral appliances don’t always affect the nasal area. We do need to sometimes treat that area as well.
There’s tonsillectomy. This is a common procedure. It’s not so common anymore because what we’re realizing is that obstructions aren’t in the soft palate and uvula area. This is most commonly referred to as UPPP. We don’t use uvupalatopharyngoplasty. This is a patient that just came in a few weeks ago. This is post-surgery, but with this patient here, you can see quite a bit of his soft palate and uvula are gone. In fact, he does have trouble swallowing in that area now. So, he said that he’s cured of sleep apnea. I said, “What does your follow-up sleep study say.” He said, “Oh, I never had one.” He figured since he doesn’t snore anymore, he’s fine, but every time he comes in, he falls asleep on my chair. So, I said, “Well, let’s just do a screening for you. Let’s work with someone so we can just see what’s going on.” He ended up having an AHI of 43, and he said he was cured. So, it doesn’t always work.
A tongue resection and hyoid suspension is another common procedure, and it’s where they place a screw in the mandible attached to sutures and wrapped around the myeloid bone to stabilize it. It doesn’t always pull the muscles tight, but it helps prevent the collapse during the sleep at night. A tongue resection, of course, is you’re just taking out a section of the tongue, too.
This is a patient of mine that was actually getting treated by a dentist in Seattle when she moved here, and she had an oral appliance. She extracted a few of the teeth that I had worked on, and I was upset by it. So, I sent her to an orthodontist, and he basically sent her back to me and said, “Breathing at night is more important than a few shifted teeth.” That’s when I finally realized that I had to get out of my dental mentality and look at the patient and treat them as a medical patient.
So, she actually ended up going and getting a [48:27], and that’s where they take a block of bone right where the muscles of the tongue and throat attach, pull it out, twist it 90 degrees, and put it back in. Because she was petite, this worked out really well for her, and she did do a follow-up study.
Maxilomandibular advancement. This is the most successful treatment, usually works out 90% because we are taking the maxilla and mandible and moving it forward 10 millimeters. So, by doing that, you’re not only stabilizing the hyoid bone and all the muscles attached to it but also creating more space for that airway. You can see, it’s moving the nasal area forward, too. This is actually a local patient. Of course, the 100% solution is just to bypass the airway altogether.
Now, CPAP is continuous positive airway pressure. It doesn’t give the patient oxygen. It doesn’t supplement oxygen. It doesn’t make their blood richer and full of oxygen. It just flows enough air out to move the soft tissue out of the way. So, the more blockages there are, the higher the pressure’s going to be. I don’t know if you’ve ever tried one or tried one on, but it is a really weird experience. For patients who are really sick and really severe, it’s really easy for them to use because they feel so much better. It is a gold standard because it does work, but the compliance is really low. I’m glad you guys saw a better picture of me because this is what I took in my sleep study.
The compliance is low, but it is getting better. When I asked my local sleep physician where his compliance was, he told me it was high 80s, and then you see numbers in studies that say 40%. So, there’s a huge range, and there’s also a really liberal definition of what compliance is. A successfully treated patient is someone who wears a CPAP four nights a week and, of those nights, four hours a night. So, they say that’s enough treatment to get to lower their chance of co-morbidities, but in my opinion it seems like a really liberal definition because that is not a whole lot of sleep.
Most of the patients actually wear their appliance all night, and when I ask them about their use, they’re embarrassed to admit that they take it out at 5:30 in the morning and sleep until 6. I say, “That’s okay. I think you got some good treatment there.” It is getting better because they have different masks. Some of the chronic complaints are claustrophobia. “The mask leaks air into my eyes and causes irritation,” or it can cause irritation on the bridge of the nose or they take it off and they don’t know why. A lot of times they can work around that with dry mouths with the use of humidifiers. They do help. It does limit your sleep positions so that bugs a lot of people sometimes, but there are even masks now where you can sleep on your side.
Of course, the reason we’re all here now, where we fit into the piece of the puzzle, is by treating with oral appliances. So, we prevent the collapse but also improve the muscle tone, and it’s counter-intuitive because you think that by pulling that mandible forward, we’re opening up the airway in the anterior and posterior way, but the way the pharyngeal constrictors is that they open the airway laterally. In addition, by pulling that mandible forward, the pterygomandibular raphe, it tightens up the palatine aponeuroses, which is all the tissue of the soft palate, and by tightening that, you actually prevent the vibration and prevent the snoring.
The best dentist San Diego has available to it is a holistic dentist with decades of experience satisfying his patients, keeping them comfortable and looking after their overall health too. Should you be one of his patients?
Getting To Know Dr. Vinograd
Dr. Daniel Vinograd has a DDS degree from USC and a dental certificate from Universidad Technlogica de Mexico. He also has a degree in holistic medicine. More recently, he has received a BCLAD from San Diego State University.
All of Dr. Vinograd’s extensive education is aimed at helping people. Although he has chosen holistic dentistry and biocompatible dentistry as his profession, his patients will tell you that he helps them in many way that extend far beyond dentistry. He works with patients on the connection between dental health and overall health and makes sure his patients are well informed about how to keep their mouths and their bodies functioning at an optimal level.
Today, Dr. Vinograd offers his patients more than 30 years experience, most as the go-to dentist San Diego depends on for both dental care and overall life enhancement strategies.
So Much More To Dr. Vinograd
But there’s more to Dr. Vinograd than you might imagine. In fact, there are aspects of his life that even some of his patients don’t know.
For example, he is an associate professor of dentistry at the University of Southern California. That’s right: his alma mater thinks so much of Dr. Vinograd and his skills that they allow him to teach for them. That says something about him and his commitment to his profession.
But Dr. Vinograd also works to help those less fortunate than himself. That’s why he’s participated in several dental mission trips within the United States and abroad.
If Dr. Daniel Vinograd sees a way he can help, he does what he can. And as the dentist San Diego residents confidently depend on, he can put his commitment to work for you if you allow him to become your San Diego dentist.
Did you know that most toothpastes at grocery and discount stores contain chemicals you shouldn’t put in your mouth? That’s why many big-name toothpastes are hazardous to your health.
When you’re attempting to choose the best toothpaste for your family, choose a brand that has your best interests at heart — or make your own toothpaste. Whatever you do, avoid these substances that are common in many brands of toothpaste:
- Triclosan, a chemical that may be contaminated with the pesticide doxin. It can disturb your hormonal balance.
- BHT or Butylated Hydroxytoluene, a substance that’s toxic to your immune and reproductive systems. You might be allergic to it also.
- Sodium Fluoride or fluoride in any form. It’s in almost all toothpastes, but it has been shown to have developmental and reproductive toxicity.
- PEG-12, a toxin that may be contaminated with ethylene oxide.
- FD&C Blue, which can be toxic as it accumulates in your body.
- DEA or Diethanolamine, a foaming agent that can lead to cancer and can disrupt hormones.
You also want to avoid toothpastes with SLS or Propylene Glycol. There’s no reason to choose a toothpaste with Sodium Saccharin, Carrageean, Manganese Gluconate or Sorbitol either.
To find the best toothpaste for you and your family, avoid the well-known big-name brands and choose a brand that’s labeled as organic or natural or sold in a health food store. But that’s no guarantee you’re getting a safe toothpaste. Read the label carefully, looking for the ingredients mentioned above that aren’t recommended. If a complete ingredients list isn’t available, don’t buy the product.
Many people are making homemade toothpaste these days because finding a fluoride-free toothpaste that also doesn’t contain any of the ingredients listed above is difficult.
Because substances are so easily absorbed through your mouth, it makes sense to take real care about what you put in it.
So, in our practice, if we had an average of patient roll of 2,000, 20% of the population has obstructive sleep apnea, and 80% to 90% are undiagnosed. It’s really because the physicians don’t have time to look for it, and they really have very little training just because in medical school they’re covering so much more. Maybe it’s half a day. Maybe it’s three hours of lecture in medical school that talks about sleep apnea.
Now, with that many undiagnosed, there’s even more people who have been diagnosed and are untreated. They’re not using their CPAP, they just couldn’t tolerate it, or they did surgery and it didn’t quite work. So, a lot of dentists make snore-guards. There were a million snore-guards manufactured last year, and that can be a dangerous territory if we don’t have a baseline. If we make someone quite but they’re still having apnic events, we don’t know it because there’s no follow-through. So, we really need to make sure that we get diagnosis first or screening and make a snore-guard for someone when they only, truly are snoring.
We are in the front lines, and the reason why I say that is because we are. We spend more time with our patients. We know them. We know their wives. We know their kids. We sometimes spend more than an hour with them, and we look at airways all day long, and I really trained my staff and my hygienists to look at these things, too. In fact, just before I went on this webinar, they knocked on my door to see if I could do a sleep apnea consult. So, it’s everywhere you look.
Now, this is a patient that I’ve seen from day one in my practice. I’ve been practicing for about 10 years, and I love it when Richard comes in. We like to two-step down the hallway. I’ve been bugging him for years. Once I got my training, he was one of the first people that popped into my head as having a red flag for sleep apnea, but he was a little bit unwilling to hear it. He said he has other problems. He has high blood pressure and diabetes, and he’s tired all the time. He’s been talking with a nasal voice. This is actually really a good picture of him because he has lost weight since he’s been treated.
I finally got him to a point where he was willing to talk to a sleep physician. He told me he was tired of being tired, and he went to talk to him. I said, “You may not be a candidate for oral appliance, but we want you to get help.” He went to the sleep physician. He had a CPAP put on the night of his sleep test, and he was been sleeping wonderful ever since. I actually get gifts from him every time I see him.
Now, Shawn, I’ve been treating his daughters and his family forever, and Shawn doesn’t fit that profile. Remember, it says obese, elderly. He is male. He’s 45 years old even though he has gray hair. He’s a pharmaceutical rep, and he saw my sign out in the waiting room about snoring. He said, “You know, I started to have to sleep in the other room, and I noticed that every time I get on the plane, I fall asleep right away. I didn’t use to do that.” He thought it was because he was just getting old, and when I looked in his mouth, I saw a lot of the things that went unnoticed before when I wasn’t trained to look for it.
We got him tested. He was actually able to do a home sleep test because he didn’t have a lot of the other sleep issues going on, and he had moderate sleep apnea. We treated him with an oral appliance, and he takes it with him when he travels. He doesn’t have to carry that CPAP machine, and he feels awesome. His wife, of course, is the happiest camper of them all.
So, I do some external marketing as well as working with the physicians, and one day, Cindy saw my ad in the paper. She came because she had a lot of insomnia, and her physician was treating her. She had been treated for insomnia with a sleeping aid and depression with an antidepressant. She is actually a RN that works in our Pan Handle district so she knows a little bit about health, and she came because she doesn’t snore. She has to sleep in a recliner because every time she goes to sleep, she gets a panic attack. Of course, her doctor wanted to give her a Valium® for that.
Come to find out, it was her airway narrowing and her body’s way of treating or trying to open up that airway. She would get these panicky type feelings. So, she has been for a year only two nights without her appliance, and that same feeling came back. So, she can’t live without it.
Now, when we’re screening patients, some doctors have come up with different screening tools, one of them being STOP-BANG. The anesthesiologists use this prior to surgery so when they’re putting a patient under and their airway’s relaxed, they can identify people they may have problems with. The S stands for snore, and the T is for tired. Are you tired during your day? O, obstruction. Have you noticed yourself stopped breathing, or has your spouse or anyone noticed you stopped breathing? Do you have high blood pressure? If you answered two out of four on the top part, you have a really high correlation to having sleep apnea.
On the second part, depending on how many you answer positive to, you have a chance for having sleep apnea. In the BANG part, B is BMI. A is age. N is neck, and G is gender. This is something really important to put in our history. I know dentists that add that to their paperwork to screen virtually every patient.
This is the Epworth Sleepiness Scale. This is the standard scale used. There’s probably 10 out there, but these are the two most common ones. Now, this tests how sleepy you are in certain situations. Now, if you answer eight or more, that usually means that you are overtired. I think I actually have a 17. I haven’t seen the end of a rented movie in probably five years. I just think it’s because I get up too early, but when a patient complains of being tired and they only have a score of 6 or 7, it’s worth going through the questionnaire with them because we did have a patient one time. She was so tired, and that’s what she was complaining about. When I went through it, she was like, “Well, I don’t own a TV.” So, she had put a 0 there. So, for some of these questions, you do need to discuss with the patient to get a better idea.
So, when we’re looking at a patient, as far as dentists being in the front line, we have their health history. We have their medication lists. We take their blood pressure. There’s so many things that we do to help treat the whole patient, and there’s a lot of clues in the mouth, one of them being a large tongue. Now, this is Otis, and he actually has an AHI of 86. He was referred to me because no matter how hard he tried he couldn’t keep a sleep app on. He said he put it on, and the next thing he knew it was off on the side of the bed.
With his tongue, you can see that it’s folder in the middle. He doesn’t have enough space for the amount of room allowed. You can see he’s not overweight too bad. He’s normal looking, but there’s enough anatomical structures that were causing an obstruction. Scalloped tongue. We see these quite often, too, especially when you’re trying to do a crown on number two, and the tongue still gets in the way. That’s another good indication that they may have an obstruction. Scalloped tongue tells us that there’s too much tongue than the room allowed. Again, it actually causes indentations. So, you can see different degrees of that.
This is Otis’s throat, and you can see how beat up that uvula is. So, it’s no wonder he has sleep apnea. His tonsils aren’t big, but his uvula is a battered uvula as it’s that swollen. In addition, his pharyngeal grade is also high, too, and that’s the width of that airway there. You can see the pillars or the walls encroach upon that airway.
Now, this is a good indication. When my husband and I play “Who Has Sleep Apnea?” in the airport, this is one of the telltale signs. This is Cindy on the right that I told you about. She has an inferiorly placed hyoid bone, and this is what we should look like. That is a nice crico-hyoid space.
Overbite. Overbite tells us that the mandible is pushed back, that it’s trapped back there. Along with the mandible is the attachment to the tongue in the throat. So, if the mandible is held back, so are those muscles and the airway.
Acid reflux. I know acid reflux doesn’t always present heartburn. A lot of times we can question the patients. A lot of times you’ve seen those areas that are eroded, and this is a pretty severe example here. I think, as dentists, we can see it first. When we ask the patients about it, it could be the acidic food that they eat. I know in the Pacific Northwest, we have a lot of fruit and smoothie drinkers and health nuts. So, I do see this front tooth, but when I question patients about it, they, “No, I’m fine. I don’t have heartburn.”
It doesn’t always show up as heartburn. I was diagnosed with it after I had chronic cough for two months. Anytime I went out in the cold or if I exercised, I would cough and cough and cough because the acid had affected the vocal chords and irritated them. In addition, you can have constant clearing of the throat. If you know someone that has that or they say they have allergies all year long in that post-nasal drip, it begs a question to ask about acid reflux. One way to test it is to do Prilosec OTC® once a day, and if it helps their post-nasal drip, then, that’s a clue that it was acid reflux.
Again, I talked to you about bruxing, and that’s a sign. That’s a way our brain tells us to kick start our breathing again. There’s severe cases where we see this every day, and by doing a night-guard, you are actually crowding that space, crowding the tongue. So, that’s a question to ask before you make a night-guard for someone. Do they have other signs and symptoms such as if they are possibly snoring or possibly have sleep apnea?
Clenching. It’s a way for our body to posture that mandible forward and open up the airway and pull that tongue forward. Mouth-breathing. This is common, and we, as dentists, see it because the patient’s gingiva is all red and their mouth is hanging open. The plaque just dries on the front teeth. We see it a lot on kids. Sometimes they outgrow it. Sometimes they don’t, but that tongue pressure is important to form the palate. So, early intervention in kids is important. We don’t treat them all the time with CPAP. Most of the time, it’s getting their tonsils out and adenoids out and expanding the palate is a good way to prevent them from being adult apnics. Of course, we see it in adults, too.
With a vaulted palate, it tells us that as a kid, they didn’t breathe right. Maybe they breathe right now, but if you think about a vaulted palate, it actually pinches on the nasal component. So, it narrows that passageway even more. This is a patient of mine. You can’t get a good appreciation for how high his palate really is in this picture. If you notice, growing up he couldn’t afford braces so if you notice, in order to prevent that crowding, they pulled the premolars to try to help these teeth into that. If you pull the premolars right into the space where they’re actually growing the most, you actually prevent the mandible from growing forward, too. That’s another way that crowds the airway.
Now, hyperapnia, if you remember, is a buildup of CO2, and CO2 is actually what causes our brain to breathe. It’s the reaction our brain has to CO2 rather than oxygen that tells our body to breathe. So, once we realize that, our brain sends an activator, a little squirt of adrenaline. That is the smooth muscle contractor that gets the airway open again. So, we can grab a few breaths, relax again, and go to sleep. Then, the whole system starts over again, and you wonder why we’re tired.
This is a video of a man having an apnic event. As you can see, he’s trying to breathe, trying to breathe. He’s quite because he has an obstruction in airflow, and he still continues to try to breathe. You can do it, buddy. Now, I guarantee you, if you try to do that even being awake, it would be difficult to hold your breath that long.
It’s like holding your breath at the bottom of the swimming pool. Your body’s going to do anything to try to get the air. So, sometimes we gasp or our legs kick or we grind our teeth together, whatever it takes to get that diaphragm moving again, and it’s almost worse than holding your breath underwater because if you see, he started getting the obstruction right at the end of the breath, at the end of the expiration. So, it’s like trying to release all the air out of your lungs and then holding your breath for that long. You can see why most people don’t wake up refreshed.
The typical signs and symptoms of obstructive sleep apnea are of course obesity. We have a huge obesity problem in America, and we see the census every year changing. We have more categories of obesity, which is really scary for our health care. Then, with snoring, that is basically pre-empting it. That is usually the chief complaint that brings people in. Most of the time when people come in for a consult it’s because their wife or husband forced them, and a lot of times it isn’t the daytime sleepiness. The chief complaint is snoring.
In fragmented or light sleep, a lot of people say they have a lot of trouble sleeping or say they have insomnias. A lot of times it can be related to sleep apnea, and the most tell-tale sign really is when a wife or husband tells us that they have to nudge their spouses again to start breathing, that they get scared something’s going to happen to them when they sleep.
Again, our memory and learning take place during REM sleep, and if we never reach that, we’re going to have poor memory, morning headaches from oxygen depletion. A lot of time when people complain to us about headaches, we think TMJ. It kind of begs the question to ask them about their sleep, and, of course, if someone’s grumpy, their family’s not going to like being around them.
The nocturnal enuresis is basically the safety word for getting up and using the restroom often in the night. The reason I included that is I never realized how common it was until I started talking to my patients about it. We actually treated my hygienist’s husband. She tells me all the time how much lower their water bill is because he always thought he had a bad prostate and had to get up four or five times a night, but he little squirt of adrenaline that your pituitary gland allows the release of actually can get our bladder moving, too.
So, why do we want to treat it? Like Dr. Lavine said, there’s a lot of health consequences, and, especially as dentists, we are a lot more than just people who cut on enamel rods. With treating perio, we see that there’s a link between the oral cavity and the whole body. So, we see 80% of nocturnal stroke victims have untreated obstructive sleep apnea. Heart attacks. You have a 30% higher chance of having a heart attack. Dementia. When they tested people in the Alzheimer’s Board, they found out that 90% of them had untreated obstructive sleep apnea. Acid reflux.
Hypertension, especially with patients whose hypertension is not controlled even with medication, 83% of the patients have obstructive sleep apnea. Cancer. I should you that new release, that study that they’re three times more likely to die, and, of course, it’s related to obesity. I think that’s a vicious cycle because when you’re tired and not feeling good, you’re not going to want to get up and go to the gym. In addition, the sleep cycle is where those appetite suppressant hormones are released and our hunger hormones are released. So, if we’re not getting the proper regulation, I just don’t think that we’re motivated to eat right.
Diabetes. Again, sleep is when those hormones a regulated. You’re two and a half times more likely to have diabetes if you have obstructive sleep apnea. With auto accidents, drowsy drivers are just as dangerous as drunk drivers. In fact, they found that the crashes that drowsy drivers get in are five times more serious and more fatal.
Of course, if we’re not sleeping, we’re not doing good, and the only reason why I included this one is even my six year old knows that Cialis® is for daily use. I think that I don’t talk to my patients a lot of about this and they don’t really admit it, but it has a huge effect. The lack of oxygen in our bodies have a huge effect on this area. It’s something that we don’t talk about, but it’s obviously out there because I hear a commercial or see a commercial probably five times a day.
Death. This is Reggie White. His wife is actually a spokesperson for sleep apnea now, trying to get low income people get diagnosed as well as treated. If you remember, he died in his sleep. They never say that a patient died from sleep apnea. It’s usually heart failure or natural causes, but dying at 50 of heart failure is not really natural in my opinion. Sleep is where we’re supposed to be resting, not dying.
So, how do we get diagnosed? That’s the first step. It must be made by a sleep physician, and we do that by getting a sleep study. The most common is PSG or polysomnograph in which you go to a sleep lab, and they’re actually really comfortable. I have one that is in a hospital and one that is a sleep lab. It’s a little bit like a hotel. You have TV and the amenities at home, and you’re allowed to bring your own pillow.
This is what we do. There’s a lot of wires, but they test for a lot of things. There are wires to your heart for ECG and wires attached to your head for REM, which is rapid eye movement. Brain waves as well as channels on your chin to test for bruxing as well as on your legs to test for restless leg syndrome or periodic limb movements, which are leg kicks, which are common with apnea as well. Then, of course, there are nasal flow, pulse oxygen. They can test more than just sleep apnea because there are many sleep disorders.
It is technician-assisted. This is actually my dental sleep coordinator right here. She makes the best coordinator because she actually has sleep apnea herself and really can’t sleep without her oral implants. So, she is great with the patients and really advises them. So, the technician sets it up, and, in my opinion, it’s a nice night away from home. I actually had one as well, and I thought, “This is great, and my husband’s not pestering me to move around.”
Then, they print out a report. I know this looks confusing and it looks like a bunch of squiggles, but when you enter dental sleep medicine world, you’ll see that you’ll be able to see what this means and interpret it for your patients. This is a typical sleep apnea patient. Here is his chin movement. So, bruxing can be associated with obstructive sleep apnea as well.
In addition, there are home sleep tests that are becoming more and more common because more patients aren’t wanting to go to a sleep lab. They’re more resistant to seeking treatment. More and more physicians are open to home sleep testing. In addition, if there are no other co-morbidities and no other sleep disorders, obstructive sleep apnea is what they have, then, the physicians can do a home sleep study.
This is one type. The type IV just means that there are two channels that are measured, and I’ll talk about that in a moment. Type II is basically a PSG at home. There is no technician, but there’s still those leads and wires. Type III is what you see here. There’s a respiratory valve as well as a reader and nasal canula to study oxygen flow. This is another type where he just wears it on the head, and it can test position, airflow, pulse, and the oxygen saturation. It does rely on the patient’s place, and sometimes, they can’t get it right. I know my in-laws were visiting, and they did a home sleep test. I had explained it to them but still had to help them.
Okay, this is the type IV I was talking about, and only two channels are read. Patients, when I ask them if they snore or if they possibly have sleep apnea, I can see a lot of the signs, they say, “Oh, I was tested, and I don’t have it.” Well, I asked them what kind of test they had, and usually, they said they wore something on their finger. It’s really common for primary care physicians to send their patient home with this just to test them, but it’s not really going to show you if you have mild or moderate sleep apnea. It’s mostly if you have severe desaturations during your sleep. So, it’s really going to show you severe sleep apnea but not the mild and moderate. So, I don’t really consider it a good screening tool, but a lot of physicians use it because it’s cheap and easy.
Now, when you talk to physicians, we’re entering their world. It’s dental sleep medicine so we have to put on our doctor hats for a little bit, and in doing that, we talked in AHI. That’s how you determine how severe or mild someone’s sleep apnea is, and that stands for apnea-hypopnea index. The apnea-hypopnea index is where you take the amount of apneas, where there stop breathing for 10 seconds or more, and add in the hypopneas, where there is the narrowing of the airway and their oxygen desaturates by 4%. Then, you divide it by the amount of hours slept. So, that gives us a number and a scale so that we can now how bad somebody is. I’ve had a patient as high as 128, and he was a [26:04]. So, that was pretty severe.
Now, the RDI. That’s another thing that people will talk about, and that’s the respiratory disturbance index. That’s where they add in the RERAs. RERAs stands for respiratory effort related arousal in which you are aroused to a higher stage of sleep, but there is no oxygen desaturation. So, sleep cycle’s still getting disturbed and interrupted. I had a patient who had an AHI of 7 but an RDI of 20. They were very tire. So, we were able to get medical insurance to cover them. Now, typically, this is what doctors will see. Someone who’s overweight, old, male, and has a large, thick neck, those are the ones that usually get diagnosed, but there are many who go undiagnosed.
see the video: http://vimeo.com/57383873
Dr. Lavine:
Well, we’re going to go ahead and get started. Welcome, everyone. This is Lorne Lavine. Most of you know me as the digital dentist. I wanted to welcome you all to tonight’s webinar. As of this morning, we have almost 450 people that were registered for the webinar. I think it really the interest in this topic, and a good chunk of you are already here. I’m only going to spend a couple of minutes talking so that we make sure that Dr. Elliott could speak as long as she’d like. We also want to make sure that we leave time for any questions.
All of you, on your screen, should have a little “Go to Webinar” control panel. Go ahead and type in your questions as you think about them. Depending on where we’re at in the presentation, we may not be able to get to them until the very end, but as you think about them, just go ahead and type them in. I’ll do my best to make sure we get to all those questions before the evening’s done. By the next week, you should all get a number of things. When log out tonight, indicate if you would like Dr. Elliott to follow up with you or whether you want me to follow up with you. That will just be a short, little two-question survey there. Also, many of you know what I do record these webinars. So, within a day or two, you are going to get an e-mail with a link where you can download the entire presentation. So, don’t worry if you have to take a phone call or the kids are screaming. We’re going to give you the whole presentation to listen to when you’d like.
I also want to thank our sponsor tonight, Golden Dental Solutions. They have graciously agreed to provide an hour and a half of continuing education credits for everyone. Many of you are probably familiar with Golden Dental because we’ve done a lot of webinars with them in the past, the Physics Forceps and other products. They’re going to be coming on later tonight, and they’ll offer a special deal for everyone as well.
So, many of you already know me. I am known as the Digital Dentist. I did practice as a periodontist for 10 years. What I’ve been doing for the last few years is to present webinars that are topics of interest even if they’re not necessarily in my area of expertise, which is technology. Really, the goal of these courses is to provide concepts that I think are interesting and stimulating, maybe a little controversial but hopefully beneficial, and I think we’re going to hit on all those topics tonight.
As dentists, we are constantly looking for ways that we can improve our practices, looking at new things that we can do, and this is really the focus of webinars I’ve done over the last year or so. Many of you have been on some of my previous webinars where we talked about Physics Forceps where general dentists are now handling tough extractions or Six-month Smiles where dentists are now doing short term ortho. I think sleep apnea, sleep medicine really falls into that area because dentists can definitely play a role.
As many of you probably know, if left untreated, it can cause all kinds of problems, heart failure, stroke, high blood pressure, diabetes. So, I really think this is a great tool, a great service we can provide our patients as long as we have the training and the knowledge to be able to do that.
Now, as much as I’d love to talk about sleep apnea until the cows come home, the fact is I don’t know much about it. My role, really, is a as a moderator tonight. It’s interesting that as a speaker, as a consultant, I’m out there a lot, and I talk to a lot of other dentists, other consultants. So, we get to hear when there are new rising stars in our field, and Dr. Elliott, I hear about her for a few months. I had the pleasure of meeting her at a social event at the Greater New York Meeting back in the end of November.
I was just so impressed with the passion that she brings to this topic and how she has helped so many of her patients with it, and I said to her that this would be a great webinar topic. She graciously agreed to come on. She is a practicing general dentist with a private practice. She’s in Post Falls, Idaho. She does a lot of things other than sleep apnea. She practices general dentistry, cosmetic dentistry, ortho, but, definitely, sleep apnea is where she’s becoming a real expert. She’s an active member of the American Academy of Sleep Medicine and American Academy of Dental Sleep Medicine.
She’s authored several articles on dental sleep medicine, including her latest article which was in the October issue of Dental Economics. It was called “Take the Time to Check for Sleep Apnea”. She is considered a national expert in this growing field of dentistry, and she’s lectured extensively, educating dentists on how to incorporate sleep dentistry medicine into their practices.
So, without further ado, I’m going to turn the microphone and the screen over to her, and welcome Erin. It’s a pleasure to have you tonight, and we’re really looking forward to the presentation.
Dr. Elliott:
Thank you, Dr. Lavine. I’m looking forward to sharing with everybody the passion I have for not only helping my patients but in helping other dentists help their patients as well. Like you said, I practice in Post Falls, Idaho, which actually has a population of 27,000. So, like many of you, I don’t practice in a big metropolis with thousands and thousands of patients around. Our county actually has about 125,000, and two [05:11] physicians that I work with very closely, and it didn’t happen overnight.
It’s something that I started about three and a half years ago, and, since then, have really taken it as a whole other part of my practice. Within Post Falls Family Dental, I have Sleep Better Northwest and a dental sleep medicine coordinator that actually handles a lot of the administrative staff as well as the follow-up appointments while I’m still practicing general dentistry. In fact, today I did occlusions on a four year old and an extraction on a 60 year old using the Physics Forceps, and I just do everything to help serve the families in the county.
Dr. Lavine:
We’re not seeing your screen, yet, Erin. So, I don’t know if you’ve clicked the button yet.
Dr. Elliott:
Oh, okay. Alright.
Dr. Lavine:
The presentation always goes better when we can see the screen. There we go. Perfect.
Dr. Elliott:
Sorry about that. There’s my practice in Post Falls. So, recently, we’ve seen in the news. This was actually when I traveled to the Greater New York Meeting. On the way there, I took Delta, and there was an article in the inflight magazine about sleep. On the way home, I took Alaska, and there was an article about sleep. It affects a lot of Americans because, really, we don’t get enough sleep with all the electronics we use and caffeinated beverages and sleep aids. There’s so much that we’re missing in our sleep.
Now, even in the news, every week I see different press releases about obstructive sleep apnea and the effects it has on our health. This one just came out this summer in which patients are more likely to die from cancer, and it really affects a lot of us. It’s really important because there are four stages to our sleep. That includes deep sleep and REM sleep that we know about where we dream. If it is interrupted, we don’t get the restful sleep we need, and with already surviving on so little sleep, we aren’t getting the hormone regulation. Our body’s not resting. Our cells aren’t regenerating and healing, and it has a hug economic impact as far as untreated sleep apnics using twice the amount of health care dollar.
So, there are about 84 different sleep disorders, and the once that the dentists concentrate on, of course, are sleep disorder breathing category. Other categories include sleep walking, sleep talking, something called REM behavior disorder. My patient actually just got diagnosed disorder in which she was acting out her dreams. So, fortunately, she’s safe and her husband’s safe. She was actually going after him in her dreams.
With the snoring, we all know about snoring, and it’s not really a joke. We all know we like to joke about it. Upper airway resistance syndrome is when patients are snoring, and they’re consistently getting interrupted because of the snoring, whether it be an arousal from their life or an arousal from a deep sleep into a lighter stage of sleep. These are people that wake up unrested. Central sleep apnea is a category of sleep apnea that’s actually pretty rare. That’s when our brain tells us not to breathe. So, we have two different types of sleep apnea that we deal with, and obstructive is the one the dentist can treat because there’s an actual physical blockage affecting our sleep pattern.
We’re going into snoring. I guess, recently, due to my cold, I have been snoring more lately, and my husband sent this to me on our Facebook account with love. He has resorted to this occasionally, the pillow technique, and like I said, we see it on the cartoons, in articles, in the news. A lot of the population snores, but many people tell me they don’t snore. When I talk to their wives or husbands, I hear the real truth. Most of the time when I ask if somebody snores, they say, “No, I don’t. I sleep just fine. I don’t snore, but my wife tells me I do.”
I thought it was interesting that a lot of the custom built homes that are being built actually going to have two separate master bedrooms, and that’s already started in Europe. They’re called snore rooms. So, it has become a pretty common thing, and snoring occurs when there is a narrowing of the airway and vibration of the soft tissue. That can be in the nasal component or the back of the throat.
As we sleep, there can be a continuum of snoring, especially as we age or start gaining weight. As we age, we lose muscle tone. So, our normal sleeping becomes a non-sleepy snore, and, like I said, that upper airway resistance is when we’re interrupted enough that we don’t get enough sleep. We become a sleepy snorer, and eventually obstructive sleep apnea is diagnosed.
Obstructive sleep apnea is where there’s repetitive episodes of apnea, insufficient airflow or without rest, and the difference between obstructive sleep apnea and central sleep apnea is actually when there’s ventilatory effort. It’s when we’re trying to breathe, but we can’t because there’s blockage.
So, as you can see, when we lay down supine on our back, we normally maintain an airway with the soft palette and uvula allowing us to breathe. Now, with snoring, there’s a partial obstruction of the airway, and the nasal cavity and the soft tissue there could be vibrating. There could be a narrowing there or the soft tissue and uvula area. Then, apnea occurs. Obstructive sleep apnea occurs when there is a complete blockage, and our oxygen desaturates.
So, as we become increasingly obstructed, that is called hypopnea. Hypopnea means that basically there’s a little kink in the hose. The airway is narrowed enough that our oxygen desaturates 4% or more. Now, with apnea, we have a complete obstruction for 10 seconds or more, and our oxygen desaturates. So, we get into this continuum, this pattern where we fall sometimes pretty easily. Sometimes it takes us a while. As our muscle relaxes, the soft tissue relaxes. The tissue vibrates, and the tissue actually relaxes. Snoring is the vibration. Then, it narrows enough to the point it collapses, and we have an apnea.
The next best thing is aquahexine mouthwash, and I think this is actually a superb product that Virbac have got. I think it’s horribly underutilized in practice. Chlorhexidine is a very unstable molecule, but it’s got a really good property, which means it will actually bind to the tooth surface, on to the tongue, and it can last up to 12 hours in the mouth and have an antibacterial effect. So, it is a good product.
I think we should be using it, following all dental treatments in animals that are teething, following extractions, for example. A lot of people reach for antibiotics rather than something like aquahexine mouthwash which is all you would need. I use it preoperatively and before I start getting into polishing to reduce my bacterial aerosol. I use it postoperatively so once I finish scaling and polishing, I just flush out the mouth. I use it in things where I’m going to be doing oral surgery. You can’t always prep the area like you could if you were doing abdominal surgery, so I use chlorhexidine to get the mouth as clean as possible after jaw fractures or during lump removals or gingiva and things.
I think it’s absolutely invaluable in cases of chronic gingivostomatitis or in these really young cats where they get a juvenile gingivitis or an eruption gingivitis. Often, you can get it well under control if the client’s using a good quality chlorhexidine product from an early age.
There are a whole range of products out there with dental claims, and I think you should be really, really careful with what you recommend. Some of these on the screen, I do recommend. I do recommend dental diets. I think they are good, but I think the client has to be aware of the limitations. As I said, when a tooth sinks into the kibble, the whole crown is going to be effectively cleaned, but the gingival margin is where your disease process is occurring. The plaque there is not going to be affected.
So, when you’re reading any published studies that are related to any of these products, always look at what do you change at the gingival margin, and dental trials should separate out the gingival margin and the coronal margin. The coronal margin is the tip of the tooth. I’m not that bothered if there was calculus reduction or plaque reduction on the tip of the tooth. What I’m really worried about is was there a change at the gingival margin because that’s where it’s going to have an impact on the animal’s health.
I would strongly encourage you, if you get drug reps coming around or if you get somebody recommending a dental product, that you actually ask what the claims are and look at the published studies because, at the end of the day, a lot of these products are costly. Clients think they’re doing the right thing by adding an additive to the diet where perhaps there’s not a lot of science to support the product.
I think I’ve probably discussed this, and I’ve said it myself. Once again, when you’re looking at these trials, what do the results mean? What I’d just like to mention here is the Veterinary Oral Health Council. When you look the claims, for example [01:01:04] has got the VOHC seal of approval. Immediately you think, well that’s good because that’s going to have a health benefit, but all that indicates is that there is a claim that it’s going to reduce plaque accumulation. It’s going to reduce calculus accumulation. The VOHC doesn’t say that this is going to be of a health benefit to your pet. So, when you are looking at these trials, really do look at it. What does this mean for my pet? Is it a product worth using?
So, when is plaque control adequate. Basically, it is adequate when there is no gingivitis. You know, a dog like this, I would start tooth brushing and see how you get on.
The last thing I’m just going to finish with are just the management of two cases. The first is a five year old pug. It’s in for a routing dental treatment. There is no home care. I’ve put routine dental because that’s one thing that absolutely drives me mad. Routine dental, we use it all the time or a lot of vets use it all the time. What does dental mean? It means nothing to the client. They don’t come in for cardiacs. They don’t come in for dermals. So, why are they coming in for dentals? We should always be using the phrase, “They come in for dental treatment,” because immediately, the client starts thinking along a different line.
So, there’s no homecare, but the clients are willing to try postoperatiely. So, this is what we find under and anesthetic. This is the lower molar. You can see that there’s an overlap between the fourth premolar and the first molar. We’ve got a probing depth in that area. We’ve also got a probing depth on the lower canine, and you can see a very heavy calculus accumulation.
So, if we go back to important teeth, functional teeth, what is the owner going to be able to do? Immediately, following scaling and polishing and radiographs, I would be considering extracting this tooth, purely because you’re going to be getting an area of plaque stagnation where the client is going to find it very difficult to brush in between those teeth and to keep it clean. On this tooth, on the lower canine, there is a 5 millimeter periodontal probing depth. Now, in a pug, 5 millimeters is probably borderline whether I would extract it or not.
On the other side, which you can’t see, is we had a deep probing depth between the incisor and the canine. So, I would always extract the incisor because you don’t want an area of plaque accumulation. I would clean that thoroughly, but then you can actually discuss with the client why you’ve kept the tooth in (the lower canine is such an important functional tooth), why they need to toothbrush, and how they can toothbrush.
The next case is a seven year old Maltese terrier. The owners do meticulous home care. They brush twice daily, and they do use a chlorhexidine mouthwash. He also uses little teepee brushes to clean between the furcation. So, this is what we’ve got with this little dog. X-rays show that we’ve got some bone loss between the molar and the fourth premolar.
Once again, I would be tempted to extract this tooth. We do have the 3 millimeter dental probing depth here, but because the client is brushing and because he’s got a good boney attachment, the rest of the tooth, which I can see radiographically, I wouldn’t consider extracting that lower molar.
On the top, you can see the third premolar. We’ve got an area of bone loss over here. We’ve got an area of bone loss over here, but given how well the client is tooth brushing, I would opt to keep those in for now purely because he is tooth brushing so well. The last molar, unfortunately, you can see a [01:05:00] where you get bone destruction around the root of that tooth. So, my radiographs are showing me that this is affected. It really has got almost the equivalent of a peri-apical abscess. So, that tooth would need to be extracted, but it’s showing you how a combination of radiographs, periodontal probing, and knowing what your client is going to be able to do postoperatively. It’s going to help you with your decision making.
So, I think that’s all I’ve got to say. It’s just, hopefully, a different way of think about periodontal disease and just remembering that it’s not just about smelly breath. It’s not a cosmetic procedure that you’re doing. You’re actually doing something to try and help these animals.
Thanks, Lisa. Buh bye.
It’s the most effective way that you can remove dental plaque, maintain oral hygiene, and control gingivitis. There are various toothbrushes in the market, and my recommendation is to use any good quality toothbrush. In certain cases, I recommend finger brushing or cotton buds to get started. I find cotton buds fairly useful in cats just to get them used to something in their mouth before progressing them to the toothbrush. Finger brushes, I’m not a big fan of, and I find them quite bulky. I don’t find the bristles effective. The ones with the rubber nipples in the end are, in my opinion, almost useless, but sometimes like them. So, it’s what you can do to get them going. I think a good quality toothbrush is definitely the way to go.
Regardless of what toothbrush you’re using, I would recommend an animal toothpaste. The reason is that human toothpaste contains various things like enzymes and fluoride and flavoring. So, the mint flavoring in our toothpaste can be quite powerful for an animal, and they don’t always like it. The frothing agents, they don’t like, but, as I said, the biggest concern is possibly the fluoride content.
So, an animal is going to swallow a toothpaste. Strictly speaking, a toothpaste doesn’t have many advantages in animal dentistry. The main advantage that that it’s flavorful. The animals like it. So, they tolerate toothrbrushing better. The Virbac toothpaste contains an enzymatic system, which is something that occurs in the saliva anyway, but it does help reduce plaque accumulation to a degree. I like their toothpastes purely because they’re nice flavors, and the animals like them, not because they’re sponsoring the webinar this evening. As I’ve said, I do find them effective.
The one thing that I tell my clients to do though is to squish the toothpaste into the bristles. I find if you put it nicely on the top like we do on our own toothbrushes, the animals lick them off, and it’s gone within a few seconds. They think they’ve had their treat, and they don’t compromise with tooth brushing. So, my own dog, after I finish brushing her teeth, I usually give her a bit of the paste as a treat afterwards, and she loves it. If she sees the toothpaste, she’ll come right away. She’s not keen on the tooth brushing, but she likes the toothpaste. So, that makes it quite peaceful.
The big thing is to always show the client how to brush the teeth. I always recommend that the mouth is closed, usually putting your hand across the muscles, and it depends on how compliant the dog is. So, always start at the back of the mouth and work forward. The front of mouth is very sensitive, and the minute that you go to the upper incisors, they’ll start sneezing or they’ll lick or wriggle. So, I always start at the back and go forward. If you don’t tell a client that, instinctively, they’re going to the front of the mouth and start brushing from the front because that’s the area that they can see.
I do everything with the mouth that I can see, start at the back and work forward. I gently, then, open the grip so that I can get to the gingival margin of the mandibular teeth because, remember, the maxillary premolars almost overlie the premandibular molars. So, you need to just open the mouth just slightly to be able to get to the gum margin on the mandibular teeth. Come forward. Once I’ve done everything on that side, I do the other side, and then come to the front to do the incisors.
Cats. This is my own cat, Charlotte. They’re not like dogs. I think cats tolerate tooth brushing unlike dogs. They quite like it, but cats, you need to get them in a headlock, tilt the head to one side. What you want to aim for in the cat is all the bristles are inside the mouth, but the head, the plastic part of the toothbrush is usually outside the mouth. I tilt the head slightly and pull back that lip with my thumb, gripping on the zygomatic arch and pulling the cheek back. I either do them on the ironing board or I wedge them in between my knees and do them on the carpet so that the front legs hopefully go into the cover of the ironing board and they come and pull my hands.
This is a nurse friend of mine. You can see the size toothbrush that she was using, and these were adult cats when they started brushing their teeth. They tolerate it extremely well, and you can see she’s taken the position of sitting on the floor, the cat wedged between her legs. The cat can’t move back there, and they feel quite secure because they can’t move to the side. So, that’s how I recommend tooth brushing cats.
I think we’ve discussed most of this. The three things that I would point out would probably be, I only recommend brushing the toothbrush once only all the teeth have erupted. The reason for that is until all the teeth have erupted, you’re getting changes in the mouth, and I think if there’s a deciduous tooth that’s starting to become loose, it can irritate the dog with the client’s tooth brushing. That’s not to say that the animal shouldn’t be getting its mouth cleaned. They should be getting used to their mouth handled, not to get used to the client putting bits of toothpaste on the deciduous teeth, but actually physically start using a toothbrush I usually recommend from 6 months of age.
Always warn the clients that the gums may bleed when they are tooth brushing, and this indicates that there is some gingivitis. If you don’t warn the clients, what happens is they think they’ve done something wrong, and they stop. They don’t come back and tell you, but they just stop. What I usually recommend is if the gingivitis is infecting in about three to five days, they should come back and see me so I can look at the area and see why that’s occurring. For my long term finds, they are tooth brushing every day. That’s one of the indicators that there’s a problem is when somebody gets a bleeding in an area, and it’s not reducing. I always get them to come back and see me.
I think getting owner compliance is difficult, and I appreciate that I’m in veterinary practice. So, immediately, I got much more bond with clients, but the clients that we get with periodontitis, a lot of the time, the disease just hasn’t been explained to them. So, they don’t understand why they’ve got to brush. They don’t understand benefits of tooth brushing, and so many times in practice, they would have been given chews. They would have been given water and all sorts of things, and they spend a lot of money on things. They think they’re doing what’s right for the animal. It’s just purely because they want to help, but they really haven’t been given the proper instructions.
I think it’s worth spending your time, and this is where nurses are invaluable in practice. They’ve got the time to spend with clients. They’ve got the time to actually show them how to brush to get them more used to tooth brushing, and clients are more open with nurses. They’ll often say, “The crazy lady old me that I’ve got to brush my cat’s teeth. How am I going to do it?” They don’t say that directly to my face. So, I do think nurses are invaluable here.
I do think it’s important that the client understands why they brush and that it’s not just about smelly breath. You are doing it to prevent potentially systemic disease. So, I think once they understand that, they’re much more like to get on board. If they’ve got the support and encouragement of the practice and all that information is constantly reinforced with frequent checkups, they will get bonded, and they will comply. It’s important that everyone in the practice is saying the same thing. There’s no point in you recommending tooth brushing and trying really hard, and the receptionist says, “Why don’t you just buy a bag of food? That’s going to be much better.” That’s when it gets laid down because unfortunately, human nature says we are all up for an easy option if we’ll save.
Sometimes, even if an owner is really, really compliant, they’re not going to be able to toothbrush. A lot of them can’t always cope with restraining their animal or with cats, they’re not used to gripping, getting them in a headlock. There are some animals that just won’t tolerate tooth brushing, but as the first line, I would always recommend tooth brushing.
This is just an example in a cat where the probe advances the whole way. That’s 12 millimeters of attachment loss indicating a severe probing depth. The reason why I mention probing depths is because some of the prognosis and your decision whether to extract teeth or not is going to be based on how much attachment loss there is.
Gum recession is also a useful indicator. We measure it in millimeters, again, and it’s the distance from the cement and the enamel junction so where the base of the crown is to the where the level of the gum is. We also check for mobility because if the tooth is loose, there’s a good chance that you’ve had significant attachment loss and that tooth needs to be extracted.
I just want to mention the difference between gum recession and periodontal probing depth. Gum recession, you can see, and it’s on the outer surface of the teeth. The gum has receded back along the root surface. So, what you see is what you’ve got. In this upper canine, for example, the gum margin should be at the level over here, and we’ve got it receding back. There’s no periodontal pocket underneath that. This tooth, you’ve got that deep periodontal pocket of sort of 12 millimeters past. From the prognosis point of view, a gum recession you can see, which means you are able to keep it clean.
So, in most cases, a tooth with recession doesn’t necessarily need to be extracted, whereas with a periodontal pocket, if the owner is not going to be able to keep it clean, then that tooth should be extracted. Though, for example, a periodontal pocket of maybe 2 or 3 millimeters, once you’ve done meticulous scaling and polishing and cleaned all the calculus, removed all the plaque from that pocket, you might get a little bit of reattachment. If the client is tooth brushing, they’ll be able to clean probably 2 millimeters. So, up to a 3 millimeter pocket can be acceptable on some animals, not on every tooth but just a football park figure that may be acceptable.
A 12 millimeter pocket with the best in the world, the client is never ever going to be able to keep that clean. So, that tooth would need to be extracted, but, for example, if it was gum recession and I had 8 millimeters of recession on one aspect of the canine tooth, I wouldn’t necessarily extract the tooth if there was no probing depth and I had an owner that was going to totally care.
Coming back to gingival recession, I said that on some teeth it wasn’t an issue whereas on others it was. On a single rooted tooth like an incisor or a canine, if you’re just getting 1 or 2 millimeters, the client keeping that clean is not a problem. If you’re looking at your multi-rooted teeth, for example, the becomes involved very, very quickly purely because the furcation is very high in an animal compared to in a person. If the furcation becomes involved on a multi-rooted tooth, unless your client is very, very dedicated and they’re going to be using things like teepee brushes where they can actually clean in between that area, even if it’s 1 or 2 millimeters, it may be better that that tooth is extracted rather than left in.
So, periodontal disease, it is a disease that affects animals. It’s got systemic consequences. It needs to be addressed, but it can also be prevented to a degree. It’s easy. You just need to brush the teeth, but it’s easier said than actually being practiced and done. So, we’re going to just discuss the management of period now. This is very brief because I think a lot people know about brushing and scaling and polishing, and I don’t want to go other things. I’d rather use the time to perhaps other thoughts that concern you about periodontitis.
So, under an exam, general anesthetic, the mouth is examined, and all the teeth are cleaned. They scale using an ultrasonic scaler, and that’s above and below the gum margin. If you are using an ultrasonic scaler, you do need specific tips if you are going to be working below the gingival margin. If you don’t have those specific tips, you should be using hand scaler, and what we say in veterinary dentistry is everything you do above the gum margin, you’re doing for the kind. Everything you’re do below the gum margin, you’re doing for the pet. So, you’ve got to remember that this disease is occurring at the gum margin and below the gum margin. So, that’s an area that you really, really want to keep clean.
Root planning and subgingival curettage. This comes in and out of favor in human dentistry, but the rationale behind that is that you’re making the root surface as smooth as possible so that you get less plaque accumulation on that root surface. Subgingival root curettage means any diseased epithelium. I think that’s a little bit out of favor at the moment on the human side.
Polishing teeth. This is mostly debatable. A lot of damage gets done when people polish badly. So, if you are using your polisher at too high a speed, the general recommendation is if you put your polisher onto the surface of the tooth, it should be running at a speed where if you just contact the surface of the tooth, it slows down. The cap of the polisher should also flare out so that you are able to clean under the margin, and it should be running at a speed where you’re not going to cause any friction or heat buildup. You always need to use a fine polishing paste.
If you use anything more coarse (you get medium, you get coarse, you get extra coarse polishing paste), you’re actually going to course surface scratchers on the surface of the tooth, which is going to aggravate plaque accumulation. So, in a lot of published texts, you will see that polishing is done to remove the scratches caused by scaling. In an ideal world, you shouldn’t be causing those scratches by scaling. Yes, you are always going to cause a very, very superficial, but don’t think that by you polishing, the more you’re actually going to smooth those out. If you think about it ideologically, to remove a scratch on the surface of the teeth, you’re going to have to remove enamel, and you’re going to be removing a lot of enamel if you’re going to totally get rid of that scratch. So, once I do recommend polishing, I always recommend slow polishing with a fine paste so that you actually don’t cause more damage to the surface of the teeth.
Part of the management of periodontics is also periodontal surgery. So, for example, if there are areas of gum, you cut those back so you’re making the area easier for the client to look after. You’re reducing the areas of plaque accumulation. Tooth extraction is the ultimate treatment for periodontitis. You know, once the tooth is gone, you don’t have to worry about it again.
Having said all of this, other than getting rid of the teeth and getting the animal pain free, there is no point of a scale and polish if they client is not going to be looking after the teeth afterwards. We know that plaque has already started accumulating even before the dog has been discharged from surgery, and if the client is not going to be tooth brushing at home, plaque accumulates within 48 hours to the degree where it’s going to be causing harm. So, you really, really need to discuss this with the client, and I discuss home care at the time where I diagnose the problem, when I’m booking them in for surgery. We also discuss home care on admission, and we don’t say, “Are you willing to toothbrush?” The question is, “How often are you willing to toothbrush?” Immediately, the client has been thinking about it, and they realize that perhaps their pet is coming in for treatment because they’ve let it down if they haven’t been tooth brushing.
It also helps me decide how many teeth I’m going to extract. If I know what level of home care the clients are going to be doing, if you get some clients they come and they’re like, “Well, it’s a lot of rubbish. There’s absolutely no way I’m going to be tooth brushing my dog’s teeth at home,” then, I would spend time extracting the teeth. When I’m looking a tooth and say, “Should it stay or should it go?” I’d rather extract it than leave it up with a problem.
So, when I’m examining these mouths, my aim when I’m doing periodontal treatment is to deal with any plaque retentive surfaces. So, are there perhaps fracture teeth? Are there areas where there’s gingival recession with [47:57] exposure? Sometimes dealing with those means extracting teeth. I also reduce areas of plaque stagnation. For example, if there was overcrowding or if there was overlap between teeth, I may choose to extract a tooth to save another tooth or to make it easier for the client to brush their teeth and enable ongoing plaque control for the long term.
We know that the mouth is exactly in the same condition as before treatment within 3 months following dental treatment. So, as I say, it’s really important to talk to your clients before you even do anything about home are. The gold standard is obviously tooth brushing, and what I say to all my clients is if there was a diet that good or a chew that good or a water that’s running that’s good, we’d all be having it. At the end of the day, we brush our teeth. So, that’s what we should be doing for our dogs.
So, why is this so important? No animal is dropping dead in front of us because of periodontal disease. Is it important to know if I’m saying that 80% of animals have got periodontitis? Why is it causing a problem? I think it’s not just about smelly breath. Advanced periodontitis is painful. These animals, if teeth become loose, the periodontal ligament has got pressure receptors. So, if you’re getting movement on the tooth every time that they’re always eating, they do become painful. It’s not pain that’s there all the time, but it does become just irritating in a chronic dull pain. ‘
We know this because you’ve heard it in practice where a client has a dental treatment. The client comes back in and says, “Oh, they’re like a different dog again. They’re eating so much better. They’re more playful. They’re more social.” In certain cases, you can also get a local abscess forming in the periodontal pocket and an abscess all around the root surface is incredibly painful. We know because of thinking about what people feel with these conditions.
We know that when there is advance periodontitis, there is ulceration of the periodontal pocket, which means that bacteria can actually invade the tissue. So, every time this animal eats or every time this animal chews, bacteria are potentially entering the bloodstream, and that’s going to cause problems.
Some of these I’ll illustrate with pictures here. The only other one I’m going to comment on is the last one, which is ocular complications, and this was a relatively new one to me. There’s two things I’m going to comment about this. In small, brachiocephalic dogs, the roots of the carnassial and the molars, lie very close to the eye, and the complications arise purely from extension of disease where there’s severe inflammation and infection around the roots. I had one dog recently referred. It was actually a greyhound where the owners where brushing the teeth. They had just never seen the back molar. They got a root abscess, a periodontal abscess on the molar. The dog went blind because of the extension of that abscess behind the eye, and the pressure from the abscess caused pressure on the optic nerve. So, it was a very unfortunately complication because the owners were actually committed to home care.
What is a big issue is when you’re extracting these teeth because potentially the bone is going to be weaker around that area. You have to be very careful that you don’t accidentally slip with the elevators of your [29:24] and cause damage to the eye. There was one published in the Journal of Veterinary Dentistry that showed, I think, it was five animals that lost eyes, and one animal, she got a brain abscess following extractions. This was purely because of poor extraction technique. In these cases, the extraction isn’t always easy because you’re dealing with anatomy because of the bone loss. So, just aware of that.
This is a picture of a lateral periodontal abscess in a cat. Just out of interest, this cat was presented to me, and it was actually presented to the neurologist of the practice where I used to work because the owner saw it was having a fit every time it ate. When you examined the teeth, it had deep periodontal pockets, and it was clearly an abscess around that tooth. We extracted the tooth, and the cat was actually fine.
Mandibular fractures. I’m sure some of you that are listening to me have encountered this in practice. When little dogs get advanced periodontal disease, it’s often in the area of the lower molar or the fourth premolar or, in some cases, in the part of the lower canines, and when there is bone loss around one of the roots, it doesn’t take a lot to fracture that jaw. So, this dog presented because the other dog just went for it, and they grounded one another and crashed. The jaw broke, and the reason for the jaw fracture was the underlying periodontal disease that the bone was weaker. You can see that there was only 2 or 3 millimeters that was holding that jaw in place. Unfortunately, if you’re not taking preoperative grafts, if you’re not examining these patients and probing around these teeth, you’re not always going to pick up these problems. If you start extracting the tooth like this, you may actually cause the mandibular fracture yourself.
This was a case that was referred. I apologize for the poor quality radiograph, but it was destroyed. There wasn’t much bone left, and you can see that we’ve virtually only got millimeters at the end of those teeth. This dog, we didn’t fracture any of the jaw extracting the teeth, but you can see, this radiograph was taken prior to any calculus removal purely because I’ve had one case where the calculus was acting as a bridge as a splint from the jaw fracture. So, in cases where I’m suspicious of severe bone loss, I will x-ray the mouth before I even touch the mouth, purely from an almost illegal point-of-view that you don’t know what you’re dealing with before you start.
In general practice, you might take one look at this and think, “I’m not touching this. I’d rather [32:09] which is absolutely fine. The important thing is if you do take a radiograph, I would always inform the client and warn them beforehand. Say, “Mrs. Jones, Daisy has got severe periodontal. This means that she’s had bone loss around the roots, and it means that the jaw’s very fragile. The tooth or the teeth do need to be extracted because they are the source of the problem, but I just wanted to warn you that there is a risk of jaw fracture.” It’s a much easier conversation to have than going to Mrs. Jones and saying, “Unfortunately, the jaw fractured when I was taking out the teeth.” So, it’s all about client management, really.
In little dogs, coming back to why they break their jaws, in the little dogs, the roots of the lower molar contribute much more to the width of the mandible compared to a large dog. There was one study on the Journal of Veterinary Dentistry that looks at small breeds, like a 20 kilogram dog, and a larger breed, and showed the relative width compared to the width of mandible. This was a Labrador, and you can see the root finished above the mandibular canal. Relatively, your puppy’s got the same width below the end of the root to the eventual end of mandible, compared to this dog where even if you’ve got a few millimeters of bone beyond the apex of that tooth.
Oronasal fistula. You’ve seen this picture before. The reason why I bring this up as a complication, why it’s important, remember we’re discussing why is periodontitis important. In oronasal fistula, there isn’t a lot of bone between the root of the upper canine and the nose equally on the [34:01] tooth between the palatal root and the nose. If an animal gets an infection or if you get advanced periodontitis with plaque accumulation, that dog is constantly inhaling bacteria. So, it is an area that, particularly, can cause systemic effects for that dog.
Systemic consequences of periodontitis. I mean there used to be a chart that showed all the arrows linking the heart and the kidneys and the liver that loads of people had in practice, and, you know, there were some studies that were published quite a few years ago that linked periodontal disease and systemic consequences. They are all, to a degree, suspected, and what we know from [34:52], is that there are certain links with a bad mouth and bacteremias and chronic inflammation and the effect it has on the body. The latest article that’s been published was in March this year in the Journal of the American Veterinary Medical Association that looked at things like C- reactive protein, and they looked at kidney values, things like that. The conclusion was we really need more studies, but there is the link to potentially systemic consequences from a badly infected mouth.
So, periodontitis, coming back to it, is not just a smelly breath. We know that, potentially, our host has got an immune response, and they’re not responding well or they’re overresponding. We potentially know that these dogs get bacteremia. Every time they’re chewing, they get bacteremia.
So, just something that I think we should be thinking about is that most of these animals are presented to us at the time of vaccination, for example. You examine the mouth and say, “Mrs. Jones, Daisy really needs to come in to have her teeth sorted out,” but should we be vaccinating them? You know, if we potentially know that you’ve got C-reactive protein and you’ve got bacteremias, that animal isn’t considered healthy. In an ideal world, it would be good to change the whole way we think about this sort of disease, and say, “Your animal is sick.”
If, for example, we had an area equivalent to the area of a Yorkshire terrier’s mouth that’s dripping or inflamed that has plaque accumulation, if that area was on the skin, we’d probably have a good time to circle off skin inflammation and skin infection. We wouldn’t think twice about saying, “Mrs. Jones, you can’t have the vaccination today. Take her a course of antibiotics. Let’s get this infection cleared up, and then we will vaccinate her,” but, for some reason, people don’t view the mouth like that. It’s because the animal just carries on. They’re still eating. They’re still coping. So, the owner doesn’t perceive a problem, and it’s down to us to show them and to highlight the issues that are going on in this animal’s mouth.
So, some of the diagnosis of periodontal disease is easy where you can look at the mouth, and you can see attachment loss. So, for example, when there is severe gum recession, you can see the roots overexposed, and you can see the furcation’s exposed, but the actual diagnosis can only truly be made under an anesthetic because that’s where you can see the degree of damage. That’s where we can assess whether there’s a periodontal pocket or not.
This makes is very difficult in general practice when you’re actually trying to book an animal for dental treatment and give estimates and explain what’s involved to a client because sometimes you think this animal isn’t going to need any extractions. Then, you get them under and anesthetic, and they need six or seven teeth taken out. So, it’s really important beforehand to explain this to a client that you get an initial look in a consultation, but the diagnosis is only made under and anesthetic.
Okay, this is just an example again. I was convinced, in this patient, that we would have deep periodontal depths, given how marked the gingivitis was, but when examined, the mouth showed absolutely no sign of periodontal pockets anywhere. So, once again, purely gingivitis. I just said, “Strictly speaking, the general anesthetic, just take some scale and polish,” if the client had just been tooth brushing.
When they are under the anesthetic, we want to take a periodontal probe, which is a blunt-ended instrument. It’s got graduated markings, and we want to check the whole circumference around the tooth. We want to ensure that there is no attachment loss, that it isn’t advanced where the ligament has been lost around the tooth. We measure that in millimeters.