Feb. 15 -  March 3, 2013

It’s late Thursday night after a long week of work, and it’s time to pack for a world wind trip of unknowns.  Leaving in just a few hours with the lingering question of “what have I forgotten”, which will answer the questions of success or waste of time.  Leaving with passport in hand and cash in pocket.   With a bag of dental tools and supplies in tow, I climb aboard a commuter plane, which will launch me through 11 time zones in the next 30.5 hours.

Dr. Phil Openshaw teaching at the local Dental University

The first sign of encouragement is in Brussels, where two Dental Hygienists, Katie and Alisha with the perfect smiles, made a grand entrance just minutes before the next flight left for East Africa.  Katie and Alisha were amazing and inspiring because of their love and passion for serving.  We all arrived a bit jet lagged at a bout 2 AM Sunday morning at the LDS mission apartments. Luckily, church wasn’t until 10 am, which gave us time to catch a couple of zz’s.   

Katie & Allsha – two great dental hygienists who always “stuck their necks out” to help.

It has always amazed me how you can go half way around the world and never miss a beat in the spiritual feeding trough of the church.  From the Sacrament to the lessons taught in SS, it could have been any awesome ward back home. This was the incredible Klololo Ward, which was even fun to say, and as friendly a ward as I have ever visited.

Now this was no back room extraction clinic trip where you count the number of teeth you can remove in a day!  We were invited to practice our skills in one of the most modern dental schools in East Africa and maybe anywhere in Africa.  The Mulago School of Dentistry was a direct result of donations of many groups, including Rotary International and the LDS Church.  

We got an early start Monday morning, but I should have remembered that in Africa, 9 am is a little more realistic.  But by 9:30 we really got started with taking Digital x-rays and deep cleanings and fillings.  The Digital x-rays blew their socks off – they had never seen any thing that cool before.

Everyone had to come see it in action even dentists in the outlying areas came to investigate. The dental students were essential to what we accomplished. We were kept busy answering questions as they assisted us with every patient.

By the end of two weeks, we had completed 81 exams, 148 x-rays, 65 deep cleanings, 156 fillings with 200 surfaces, removed 16 teeth, did one root canal.  97% of the dental treatment was preventive.  This is what one might expect as normal in advanced countries, but in Africa 97% of all dental treatment is the removal of teeth.

The Mission of LDS African Smiles Inc. is to first provide training for dental providers, helping them move forward from just removing a problem to preventing the problem.  We do this by teaching them how to be preventive minded. X-rays and cleanings are the building blocks. It makes great medical sense as well as financial, as it costs the same to remove a tooth as it does to do a filling, if it is done at the right time. Prevention is everything in Africa.

Our second goal is to take care of the hundreds of native LDS missionaries serving in Africa that have never seen a dentist except for having teeth removed. Our third goal is to help with worthy non-profit organizations like “Set Her Free”, a safe-house for young girls that have been rescued from the evils of human trafficking.

We saw Elders and Sisters from the Congo, Kenya, Uganda, Zimbabwe, South Africa, Madagascar and even the USA.  I would normally ask the Sisters and Elders where they are from because my mission included many of their areas.

One of my favorite memories was the Elder from East London, South Africa. I quickly asked him if he knew one of my old missionary companions who was a Stake President there, and he replied with a big smile that he was a close friend of his and his family. He left with four fillings and the promise to say hello for me the next time he emailed home. It only proves how small a world we live in.

Another experience I will always remember was Angglla from the “Set Her Free.”  When I met her, I couldn’t get her to even smile for me, which isn’t usually that hard. But her front teeth were a mess and she would not allow a smile, no matter how hard we tried. We spent a good hour or more repairing her front teeth and when we asked her to smile she still wouldn’t —until she got a mirror and then she started to cry and laugh at the same time. Her friends that came with her were so excited! It sounded like a New Year’s Eve party with everyone started to dance and sing.   Only then did I realize the impact of our dental team.

This year’s trip was the best so far.  The Uganda Mission President, Eric Jackson, was incredibly supportive and inspiring.   The senior missionary couples, especially the Jonsons and Grundys, were fantastic!   I now consider them some of my newest and most cherished friends.  To see them in action, you know this is the best mission in the world.  What a great place to go. Now that I have returned, albeit a bit jet lagged, I realize no one takes off on a journey 11 time zones away without a few unknowns and without forgetting something they once thought irreplaceable.  It’s called faith and being anxiously engaged in a good cause, and doing many things of their own free will.  This truly makes it all work out in the end.  I’m even more excited to return next year because of the life-changing experiences that will never be forgotten.

For more information on service in East Africa, please contact: 

Clinic in Nurses Station of Moroni High School

  Our most recent trip to the Republic of Kiribati in the South Pacific (surprisingly pronounced KIT-ty bas) was the most spiritual dental service project I have had the pleasure of going on.  Perhaps it was because of the sacrifice of the two Tongan dental assistants, who went with me, leaving their jobs and husbands; perhaps it was the sweet spirit of the 150 prospective missionaries that came to get their dental work done so they could turn in their papers for their mission; or perhaps it was the humble spirit of the students of Moroni High School.

     The Republic of Kiribati is made up of 31 coral atolls scattered along the equator, with a total population of about 100,000.  60% of the population lives in South Tarawa—six little islands joined together with causeways.  The average family income is $1,000 US per year.  It is part of the Marshall Islands Marjuro Mission.

Feast and entertainment to say thanks

     The Church is relatively new in the country.  It has been there for only 36 years but the Church membership is now 15% of the population.

        In addition to seeing the prospective missionaries and the full-time missionaries serving in Kiribati, we were able to see all of the Form 7, Form 6, and most of Form 5 students of the Moroni (LDS) High School and any of the younger ones that were in pain.  (Form 6 is the same as 12^th grade and Form 7 is like a college prep, needed to attend BYU, Hawaii or other colleges.)

     The clinic is composed of 2 portable ADEC chairs and ADEC portable units crammed into a little nurses station on the Campus of Moroni High School.  The school nurse is an RN and has been trained to do dental prophylaxis on the students.  Moroni has a student body of 600, mostly members of the Church of Jesus Christ of Latter-day Saints.  It is the most sought after school in the country to attend.

     The people of Kiribati have a low incidence of dental caries but a high incidence of periodontal disease starting at a very young age.  A good portion of our effort is directed towards teaching proper brushing and flossing.  The students are very good about their oral hygiene once they are taught.  They have a great desire to keep their teeth.

     It takes three days to get there with a one-day layover in Fiji with it’s beautiful beaches (what a sacrifice), but it’s worth the effort.  We stayed on the High School Campus and had a vehicle at our disposal.  The Service Center Manager took us fishing and we were treated with a beautiful evening of singing, dancing, and food to say thanks for coming.

]]> http://academyofldsdentists.com/kirtibati-south-pacific-2012/feed/ 0 http://academyofldsdentists.com/dental-care-for-full-time-missionaries-while-they-serve/ http://academyofldsdentists.com/dental-care-for-full-time-missionaries-while-they-serve/#comments Sun, 06 Jan 2013 20:06:56 +0000 Allen http://academyofldsdentists.com/?p=3205 Dear Dental Colleague,

There are many of you who are already helping the missionaries, and we are truly grateful for all you have done and continue to do. With the increase in the number of missionaries being sent out we are in need of expanding our database of dentists who might be willing to help. 

The Academy Leadership has been approached by the Missionary Medical Department of the Church regarding care for LDS missionaries’ dental work.  We need your help!

When young missionaries from the United States and Canada have dental issues, Missionary Medical requests that the missionaries’ respective home stake president take care of the bill – either from their parents’ or from their home stake funds.  However, foreign missionaries are handled differently and this is where they are particularly interested in our help. 

Many of these missionaries have had inadequate dental care and may need extensive work while serving on their missions. Missionary Medical has asked us to contact LDS dentists, especially those in the Utah/Idaho area, who might be interested in helping to take care of missionaries from foreign countries serving in our respective areas.

IT IS NOT THE INTENT OF MISSIONARY MEDICAL TO COMPLETELY REHABILITATE THESE MISSIONARIES, BUT TO DO ONLY WHAT IS NEEDED TO HELP THEM COMPLETE THEIR MISSION WITHOUT FURTHER DENTAL PROBLEMS OR COMPROMISING THE HEALTH OF THE MISSIONARY. 

When these missionaries are sent to non-LDS dentists they often have extensive treatment plans developed with the intent of completing all that needs to be done.  While this is a commendable desire, it is outside the scope of what the Missionary Medical can afford.

They would, therefore, like to identify LDS dentists throughout the missions of the Church that are sensitive to these issues.  Missionary Medical will refer missionaries needing dental care to you, if you are interested.

Missionary Medical WILL REIMBURSE THE DENTIST for the work but are also grateful for any discount that can be given.  They do not expect you to give the work away.  They realize that this is our livelihood and that we cannot afford to do everything for free, but again, if you can discount the service, then the money can be used for another missionary in need. 

These issues are all delicate balances, which Missionary Medical feels can best be appreciated by LDS dentists who understand the situations.  The Academy is a great reserve of help for the Church and can be of assistance in furthering the missionary work. We can utilize the gifts and talents we have been given to bless these missionaries so they can do the work without the hindrance of dental problems. 

Thank you for your time and consideration regarding this matter.

With sincere gratitude,
 

Evan M. Roundy, DDS
Academy President, 2012-2014

. . . We’ll be opening the clinic in the morning, just got power last night after no power for 8 days, but water is still rationed. 
. . . . We are fine.  Julie has been doing lots of cooking and baking for people, washing, and babysitting.  
I have been delivering bread and rice to our 5 volunteers families and running a chain saw and machete to help clear trees from off ward members’ homes. . . .
The Temple roof was damaged some, but has been repaired. . . .

Then from a letter dated December 29th, they write:

We are seeing all our normal patients at the clinic, taking dental services to meeting houses where people are living, preparing new pre-missionaries dentally for their call, caring for full time Elders and Sisters dentally, cooking at mission home (20 missionaries there). . . .

We’re thankful that the members and missionaries were not injured.  Major cyclones are not as common, and the beautiful weather far outweighs the intense storms that sometimes occur.  Non-the-less, you’ll have a pleasant experience volunteering at any one of the South Pacific clinics.  For more information about volunteer opportunities, CLICK HERE.

During the past year we have implemented, in the Tongan Islands, a Temporal Welfare Program in the prevention of dental disease. This unique program approach has been developed over the past three years through considerable time, effort, much inspiration, and experience developed early in my career with the U.S. Public Health Service. The South Pacific Area Presidency, in conjunction with their welfare department, have encouraged this program development.

This program is now available as an organized starting place for use in any part of the world where the need is so great.   Myself, and the Church’s audiovisual department have jointly produced a preventive dentistry DVD.  A thirty page  “how to” program booklet titled “Implementation of a Short Term Temporal Welfare Project for Preventive Dentistry” has also been produced.

This dental service has been the most rewarding of my dental career. President Uchdorf spoke of this service in the October 2011 General Conference- “Providing in the Lord’s Way”

According to the World Health Organization and the Center for Disease Control, dental disease is the most common infectious disease in the world, next to the common cold. Five billion people in the world suffer from dental disease and 90% goes untreated in developing countries. We can never “drill” our way out of this “hole”.

This program addresses the problem, cause, and solution to dental disease. The solution, when applied with the principle of self-reliance, becomes so simple that anyone can understand it, and everyone can do it!

During a four-month period of implementation, we personally taught over 14,000 people in the 18 Stakes throughout Tonga, and left in place a program to contact 30,000 more people in the following six months.

I believe this program format can be successfully used and should be used in many parts of the world requiring only translation of the needed materials. This will bring joy to the giver and life changing knowledge to the receiver, which will bless their lives for years to come. What a great resource the Academy has to accomplish this “most” worthwhile effort, while working with the Area Presidents of the Church.

Haitian patients standing in line to be seen

1. Work alongside our dental partners in Haiti and teach and support them in the delivery of quality care;
2. Treat dental infections, relieve pain, restore function while being concerned for esthetics;
3. Assess the results, successes and failures of previous dental teams visits;
4. Assess and implement lasting protocols to improve logistics of the clinic such as registration, triage, priority treatments, follow ups, patient selection and equipment list; and
5. Help equip and train Haitian dental students (Guichard and Jean Paul) as to the proper use of materials and instruments that were donated.

Community health worker teaching a patient how to floss

In the previous 3 humanitarian missions, the Dental Team went along with the Medical Team. These groups reported that the clinic was too crowded. In an effort to minimize confusion and maximize efficiency the Dental Team and Agricultural Team partnered up and found this to be extremely beneficial. Another concern that previous teams had encountered was access to care. One suggestion given was to have 3 portable dental units. Taking the 3rd dental unit made it possible for Guichard and Jean Paul, second year dental students at the Universite Autonome de Port-Au-Prince (UNAP), to treat patients under our supervision while at the same time Dr. Phil Terribilini and I were able to see our patients. I’d suggest taking more dental personal. It would be ideal to have 4 general practitioners and 1 oral surgeon.

Haitian children with their new toothbrushes

A suggestion was given by previous teams to have a hygienist properly triage and anesthetize patients. While we ran into a few problems, this is a great model to improve upon. I suggest the protocol for Triage should be to 1) identify infection, 2) identify pain 3) identify and restore posterior teeth to proper health with an emphasis on function and 4) restore anterior teeth with emphasis first on functionality and then esthetics. A great deal of time was spent educating patients with rampant deep decay that fixing the front teeth was “unhealthy” due to extent of decay and infection. In the future it would be nice to have a clinic set up to do root canals or have the means to replace missing teeth with a prosthetic. This could be easily accomplished if the team included a lab technician. I recommend to only place glass ionomer fillings or amalgam (dycal) in the posterior. I would only place small composite fillings on anterior teeth. In numerous occasions we found that abscesses formed where composite fillings were previously placed. (I have several radiograph examples).

The team – October 2012

I saw a patient that had 10-12 amalgam fillings placed 20 + yrs ago. They were still in great shape. I’m a believer that amalgam fillings will serve our Haitian patients much longer. Research indicates that composite fillings last 3-7 yrs where amalgam fillings last 11-15 yrs. Another problem that we came across with placing composite fillings was our ability to keep a dry environment. With the humidity in Haiti and our air compressors – it was impossible to have dry air. Our air compressors at home have filters to remove the water from the air. I could actually blow air on a paper towel and see that it would get saturated with water. It’s very difficult to do composite fillings that have a chance to last long term under the conditions in which we were placed.

The set up and organization of the clinic was well planned and facilitated an efficient flow of patients. We made an attempt to streamline the number of patients that were treated each day by distributing tickets to a given number of patients. The idea was great but we had some issues as to who received tickets. One frustration that I noted was that I saw the same patient 2 or 3 days in a row. I suspect that whoever distributed the tickets knew this person. I suggest that on day one hand out a predetermined number of tickets for several days. So the first 60 tickets are for Sunday, the next 60 tickets are for Monday and so on. This would prevent patients from having to get to clinic at 2 am, wait all day and never be seen. Color coordinate each day with a different color ticket.

Dental assistant taking X-Rays

One of the most obvious successes from a dentist’s perspective was the fact that many people had been to the clinic previously. They learned from the great education team how to brush and care for their teeth. They had healthy mouths with sound restorations. They had the knowledge and desire to care for their mouths. They are passing this on to their children and friends. Another noteworthy success was the fact that the Haitian component of HHI takes pride in what is being accomplished. This is their community. They recognize the good of which they are a part.

You can feed a man fish or you can teach him how to fish. HHI is figuratively teaching this community how to fish.

While reading the newsletter from the Academy of LDS Dentists, I noticed a planned humanitarian mission to China.  I felt inspired to call the leader of the Xi’an group and see there were any spaces left.  He said there were and if I wanted to go, I should fill in the application and get it to him as soon as possible.  After all the necessary papers, visas, etc., I purchased my airline tickets and was ready to go.

We flew into Xi’an on a direct flight from Los Angeles and were met by the contact dentist sponsoring the mission.  He was Chinese as well as a member of the Church.  We were driven to our 5-star hotel and after settling in, were taken to a classy restaurant for a multi-course meal.

The next day we were taken to a relatively new private dental school owned by our sponsor. (Named “Little White Rabbit”)  This was a pleasant surprise for in a previous mission to Mexico, we had to set up army portable dental equipment in a classroom of a Catholic orphanage.  Here in Xi’an, they brought the children from the orphanage into the school for treatment.  We were given six units to work in.  They were very modern and functioned well.

This gave us four units for the dentists, one for the two hygienists and one for triage.  I worked with Delmar Gray who examined and I charted a treatment plan for each child, which hastened their treatment since the dentists didn’t have to re-examine every patient.

A nanny that spoke English and translated

We had six general dentists, one endodontist and one oral surgeon.  Since the cleft palate/lip children had been done by a German team the week before, the oral surgeon found himself doing operative dentistry, which he hadn’t done since dental school.  He was pleased to see how soon it all came back to him.  We removed the sutures on the two cleft palate/lip children on Thursday.  I should note here that this was a special-needs orphanage with a wide variety of infirmities.  We had children who were mentally challenged, deaf and/or mute, and physically handicapped.  Nannies from the orphanage interpreted for us using sign language and spoken Chinese.

Each of our dentists, included the hygienists, had school staff dentists working as their chair-side assistants, which served the additional purpose of teaching American techniques in the various disciplines of our group.  Every dentist and hygienist had a group of school students or teachers gathered around them to watch and learn their technique and methods.

We worked steady, eight to nine hours for four long days and due to a well-organized system, and extremely capable practitioners, were able to see and treat, when necessary, one hundred and sixty children.  It was so rewarding when they thanked us with their grateful smile or spoken word.  Treatment included root canals, composite fillings, SS crowns and extractions.

There were several wives and chair-side assistants who accompanied us and they went directly to the orphanage each day with bags of toothbrushes and tooth paste to teach oral hygiene to the orphans.  They also taught the Nannies how to teach the children that they weren’t able to reach.

List of those who went to Xi’an, China -

April 20-30, 2012

Dentists:

Dr. Delmar Gray (Luann) Boise, ID

Dr. Lou Buhrley- endodontist (Jolyn) Boise, ID

Dr. Randall Brian Smith (Lorri) Boise, ID Sons: Tanner, Parder, Braden

Dr. Tyson Noble Gray (Marie) Boise, ID

Dr. Douglas Gray    Orofino, ID

Dr. Paul Brown   Orem, UT

Dr. James Bailey    Price, UT

Dr. Shad Morris (Carrie) Cedar City, UT

Hygienists:

Brianne Nulph – Pocatello, ID

Tasha Marks – Midway, UT

Guides:

Alicia Richmond

Mingmee

]]> http://academyofldsdentists.com/service-project-to-xian-china/feed/ 0 http://academyofldsdentists.com/questions-answered-8/ http://academyofldsdentists.com/questions-answered-8/#comments Fri, 16 Nov 2012 08:03:19 +0000 Allen http://academyofldsdentists.com/?p=3115

What is the role that dentists play in treating sleep apnea. I have heard that oral appliances can be very effective. How many dentists out there are currently prescribing these appliances and is it a good addition to one’s list of services?

Notice there are multiple responses listed below from various individuals…

 Kevin Mueller

Midwestern University College of Dental Medicine Arizona

What a loaded question!!!

 Over 20 million people suffer from Obstructive Sleep Apnea in america.  I believe we are the first line of defense to recognize it’s symptomology and pathology.

 We are seeing it diagnosed in very young children, due to the failure of proper maxilla development which has been shown to quit growing as low as age 8.  The symptomology in children is bruxism, poor nasal breathing, swollen tonsils, inflammed uvula, and poor sleep which leads to behavior issues that require medications.

 In the adult world, the TMD and sleep disordered breathing have a 60-70 cross-over which both at times give the same symptomology.  The adult sleep patients have common oral conditions, like red inflammed oral-pharynx, poor nasal breathing, reduced palatal width (40mm), high palatal vaults, maxillary and mandibular tori, scalloped tongue, film covering tongue, acid erosion of teeth, and wear attributed to bruxism and parafunction.

 In a nut-shell I believe dentistry can intercept the poor health consequences of sleep disordered breathing.  To prevent the inevitable results of cardio-vascular disease, hypertension, type II diabetes, obesity, depression, impotence and many more symptoms.  I have found the best appliances are the designs that allow tongue to revert back to a normal swallow.  I therefore no longer use the tap appliance, I prefer the Somnomed, EMA, and the Oasis.  Specifically, the Oasis (Mark Abrahmanson) is the only two piece appliance that has tongue pillars and nasal pillars to help with swallowing and nasal breathing which is the key to oral appliances.

Sleep Apnea continued…

Gary

Midwestern University College of Dental Medicine Arizona

In 1985, a group of 12-15 general dentists (including myself) and university research profs from the US and Canada found the Sleep Disorder Dental Society (SDDS) to study the efficacy of various types of oral appliances used to treat snoring and sleep apnea.

Our protocol would include a pre-treatment patient questionnaire to subjectively assess degrees of snoring and apnea, and then also pre- and post appliance tx sleep studies at local sleep disorder labs to measure empirical evidence of change or improvement in apnic events and O2 saturation levels. I made 3-4 different types of oral appliances for this purpose from 1985-1996 with varying degrees of success. Patients were often referred to my office from the sleep disorder labs if the patients could not tolerate using a CPAP appliance.

After I retired I lost touch with the group, but I think Jonathan Parker DDS from the Minneapolis area is still working with these appliances and presenting seminars on use of them at dental conventions around the country. The appliances were not too difficult to fabricate and required some adjustment appointments, and the patients who had the best success were those with moderate snoring and mild to moderate sleep apnea.

I’d like to think I improved a lot of marriages in that wives were very grateful to once again sleep in the same room with their husbands and not be kept awake by their partners snoring or apnic events! I found this service to be a fulfilling and profitable adjunct to my general practice, and I will be happy to contact Dr. Parker if you have further interest.

Sleep Apnea continued…

Azfar

Midwestern University College of Dental Medicine Arizona

The American Dental Association has stated that dentist play a vital role in diagnosis as well as treatment of sleep apnea. The dentist can not only help in diagnosis but also treat obstructive sleep apnea with a vast variety of oral appliances. The diagnosis of Obstructive sleep apnea (OSA) is not a clinical one, but should only be made with a Polysomnography (Sleep study).

The dentist has to work in conjunction and as a vital team member with the physician, as well as the sleep center and very often with a psychologist. There are three modes of treatment for OSA:

•  CPAP (Continuous positive airway pressure) provided with a mask that the person has to wear all night. Considered as the treatment of choice but compliance after one year has been shown to be 25% in a study

• Oral Appliances. Several oral appliances are available. The most effective ones are that position the mandible forward (Mandibular Advancement Devices (MAD)). The benefit is that it is reversible and the compliance after one year was almost 75% in a study done at University of Toronto.

• Surgery. Again many different surgeries are there. The major problem is that they are irreversible and very often has significant side effects

 I am not exactly sure how may dentists are providing this treatment but this information can probably be obtained from the American Association of Sleep Medicine. There is also the American Board of Dental Sleep Medicine. Their e-mail address is:  http://www.abdsm.org/

 I have been treating patients with oral appliances for a long time with excellent results. Unfortunately since the billing is done to the medical insurance, I am unable to provide this treatment at Midwestern due to billing limitations. I have however made a couple of appliances for the students who have been diagnosed with sleep apnea at lab cost. I have also lectured on this topic a lot and if you want me to do a presentation, I will be more than happy to do so.

Sleep Apnea continued…

Kimberly Patterson

Midwestern University College of Dental Medicine Arizona

From:  Schechter MS. Technical report: Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics 2002;109(4):e69.

Children with sleep disordered breathing are at increased risk for hyperactivity and learning problems.

 Adenotonsillectomy is the first-line treatment for Obstructive Sleep Apnea Syndrome, but requires careful postoperative monitoring because of the high risk of respiratory complications.

 http://pediatrics.aappublications.org/content/109/4/e69.full.pdf

provided to fully discuss the topic as related to the general dental patient pool, not just for adult patient considerations.

Sleep Apnea continued…

Ron Shelley

Midwestern University College of Dental Medicine Arizona

Dentistry has a twofold role:  screening and treatment.  

 First, because we as dentists tend to see our patients on a more regular basis than general physicians, we have the opportunity to screen our patients to identify those at risk.  And the risk is serious.  The serious co-morbidities of hypertension, myocardial infarctions, stroke, weight gain, diabetes, acid reflux (GERD), excessive daytime sleepiness leading to work and home injuries and motor vehicle accidents, and stroke associated with sleep disturbed breathing has made the treatment of these conditions a high priority.

 We ask the following questions to screen for sleep apnea:

1. Do you snore?
2. Do you have high blood pressure?
3. Has anyone reported that you choke or gasp for air while sleeping?
4. What is your neck size?
5. Do you awake refreshed?
6. Are you excessively tired during the day?
7. Do you use CPAP or have ever tried to use CPAP?

 The first four questions are highly predictive of sleep apnea.  Questions #5 and #6 are suggestive of sleep apnea; however, there are many other reasons for daytime sleepiness.  The last question is an obvious positive for sleep apnea, but it is important to ask because studies have shown that after three years, over 50% of CPAP users have stop using that treatment.

 Our protocol is to then refer the patient for a sleep study (polysomnogram) and diagnosis by a physician.  Sleep disturbed breathing is a medical condition which is out of the scope of dentistry’s practice and training.  In addition, since it is a medical condition, insurance coverage is by medical insurance, not dental insurance (which impacts the treatment role).

 Treatment is primarily based on the severity of the disease:  behavioral, oral sleep appliances, CPAP, and surgery.  Behavioral includes weight reduction and good sleep hygiene.  The CPAP is the physician’s gold standard and is effective in all levels of sleep apnea.  However, so many users become intolerant of the device and stop using it.  Surgery has had mixed results and are usually consider last resort.  Oral sleep appliance must be fabricated by dentists (the second role) and are very effective for treating snoring, UARS (upper airway resistance syndrome), and mild to moderate sleep apnea. 

 The second dental role of treatment involves the fabrication of oral sleep appliances.  The simplistic explanation of how oral appliances work is that the appliance maintains the mandible in a forward position which pulls the tongue forward and opens the airway.   The actual creation of the oral sleep appliance is relatively easy and well within the capacity of the ordinary dentist.  However, most dentists will not provide this service.

There are real challenges for the dentist to treat sleep apnea.  The whole science of sleep medicine is relatively new to medicine and very new to dentistry.  The science is evolving rapidly and the knowledge level is fairly low in the dental profession.  Sleep apnea is a medical condition which is diagnosed by physicians and primarily treated by medicine.  If a dentist desires to treat sleep apnea, the dentist must adopt a medical model of practice.  This involves more detail record keeping and documentation that seldom exists in dentistry.  Increased communication between the physician, dentist, patient, and all stakeholders is mandatory and not common in the dental profession.  Submitting claims to health insurance is different from dental insurance and can be very difficult.  The final challenge is due to the fact that many patients with sleep apnea also have TMD issues.  Add the fact that the oral sleep appliance could increase strain on the TMJs, muscles, ligaments, and the teeth, the dentist must be prepared to deal with and treat TMD complications.

Sleep Apnea continued…

by Brad Smith, D.D.S., C.S.

Associate Dean for Preclinical Sciences

Midwestern University College of Dental Medicine Arizona

I took my first sleep apnea course in 2003.  While I thought it was interesting then, my restorative practice was so busy I simply dabbled in it.  Now, it seems to have become mainstream, judging by the volume of invitations I receive on a weekly basis for a sleep apnea course!!

 I’m doing sleep dentistry in our practice.  Probably doing an appliance or two every month.  My young protege’ wants me to step up the marketing of appliances for our geographic area.  Fine by me.  It’s a quality of life service and can be significant in that regard.  My focus has been on occlusion and TMD, and it simply led me into sleep, since the two issues are very closely related.  

 My observations, FWIW:  Sleep dentistry, like TMD, can be complicated.  It is difficult to quantify, kinda like”how do you shoot skeet?”  There are 135+ FDA-approved appliances out there, and growing.   There are all kinds of clinicians hawking their week-end course, which concerns me.  The more I learn about sleep, the more there is to know.  For instance, just since the merger of my practice with my young protege’ on April 1st, I have taken over 64 hours of continuing education on sleep. 

 Since it is now a Medicare-approved service, that requires medical coding on insurance, and learning to live in the medical world, insurance-wise and referral-wise.  It would seem that Medicare is pushing towards the use of home sleep testing and oral appliances as a method of cost-control, in my humble opinion.  That would indicate that we as dentists ought to have at least a rudimentary understanding of how to screen for it, and refer or treat as necessary.  It’s logical for us to be involved, since patients typically are more faithful about regular checkups with us versus their medical doctor.  Since medical insurance and Medicare are now involved, that means constant change will be happening in the world of reimbursement, coding, etc., etc.

 I have found oral appliances to be an effective way to help patients with sleep apnea, especially if they have failed CPAP, or wish to have an alternative way to manage their mild to moderate apnea while on a trip, for instance, rather than cart around a CPAP device through security, etc. 

 In addition, there is a significant loss in compliance with CPAP after the first year of use.  A significant study done in 2006 indicated that oral appliances can be effective for slight to moderate sleep apnea, so that was dentistry’s confirmed entree’ into the sleep apnea world. 

 I have talked to others on staff who are treating sleep in their respective practices.  From my experience with continuing education on sleep medicine in dentistry, there are lots of ways to treat/incorporate sleep into a dental practice, and they are constantly evolving..  

 That’s just my two cents……….Some restrictions apply, your mileage may vary, etc., etc……

Which procedures do you think a recent graduate should be proficient performing?

by Brad Smith, D.D.S., C.S.

Associate Dean for Preclinical Sciences

Midwestern University College of Dental Medicine Arizona

A recent grad should be competent in many areas and proficient in a few. Competent means you can perform them on your own without hurting the patient. This includes diagnosis , all operative procedures and single crowns, along with simple extractions and single,two and three canal endo’s that are straight forward. I’m not sure if any graduating seniors are truly competent in Removable   You should feel very comfortable with Scale and root planning.  As far as proficient. Get 100 procedures under your belt and you will begin to be proficient   In a busy office that won’t take long. If you have time and the ability to enhance your surgery skills that will pay big dividends in many areas. Learn to restore implants.

 What specific characteristics would you look for in a possible partner/associate?

 by Brad Smith, D.D.S., C.S.

Associate Dean for Preclinical Sciences

 Midwestern University College of Dental Medicine Arizona

The Characteristics I would look for would be:

1.  Honesty;

2. A hard worker;

3.  A people person.

Someone who communicates well thinks of others. Listens well and is willing to sacrifice their time for others.  Skill level they will typically learn that is much easier than the behavioral side.