Dentistry's role in the diagnosis and co-management of patients with sleep apnoea/hypopnoea syndrome.

The sleep apnoea/hypopnoea syndrome (SAHS) is characterized by repeated upper airway narrowing or collapse during sleep. The obstruction is caused by the soft palate and/or base of tongue collapsing against the pharyngeal walls because of decreased muscle tone. These episodes are accompanied by hypoxaemia, surges in blood pressure, brief arousal from sleep and pronounced snoring. Individuals with occult disease are at heightened risk of motorway accidents because of excessive sleepiness, sustained hypertension, myocardial infarction, and stroke. The signs and symptoms of SAHS may be recognisable in the dental practice. Common findings in the medical history include daytime sleepiness, snoring, hypertension, and type 2 diabetes mellitus. Common clinical findings include male gender, obesity, increased neck circumference, excessive fat deposition in the palate, tongue (macroglossia) and pharynx, a long soft palate, a small recessive mandible and maxilla, and calcified carotid artery atheromas on panoramic and lateral cephalometric radiographs. Dentists who recognise these signs and symptoms have an opportunity to diagnose patients with occult SAHS. After confirmation of the diagnosis by a physician, dentists can participate in the management of the disorder by fabricating mandibular advancement appliances that enlarge the retroglossal space by anterior displacement of the tongue and performing corrective upper airway surgery that prevents recurrent airway obstruction.

Diagnosing and comanaging patients with obstructive sleep apnea syndrome.

BACKGROUND: Obstructive sleep apnea syndrome, or OSAS, is a common, but underdiagnosed, disorder that potentially is fatal. It is characterized by repetitive episodes of complete or partial upper airway obstruction leading to absent or diminished airflow into the lungs. These episodes usually last 10 to 30 seconds and result in loud snoring, a decrease in oxygen saturation, and chronic daytime sleepiness and fatigue. The obstruction is caused by the soft palate, base of the tongue or both collapsing against the pharyngeal walls because of decreased muscle tone during sleep. Potentially fatal systemic illnesses frequently associated with this disorder include hypertension, pulmonary hypertension, heart failure, nocturnal cardiac dysrhythmias, myocardial infarction and ischemic stroke. CLINICAL IMPLICATIONS: The classic signs and symptoms of OSAS may be recognizable by dental practitioners. Common findings in the medical history include daytime sleepiness, snoring, hypertension and type 2 diabetes mellitus. Common clinical findings include obesity; a thick neck; excessive fat deposition in the palate, tongue (enlarged) and pharynx; a long soft palate; a retrognathic mandible; and calcified carotid artery atheromas on panoramic and lateral cephalometric radiographs. CONCLUSIONS: Dentists cognizant of these signs and symptoms have an opportunity to diagnose patients with occult OSAS. After confirmation of the diagnosis by a physician, dentists can participate in management of the disorder by fabricating mandibular advancement appliances and performing surgical procedures that prevent recurrent airway obstruction.

The prevalence of carotid atheromas seen on panoramic radiographs of patients with obstructive sleep apnea and their relation to risk factors for atherosclerosis.

PURPOSE: Persons with obstructive sleep apnea syndrome (OSAS) suffer inordinately high rates of stroke, but the cause remains in doubt. Atherosclerosis (atheroma formation) of the extracranial carotid artery has been suggested as a possible cause. Because atheromas can be recognized on panoramic radiographs, this study compared their prevalence in subjects with OSAS and normal controls and analyzed their relation to atherogenic risk factors. PATIENTS AND METHODS: Panoramic radiographs and medical records of 54 male subjects (mean age, 60.4 years) with OSAS (apnea/hypopnea index [AHI] of 15 or greater and a history of snoring and excessive daytime sleepiness) were assessed for atheromas and risk factors. Age-matched controls were likewise assessed. RESULTS: Twelve individuals (22%) with OSAS showed atheromas on their radiographs. The radiographs of the controls showed that 3.7% had atheromas. This finding was statistically significant (P = .0079). The prevalence of type 2 diabetes mellitus among individuals with OSAS and atheroma formation (7 of 12 persons, 58%) was far greater than the prevalence of diabetes (10 of 42 persons, 24%) experienced by individuals with OSAS but free of atheroma formation. This finding was also statistically significant (P = .035). The lesions seen in both the subject and control populations were similar and were located in the neck, 1.5 to 2.5 cm inferior-posterior to the angle of the mandible. CONCLUSIONS: Persons with OSAS are more likely to manifest calcified atheromas on their panoramic radiographs than age-matched controls. Type 2 diabetes is significantly more prevalent in individuals with both OSAS and calcified atheromas.

Identification of stroke prone patients by panoramic radiography.

Stroke (cerebrovascular accident, CVA) is the third leading cause of death and an important cause of hospital admission and long term disability in Australia. Atherosclerotic lesions at the bifurcation of the common carotid artery are the most common cause of stroke. On occasion these lesions are partially calcified and visible on a conventional panoramic dental radiograph. The atheroma may appear either as a nodular radiopaque mass or as two radiopaque vertical lines within the soft tissues of the neck at the level of the lower margin of the third cervical vertebra (C3). These opacities are separate and distinct from the hyoid bone and variably appear above or below it. Dentists should scrupulously review the panoramic radiographs of all individuals over age 55 with medical histories of hypertension, diabetes mellitus, hypercholesteraemia and coronary artery disease, or whose behaviour includes smoking, ethanol abuse, or dietary indiscretion coupled with overweight and a sedentary lifestyle which are known to be associated with atherosclerosis and stroke.

Detection of radiation-induced, accelerated atherosclerosis in patients with osteoradionecrosis by panoramic radiography.

PURPOSE: Osteoradionecrosis (ORN) of the mandible has long been considered the most destructive complication of head and neck irradiation. Recently, therapeutic irradiation has been implicated as the cause of induced/accelerated atherosclerosis of the cervical carotid artery and subsequent stroke. Panoramic radiography, previously shown to be capable of identifying carotid artery atherosclerosis in nonirradiated individuals, was used to assess the carotid vasculature of patients being treated for ORN. PATIENTS AND METHODS: The panoramic radiographs of 61 men (mean age, 60.5 years; range, 41 to 77 years) who received therapeutic irradiation to the neck 36 months or more previously were assessed for the presence of carotid artery atherosclerotic lesions. Sixty-one control subjects who never received therapeutic irradiation, but who were similarly susceptible to atherosclerosis by virtue of age, were assessed in a like manner. RESULTS: The irradiated individuals sustained a dose of 40 to 72 Gy to the area of the carotid bifurcation. Seventeen individuals (27.9%) with an irradiation dosage to the carotid bifurcation that averaged 59.2 Gy had a panoramic radiograph with a carotid atheroma (11 with unilateral lesions and six with bilateral lesions). The radiographs of the control subjects showed that three individuals (4.9%) had calcified carotid lesions. The mean age of these subjects was 66.1 years; two had unilateral lesions, and one had bilateral lesions. The difference in the proportion of individuals with ORN who manifested carotid artery atherosclerosis on their panoramic radiographs was statistically significant (P = .001) when compared with the nonirradiated control subjects. The lesions seen in both populations had a similar morphologic appearance and were radiographically located within the soft tissues of the neck 1.5 to 4.0 cm inferior-posterior to the angle of the mandible. CONCLUSIONS: Individuals with radiation doses sufficient to cause osteoradionecrosis of the mandible are at significantly higher risk of developing carotid artery atherosclerotic lesions than age-matched, nonirradiated controls.

Panoramic dental radiography: an aid in detecting individuals prone to stroke.

Stroke (cerebrovascular accident, CVA) is the third leading cause of death and an important cause of hospital admission and long-term disability in England and Wales. Atherosclerotic lesions at the bifurcation of the common carotid artery are the most common cause of stroke. On occasion, these lesions are partially calcified and visible on a conventional panoramic dental radiograph. The atheroma may appear either as a nodular radiopaque mass or as two radiopaque vertical lines within the soft tissues of the neck at the level of the lower margin of the third cervical vertebra (C3). These opacities are separate and distinct from the hyoid bone and variably appear above or below it. Dentists should scrupulously review the panoramic radiographs of all individuals over the age 55 with medical histories (hypertension, diabetes mellitus, hypercholesterolaemia, coronary artery disease) and behaviours (smoking, alcohol abuse, dietary indiscretion, overweight, sedentary life-style) known to be associated with atherosclerosis and stroke.

Dental management of the child with developmental dyslexia.

Dyslexia, a biologically determined reading disorder effects an estimated 3 percent to 10 percent of school-age children in the United States. Standard pediatric dental protocols frequently have to be modified because many of these children concurrently suffer attention-deficit-hyperactivity disorder (ADHD), asthma, thyroiditis and inflammatory bowel disease (ulcerative colitis and Crohn's disease). Youngsters suffering from dyslexia and ADHD should have their dental appointments scheduled in the morning when they are most attentive and best able to remain seated in the dental chair. An aspirating dental syringe must be used in order to avoid an intravascular injection and the possibility of an adverse interaction between the pressor agents used with local anesthesia and the medication used to treat ADHD. Aspirin, other nonsteroidal antiinflammatory agents (e.g., ibuprofen) and local anesthetic agents containing vasoconstrictor and preservative (antioxidants, i.e., sulfite) agents should be avoided in children with concurrent asthma because of their propensity to trigger an asthmatic attack. Children with uncontrolled hyperthyroidism should receive only emergency care and this care should be provided in a hospital. Children with hypothyroidism are hyperresponsive to even small dosages of analgesics and anesthetic agents; proper dosing and venue of dental procedures should be a joint decision between the child's dentist and pediatrician. Children with dyslexia and concurrent inflammatory bowel disease may require shorter appointments and nitrous oxide sedation to reduce stress. Those receiving corticosteroids or with a history of steroid therapy within the past year may need supplementation to avoid an adrenal crisis brought about by the stress of dental care.(ABSTRACT TRUNCATED AT 250 WORDS)

Dental management of child and adolescent patients with schizophrenia.

Schizophrenia is a psychiatric disorder in which thought disturbances and aberrant behavior lessen an individual's ability to care for him or herself and to effectively work and communicate with others. The disorder affects 1 percent of the United States population. Onset of the florid psychotic symptoms most commonly occurs during adolescence or young adulthood, but most of these youngsters exhibit unusual behavior and peculiar thinking during childhood. Medications used in managing the disorder have numerous systemic and orofacial adverse side effects that must be recognized by dentists. Dental treatment strategies for the identification and management of these side effects are described as is a method to improve compliance with oral hygiene techniques.

Dental management of the child and adolescent with major depression.

Major depression is a psychiatric disorder in which mood, thought content, and behavioral patterns are impaired, often for an extended period of time. This condition appears to have an increasing prevalence among young children and adolescents. It may be associated with a disinterest in performing appropriate preventive oral hygiene techniques, a cariogenic diet, rampant dental decay, and advanced periodontal disease. Appropriate dental management necessitates a vigorous preventive dental education program and special precautions when administering local anesthetics and prescribing sedative and analgesic medications.

Dental management considerations in children with attention-deficit hyperactivity disorder.

Children suffering from attention-deficit hyperactivity disorder frequently have numerous orofacial anomalies of concern to the dentist. Behavioral manifestations of the disorder frequently impair the patient's ability to perform home care adequately, make dental treatment arduous, and place the patient at risk of physical abuse from family and peers. Familiarity with the symptoms and treatment of the disorder will better prepare the dentist to meet the needs of this unique group of patients.