By David Steinkraus
Journal Times | Posted: Wednesday, August 20, 2008 12:00 am
Your mouth is a doorway, not in the common way that comes to mind of food going from plate to stomach but in this way: What happens in your mouth affects and can tell you about the rest of your body. That's why dentists are no longer only caretakers of teeth.
There is a sort of movement for dentists to be more, sort of because there's nothing very formal and in any case dentists are neither trained to nor legally able to diagnose and treat diseases outside of their specialty. Yet this doesn't make their role less important. On the contrary, recent knowledge makes it more so.
Dentists have found roles in sleep apnea, the momentary cessation of breathing at night which has strong implications for heart health, and they may find one in monitoring blood pressure. Everything really is connected.
Sleep
"Not everybody who snores has issues with apnea," said Jeff Janosik, a Racine dentist. "It's what happens after the snoring. That's the serious health risk."
Since the start of the year, and regularly since March, he and his staff have been screening people for apnea. He has made oral appliances for people who have apnea and have been referred by a physician, and for several years he has made appliances to help relieve snoring ("Usually it's the wife that requests some relief."), and then he began educating himself more about the disorder.
What makes apnea more than a matter of annoyance are the links between it and heart disease. The two often co-exist, medical journals say, and apnea may trigger mechanisms that damage the heart and blood vessels.
Janosik's screening consists of a commonly used questionnaire combined with observations. For example, he said, body mass index (the measure of obesity) is linked to a greater risk of apnea as is a neck size exceeding 17 inches in a man or 15 in a woman. Aside from snoring, another sign is constant daytime fatigue, the feeling, he said, that one is never really refreshed by a night's sleep.
"It's not just an adult thing. It's a child issue as well. A lot of children get poor sleep," he said. "And children shouldn't snore."
If they do, it may be because their adenoids or tonsils are enlarged - the primary cause - or because they're obese, or because they have a small jaw which falls backward easily, closing off the throat.
Also interesting, he said, is that the signs of sleep apnea in children are fatigue, hyperactivity, and an inability to concentrate - the same symptoms displayed in attention deficit hyperactivity disorder.
"Depending on whom you believe, it's said that as many as 25 percent of young people who are diagnosed ADHD actually have sleep apnea issues, airway issues. So I say to any parent, you've got a counselor at school telling them they need Ritalin, at least look at your tonsils." In the last couple of weeks before he sat down for an interview, Janosik said he had referred three children to ear-nose-throat physicians at Children's Hospital of Wisconsin.
If a patient shows signs of apnea in the screening procedure the next step is referral to a physician. "Dentists are not legally able to diagnose sleep apnea," Janosik said.
The physician performs a sleep study in which people are monitored for a night to determine whether they go through the sleep-snore-apnea-wake cycle typical of apnea. If someone doesn't want to spend a night in a lab, Janosik has an alternative: a forehead-mounted monitor that can be worn at home and whose results are then interpreted by a physician.
He may see those people again. Mild cases of apnea may be helped with an oral appliance, something like the plastic retainers worn by people undergoing orthodontics, but this one has a different purpose. It holds the jaw forward, just like the technique you learned if you've ever had a class in CPR, so the airway stays fully open at night.
In the past few months, Janosik and his staff have found one to two dozen patients with sleep apnea out of approximately 400 who filled out the questionnaire.
"I liken this to cholesterol," he said. "Everybody now, unless you live in a bubble, knows how cholesterol is bad for you. "Fifteen years ago not everybody knew so much about that. … And I do think this will be like that in two, three years. There's a lot of study and research going into this."
Under pressure
For some dental procedures, taking a patient's blood pressure has always been the standard of care, said Racine dentist Lyndsay N. Knoell. "The kind of thing we worry about is stroke." It's anxiety over a procedure driving already high blood pressure to dangerous highs.
"We have found a few patients where we didn't proceed with what we were going to do that day because their blood pressure was so out of line."
Within the last year or so, however, he and his staff have begun regularly measuring the blood pressure of every patient. It helps them to judge later whether a higher reading truly indicates a problem or whether it is just the effect of what is known as "white coat syndrome," the unspecific anxiety that accompanies seeing a doctor or dentist and expecting the worst.
But there are also people who have hypertension - as high blood pressure is also known - and don't know it. Knoell typically refers one to two people a year to physicians because of a suspiciously high blood pressure reading.
His office now is equipped with four pieces of equipment. The starter is a wrist-mounted scanner about the size of an Oreo cookie and about as thick as two cookies stacked. It will produce a reading in 30 to 45 seconds. If the reading is normal, nothing happens. If it's not, one of Knoell's staff double-checks with an automated blood pressure monitor like those sold for home use. There's another monitor, the sort you'll find mounted on a wheeled post in any hospital, used mostly for monitoring patients during procedures. If there's a reason to distrust the machines, if a battery is near the end of its life, for example, there's always the manual cuff that can be pumped up with a rubber bulb.
Physicians sometimes question the measurements, Knoell said, and they're right to do so. "I'm not qualified to manage someone's hypertension so I err on the side of caution." Still, he said, one patient sent off to see a physician but wound up in an urgent care exam room and on medication immediately.
A movement?
From the beginning of this year and for just one semester so far, New York University tried a program to provide dental students with training to do overall health assessments. The training came through a partnership with its Nursing College. A survey of dental patients in its college program found that 15 percent of patients had medical problems that were not being adequately addressed because they didn't have a regular physician.
Involving dentists more in general health care hasn't been done much, or at least it hasn't been studied formally. A British review of published studies concluded there hasn't been enough research on what dentists are doing and whether they can be effective in helping to provide health care.
"All our dentists get trained in physical evfaluation as part of their educaition, their dental education," said Jason Mailhot, a professor and chair of the Department of Surgical Sciences at the Marquette University School of Dentistry. That means taking blood pressure and other vital signs, and students are also taught to do a basic head and neck exam. They check for signs of oral cancer, for signs of tooth decay, and for infections in the gums.
Gum infections have become more important because of recent discoveries linking bacteria in the mouth to disease elsewhere in the body. Evidence of this periodontal disease requires specific probing because the infections don't hurt even though they may be the equivalent of having an ulcer the size of your palm, Mailhot said.
"The education part is what we're working on now, is educating not only dentists to use physicians but also physicians to understand the role of the dentist. If they look in the mouth, they're not specialists in the mouth. They may see some changes, but they do not know if they (indicate) periodontal disease."
Your body, your mouth
"I really believe that dentistry is an integral part of the medical community and that patients should remember that their oral health is related to their systemic health," Knoell said.
Your oral health really is part of your whole body's health, Mailhot said. In Georgia, where he worked previously, hospitals which did transplants required patients to clear a dental exam along with all the other tests they had to have. The reason is simple: any oral infection could easily spread and would be that mush more dangerous for a patient on drugs to suppress the body's immune system in order to prevent rejection of a transplanted organ.
Next time you're dentist is talking to you, listen. OK, it's hard to do much else when your mouth is wide open and full of fingers and equipment. Even then, listening is a really good idea.
Oral hygiene has links throughout the body
For years your dentist has probably asked whether you've and any joints replaced or had an artificial heart valve implanted. There's a good reason for this: Bacteria from your mouth can enter your bloodstream during a regular dental cleaning and colonize the surfaces of artificial joints and valves. Now there's more to this story.
Bacteria from the mouth have been implicated as one of the risk factors for heart attacks and have been found in plaques in the heart, said Jason Mailhot, professor and chair of the Department of Surgical Sciences at the Marquette University School of Dentistry
It doesn't stop there. For reasons yet unknown, people with periodontal disease - infections in their gums - have a difficult time controlling their blood sugar, Mailhot said. On the other side, people with uncontrolled diabetes are much likely to have gum infections.
Some medical studies have found an association between periodontal disease and preterm births and between periodontal disease and low birth weight. It's important to note these are associations, two events happening together; that doesn't mean one problem necessarily causes the other.
What it comes down to, said a medical study that reviewed current research and was published in April, is that keeping the mouth bacteria in check can reduce inflammation in the body and have an effect on a number of diseases.
Sleep apnea
Apnea means without breath, and it's what happens to some people at night.
There are two causes of apnea. One is a problem in the brain which interrupts commands to the muscle which controls breathing. The other, which is much more common, happens when the airway closes.
As you sleep, the muscles in the back of the throat relax, and the airway closes. Breathing stops for a moment. The brain senses the reduced amount of oxygen in the blood and wakes the person, but usually not enough to bring about full consciousness; it's just enough to reopen the airway and resume breathing.
Snoring, which may be a sign of apnea, is caused by air vibrating in the throat, said Racine dentist Jeff Janosik, who has educated himself on the disorder. This snore-apnea-wake cycle can occur many times. In severe cases of apnea, it happens 30 or more times an hour, he said.
And that's why people with apnea are fatigued. They're spending all night fighting for air, he said, and they never reach the deep, restful stage of sleep where their bodies produce chemicals that start the repair of normal damage.
There are simple methods which may reduce snoring and sleep apnea. The Mayo Clinic and American Association of Oral and Maxillofacial Surgeons suggest:
* Losing excess weight.
* Avoiding alcohol, caffeine, and heavy meals especially within two hours of bedtime.
* Avoiding sedatives and tranquilizers which relax the muscles in the back of your throat.
* Sleeping on your side or stomach instead of your back.
* Considering use of a saline spray to help keep nasal passages open, or talk to your doctor about a decongestant or antihistamine.