Integrating the Arts
By David G. Jones
Dentists can play an even larger role in the overall health of their patients by paying attention to
visual and other clues that could indicate serious underlying medical conditions, suggests a
recent study.
Arthur H. Friedlander, DDS, professor of oral and maxillofacial surgery at the UCLA School of
Dentistry, and Michael Littner, an MD pulmonologist at the Veterans Administration Medical
Center in Sepulveda, are two of four researchers who collaborated on a study that for the first
time uncovered a particular link between sleep apnea and an increased risk of stroke. It also
showed that the estimated 9 million adult Americans who suffer from obstructive sleep apnea are
three times more likely to have diabetes. Their work was published in the May issue of the
Journal of Oral and Maxillofacial Surgery.
Friedlander, also the associate chief of staff for graduate medical education at the VA medical
center, said he undertook the study because he has long been interested in dentists viewing
panoramic radiographs and looking for carotid arterial blockages. By 1994, Friedlander started
looking at high-risk patient groups.
"That led me to patients with obstructive sleep apnea, because we already knew that they
suffered from strokes at a higher rate than the average population," he says.
Littner, who also serves as a professor of medicine at the UCLA School of Medicine, also knew
of studies that showed that strokes are more common in people with obstructive sleep apnea, but
he said a direct correlation had not yet been proven.
"Dr. Friedlander had an interest in the cause of strokes, and as a pulmonologist I had an interest
in sleep apnea, so we collaborated with my patients who were already diagnosed with sleep
apnea," Littner says. "The patients exhibited an increased prevalence of cardiovascular problems
with sleep apnea. The question became, 'Why?'"
Littner said the medical literature was not clear, so the researchers set about to discover a specific
link.
"We started to take panoramic radiographs of the patients, and we found large numbers to have
evidence of blockages of their carotid arteries," he says.
The researchers took panoramic X-rays of 54 randomly selected male veterans who had
previously been diagnosed with obstructive sleep apnea. Examination of the X-rays showed that
12 of the 54, or 22 percent, had calcified plaques in the carotid artery leading to the brain. The
researchers also tested the patients' blood sugar, which revealed that 17 of the 54, or 31 percent,
unknowingly suffered from adult-onset diabetes.
"No one had discovered the fact that patients with obstructive sleep apnea have a higher risk of
Type II diabetes," Friedlander says. "No one had looked systemically at patients as we
did."
The study, that began in mid-1995 and finished near the end of 1997, also showed how dentists
can play an increasingly important role in the general health of their patients. Lee V. Heldt, DDS,
MD, president of the California Association of Oral and Maxillofacial Surgeons, says that is a
logical step beyond the normal screening process dentists use with patients.
"This is a step forward from that, and if dentists can identify a pattern of calcification of the
carotid artery, it would certainly be appropriate to refer the patient for a cardiovascular workup,"
he says. "Of course the other question it raises is the importance of reviewing the past medical
history a little further and asking some questions about the quality of sleep, which could prompt
a separate consultation for sleep disturbance."
James E. Eckhart, DDS, contributing editor to the August 1998 CDA Journal issue on
snoring and sleep apnea, said the study could help raise dentists' awareness.
"It could make dentists more alert to the relationships between obstructive sleep apnea, stroke
and carotid blockage, and help the patient seek medical attention to prevent stroke when a
blockage is suspected," he says.
Friedlander outlined other clues that could indicate that a patient is at risk for sleep apnea and an
underlying and undetected diabetes or predisposition to cardiovascular problems. He said
obesity; a thick neck; excessive fat in the palate, tongue and pharynx; an enlarged tongue; a long
soft palate; and a small retrognathic mandible are all indicators for obstructive sleep apnea.
According to Eckhart, the information illustrates the value of the panoramic X-ray.
"Patients can benefit by dentists screening suspected obstructive sleep apnea patients with
panoramic films to detect possible blockages," he says. "The fact that particularly in older
patients carotid blockage can be viewed on a panoramic radiograph may be an additional reason
to obtain one of these systems."
Friedlander considers the study's results exciting.
"I think what this material does is more closely align dentistry with aspects of preventive
medicine, in which we can identify patients at risk of stroke and help them get needed
treatment," he concludes.
Tasteful Dressing
Staff personal appearance is an important part of how patients perceive a dental office. In the May 1999 issue of Dental Economics, Janice Hurley and Jana Tristao offer tips for maintaining the professional look.
They write that the best time to bring up the topic of appropriate dress is during the interview process, but that the subject can be broached with staff at any time. Two important areas should be discussed:
* The value of consistency. If how a potential staff member has dressed for the interview is appropriate for the office, the dentist should mention it and stress the importance of consistently dressing that way. The interviewee should be asked if dressing that way every day is something he or she will be able to do.
* The office's written grooming standard. Having a written policy for both front- and back-office staff is important for projecting a professional image. If what is appropriate is written in detail, it will be easier for staff to follow.
The authors also suggest that a dentist consider investing in staff office wardrobes. If a dentist chooses to do so, they suggest discussing the policy with staff, agreeing on the type of purchases before they are made and setting a dollar figure of about $500 per person.
Giving Patients a Fair Hearing
With 400,000 deaf people in America, chances are good that a dentist will encounter a deaf or hard-of-hearing person in the office. An understanding of the needs and limitations of deaf patients is important, write Claudia Schmitz, RDH, and Sandra Volkman, RDH, in the January 1999 issue of Access, a publication of the American Dental Hygienists Association.
When communicating with a hard-of-hearing person, the first step is to determine which communication method the patient prefers. There are several options, but many have limitations.
* Lip-reading. Only a small percentage of deaf people can lip-read; and, in even the best of circumstances, only a small part of what is said is understood.
* Writing. Writing can be awkward, especially when scientific terms are involved. Also, for many deaf people, English is a second language.
* American Sign Language. Even hearing people who can use ASL may not interpret responses correctly.
* Interpreter. Hiring an interpreter is the ideal solution to the problem of communicating with the deaf, according to the authors. They note that dentists might have to provide an interpreter by law because the Americans With Disabilities Act states that an interpreter must be provided for a client who requests one. Sign language interpreters certified by the Registry of Interpreters for the Deaf are available in every state and most large cities.
For communicating with a deaf patient when he or she is outside the office, e-mail and the teletypewriter are suggested.
A Key to Cleft Palate is Discovered
Researchers led by a team of University of California at San Francisco scientists have identified
the mechanism by which cleft palate -- the most common craniofacial birth defect in humans --
wreaks its havoc.
Earlier research had already established that abnormalities in the gene for Transforming Growth
Factor Alpha (TGF-a) were linked to cleft lip and palate syndromes. TGF-a is a growth factor
with many known functions, yet how it related to cleft palate had been a mystery.
The inter-institutional group, led by Rik Derynck, PhD, UCSF professor of cell biology in the
Department of Growth and Development, and Zena Worb, PhD, UCSF professor of cell biology
in the Department of Anatomy, demonstrated that during normal embryonic development,
docking of the molecule TGF-a with the Epidermal Growth Factor Receptor (EGFR), results in
the production of a class of proteins called matrix metalloproteinases (MMPs).
Using mice specially bred without the EGFR, the researchers learned that after activation of the
EGFR, MMPs regulate the closure of the palate. Palate closure must be closely coordinated with
the development of the lower jaw, a process regulated by MMPs. Simply put, if EGFR does not
function properly when TGF-a joins with it, MMPs are not produced and cleft palate frequently
results.
The study is reported in the May 1999 issue of the journal Nature Genetics.
ADA Survey Center Offers New Reports
Recently released reports available from the ADA Survey Center include:
* Annual Expenses of Operating a Dental Practice -- With statistics for 24 categories of
expenses for independent dentists, solo dentists, independent non-solo dentists and new
dentists.
* Five reports from the 1996 Dentist Profile Survey -- Each covers a single racial or
ethnic group and includes information on family and personal concerns, work-related issues and
practice characteristics.
* Dentists in Solo and Non-Solo Practice -- This report from the 1997 Survey of Dental
Practice compares various aspects of both types of dental practice, including income, gross
billings, expenses and time spent in the practice.
For more information call (312) 440-2500, Ext. 2568.
UCSF Receives Record Donation
The UCSF School of Dentistry has received a bequest of $6.5 million, the largest single gift in
the dental school's history.
The bequest came from the estate of Gladys Barber of San Francisco. Her deceased husband,
Leland, was a member of the school's class of 1919.
The gift will be used to establish two Leland A. and Gladys K. Barber Distinguished
Professorships in Dentistry, each funded at $2.5 million. The balance of the bequest will be used
to fund an endowed chair.
Some Cancer Patients Look for Alternatives
Researchers studied 200 patients with head and neck cancer to determine the prevalence
of the use of alternative therapies and the demographics of the patients using alternative
medicine. The researchers found that alternative therapies were used to specifically fight cancer
directly and as an adjunct to conventional treatment, rather than to treat the adverse effects of
conventional treatment.
A majority of patients limit or avoid the use of alternative medicine based on discouragement
from their physicians and a lack of solid medical evidence, the researchers write. Patients believe
their physicians to be the most knowledgeable source of information about alternative
therapies.
Alternative Medicines Used
Herbal medicines -- 50.7 percent
Pharmacological treatments -- 16.9 percent
Manual healing -- 10.1 percent
Diet and nutrition -- 8.7 percent
Mind-body techniques -- 7.7 percent
Traditional and folk remedies -- 5.8 percent
Honors
Eugene Manusov, DDS, and Eugene Sekiguchi, DDS, were presented with
the 1999 Distinguished Community Service Award from the Anti-Defamation League at its
recent Dental Division Dinner.
Mahmoud Torabinejad, DDS, MSD, PhD, has been elected treasurer of the American
Association of Endodontists. James A. Abbott, DDS, MS, has been elected to the Board
of Directors of the same organization.
Albert Solnit, DDS, has been awarded the Pierre Fauchard Honor Award by the Pierre
Fauchard Academy's Southern California Section. (have photo)
Peter L. Jacobsen, PhD, DDS, professor and director of the Oral Medicine Clinic at the
University of the Pacific School of Dentistry, has received the 1999 Gordon J. Christensen
Lecturer Recognition Award. (photo)
Upcoming Meetings
1999
Sept. 1-4 Surfaces in Biomaterials '99, Scottsdale, Ariz., (612) 512-9103
Sept. 2-4 Academy of Surgical Research Annual Meeting, Scottsdale, Ariz., (612)
545-1919
Sept. 16-18 CDA Scientific Session, San Francisco, (916) 443-3382, Ext. 4470
Sept. 17-18 Society for Advanced Dentistry Annual Meeting, New Orleans, (317)
290-2613
Sept. 25-29 American Academy of Periodontology Annual Meeting, San Antonio, Texas, www.perio.org
Oct. 28-Nov. 1 FDI Annual World Dental Congress, Mexico City, +44 171 935 7852
2000
April 6-8 Dentistry 2000 -- British Dental Association Annual Conference and British
Dental Trade Association Dental Showcase Exhibition, Birmingham, England, 01934
844408
April 13-16 CDA Scientific Session, Anaheim, Calif. (916) 443-3382, Ext. 4470
Sept. 17-20 American Academy of Periodontology Annual Meeting, Honolulu, www.perio.org.
To have a meeting included on this list, please send the information to Upcoming Meetings,
CDA Journal, P.O. Box 13749, Sacramento, CA 95853 or fax the information to (916) 443-2943.
