Critical Issues in Dental and Medical Management of Obstructive Sleep Apnea

This critical review focuses on obstructive sleep apnea (OSA) and its management from a dental medicine perspective. OSA is characterized by ≥10-s cessation of breathing (apnea) or reduction in airflow (hypopnea) ≥5 times per hour with a drop in oxygen and/or rise in carbon dioxide. It can be associated with sleepiness and fatigue, impaired mood and cognition, cardiometabolic complications, and risk for transportation and work accidents. Although sleep apnea is diagnosed by a sleep physician, its management is interdisciplinary. The dentist’s role includes 1) screening patients for OSA risk factors (e.g., retrognathia, high arched palate, enlarged tonsils or tongue, enlarged tori, high Mallampati score, poor sleep, supine sleep position, obesity, hypertension, morning headache or orofacial pain, bruxism); 2) referring to an appropriate health professional as indicated; and 3) providing oral appliance therapy followed by regular dental and sleep medical follow-up. In addition to the device features and provider expertise, anatomic, behavioral, demographic, and neurophysiologic characteristics can influence oral appliance effectiveness in managing OSA. Therefore, OSA treatment should be tailored to each patient individually. This review highlights some of the putative action mechanisms related to oral appliance effectiveness and proposes future research directions.

Microbialite response to an anthropogenic salinity gradient in Great Salt Lake, Utah

A railroad causeway across Great Salt Lake, Utah (GSL), has restricted water flow since its construction in 1959, resulting in a more saline North Arm (NA; 24%-31% salinity) and a less saline South Arm (SA; 11%-14% salinity). Here, we characterized microbial carbonates collected from the SA and the NA to evaluate the effect of increased salinity on community composition and abundance and to determine whether the communities present in the NA are still actively precipitating carbonate or if they are remnant features from prior to causeway construction. SSU rRNA gene abundances associated with the NA microbialite were three orders of magnitude lower than those associated with the SA microbialite, indicating that the latter community is more productive. SSU rRNA gene sequencing and functional gene microarray analyses indicated that SA and NA microbialite communities are distinct. In particular, abundant sequences affiliated with photoautotrophic taxa including cyanobacteria and diatoms that may drive carbonate precipitation and thus still actively form microbialites were identified in the SA microbialite; sequences affiliated with photoautotrophic taxa were in low abundance in the NA microbialite. SA and NA microbialites comprise smooth prismatic aragonite crystals. However, the SA microbialite also contained micritic aragonite, which can be formed as a result of biological activity. Collectively, these observations suggest that NA microbialites are likely to be remnant features from prior to causeway construction and indicate a strong decrease in the ability of NA microbialite communities to actively precipitate carbonate minerals. Moreover, the results suggest a role for cyanobacteria and diatoms in carbonate precipitation and microbialite formation in the SA of GSL.

MO-F-213AB-04: Biological Effect of Dose Shadowing by Fiducial Markers in Spot Scanning Proton Therapy with a Limited Number of Fields

PURPOSE

In spot scanning proton therapy, accurate patient positioning before and during treatment is essential. A small gold ball marker is suitable as a fiducial for prostate treatment. However, it has been pointed out that the marker causes dose shadowing because the protons are scattered with their energy quickly diminished. In this research we explore the possibility that the biological effect of dose shadowing can be mitigated with a limited number of fields.

METHODS

The proton dose distribution in prostate was simulated using Geant4. The simulations include the Hokkaido University spot scanning nozzle and a water phantom positioned isocentrically. The PTV was delineated at the center of the phantom and a gold ball of 2 mm in diameter was placed at the middle of the PTV. The plan was created by single-field optimization and each of the following beam arrangements was investigated; (1) single lateral field (2) two lateral fields (3) two lateral + one anterior fields (4) four-field box. The dose prescription was D95 = 74 GyE (37 fr). The minimum dose and tumor control probability (TCP) were compared for the four beam arrangements.

RESULTS

For (1)-(4), the minimum dose values were 55%, 77%, 78%, and 84% of the prescribed dose, respectively. The reduction of the TCP values from those in the absence of the gold marker were 50%, 2%, 1.1%, and 0.7%, using the TCP model by Wang et al. (Int.J.Radiat.Oncol.Biol.Phys. 55, 2003) and 2%, 0.7%, 0.5%, and 0.4%, using the biological parameters in Levegrün et al. (Int.J.RadiatOncol.Biol.Phys. 51, 2001), respectively.

CONCLUSIONS

Although dose shadowing by the gold marker is locally non-negligible, the size of the affected domain is tiny. It was found that with a minimum number of fields, the TCP nearly recovers to the value without the gold marker.

Mandibular advancement splints for the treatment of sleep apnea syndrome

Oral devices, in particular Mandibular Advancement Splints (MAS), which hold the mandible in a protruded position during sleep, are increasingly used for the treatment of Obstructive Sleep Apnoea (OSA). These devices can be effective in treating OSA across a range of severity. Complete resolution of OSA (Apnoea-Hypopnoea Index [AHI] reduced <5/hr) with use of an MAS occurs in around 40% of patients. Overall two thirds of patients experience some clinical benefit (≥50% AHI reduction AHI) however others will not objectively respond to this form of treatment, despite improvement in symptoms. Although MAS are less efficacious in reducing polysomnographic indices of OSA than the standard treatment, Continuous Positive Airway Pressure (CPAP), improvements in health outcomes appear to be comparable. Therefore, the superiority of CPAP in improving oxygen desaturations and reducing AHI may be extenuated by its low compliance, resulting in both treatments having similar effectiveness in clinical practice. MAS are now recommended as a first line treatment for mild to moderate OSA, as well as in more severe patients who are unable to tolerate or refuse CPAP. Success with MAS treatment has been associated with factors such as female gender, younger age, supine-dependent OSA, lower BMI, smaller neck circumference and craniofacial factors, however a reliable, validated method for prediction in the clinical setting has yet to be established. MAS are well tolerated, however short-term side effects are common although generally minor and transient. Long-term dental changes are for the most part subclinical, but can be problematic for a minority of patients. MAS are a dental-based treatment for a medical sleep disorder and, as such, an interdisciplinary care model is considered important for the attainment of optimal patient outcomes.

Piecing the puzzle together: foreign-born tuberculosis in an immigrant-receiving country

In major immigrant-receiving countries, annual foreign-born tuberculosis (TB) case counts and rates are relatively constant. Why this is so, and who might be a high-yield target for screening for latent TB infection, remain open questions. Foreign-born TB in Canada during 1986-2002 was retrospectively examined using national TB and immigration data as well as census data. Case counts and rates were analysed in relation to demographics, immigration period and time since arrival. Pre-1986 immigrants (n=3,860,853) and 1986-2002 immigrants (n=3,463,283) contributed 8,662 and 9,613 TB cases, respectively. Immigrants arriving ≤ 5 yrs ago and those arriving >10 yrs ago contributed almost equally to the annual foreign-born TB case count despite a 3.5-fold difference in in-country person-yrs. Remarkably stable and relatively low TB incidence was observed among immigrants >10 yrs post-arrival. Conversely, TB incidence within 5 yrs of arrival was dynamic, demonstrating a strong inverse association with time since arrival and higher sensitivity to changes in immigration level than shifts toward higher incidence source countries. Relative constancy in foreign-born TB incidence is explained by a complex convergence of several factors. Immigrants born in high-incidence countries who arrived ≤ 2 yrs ago and were aged 15-34 yrs upon arrival constitute high-yield targets for preventive therapy.

Expression of taste molecules in the upper gastrointestinal tract in humans with and without type 2 diabetes

OBJECTIVE

Nutrient feedback from the small intestine modulates upper gastrointestinal function and energy intake; however, the molecular mechanism of nutrient detection is unknown. In the tongue, sugars are detected via taste T1R2 and T1R3 receptors and signalled via the taste G-protein alpha-gustducin (G alpha(gust)) and the transient receptor potential ion channel, TRPM5. These taste molecules are also present in the rodent small intestine, and may regulate gastrointestinal function.

SUBJECTS AND METHODS

Absolute transcript levels for T1R2, T1R3, G alpha(gust) and TRPM5 were quantified in gastrointestinal mucosal biopsies from subjects with and without type 2 diabetes; immunohistochemistry was used to locate G alpha(gust). Effects of luminal glucose on jejunal expression of taste molecules were also quantified in mice.

RESULTS

T1R2, T1R3, G alpha(gust) and TRPM5 were preferentially expressed in the proximal small intestine in humans, with immunolabelling for G alpha(gust) localised to solitary cells dispersed throughout the duodenal villous epithelium. Expression of T1R2, T1R3, TRPM5 (all p<0.05) and G alpha(gust) (p<0.001) inversely correlated with blood glucose concentration in type 2 diabetes subjects but, as a group, did not differ from control subjects. Transcript levels of T1R2 were reduced by 84% following jejunal glucose perfusion in mice (p<0.05).

CONCLUSIONS

Taste molecules are expressed in nutrient detection regions of the proximal small intestine in humans, consistent with a role in "tasting". This taste molecule expression is decreased in diabetic subjects with elevated blood glucose concentration, and decreased by luminal glucose in mice, indicating that intestinal "taste" signalling is under dynamic metabolic and luminal control.

A novel preparation to study rat pancreatic spinal and vagal mechanosensitive afferents in vitro

The management of pancreatic pain is a significant clinical problem so understanding of how sensory signals are generated in pancreatic tissue is fundamental. We aimed to characterize mechanosensitive and chemosensitive properties of pancreatic spinal and vagal afferents in vitro. Spinal and vagal afferent preparations from Sprague-Dawley rats were established incorporating the left splanchnic nerve or vagus nerves respectively. The common bile duct was cannulated for distension of the pancreatic duct with fluid. Nerve discharge evoked by blunt probing, duct distension or electrical stimulation was obtained from teased nerve bundles using standard extra-cellular recording. Discharge from 197 spinal afferent bundles was recorded, of which 57% displayed spontaneous activity. Blunt probing revealed 61 mechanosensitive receptive fields which were associated primarily with arteries/blood vessels (33/61) and the parenchyma (22/61). All mechanosensitive responses were slowly adapting, with 33% continuing to discharge after termination of the stimulus and 60% displaying a response threshold <10 g. Application of chemical mediators (bradykinin, histamine, 5-hydroxytryptamine, cholecystokinin octapeptide) evoked a response from 31/57 units, with 33% excitatory and 23% inhibitory. Spontaneous discharge was recorded from 72% of 135 vagal bundles. Mechanosensitive receptive fields were not identified in the pancreas but were evident in adjacent organs. No spinal or vagal afferent response to duct distension was obtained. In conclusion, pancreatic mechanosensitive spinal afferents are common, in contrast to pancreatic mechanosensitive vagal afferents indicating that pancreatic sensory innervation is predominantly spinal. Chemosensitive spinal afferent nerve endings are present in the pancreas and respond to a variety of inflammatory and physiological mediators.

The effect of towing a range of relative resistances on sprint performance

The aim of this study was to compare sprint performance over 10 and 20 m when participants ran while towing resistances, weighing between 0 and 30% of body mass. The sample of 33 participants consisted of male rugby and soccer players (age 21.1 +/- 1.8 years, body mass 83.6 +/- 13.1 kg, height 1.82 +/- 0.1 m; mean +/- s). Each participant performed two sets of seven sprints over 20 m using a Latin rectangular design. The times were recorded at 10 and 20 m using electronic speed gates. The sprints of 13 players were video-recorded to allow calculation of stride length and frequency. For both sprints, a quadratic relationship was observed between sprint time and resistance as sprint time increased from 2.94 s to 3.80 s from 0 to 30% resistance. This relationship was statistically significant but considered not to be meaningful for performance because, over the range of resistances used in this study, the quadratic model was never more than 1% (in terms of sprint time) from the linear model. As resistance increased, the stride length shortened, with mean values of 1.63 +/- 0.13 m at 0% body mass and 1.33 +/- 0.13 m at 30% of body mass. There was no significant change in stride frequency with increasing resistance. The results show that in general there is an increase in sprint time with an increase in resistance. No particular resistance in the range tested (0 - 30%) can be recommended for practice.

Improving secondary prevention in coronary bypass patients: closing the audit loop

OBJECTIVES

To complete the audit loop assessing secondary preventative care of patients who had had coronary artery bypass graft (CABG) surgery.

DESIGN

Two separate surveys of 1000 patients who had had CABG at the regional centre between 1988 and 1997, selected in 1998 and 2001. A single page questionnaire was sent to the patient's general practitioner.

INTERVENTIONS

A list was sent to each general practice in Lothian, Scotland, of their patients on the CABG database and the results of the original survey. Lothian Health organised a project to contact and recall patients with cardiac disease in each practice. Sixty five (of 128) practices participated.

MAIN OUTCOME MEASURES

Blood pressure, smoking status, serum cholesterol concentrations, and prescription of lipid lowering drugs and aspirin.

RESULTS

918 questionnaires (92%) in the second survey were returned describing 875 patients: 151 (17%) patients smoked and 752 patients (86%) took aspirin. Mean (SD) systolic blood pressure was lower in the second survey (142.5 (19.2) mm Hg in the first survey v 139.4 (19.1) mm Hg, p < 0.005). In our first survey 34% of patients had cholesterol concentrations less than target (5.2 mmol/l). This increased from 12% of patients operated on in 1988 to 50% of patients operated on in 1997 (Spearman rank correlation 0.77, p < 0.01). In the second survey this proportion had risen to 65% and the correlation with year of operation was abolished.

CONCLUSIONS

By closing the audit loop, substantial improvements were shown in the management of risk factors in patients who have had coronary artery surgery in Lothian.

Transmission characteristics of tuberculosis in the foreign-born and the Canadian-born populations of Alberta, Canada

SETTING

All notified cases of tuberculosis in the province of Alberta, Canada, 1994-1998.

OBJECTIVE

To compare the transmission characteristics of tuberculosis among foreign-born and Canadian-born cases.

DESIGN

Retrospective analysis using DNA fingerprinting (IS6110 restriction fragment length polymorphism and spoligotyping) and patient information from the Alberta Tuberculosis Registry. Transmission indexes were determined by calculating the average number of culture-positive pulmonary cases generated by a single source case.

RESULTS

Of the 750 cases of active tuberculosis, 437 (58.3%) were in the foreign-born. DNA fingerprinting of Mycobacterium tuberculosis isolates from all 573 culture-positive cases over the 5 years from 1994 to 1998 showed that there was significantly less clustering among foreign-born isolates (9.8%) compared to Canadian-born non-Aboriginal (28.8%) and Aboriginal (44.7%) isolates. The transmission index was significantly higher for males, lower for those > or =65 years of age, and higher for Aboriginals.

CONCLUSION

Although cases of tuberculosis in the foreign-born constitute the majority in Alberta, there is little transmission to other foreign-born or to Canadian-born individuals. Transmission of tuberculosis among the Aboriginal population remains a significant problem in Alberta.

The epidemiology of tuberculosis among foreign-born persons in Alberta, Canada, 1989-1998: identification of high risk groups

BACKGROUND

To date, there have been no comprehensive epidemiological studies in Canada of the incidence rates of tuberculosis among foreign-born persons. Accurate rate estimates are needed to develop cost-effective strategies for the prevention, control, and ultimate elimination of tuberculosis.

METHODS

Most new immigrants to Canada settle in one of four provinces: Ontario, British Columbia, Quebec and Alberta. Data from the provincial reporting system for tuberculosis, from Statistics Canada censuses and population estimates of Treaty Status Indians provided by the Department of Indian and Northern Affairs Canada, were used to estimate the rate of tuberculosis in Alberta's Canadian-born and foreign-born population between 1989 and 1998.

RESULTS

Age-adjusted tuberculosis case rates per 100,000 person-years were 19.4 and 61.9 in the foreign-born and Canadian-born Treaty Indians-approximately 10 times and 30 times, respectively, higher than the rate in the remainder of the Canadian-born population (2.1/100,000 person-years). Age-specific rates in male and female foreign-born persons were highest at ages 15-34 and > or = 65 years, whereas rates in Canadian-born non-Treaty and Treaty males and females increased incrementally, with a single peak at > or = 65 years. Tuberculosis case rates in the foreign-born varied significantly according to World Bank region and country of birth. By far the highest rates were seen in immigrants to Canada from Asia, in particular Vietnam, the Philippines, China, Hong Kong and India. Most (90%) tuberculosis patients from these countries had not been identified as requiring medical surveillance in Canada after arrival.

CONCLUSION

Immigrants to Alberta from Asia and Treaty Status Indians are at high risk for tuberculosis. Physicians in Alberta who care for foreign-born persons should be aware that their patients are at increased risk for tuberculosis, even if they have been medically cleared during the legal immigration process.

An analysis of the diagnostic accuracy of the Hawkins and Neer subacromial impingement signs

The purpose of this study was to assess the diagnostic accuracy of the Neer and Hawkins impingement signs for the diagnosis of subacromial bursitis or rotator cuff pathosis. Eighty-five consecutive patients undergoing shoulder arthroscopy by a single surgeon were documented prospectively for the positive and negative clinical and arthroscopic pathologic findings. The Neer sign was found to have a sensitivity of 75% for the appearance suggestive of subacromial bursitis; this compared with 92% for the Hawkins sign. For rotator cuff tearing, the sensitivity of the Neer sign was 85% and the sensitivity of the Hawkins sign was 88%. Specificity and positive predictive values for the two tests were low, being not much higher than pretest probability. The two tests had a high negative predictive value (96% for bursitis, 90% for rotator cuff tearing) when they were combined. The results are compared with those reported in the literature. We conclude that the Neer and Hawkins signs are sensitive for appearances suggestive of subacromial bursitis and rotator cuff partial or complete tearing with a high negative predictive value. However, they lack specificity in comparison with arthroscopic findings.

The efficacy of magnetic resonance imaging in acute knee injuries

OBJECTIVE

To evaluate the clinical efficacy of magnetic resonance imaging (MRI) of the knee in acute injuries with indeterminate clinical findings, using arthroscopy as a gold standard.

DESIGN

A prospective double-blind study was performed. All patients underwent MRI on a 1.5 T magnet using dual spin echo pulse sequences. This was followed by arthroscopy.

SETTING

Tertiary care referral center.

PATIENTS

Twenty-three patients with an average age of 26 years satisfied the study criteria. Patients had to have been seen by one of two orthopaedic surgeons within 6 weeks of sudden trauma to the knee complicated by a hemarthrosis, clinical assessment of which was equivocal.

RESULTS

The respective sensitivity and specificity for MRI of the knee were 90% (18/20) and 67% (2/3) for detecting any anterior cruciate ligament injury, 50% (1/2) and 86% (18/21) for detecting medial meniscal tears, and 88% (7/8) and 73% (11/15) for detecting lateral meniscal tears. MRI also identified injuries that could not be assessed on arthroscopy, including 14 bone bruises, five posterior cruciate ligament tears, nine medial collateral ligament tears, and one lateral collateral ligament tear. The detection of composite injury requiring surgical intervention yielded a sensitivity of 100% (16/16) and a specificity of 71% (5/7). Prospective use of MRI evaluation of the knee could have prevented 22% (5/23) of diagnostic arthroscopic procedures.

CONCLUSION

Equivocal clinical findings in patients with acute knee injury should lead to use of MRI in an appropriate clinical setting. To our knowledge a prospective study of the efficacy of MRI of the knee in this patient population has not been reported. In the presence of such inclusion criteria, the results of our study support the use of early MRI to guide further surgical management.