Hi everyone!

Well, once again it has been too long since I've written in this blog.   Recently, a patient form Farmington Hills who came in for some cosmetic dentistry mentioned he was using a CPAP and I remembered that I had neglected to follow up on my visit to the American Academy of Dental Sleep Medicine ( http://aadsm.org/index.aspx ) meeting in Baltimore in early June.  I was privileged to be able to take part in 3 days of scientific sessions, classes and forums relating to the dental treatment of sleep disorders.

In a previous blog, I mentioned TAP and SOMNOMED appliances.  In Baltimore, I had a chance to work with many other removable appliances such as the SILENCER, the HERBST appliance, the KLEARWAY appliance, the SUAD DEVICE, the EMA, the OASYS, and others.  They all do essentially the same thing, that is move the lower jaw and floor of the mouth (tongue, etc.) forward slightly to open up the collapsed airway in the pharynx (throat) that causes the obstruction to breathing.   In additon I had the opportunity to personally try out some sleep monitoring devices that provide a means of documenting the presence or absence of apneas (stopped breathing events during sleep) at home, such as the WATCH-PAT 100. the EMBLETTA,  the Respironics STARDUST II, the ARES, and the MEDIBYTE.  Although diagnosis of Obstructive Sleep Apnea Syndrome (OSAS) is best done by  Polysomnography (PSG) done at a certified sleep clinic and interpreted by a pulmonogist, these are ideally suited to be used as follow ups to determine the effectiveness ot the dental appliances and to monitor treatment outcomes. The appliances are adjustable (titratable) and they may actually stop snoring but not stop apneas until the jaw is advanced further.  These at-home diagnostic appliances can tell us if we are done titrating or need to advance the mandible (lower jaw) additionally to stop the sleep apnea.  

More on this later.  Until next time,

Mark W Langberg, DDS, FAGD

Hi everyone!

    It's been too long since I've written in, but I've been really busy and somehow my blog ended up near the bottom of my "to-do" list.  I hope you'll forgive me!

    Much of my free time has been spent reading and studying about dental treatment of Obstructive Sleep Apnea(OSA).   In April I attended 3 days of intensive "hands on" training in the new field of dental appliance therapy for folks with OSA.  The class was given by Dr. Barry Glassman, of the Allentown Pain Center in Pennsylvania( http://www.allentownpaincenter.com/ ) who is board certified by the American Board of Dental Sleep Medicine ( http://aadsm.org/index.aspx ).  We are all familiar with snoring, which is the sound of partially obstructed breathing during sleep.  If the structures of the throat are formed in a certain way and our muscles relax enough during sleep to cause the airway to narrow and partially obstruct the flow of air, our throat structures will vibrate and cause the sound we know as snoring.  Such factors as large tonsils, a long soft palate and uvula, certain jaw configurations,  alcohol or medications, sleep posture and fat deposits contribute to the collapsibility of the airway.

    Obstructive Sleep Apnea occurs when the airway completely collapses during sleep and breathing itself stops multiple times per hour.  When no air can be drawn into the lungs, the oxygen level in the blood drops and the waste gas level rises and signals the brain to partially awaken in order to stimulate the troat muscles to open and clear the obstruction. This usually but not always happens with a loud gasp or choke.  Once a breath is taken the arousal subsides, the muscles relax and the process continues over and over all night.  People with OSA experience continally disrupted sleep and drops in oxygen levels all night.  This has been associated with  irregular heartbeat, hypertension (high blood pressure), heart attack, stroke, GERD (Reflux Disease), depression and mood alteration, and excessive daytime sleepiness which can play out with deadly consequences on our roadways.  It has even been implicated in the tragic Exxon Valdiz oil tanker accident in Alaska.

    Obstructive Sleep Apnea is typically diagnosed at a Sleep Cinic using a test called a Polysomnograph, and in the past has been treated with lifestyle changes (eg. weight loss), behavioral modification (no alcohol, changing sleep posture, etc.), surgery to enlarge the airway (painful and not as effective longterm) and CPAP or Continuous Positive Airway Pressure (a mask worn over the mouth and nose at night which pumps air into the lungs).  CPAP is almost always a very effective treatment for sleep apnea, but it is fairly cumbersome, uncomfortable, and fairly "unromantic" so compliance with its use is predictably low (<40%).

    The American Academy of Sleep Medicine and the FDA has recently approved dentist fabricated oral appliances for patients with mild to moderate OSA who either perfer their use to CPAP or who are not candidates or responsive to CPAP.  These appliances are comparatively comfortable and non-invasive and go by names such as Oasys, TAP, and Somnomed.   These appliances are what we were trained to make, use, and maintain in the course I took.  I will write more on these in the near future.

    By the way, in early June I will be attending an additional 3 days of training at the American Academy of Dental Sleep Medicine annual meeting in Baltimore, MD.

    That's enough for now.  Until next time,

    Mark W Langberg, DDS, FAGD

    Hi everyone!  This last weekend I took a 3 day class in Toronto entitled "Advanced Cardiac Life Support for Dentists".   It was offered by DOCS  (I belong to the Dental Organization for Conscious Sedation - www.docseducation.com ) and this is the 3rd 3 day class I have taken from them.  The teaching staff was from Life Support Services, Inc., out of Ann Arbor, MI, and they were excellent!  (Find them online at: www.LifeSupportServicesInc.com  .  They handle the emergency medical services for the University of Michigan Hospital, Washtenaw and western Wayne Counties.)  The subject of the training were the additional procedures that are recommended by the American Heart Association beyond CPR and AEDs (defibrillators) to support life in the event of a heart attack, stroke, or similar.  This included lectures on physiology, pharmacology, diagnosis, as well as intubating/establishing airways with King tubes, accessing EKGs on advanced AEDs with monitoring displays to determine when to shock and when not to, delivery of emergency drugs such as epinephrine, atropine, lidocaine, etc.and all manner of decision making needed in a emergency.

    Essentially we were taught to do what paramedics and advanced emergency medics do when they pull up in their ambulances and transport patients to the emergency room. The 3 days consisted of lectures and hands on practice with a computerized dummy who talked, breathed, and had a pulse (sometimes!).  It ended with a practical and written exam on which your dentist scored 100%.  We plan to continue our training by having them come to our office and spend a day with our entire staff running mock drills and "codes" to make sure we are able to function as a team at the highest level to insure the safety of our patients in the unlikely event of an emergency!

Until next time!

Mark W Langberg, DDS

No, in most instances, adults with conditions such as exposed root surfaces (which make them more susceptible to decay or sensitivity),  periodontal (gum) disease, significant restorative dentistry (veneers, crowns and bridges), or significant decay issues can benefit from fluoride treatments.  The University of Michigan Dental School is now advising fluoride treatments in the dental office at hygiene visits for adults with these problems.  Home applied topical fluorides (prescription high fluoride toothpastes or rinses) are a very effective alternative.   In our office we prescribe 5000 ppm Sodium Fluoride toothpaste both with and without 5% Potassium Nitrate (the active ingredient in Sensodyne toothpaste) to manage tooth and root sensitivity.  The brand we prescribe most often is Prevident 5000 Plus by Colgate.  For those patients that do not have prescription coverage or have prescription copays greater that $15, we dispense Flouridex toothpaste (another 5000 ppm Fluoride toothpaste by Discus Dental with or without the Potassium Nitrate) for $15 (our approximate cost) to our patients as a convenience.  Prevention is always cheaper that treatment, and ultimately the use of topical fluoride in adults saves time and money and reduces sensitivity.  It makes good sense to protect your investment in your teeth!

Until next time,

Mark W Langberg, DDS, FAGD

    Waterpiks do a great job of flushing food and debris out from between teeth, under braces and arch wires, and especially under and around fixed (non-removable) bridges.  They are also helpful in washing away accumulated bacterial toxins in hard to get and chronically under-cleaned areas around restorative dentistry , tight spaces between teeth, or shallower periodontal (gum) pockets.  Unfortunately, they DO NOT remove plaque (bacterial colonies) like floss does because effective flossing literally "wipes" the sticky plaque off teeth and Waterpiks can only "rinse" these areas.  However, combining both flossing and Waterpics can achieve great results!   Folks with dexterity problems or people who will just never floss will greatly benefit from Waterpik use and it is definitely better than doing nothing to clean in between your teeth.  If you are not a flosser and are unwilling to put forth the effort to floss daily, then Waterpic use is a hugely beneficial alternative to just brushing, which does not clean in between your teeth where most dental disease occurs.  And if you have fixed bridges you will find that regular Waterpic use will make your breath smell fresher, your food taste better, your mouth feel cleaner, and your bridgework last longer! More on Are Waterpiks a substitute for flossing?

    In addition to completely sterilizing all instruments we use, liberal use of disposables and barriers, we have also responded proactively to concerns about bacteria which inevitably live and grow in water lines from municipal water supplies.   All of the coolant  water which comes out of our dental units in our handpieces is isolated from city water by a separate system of tubing which allows us to supply our own water, distilled and sterile, to our dental units. In addition, at night the water lines are purged to insure that bacterial counts are always well below tap water and your visits to our office will always be safe!

    The vacuum, high heat, and steam used to autoclave each and every handpiece takes a significant toll on the bearings and the turbines.  In order  to thoroughly sterilize handpieces after each use we have accepted and absorbed significant costs to routinely replace these turbines and bearings.   Each turbine/bearing assembly costs approximately $350. to replace, and this needs to be done quite often.  Unfortunately, the technology of the bearings and fiber optics has not evolved to adequately cope with the stresses of frequent autoclaving.  Unlike hospitals that can itemize and bill for all additional costs involved in patient treatment, there are many costs similar to this that we incur that are not separately charged to patients that figure into the cost of modern dental treatment and are absolutely essential to insure everyone's safety.  We refuse to cut corners to save money on your safety!

Until next time,

Mark W Langberg, DDS, FAGD

Everything we use at our office on patients is either heat sterilized or disposable.  In our office, all the doctor's and hygienists' instruments and handpieces are thoroughly cleaned in an ultrasonic cleaner before being placed in sealed sterilizer bags and placed in one of  2 autoclaves (hot steam sterilizers) and completely and totally sterilized.  In addition, every other day our assistants run monitoring packets through the sterilizers which are analyzed by an independent service to be certain that the autoclaves are functioning properly to protect our patients and staff.  Items which cannot be autoclaved are disposable.  All surfaces in the treatment rooms are thoroughly disinfected with a hospital grade, EPA approved surface disinfectant and difficult to completely disinfect surfaces (such as headrests or electrical switches) are covered with plastic barriers which are changed between each patient.   All of this is very time consuming (about 10 minutes added to each patient visit) and fairly expensive but is absolutely essential to keep our patients and staff safe and your dental treatment worry free! 

Until next time,

Mark W Langberg, DDS, FAGD

We use only the best American dental laboratories and the best, highest quality materials for your crowns, bridges, veneers and dentures. The latest trend in dentistry is to outsource dental labwork to other countries to save on labcosts. Many dentists are using labs in China, Vietnam and India that will do dental labwork for 1/4 the cost of American labs. There is no regulatory oversight for these labs and you have no idea what kind of metals or ceramics are being used. As with most things, you get what you pay for. 

We are extremely "picky" about who does our labwork, and our standards are very high. Since our reputation rides on all the restorative dentistry we place in your mouth, the choice of labs is 100% determined by the quality of the restorations, and 0% determined by the labfees our office pays. Anything else just doesn't work for us.

We use the best dental materials from such proven American companies as 3M, Kerr (Romulus, MI based) and Kodak. There are cheaper generics for almost everything. We don't use them.

Until next time,

Mark W Langberg, DDS, FAGD

Dear Patients:

This is a first for us, and I hope to make this blog a regular habit. It is always exciting to plunge into new territory and technologies, and I am grateful to have this blog forum available to us to further enhance the level of communication we have with our patients and potential patients. We pride ourselves on some of the things that are clear and evident to each of you that have visited our office: 

• We pretty much stay on schedule!
• We keep you comfortable!
• We explain treatment and fees in advance.
• We see you promptly if you have an emergency.
• I am available 24/7 evenings and weekends for those "unexpected" dental problems and will gladly meet you at the office after hours.
• If you have significant treatment you will get a follow up telephone call from me within 24 hours.
• Our facility is clean, modern, and pleasant to be in.
• Our equipment is state of the art.
• We offer the best in treatment quality, and work with excellent specialists.

With over 30 years of experience, we are really good at what we do! Yet there are many things that you may never be aware of that go on behind the scenes in our practice.  These are often even more important in providing safe, high quality dental care. In the next few blogs, I will briefly discuss these "behind the scene" things.

Thanks again for choosing us to privide you and your family with your dental needs. Just a reminder, Appointments can be requested on our website. For those patients that want to learn more about specific dental subjects and oral health, a helpful "Patient Education" section is also available.

See you next time! Bye!

Mark W Langberg, DDS, FAGD