Obstructive Sleep Apnea Could be a Dental Nightmare

You're listening to the Phil Klein Dental Podcast Thanks for joining us. I'm Dr. Phil Klein. Obstructive sleep apnea is more common than you think, and as dentists, it's critical to identify this insidious condition as early as possible. Not only can it wreak havoc on your patient's teeth and gums, it can also cause serious systemic health issues for the adult, child, and even newborn. Today, we'll discuss integrative oral medicine. and how it relates to conditions like obstructive sleep apnea. We'll also discuss the importance of using biologically kind restorative materials that promote systemic health and predictable long-term clinical success. Our guest is Dr. Mark Cannon, a professor of otolaryngology, Division of Dentistry at Northwestern University, Feinberg School of Medicine, and he's a member of the International Association of Pediatric Dentistry. In addition to maintaining a large private practice in the suburbs of Chicago, he is the research coordinator of the residency program at Ann and Robert Lurie Children's Hospital, Chicago, Illinois. Dr. Cannon is on the executive board, current president, 2023. and a Master Fellow of the American Academy of Oral and Systemic Health. Before we get started, I'd like to mention that Dr. Cannon's webinar titled Total Pediatric Dentistry is now available as an on-demand webinar on VivaLearning .com. Simply type in the search field, Cannon, C-A-N-N-O-N, and you'll see it. It's an excellent webinar for the entire dental team. Dr. Cannon, it's a pleasure to have you on the show. Well, thank you so much for having me on, Phil. This is so much fun. We haven't done this in some time. We should do it more often. Yes, I would love to. With all the knowledge that you have to share with our audience, I would love to. And I'm glad we're doing this one so I can't get greedy. So this is an interesting topic. We're talking about integrative oral medicine, but from your standpoint, we're talking about starting this whole process, not only with children, but even before they're born, which is something that is quite surprising to me. And an example of this is obstructive sleep apnea during pregnancy. So if you would, talk to our listeners about integrative oral medicine briefly. Tell us what that is and then go into how it starts even before the patient's born as it's linked to patients that are pregnant that are suffering from obstructive sleep apnea. Well, I think, you know, I've been involved with... pediatric dentistry since the 70s and I've we see a lot of children when they're like one years of age they come in for their first checkup and one of the first things you do is evaluate airway for lip ties and tongue ties and I see a lot of babies coming in young babies you cannot feed I see those all the time where we have to do evaluation for laser therapy of a lip tie or tongue tie etc but going back to the airway often I'll be discussing with a mother or if I'm seeing a three-year-old, I notice a mother is expecting another child. We discuss things like obstructive sleep apnea during pregnancy. It depends on the study, but in many studies, a number of women having OSA doubles during pregnancy due to the additional and the necessary gaining of weight for the baby. Their sleep positions all change and all that. And sleep apnea during pregnancy has some very significant potential negative outcomes when it comes to developing child. So we always discuss that because, quite frankly, treating sleep apnea during pregnancy is relatively easy. It's a short-term treatment, often with dental appliances. So there's absolutely no reason not to treat it. So let's switch gears a bit for now. I do want to say that we're going to get back into talking more about obstructive sleep apnea and how it affects the dentition, the whole body, what dentists can do about it later on in this podcast. So we're going to get back into it. But before we do that, I want to talk about dental materials for a few minutes, bio-friendly materials, so that we do the best we can. for the health of the patient. And that means not using materials that could be detrimental to the body by being absorbed through the tooth and so forth. One of the most important things we do in dentistry as far as restorative dentistry is use baseliner material. In the past, we've had some contraindications for using baseliner materials. So tell us about that. Well, that's a very important issue because you mentioned things and materials you don't want. Just recently you saw that a lot of breast milk is contaminated with fire retardant from the clothes that the mothers are wearing, and they're unfortunately giving the fire retardant to their child. So people didn't know to be worried about that. But over a period of time, we've changed restorative materials, right? We went from silver, we went from gold. which were strong materials that didn't need support, and we could just place those on top of any old calcium hydroxide product like diacol, and we've gone to a lot more resins, and people are doing some extremely large composites. I've done some very large composites very successfully, but then what's underneath that resin-based composite becomes very important. It has to be strong. It should actually adhere to the tooth structure. Now, during the period of development of these baseliners, we had this little interim where there was a compromise that was done. People would apply a little Dichal calcium hydroxyl. I'd cover it with a glass ionomer so they could catch and rinse without disturbing the Dichal. And it was a compromise because it didn't quite work well. As we know from many studies, there was no adhesion between the dical and the dentin, and there was no adhesion between the dical and the glass ionomer. And so you basically had a very weak substructure. But wait, there's another issue. The fluoride release from the glass ionomer would actually... react with the calcium be released from the glass, from the dical, making calcium fluoride crystals, which are insoluble and inert. So we have shown in research that you actually reduce the amount of calcium and reduce the amount of fluoride by putting both products together. Thank God there's a replacement. I mean, one of my favorite things. and I absolutely really admired the chemists who worked on this, was the development of Therabase, which is a Bisco product. And Therabase does everything. It adheres to the dentin. It's dual cured, so you know it's cured all the way down. It has a very high degree of polymerization, so it has a lot of strength to it. It does release calcium. So you get the calcium release. And because of how it's formulated, there can be some fluoride release also. It is radiopaque. And it replaces the missing dentin and mechanical properties. So it basically does everything you want. So you can place a composite that is a large composite and be certain you're doing what the patient needs. You're doing what's good for the dentin. And of course, the alkalinity of it is very good for the pulp, stimulating more dentin formation. You also give the calcium for the dentin formation. But the alkalinity inhibits bacterial growth, as we all know. So, you know, a glass ionomer is acidic. In fact, it's known to be cytotoxic if it gets too close to the pulp. So you have to keep at least a half millimeter or more dentin to protect the pulp. This is something that I think should be routine for dental practices. Let's talk about the application. So the clinical application is a large composite. But let's talk about where we're very, very deep versus we're not super deep. Do we use anything different or we just put TheraBase on in both cases? We're not talking about a pulp exposure now. We're talking about a deep filling versus one that's just average and there's enough dent and not to worry. Well, if it's just a regular restoration and you just want to provide some pulp, you know, indirect protection, you want the alkalinity, the calcium release, and you want to reduce sensitivity. because this absolutely reduces sensitivity, you can use Theracal LC, which is a light cured, tricalcium, dicalcium, select that product, apply that light cure, go right straight to work, and finish restoring it. Now, if you have a large carious lesion, I always go with Therabase. And because it has the additional strength, and of course it's dual cured. And one thing with Therica LC, again, being light cured, being very opaque, and it's a very opaque product, you don't want to put it on too thick. You want to keep the layers very thin. So it would take a long time to build that up completely. So you don't want to do that. You want to go from Therica LC and conservative restorations to the large restorations you want to use, the Therabate. I think the Thera family has that well covered, along with, of course, having then the TheraCem, the cement product, too. And I assume this all works very well, leaving a small amount of affected dentin when you're doing an indirect pulp cap that's very deep? Oh, yeah. Well, indirect pulp cap, you leave a little bit of decay. But you see, if you leave a little bit of what they call affected dentin, which is dentin that does not... huge bacterial load that would be infected dentin if you leave a little affected denting you still have weakened the tooth that is why some people have had failures within direct pulp caps is because what they place on top of that area is too weak to support the restoration for a long period of time and the restoration will flex you'll get some micro leakage and return of contamination and then you end up having um the pulp go necrotic two years later three years later and people say well i try it it doesn't doesn't work in my hands well that's why you need to have a good strong restoration have a good strong seal Can you just also talk about the pulp exposure? So you have a small pulp exposure due to trauma or it's a carous exposure and you do get some bleeding. So it shows the pulp is vital because if there's no bleeding and it's necrotic, a pulp cap is not going to help you if the diagnosis of the tooth is necrotic pulp. So what do we do there if we have a direct exposure, small? Well, of course, it depends a lot upon the patient's age and what tooth you're looking at and what else they have going on. For instance, if you're looking at an older patient who's had a lot of endodontic procedures and crowns, you might actually in your mind be giving that tooth a little bit less of a chance to remain vital, especially if they have a lot of medical compromises at the same time. But yeah, if you're looking at a young patient like I would look at who obviously has never had any root canal. procedures ever done and it's like a sole tooth coming in i would give it every opportunity to remain vital and i would tell you that everyone who does this will say they probably have like a 90 success rate where the direct pulp cap when it's properly done when you have a good seal and it's a tooth where the pulp was vital not a big history of pain, not a lot of sensitivity. I've had some that have had some sensitivity and they've been fine just with a direct bulb cap for many, many years. It's kind of important with young people to not burn them out on dentistry too fast. We have kids who are teenagers who come in who've been burned out and they're not good dental patients and they're only 14, 15 years of age. You can't treat your 13-, 14-, 15-year-old as if they're in their 50s and 60s. When you say burned out, you mean too much clinical dentistry has been done for them? Yeah, a lot of clinical dentistry, and they've given up. You can see when you talk to them, their motivation levels are lower. This is where it becomes very important to give them all the benefits of preventive care and talk to them about prebiotics and probiotics to build them back up to be good dental patients. And utilizing a good material, like I cannot tell you how many patients I've had who've always complained about having had sensitivity. After seeing a dentist, we'll go ahead and do our standard procedure. We'll utilize the TheraCal LC or the TheraBase. And the sensitivity rates are so much less. They don't fear coming in. If you keep them comfortable during the procedure, they have no postoperative sensitivity. It was really rare to have postoperative sensitivity. And when I was in full-time practice and I would see all those thousands and thousands of young people doing composites, it was really rare to see it. Are we entering a stage now in dentistry where we all are going to be using bioactive materials as our restorative materials? And the days of inert restorative materials are coming to an end? In the past, we always used things that were noble that were kind of bio-inert. Now we've moved more to bioactive. We like to use terms like just biological. Because we want to make sure it's not just the goal of forming a little appetite, which is a calcium phosphate crystal. You want to make sure you're doing more in that environment. Number one, you want to make sure that the ion release reduces any chance in any future recurrent caries. You want to work with a lack of sensitivity. You want to make sure that the aesthetics are there and that the strengths are there. I mean, you can call something bioactive, but that doesn't mean it's strong. Right. What's happened to glass ionomer now in dentistry? There's still a major application for glass ionomer, correct? Yeah, but there's much less. I mean, I'm a big glass ionomer person. You know, I spent many, many years lecturing about some of my favorite glass ionomer materials and all that was true then. It's still true today, but there's far less of a need because we have newer. better materials. Again, I know we've talked about Therabase a few times, but that is definitely, I don't use a glass ionomer as a base anymore. It's not used as a base. I will use it as a temporary. In pediatric dentistry, I'm an endodontist retired, but I always thought in pediatric dentistry, glass ionomers were a better choice for kids. the fluoride aspect of it. And they're relatively moisture friendly. Right. So, yeah, we still do a lot of glass ionomers in situations of, let's say, atraumatic restorative care or alternative restorative care treatment where we'll go in and maybe do some SDF treatment of some large carious lesions, but more in the anterior where it might show the darkness. We'll do a lot of glass ionomers. Oh, yeah. They'll have a... don't have a purpose for a long time. By long time, I mean at least another five years. Right, until something else comes out. Let's end up with, again, talking about obstructive sleep apnea because that's something that actually affects the prognosis or the predictable success. It lowers the success rate of standard periodontal disease treatment, which is scaling and root planning. Talk about that for a few minutes. Well, there's been some really... done and published studies like in British Dental Journal about the success rate when you have someone who is a mouth breather as opposed to someone who has good nasal breathing technique. The success rate drops by about half. So it makes absolutely no sense to just go in and do periodontal treatment, standard of care treatment without actually addressing the nasal breathing and relax. of now going back to children with moms who have obstructive sleep apnea it does a whole lot of things and at least in animal studies when it does is it can cause neurodevelopmental defects in the developing animal. That is shocking and horrifying to me because I used to see a lot of kids with developmental delays and sensory issues. They often wondered there'd be no reason why this occurred that they would know of. I wondered if it wasn't due to obstructive sleep apnea in the mom. Also, it can cause, and this is in animal studies because we can't really prove this in humans, it can cause a lower jaw. to be underdeveloped in the developing uh pup or or animal and you think of all these kids born with no lower jaw you're wondering if that isn't happening in humans but it does cause for the mom gestational diabetes it causes weight gain um it makes them more prone to perio and the perio makes them more prone to become insulin resistant so they have more weight gain having more gestational diabetes and a higher risk than of c-section And yet it's so easy to treat and so easy to diagnose. Dentistry has been missing out on this. What's behind the scenes that contributes to the etiology of these kinds of conditions from OSA? What's actually happening from the local area of the sleep apnea in the mouth? How does it do this to the rest of the body and also the developing child? Well, so it's so interesting because, of course, whenever you have obstructive sleep apnea, there's a constant stress reaction in the body at night. So you always have the increase in cortisol production within the body, which means, again, you're going to start putting away weight, which is because then you have women who gain all the extra poundage during pregnancy and they have to work hard to get rid of it later. That increases the sleep apnea, but the increase in mouth breathing increases the growth of all the pathogens. I mean, you'll have an increase in strep mutants, you'll have an increase in caries, you'll have also an increase in periodontal disease. And the circulating pro-inflammatory cytokines cause insulin resistance because they increase the inflammatory response to the entire body. And when that happens, you get insulin resistance. That's part of what happens as the body tries to shut down all the glucose uptake that goes into the cells. So you really have a cascading effect. that results with, in some studies, just snoring was linked to an increase in preeclampsia. So it's easy to diagnose, it's easy to ask the questions, and it's easy to treat. We just haven't been doing it. So the oral systemic link that was somewhat of a concept 10, 15 years ago, it's proven now that this is exactly what happens. And it's the bacteria under the gums that are really the culprit to all this? A great deal of the culprit. As I was lecturing at the CDS meeting and someone asked me what I was lecturing on, I told him, he goes, well, I just thought there was just like a link that was maybe published and not the world's best journals. I was laughing going, my friend, if you put the word periodontal and atherosclerosis in PubMed, you get over 7,600 publications, many of which are in the top cardiology journals. There is no. They have cause and effect. You can take porphyrmonus gingivalis and give it to pregnant mice and see increase in miscarriages and preeclampsia. You can take the microbiome from a woman with preeclampsia and give it to a germ-free pregnant mouse and it will get preeclampsia. The mouse will. You can do all these great studies. You can do porphyrmonus gingivalis. and this was published in a great journal, by the way, over a period, twice a week, I think it was, or three times a week for a month, three times a week for a month, 12 treatments of porphyrmonis gingivalis in the mouth. And the mice got all the histopathological markers of Alzheimer's. They got the insulin resistance. They started to gain weight. They had cognitive decline. They could no longer do the mazes as well, and they could no longer find the cheese as well. They can show cause and effect. There is no more theory. It's written like the Bible now. So what's your conversation with a new patient, or an existing patient for that matter, on a re-care visit where you could identify that that patient has OSA? And when you do identify that that patient has OSA, what is the first thing you do? Well, we often do a simple, there's Epworth sleepiness scale that we can run. But we also do home sleep apnea tests. s-a-t um there's one i use called sleep image and we use that and it's just fascinating and we refer people to a sleep center but yeah we take care what the problem is we get them worked up by uh ear nose and throat sometimes the kids it's just large tonsils and adenoids get those out the kids stop snoring everything gets much better by the way the first time i ran into that was over 20 some odd years ago 20 what five years ago with my middle son, Christopher, who needed to have his tonsils out. It changed him. Unbelievable. 25 years ago. So the dentist, yeah, that's unbelievable. So the dentist doesn't really need to do any definitive treatment per se. I mean, they don't have to, they can, but they don't have to participate in the treatment of OSA, but for them to identify it because the... is seeing them and they're looking in their mouth and talking to the patient, probably more than most other healthcare providers, the dentist being the most commonly visited healthcare provider, just identifying it and referring it to someone that can deal with it is really a tremendous service to the patient. Do you agree? Oh, yeah. Here's a classic example, published in the International Journal of Ear, Nose, and Throat. They looked at many hundreds of kids having their tonsils and adenoids removed because of airway issues. All of them had dental disease. All of them did. In fact, over 60% of them had severe to moderate decay. And these are kids who are four or five years of age. In other words, there's a very strong association between the mouth breathing and dental disease. So if you see a child come in and they have a mouthful of cavities and they're four years old or three years old, there's a good possibility you have a child with sleep disturbed breathing too. And the microbiome that's being disrupted there with mouth breathing, is that just due to the dryness of the environment and the lack of the ability for the saliva to help clean things up while they're sleeping? That's the most direct and simple answer to the whole thing. is in fact, as you mouth breathe, you do desiccate the oral cavity and the saliva cannot do what's supposed to. You will not have all the antimicrobial proteins, the lubricant. You won't have the commensals you normally would have in the saliva floating around that are protecting you. So you just get the pathogens overgrowing. And this is something one day, Phil, we got to sit down. We have to really talk about this in depth. Yeah, because this is something that is, I mean, it's like... know, you're trying to fix an automobile and the frame is bent and you keep putting new parts in and every 10 miles the thing wears out and the other part's being stressed because it's never going to be fixed because the frame is bent. I actually got a vehicle with a bent frame. I am laughing so hard because it would never track right. Because the front and the back, it was a bent frame. Right. It would never drive correctly. And I'm laughing. No one today knows what we're talking about because that was prior to unibody construction. Yeah, right. buy a salvaged car and you got to make sure you don't get a bend frame but you know they straighten it out the best they can but the point is unless you get down to the root of the problem and that's the problem with a lot of medicine i mean we're not just talking about dentistry we're talking about a ton of diseases we're a sick country we have many many people that are unfortunately overweight obese diabetics and a lot of this stuff can be prevented with better diet and you know that's where the wellness dentistry is coming in. We're starting to do more podcasts on wellness dentistry. But this obstructive sleep apnea is a major concern in the dental profession that should be looked at. Like I said, I hate to use the term bent frame, but if you can't fix the OSA in a patient, everything you do is destined for failure, right? Every restoration you place in the mouth. Eventually, yeah, your recurring caries rate will be so much higher. And you're absolutely 100% correct me. You said root cause. Functional medicine and functional dentistry is looking for the root cause. Yeah. All right. Well, listen, again, a great podcast, Dr. Cannon. I hope I didn't talk too much because you're the one that knows everything. No, no. This is fun. It's always fun. We're just not doing a podcast together. We're friends having a conversation. No, absolutely. Yeah. So we need to do more on this OSA stuff. We need to get you back on and get more into detail about how a dental practice can kind of transform their approach to treating patients so that they could get to the root cause. And maybe, I mean, I think they would probably do a great, besides service for their patients, they would build their practice up from the marketing standpoint very quickly, just because there are so many people that suffer from OSA. Having that wellness approach, that whole body approach, to me, is an attractive thing for a patient to go to a dental office instead of just being a tooth doctor. I would say that all the young people, all the young parents are looking for someone who does more than just fixed teeth. They want someone who's going to be there, who's going to advise them and help them pick the right type of products to use. for themselves, the right type of toothpaste, everything. People are more educated now about, they know, a lot of them will, I just saw a thread, a conversation where a periodontist recommended using chlorhexidine and the physician patient said, wait a second, here's all the side effects chlorhexidine has. By the way, he did not go into the main side effect of it raising the blood pressure. So, you know, there's a lot of things that, people now are learning about and our patients are hearing about. So we've got to be aware of. Yeah. And that's why we do these podcasts and that's why we encourage everybody to continue on with their continuing education because it doesn't stop at dental school diploma. That's for sure. All right, Dr. Cannon, thank you very much. And we look forward to having you. Yeah. We look forward to having you on a future podcast very soon. You bet. Take care of my friend. Always good to talk to you. And help others discover our show.