Listen on iTunes
Stream Audio here:
|
AUDIO - HSP #216 - Radhika Chigurupati
|
Watch Video here:
|
VIDEO - HSP #216 - Radhika Chigurupati
|
Learn how to recognize facial skeletal abnormalities, and how to help patients help themselves.
Dr. Radhika Chigurupati is a board certified Oral and Maxillofacial Surgeon who specializes in orthognathic surgery for correction of developmental and acquired jaw and facial deformities. She sees both children and adults with jaw deformities, cleft and craniofacial anomalies, tooth eruption disturbances, jaw tumors and maxillofacial pathology, and sleep disorders/obstructive sleep apnea (OSA). She works with her colleagues in other medical and dental specialties to provide interdisciplinary care for these patients at Boston Medical Center (BMC), Beth Israel Deaconess Medical Center (BIDMC) and Franciscan Hospital for Children (FCFH).
She has joined Boston University Henry M. Goldman School of Dental Medicine in March 2013 after spending 9 years at University of California San Francisco (UCSF) and one and half years at University of Maryland, Baltimore. During that time, she has practiced at UCSF Moffitt Medical Center, UCSF Benioff Children’s Hospital and University of Maryland Shock Trauma Center. Dr. Chigurupati completed her Oral and Maxillofacial Surgery training at University of Washington (UW), Seattle and subsequently a fellowship in Pediatric Maxillofacial Surgery at the Royal Children’s Hospital (RCH) in Melbourne, Australia. She has been an active member of the cleft and craniofacial teams at UW, UCSF and RCH.
Radhika Chigurupati, DMD, MS
Associate Professor
Oral and Maxillofacial Surgery
100 East Newton Street Suite 407
Boston, MA 02118
617-638-4386
Email: rchiguru@bu.edu
Howard: It is a huge honor today to be interviewing an oral and maxillofacial surgeon who comes very well recommended by our friend Ann Marie Gorczyca. Did I say her name right?
Radhika: Gorczyca.
Howard: Gorczyca. Sounds like that must be a Polish name. Gorczyca.
Radhika: That's correct.
Howard: Polish. Your name is Radhika Chigurupati. Did I get your name right?
Radhika: That is correct.
Howard: That was close enough? I was so excited to talk to you because you're talking to you about 7,000 general dentists, about 85% in the United States. 15% in another 200 countries. The rarest thing that we deal with is a patient, and we're wondering if they need orthognathic surgery. I mean, this is something that just hardly ever comes up. I mean, we do several fillings and crowns every single day and cleanings and check-ups, but everything you do is so rare and foreign to us and what I want to do is spend time with you today and talk about, you know, orthognathic surgery, recognizing facial skeletal abnormalities. Everything you do. So thank you for sharing time with me today.
Radhika: No problem. Thank you for giving me the opportunity.
Howard: Oh thank you. As a general dentist, you know, most dentists have one or two hygienists, it's, you know, maybe a patient every hour. What should we be thinking about when we look at someone's developing face and jaws? Is orthognathic surgery still a child development ... I mean, an orthodontic issue? I mean, is it people, we're looking at their bite and wondering if this can be fixed with an orthodontist or does it need surgery and what could we have seen when they were a child that maybe we could have intercepted or intervened on?
Radhika: Sure.
Howard: You're so intelligent, I don't even know what the right questions are to ask you.
Radhika: No, no, no, don't ...
Howard: So why don't you just edumucate all my homies on what we should be thinking about when we think of the words orthognathic surgery.
Radhika: Sure. When a patient presents to the dentist, they don't usually come with problems saying I need orthognathic surgery. They usually say they don't like their smile or they say they don't [inaudible 00:02:30] bite or they may not even reveal that they don't like their facial appearance, most patients, unless you ask them, do not usually complain about their facial appearance in general. They usually are a bit shy.
We often come across two groups of patients. The younger patients, adolescents, that present along with their parents who come for a routine evaluation to the pediatric dentist or orthodontist for correction of their bite. Then the other group of patients who are adults, who may present for problems related to their bite sometimes problems related to their joint sometimes, or problems related to symptoms of obstructive sleep apnea. All of these patients are candidates for possible orthodontic intervention sometimes combined with surgery or sometimes exclusively orthodontic intervention. However, it's the role of the dentist, the hygienist, and oral health care providers to educate our patients based on their problems.
Howard: Now, I graduated 28 years ago and that was in '87 and I think my orthognathic surgery case lecture in ortho was like freshman year so it was 1984. So what I know about this is so old in age, it was 30 years ago, but my teacher told me that all of this was caused by what he called miscegenation. I don't even know if that's a word anymore. I don't think I've heard it since that. Basically, he said, the 187 species, apes and monkeys, all have good bites and teeth, everything straight and then the great apes, humans, gorillas, chimpanzees, orangutans, gibbons, bonobos, they're all dominant brown hair, brown eye, class one molar, class one occlusion.
What happened was, three major groups left Africa about 70,000 years ago and they inbred one group into Europe, another group went out of Africa into Iran, up to Russia into North America, the North American Indians. Then a third group went past Iran, went into China, Indonesia, Hawaii, and then, to Americas, Inca, Aztecs. That basically, when you see someone like Jay Leno with a big lower jaw and a little upper jaw that it was miscegenation, mixed breeding back in and he inherited a lower jaw from a six-foot tall German or Russian or Pole and a upper jaw from a little Italian, Spanish, Portuguese woman, and that in three million years, just like all the apes and monkeys, we would be back to normal of all dominant brown hair, brown eye, class one molar, class one occlusion. Is that still the theory 30 years later or is that just completely crazy?
Radhika: Well I don't know about exactly that theory, but clearly facial patterns and characteristics are inherited from our parents. There is genetic inheritance as well as some acquired abnormalities due to what occurs during our early childhood. So if a child has a traumatic event, they could then have an acquired abnormality of the jaw. They may have fusion of the joint that may not allow the lower jaw to grow or they may have an abnormality in the mid face after a mid-face injury. However, most of the jaw discrepancy in size or shape may be inherited from parents. So it is an inherited characteristic.
Howard: I'm still mad at my mother for marrying a short fat bald guy. Why didn't she marry ...?
Radhika: [crosstalk 00:06:18] inherit one from one parent and another from another parent so you may have a small lower jaw and a large upper jaw or you may have a large lower jaw and a small upper jaw. These are characteristics that you inherit primarily from your family members.
Howard: In the last 10, 20, 30 years, is orthognathic surgery remaining steady, is it growing in popularity? Are orthodontists using it less? What's the state of orthognathic surgery today? Do the 10,000 American orthodontists still use this modality like they have 10, 20, 30 years ago? Are they getting away from it? Are they doing it more?
Radhika: I think orthognathic surgery about 50 years ago when it was born, it was not as popular. However, over the last few years, the techniques have been refined, the recovery from the surgery is much better, the fixation that we use is more rigid compared to when we used to use biofixation. There are advances in the way we treatment plan these patients with [inaudible 00:07:27] surgical planning. So there are a lot of advances. Also, there have been changes in indications for orthognathic surgery. Primarily for obstructive sleep apnea, now in adults, and adult orthodontics in orthognathic surgery is also becoming more popular in recent years. These are some of the trends that have changed over the recent years compared to the last, I would say, maybe prior to '80's.
Howard: If I was your patient, I was a 53-year-old male and I was going to have orthognathic surgery. The basic questions they're going to ask ... How much is it going to cost? How long will I miss work? And what's a chance when you're done with me, I'll be numb and won't have any feeling for the rest of my life?
Radhika: I'm in an academic hospital practice setting and I won't be able to give you the details of the cost, but I can tell you, roughly, it would be at least for each jaw surgery, depending on what the insurance pays, most practices in academic practice accept insurance. It would be about $2,500 for maxillary jaw surgery and another $2,500 for the lower jaw surgery. Now, this can vary anywhere from $2,500 to $10,000 depending on the practice, depending on the type of institution, depending on the insurance, but the vast majority of patients in academic teaching hospitals are covered by some health care provider or an insurance.
Howard: That's basically the same cost as any elective surgery. A face lift is, on average, about $5,000, but can vary to 25. Breast augmentation is about $5,000, but can vary all the way to 20. So this is basically in the range of any popular cosmetic surgery.
Radhika: Yeah. I mean, it can vary depending on the number of osteotomies, the type of osteotomy, the complexity of the surgery. So there are different levels of that, but the range is approximately correct.
Howard: How long am I going to miss work and what's the chance of paresthesia?
Radhika: The biggest risk with this surgery, let me go back to the question on how long you're going to miss work. The approximate recovery time for orthognathic surgery is approximately three to four weeks. The first two weeks are really the most difficult weeks for the patient. They usually do well. The younger patients better than older patients.
Howard: Why is that?
Radhika: I think the older patients, their lifestyle is different. They have more pain, more discomfort, their healing time is little longer overall. They're probably wanting to return to work more faster and feeling a bit more restless wanting to go back to their regular dietary habits. In general, tissues in younger patients heal faster. The average time is about two to three weeks. I tell the patients who have slightly increased length of surgical time or increased complexity of surgery, they may need up to four weeks, but in general, patients should take at least two to three weeks off after the surgical procedure. I think the younger patients usually are back to normal routine by about two weeks. I just saw my patient who came back at the end of two weeks and he is ready to roll and get back to work.
Howard: Then what about the paresthesia? That seems to be the big question, I mean, people are always afraid.
Radhika: The biggest risk with this procedure is the paresthesia. This is particularly important in the lower lip. The lower jawbone has a nerve that runs through, within the jawbone and the way the osteotomies, which means the way the bone is cut, depends on where the nerve lies relative to the outer cortex and the inner cortex of the mandible. So there is a high incidence of bruising of the nerve when we make the osteotomies in the mandible.
There is some stretch of the nerve also in the upper jaw depending on how high the level of the osteotomy is for the maxilla. However, the recovery in the maxilla is much faster as we don't actually intervene or do not make the cut very close to the nerve. It's usually a stretch injury a little bit when we are making the osteotomy, whereas in the lower jaw, the nerve lies within the jawbone and it is within the lines of the osteotomy. So often the nerve gets bruised a little bit more and they do have paresthesia, and in some cases, in older individuals, there is a higher risk of recovery of the sensation for longer periods of time compared to younger adults.
Howard: How long does it actually take you, an oral surgeon, to do an osteotomy for a maxilla or a mandible. How long of a surgery is that?
Radhika: It can vary depending on the experience of the surgeon, depending on the complexity of the surgery. Anywhere from 90 minutes to five hours. So when I talk about one jaw, surgery can be up to 90 minutes and a two-jaw surgery can be up to three and a half hours. A more experienced and faster surgeon may finish it in three hours, whereas the less experienced and a surgeon who is teaching may take a little longer, up to five hours, for two jaw surgeries.
Howard: For you personally, is that exhausting? I mean, when you're in there for three hours or more or it gets complicated and you're in there five hours, when you're done, do you just feel like you were ran over by a bus?
Radhika: No. No, not at all.
Howard: Really?
Radhika: It can be exhausting when things are not going right, but it's a pleasure to take care of patients and I enjoy what I do. I do enjoy teaching the residents while doing the surgery and sometimes there are more difficult patients where patients are a little bit more obese, where their jaw is more retruded, patients with obstructive sleep apnea, patients with clefts, the orthognathic surgery is more complicated, there's more scar tissue in some of these patients, and the surgery can be more complex and it can be tiring.
Howard: Are you ever working up a patient ... Say they're 30, they're done growing. Say they're 21 and over. Are you ever looking at this case and thinking to yourself, well, this is kind of sad because if the general dentist would have done, you know, referred to an orthodontist or did this when the child was still developing his arches, none of this would have happened. How often do you think that is the case, that the general dentist is kind of asleep behind the wheel, didn't recognize what was going on, didn't get it referred to a pediatric dentist or an orthodontist where they could have expanded the upper jaw with a rapid palatal expander or something to that effect.
Radhika: I think I occasionally see those patients but it's not that anything cannot be done. So, the real problem is when something is done where they actually take out the teeth when surgery would have been appropriate and then you cannot undo what was done previously. It's okay if nothing is done and the patient arrives at your office much later, at a later date, and we can offer them the options even at a later date.
However, there are times when people try to compromise the skeletal deformity by correcting it dentally, which then compromises the results. The skeletal abnormality is not treated and here you're left with limited options for the patient which should have been corrected both skeletally and dentally. So it's not ideal in those situations. I think that is far more worse than not having informed the patient. I think in general it is our responsibility as oral health care providers to inform the patients about available treatment options for correction of obstructive sleep apnea, for a correction of functional problems such as jaw/joint problems and for correction of difficulty in chewing and also for improvement of aesthetics. It's our responsibility to inform them that this may be a combination of dental and skeletal problems.
Howard: Okay, for your level of expertise, you know, a board certified oral and maxillofacial surgeon, teacher, all your credentials. Can you spot the skeletal abnormalities just by looking at someone or do you need to be looking at a ceph or a pano? Can you educate 7,000 general dentists how they can quicker, you know, identify skeletal abnormalities?
Radhika: Yeah, I think facial appearance tells us a lot. When you look at a patient, you look at them in thirds. There are the golden proportions of the upper third, the middle third, and the lower third being proportionate. You can look at some hollowing in the infraorbital region below the eye. You can look at the area of the cheek bones. You can look at facial width. You can look at the area around the nose to see if the nasolabial folds are deep. You can look at the upper lip support to see their smile line. To see how much of their teeth are displayed when they smile. As we age, we show less of our upper teeth. Our nasolabial folds become deep. We also have difficulty in bringing our lips together sometimes when there is mentalis strain and our jaw is retruded and our chin is retruded. So these are some of the signs to look for to look at skeletal abnormalities.
Howard: Now, the most common, you know, besides a bite wing or a periapical, probably the most common x-ray everyone listening to you looks at bigger than a tooth, would just be a pano. Can you really see any skeletal abnormalities on a pano?
Radhika: You can see some. A panoramic radiograph is a good screening tool, but you will not be able to fully use only exclusively a panoramic radiograph to make a full diagnosis, but it's definitely a screening tool if you're suspecting any excessive jaw growth, abnormalities, or temporomandibular joint or ramus or body of the mandible if you want to look at abnormalities in this area.
Howard: I've been out long enough where ... You know, practicing 30 years, you know, sometimes things come out in dentistry and they turn out to be a fad like maybe micro air abrasion, it was all the rage and then it faded away. When I got out of school, they had these yag dags that were $50,000, they sold like a thousand and went out of business. It seems like, with sleep apnea, you never heard of it from 1980 to 1990 you never heard of it, 1990 to 2000 never heard of it, and then all of a sudden about five years ago, my God, you can't read anything in dentistry without seeing three articles on sleep apnea. Is this a fad, is it over blown? What's the reality of sleep apnea? Just tell us all your thoughts on sleep apnea.
Radhika: I think maybe there is an increase in awareness in the last few years about obstructive sleep apnea. [crosstalk 00:19:57]
Howard: There was a lady on, gosh, who's the lady who just sold the Huffington Post? Arianna Huffington.
Radhika: Yeah, Huffington.
Howard: She was on Bill Maher saying that the reason Bill Clinton had an affair with Monica Lewinsky is because of sleep apnea and he wasn't getting enough sleep and he was being irrational, making bad decisions. I mean, it just seems like, on the internet, it's just a cure for everything. Weight loss, you know, you're not sleeping enough, you know, just everything is cured by sleep apnea. So I'm sure it's going to come back a little.
Radhika: Yeah, I think maybe it's a little overrated, but definitely there is more awareness about the importance of sleep for memory, for functional tasks, as well as for daily performance. I think that maybe both in the dental and the medical field, physicians are recognizing that people with co-morbid factors, there is a correlation between people with cardiovascular disease, hypertension, sleep apnea, and stroke. So there in increased awareness, however, I don't think everything can be said to be related to sleep apnea.
Howard: How are you screening for sleep apnea and when is surgery a part of the solution for sleep apnea as opposed to a CPAP or a dental retainer?
Radhika: Sure. So patients present with symptoms of sleep apnea. You can also look at some of the skeletal facial features and see if these patients have some of the features that may be causing them to ... Sleep apnea is a continuum of a problem. From snoring ... Snoring does not necessarily mean a patient has sleep apnea. The patient may have snoring as a problem, but they may not have obstructive sleep apnea. So it's important to differentiate between the two. Patients have facial characteristic signs, but not all patients with those facial characteristics will have sleep apnea.
In general, males above the age of 40 or 45 are at a higher risk. Patients who have other co-morbid factors with hypertension, increased neck girth, they are smokers and alcohol users, and who are males above the age of 45, you can screen them and ask them questions about whether they snore at night, whether there are witnessed apneic episodes, if they sleep with a partner, the partner may notice that they stop breathing and gasp for air. This may happen quite frequently. They may feel increased daytime somnolence or weariness. They may fall asleep frequently when they're driving or performing their daily tasks. These are some of the questions you can ask patients who you think are at a higher risk.
As I mentioned earlier, increased risk factors are males above the age of 45, increased neck girth, smokers and alcohol users, and also patients who have different, irregular sleep hours because of their work.
Howard: Now, do you recommend when a dentist is seeing a patient on recall and it's a older fat male like myself, to just whip out a tape measure and go around the neck? I mean, are you looking for an inch? What is it, 16 1/2 or greater?
Radhika: It's 18 inches or greater.
Howard: 18 inches or greater?
Radhika: I don't usually measure with a tape, but you can tell the physical appearance and ...
Howard: Okay, just by looking at me, I'll move my microphone.
Radhika: [crosstalk 00:23:53] objective assessment I do ask them their collar size sometimes and I will do a tape measurement when I'm truly doing an assessment of a patient. I do check their blood pressure. I ask them questions about witnessed apneic episodes. I ask them questions about whether they fall asleep at the wheel. These are some of the questions I ask. [crosstalk 00:24:15]
Howard: So just looking at my neck, you think I'm close or not?
Radhika: Well, I do think you have mild obesity.
Howard: Mild. Wow, that's the first woman that ever said mild. Usually they say it's extreme obesity and they put a sack over my head, and then they say I'm going to turn out the lights to enhance your appearance. But, no, I was worried about myself and I went down there and it gave me great peace of mind because I did the sleep study and the guy told me the next morning, he goes, "You actually sleep exceptionally well." He said, "You might have been the best sleeper I've had in like two months." Because, you know, I have the obesity thing going, I got the big neck. So, you do or don't recommend us measuring the neck in the dental chair if we're ...
Radhika: I don't think it is necessary. These are all factors to look for. You don't need to measure everybody. But you can ask them questions that will help you counsel them appropriately to seek care if necessary. You can ask them whether they feel like they're sleeping well, whether they're smokers, whether, you know, they've had any witnessed apneic episodes, whether they feel tired during the day, whether they drink a lot of coffee to keep themselves awake and alert.
Howard: Is the smoking and the coffee the same thing? Is just that they're abusing a stimulant and the stimulant interrupts their sleep at night whereas some say you shouldn't have any coffee or any stimulants after, like what, four hours before you go to bed, or what are your thoughts on that?
Radhika: In general, good sleep hygiene is recommended by all sleep specialists. Good sleep hygiene meaning you can sleep at the same time, try to wake up at the same time, and try to keep regular hours and avoid stimulants or caffeinated products after a certain time to keep the number of hours of at least 6 1/2 to 7 1/2 hours of sleep per night.
Howard: You know, that was the best thing that came out of sleep apnea for me is I went there with my, two dentists I work with and, for me personally, after I did that course, I took the television ... I quit using the television in my room and I did focus on the ... I now have a bedtime at 9:30 because I get up every morning at 5:00. The room colder, I turn the ceiling fan on, but sleep hygiene was really neat for me. Because I never thought I was sleep ... You know, I was laying there and the TV's on half the night. Your cell phone's dinging and every time you get an email, so that was good. I couldn't ask my partner if I had any episodes because every time I asked my two cats, they wouldn't say anything. So I thought maybe since they're not saying anything, I should go get it checked out.
When is sleep apnea need surgery versus a CPAP machine?
Radhika: So a CPAP is the most effective treatment for patients with obstructive sleep apnea. The severity of sleep apnea is graded as mild, moderate, and severe. The first device or appliance that most people recommend is CPAP. However, using CPAP is quite cumbersome for most patients and most patients don't like using a device at night that causes them to have to put this mask on the nose and sleep on their side and have to have this machine attached to them. It's not a fun piece of device to have all night. It's mostly compliance that makes it difficult to maintain. Therefore, they're looking for alternative therapies. However, CPAP is the most effective treatment for obstructive sleep apnea. It's when patients cannot tolerate this device.
Howard: Say it again, what is the most effective after CPAP?
Radhika: CPAP.
Howard: Okay.
Radhika: Continuous positive airway pressure.
Howard: So when would surgery be indicated?
Radhika: We do get patients who are unable to tolerate CPAP who have severe obstructive sleep apnea and these are patients that may have different levels of obstruction at the level of the nasopharynx, at the level of the oropharynx, and the hypopharynx. The theory is that by moving the upper jaw and the lower jaw forward, you can affect all three levels of obstruction at the nasopharynx, oropharynx, and hypopharynx and therefore maxillomandibular advancement can be an effective treatment modality for obstructive sleep apnea.
Howard: Was this non-existent ten years ago and growing more common ...?
Radhika: No, it was existent, it was definitely a surgical modality that was advocated for patients with sleep apnea.
Howard: Ten years ago?
Radhika: Yes.
Howard: Are you seeing that procedure getting more common since sleep apnea is everywhere in the media, everywhere in social media, everybody's talking about sleep hygiene, sleep apnea. Are you seeing more mandibular, maxillary advancements through orthognathic surgery for the treatment of sleep apnea?
Radhika: I would say there is more increased awareness and there is evidence in the literature that bimaxillary advancements may be a treatment modality for patients with severe obstructive sleep apnea with multi-level obstruction.
Howard: You're saying bimaxillary. So just the [maxillafore 00:30:06], not the [mandiblefore 00:30:07]?
Radhika: No, bimaxillary meaning upper and lower jaw.
Howard: Oh, bimaxillary means upper ...
Radhika: And lower jaw.
Howard: ... upper maxillary and lower mandible?
Radhika: Yeah.
Howard: That seems like a weird term. Why would ... bimaxillary would think two maxills, not a maxill and a mandible.
Radhika: You can just call it maxillomandibular advancement which is the more common term, MMA.
Howard: MMA. Huh. You know, they always say you should think positive and I positively think all my patients hate their CPAP.
Radhika: Yeah. (laughs)
Howard: What percent of patients ...?
Radhika: I think patients have to be educated about the CPAP and I often refer the patients back to their pulmonologist or neurologist who see them often for sleep apnea and ask them to educate them and see if you can get a better fitting mask, better fitting device. Certainly, surgery is no fun for anybody. If there is a non-surgical option, I encourage patients to go with the non-surgical treatment option first and give it a try.
Howard: I did this volunteer missionary dental trip down in Mexico with about ten dentists and the guy sleeping next to me, there was like four in a room, had a CPAP and he was telling me how ten years ago, it was this loud, noisy thing and, I mean, it looked like a CD player and I didn't hear a thing all night and not one person in the room said they heard it or annoyed them or anything. He said it just come a massively long way.
Radhika: Uh-huh.
Howard: Is there anything that would apply more to the general dentist? You know, most of my audience is general dentist, but I mean, you could talk about everything. You could talk about cleft palates, I mean, you could talk about anything. What do you think would be the best ... We're half done. We're 30 minutes down and 28 to go. What could you utilize this half hour for to edumucate general dentists on things they should know more from your perspective?
Radhika: I think the most important thing is since we are on the topic of sleep apnea, is to ask patients when they see certain skeletal abnormalities, for example, in a patient where they may see that they're lying in the chair, but having some difficulty with breathing through their nostrils and they're constantly sniffing, look for enlarged inferior turbinates, ask them whether ... look for signs of a deviated nasal septum, ask them if they have trouble breathing through their nose, look for enlarged tonsils.
Do a proper exam when they're in the chair. Ask them if they have a spouse accompanying them, whether there are witnessed apneic episodes. In a child, to look for a narrow, high-arched palate, their mouth posture, whether they're mouth breathers. Children especially when they're growing, if they're mouth breathers, they will have a low tongue position and the palate will remain narrow and constricted. An expansion of the palate has shown to improve symptoms of obstructive sleep apnea.
Howard: Yeah, that was a lot. You know, I'm so old, do you realize when I got out of school, people with snoring problems were going to ENT's who were taking CO2 lasers and just reaming out the back of their throat, I mean, the uvula, they just boared it all out and I had about, I don't know, maybe five patients that did that for maybe '87 to '92 and every one of them was depressed because they lost so much sense of taste and smell by having the back of their throat Roto-Rootered out with a carbon dioxide laser. Do you remember those days or do you remember that?
Radhika: Yeah, UPPP was a common procedure. It's still ...
Howard: What was it called, triple P?
Radhika: UPPP. Uvulopalatopharyngoplasty.
Howard: Wow.
Radhika: Is a common procedure. It still, there are indications for soft tissue surgery intrapharyngeal procedures in certain patients which include the tongue base reduction with the radio frequency ablation. Reduction of the soft palate [lens 00:34:26] to increase the tautness of the soft palate. These are all procedures. However, the indications for the procedure and selection of the patient is very important. So, I think consultation with the surgeons to indicate which procedures suits the patient best is something that has to be done and the dentist can also use oral appliances or oral devices in patients with mild and moderate sleep apnea to see if a mandibular advancement or mandibular repositioning device can help patients with obstructive sleep apnea.
Howard: I want you to switch to tonsils and adenoids because again, going back in the '80's. When I was little and just got out of school and you look down a child's throat and they had tonsils the size of ping pong balls and you send them to the ENT, they just whacked them out every time. I would say, and that was in the '80's, I'd say by the end of the '90's, by 2000, you almost couldn't get a ENT to remove tonsils and adenoids. Talk to us about tonsils and adenoids. Are you aware of that shift from a long time ago to now where they were all, I would say they were almost routinely removed in the '60's and '70's. I mean, if in doubt, you just removed the tonsils and adenoids. Then it shifted all the way over to, I really need a really good reason to remove these. So what should a dentist be thinking about with sleep apnea or a child with tonsils and adenoids?
Radhika: I think it's up to the dentist to at least look for the airway. Look at the airway and determine if they have enlarged tonsils. Ask the parent about symptoms of snoring, about symptoms of witnessed apneic episodes, and symptoms of frequent upper respiratory tract infection. If all three of these are present, then the child should be referred to a pediatric otolaryngologist for further consultation if they do have symptoms of sleep apnea or they have very frequent upper respiratory tract infection with enlarged tonsils and symptoms of tonsillitis. So, examining the airway is important and not every child gets their tonsils and adenoids removed these days like they used to in the past, but at least the pediatric otolaryngologist, who is the expert in the area, can counsel the parent appropriately then. The primary care physician also is in a better position to appropriately counsel the patient and refer them to a specialist, if needed.
Howard: When you have a patient that has, you know, mild, moderate sleep apnea symptoms and I know it's a co-morbid and you're looking at this full spectrum, but they definitely have a deviated septum, they have difficulty breathing through their nose. How big of a factor is that in getting the deviated septum fixed, or breathing.
Radhika: Well, it's not an exclusively one factor that causes this so the first thing is to do an objective assessment of the airway. The nasopharynx, which may have to be done both by direct clinical examination and endoscopic clinical examination to determine the level of obstruction. If it is very severe and they are only breathing through one nostril, then it should be appropriately corrected. Enlarged turbinates in patients who have frequent allergic rhinitis symptoms and a extremely deviated septum can cause moderate obstruction of the nasopharynx and the nasal passages. You can see these signs by use of accessory muscles when their nostrils flare, when they're inhaling and exhaling. These are some of the signs that you look for to see on clinical examination, but using an endoscope will give you a much better perspective of the evaluation of the nose and the dentist may not be able to do this in his office, but the otolaryngologist can certainly do this with a speculum and a scope.
Howard: Have you ever thought about changing you name to Dr. Dental Wikipedia?
Radhika: No. (laughs)
Howard: Man those words flowing off your mouth, I can't even google them fast enough to figure out what all the terms you're saying. They just flow from you. What else do they know? What else do dentists know? I'm not even smart enough to ask you questions. We're 40 minutes down, I only get you for 20 more minutes.
I want to ask you this. This is what I want to [inaudible 00:39:09] from. We started Dentaltown in 1998 and I thought it'd be a couple of hundred dentists on an internet study club. We signed up a thousand a month since 1998. We have 205,000 dentists from every single country on earth and we have never ... We put up 350 on-line courses and they've been viewed over half a million times. What makes it the most romantic to me is, okay, so it helps Americans, Canadians, Australians, you know, rich countries, Germany, Scandinavia. It helps those dentists be a little better. But when you go to dental schools in Africa and Asia and South America, it's their entire curriculum. We have never had a oral surgeon like yourself make a case, all this would probably be better if it were slides or whatever. Would you ever consider creating an on-line CE course for Dentaltown on all this amazing stuff that you know?
Radhika: Yeah, I'd be happy to. Yeah.
Howard: Oh my God. Because I go to some of these dental schools in Asia. I mean, I walked in a dental school in Kathmandu and the dean of the dental school, she started crying because she's like, "Oh my God, it's everything." You know, "It's free."
Radhika: I'd be happy to educate on-line any time.
Howard: And there's so many private dental schools popping up all over Brazil and India and Africa and their curriculum, they don't even have a textbook. It's all internet, YouTube. Dentaltown has a nice ... It's really becoming the first on-line dental school and a lot of what you're saying, it would really help if you saw a slide or something about what you're talking about.
Radhika: Yeah, no, I'd be more than glad to help.
Howard: It would be the greatest honor to capture your amazing mind and see this all on a CE course, but hey, thank you for all that you do. A big shout out to Ann Marie Gorczyca. Am I saying it right? Gorczyca?
Radhika: Gorczyca.
Howard: Gorczyca. Huh. I always call her Ann so I never say Gorczyca. A big shout out to ...
Radhika: Well, thank you for giving me the opportunity, I would love to educate other dentists and other specialists on-line any time.
Howard: Well, just send me ... I'm howard@dentaltown.com. Howard Goldstein's in charge of on-line CE so his email is hogo, h-o-g-o, @dentaltown, hogo@dentaltown, but email me howard@dentaltown and CC hogo@dentaltown, but you're like ... There's 2,000,000 dentists on earth and you're one of three people probably on the planet that could talk at this level about everything you're talking about.
Radhika: There are plenty who can talk, but I'm happy to give my time.
Howard: Okay, well, thank you very much for all that you do.
Radhika: There are many maxillofacial surgeons who are experts in what I do and more than experts than me so I think I'm available to do this and I'll be more than glad to do it.
Howard: Ann Marie told me that you were the smartest one on earth in this field. She said that and I believe her over your humility and humbleness. So have a good flight and I look forward to doing this again on facial abnormalities, cleft palates, and I would kill to have an on-line course at any length you want. It could be an hour, it could be six hours. Whatever you think it takes.
Radhika: Okay. That's great.
Howard: And just remember when you're preparing it, for many dental schools in Africa, Asia ...
Radhika: Absolutely.
Howard: And Latin America, it will be the only curriculum they get so ...
Radhika: Yeah, as long as I don't share patient information or photos that violates HIPAA, I will put all the educational material together and I will review it and send it to you.
Howard: Or what you could do is you could photoshop my face on those patients and then they'll just all think it was me and I'll sign a release.
Radhika: Okay. (laughs)
Howard: All right. Have a great day.
Radhika: You too. You too.
Howard: Bye bye.
Radhika: Bye bye.