Having the California Dental Board conditionally accept the AGD transcript – as proof that CE credits have been earned – is a great benefit for our members. Remember that the burden of proof that a dentist has taken the required CE units to maintain their licensure is the responsibility of the licentiate. On January 16, 2015 AGD’s Board adopted AIRW15#16, requiring a course completion certificate in order for CE credit to be displayed on members AGD Licensing and Award Transcripts. The AGD has taken extraordinary measures to archive members continuing education certificates in the event any of its members were to be audited by the Dental Board. This would assist our members in that all submitted certificates are archived by the AGD. Not only is this a convenient benefit for our members, the AGD has researched the requirements to maintain licensure specifically for each state. By viewing the Licensure Transcript, you can easily track your progress and to plan accordingly to take the required CE courses before your next licensure renewal.
At the AGD website on the Education and Events menu “Manage My CE,” our California requirements can be found, and as part of the fifty hours of CE necessary for each renewal period are: CPR, two hours of California Infection Control, two hours of the California Dental Practice Act. A maximum of ten of the fifty hours may come from practice management courses that primarily benefit the licensee.
Submission of this transcript to your licensing board does not guarantee that you will not be audited, nor that all of the CE records will be accepted by the board. Your licensing board has the final say in evaluations of your CE records. Please maintain all your original course documentation.
I was proud and honored to represent the AGD at the California Dental Board Meetings in March to request that our AGD Transcript be considered after conditional acceptance. This request was honored, and it was placed on the agenda for a vote in May. The California Dental Board voted to accept the AGD Transcript as conditional proof of CE. Mr. Nick Femyer from AGD Chicago was most instrumental in identifying the need for this member benefit. California is currently the latest and the thirty-fourth state constituent to reach this agreement with their respective licensing board.
Look for this PACE logo on all of the course advertising for proper credit with the AGD and the California Dental Board:
Approved PACE Program Provider
Approval does not imply acceptance
by a state or provincial board of
dentistry or AGD endorsement
The pharynx manages some of the most complex functions of the human body, changing tone and shape with every breath, swallowing effort, and vowels we pronounce. Unlike animals that have rigid and strutted airways, ours is flexible and supported only by muscle tone. Indeed, it is precisely the floppiness and length of our airway that sets us apart from animals: not only do we possess the physical prerequisites for speech; we also have the cortical equipment needed for expression of abstract thought through language. But at night we are bound to the same physiologic principles as other mammals when sleep commands muscles to rest, but leaving us uniquely vulnerable to airway collapse. Snoring and obstructive sleep apnea (OSA) is a measure of this collapse when airflow is diminished through changes in either muscle tonus or altered caliber.
We understand now that both the muscular (tissue compliance) and neurologic (reflexive) components that help the airway respond to closing pressures during sleep are altered in OSA patients. For patients with sleep apnea that undergo sedation, pharyngeal muscle tone is diminished further, risking exacerbation and dangerous hypoxia. Anesthesiologists are keenly aware to follow tailored protocols for patients with a diagnosis of sleep apnea in the outpatient surgery and hospital setting, as set forth by the American Society of Anesthesiology1. However, it is the undetected apneic that is at particular risk and this is why any healthcare provider administering sedation or narcotics should use precautions to identify and protect these patients.
Identification of at-risk patients can most easily be accomplished thru the intake health history, plus adding two or three additional questions once co-morbidities to OSA are found. For example, given that a patient presents with hypertension and is also obese, one may consider asking about snoring or repeated arousal and un-refreshing sleep. A level of suspicion about OSA can quickly be developed and referral for evaluation recommended. Taking it one step further, a short questionnaire designed specifically to identify OSA risk is preferred.
In a study conducted last year, two dental offices in San Diego were asked to administer the “Apnea Risk Evaluation System” (ARES) questionnaire to consecutive patients in order to assess prevalence of undiagnosed OSA in those patient populations, as part of a larger NIH funded grant designed to study the effects of oral appliances2. Both offices demonstrated very similar prevalence, showing that 67% of men and 24% of women were in need of a sleep study. A random subset of those queried were given sleep studies that showed the questionnaire correctly correlated sleep disordered breathing with 98% sensitivity. Further, the questionnaire also correctly predicted that 70% of those surveyed would have moderate or severe OSA. Given these results, one might expect statistically to find considerable numbers of patients with untreated OSA in their practices.
Physical inspection of the oral cavity and oropharynx can also be quite telling. The classic “tongue too big for the mouth” patient that has your assistant complaining quickly about their forearm muscles may also have apneic tendencies. Many of these patients will show signs of bruxism and/or clenching, understood now to be compensatory maneuvers to thwart pharyngeal collapse. Some of these signs are: scalloping of the lateral borders of the tongue, linea alba, as well as tooth wear and headache. They may also be those folks who have the most disdain for your dentistry: would you complain if you already have a crowded pharynx and then someone wanted you to open wide (closes airway), stuff cotton rolls in your mouth (closes airway), and then pushes your tongue back and sprays water (chokes you)? Sounds like that could cause anxiety. Aren’t those the same patients we’re sedating?
Sedation dentistry is a wonderful opportunity to make our patients comfortable during care and has a proven track record of safety. Understanding the added risks of sedating patients who are predisposed to airway collapse in the post-operative period is our responsibility. Simple questioning to uncover covert OSA, as well as guiding the patient toward evaluation and taking the proper precautions during the recovery and pain management phase of care is not only prudent, but may also be a life-saving service to our patients.
Dr. Todd Morgan maintains a general practice in Encinitas at Scripps Memorial Hospital. He has been treating OSA in his practice since 1990, and is a charter member of the American Academy of Dental Sleep Medicine. He has authored a book chapter and published several articles in peer-reviewed medical journals. Recently, his group completed one of the largest NIH funded studies on the effects of oral appliances for sleep apnea. Dr. Morgan also offers “Over the Shoulder” style courses at his office for dentists interested in expanding their knowledge. He can be reached at: [email protected]
1. A Report by the American Society of Anesthesiologists Task Force, Practice Guidelines for the Perioperative Management of Patients with OSA. Anesthesiology, 2006.
2. Morgan TD, Levendowski DJ, Montague J, Metzler V, Westbrook PR. Prevalence of Probable Obstructive Sleep Apnea Risk and Severity in a Population of Dental Patients, Sleep Breath 2008
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