Airway Perspective on AAO Obstructive Sleep Apnea and Orthodontics White Paper – Spear Education

Author’s note: The topic of the impact of tooth extraction on the airway can be very contentious. My hope is this article serves as a tool to allow collegial discourse between restorative dentists concerned with airway and the orthodontists who they look to for solutions.

Recently, I had a new patient come to see me “looking for some veneers.” She had four bicuspids removed for orthodontics in the early 1970s and was given a headgear, but routinely found it on the floor at night. Also, her tonsils and adenoids were removed when she was very young due to recurrent infections.

She complains of a lifetime of poor sleep and never feeling refreshed. She is on multiple high blood pressure medications and has reflux. Ten years ago, she was snoring so badly her husband requested a sleep study.

The study diagnosed her with snoring and apnea. The treatment was UPPP (palatal surgery) and repair of a deviated septum. She feels that she can breathe better than before the surgery, but the symptoms never cleared. She still snores and has unrefreshing sleep.

My examination revealed multiple teeth with recession, some significant. Generalized pathologic wear and erosion. The maxillary anterior teeth were retroclined with lingual facets from pathway wear. The lower anteriors were over erupted. The tongue volume appeared normal, but the oral volume was limited. Her airway, on examination, was constricted with an exaggerated protective retraction of her tongue during examination of the oropharynx.

I thought to myself, “Could the removal of four teeth and subsequent retraction of the anterior teeth be culpable in her medical and dental history?”

The OSA and orthodontics relationship is relatively new

In 2019, the American Association of Orthodontists (AAO) released its “Obstructive Sleep Apnea and Orthodontics” white paper. It was the culmination of a two-year project by a panel of sleep medicine and dental sleep experts. They were tasked to produce guidelines for the role of orthodontists in the management of obstructive sleep apnea (OSA).

In the end, the group could not develop any formal OSA guidance for orthodontists. This is interesting given that orthodontists are charged with managing the anatomy of the airway and they work with medical providers on airway anatomy issues like cleft palates and orthognathic surgery.

While it was not stated in the paper, in my opinion, the reason for the lack of specificity of recommendations comes from the nature of the science that was being evaluated. When medical colleagues review dental literature, routinely they are struck by the poor quality of the data. Dental research is typically not well funded, the numbers of participants are limited, the follow-up is short, and it lacks untreated control subjects.

Orthodontics takes years to complete and many years to determine any impact. And finally, the relationship between OSA and orthodontics is a relatively new concept that has rarely been tested in sleep laboratories. Instead, most studies on airway change look at cephalometric or CBCT volumetric alteration and infer (all be it incorrectly) that bigger is better. The conclusions of the AAO white paper are, therefore, going to be constrained by this lack of quality evidence.

Bicuspid extraction addressed

Curiously, section 12 of the AAO white paper, “Fallacies About Orthodontics in Relation to OSA,” addresses the issue of bicuspid extraction. It begins, “Conventional orthodontic treatment never has been proven to be an etiologic factor in the development of obstructive sleep apnea. When one considers the complex multifactorial nature of the disease, assigning cause to any one minor change in dentofacial morphology is not possible.”

This conclusion is true, but the key word is “proven.” There is also a lack of proof orthodontics is not a factor in the development of OSA. The disease is multifactorial but minor changes in oral volume, vertical dimension, and mandibular protrusion have been shown to change the airway and sleep apnea significantly. To argue that removal of four teeth is an unremarkable change is, at least, questionable given available data.

The paper continues, “The specific effects on the dental arches and the muscles and soft tissues of the oral cavity following orthodontic extractions can differ significantly, depending on the severity of dental crowding, the amount of protrusion of the anterior teeth and the specific mechanics used to close the extraction spaces.”

Zhiai Hu1 published a systematic review evaluating the effect of teeth extraction on the upper airway. It included only seven articles. They were divided by the reason for treatment:

The Class I bimax group all had anterior tooth retraction without boney changes. Three of the four articles showed a reduction in upper airway dimension, the last showed a reduction but not to the level of significance.

The one article on crowding differed because the orthodontic technique allowed the molars to move forward ~3mm. That created an increase in the airway dimension.

Finally, the unspecified group did not provide a discussion of the direction of movement (retractive or molar movement) and found small increases for both extraction and non-extraction groups. A conclusion that can be reached from this review is if you retract the anterior teeth, the airway size reduces and if the molars move forward, the airway improves or remains the same.

Impact of volumetric change

The white paper goes on to state, “The impact that orthodontic treatment with or without dental extractions may have on the dimensions of the upper airway also has been examined directly, first with two-dimensional cephalograms and more recently with three-dimensional CBCT imaging…

“In discussing orthodontic treatment to changes in the dimensions of the upper airway, it also is helpful to understand that an initial small or subsequently reduced or increased size does not necessarily result in a change in airway function.”

This is one of the issues medicine has with dental literature. Dental researchers rarely study the actual impact of the volumetric change. It is not enough to say the space is smaller. It needs to be quantified with sleep data. It also needs to be followed over time.

However, Christian Guilleminault highlighted a reduction in the ideal size of the upper airway can lead to abnormal breathing over time, initially with flow limitation, then with a progressive worsening toward full-blown OSA.2> Rarely would testing at the completion of orthodontics demonstrate a compromise. It is the stressful breathing night after night that compromises the airway and makes people more prone to breathing issues during sleep.

Existing evidence suggests the opposite

The AAO white paper does highlight a paper that attempts to answer the question about compromise later in life.

“One such study assessed dental extractions as a cause of OSA later in life with a large retrospective examination of dental and medical records… The study concluded that the prevalence of OSA was essentially the same in both groups, and that dental extractions were not a causative factor in OSA.”

A.J. Larsen3 reviewed insurance records for 5,500 patients between the ages of 40-70. Dental radiographs determined if the subjects were missing four bicuspids or had a full complement of teeth. They matched the two groups for age, BMI, etc. Then they reviewed their medical records to see if the subject had received a diagnosis for apnea.

The results showed that 9.56% of the non-extraction and 10.71% of the extraction group had a diagnosis of OSA. This was not significantly different. Thus, the authors’ conclusion was there was not a relationship between OSA and premolar extractions.

It is currently estimated that 80-90% of OSA patients are undiagnosed. Larsen’s paper states because the subjects all have insurance, they would expect physicians would note the symptoms and get them a sleep study and diagnosis.

There is absolutely no evidence to support that assertion and the existing evidence suggests just the opposite. From pediatricians to primary care, physicians are not diagnosing apnea effectively. The conclusion of the article should be extraction and non-extraction individuals are underdiagnosed at almost the same rate.

Orthodontic literature is not conclusive

The AAO paper goes on to state, “Overall it can be stated that existing evidence in the literature does not support the notion that arch constriction or retraction of the anterior teeth facilitated by dental extractions, and which may (or may not) be the objective of orthodontic treatment, has a detrimental effect on respiratory function.”

Once again, it is true existing evidence does not support that position because there is no quality evidence at this time, not that the relationship does not exist. This should, in my opinion, be a call for more research rather than posturing the topic as a fallacy.

Orthodontic literature is not conclusive on whether premolar extractions impact the airway. A weakness of all the studies is they are based on CBCT or cephalometric radiographic measurements and not sleep data. How a patient uses the existing airway volume is more critical than the size and that’s never measured.

Is there ever a time when I agree with an orthodontic recommendation of extractions? Absolutely. I will, however, ask my specialist:

The most important take away should be the need to intervene earlier. Attempting to direct craniofacial development may keep us from ever needing to know the answer to, “Does the extraction of four bicuspids impact the airway?”

Jeffrey Rouse, D.D.S., is a member of Spear Resident Faculty.

1. Hu Z, Yin X, Liao J, Zhou C, Yang Z, Zou S. The effect of teeth extraction for orthodontic treatment on the upper airway: a systematic review. Sleep and Breathing. 2015;19(2):441-451.

2. Guilleminault C, Huseni S, Lo L. A frequent phenotype for paediatric sleep apnoea: short lingual frenulum. ERJ Open Research. 2016;2(3):00043-02016.

3. Larsen AJ, Rindal DB, Hatch JP, et al. Evidence Supports No Relationship between Obstructive Sleep Apnea and Premolar Extraction: An Electronic Health Records Review. Journal of Clinical Sleep Medicine. 2015;11(12);1443-1448.

This content was originally published here.

G.O.P. Faces Risk From Push to Repeal Health Law During Pandemic – The New York Times

“People now see a clear and present threat when others don’t have health care,” he said. “Republicans have no response to that because their entire worldview on health care is built on an assumption that’s now out of date.”

And with Mr. Trump making dubious claims about health care — like suggesting people inject or drink bleach, and promoting an unproven malaria drug — Democrats are seeking to paint him and his party as ignorant on an important issue.

In a recent survey, Mr. Ayres asked swing-state voters how government should help workers who have recently lost insurance coverage. The poll found that 47 percent supported a major government expansion of health care, 31 percent believed the best option for laid-off workers was to go on Medicaid, and only 16 percent preferred federal subsidies for Affordable Care Act premiums.

Based on that research, and given the Republican inclination to favor a private-sector approach, Mr. White, who is president of a business-oriented coalition called the Council for Affordable Health Coverage, has called for the government to help pay for premiums under COBRA, the program that allows unemployed workers to buy into their former employers’ plan.

“Republicans must offer private market coverage solutions that are preferable to Medicaid (which is now more popular than Obamacare),” Mr. White wrote in a policy memo.

Ms. Pelosi’s bill is aimed at shoring up the Affordable Care Act, which she helped muscle through Congress during her first speakership, and reducing premiums, which are skyrocketing. Ms. Pelosi had intended to unveil the measure in early March, for the health law’s 10th anniversary, at a joint appearance with former President Barack Obama. But the event was canceled amid the mounting coronavirus threat.

The bill would expand subsidies for health care premiums under the Affordable Care Act so families would pay no more than 8.5 percent of their income for health coverage; allow the government to negotiate prices with pharmaceutical companies; provide a path for uninsured pregnant women to be covered by Medicaid for a year after giving birth; and offer incentives to those states that have not expanded Medicaid under the law to do so.

One thing it will not have, aides to Ms. Pelosi say, is a “public option” to create a government-run health insurer, an idea embraced by former Vice President Joseph R. Biden Jr., the presumptive Democratic presidential nominee. The bill being introduced by Ms. Pelosi has no chance of passing the Senate and becoming law, but it will give Democrats another talking point to use against Republicans.

The health law has already survived two court challenges. In the current Supreme Court case, 20 states, led by Texas, argue that when Congress eliminated the so-called individual mandate — the penalty for failing to obtain health insurance — lawmakers rendered the entire law unconstitutional. The Trump administration, though a defendant, supports the challenge.

The justices are expected to hear arguments in the fall, just as the presidential and congressional races are heating up. But Mr. Cole, the Republican congressman, said other issues related to the coronavirus pandemic would also be at play in November.

“If we look like we’re on top of it in September or October and we’re on the way to a vaccine, then it will break to the president’s advantage,” he said. “If we’re in the middle of a second wave, obviously not.”

This content was originally published here.

Virginia Health Dept Urges Citizens to Snitch on Churches and Gun Ranges | Dan Bongino

Virginia’s Department of Health is joining others who have encouraged their state’s citizens to snitch on each other – but only for select reasons.

As the Washington Free Beacon’s Andrew Stiles reports:

The Virginia Department of Health is encouraging citizens to lodge anonymous complaints against small businesses for violating Gov. Ralph Northam’s (D.) coronavirus-related restrictions on public gatherings.

Virginia residents can report alleged violations of Northam’s executive orders regarding the use of face masks and capacity requirements in indoor spaces via a portal on the health department’s website, a practice commonly known as “snitching.” 

The webpage gives snitchers several options regarding the “type of establishment” on which they are intending to snitch. These include “indoor gun range” and “religious service,” among others. Republican state senator Mark Obenshain expressed concern that churches and gun ranges were “specifically” singled out, noting, “there is nothing to prevent businesses from snitching on competitors, or to prevent the outright fabrication of reports.”

Meanwhile, when protesters were out in full force in the tens of thousands earlier in the month, VA’s health department merely encouraged them to wear masks and wash their hands. They also recommended social distancing, which would obviously be impossible in such an environment. “We support the right to protest, and we also want people to be safe” they said.

What do they think is going to do more to spread the virus, a dozen people at a gun range, or tens of thousands in the streets? Even if those at the gun range transmitted the virus at a higher rate, the latter would still infect more people due to sheer volume.

It is indeed the case that coronavirus cases are on the rise nationally (as you’d expect after weeks of mass protest), but not all cases are created equal. The vast majority of cases are mild and asymptomatic, and the median age of those infected is drastically lower than it was months ago (meaning most new cases are among those least likely to die of the virus).

That’s evident in Florida, where cases are exploded – but the death rate has precipitously declined because the average person infected is now only 37 years old. In March it averaged in the mid fifties.

In many states more people above the age of 100 have died of the virus than those under 40. On the day coronavirus deaths peaked, for every person aged 24 or younger that died of the virus, 319 people above the age of 85 died of it.

This content was originally published here.

Henry Ford Health study: Hydroxychloroquine lowers COVID-19 death rate

Hydroxychloroquine lowers COVID-19 death rate, Henry Ford Health study finds

Sarah Rahal and Beth LeBlanc
The Detroit News
Published 6:42 PM EDT Jul 2, 2020

A Henry Ford Health System study shows the controversial anti-malaria drug hydroxychloroquine helps lower the death rate of COVID-19 patients, the Detroit-based health system said Thursday.

Officials with the Michigan health system said the study found the drug “significantly” decreased the death rate of patients involved in the analysis.

The study analyzed 2,541 patients hospitalized among the system’s six hospitals between March 10 and May 2 and found 13% of those treated with hydroxychloroquine died while 26% of those who did not receive the drug died.

Among all patients in the study, there was an overall in-hospital mortality rate of 18%, and many who died had underlying conditions that put them at greater risk, according to Henry Ford Health System. Globally, the mortality rate for hospitalized patients is between 10% and 30%, and it’s 58% among those in the intensive care unit or on a ventilator.

An arrangement of hydroxychloroquine pills.
John Locher, AP

“As doctors and scientists, we look to the data for insight,” said Steven Kalkanis, CEO of the Henry Ford Medical Group. “And the data here is clear that there was a benefit to using the drug as a treatment for sick, hospitalized patients.”

The study, published in the International Society of Infectious Disease, found patients did not suffer heart-related side effects from the drug. 

Patients with a median age of 64 were among those analyzed, with 51% men and 56% African American. Roughly 82% of the patients began receiving hydroxychloroquine within 24 hours and 91% within 48 hours, a factor Dr. Marcus Zervos identified as a potential key to the medication’s success. 

“We attribute our findings that differ from other studies to early treatment, and part of a combination of interventions that were done in supportive care of patients, including careful cardiac monitoring,” said Zervos, division head of infectious disease for the health system who conducted the study with epidemiologist Dr. Samia Arshad. 

Other studies, Zervos noted, included different populations or were not peer-reviewed.

“Our dosing also differed from other studies not showing a benefit of the drug,” he said. “We also found that using steroids early in the infection associated with a reduction in mortality.”

But Zervos cautioned against extrapolating the results for treatment outside hospital settings and without further study. 

Lynn Sutfin, spokeswoman for the Michigan Department of Health and Human Services, respond to the study Thursday by noting “prescribers have a responsibility to apply the best standards of care and use their clinical judgment when prescribing and dispensing hydroxychloroquine or any other drugs to treat patients with legitimate medical conditions.”

Dr. Marcus Zervos identified administering steroids early in the infection as a potential key to the medication’s success.
Zoom screenshot

The study found about 20% of patients treated with a combination of hydroxychloroquine and azithromycin died and 22% who were treated with azithromycin alone compared with the 26% of patients who died after not being treated with either medication. 

Henry Ford Health has been working on multiple clinical trials of hydroxychloroquine, including one that is testing whether the drug can prevent COVID-19 infections in first responders who work with coronavirus patients. The first responder clinical trial was trumpeted by Trump administration officials early in the pandemic.

Many health care institutions, including the World Health Organization, suspended clinical trials of the drug touted by President Donald Trump after a faulty study was published in the British medical journal The Lancet on May 22. The WHO restarted the trials in June.

The study is vital, Zervos said, as medical workers prepare for a possible second wave of the virus and there is plenty of research that still needs to be conducted to solidify an effective treatment.

In this May 18, 2020 file photo, President Donald Trump tells reporters that he is taking zinc and hydroxychloroquine. Results published Wednesday, June 3, 2020, by the New England Journal of Medicine show that hydroxychloroquine was no better than placebo pills at preventing illness from the COVID-19 coronavirus. The drug did not seem to cause serious harm, though – about 40% on it had side effects, mostly mild stomach problems.
Evan Vucci, AP, File

Still, use of the malaria drug became highly controversial.

Doctors at Michigan Medicine, the University of Michigan’s health system, remain steadfast in their decision not to use hydroxychloroquine on coronavirus patients, which they stopped using in mid-March after their own early tracking of the treatment found little benefit to patients with some serious side effects.

Michigan’s largest system of hospitals, Southfield-based Beaumont Health, also stopped using the decades-old anti-malarial drug as a coronavirus treatment after deciding it was ineffective. 

St. Joseph Mercy health system has also backed away from the treatment. The system has St. Joseph hospitals in Ann Arbor, Chelsea, Howell, Livonia and Pontiac, as well as the Mercy Health hospitals in Grand Rapids, Muskegon and Shelby. 

Heidi Pillen, director of pharmacy at Beaumont Health, confirmed on Thursday that the health system is not using hydroxychloroquine to treat COVID-19 patients. 

A recent United Kingdom study evaluating hydroxychloroquine in hospitalized patients with coronavirus was stopped after preliminary analysis found it didn’t have any benefit. About 26% of patients in the trial using the drug died, compared with about 24% receiving the usual care, according to the Oxford University study. 

But doctors at Detroit Medical Center’s Sinai-Grace told The Detroit News in April, when the hospital was overloaded with senior COVID patients, that they were giving the drug to anyone they could.

srahal@detroitnews.com

Twitter: @SarahRahal_

This content was originally published here.

Motivated by his son Beau, Joe Biden pledges help for veterans with burn pit health issues – CBS News

Throughout his presidential campaign, one of the most striking elements of Joe Biden‘s appeal has been his empathy. The personal tragedies he has suffered inform his interactions with voters who are also experiencing loss. And his sorrow could also guide policy decisions as commander-in-chief, offering assistance to veterans who may be suffering from service-related medical conditions — as he believes his son did. 

With a familiar quiver in his voice, Biden regularly on the campaign trail shares memories of his son Beau, who died in 2015 from glioblastoma brain cancer. A handful of times Biden detailed how he thinks his son’s cancer may have been related in part to the large, military base burn pits during his 2009 service in the Iraq War.

“He volunteered to join the National Guard at age 32 because he thought he had an obligation to go,” Biden told a Service Employees International Union convention in October. “And because of exposure to burn pits — in my view, I can’t prove it yet — he came back with Stage Four glioblastoma.”

Biden’s precise language — “in my view, I can’t prove it yet” — appears to be intentional as he lends his voice to the ongoing and somewhat controversial debate over whether the burn pits caused lasting health issues for American veterans.

“We don’t have 20 years”  

As the Iraq and Afghanistan military operations grew, so did the installations of bigger burn pits on military bases, rather than the smaller burn barrels that had previously been used. The pits were meant to dispose of everything from garbage to sensitive documents and even more hazardous materials. 

“They build as big as this auditorium,” Biden said to a CNN town hall audience in February, “It’s about 8-to-10-feet-deep and they put everything in it they want to dispose of and can’t leave behind, from flammable fuel to plastics to all range of things.”

But in the middle of a war zone, concern about the burn pits was sometimes considered secondary to other safety issues. 

“You’ve got dust storms, you have the enemy, you have all sorts of things going on that some smoke in the air doesn’t really seem like as important of an issue at the moment,” Jim Mowrer, who befriended Beau at Camp Victory in Iraq in 2009, told CBS News. Other times, Mowrer, 34, who now serves as co-chair for the Veterans for Biden committee, said he tried to filter the air by wearing a face covering.

“The concern factor became more of a concern after we came home,” Beau’s overseas boss, Command JAG Kathy Amalfitano, 59, told CBS News. Amalfitano said she remembers discussing the burn pits with Beau a few times, but added “I know our thought process was that this was part of the deployment.”

Biden is not alone in thinking burn pits impacted soldiers’ health.

Since 2014, more than 200,000 Afghanistan and Iraq War veterans have registered in the “Airborne Hazards and Open Burn Pit Registry” run by the Department of Veterans Affairs (VA), detailing exposure to service-related airborne hazards from burn pit smoke and other pollution.

And while these veteran health concerns seem widespread, the VA’s policy only recognizes “temporary” irritation from burn pit exposure. Citing a range of studies, the department states that “research does not show evidence of long-term health problems from exposure to burn pits.”

One ongoing study is by National Jewish Health and funded by the Defense Department, and is examining lung issues and has yielded “a spectrum of diseases that are related to deployment,” the study’s principal investigator Dr. Cecile Rose told CBS News last year. ” [The diseases] weren’t there before, and they are clearly there after people have returned from these arid and extreme environments.” However, Rose cautioned that findings are complicated by other possible culprits, like desert dust and diesel exhaust.

Advocates for veterans say not enough is being done to address veterans’ health claims regarding the burn pits.

From 2007 to 2018, the VA processed 11,581 disability compensation claims that had “at least one condition related to burn pit exposure,” a department spokesman told The New York Times last year. But the department only accepted 2,318 of these claims. The department said the rest did not show evidence connected to military service or the condition in the claim was not “officially diagnosed,” the Times noted. 

The VA did not respond to CBS News’ request this week for updated numbers.

“I always push back on…the VA administration folks who try to use the ‘perfect study’ as a criteria to show proof,” California Representative Raul Ruiz, a doctor and vocal burn pits critic, told CBS News. Ruiz criticized the VA’s reliance on long-term studies to validate clams. 

“We don’t have 20 years because then these veterans are going to be dying without the care they need,” Ruiz said.

A report five years ago by a Defense Department inspector general said it was “indefensible” that military personnel “were put at further risk from the potentially harmful emissions from the use of open-air burn pits.” But the Supreme Court last year rejected a victims’ lawsuit against contractors who oversaw some of the burn pits.

“If these [burn pits] had happened in the United States, the Environmental Protection Agency and Centers for Disease and Control would have this corrected immediately,” said Iraq War veteran Jeremy Daniels, adding he believes burn pits caused him to be wheelchair bound.

Modern-day “Agent Orange”?

Biden on the campaign trail invoked the healthcare struggles of Vietnam veterans exposed to the herbicide Agent Orange to explain the need to address burn pits.

“You were entitled to military compensation if you could prove that Agent Orange caused whatever the immune system damage was to you,” Biden said, accenting the word “prove” during a Veterans Day town hall in Oskaloosa, Iowa. “But you had to prove it and it’s very hard to prove.”

After reading a book on burn pits detailing Beau’s case, Biden has advocated easing this burden of proof for veterans who say the burn pits have harmed them in some way, as he first told PBS.

Biden has a plan that pushes for congressional approval to expand the list of “presumptive conditions”– meaning veterans’ health conditions would be presumed causal to the burn pits making them eligible for greater VA healthcare. He also aims to expand the claim eligibility period for toxic exposure conditions to five years after service instead of one year and increase federal research by $300 million in part to focus on toxic exposure from burn pits.

This push has intensified in recent years on Capitol Hill, and bills funding more research into burn pits have already been signed by President Trump. The recent National Defense Authorization Act also required the Department of Defense to implement a plan to phase out burn pits and disclose the locations of the still-operating pits. Enclosed incinerators are an alternative.

There were nine active military burn pits in the Middle East as of last year, according to the Defense Department’s April 2019 “Open Burn Pit Report to Congress” shared with CBS News, though some advocates think the actual number is higher. 

Some veterans expressed doubt that recent efforts will lead to more aid for veterans exposed to burn pits, given the slow-moving bureaucracy and concern over higher health care costs. And others question whether a Biden administration would act more decisively than the Obama administration, which primarily focused on long-term studies.

But Biden says that his motivation is far greater than his family’s own personal loss, and that the “only sacred” commitment the United States has is to American soldiers.

“It’s not because my son died…[he] went from very, very healthy but he lived in the bloom of those burn pits for a long time. He’s passed—it doesn’t affect him,” Biden said in Oskaloosa. “But the point is that every single veteran shouldn’t have to prove and wait until science demonstrates beyond a doubt…We just have to change the way we think a little bit.”

May 30 will mark the five-year anniversary of Beau Biden’s death.

This content was originally published here.

Enter For Your Chance to Win Invisalign For Your Child – SheKnows

When the final school bell rings and two months of unstructured free time stretch out before your kids, back-to-school season may feel like a lifetime away. But in reality, it’s just a few weeks, meaning now is the time to schedule all those late-summer doctors appointments. And if your child is one of the millions of kids in North America who will likely seek orthodontic help this year (according to the American Association of Orthodontists), you can add the orthodontist to that list.

With more than 6 million patients, parents and teens are increasingly choosing Invisalign treatment for everything from simple to complex cases. The clear aligners not only have the confidence-boosting benefit of being less noticeable, but because they are removable, they make it easier for teens to enjoy every type of food and care for teeth. They also are more convenient for teens who play instruments and safer for those who play sports. In fact, with Invisalign treatment, there are no emergency visits due to broken wires of brackets. If you want to learn more about Invisalign treatment, click here.

This summer SheKnows has partnered with the Invisalign brand to give parents a chance to win free Invisalign treatment for their child. Enter below for your chance to win. 

And once you’ve entered, follow the Invisalign brand on Instagram for more smiles. 

This post was created by SheKnows for Invisalign Brand. 

This content was originally published here.

Ontario’s health minister shopped at Toronto LCBO while awaiting COVID-19 test results | CP24.com

Ontario’s health minister says she was following the advice of medical professionals when she decided to shop at a Toronto LCBO on Wednesday afternoon while awaiting her COVID-19 test results.

Health Minister Christine Elliott and Premier Doug Ford, who have since tested negative for the virus, underwent COVID-19 testing on Wednesday after learning that the province’s education minister, Stephen Lecce, had earlier come in contact with someone who tested positive for the virus.

Ford and Elliott, who had held a joint press conference with Lecce one day earlier, decided to skip their daily briefing at Queen’s Park on Wednesday afternoon out of an abundance of caution.

Elliott also cancelled an appearance at a Brampton mobile testing site that was scheduled for 3 p.m.

Lecce released a statement shortly before 2 p.m. on Wednesday confirming that his test results had come back negative and about an hour-and-a-half later, Elliott was seen shopping at an LCBO near Dupont Street and Spadina Avenue.

A photo sent to CP24 shows Elliott, who is wearing a surgical mask, standing beside a basket and looking at the store’s VQA wine selection.

“Minister Lecce’s results came back negative before I went for testing and so while there was no real need for me to go to be tested, I had made a public commitment to do so and so that’s where I went,” Elliott told reporters at Queen’s Park on Thursday.

“I went and while I was at the assessment centre having the test, I was advised that because I had not directly been in contact with anyone with COVID that I did not need to self-isolate…That was the medical advice I was given and that is what I did and my test results came back negative of course.”

Elliott and Ford returned to Queen’s Park for their daily COVID-19 update on Thursday afternoon.

“To be clear, both Premier Ford and Minister Elliott have had no known contact with anyone who has tested positive for COVID-19, and as a result, there is no need for either of them to self-isolate,” a statement from the premier’s office read.

“They will continue to follow public health guidelines.”

Lecce’s office confirmed Thursday that he will continue to self-isolate.

“Minister Lecce is feeling well and continues to work from home. He is following the advice of his doctor by continuing to monitor for any symptoms,” a statement from the education minister’s office read.

“Out of an abundance of caution, although the exposure risk was extremely low, he will be self-isolating for the remainder of the 14 days since the time of exposure, on June 6. The Minister again would like to offer his sincere thanks to the team at UHN and everyone yesterday who sent positive thoughts and messages.”

Public health experts have cautioned that negative test results are not always an indication that a person isn’t infected with the virus, especially when tests are conducted a short time after exposure.

Those who have tested negative for the virus are still advised to monitor for symptoms as the virus has an incubation period of 14 days.

“As we outlined our testing criteria at the assessment centres… if you have signs and symptoms and you’re suspected of being a COVID case, you will get your test and then you are supposed to stay in self-isolation until you get results,” Dr. David Williams, Ontario’s chief medical officer of health, said at a news conference on Thursday.

“Other criteria, you say, ‘Well, I was in contact with a known positive.’ That is another reason to get tested and you still have to self-isolate until you get that result back, including people who say, ‘Well I’m not sure but I was in a highly risky area, I don’t know.’’”

He noted that the rules are different for people who are not experiencing symptoms of the virus and have not been in contact with a known case.

“Testing asymptomatic people… say 5,000 workers, none of them have symptoms, none of them are cases, we are not going to say all 5,000 wait for five, six days to get results back. They just continue going to work because it is asymptomatic testing,” he added.

“They have no signs and symptoms, they have no contact with a case, no possible contact with a case, and there is no evidence of an outbreak. So it is a different situation altogether.”

This content was originally published here.

Arizona coronavirus: Banner Health reaches capacity on ECMO lung machines

Arizona’s largest health system reaches capacity on ECMO lung machines as COVID-19 cases in the state continue to climb

Stephanie Innes
Arizona Republic
Published 2:24 PM EDT Jun 6, 2020
Coronavirus 2019-nCoV vials
solarseven, Getty Images/iStockphoto

Hospitalizations in Arizona of patients with suspected and confirmed COVID-19 have hit a new record and the state’s largest health system has reached capacity for patients needing external lung machines.

Arizona’s total identified cases rose to 25,451 on Saturday according to the most recent state figures. That’s an increase of 4.4%, since Friday when the state reported 24,332 identified cases and 996 deaths. 

Some experts are saying that Arizona is experiencing a spike in community spread, pointing to indicators that as of Saturday continued to show increases — the number of positive cases, the percent of positive cases and hospitalizations.

Also, ventilator and ICU bed use by patients with suspected and confirmed COVID-19 in Arizona hit record highs on Friday, the latest numbers show.

Statewide hospitalizations as of Friday jumped to 1,278 inpatients in Arizona with suspected and confirmed COVID-19, which was a record high since the state began reporting the data on April 9. It was the fifth consecutive day that hospitalizations statewide have eclipsed 1,000.

On Saturday morning, officials with Banner Health notified the Arizona centralized COVID-19 surge line that  Banner hospitals are unable to take any new patients needing ECMO — extracorporeal membrane oxygenation.

ECMO is an an external lung machine that’s used if a patient’s lungs get so damaged that they don’t work, even with the assistance of a ventilator.

The Arizona surge line is a 24/7 statewide phone line for hospitals and other providers to call when they have a COVID-19 patient who needs a level of care they can’t provide. An electronic system locates available beds and appropriate care, evenly distributing the patients so that no one system or hospital is overwhelmed by patients.

Banner Health, which is the state’s largest health system, is also nearing its usual ICU bed capacity, officials said Friday and if current trends continue is at risk of exceeding capacity. Banner Health typically has about half of Arizona’s suspected and confirmed COVID-19 hospitalized patients.

The state’s death toll on Saturday was 1,042, with 30 new deaths reported. On Friday the tally for the first time reached four figures — 1,012 total deaths —  three weeks after Gov. Doug Ducey’s stay-at-home order expired.

What we know about the known deaths, based on the state data:

Ducey said at a Thursday news conference that “we mourn every death in the state of Arizona.”

“… I’m confident that we’ve made the best and most responsible decisions possible, guided by public health, the entire way,” Ducey said.  

Saturday marked Arizona’s fifth consecutive day of high numbers of new coronavirus cases reported, with 1,119 positives reported Saturday, a record 1,579 reported on Friday, 530 on Thursday, 973 on Wednesday and 1,127 new cases reported on Tuesday.

Dr. Cara Christ, director of the Arizona Department of Health Services, said at a Thursday news conference that the increase in cases was expected given increased testing and reopening. 

“As people come back together, we know that there is going to be transmission of COVID-19,” Christ said. “We are seeing an increase in cases, and so we will continue to monitor at this time. But we have to weigh the impacts of the virus versus the impacts of what a stay-at-home order can have on long-term health as well.”

Before this week, new cases reported daily have typically been in the several hundreds. The state has reported new cases each day, typically in the several hundreds. The daily increase in case numbers also reflects a lag in obtaining results from the time a test was conducted.

Additional deaths are reported each day as well and have varied between single- and double-digit increases. The number of deaths reported each day represents the additional known deaths reported by the Health Department that day, but could have occurred weeks prior and on different days.

The date with the most deaths in a single day so far is April 30 with 26 deaths, followed by May 7 with 25 deaths and April 23 and May 8 with 24 deaths each. Next comes April 20 with 23 deaths and April 19, May 3 and May 5 with 22 deaths on each of those days, according to Friday’s data, which is likely to change in the days ahead as more deaths are identified.

Maricopa County’s confirmed case total was at 12,761 on Saturday according to state numbers. 

“We are seeing some indicators that the number of cases in Maricopa County are starting to rise,” county spokesman Ron Coleman said this week in an email. “This is in addition to an increase from increased testing.”

The number of Arizona cases likely is higher than official numbers because of limits on supplies and available tests, especially in early weeks of the pandemic. 

The percentage of positive tests per week increased from 5% a month ago to 6% three weeks ago to 9% two weeks ago, and 11% last week. The ideal trend is a decrease in percent of positives tests out of all tests. 

In addition to an increase in hospitalizations, ventilator use in Arizona by suspected and positive COVID-19 patients statewide jumped to 292 on Friday, which was the highest number reported since the state data began on April 9.

Also, ICU bed use by patients with positive and suspected COVID-19 on Friday was 391 — a record high and the 11th consecutive day that the number has been higher than 370.

The latest Arizona data

As of Saturday morning, the state reported death totals from these counties: 489 in Maricopa, 205 in Pima, 85 in Coconino, 72 in Navajo, 57 in Mohave, 49 in Apache, 41 in Pinal, 24 in Yuma, six in Yavapai, 4 in Cochise, three in Santa Cruz and three in Gila.

La Paz County officials reported two deaths and Graham County reported one death, although the state site listed them as just having fewer than three deaths. Greenlee County reported no deaths.

Of the statewide identified cases overall, 47% are men and 53% are women. But men made up a higher percentage of deaths, with 54% of the deaths men and 46% women as of Saturday.

Overall, Arizona has 354 cases and 14.49 deaths per 100,000 residents, according to state data.

The scope of the outbreak differs by county, with the highest rates in Apache, Navajo, Santa Cruz, Yuma and Coconino counties.

Of all confirmed cases, 9% are younger than 20, 42% are aged 20 to 44, 16% are aged 45 to 54, 14% are aged 55 to 64 and 17% are over 65. This aligns with the proportions of testing done for each age range.

The state Health Department website said both state and private laboratories have completed a total of  271,646 diagnostic tests for COVID-19, and 109,266 serology, or antibody, tests.

Most COVID-19 diagnostic tests come back negative, the state’s dashboard shows, with 7.2% positive. For serology tests, 3% have come back positive.

Maricopa County’s Department of Public Health provided more detailed information on a total of 12,685 cases Friday (the state reported the county case total at 12,761):

Cases rise in other counties

According to Friday’s state update, Pima County reported 2,950 identified cases. Navajo County reported 2,152 cases, while Yuma County reported 1,850; Apache County 1,692; Coconino County 1,267; Pinal County 1,067; Santa Cruz County 530; Mohave County 485; and Yavapai County 326. 

La Paz County reported 158 cases, Cochise County 122, Gila County 43, Graham County 39 and Greenlee County nine, according to state numbers.

The Navajo Nation reported a total of 5,808 cases and at least 269 confirmed deaths as of Friday. The Navajo Nation includes parts of Arizona, New Mexico and Utah.

237 cases in Arizona prisons

The Arizona Department of Corrections’ online dashboard said 237 inmates had tested positive for COVID-19 as of Friday, up from 198 one day prior. 

The cases were at these eight facilities: 75 in Florence, 97 in Yuma, 28 in Tucson, 12 in Phoenix, nine in Marana, six in Eyman, six in Perryville, two in Kingman and two in Lewis.

Four inmate deaths have been confirmed — two in Florence and two in Tucson, and three deaths are under investigation, the dashboard says.

Ninety-nine staff members have self-reported positive for the virus, and 69 have been certified as recovered, the department said. 

Both legal and nonlegal visitations have been suspended through June 13, at which point the department will reassess. Temporary video visitation will be available to approved visitors and inmates who have visitation privileges, the department announced. Inmates are eligible for one 15-minute video visit per week. CenturyLink also is giving inmates two additional 15-minute calls for free during each week visitation is restricted.

Separately, the Maricopa County Jail system as of Friday was reporting 30 inmates who had tested positive for COVID-19, county officials said. That was up from six positive inmates one week prior.

Arizona Republic reporter Alison Steinbach contributed to this article

Reach the reporter at Stephanie.Innes@gannett.com or at 602-444-8369. Follow her on Twitter @stephanieinnes

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