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A tooth-bleaching agent may improve the oral health of elderly and special-needs patients, say dentists at the Medical College of Georgia and Western University of Health Sciences.
Standard oral hygiene, such as brushing and flossing, can be difficult or impossible for patients with mental challenges or impaired manual dexterity. Additionally, when health problems or medications cause xerostomia, or dry mouth, the lack of saliva reduces the mouth's natural protective mechanisms. These problems lead to plaque accumulation, cavities and periodontal disease, and could further impact the patient's health.
A report featured on the cover of this month's Journal of the American Dental Association noted that applying the tooth whitener carbamide peroxide through a custom-fit mouth tray might combat those problems. The report was based on a literature review and the authors' clinical experiences with special-needs patients and tooth bleaching.
"What we've noticed through whitening patients' teeth over the years is that as they bleached, their teeth got squeaky clean and their gingival health improved," said Dr. Van Haywood, professor in the Medical College of Georgia School of Dentistry and co-author of the report.
Dentists have used carbamide peroxide, or urea peroxide, for decades to whiten teeth, but its original use was as an oral antiseptic. It removes plaque, kills bacteria and elevates the mouth's pH above the point at which enamel and dentin begin to dissolve, which results in fewer cavities.
"All these benefits lead us to believe that tray bleaching can be a very effective supplemental method of oral hygiene for patients facing greater challenges keeping their mouths clean," said Dr. David Lazarchik, associate professor in the Western University of Health Sciences College of Dental Medicine and the report's co-author.
The trick is in the tray, Haywood said. After a complete dental exam, the dentist can make the custom-fit tray that the patient can wear comfortably at night or for several hours during the day. The carbamide peroxide gel can be prescribed or purchased over-the-counter.
Lazarchik said further research is needed to determine a specific protocol for using tray-applied carbamide peroxide specifically to improve oral health.
Wednesday, June 30, 2010
Wednesday, June 23, 2010
Decay of baby teeth may be linked to obesity, poor food choices, study suggests
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A preliminary study of young children undergoing treatment for cavities in their baby teeth found that nearly 28 percent had a body mass index (BMI) above the 85th percentile, indicating overweight or obesity.
That percentage is more than 5 percent higher than the estimated national average, adding more fuel to the growing concern that poor food choices, including those sugary drinks and fruit juices so popular and convenient, likely are contributing to both obesity and tooth decay in very young children.
The findings will be presented today (June 22) at the 2010 annual meeting of the Endocrine Society being held in San Diego, Calif. The study is one of 38 abstracts (out of 2,000 accepted) selected for inclusion in the society's Research Summaries Book, which is provided to the media for future reference.
Kathleen Bethin, MD, associate professor of pediatrics at the University at Buffalo and director of the pediatric endocrinology and diabetes fellowship program at Women and Children's Hospital of Buffalo, is first author.
Dental cavities are the most common chronic disease of childhood, according to Healthy People 2010 -- 5-10 percent of young children have early childhood cavities -- and childhood obesity has more than tripled in the past 30 years, reaching nearly 20 percent by 2008.
"We hypothesized that poor nutritional choices may link obesity and dental decay in young children, but there is very little published data associating these two health issues," says Bethin.
"The aim of our study was to obtain preliminary data on BMI, energy intake and metabolic profiles in young children with tooth decay."
The study involved 65 children ages 2-5 who were treated in the operating room at Women and Children's Hospital. All children required anesthesia due to the severity of their dental problems or other issues.
The children, who had been fasting for 8-12 hours, were weighed and measured for height. After the patients were anesthetized, researchers measured waist circumference and drew blood. Parents completed a food questionnaire while their children were in surgery.
The data showed that:
Eighteen of the 65 children, approximately 28 percent, had a BMI above the 85th percentile, which Bethin noted might be higher if the children hadn't been fasting.
Waist circumference compared to height was significantly higher in the overweight and obese children compared to the children of normal weight, measurements showed.
Approximately 71 percent of the children had a calorie intake higher than the normal 1,200 per day for their age group.
"The main point of our findings is that poor nutrition may link obesity to tooth decay," says Bethin. "Thus the dental office, or 'dental home,' may be an ideal place to educate families about nutrition and the risks of obesity and dental decay.
"Our results found no difference in total calories consumed by the overweight and healthy-weight kids," noted Bethin, "so the problem isn't overeating, per se, just making the wrong food choices."
Bethin and colleagues now are analyzing whether the overweight children eat more processed sugar, drink more juice and have other unhealthy eating habits compared to the healthy-weight children.
A preliminary study of young children undergoing treatment for cavities in their baby teeth found that nearly 28 percent had a body mass index (BMI) above the 85th percentile, indicating overweight or obesity.
That percentage is more than 5 percent higher than the estimated national average, adding more fuel to the growing concern that poor food choices, including those sugary drinks and fruit juices so popular and convenient, likely are contributing to both obesity and tooth decay in very young children.
The findings will be presented today (June 22) at the 2010 annual meeting of the Endocrine Society being held in San Diego, Calif. The study is one of 38 abstracts (out of 2,000 accepted) selected for inclusion in the society's Research Summaries Book, which is provided to the media for future reference.
Kathleen Bethin, MD, associate professor of pediatrics at the University at Buffalo and director of the pediatric endocrinology and diabetes fellowship program at Women and Children's Hospital of Buffalo, is first author.
Dental cavities are the most common chronic disease of childhood, according to Healthy People 2010 -- 5-10 percent of young children have early childhood cavities -- and childhood obesity has more than tripled in the past 30 years, reaching nearly 20 percent by 2008.
"We hypothesized that poor nutritional choices may link obesity and dental decay in young children, but there is very little published data associating these two health issues," says Bethin.
"The aim of our study was to obtain preliminary data on BMI, energy intake and metabolic profiles in young children with tooth decay."
The study involved 65 children ages 2-5 who were treated in the operating room at Women and Children's Hospital. All children required anesthesia due to the severity of their dental problems or other issues.
The children, who had been fasting for 8-12 hours, were weighed and measured for height. After the patients were anesthetized, researchers measured waist circumference and drew blood. Parents completed a food questionnaire while their children were in surgery.
The data showed that:
Eighteen of the 65 children, approximately 28 percent, had a BMI above the 85th percentile, which Bethin noted might be higher if the children hadn't been fasting.
Waist circumference compared to height was significantly higher in the overweight and obese children compared to the children of normal weight, measurements showed.
Approximately 71 percent of the children had a calorie intake higher than the normal 1,200 per day for their age group.
"The main point of our findings is that poor nutrition may link obesity to tooth decay," says Bethin. "Thus the dental office, or 'dental home,' may be an ideal place to educate families about nutrition and the risks of obesity and dental decay.
"Our results found no difference in total calories consumed by the overweight and healthy-weight kids," noted Bethin, "so the problem isn't overeating, per se, just making the wrong food choices."
Bethin and colleagues now are analyzing whether the overweight children eat more processed sugar, drink more juice and have other unhealthy eating habits compared to the healthy-weight children.
How to rapidly assess children's tooth decay risk
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The study, published in Pediatric Dentistry, indicates that ATP-driven (adenosine triphosphate-driven) bioluminescence is a useful tool at the dentist's office for predicting children at high risk for tooth decay
PORTLAND, Ore. — Researchers at the Oregon Health & Science University School of Dentistry have determined that ATP-driven (adenosine triphosphate-driven) bioluminescence — a way of measuring visible light generated from ATP contained in bacteria — is an innovative tool for rapidly assessing in children at the chair-side the number of oral bacteria and amount of plaque that can ultimately lead to tooth decay.
The study is published online in the May-June 2010 issue of Pediatric Dentistry.
Caries (microbial disease) prevention is one of the most important aspects of modern dental practice. Untreated, large numbers of cariogenic bacteria adhere to teeth and break down the protective enamel covering, resulting in lesions and cavities. There is a critical need in dentistry to develop better quantitative assessment methods for oral hygiene and to determine patient risk for dental caries, because disease as well as restorative treatment results in the irreversible loss of tooth structure. Previous caries risk assessments have focused on social, behavioral, microbiologic, environmental and clinical variables.
The goal of the OHSU study was to examine the use of microbiological testing, specifically ATP-driven bioluminescence, for quantifying oral bacteria, including plaque streptococci, and assessment of oral hygiene and caries risk. Thirty-three randomly selected OHSU pediatric patients, ages 7 to 12, were examined, and plaque specimens, in addition to saliva, were collected from one tooth in each of the four quadrants of the mouth. The oral specimens were then assessed to count total bacteria and streptococci and subjected to ATP-driven bioluminescence.
The OHSU team found statistical correlations, linking ATP to the numbers of total bacteria and oral streptococci. Their data indicated that ATP measurements have a strong statistical association with bacterial numbers in plaque and saliva specimens, including numbers for oral streptococci, and may be used as a potential assessment tool for oral hygiene and caries risk in children.
"The use of ATP-driven bioluminescence has broad implications in dentistry and medicine and can be used translationally in the clinic to determine the efficacy of interventional therapies, including the use of mouth rinses and perhaps in the detection of bacterial infections in periodontal and other infectious diseases," noted Curt Machida, Ph.D., principal investigator and OHSU professor of integrative biosciences and pediatric dentistry.
The study, published in Pediatric Dentistry, indicates that ATP-driven (adenosine triphosphate-driven) bioluminescence is a useful tool at the dentist's office for predicting children at high risk for tooth decay
PORTLAND, Ore. — Researchers at the Oregon Health & Science University School of Dentistry have determined that ATP-driven (adenosine triphosphate-driven) bioluminescence — a way of measuring visible light generated from ATP contained in bacteria — is an innovative tool for rapidly assessing in children at the chair-side the number of oral bacteria and amount of plaque that can ultimately lead to tooth decay.
The study is published online in the May-June 2010 issue of Pediatric Dentistry.
Caries (microbial disease) prevention is one of the most important aspects of modern dental practice. Untreated, large numbers of cariogenic bacteria adhere to teeth and break down the protective enamel covering, resulting in lesions and cavities. There is a critical need in dentistry to develop better quantitative assessment methods for oral hygiene and to determine patient risk for dental caries, because disease as well as restorative treatment results in the irreversible loss of tooth structure. Previous caries risk assessments have focused on social, behavioral, microbiologic, environmental and clinical variables.
The goal of the OHSU study was to examine the use of microbiological testing, specifically ATP-driven bioluminescence, for quantifying oral bacteria, including plaque streptococci, and assessment of oral hygiene and caries risk. Thirty-three randomly selected OHSU pediatric patients, ages 7 to 12, were examined, and plaque specimens, in addition to saliva, were collected from one tooth in each of the four quadrants of the mouth. The oral specimens were then assessed to count total bacteria and streptococci and subjected to ATP-driven bioluminescence.
The OHSU team found statistical correlations, linking ATP to the numbers of total bacteria and oral streptococci. Their data indicated that ATP measurements have a strong statistical association with bacterial numbers in plaque and saliva specimens, including numbers for oral streptococci, and may be used as a potential assessment tool for oral hygiene and caries risk in children.
"The use of ATP-driven bioluminescence has broad implications in dentistry and medicine and can be used translationally in the clinic to determine the efficacy of interventional therapies, including the use of mouth rinses and perhaps in the detection of bacterial infections in periodontal and other infectious diseases," noted Curt Machida, Ph.D., principal investigator and OHSU professor of integrative biosciences and pediatric dentistry.
Monday, June 21, 2010
Children with Special Needs Are at Increased Risk for Oral Disease Common Medical Conditions Can Negatively Influence Dental Health
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At the beginning of 2010, as many as 17 percent of children in the United States were reported as having special health care needs. Behavioral issues, developmental disorders, cognitive disorders, genetic disorders and systemic diseases may increase a child’s risk of developing oral disease, according to an article published in the May/June 2010 issue of General Dentistry, the peer-reviewed clinical journal of the Academy of General Dentistry (AGD). For a child with special health care needs, special diets, frequent use of medicine and lack of proper oral hygiene can make it challenging to maintain good oral health.
“By the time these children are 12 months old, they should have a ‘dental home’ that will allow a dentist to administer preventive care and educate parents about good oral health habits tailored to fit their child’s needs,” says Maria Regina P. Estrella, DMD, MS, lead author of the article.
For example, some parents may not know that special diets for children with below-average weight or unique food allergies can unintentionally promote tooth decay. Underweight children may be directed to consume drinks containing high amounts of carbohydrates, which can cause demineralization of teeth. Medications can also be a source of concern. Because children often find it difficult to swallow pills, many of their medicines may utilize flavored, sugary syrups. When parents or guardians give these syrups to a child, especially at bedtime, the sugars can pool around the child’s teeth and gums, promoting decay.
“Children should continue with the diet and medications as directed by their physician, but a dentist may recommend more frequent applications of fluoridated toothpaste and mouthrinse and rinsing with water to decrease the risk of decay,” says Vincent Mayher, DMD, MAGD, spokesperson for the AGD.
Additionally, adults will need to help children who lack the dexterity to brush their own teeth. When brushing a child’s teeth, it may be helpful for caregivers to approach their child from behind the head, which will provide caregivers with good visibility and allow them to control the movement of both the child’s head and the toothbrush. This approach is especially helpful with wheelchair-bound children.
Taking children with special health care needs to the dentist is as important as caring for their other medical needs. A dentist who understands a child’s medical history and special needs can provide preventive and routine oral care, reducing the likelihood that the child will develop otherwise preventable oral diseases.
At the beginning of 2010, as many as 17 percent of children in the United States were reported as having special health care needs. Behavioral issues, developmental disorders, cognitive disorders, genetic disorders and systemic diseases may increase a child’s risk of developing oral disease, according to an article published in the May/June 2010 issue of General Dentistry, the peer-reviewed clinical journal of the Academy of General Dentistry (AGD). For a child with special health care needs, special diets, frequent use of medicine and lack of proper oral hygiene can make it challenging to maintain good oral health.
“By the time these children are 12 months old, they should have a ‘dental home’ that will allow a dentist to administer preventive care and educate parents about good oral health habits tailored to fit their child’s needs,” says Maria Regina P. Estrella, DMD, MS, lead author of the article.
For example, some parents may not know that special diets for children with below-average weight or unique food allergies can unintentionally promote tooth decay. Underweight children may be directed to consume drinks containing high amounts of carbohydrates, which can cause demineralization of teeth. Medications can also be a source of concern. Because children often find it difficult to swallow pills, many of their medicines may utilize flavored, sugary syrups. When parents or guardians give these syrups to a child, especially at bedtime, the sugars can pool around the child’s teeth and gums, promoting decay.
“Children should continue with the diet and medications as directed by their physician, but a dentist may recommend more frequent applications of fluoridated toothpaste and mouthrinse and rinsing with water to decrease the risk of decay,” says Vincent Mayher, DMD, MAGD, spokesperson for the AGD.
Additionally, adults will need to help children who lack the dexterity to brush their own teeth. When brushing a child’s teeth, it may be helpful for caregivers to approach their child from behind the head, which will provide caregivers with good visibility and allow them to control the movement of both the child’s head and the toothbrush. This approach is especially helpful with wheelchair-bound children.
Taking children with special health care needs to the dentist is as important as caring for their other medical needs. A dentist who understands a child’s medical history and special needs can provide preventive and routine oral care, reducing the likelihood that the child will develop otherwise preventable oral diseases.
Thursday, June 17, 2010
Dental pulp cells for stem cell banking
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Defined sets of factors can reprogram human cells to induced pluripotent stem (iPS) cells. However, many types of human cells are not easily accessible to minimally invasive procedures. In a paper published in the International and American Associations for Dental Research's Journal of Dental Research, lead researcher K. Tezuka and researchers N. Tamaoki, H. Aoki, T. Takeda-Kawaguchi, K. Iida, T. Kunisada and T. Shibata all from the Gifu University Graduate School of Medicine, Japan; and K. Takahashi, T. Tanaka and S. Yamanaka, all from Kyoto University, Japan, evaluate dental pulp cells as an optimal source of iPS cells, since they are easily obtained from extracted teeth and can be expanded under simple culture conditions.
From all six cell lines tested with the conventional three or four reprogramming factors, iPS cells were effectively established from five lines. Furthermore, determination of the HLA types of 107 DPC lines revealed two lines homozygous for all three HLA loci and showed that if an iPS bank is established from these initial pools, the bank will cover approximately 20 percent of the Japanese population with a perfect match.
Analysis of these data demonstrates the promising potential of dental pulp cell collections as a source of cell banks for use in regenerative medicine. Direct reprogramming of patients' somatic cells would allow for cell transplantation therapy free from immune-mediated rejection. An alternative approach is to establish an iPS cell bank consisting of various human leukocyte antigen (HLA) types. Safety issues must be considered as to which types of somatic cells should be used for such iPS cell banks.
"This work is significant in that it proposes the exciting potential of stem cell banking from readily available extracted teeth," said JDR Editor-in-Chief William Giannobile. "Although at an early stage of development, this innovation offers prospects for cell therapy approaches for the treatment of human disease."
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The complete research study is published in the Journal of Dental Research.e
Defined sets of factors can reprogram human cells to induced pluripotent stem (iPS) cells. However, many types of human cells are not easily accessible to minimally invasive procedures. In a paper published in the International and American Associations for Dental Research's Journal of Dental Research, lead researcher K. Tezuka and researchers N. Tamaoki, H. Aoki, T. Takeda-Kawaguchi, K. Iida, T. Kunisada and T. Shibata all from the Gifu University Graduate School of Medicine, Japan; and K. Takahashi, T. Tanaka and S. Yamanaka, all from Kyoto University, Japan, evaluate dental pulp cells as an optimal source of iPS cells, since they are easily obtained from extracted teeth and can be expanded under simple culture conditions.
From all six cell lines tested with the conventional three or four reprogramming factors, iPS cells were effectively established from five lines. Furthermore, determination of the HLA types of 107 DPC lines revealed two lines homozygous for all three HLA loci and showed that if an iPS bank is established from these initial pools, the bank will cover approximately 20 percent of the Japanese population with a perfect match.
Analysis of these data demonstrates the promising potential of dental pulp cell collections as a source of cell banks for use in regenerative medicine. Direct reprogramming of patients' somatic cells would allow for cell transplantation therapy free from immune-mediated rejection. An alternative approach is to establish an iPS cell bank consisting of various human leukocyte antigen (HLA) types. Safety issues must be considered as to which types of somatic cells should be used for such iPS cell banks.
"This work is significant in that it proposes the exciting potential of stem cell banking from readily available extracted teeth," said JDR Editor-in-Chief William Giannobile. "Although at an early stage of development, this innovation offers prospects for cell therapy approaches for the treatment of human disease."
###
The complete research study is published in the Journal of Dental Research.e
Thursday, June 10, 2010
FDA Advisory Panel to Review Dental Amalgam
Agency to consider risks to vulnerable populations
Advanced viewing - details about the advisory panel meeting
FDA website on dental amalgam
International Academy of Oral Medicine et al (Titus Hillis Reynolds Love, Dickman & McCalmon) - Citizen Petition
Citizens for Health, et al (Swankin & Turner) - Petition for Reconsideration
Richard F. Edlich, M.D., Ph.D., et al - Citizen Petition
Moms Against Mercury, et al. - Petition for Reconsideration
The U.S. Food and Drug Administration today announced plans to hold an advisory panel on Dec. 14-15, 2010, to discuss several scientific issues that may affect the regulation of dental amalgam, used for direct filling of carious lesions or structural defects in teeth. The panel meeting will focus particularly on the potential risk to vulnerable populations, such as pregnant women, fetuses, and young children.
Used to treat tooth decay, dental amalgam is a mixture of metals, composed of liquid mercury and a powdered amalgam alloy, composed primarily of silver, tin, and copper.
On July 28, 2009, the FDA issued a final rule that reclassified dental mercury from a class I device to class II, classified dental amalgam as a class II device, and designated special controls for dental amalgam, mercury and amalgam alloy. The special control for the devices is a guidance titled, “Class II Special Controls Guidance Document: Dental Amalgam, Mercury and Amalgam Alloy.”
Since that time, the agency has received several petitions raising various issues relating to the final rule and special controls.
The concerns raised include the adequacy of the risk assessment method used by the FDA in classifying dental amalgam, the bioaccumulative effect of mercury, the exposure of pediatric populations to mercury vapor, and the adequacy of the clinical studies on dental amalgam. In addition, a recent report on risk assessments issued by the National Academy of Sciences, titled “Science and Decisions: Advancing Risk Assessment, NAP 2009,” proposes new approaches to conducting risk assessments. These may be some of the issues the agency asks the advisory committee to review.
Details about the advisory panel meeting will be published in the Federal Register on June 11, 2010 and is available for advanced viewing today only.
For more information:
Petitions on dental amalgam:
Monday, June 7, 2010
US dental schools leave graduates unprepared to screen for sleep disorders
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According to new research, the majority of U.S. dental schools have not adequately prepared their graduates to screen for sleep disorders, which affect more than 70 million adults in the U.S.
Researchers from the University of California - Los Angeles (UCLA) School of Dentistry surveyed each of the 58 U.S. dental schools to determine the average number of curriculum hours offered in dental sleep medicine (DSM). DSM focuses on the management of sleep-related breathing disorders, such as snoring and obstructive sleep apnea (OSA), with oral appliance therapy (OAT) and upper-airway surgery.
Forty-eight schools responded to the survey, indicating that dental students spend an average of 2.9 instruction hours during their four years of dental school studying sleep disorders.
According to lead author Michael Simmons, DMD, D. ABOP, part-time instructor at both UCLA and USC, sleep medicine is being introduced at the majority of U.S. dental schools, but the total hours taught are inadequate given the epidemic proportion of people with OSA.
More than 18 million Americans suffer from OSA. An estimated 80 to 90 percent of patients with OSA are undiagnosed and more go untreated. Untreated sleep apnea can raise a patients' risk for heart attack, stroke, hypertension, diabetes, and obesity, among other health problems and premature death.
The survey asked which sleep topics were taught, which treatments were covered, and which departments were responsible for the teaching of dental sleep medicine.
Results show that classroom topics covered diagnosis of obstructive sleep apnea, sleep bruxism, snoring and upper-airway resistance syndrome, and treatments including oral appliance therapy, continuous positive airway pressure and surgery. Eight schools also discussed at-home sleep tests, which dentists can use to monitor treatment success.
Oral Surgery, TMJ/Orofacial Pain, Oral Medicine, Prosthodontics, and Orthodontics, were the most common academic departments that taught sleep medicine. The researchers were surprised by the variety of dental departments teaching sleep disorders, and that DSM could not be attributed to any particular discipline.
The authors suggest that because dentists see patients on a regular basis, they can notice early warning signs of sleep disorders.
"Dental students and dentists need to screen for sleep-related breathing disorders as part of patients' routine work-ups. Then, with additional interest and adequate training, they can learn to co-treat these serious medical conditions with their patients' physicians as an integral part of the sleep medicine team," said Simmons.
According to new research, the majority of U.S. dental schools have not adequately prepared their graduates to screen for sleep disorders, which affect more than 70 million adults in the U.S.
Researchers from the University of California - Los Angeles (UCLA) School of Dentistry surveyed each of the 58 U.S. dental schools to determine the average number of curriculum hours offered in dental sleep medicine (DSM). DSM focuses on the management of sleep-related breathing disorders, such as snoring and obstructive sleep apnea (OSA), with oral appliance therapy (OAT) and upper-airway surgery.
Forty-eight schools responded to the survey, indicating that dental students spend an average of 2.9 instruction hours during their four years of dental school studying sleep disorders.
According to lead author Michael Simmons, DMD, D. ABOP, part-time instructor at both UCLA and USC, sleep medicine is being introduced at the majority of U.S. dental schools, but the total hours taught are inadequate given the epidemic proportion of people with OSA.
More than 18 million Americans suffer from OSA. An estimated 80 to 90 percent of patients with OSA are undiagnosed and more go untreated. Untreated sleep apnea can raise a patients' risk for heart attack, stroke, hypertension, diabetes, and obesity, among other health problems and premature death.
The survey asked which sleep topics were taught, which treatments were covered, and which departments were responsible for the teaching of dental sleep medicine.
Results show that classroom topics covered diagnosis of obstructive sleep apnea, sleep bruxism, snoring and upper-airway resistance syndrome, and treatments including oral appliance therapy, continuous positive airway pressure and surgery. Eight schools also discussed at-home sleep tests, which dentists can use to monitor treatment success.
Oral Surgery, TMJ/Orofacial Pain, Oral Medicine, Prosthodontics, and Orthodontics, were the most common academic departments that taught sleep medicine. The researchers were surprised by the variety of dental departments teaching sleep disorders, and that DSM could not be attributed to any particular discipline.
The authors suggest that because dentists see patients on a regular basis, they can notice early warning signs of sleep disorders.
"Dental students and dentists need to screen for sleep-related breathing disorders as part of patients' routine work-ups. Then, with additional interest and adequate training, they can learn to co-treat these serious medical conditions with their patients' physicians as an integral part of the sleep medicine team," said Simmons.
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