- Email: [email protected]
The effect of external nasal dilators on blood oxygen levels in dental patients
T
I
he use of external nasal dilators, or ENDs (also called nasal breathing strips), can make dental appointments easier, more pleasant experiences for dentists and particularly for patients who predominantly use their mouths to breathe.1 The article pointed out that patients with obstructed nasal breathing need to keep their oral airways open to breathe, so they are conThe results of stantly swallowing, choking or gagging this study during most dental procedures. Also, the patient’s oral breathing fogs the dendemonstrate tist’s mirror, hiding the dentist’s visualthat the use of ization of the working field. an external An END is made of flat spring-action nasal dilator strips placed under a contoured piece of facilitates nasal adhesive tape. When the tape is adhered breathing in transversely across the nose, the device lifts the skin and opens the nasal pasdental patients. sages. The subjective impression of people who breathe through their mouths is improved nasal breathing.1 Three changes have been quantified objectively in clinical studies as a result of using ENDs: dincrease in cross-sectional area at the nares2-9; dincrease in transnasal airflow2,6,9; ddecrease in nasal airflow resistance.3,6,7,10,11 If ENDs do all that, it might be logical that using an END would result in a rise in blood oxygen levels. Our current study focuses on determining whether use of an END, as a result of making nasal breathing seem easier for dental patients who are identified primarily as mouth breathers, results in an increased level of oxygen saturation as measured by pulse oximetry, or SpO2.
T
ALLEN J. MOSES, D.D.S.; MARCUS LIEBERMAN, Ph.D.
Background. The authors conducted a study to examine the use of external nasal dilators, or A D A J ENDs, on dental patients ✷ ✷ ® and to determine whether the subjective improvement in comfort N C U level noted in dental A ING EDU 4 R patients using ENDs is TICLE accompanied by a rise in the level of oxygen saturation as measured by pulse oximetry, or SpO2. Methods. The authors used a hand-held pulse oximeter to monitor 45 patients’ SpO2 levels during routine dental procedures. Results. The data suggest that dental procedures in general result in a lowering of the SpO2 level and that patients using an END do experience a rise in the SpO2 level. Conclusions. The data do not clearly establish that the increase in patient comfort with use of an END is due to a rise in the SpO2 level. Clinical Implications. The results of this study demonstrate that the use of an END facilitates nasal breathing in dental patients. CON
The effect of external nasal dilators on blood oxygen levels in dental patients
ABSTRACT
IO N
M E D I C I N E
T
&
A
D E N T I S T R Y
METHODS AND MATERIALS
A group of 45 ambulatory dental patients in an urban practice comprised the study group. The multiracial group consisted of 33 men and 12 women. Their ages ranged from 26 to 82 years. We performed each dental procedure with the patient in a supine position. A rubber dam was not used for any of these procedures. At the beginning of the dental appointment, we placed the Nonin 8500M hand-held pulse oximeter (Nonin Medical, Plymouth, Minn.) over the patient’s index fingernail using a finger clip to determine the patients’ levels of arterial SpO2. We left it in place for the entire time the patient was in the dental chair. Shelledy and colleagues12 conducted a study in which they compared the performance of a pulse oximeter (Nonin
JADA, Vol. 134, January 2003 Copyright ©2003 American Dental Association. All rights reserved.
97
D E N T I S T R Y
&
M E D I C I N E
9500 [with circuitry identical to that of the Nonin perform statistical analyses of the data. 8500], Nonin Medical) to a device using coRESULTS oximetry (the actual measure of blood gases) and the results correlated significantly. The results Initially we classified the study population into using the Nonin 8500M Pulse Oximeter were both four groups: accurate and consistent for the purposes of our dgroup 1: mouth breathers with an initial arstudy. terial SpO2 level at or below 95 percent (we placed The Nonin 8500M pulse oximeter records data ENDS on these patients); every four seconds. It shines hemoglobin red and dgroup 2: mouth breathers with an initial arinfrared light through the tissue and detects the terial SpO2 level above 95 percent (we did not fluctuating signals caused by the arterial blood place ENDs on these patients); pressure pulses. Well-oxygenated blood is bright dgroup 3: nose breathers with an initial arterial red, and poorly oxygenated blood is dark red. The SpO2 level at or 95 percent (we placed ENDs on pulse oximeter determines the level of oxygen these patients); saturation from the color differences in the blood dgroup 4: nose breathers with an initial arterial by measuring the ratio of absorbed SpO2 level above 95 percent (we did hemoglobin red and infrared light. not place ENDs on these patients). Steady conditions such as venous The computer program in the The etiology of the blood flow, skin thickness and the pulse oximeter displayed a graph of aspirating and presence of bone and fingernails do the arterial SpO2 level for each choking in not cause fluctuations and, therepatient during the time he or she mouth-breathing fore, do not affect the saturation was being monitored. We noted perireading. Dark fingernail polish, odic fluctuations in blood oxygen dental patients may which can affect the light intensity, levels in all of the patients. In the be elevated carbon could produce an inaccurate group of mouth breathers who used dioxide levels in the reading. Therefore, we excluded ENDs, seven of 10 patients had one blood and not low patients who were wearing red finor more desaturation events (Table oxygen levels. gernail polish from the study, 1). A desaturation event is a which may have resulted in the low percentage of women in this study. We used Moyers’13 clinical technique to differentiate patients who predominantly breathed through their mouths from those who predominantly breathed through their noses. We instructed patients to seal their lips and inhale through their nose as rapidly and deeply as they could. In patients who habitually breathed through their noses, their nares flared; however, in patients who breathed predominately through their mouths, their nares constricted. We then placed an END (Breathe Right Nasal Strips, CNS, Minneapolis) according to the manufacturer’s instructions on any patient who had an initial arterial SpO2 level at or below 95 percent. We left the END in place for the entire dental procedure. We used Profox Oximetry Software (Version PFW OAT 08/99, PROFOX Associates, Escondido, Calif.) to transfer the oximetry data from the Nonin 8500M to a personal computer for graphic display and data analysis. We used SPSS data software (SPSS, Version 11.5, SPSS, Chicago) to 98
decrease in the arterial SpO2 level of 4 percent or more within a threeminute period. In the group of mouth breathers who were not wearing ENDs, two of six patients had desaturation events. In the group of nose breathers who were wearing ENDs, one of five patients had a single desaturation event. In the group of nose breathers who were not using ENDs, 10 of 24 patients had desaturation events. There appeared to be no relationship between the occurrence of desaturation events and the use of ENDs. The mean arterial SpO2 level was above 95 percent in eight of 15 people with initial SpO2 levels at or below 95 percent (Table 1). The initial reading of 95 percent, however, does not represent an average over a specific period, but merely a momentary initial reading. The trend over the entire period the patient was monitored is more reflective of what happened to his or her arterial SpO2 level during the time the END was used. Using the raw data, we calculated the slope for each of the 45 patients. We used a sequence number for the independent variable and the arterial SpO2 level reading as the dependent vari-
JADA, Vol. 134, January 2003 Copyright ©2003 American Dental Association. All rights reserved.
D E N T I S T R Y
able. We ran a simple linear regression to calculate the value of the coefficient (slope). In many cases, the slope varied from a visual conclusion. We categorized the slopes into three groups. Slopes greater than .001 were “positive,” slopes less than −.001 were “negative,” and level lines showing no trend were termed “zero.” Table 2 shows the independent variables mouth breathers (1) or nose breathers (2). We found no relationship between type of breather and slope group. Table 3 looks at the relationship between using and not using the END. We found that there was a significant relationship between using or not using the END and the slope group. Using the END resulted in a positive slope in the SpO2 level, and not using it resulted in a negative slope, irrespective of whether the patient was a mouth breather or nose breather. DISCUSSION
A trend for the arterial SpO2 level rising with the use of an END on patients (mouth breathers and nose breathers) with an initial arterial SpO2 level reading of at or below 95 percent from the beginning to the end of the dental appointment was demonstrated in this study. We noted a lowering of the arterial SpO2 level in a statistically significant number of patients who did not use ENDs during their dental pro-
&
M E D I C I N E
TABLE 1
STUDY RESULTS. PATIENT NUMBER
MEAN SPO2* LEVEL
MEAN PULSE (BEATS PER MINUTE)
NO. OF DESATURATION EVENTS
SEX
SPO2* SLOPE
Group 1: Mouth Breathers, Used END † 1 2 3 4 5 6 7 8 9 10
93.9 93.6 94.1 94.8 95.3 96.0 92.3 92.4 95.1 95.2
66 83 72 75 87 65 83 88 67 94
13 2 0 1 1 3 5 0 6 0
Male Male Male Male Male Male Male Male Female Male
.000647 .001134 −.010200 −.000003 .002370 .000751 −.000427 .003540 −.000452 .000055
Group 2: Mouth Breathers, No END Used 11 12 13 14 15 16
98.2 96.8 95.8 94.6 97.2 96.3
73 74 54 71 61 80
3 2 0 0 0 0
Female Male Male Male Male Female
−.001820 −.001930 −.004470 .003918 −.002690 .001435
Group 3: Nose Breathers, Initial Sp O 2 Level of at or Below 95%, Used END 17 18 19 21 22
95.4 96.8 95.5 94.1 95.2
73 75 83 73 70
0 0 1 0 0
Male Male Female Male Male
−.001240 .014550 .009394 .000027 .001516
Group 4: Nose Breathers, Initial Sp O 2 Level Above 95%, No END Used 20 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45
95.0 99.9 97.3 97.3 97.5 97.0 97.7 97.7 97.9 97.9 96.5 98.0 97.1 97.2 95.9 95.6 96.4 97.0 97.5 98.2 96.4 98.7 97.5 97.2
62 75 61 72 60 70 64 59 89 66 65 78 62 75 73 90 90 64 75 98 98 76 65 58
0 0 0 0 0 0 0 0 0 0 0 0 1 2 2 2 3 1 2 14 5 1 0 0
Male Female Male Male Male Male Male Male Male Male Male Male Male Male Male Male Male Female Female Female Female Female Male Female
−.000490 .000166 −.002950 −.002040 .002820 −.006170 −.001980 −.004710 .000384 −.000444 .005650 .001020 −.003550 .000319 .001010 −.015900 −.002190 −.000385 .003240 −.004370 −.002990 .001330 −.001630 −.003840
* SpO2: Oxygen saturation as measured by pulse oximetry. † END: External nasal dilator.
JADA, Vol. 134, January 2003 Copyright ©2003 American Dental Association. All rights reserved.
99
D E N T I S T R Y
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M E D I C I N E
TABLE 2
While demonstrating that using an END did STATISTICAL ANALYSIS OF THE ACTUAL SLOPE OF increase blood oxygen THE DATA FOR ALL SUBJECTS.* levels in dental patients (both mouth breathers and GROUP SPO2† TOTAL nose breathers) with an iniNegative Zero Slope Positive Slope tial SpO2 level at or below Slope 95 percent, the results of Mouth Breather this study do not establish No. of occurrences 5 6 5 16 the exact physiological % within group 31.3 37.5 31.3 100 Adjusted residual mechanism by which the −.9 .9 .0 END increases patient Nose Breather No. of occurrences comfort. 13 7 9 29 % within group 44.8 24.1 31.0 100 According to West,14 the Adjusted residual .9 −.9 .0 most important factor in TOTAL the control of ventilation is No. of occurrences 18 13 14 45 % within group the partial pressure of 40.0 28.9 31.1 100 carbon dioxide, or PCO2, of * χ2 = 7.033, P = .573. the arterial blood. This is † SpO2: Oxygen saturation as measured by pulse oximetry. reportedly a very sensitive mechanism. The etiology of TABLE 3 the aspirating and choking ANALYSIS OF THE RESULTS FROM PATIENTS in mouth-breathing dental † patients may be elevated USING END* AND NOT USING END. carbon dioxide, or CO2, END USE GROUP SPO2‡ TOTAL levels in the blood and not low oxygen levels. Further Negative Zero Slope Positive Slope Slope research is warranted to examine whether it is Yes No. of occurrences really the high level of CO2 7 6 15 2 % within group 46.7 40.0 100 13.3 in the blood that is the iniAdjusted residual 1.9 .9 −2.6 tiating factor in the brain No that forces aspiration and No. of occurrences 6 8 30 16 % within group the subsequent choking 20.0 26.7 100 53.3 Adjusted residual −1.9 −.9 2.6 and gagging during dental TOTAL procedures on mouth No. of occurrences 13 14 45 18 breathers. % within group 28.9 31.1 100 40.0 This study relates to the * END: External nasal dilator. use of END for dental † χ2 = 7.033, P = .03. ‡ SpO2: Oxygen saturation as measured by pulse oximetry. patients, and the results do not necessarily extrapolate cedures. We also noted a rising trend in arterial to use of ENDs while sleeping. SpO2 level in just the mouth-breathing group of CONCLUSION patients, but it was not a statistically significant number. This is consistent with the fact that This study indicates that dental procedures in nasal breathing is predictably obstructed in the general result in a lower arterial SpO2 level at the mouth-breathing group. The data also seem to end of the appointment than was noted at the substantiate Moyers’ criteria for differentiating beginning in a statistically significant number of nose breathers and mouth breathers. patients. Use of an END during a dental appointThe data did not validate the premise that the ment, however, resulted in an increase in the increased comfort level mouth breathers have arterial SpO2 level in a statistically significant from using ENDs during dental appointments is number of dental patients. The increase in the based on a rise in the arterial SpO2 level. arterial SpO2 level noted in the group of both 100
JADA, Vol. 134, January 2003 Copyright ©2003 American Dental Association. All rights reserved.
D E N T I S T R Y
mouth breathers and nose breathers with an initial arterial SpO2 level at or below 95 percent Dr. Moses is in private Dr. Lieberman is presiwho wore ENDs practice, 233 S. Wacker dent, Responsive during their Drive, Chicago, Ill. Methodology, Albu60606, e-mail querque, N.M. dental procedures “[email protected] demonstrates net”. Address reprint requests to Dr. Moses. that ENDs facilitate nasal breathing. Any facilitation of nasal breathing would tend toward idealization of both oxygen and CO2 levels. The exact relationship between the arterial SpO2 level and PCO2 relative to choking, gagging and constant swallowing to clear the oral airway of mouth-breathing patients in the supine position in the dental chair was not elicited by this study. ■ 1. Moses AJ. External nasal dilators: a clinical aid for dentists, patients. JADA 2001;132:1555-6. 2. Roithmann R, Cole P, Chapnik J, Shpirer I, Hoffstein V, Zamel N.
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Acoustic rhinometry in the evaluation of nasal obstruction. Laryngoscope 1995;105:275-81. 3. Roithmann R, Chapnik J, Zamel N, Barreto SM, Cole P. Acoustic rhinometric assessment of the nasal valve. Am J Rhinol 1997;11: 379-85. 4. Amis TC, Kirkness JP, Di Somma E, Wheatley JR. Nasal vestibule wall elasticity: interactions with a nasal dilator strip. J Appl Physiol 1999;86:1638-43. 5. Griffin JW, Hunter G, Ferguson D, Sillers MJ. Physiologic effects of an external nasal dilator. Laryngoscope 1997;107:1235-8. 6. Di Somma EM, West SN, Wheatley JR, Amis TC. Nasal dilator strips increase maximum inspiratory flow via nasal wall stabilization. Laryngoscope 1999;109:780-4. 7. Roithmann R, Chapnik J, Cole P, Szalai J, Zamel N. Role of the external nasal dilator in the management of nasal obstruction. Laryngoscope 1998;108:712-5. 8. Ng BA, Mamikoglu B, Ahmed MS, Corey JP. The effect of external nasal dilators as measured by acoustic rhinometry. Ear Nose Throat J 1998;77:840-4. 9. Gosepath J, Mann WJ, Amedee RG. Effects of the Breathe Right nasal strips on nasal ventilation. Am J Rhinol 1997;11:399-402. 10. Kirkness JP, Wheatley JR, Amis TC. Nasal airflow dynamics: mechanisms and responses associated with an external nasal dilator strip. Eur Respir J 2000;15:929-36. 11. Gehring JM, Garlick SR, Wheatley JR, Amis TC. Nasal resistance and flow resistive work of nasal breathing during exercise: effects of a nasal dilator strip. J Appl Physiology 2000;89:1114-22. 12. Schelledy DC, Smith PK, Downing RA, Accuracy of the Nonin Onyx 9500 pulse oximeter for the measurement of arterial oxygen saturation (abstract). Respir Care 1999;44(10):1226. 13. Moyers RE, ed. Handbook of orthodontics for the student and general practitioner. 3rd ed. Chicago: Year-Book; 1972:331. 14. West JB. Respiratory physiology: The essentials. 6th ed. Philadelphia: Lippincott Williams & Wilkins; 1999:110-14.
JADA, Vol. 134, January 2003 Copyright ©2003 American Dental Association. All rights reserved.
101
I
he use of external nasal dilators, or ENDs (also called nasal breathing strips), can make dental appointments easier, more pleasant experiences for dentists and particularly for patients who predominantly use their mouths to breathe.1 The article pointed out that patients with obstructed nasal breathing need to keep their oral airways open to breathe, so they are conThe results of stantly swallowing, choking or gagging this study during most dental procedures. Also, the patient’s oral breathing fogs the dendemonstrate tist’s mirror, hiding the dentist’s visualthat the use of ization of the working field. an external An END is made of flat spring-action nasal dilator strips placed under a contoured piece of facilitates nasal adhesive tape. When the tape is adhered breathing in transversely across the nose, the device lifts the skin and opens the nasal pasdental patients. sages. The subjective impression of people who breathe through their mouths is improved nasal breathing.1 Three changes have been quantified objectively in clinical studies as a result of using ENDs: dincrease in cross-sectional area at the nares2-9; dincrease in transnasal airflow2,6,9; ddecrease in nasal airflow resistance.3,6,7,10,11 If ENDs do all that, it might be logical that using an END would result in a rise in blood oxygen levels. Our current study focuses on determining whether use of an END, as a result of making nasal breathing seem easier for dental patients who are identified primarily as mouth breathers, results in an increased level of oxygen saturation as measured by pulse oximetry, or SpO2.
T
ALLEN J. MOSES, D.D.S.; MARCUS LIEBERMAN, Ph.D.
Background. The authors conducted a study to examine the use of external nasal dilators, or A D A J ENDs, on dental patients ✷ ✷ ® and to determine whether the subjective improvement in comfort N C U level noted in dental A ING EDU 4 R patients using ENDs is TICLE accompanied by a rise in the level of oxygen saturation as measured by pulse oximetry, or SpO2. Methods. The authors used a hand-held pulse oximeter to monitor 45 patients’ SpO2 levels during routine dental procedures. Results. The data suggest that dental procedures in general result in a lowering of the SpO2 level and that patients using an END do experience a rise in the SpO2 level. Conclusions. The data do not clearly establish that the increase in patient comfort with use of an END is due to a rise in the SpO2 level. Clinical Implications. The results of this study demonstrate that the use of an END facilitates nasal breathing in dental patients. CON
The effect of external nasal dilators on blood oxygen levels in dental patients
ABSTRACT
IO N
M E D I C I N E
T
&
A
D E N T I S T R Y
METHODS AND MATERIALS
A group of 45 ambulatory dental patients in an urban practice comprised the study group. The multiracial group consisted of 33 men and 12 women. Their ages ranged from 26 to 82 years. We performed each dental procedure with the patient in a supine position. A rubber dam was not used for any of these procedures. At the beginning of the dental appointment, we placed the Nonin 8500M hand-held pulse oximeter (Nonin Medical, Plymouth, Minn.) over the patient’s index fingernail using a finger clip to determine the patients’ levels of arterial SpO2. We left it in place for the entire time the patient was in the dental chair. Shelledy and colleagues12 conducted a study in which they compared the performance of a pulse oximeter (Nonin
JADA, Vol. 134, January 2003 Copyright ©2003 American Dental Association. All rights reserved.
97
D E N T I S T R Y
&
M E D I C I N E
9500 [with circuitry identical to that of the Nonin perform statistical analyses of the data. 8500], Nonin Medical) to a device using coRESULTS oximetry (the actual measure of blood gases) and the results correlated significantly. The results Initially we classified the study population into using the Nonin 8500M Pulse Oximeter were both four groups: accurate and consistent for the purposes of our dgroup 1: mouth breathers with an initial arstudy. terial SpO2 level at or below 95 percent (we placed The Nonin 8500M pulse oximeter records data ENDS on these patients); every four seconds. It shines hemoglobin red and dgroup 2: mouth breathers with an initial arinfrared light through the tissue and detects the terial SpO2 level above 95 percent (we did not fluctuating signals caused by the arterial blood place ENDs on these patients); pressure pulses. Well-oxygenated blood is bright dgroup 3: nose breathers with an initial arterial red, and poorly oxygenated blood is dark red. The SpO2 level at or 95 percent (we placed ENDs on pulse oximeter determines the level of oxygen these patients); saturation from the color differences in the blood dgroup 4: nose breathers with an initial arterial by measuring the ratio of absorbed SpO2 level above 95 percent (we did hemoglobin red and infrared light. not place ENDs on these patients). Steady conditions such as venous The computer program in the The etiology of the blood flow, skin thickness and the pulse oximeter displayed a graph of aspirating and presence of bone and fingernails do the arterial SpO2 level for each choking in not cause fluctuations and, therepatient during the time he or she mouth-breathing fore, do not affect the saturation was being monitored. We noted perireading. Dark fingernail polish, odic fluctuations in blood oxygen dental patients may which can affect the light intensity, levels in all of the patients. In the be elevated carbon could produce an inaccurate group of mouth breathers who used dioxide levels in the reading. Therefore, we excluded ENDs, seven of 10 patients had one blood and not low patients who were wearing red finor more desaturation events (Table oxygen levels. gernail polish from the study, 1). A desaturation event is a which may have resulted in the low percentage of women in this study. We used Moyers’13 clinical technique to differentiate patients who predominantly breathed through their mouths from those who predominantly breathed through their noses. We instructed patients to seal their lips and inhale through their nose as rapidly and deeply as they could. In patients who habitually breathed through their noses, their nares flared; however, in patients who breathed predominately through their mouths, their nares constricted. We then placed an END (Breathe Right Nasal Strips, CNS, Minneapolis) according to the manufacturer’s instructions on any patient who had an initial arterial SpO2 level at or below 95 percent. We left the END in place for the entire dental procedure. We used Profox Oximetry Software (Version PFW OAT 08/99, PROFOX Associates, Escondido, Calif.) to transfer the oximetry data from the Nonin 8500M to a personal computer for graphic display and data analysis. We used SPSS data software (SPSS, Version 11.5, SPSS, Chicago) to 98
decrease in the arterial SpO2 level of 4 percent or more within a threeminute period. In the group of mouth breathers who were not wearing ENDs, two of six patients had desaturation events. In the group of nose breathers who were wearing ENDs, one of five patients had a single desaturation event. In the group of nose breathers who were not using ENDs, 10 of 24 patients had desaturation events. There appeared to be no relationship between the occurrence of desaturation events and the use of ENDs. The mean arterial SpO2 level was above 95 percent in eight of 15 people with initial SpO2 levels at or below 95 percent (Table 1). The initial reading of 95 percent, however, does not represent an average over a specific period, but merely a momentary initial reading. The trend over the entire period the patient was monitored is more reflective of what happened to his or her arterial SpO2 level during the time the END was used. Using the raw data, we calculated the slope for each of the 45 patients. We used a sequence number for the independent variable and the arterial SpO2 level reading as the dependent vari-
JADA, Vol. 134, January 2003 Copyright ©2003 American Dental Association. All rights reserved.
D E N T I S T R Y
able. We ran a simple linear regression to calculate the value of the coefficient (slope). In many cases, the slope varied from a visual conclusion. We categorized the slopes into three groups. Slopes greater than .001 were “positive,” slopes less than −.001 were “negative,” and level lines showing no trend were termed “zero.” Table 2 shows the independent variables mouth breathers (1) or nose breathers (2). We found no relationship between type of breather and slope group. Table 3 looks at the relationship between using and not using the END. We found that there was a significant relationship between using or not using the END and the slope group. Using the END resulted in a positive slope in the SpO2 level, and not using it resulted in a negative slope, irrespective of whether the patient was a mouth breather or nose breather. DISCUSSION
A trend for the arterial SpO2 level rising with the use of an END on patients (mouth breathers and nose breathers) with an initial arterial SpO2 level reading of at or below 95 percent from the beginning to the end of the dental appointment was demonstrated in this study. We noted a lowering of the arterial SpO2 level in a statistically significant number of patients who did not use ENDs during their dental pro-
&
M E D I C I N E
TABLE 1
STUDY RESULTS. PATIENT NUMBER
MEAN SPO2* LEVEL
MEAN PULSE (BEATS PER MINUTE)
NO. OF DESATURATION EVENTS
SEX
SPO2* SLOPE
Group 1: Mouth Breathers, Used END † 1 2 3 4 5 6 7 8 9 10
93.9 93.6 94.1 94.8 95.3 96.0 92.3 92.4 95.1 95.2
66 83 72 75 87 65 83 88 67 94
13 2 0 1 1 3 5 0 6 0
Male Male Male Male Male Male Male Male Female Male
.000647 .001134 −.010200 −.000003 .002370 .000751 −.000427 .003540 −.000452 .000055
Group 2: Mouth Breathers, No END Used 11 12 13 14 15 16
98.2 96.8 95.8 94.6 97.2 96.3
73 74 54 71 61 80
3 2 0 0 0 0
Female Male Male Male Male Female
−.001820 −.001930 −.004470 .003918 −.002690 .001435
Group 3: Nose Breathers, Initial Sp O 2 Level of at or Below 95%, Used END 17 18 19 21 22
95.4 96.8 95.5 94.1 95.2
73 75 83 73 70
0 0 1 0 0
Male Male Female Male Male
−.001240 .014550 .009394 .000027 .001516
Group 4: Nose Breathers, Initial Sp O 2 Level Above 95%, No END Used 20 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45
95.0 99.9 97.3 97.3 97.5 97.0 97.7 97.7 97.9 97.9 96.5 98.0 97.1 97.2 95.9 95.6 96.4 97.0 97.5 98.2 96.4 98.7 97.5 97.2
62 75 61 72 60 70 64 59 89 66 65 78 62 75 73 90 90 64 75 98 98 76 65 58
0 0 0 0 0 0 0 0 0 0 0 0 1 2 2 2 3 1 2 14 5 1 0 0
Male Female Male Male Male Male Male Male Male Male Male Male Male Male Male Male Male Female Female Female Female Female Male Female
−.000490 .000166 −.002950 −.002040 .002820 −.006170 −.001980 −.004710 .000384 −.000444 .005650 .001020 −.003550 .000319 .001010 −.015900 −.002190 −.000385 .003240 −.004370 −.002990 .001330 −.001630 −.003840
* SpO2: Oxygen saturation as measured by pulse oximetry. † END: External nasal dilator.
JADA, Vol. 134, January 2003 Copyright ©2003 American Dental Association. All rights reserved.
99
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TABLE 2
While demonstrating that using an END did STATISTICAL ANALYSIS OF THE ACTUAL SLOPE OF increase blood oxygen THE DATA FOR ALL SUBJECTS.* levels in dental patients (both mouth breathers and GROUP SPO2† TOTAL nose breathers) with an iniNegative Zero Slope Positive Slope tial SpO2 level at or below Slope 95 percent, the results of Mouth Breather this study do not establish No. of occurrences 5 6 5 16 the exact physiological % within group 31.3 37.5 31.3 100 Adjusted residual mechanism by which the −.9 .9 .0 END increases patient Nose Breather No. of occurrences comfort. 13 7 9 29 % within group 44.8 24.1 31.0 100 According to West,14 the Adjusted residual .9 −.9 .0 most important factor in TOTAL the control of ventilation is No. of occurrences 18 13 14 45 % within group the partial pressure of 40.0 28.9 31.1 100 carbon dioxide, or PCO2, of * χ2 = 7.033, P = .573. the arterial blood. This is † SpO2: Oxygen saturation as measured by pulse oximetry. reportedly a very sensitive mechanism. The etiology of TABLE 3 the aspirating and choking ANALYSIS OF THE RESULTS FROM PATIENTS in mouth-breathing dental † patients may be elevated USING END* AND NOT USING END. carbon dioxide, or CO2, END USE GROUP SPO2‡ TOTAL levels in the blood and not low oxygen levels. Further Negative Zero Slope Positive Slope Slope research is warranted to examine whether it is Yes No. of occurrences really the high level of CO2 7 6 15 2 % within group 46.7 40.0 100 13.3 in the blood that is the iniAdjusted residual 1.9 .9 −2.6 tiating factor in the brain No that forces aspiration and No. of occurrences 6 8 30 16 % within group the subsequent choking 20.0 26.7 100 53.3 Adjusted residual −1.9 −.9 2.6 and gagging during dental TOTAL procedures on mouth No. of occurrences 13 14 45 18 breathers. % within group 28.9 31.1 100 40.0 This study relates to the * END: External nasal dilator. use of END for dental † χ2 = 7.033, P = .03. ‡ SpO2: Oxygen saturation as measured by pulse oximetry. patients, and the results do not necessarily extrapolate cedures. We also noted a rising trend in arterial to use of ENDs while sleeping. SpO2 level in just the mouth-breathing group of CONCLUSION patients, but it was not a statistically significant number. This is consistent with the fact that This study indicates that dental procedures in nasal breathing is predictably obstructed in the general result in a lower arterial SpO2 level at the mouth-breathing group. The data also seem to end of the appointment than was noted at the substantiate Moyers’ criteria for differentiating beginning in a statistically significant number of nose breathers and mouth breathers. patients. Use of an END during a dental appointThe data did not validate the premise that the ment, however, resulted in an increase in the increased comfort level mouth breathers have arterial SpO2 level in a statistically significant from using ENDs during dental appointments is number of dental patients. The increase in the based on a rise in the arterial SpO2 level. arterial SpO2 level noted in the group of both 100
JADA, Vol. 134, January 2003 Copyright ©2003 American Dental Association. All rights reserved.
D E N T I S T R Y
mouth breathers and nose breathers with an initial arterial SpO2 level at or below 95 percent Dr. Moses is in private Dr. Lieberman is presiwho wore ENDs practice, 233 S. Wacker dent, Responsive during their Drive, Chicago, Ill. Methodology, Albu60606, e-mail querque, N.M. dental procedures “[email protected] demonstrates net”. Address reprint requests to Dr. Moses. that ENDs facilitate nasal breathing. Any facilitation of nasal breathing would tend toward idealization of both oxygen and CO2 levels. The exact relationship between the arterial SpO2 level and PCO2 relative to choking, gagging and constant swallowing to clear the oral airway of mouth-breathing patients in the supine position in the dental chair was not elicited by this study. ■ 1. Moses AJ. External nasal dilators: a clinical aid for dentists, patients. JADA 2001;132:1555-6. 2. Roithmann R, Cole P, Chapnik J, Shpirer I, Hoffstein V, Zamel N.
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Acoustic rhinometry in the evaluation of nasal obstruction. Laryngoscope 1995;105:275-81. 3. Roithmann R, Chapnik J, Zamel N, Barreto SM, Cole P. Acoustic rhinometric assessment of the nasal valve. Am J Rhinol 1997;11: 379-85. 4. Amis TC, Kirkness JP, Di Somma E, Wheatley JR. Nasal vestibule wall elasticity: interactions with a nasal dilator strip. J Appl Physiol 1999;86:1638-43. 5. Griffin JW, Hunter G, Ferguson D, Sillers MJ. Physiologic effects of an external nasal dilator. Laryngoscope 1997;107:1235-8. 6. Di Somma EM, West SN, Wheatley JR, Amis TC. Nasal dilator strips increase maximum inspiratory flow via nasal wall stabilization. Laryngoscope 1999;109:780-4. 7. Roithmann R, Chapnik J, Cole P, Szalai J, Zamel N. Role of the external nasal dilator in the management of nasal obstruction. Laryngoscope 1998;108:712-5. 8. Ng BA, Mamikoglu B, Ahmed MS, Corey JP. The effect of external nasal dilators as measured by acoustic rhinometry. Ear Nose Throat J 1998;77:840-4. 9. Gosepath J, Mann WJ, Amedee RG. Effects of the Breathe Right nasal strips on nasal ventilation. Am J Rhinol 1997;11:399-402. 10. Kirkness JP, Wheatley JR, Amis TC. Nasal airflow dynamics: mechanisms and responses associated with an external nasal dilator strip. Eur Respir J 2000;15:929-36. 11. Gehring JM, Garlick SR, Wheatley JR, Amis TC. Nasal resistance and flow resistive work of nasal breathing during exercise: effects of a nasal dilator strip. J Appl Physiology 2000;89:1114-22. 12. Schelledy DC, Smith PK, Downing RA, Accuracy of the Nonin Onyx 9500 pulse oximeter for the measurement of arterial oxygen saturation (abstract). Respir Care 1999;44(10):1226. 13. Moyers RE, ed. Handbook of orthodontics for the student and general practitioner. 3rd ed. Chicago: Year-Book; 1972:331. 14. West JB. Respiratory physiology: The essentials. 6th ed. Philadelphia: Lippincott Williams & Wilkins; 1999:110-14.
JADA, Vol. 134, January 2003 Copyright ©2003 American Dental Association. All rights reserved.
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