Category: Health

Parkinson’s Disease: Solving The Mystery

Although an understanding of Parkinson’s disease dates back to at least the early 19th century, there is still much research to be done. Here is what you need to know about diagnosis and treatment options.

By Elena Acoba

Parkinson’s disease is confounding. The medical community doesn’t know what causes it. No two patients have the same symptoms or progress through the degenerative movement disorder in the same way. It’s hard to diagnose. There is no cure or way to slow its progression. And medical treatments lose their effectiveness over time.

But that doesn’t mean that someone with Parkinson’s can’t live a fulfilling life. “There are currently no treatments that delay the progression of Parkinson’s disease,” says Sarah Sullivan, D.O., a neuro-hospitalist with Northwest Medical Center and Oro Valley Hospital. “There are treatments, however, that improve a patient’s symptoms and quality of life, as well as decrease risks such as falls.”

About 60,000 Amer-icans are diagnosed with Parkinson’s disease every year. Around 10 to 20 percent of them have young onset, meaning they were diagnosed at age 50 or younger, says Rebecca Gilbert, M.D., Ph.D., vice president and chief scientific officer of the American Parkinson Disease Association. Some one million Americans live with the disease, including about 14,200 Arizonans.

It’s a difficult diagnosis for someone to receive.

“Patients often feel overwhelmed and anxious upon first hearing the words,” says Dr. Sullivan. “I review the medication and treatment options that we will consider in an effort to reassure patients that although we cannot cure the disease, there are many things we can do to manage it.”

Sarah Sullivan, D.O., a neuro-hospitalist with Northwest Medical Center and Oro Valley Hospital.

The first line of treatment for symptoms is the medication levodopa in various formulations and dosages. This drug allows the brain’s nerve cells to create dopamine, the neurotransmitter whose absence triggers Parkinson’s symptoms. The exact formula and dosage need continual adjustment taking into account the patient’s specific symptoms and disease progression.

The medication eventually no longer works, or its side effects become hard to tolerate. At that point, patients can consider deep brain stimulation (DBS). This could extend the relief of movement symptoms for 10 years or more, says Joseph Christiano, M.D., a neurosurgeon with Western Neuro.

In the procedure, two electrodes are placed in areas of the brain where Parkinson’s is disrupting movement control. These leads are connected to a battery pack that’s inserted under the skin of the chest. Electrical pulses adjusted to the patient’s specific needs are transmitted into the brain to help it control tremors and other movement symptoms.

“Ninety-plus percent of people see results,” says Dr. Christiano. “They can get significant improvement for various symptoms such as tremor, slowness and stiffness, gait issues and imbalance.”

With results like that, one might seek out the brain surgery as soon as possible. But, like a lot about Parkinson’s, it’s not that simple.

“Every patient’s Parkinson’s is slightly different,” Dr. Christiano says. “Medication often is very effective in the early stages and allows time for both the diagnosis and the trajectory of the disease to become clear. There are other disorders that appear similar to Parkinson’s disease, and it is important to clearly establish the right diagnosis.”

A typical Parkinson’s patient can consider DBS as early as three years after diagnosis, but this may depend on how fast the symptoms worsen.

“DBS is a well-studied, safe and effective treatment for Parkinson’s disease, and will be the next logical choice for many patients at some point in their disease,” says Dr. Christiano.

“There are other disorders that appear similar to Parkinson’s disease, and it is important to clearly establish the right diagnosis” – Joseph Christiano, M.D.

The Federal Drug Administration recently has approved the use of focused ultrasound to manage tremors. The nonsurgical procedure creates a lesion in the area of the brain where Parkinson’s has caused abnormal circuitry for movement.

Although medical options appear limited, many people can keep Parkinson’s symptoms at bay with lifestyle changes. This may be one benefit of having an early diagnosis even though there is no cure.

Rebecca Gilbert, M.D., Ph.D., vice president, chief scientific officer of the American Parkinson Disease Association. Photo by Abdulai Sesay.

“Some would argue that knowing that you have the disease is vital so that you can understand the changes that are happening in your body, increase exercise and plan for the future,” says Dr. Gilbert. “This should occur as early as possible.”

There are many ways to keep movement stable as long as possible.

Some physical therapy programs specific to Parkinson’s focus on exaggerating movements like arm swing and stride. Exercises that encourage loud speech help with maintaining vocal control.

Movement-dependent activities like video games, boxing, yoga, dance, swimming and tai chi help elevate mobility and mood. Any exercise is good, but doing them as intensely as possible shows more benefit.

Appropriate diets can address constipation, a common issue with Parkinson’s patients. Dr. Sullivan also suggests working with a doctor or dietician on the timing of eating certain foods, such as those high in protein, which can affect levodopa absorption.

An entire health team can respond to issues as they come up. Dr. Gilbert suggests a movement disorder specialist, primary care provider, rehabilitation specialists, nurse, nutritionist, neuropsychologist and social worker.

Research continues on many fronts: discovering genetic and environmental factors that cause the disease; detecting it before symptoms occur and brain damage becomes irreversible; and formulating treatments that can slow or stop its progression and for non-motor symptoms.

Joseph Christiano, M.D., a neurosurgeon with Western Neuro.

For Dr. Christiano, the way DBS is done — the procedure doesn’t change the brain structure — shows that the medical community has not given up.

“The key point,” he says, “is we are hopeful that somebody will come up with a cure for Parkinson’s, and since we didn’t change the brain cells, it might still be effective for DBS patients.”

PARKINSONISM

Some people who present with typical Parkinson’s symptoms also may show unrelated symptoms. This condition is known as Parkinsonism or Parkinson’s plus. Parkinsonism can appear in people with a history of stroke, head injuries or exposure to certain medications. It’s also evident in other diseases, such as Lewy body dementia and progressive supranuclear palsy.

“Because there is no single definitive test of Parkinson’s disease, these conditions sometimes are misdiagnosed as Parkinson’s early on,” says Dr. Sullivan.

Medications and therapies for classic Parkinson’s don’t work as well in these patients, and the disease may progress faster.

CHARACTERISTIC SYMPTOMS OF PARKINSON’S DISEASE

  • Tremors at rest
  • Decreased blinking
  • Handwriting that gets smaller
  • Small movements of the hands and feet
  • Arm, leg stiffness
  • Stooped posture
  • Decreased arm swing
  • Shuffling walk
  • Turning by taking several steps instead of pivoting
  • Changes in vocal quality There also are symptoms not related to movement, including
  • Loss of smell or reduced sensitivity to odors
  • Sleep problems
  • Depression, anxiety, psychosis
  • Gastrointestinal, urinary issues
  • Excessive sweating
  • Cognitive, personality changes

RESOURCES

April is Parkinson’s Disease Awareness Month, and Tucson has several resources to offer. Dr. Sullivan sees much interest among patients on how to live well with Parkinson’s.

“It’s something I see in Tucson a lot,” she says. “They are hungry for more information, more education. Many Tucson patients and winter visitors are intensely motivated to participate in their care. They want to stay young, vital, vibrant and active.”

Here are some locally based resources.

American Parkinson Disease Association Arizona runs three programs: a lecture series on the first Tuesday of the month; a support group for patients and caregivers every third Tuesday of the month; and for newly diagnosed patients, an eight-week class: “Parkinson’s Roadmap for Education and Support Services.” For more information: www.apdaparkinson.org or 326-5400.

The Parkinson and Movement Disorder Alliance lists several support group meetings and exercise classes, as well as online and streaming resources. The organization will hold an educational event July 25. For more information: www.pmdalliance.org or 800-256-0966.

Parkinson Wellness Recovery focuses on exercise and other ways for the brain to adapt to the effects of the disease. For more information: www.pwr4life.org or 591-5346.

Digging Up a Diagnosis

Valley fever can affect people, pets and livestock here in Southern Arizona, and can be hard to diagnose.

The University of Arizona’s Valley Fever Center for Excellence and Banner Health have created a tutorial to help local physicians speed up the process. Here’s what you need to know about this pervasive disease.

By Anne Kellogg | Photography by Kris Hanning

It can come on like the flu but may take weeks or months to run its course.  In rare cases, Valley fever can result in severe lung issues or meningitis.  Its symptoms mimic many other illnesses — such as rheumatism and even cancer — causing patients to undergo painful testing and unneeded treatment with antibiotics or steroids.  John Galgiani, M.D., director of the Valley Fever Center for Excellence, professor of medicine in the Divisions of Infectious Diseases at the UA Colleges of Medicine in Tucson and Phoenix, member of the UA BIO5 Institute and medical director of the Banner — University Medicine Valley Fever Program, has developed a way to assist physicians in the timely diagnosis of this challenging disease.

What is Valley Fever?

Have you experienced a fever, profuse sweating at night, chest pain and cough, muscle and joint aches — especially in the ankles and knees — loss of appetite, and a rash that resembles measles or hives?  You In Health may have thought you had the flu, but these symptoms also are those of Valley fever, which is caused by spores that live in the soil in Southern Arizona.  In addition to areas of our state, Valley fever can occur in semi-arid and arid soils of California, Nevada, Utah, New Mexico and Texas, as well as the states of Sonora and Chihuahua in Mexico, and Central and South America.

The corridor between Tucson and Phoenix is one of the most endemic regions for Valley fever, so the University of Arizona’s Valley Fever Center for Excellence (VFCE) was established by the Arizona Board of Regents in 1996 to promote education, research and care for this disease.  Dr. Galgiani explains that Valley fever is a difficult disease to detect and treat, frequently leading to misdiagnosis.

Its medical name, coccidioidomycosis, means fungal infection caused by the fungus Coccidioides . The name is often shortened to “Cocci” (pronounced “kok-see”).  This organism grows in the top six inches of soils in areas of low rainfall, high summer temperatures and Moderate winter temperatures.  In susceptible people or animals, infection occurs when a spore is inhaled.

Infection by the spores doesn’t always lead to detectable disease.  In nearly 60 percent of cases, the symptoms are so mild that individuals may not even realize they are infected.  In the remaining cases, symptoms may range from uncomfortable to miserable to even fatal.  It occasionally can develop into a severe, life-threatening form that may involve skin, bones, or other parts of the body, as well as the brain.  Overall statistics for Valley fever show about 150,000 infections per year, with only one-quarter of one percent contracting meningitis (i.e., roughly two cases per thousand), but increased numbers of cases cause a corresponding increase in serious disease.  Serious forms of the infection require anti fungal therapy.

The diagnosis of this disease is complicated because of the way the lungs respond to the inhaled spores.  Initially the infection causes a pneumonia, which sometimes can turn into a lung nodule or even a

The catheterization lab at Tucson Medical Center.

cavity.  Nodules are small, residual patches of infection that generally appear as single lesions (from one, to one and a half inches, in diameter).  If it is documented that the nodule is caused by Valley fever, no other treatment is required.  However, if the original Valley fever infection goes undiagnosed and the nodule is found on a chance X-ray, it looks no different fromfrom a lung cancer, and a physician may suggest biopsy or even removal.  Nodules caused by cocci can remain forever.  Those who had a mild case may have no symptoms or scarring.  Cavities occur in about 5 percent of patients, and may cause the patient to cough blood or have other chest symptoms.  For some patients, the best management is to have the cavity surgically removed.

In Arizona, infection is likely to occur from May to July and again following Monsoon season, from October to the end of December.  Those in occupations that involve disturbing the soil (such as construction, agriculture or archeology), as well as recreational gardeners, may be at greater risk of contracting the disease.

Two-thirds of all U.S. Valley fever infections occur in Arizona.  Roughly 75 percent occur in Maricopa county, with 20 percent or so occurring in Pima County.  According to Arizona Department of Health Statistics, those susceptible to the most serious consequences of Valley fever include people on chemotherapy, on immune suppression medications because of organ transplant, the elderly, or those with immunodeficiency, such as AIDS.

The Benefits of Early Diagnosis

A primary reason for diagnosing early is removing the patient’s fear of the unknown.  Patients suffering from these long-lasting Respiratory symptoms often undergo multiple diagnostic blood tests, chest X-rays, CT scans, PET scans, bronchoscopy, percutaneous fine-needle aspiration, and even thoracotomies.  They often are prescribed multiple courses of antibiotics from their primary care physicians.  In one study, 81 percent of patients with Valley fever pneumonia received at least one course, and 31 percent received multiple courses.  In addition to the cost, it can create antibiotic resistance.  Another issue is doctors prescribing corticosteroids for the rheumatologic complaints (a synonym for Valley fever is “desert rheumatism”).  The anti-inflammatory effects of corticosteroids may create adverse reactions in patients, as well as increasing the chances of Valley fever complications.

Developing the Tutorial

Out of the need to get Valley fever patients treated early and effectively, Dr. Galgiani and his cohorts at the VFCE teamed with Banner Health to help physicians.  “I am quite excited about this — it’s one of the most positive things to come out of the merger between Banner Health and the University of Arizona faculty medical group,” Dr. Galgiani enthuses.  “Banner Health has specific clinical practices that they share with all of their physicians, and the Valley Fever Center for Excellence developed this information for local and national dissemination.  This will help doctors in other states whose patients visited our area and now have respiratory symptoms associated with Valley fever.

“We spent last year in a planning process, where we designed and refined the ABCs of what a primary care physician should do to diagnose Valley fever early and manage it correctly.  This past September we held a webinar on the topic, and we’ll be training Banner physicians all year.  VFCE is a department of the University of Arizona, not part of Banner, so we’ve made all the tools we developed in this process publically available to any doctor who wants to do what we’re doing.”

The new approach for recognizing and treating a new Valley fever infection is centered around the acronym COCCI:

Consider the diagnosis
Order the right tests
Check for risk factors
Check for complications
Initiate management

Physicians are encouraged to consider Valley fever if any of the following indications are present:

  • Respiratory symptoms and at least one of the following:
    • more than one office visit
    • chest X-ray ordered
    • antibiotics prescribed
  • Two of the following have been present for a prolonged period: fever, fatigue and/or arthralgia (joint pain)
  • High numbers of eosinophils (a type of white blood cell) found in a blood sample
  • Skin rashes known as erythema nodosum or erythema multiforme

The tutorial and all the other resources created for the clinical practice training can be accessed online at https://vfce.arizona. edu/education/banner-valley-fever-clinical- practice-toolbox.

For more information on the new UA/ Banner clinical practice protocols, see the Valley Fever Clinical Practice Toolbox at the VFCE website, which includes the webinar mentioned earlier.

The protocols were developed with assistance from David Valenzuela, M.D., a Phoenix-area family practice physician, clinical assistant professor at the UA College of Medicine — Phoe

nix and the physician executive who heads Banner Medical Group Primary Care.

As part of the effort, Dr. Galgiani and Fariba Donovan, M.D., Ph.D., another VFCE researcher and faculty physician with the UA Division of Infectious Diseases, are providing small group training sessions for six to 12 clinicians each at 39 Banner Health clinical sites across the State.

They completed about a half dozen sessions by the end of January.

I Want a New Drug…

“There have been no recent breakthroughs or changes in the antifungals that are used in Valley fever,” Dr. Galgiani notes.  “There are a lot of divergent opinions on whether to start patients on fluconazole … it depends on the patient’s clinical presentation.  The antifungal treatments don’t cure it — they can help, but only by suppressing it.  If the patient’s immune system doesn’t ‘step up to the challenge’ when the antifungal drugs are stopped, those who really needed treatment will relapse.”

Researchers at UA have been working on a drug called nikkomycin Z as a new treatment for fungal infections, particularly Cocci.  “It works by blocking an enzyme that is important in making the cell wall,” Dr. Galgiani explains.  “An key part of the cell wall is ‘chitin.’ Chitin is made by an enzyme called chitin synthase, and nikkomycin Z blocks that enzyme.  In that regard it’s similar to penicillin, which acts by blocking formation of the cell wall of a bacterium.”

Because this drug’s most important use would be for Valley fever here in the Southwest, which isn’t a worldwide disease, drug companies haven’t had a strong incentive to develop it.

“We’re trying very hard to get it back into clinical trials, and have been making progress, but the bottom line is that it needs more financial support than we’ve been able to get.  The National Institutes of Health has been very supportive, but they’re not a pharmaceutical company.

They want this drug to go forward, but we haven’t yet gotten the support to do it.  It’s frustrating … we hope to find a pharmaceutical company that would be willing to partner with us.”

When a medication or a vaccine is created for human use, it must go through many clinical trials and intense scrutiny by the Federal Drug Administration (FDA).  Drugs for dogs and other veterinary purposes also require FDA approval.  However, veterinary vaccines are cleared by the United States Department of Agriculture (USDA).  “Work on an effective vaccine for the prevention of Valley fever has been ongoing for decades,” says Dr. Galgiani.  “Currently, we have a vaccine candidate that shows excellent protection in mice.  We are proceeding through the steps to bring this Vaccine through USDA approval for use in our canine patients.  That itself would be a wonderful accomplishment.  Just as exciting, if our vaccine candidate is found to protect dogs from Valley fever, that will add to the evidence that a similar vaccine might ultimately be used to protect ourselves.”

Work on the vaccine is being coordinated through the following VFCE research partners: Marc Orbach, Ph.D., Jeffrey Frelinger, Ph.D., and Lisa Shubitz, DVM, at the University of Arizona; Colorado State University’s Richard Bowen, DVM, Ph.D.; and Anivive Lifesciences Inc., a Californiabased biotechnology company that licensed the vaccine in 2017 from the UA through Tech Launch Arizona, the university unit that helps commercialize innovations developed at UA.

Getting the Word Out

In addition to helping physicians diagnose Valley fever earlier, the Valley Fever Center for Excellence (VFCE) at the University of Arizona and the Arizona Department of Health Services (AzDHS) also are trying to educate the public.

For example, a billboard will go up this month in Phoenix with the words ““Pneumonia or flu for weeks? It could be Valley fever. Ask your doctor for the test.”

The campaign is being funded by a grant from IMMY, a Norman, Oklahoma-based firm that specializes in high-quality diagnostic tools for diseases caused by fungi such as Aspergillus, Blastomyces, Candida, Coccidioides, Cryptococcus and Histoplasma.

It’s coordinated through the VFCE; Kenneth Komatsu, M.P.H., state epidemiologist and chief of the Office of Infectious Diseases with the AzDHS Division of Public Health Preparedness; and Rebecca Sunenshine, M.D., a captain in the U.S. Public Health Service, epidemiology field officer for the U.S. Center for Disease Control and Prevention and medical director of disease control for Maricopa County Public Health.

Look for the billboard along Interstate 10 or the 202 Loop in Phoenix starting March 4.

A Matter of the Heart


Many factors can play into a heart attack, including genetic predisposition, lifestyle, and excessive stress. Here is one local woman’s firsthand account of the path that led her to a heart attack, and the road back.

Before

I had a heart attack on Feb. 9, 2018. It scared the you-know-what out of me, but it also annoyed me no end! I was so busy — doing things for everybody and being everywhere. My days were planned to the max with no wiggle room for delays. I was irritable with stress and now peeved because things didn’t go my way. How inconvenient! I was in the middle of a late-life career path — teaching writing, publishing a book, running a writer’s group, and tons of other social stuff. My to-do list was a mile long, and I liked my busy lifestyle. But something wasn’t right. I was ridiculously tired to the point of fatigue. I couldn’t get through the day without lying down, and if I didn’t get an afternoon rest, I was uncharacteristically cranky in the evening. I was getting up at 5:30 in the morning to tackle that to-do list, thinking I was just sleeping poorly. I blamed everything from my pillow to the full moon. Unbeknownst to me, that nagging pain in my collarbone and the occasional lightheadedness were common signs of heart attacks in women. Women experience a heart attack differently than men. Men typically have the “Hollywood” attacks we see in movies. You know the kind: pain in the left arm, clutching the chest, collapsing. But I had none of those. However, the day before my heart attack, I had nine symptoms in total and still refused to go to the emergency room — fatigue, cold sweats, heart palpitations, lightheadedness, pain in my collarbone, cold/numb fingers and toes, shortness of breath, dizziness, and feeling faint. I believed I could be just having an anxiety attack. I was too busy and “didn’t have time” to have a major health issue interrupt my full schedule. On Thursday, Feb. 8, I was the spotlight speaker at one of my networking groups. This meant I had 10 minutes to stand before the group and give a presentation. That morning my fingers and toes were icy cold. I was tired and hadn’t been sleeping well, but I chalked it up to one of any number of things: a poor dinner choice the night before, a case of nerves, or maybe sleep apnea. My collarbone ached like someone was pinching it. As I wrote my speech notes onto blue note cards, I felt like I’d been holding my breath. While loading the supplies into my SUV, I noticed I was winded even from that effort. At the restaurant, I took an end seat so I could get up easily to do my presentation. When it was my turn to speak, I stood at the front and grasped the microphone for dear life. I talked easily for 10 minutes, though I realized I was getting short of breath. Then my heart started pounding, because (I thought) I was probably holding my breath — until it pounded faster, and I mean really pounded. It took everything I had to appear calm and composed. Then I started feeling lightheaded to the point of dizziness. At the end of my time, I took a few questions and sat down just before the room started to spin. Immediately, sweat formed at my hairline and trickled down my forehead like a menopausal hot flash. I dabbed at my forehead with a napkin, desperate to be “fine.” A friend noticed that all the color had drained from my face. She brought me water and the waiter gave me a Sprite. They wanted to call 911, but I resisted, saying, “NO! I’m fine, just feeling a bit woozy….” I sensed I might pass out, and wanted to lie down, but there was nowhere I could do that. So, I just kept saying, “I’m fine. Honest, I’m fine.” Finally, after lots of water and napkins to mop up the cold sweat pouring from my scalp, I felt somewhat recovered. Knowing I couldn’t drive in this condition, I called my husband Tomas to come and take me home. Once there, I lay on the couch, very still, and Googled my symptoms. Voila! It’s an anxiety attack. That explained everything! Somehow that made me feel better, even though I couldn’t imagine what I might have been anxious about — but anxiety had to be it. On Friday, Feb. 9, I awoke with a head full of plans and a long to-do list. In the shower, raising my arms to wash my hair seemed like such an effort. I was quickly out of breath. So, with a towel wrapped around my head, I put on my robe and lay down on the bed until my breathing returned to normal.

Before her heart attack, Susan was a featured speaker at many networking events.
Before her heart attack, Susan was a
featured speaker at many networking events.

Blow-drying my hair caused the same effect. Holding a brush in one hand and the blow-dryer in the other with my arms above my head was a challenge. I was again exhausted and short of breath. Back to bed I went, lying down for the second time that morning — and it wasn’t even eight o’clock. I thought, This is unacceptable. I have too much to do to be lying down every five minutes! Knowing something wasn’t right, I was determined to push through and prepare for my writing class the next morning. So, I charged off to shop for groceries. I knew exactly where to find all my favorite foods for the class, but in the cookie aisle, it hit me. I reached for a pack of gourmet cookies and they fell to the floor. As I bent down to retrieve them, I suddenly knew I’d faint if I leaned all the way down. I left the cookies on the floor and retreated to the register to check out. My legs felt so heavy, I could barely move. Thinking a jolt of caffeine and sugar would pick me up, I grabbed a cold soda from the case and gulped it down. I slowly loaded the two bags of groceries into the back of my SUV as if I were moving through syrup. I was short of breath again and recognized the pain in my collarbone as constant. After I got home, I finally gave in and called my primary care doctor. “Sorry, he’s out of town,” said the nurse who answered the phone. “Is someone covering for him? Who can I see?” I begged. Her answer was short and sweet. I could either call my cardiologist or go to the hospital emergency room. “I can’t go to the ER. I have too much to do!” I wailed. Her reply would haunt me for weeks, months, even longer: “You can’t do anything if you’re dead.” Thankfully, I had a cardiologist to call. The receptionist found my file (it had been 10 years since my last visit) and said the doctor could work me in that day. I called Tomas and we drove there together. After I was hooked up to an EKG, the tech shook his head as he watched the needle move. Cardiologist Timothy Marshall, M.D., entered the room, stared at the EKG machine, and I knew something was up. “Susan, you’re having a heart attack right now,” Dr. Marshall said. What? It can’t be. I thought he would just give me blood pressure pills and send me on my way. Terrified, I looked over at my husband who appeared terrified, too. The doctor said we had to go to the ER — now. Then things happened fast. The tech gave me a baby aspirin and had me place a nitroglycerine tab under my tongue. I heard Dr. Marshall on the phone swiftly making arrangements for me. Oh, God, I prayed silently.

After

Day One

Susan shows off the defibrillator life vest she wore for six weeks following her heart attack.
Susan shows off the defibrillator life vest she wore for six weeks following her heart attack.

Tomas dropped me off at Tucson Medical Center’s ER entrance, which was only four blocks from the doctor’s office. I was whisked inside and placed on a gurney. I winced as the attendant peeled off my brand-new black leggings and my underwear. I was allowed to take off my top and bra myself, and the hospital gown went on so quickly, nobody could see my nakedness. The medics swarmed around me. Doctors, nurses, techs, all said their names and what they would do to me. Calmly, they took some blood, put in a needle for an IV, and asked about my health history, my medications, and my nail polish. Yes, my nail polish. They wanted to remove it so they could clip a heart monitor onto my finger. They said the polish would interfere, but I knew it wouldn’t come off because it’s made of shellac. I tried to explain this but to no avail. Instead, they attached a heart monitor to my ear. I felt a breeze on my face from the speed of the moving gurney. They rolled me to the Cath Lab, explaining every movement and location along the way. But having received anesthesia, soon I didn’t care. Surrounded by nurses, equipment, and blinking monitors, the doctor threaded a tiny wire with a balloon on the end through the catheter tube in my groin. From there, he inserted a stent in my right coronary artery. It was 95 percent blocked and resistant to opening, but with the stent in place, my blood flow improved to 60 percent. Less than 20 minutes had passed since I walked into the ER. When I woke up from the anesthesia, I found myself in a private room with nurses, techs, and orderlies coming in and out. Tomas was there and so was my son Tim. I was starving, but I couldn’t eat until another round of tests were run. That night was a blur of fitful sleep, bad dreams, a dinner tray at 10 p.m. and a constant struggle to get comfortable.


Day Two

The early morning ushered in more nurses drawing blood, bringing pills,and taking my vitals. My breathing was still labored, and my collarbone pain had moved to my chest. Three doctors visited and determined I wasn’t better, so they ordered a few tests. They gave me something for the pain and to get the fluid off my lungs, then sent me off for a chest x-ray. After that, I was wheeled out on yet another gurney for an echocardiogram, a test that uses ultrasound to evaluate one’s heart muscle and heart valves. Hours later, the hospital’s cardiologist Dr. Thomas Waggoner told me he was taking me back to the Cath Lab to fix another artery with a stent. I trusted him. I knew something had to be done because I felt so bad — constant chest pain, shortness of breath, fitful sleeping and non-stop sweating. And I saw how the nurses frowned with concern when they took my blood pressure and peered at my monitors. After receiving a second stent, I improved dramatically. The second stent opened up the left circumflex artery, improving the blood flow along with oxygen to my body. My test results improved. Everyone noticed! This fix marked the beginning of a slow recovery as my heart began to grow stronger.

Day Three

My brain was on overload trying to take in every face, test result, and procedure explanation. I had three cardiologists, four nurses, a dietician, a pharmacist, a physiologist, and a hospitalist who managed my case. One nurse was a counselor who had a soothing voice and wore a fuzzy cardigan. Dr. Juan Pena, my hospitalist, visited me every day. He’d squat down to look me in the eye, hold my hand, and ask if I knew what happened to me. His soft voice calmed me. He made sure I knew I’d had a heart attack and then stent surgery procedures. Whatever the circumstance, he took care to explain the details to me. Sarah, the nurse with the fuzzy cardigan, told me, “Because you almost died, you’ll find yourself feeling depressed. Just expect this to happen at some time.” A kid in blue scrubs (a cardiac rehab intern) said he’d walk me down the hall to see how far I could go. This excited me! I wanted to prove I was strong enough to be released. He offered his arm, and we started our walk. Yet I could only make it a few steps out the door of my room before I was so winded that I had to stop. My ankles felt wobbly, my legs weak.

Susan and her husband happily walking through the park.
Now, I make it a priority to fill my heart with memories
of love, joy, and togetherness with those I hold dear. I
try extra hard to say how much I appreciate them and
make an effort to spend time together.

Then came Debbie, whose job it was to explain how to use a defibrillator life vest. She opened a color brochure describing a contraption I was supposed to wear 24/7 for the next six weeks. The vest, like a fabric sports bra with metal paddles in the back, would shock my heart if I should have a heart attack while wearing it. It’s also full of sensors to monitor everything about my heart and transmit the data to a far-away location via modem. Because it was a Sunday, though, I wouldn’t get the actual vest until Monday. A dietician wearing red scrubs was sweet as she launched into long explanations of what I should be eating for the rest of my life. I was especially intrigued with her visual of the desired salt intake. “Just make a little mound about the size of a dime in the palm of your hand,” she said. “That’s how much salt you can have in a day. Not just from the salt shaker but from everything you eat.” Then she showed me how to read labels on food products, especially the sodium content. At one point in our conversation, my eyelids drooped as I cradled the stack of brochures she’d brought. “This is a lot to take in!” I declared. Before I drifted off, I heard Tomas and my doctor talking about the “ejection fraction” or EF numbers. EF is a measure of how well the left ventricle is pumping blood to the right ventricle, and my EF was low at 15 (with a normal heart putting out 35 to 55 EF). This explained the need for wearing a defibrillator vest. That afternoon, I ordered heart-healthy chicken soup for dinner, but it tasted like dish water. So I ate the saltine crackers, I craved salt so badly! I dozed off again and heard the clicking of heels come into my room. I opened my eyes and saw my best friend bearing a vase of flowers. ”Happy birthday,” she said. “I told you not to come!” I blurted. “I had to see you with my own eyes to make sure you’re okay,” she replied. That’s when I started to cry. I didn’t want anyone to see me so debilitated — oxygen tube, catheter bag, tubes and needles in both arms, bruises on every visible surface. I wanted to tell her I almost died and how scared I was, but my breathing was so labored, I couldn’t get out any more words. We simply hugged.


Day Four

Finally, Monday morning came and so did a flurry of activity. A young man in gray scrubs went through my discharge papers. One by one, he explained what they meant so I could knowledgeably sign the papers. Most important was getting the long list of drugs, their names, dosages, and what they would do for me. It felt like a barrage of instructions: Do this, do that, make an appointment for this doctor, that blood test. Then a chipper nurse dressed in brown corduroy came in with a lot of enthusiasm and a defibrillator life vest. She showed me how to put it together by inserting the paddles into the slots and the round sensors with their skinny black cords. I noticed a two-and-a-half-pound battery pack was attached with a cord on the side. “Put on the life vest and get me out of here!” I wanted to shout. But no, I’d have to prove to her I could put it together as she did. The vest already was complicated, and it came with a long list of things to do every day. I knew that no slacking off was allowed; wearing this vest was serious, life-saving stuff! The kid in scrubs came to walk me again. This time, I made it farther than before. I wanted to jump for joy, but my arm wouldn’t let go of his.

Day Five

My First Night Home

Tomas and I decided I should sleep in the guest room and keep the walker nearby. I would need it when I got up to go to the bathroom — I wasn’t strong enough to make it there on my own. That night, I had a nightmare, awoke with a start, and begin to hyperventilate. My breath wouldn’t come — I was terrified. I made my way to the family room, got into the recliner, and covered up with an afghan. I realized I could breathe better sitting up. While in that chair, I had a long talk with God thanking him for sparing my life. I asked Him to help me breathe better right now! Then I asked Him what I did to deserve this and what I could do to repay Him for saving me. Over the next few months, I followed my doctor’s orders strictly. That meant attending cardiac rehab three times a week, eating heart-healthy meals, and taking my meds faithfully. The hardest order was eliminating stress from my life. Weeks passed and gradually I regained my strength. My ejection fraction or EF rose to 55, which meant getting released from the defibrillator life vest. In the meantime, I cancelled my writing groups, gave up teaching classes, and reimbursed my students for money they’d paid. I also stopped networking and posting on Facebook, plus I quit being annoyed at interruptions. Thankfully, I began feeling like a normal human being. I learned to drop the “too busy” persona and practiced my new mantra: “JUST BE.”

Six Months Later

Grief, Guilt, and Gratitude

When I had my heart attack, I almost died. I mean, I could have died, but I didn’t. Faced with my mortality in this drastic and incontrovertible way, I realized it was possible I might live a shorter life than I’d anticipated. I suffered grief for the life I’d lost. No, I didn’t die, but my old life was gone for good. I grieved over what I might have missed with my husband, my children, my grandkids, my sisters and my friends. And I grieved for all I will miss in the future when I do die. Now, I make it a priority to fill my heart with memories of love, joy, and togetherness with those I hold dear. I try extra hard to say how much I appreciate them and make an effort to spend time together. Then there is the guilt, which can take on many faces. My counselor told me these feelings are normal. That brings me to gratitude. Today, I’m so grateful God gave me a reality check and a second chance. I discovered that my busy schedule was not the most important thing in my life. I thought stress was anything that caused me great upset or anxiety. But I learned from a soft-spoken cardiac nurse that stress is more than that. “Basically,” she said, “it’s taking on too much. Doing too many things without enough time. Many women take time to take care of everybody else before they even think about caring for themselves.” “Hmmm,” I thought, “she’s describing me to a T!” I had to face facts: my stress was selfinduced. The old me always said yes to everything, never realizing it was causing stress. But I’m not that person anymore. I now can say no to things that will get done without me. I have to pull back. I know my strength doesn’t have to come from a laundry list of accomplishments. I can relax. I am very lucky I didn’t die. But my life as I used to live it? That’s over.

Heart Attack Symptoms in Women

The most common symptom is some type of pain, pressure or discomfort in the chest. But it is not always severe or even the most prominent symptom. And, sometimes, women may have a heart attack without chest pain. Women are more likely than men to have heart attack symptoms unrelated to chest pain, such as:

  • Neck, jaw, shoulder, upper back or abdominal discomfort
  • Shortness of breath
  • Pain in one or both arms
  • Nausea or vomiting
  • Sweating
  • Lightheadedness or dizziness
  • Unusual fatigue

These symptoms can be more subtle than the obvious crushing chest pain often associated with heart attacks. Women may describe their chest pain as pressure or a tightness. This may be because women tend to have blockages not only in their main arteries but also in the smaller arteries that supply blood to the heart — a condition called small vessel heart disease or coronary microvascular disease.

Susan Smith is a heart attack survivor, writer, speaker, and Mayo Clinictrained WomenHeart Champion. She is writing a book titled “My Inconvenient Heart Attack.”

Top Dentists

Selection Process (Methodology)

“If you had a patient in need of a dentist, which dentist would you refer them to?”

This is the question we’ve asked thousands of dentists to help us determine who the topDentists should be. Dentists and specialists are asked to take into consideration years of experience, continuing education, manner with patients, use of new techniques and technologies and of course physical results. The nomination pool of dentists consists of dentists listed online with the American Dental Association, as well as dentists listed online with their local dental societies, thus allowing virtually every dentist the opportunity to participate. Dentists are also given the opportunity to nominate other dentists that they feel should be included in our list. Respondents are asked to put aside any personal bias or political motivations and to use only their knowledge of their peer’s work when evaluating the other nominees. Voters are asked to individually evaluate the practitioners on their ballot whose work they are familiar with. Once the balloting is completed, the scores are compiled and then averaged. The numerical average required for inclusion varies depending on the average for all the nominees within the specialty and the geographic area. Borderline cases are given a careful consideration by the editors. Voting characteristics and comments are taken into consideration while making decisions. Past awards a dentist has received, and status in various dental academies can play a factor in our decision. Once the decisions have been finalized, the included dentists are checked against state dental boards for disciplinary actions to make sure they have an active license and are in good standing with the board. Then letters of congratulations are sent to all the listed dentists. Of course there are many fine dentists who are not included in this representative list. It is intended as a sampling of the great body of talent in the field of dentistry in the United States. A dentist’s inclusion on our list is based on the subjective judgments of his or her fellow dentists. While it is true that the lists may at times disproportionately reward visibility or popularity, we remain confident that our polling methodology largely corrects for any biases and that these lists continue to represent the most reliable, accurate, and useful list of dentists available anywhere.

Who compiles the list? topDentists, LLC, based in Augusta, Georgia, has compiled a nationwide list of top-rated dentists. Do dentists pay to be on the list?

How many dentists in the immediate Tucson area are on the list? 126 How is the list determined? Read on …

Endodontics

Endodontics

Tung B. Bui
Southern Arizona Endodontics
1011 North Craycroft Road, Suite 107 Tucson, AZ 85711
520-322-0800
www.saendo.com

David G. Burros
Southern Arizona Endodontics
7493 North Oracle Road, Suite 217 Tucson, AZ 85704
520-322-0800
www.saendo.com

Christopher Douville
Southern Arizona Endodontics
1011 North Craycroft Road, Suite 107 Tucson, AZ 85711
520-322-0800
www.saendo.com

Daniel B. Funk
Southern Arizona Endodontics
7493 North Oracle Road, Suite 217 Tucson, AZ 85704
520-322-0800
www.saendo.com

Dean M. Hauseman III
Southern Arizona Endodontics
1011 North Craycroft Road, Suite 107 Tucson, AZ 85711
520-322-0800
www.saendo.com

Paul G. Hobeich
Hobeich Endodontics
6600 North Oracle Road, Suite 110 Tucson, AZ 85704
520-209-2600
www.hobeichendo.com

John R. Hughes
Southern Arizona Endodontics
1011 North Craycroft Road, Suite 107 Tucson, AZ 85711
520-322-0800
www.saendo.com

Justin S. Hughes
Southern Arizona Endodontics
1011 North Craycroft Road, Suite 107 Tucson, AZ 85711
520-322-0800
www.saendo.com

Jeffery Keippel
Southern Arizona Endodontics
1011 North Craycroft Road, Suite 107 Tucson, AZ 85711
520-322-0800
www.saendo.com

Thomas R. Kramkowski
Southern Arizona Endodontics
1011 North Craycroft Road, Suite 107 Tucson, AZ 85711
520-322-0800
www.saendo.com

Oscar M. Pena
OMP Endodontics
1605 East River Road, Suite 151 Tucson, AZ 85718
520-299-6662
www.ompendo.com

John P. Smith
Southern Arizona Endodontics
7493 North Oracle Road, Suite 217 Tucson, AZ 85704
520-322-0800
www.saendo.com

General Dentistry

General Dentistry

Michael D. Allen
Sabino Hills Family Dentistry
9155 East Tanque Verde Road, Suite 127 Tucson, AZ 85749
520-760-6044
www.familytucsondentist.com

Lenny W. Arias
5575 East River Road, Suite 171 Tucson, AZ 85750
520-299-5122
www.sabinodental.com

Robert Z. Badalov
801 North Wilmot Road, Suite G Tucson, AZ 85711
520-745-0321
www.drrobertbadalov.com

Jacqueline R. Bennett
The Art of Dentistry
1200 North El Dorado Place, Suite C-320 Tucson, AZ 85715
520-886-3303
www.bennettdds.com

Roger C. Biede II
1238 West Orange Grove Road, Suite 102 Tucson, AZ 85704
520-797-1240
www.rogerbiededds.com

Robert C. Brei
4820 East Camp Lowell Drive Tucson, AZ 85712
520-325-9000
www.drbrei.com

James K. Brimhall
Brimhall Family Dentistry
2300 North Craycroft Road, Suite 2 Tucson, AZ 85712
520-745-1220
www.Ilovemydentaloffice.com

R. Anthony Burrows
Desert Springs Family Dentistry
7320 North La Cholla Boulevard, Suite 134 Tucson, AZ 85741
520-575-5900
www.desertspringsfamilydentistry.com

Anthony C. Caputo
Southwest Dental Anesthesia Services
4723 East Camp Lowell Drive Tucson, AZ 85712
520-571-7951
www.southwestdentalanesthesia.com

Alexa Carrara
Campbell Dental Group
3320 North Campbell Avenue, Suite 100 Tucson, AZ 85719
520-322-0600
www.campbellavedental.com

Annette Carrillo
2680 East Valencia Road, Suite 130 Tucson, AZ 85706
520-889-2747

John R. Carson
7415 East Tanque Verde Road Tucson, AZ 85715
520-514-7203
www.johnrcarsondds.com

A. Jay Citrin
5601 North Oracle Road, Suite 121 Tucson, AZ 85704
520-887-8771
www.drjaycitrin.com

Robert H. Collier
6650 North Oracle Road, Suite 120 Tucson, AZ 85704
520-297-7263
www.collierdentistry.com

Luis A. Cueva, Jr.
TMJ Disorders Orofacial Pain Center
850 North Kolb Road Tucson, AZ 85710
520-298-9186
www.jaw-pain.net

William H. Daggett
4676 East Fifth Street Tucson, AZ 85711
520-323-1462

Adam R. Dalesandro Derickson & Dalesandro
762 North Country Club Road Tucson, AZ 85716
520-327-5993
www.drderickson.com

Deron M. Davenport
Davenport & Davenport Dental Practice
2300 North Craycroft Road, Suite 3 Tucson, AZ 85712
520-886-2546
www.davenportdds.com

Richard C. Davis
2777 North Campbell Avenue, Suite A Tucson, AZ 85719
520-795-9202
www.richarddavisdds.com

John A. Dehnert
Dehnert Dental 3945 East Fort Lowell Road, Suite 209 Tucson, AZ 85712
520-628-2818
www.dehnertdental.com

Jeffrey C. Derickson
Derickson & Dalesandro
762 North Country Club Road Tucson, AZ 85716
520-327-5993
www.drderickson.com

Norman P. Don
Riverwalk Dental
4015 East Paradise Falls Drive, Suite 129 Tucson, AZ 85712
520-795-1316
www.riverwalkdental.net

Phillip W. Don, Jr.
4725 East Camp Lowell Drive Tucson, AZ 85712
520-745-5301
www.phillipdondds.com

Jesse Engle
Presidio Dental
8740 North Thornydale Road, Suite 100 Tucson, AZ 85742
520-744-7388
www.presidiodental.com

James M. Flynn
Flynn Dentistry
12470 North Rancho Vistoso Boulevard, Suite 100 Oro Valley, AZ 85755
520-575-9449
www.flynndentistry.net

Bryan R. Foulk
Foulk Famiily Dentistry
7229 North Thornydale Road, Suite 149 Tucson, AZ 85741
520-744-3480
www.foulkdental.com

Sandra W. Gibson
Gibson Dental
5445 North Kolb Road, Suite 205 Tucson, AZ 85750
520-577-7667
www.doctorgibson.com

Christopher M. Granillo
2300 North Craycroft Road, Suite 6 Tucson, AZ 85712
520-298-5556
www.granillodentistry.com

Michael A. Grossman
Grossman Dental Health
6246 East Pima Street, Suite 100 Tucson, AZ 85712
520-745-5577
www.grossmandentalhealth.com

R. Todd Haft
Northridge Dental
16215 North Oracle Road Tucson, AZ 85739
520-825-2195
www.northridgedentalaz.com

Kevin R. Haley
Cañada Hills Dental
10325 North La Cañada Drive, Suite 181 Tucson, AZ 85737
520-877-3234
www.canadahillsdental.com

Kathrine Hammel
Hammel Dentistry
6026 East Grant Road Tucson, AZ 85712
520-647-2888
www.hammeldentistry.com

Eric C. Hardy
Dental Care on Golf Links
8975 East Golf Links Road Tucson, AZ 85730
520-886-6054
www.dcgl.org

Sonia S. Hariri C
raycroft Dental Care
1840 North Craycroft Road Tucson, AZ 85712
520-886-2822
www.shariridds.com

Hurley R. Harrell
2710 North Campbell Avenue Tucson, AZ 85719
520-795-2882
www.harrelldent.com

Robert F. Hawke
1575 North Swan Road, Suite 200 Tucson, AZ 85712
520-441-2004
www.drhawke.com

Jess Haymore
1830 East Innovation Park Drive Oro Valley, AZ 85755
520-297-2514
www.innovationdentalov.com

Robert P. Hohenstein
Hohenstein & Schwartz
2512 East Vistoso Commerce Loop Road Oro Valley, AZ 85755
520-797-4844
www.hsdentistry.com

Jared J. Kahl
Dental Care on Golf Links
8975 East Golf Links Road Tucson, AZ 85730
520-886-6054
www.dentalcaretucson.com

F. Timothy Leong
Bear Canyon Dentistry
8878 East Tanque Verde Road Tucson, AZ 85749
520-749-1230
www.bearcanyondentistry.com

Jeffery L. Martin
Martin – Taylor Dentistry
7350 East Speedway Boulevard, Suite 201 Tucson, AZ 85711
520-747-9024
www.Martin-TaylorDentistry.com

Shawn M. McFarland
6828 East Broadway Boulevard Tucson, AZ 85710
520-296-8549
www.dentistsintucson.com

Carol A. McGonigle
1802 East Prince Road Tucson, AZ 85719
520-323-3186
www.carolmcgonigle.com

LeeAat Mednick
Dehnert Dental
3945 East Fort Lowell Road, Suite 209 Tucson, AZ 85712
520-628-2818
www.dehnertdental.com

Jennifer Mohr
Mohr Smiles
1101 North Wilmot Road, Suite 213 Tucson, AZ 85712
520-290-8900
www.mohrsmilestucson.com

Nicholas G. Mooberry
151 Dental Care
151 West Speedway Blvd Tucson, AZ 85705
520-623-2733
www.melvindixondds.com

Philip C. Mooberry
Mooberry Dentistry 1757 North Swan Road Tucson, AZ 85712
520-795-7733
www.mooberrydentistry.com

Debra A. Oro
Oro Dental Medicine
10425 North Oracle Road, Suite 125 Oro Valley, AZ 85737
520-297-2227
www.orodental.com

Robert J. Oro
Oro Dental Medicine
10425 North Oracle Road, Suite 125 Oro Valley, AZ 85737
520-297-2227
www.orodental.com

Sharad N. Pandhi
5828 North Oracle Road, Suite 100 Tucson, AZ 85704
520-293-2166
www.smileperfectionaz.com

Adam R. Pershing
300 North Craycroft Road, Suite 4 Tucson, AZ 85712
520-722-2992
www.adamrpershingdmd.com

Michelle Romero-Chavez
Pusch Ridge Dental
180 West Magee Road, Suite 158 Oro Valley, AZ 85704
520-742-0830
www.puschridgedental.com

John H. Rosenberg, Jr.
Hillside Dental
7241 North Thornydale Road Tucson, AZ 85741
520-744-0700
www.cosmeticdentisttucson.com

Kevin M. Schmidtke
Schmidtke Dentistry
7476 North La Cholla Boulevard Tucson, AZ 85741
520-297-2727
www.kevinschmidtkedentistry.com

Gregory S. Schwartz
Hohenstein & Schwartz
2512 East Vistoso Commerce Loop Road Oro Valley, AZ 85755
520-797-4844
www.hsdentistry.com

Paul V. Spaeth
2165 West Orange Grove Road Tucson, AZ 85741
520-575-8800

David G. Spalding
7518 North La Cholla Boulevard Tucson, AZ 85741
520-887-4510

Anne E. Stolcis
Adobe Dentistry
1640 North Country Club Road Tucson, AZ 85716
520-323-9327
www.adobedentistry.com

Athena C. Storey
Studio Dental
10550 North La Cañada Drive, Suite 106 Oro Valley, AZ 85737
520-575-5576
www.studiodentalaz.com

William H. Taylor
Martin – Taylor Dentistry
7350 East Speedway Boulevard, Suite 201 Tucson, AZ 85710
520-747-9024
www.martintaylordentistry.com

Cory S. Wertz
El Rio Health Center
1500 West Commerce Court Tucson, AZ 95746
520-670-3758

Timothy G. Wilson
1751 West Orange Grove Road, Building 2 Tucson, AZ 85704
520-797-8030
www.timwilsondentistry.com

Elahe Wissinger
E Dental Solutions
2504 East River Road Tucson, AZ 85718
520-745-5496
www.edentalsolutions.net

John SooHyong Yu
SmileMore Dental
12162 North Rancho Vistoso Boulevard, Suite 140 Oro Valley, AZ 85755
520-531-8207
www.smilemoredentalaz.com

Oral and Maxillofacial Surgery

Oral and Maxillofacial Surgery

Angelle M. Casagrande
Associates in Oral & Maxillofacial Surgery
3150 North Swan Road Tucson, AZ 85712
520-745-6531
www.sazoms.com

Nicholas J. Coles
Arizona Oral & Maxillofacial Surgeons
7455 East Tanque Verde Road Tucson, AZ 85715
520-745-2454
www.azoms.com

Jerome S. Holbrook
Tucson Oral & Maxillofacial Surgery
1200 North El Dorado Place, Suite E-510 Tucson, AZ 85715
520-398-4453
www.tucsonoralsurgery.com

Caroline M. Kacer
Casas Adobes Oral & Maxillofacial Surgery
6471 North La Cholla Boulevard, Suite 101 Tucson, AZ 85741
520-742-6136
www.caosaz.com

Owen W. Kaiser
10325 North La Canada, Suite 181 Tucson, AZ 85741
520-742-6136
www.canadahillsdental.com

Daniel J. Klemmedson
Associates in Oral & Maxillofacial Surgery
3150 North Swan Road Tucson, AZ 85712
520-745-6531
www.sazoms.com

Timothy A. Lew
Associates in Oral & Maxillofacial Surgery
3150 North Swan Road Tucson, AZ 85712
520-745-6531
www.sazoms.com

Derek Miller
Associates in Oral and Maxillofacial Surgery
3150 North Swan Road Tucson, AZ 85712
520-745-6531
www.sazoms.com

Ronald C. Quintia
Southern Arizona Oral & Maxillofacial Surgery
6369 East Tanque Verde Road, Suite 230 Tucson, AZ 85715
520-290-6800
www.drquintia.com

Negin Saghafi
Arizona Oral & Maxillofacial Surgeons
7455 East Tanque Verde Road Tucson, AZ 85715
520-745-2454
www.azoms.com

John M. Schmidt
Casas Adobes Oral & Maxillofacial Surgery
6471 North La Cholla Boulevard, Suite 101 Tucson, AZ 85741
520-742-6136
www.caosaz.com

Robert S. Wood
Arizona Oral and Maxillofacial Surgeons
7455 East Tanque Verde Road Tucson, AZ 85715
520-745-2454
www.azoms.com

Orthodontics

Orthodontics

Thomas M. Blase
Blase Orthodontics
6373 East Tanque Verde Road, Suite 110 Tucson, AZ 85715
520-296-1700
www.blasebraces.com

Anthony F. Delio
Delio Orthodontics
3601 West Cortaro Farms Road, Suite 101 Tucson, AZ 85742
520-572-4244
www.delioorthodontics.com

Lindsay L. Don
Davis Pediatric Dentistry
716 North Country Club Road Tucson, AZ 85716
520-326-8516
www.tucsonkidsdentist.com

Larissa E. Freytag
Grinz Orthodontics
7488 North La Cholla Boulevard Tucson, AZ 85714
520-297-7575
www.grinzortho.com

Andrew L. Kassman
Kassman 3D Orthodontics
6700 North Oracle Road, Suite 327 Tucson, AZ 85704
520-582-9698
www.drkassman.com

Eric J. Leber
Leber Orthodontics
1647 North Alvernon Way, Suite 2 Tucson, AZ 85712
520-795-2323
www.leberortho.com

Matthew F. Linaker
Linaker Orthodontics
8070 North Oracle Road Tucson, AZ 85704
520-531-1496
www.linakerorthodontics.com

Daniel E. Pearcy
Orthodontic Specialists of Tucson
1320 West Ina Road Tucson, AZ 85704
520-742-1232
www.supersmilz.com

Yone V. Ponce
Friendly Smiles Orthodontics
1601 North Tucson Boulevard, Suite 8 Tucson, AZ 85716
520-326-1101
www.friendlysmilesortho.com

Kyle S. Rabe
Dr. Jaw Orthodontists
5747 East Fifth Street Tucson, AZ 85711
520-369-4491
www.drjaw.net

Mittida Raksanaves
Orthodontic Specialists of Tucson
1320 West Ina Road Tucson, AZ 85704
520-742-1232
www.supersmilz.com

Laura Robison-Rabe
Dr. Jaw Orthodontists
5747 East Fifth Street Tucson, AZ 85711
520-747-5297
www.drjaw.net

Andrew T. Rosen
1865 North Kolb Road Tucson, AZ 85715
520-290-0500
www.bracesbydrdrew.com

James A. Weaver
Dr. Jaw Orthodontics
5747 East Fifth Street Tucson, AZ 85711
520-747-5297
www.drjaw.net

Pediatric Dentistry

Pediatric Dentistry

Priya Y. Abramian
Tucson Smiles Pediatric Dentistry
5920 North La Cholla Boulevard, Suite 110 Tucson, AZ 85741
520-544-4171
www.tucsonsmilesaz.com

Norman J. Bunch
Northwest Children’s Dentistry
7610 North La Cholla Boulevard Tucson, AZ 85741
520-544-8522
www.nwkidsdds.com

Adam Davis
Davis Pediatric Dentistry
750 East Pusch View Lane, Suite 150 Oro Valley, AZ 85737
520-365-1118
www.tucsonkidsdentist.com

Charles “Chad” Davis, Jr.
Davis Pediatric Dentisty
716 North Country Club Road Tucson, AZ 85716
520-326-8516
www.tucsonkidsdentist.com

Charles A. Davis, Sr.
Davis Pediatric Dentisty
716 North Country Club Road Tucson, AZ 85716
520-326-8516
www.tucsonkidsdentist.com

Laila B. Hishaw
Tucson Smiles Pediatric Dentistry
5920 North La Cholla Boulevard, Suite 110 Tucson, AZ 85741
520-544-4171
www.tucsonsmilesaz.com

Lauren Hobeich
Davis Pediatric Dentistry
4566 North 1st Avenue, Suite 150 Tucson, AZ 85718
520-742-4118
www.tucsonkidsdentist.com

Michael LaCorte
8351 North Oracle Road Tucson, AZ 85704
520-297-5900
www.drlacorte.com

Kedar S. Lele
Great Grins Children’s Dentistry
3953 East Paradise Falls Drive, Suite 110 Tucson, AZ 85712
520-325-4746
www.greatgrinsdds.com

Jennifer J. Marshall
Northwest Children’s Dentistry
7610 North La Cholla Boulevard Tucson, AZ 85741
520-544-8522
www.nwkidsdds.com

Angela Wolfman
Great Grins Children’s Dentistry
3953 East Paradise Falls Drive, Suite 110 Tucson, AZ 85712
520-325-4746
www.greatgrinschildrensdentistry.com

Andrew S. Zale
El Rio Community Health Center
1500 West Commerce Court, Building 1 Tucson, AZ 85746
520-670-3909
www.elrio.org

Periodontics

Periodontics

Graig D. Brown
3148 North Swan Road Tucson, AZ 85712
520-790-2151
www.perioaz.com

Wayne K. Goodner
1751 West Orange Grove Road, Suite 101 Tucson, AZ 85704
520-742-4227
www.drgoodner.com

Brien V. Harvey
899 North Wilmot Road, Suite E2 Tucson, AZ 85711
520-745-5722
www.drharvey.info

James R. Knochel
801 North Wilmot Road, Suite E1 Tucson, AZ 85711
520-747-7944
www.knocheldds.com

Lisa A. Lear
6367 East Tanque Verde Road, Suite 210 Tucson, AZ 85715
520-577-3935
www.leardentalimplants.com

Clark R. Mackelprang
Tucson Dental Implants & Periodontics
2330 North Rosemont Boulevard, Suite A Tucson, AZ 85712
520-327-0263
www.gumsandimplants.com

Jared D. Roberts
1751 West Orange Grove Road, Suite 101 Tucson, AZ 85704
520-742-4227
www.drgoodner.com

Clyde M. Robinson III
Tucson Dental Implants & Periodontics
2330 North Rosemont Boulevard, Unit A Tucson, AZ 85712
520-327-0263
www.gumsandimplants.com

Prosthodontics

Prosthodontics

Ryan C. Farnum
Arizona Prosthodontics
7556 North La Cholla Boulevard Tucson, AZ 85741
520-323-2900
www.drfarnum.com

E. Karina Keys
Catalina Dental
8315 North Oracle Road, Suite 101 Oro Valley, AZ 85704
520-825-9305
www.catalinadental.com

Howard M. Steinberg
2385 North Ferguson Avenue, Suite 111 Tucson, AZ 85712
520-886-3030
www.tucsonsmile.com

Howard M. Steinberg 2385 North Ferguson Avenue, Suite 111 Tucson, AZ 85712 520-886-3030 www.tucsonsmile.com TL

DISCLAIMER This list is excerpted from 2018 the topDentists™ list, which includes listings for 126 dentists and specialists in the Tucson Area. For more information call 706-364-0853; write P.O. Box 970, Augusta, GA 30903; email info@usatopdentists. com or visit www.usatopdentists.com. topDentists has used its best efforts in assembling material for this list but does not warrant that the information contained herein is complete or accurate, and does not assume, and hereby disclaims, any liability to any person for any loss or damage caused by errors or omissions herein whether such errors or omissions result from negligence, accident, or any other cause. Copyright 2018 by topDentists, Augusta, GA. All rights reserved. This list, or parts thereof, must not be reproduced in any form without permission. No commercial use of the information in this list may be made without permission of topDentists. No fees may be charged, directly or indirectly, for the use of the information in this list without permission.

In Health

Seizures — What you must know.

By Anne Kellog

Seizures can be caused by something as simple as becoming dehydrated, and do not always indicate epilepsy. However, they always can be dangerous … even life threatening. We spoke with two neurologists on the subject, one of whom shares her experience of experiencing seizures as a result of a metabolic epilepsy disorder.

“A seizure  indicates abnormal brain wave activity,” according to Mateja de Leonni Stanonik Spindler, M.D, M.A., Ph.D., of Vita Medica Institute. “I liken it to a sort of ‘electrical earthquake’ in the brain,” she says. “That description speaks to what it’s like for patients with these electrical discharges.”

Seizures can vary greatly in their degree and causation. Some are barely noticeable, while others are dramatic to witness.

Dr. de Leonni notes, “The general public should understand that seizures are far more common than we are led to believe, and that the least common type we see are the stereotypical grand mal seizures (with violent muscle contractions and sometimes unconsciousness).”

Some patients develop seizures in infancy — in most cases because of an epilepsy disorder — but even people who never have had a seizure in their lives can have one.

Symptoms

Imagine you’re at Wildcat football game on a hot, sunny day, and perhaps you have consumed several beers while tailgating. You’re having a terrific time but suddenly you feel a little peculiar, start convulsing and drop to the ground. What happened? You’ve never had a seizure before, so what gives?

In many cases, a seizure can be a one-time thing or multiple seizures can occur even in a nonepileptic patient due to a combination of triggering factors.

“On a biochemical level, usually we discover there’s an imbalance between the sodium and potassium ions in the brain cells, which cause electrical abnormality between nerve cells,” Dr. de Leonni states. “Certain medications, for example, can disturb the balance of sodium, potassium, and sometimes calcium in the brain, which can bring on a seizure.

“Let’s say you get very dehydrated and don’t sleep well that night, or maybe had an infection going on — that’s a perfect storm to bring on a grand mal seizure. Those who have consistent seizures have epilepsy or an epileptic disorder, for which they often are genetically predisposed.”

An epileptic seizure can be presaged by an “aura,” or perceptual disturbance such as flashes of light or an unpleasant smell. These auras often give the patient enough warning that he has time to avoid injury.

I will ask the patient to keep a diary that includes their sleep patterns, daily diet, stress levels and any seizure activity.” — Mateja de Leonni StanonikSpindler, M.D., M.A., Ph.D.

Diagnosing the Cause of the Seizures

Dr. de Leonni gathers information as part of taking a patient history. Photo by Chris Richards

Job one for the neurologist is to help the patient reduce or even stop the seizures altogether, if possible. The neurologist will take a patient history, do a full physical workup, and perform an electroencephalogram (or EEG), to look at the brain’s electrical activity. “There are definitive signs in the brain waves that indicate to the neurologist that a seizure has occurred, or is about to occur,” Dr. de Leonni explains. “We always perform imaging tests as well, such as magnetic resonance imaging (MRI), to look at the brain’s anatomy and check for structural anomalies or scarring from a stroke or injury.”

Depending on the severity and frequency of the patient’s seizures, the neurologist may have the patient wear an EEG monitor for several days at home, or he’ll be put in the hospital and observed 24 hours a day for several days. In that way, a certain course of medication can be tried and the EEG closely monitored to see how he responds. In a patient with an epilepsy disorder who has many disruptive seizures, it may require trying several different types of medications before an optimal match is found,

“I will ask the patient to keep a diary that includes their sleep patterns, daily diet, stress levels and any seizure activity,” Dr. de Leonni notes. “Sleep, or lack thereof, is extremely important in seizure patients, so I always address sleep issues, as well as any coexisting mood disorders (i.e., anxiety or depression).

“I also check the patient history for any type of heart issues, such as any history of arrhythmia or atrial fibrillation. The heart and the brain are connected electrically, and when atrial fibrillation or arrhythmias occur in the heart, a seizure can be brought on, and vice versa. When seizures occur, the incidence of heart arrhythmias — particularly ventricular arrhythmias, the most dangerous ones — is higher, and death can be imminent.”

Seizures in Infants and Children

“Seizures that start in babies and small children — unless caused by high fever or other trigger — usually indicate they’ll have epilepsy in adulthood,” Dr. de Leonni contends. “Sometimes the child can outgrow it.

“It is believed that in some cases the area of the brain causing the childhood seizures has its etiology in abnormal development of the brain, either in utero or shortly after birth. Those areas can serve as  focal points for abnormal brain wave activity. With imaging techniques such as functional MRI, we’re better able to detect those areas and, in some cases, surgical excision of those areas can be curative. Epileptic surgery is a fairly new and very much evolving field.

“In babies who die of Sudden Infant Death Syndrome, we believe that at least half, if not the majority, actually are caused by a heart rhythm abnormality that then translates into a brain wave abnormality as well.”

Seizures in Older Adults

As one ages, shrinking of the brain is inevitable — it’s a normal part of aging. However, many seniors also suffer from chronic conditions like high blood pressure, diabetes, or high cholesterol. “That predisposes you to have hundreds or possibly thousands of transient ischemic attacks (TIAs), or mini-strokes, over time,” says Dr. de Leonni. “These TIAs leave scars in the brain that serve as foci for seizures. I have many older patients who are on medications for some or all of these ailments. There may come a time when they’ve become dehydrated, are running a fever or are stressed, and boom, they can have a seizure.

“If the patient is someone who already has had a stroke or TIAs, the likelihood of their having a seizure can be higher than 80 percent. If the patient is someone without these risk factors for stroke (such as high cholesterol, diabetes, hypertension, obesity), the percentage is probably lower.” 

Treatment

To perform an electroencephalogram (EEG), electrodes must be placed in specific locations on the scalp so brain wave activity can be monitored.

If a patient is diagnosed with epilepsy, the number and severity of their seizures, combined with test results, will dictate the medication the neurologist may choose. In the majority of those with epilepsy disorders, their seizures can be brought under control with medication and they go on to live relatively normal lives. Dr. de Leonni notes that some epilepsy disorders are typified by “intractable” seizures, meaning that medications do not bring the condition under control. In these cases, neurosurgery may be the answer, especially if the epilepsy only affects one side of the brain, such as in refractory partial epilepsy. A surgeon can remove the area of the brain that’s responsible for the seizures.

In those patients without epilepsy, a seizure can be a one-time thing, caused by specific triggering factors, such as our example of the football fan. These incidents can occur more than once.

Seizure triggers can include:

• Jet lag, sleep deprivation

• Electrolyte disturbance (usually caused by dehydration)

• Withdrawal from overuse of alcohol. Other illicit drugs also can produce seizures, such as cocaine, heroin and even marijuana, if it is ingested in toxic levels

• Some prescription meds will lower the seizure threshold, for example Tramadol (a pain management medication) and certain antibiotics to which the patient is sensitive.

• Specific foods can trigger seizures in individuals who are sensitive to them, such as honey, carbohydrates and artificial sweeteners.

Magnetic resonance imaging (MRI) allows the neurologist to look for structural abnormalities in the brain.

• Certain metabolic issues such as liver or kidney problems

• Any infection that produces high fevers

• Flashing lights — even the slight fluctuations in fluorescent lights

• For women, the changing blood levels of estrogen and progesterone right around their periods

• A drop in blood sugar below 70, and especially below 50

• Excess caffeine

In addition to medications and trigger avoidance, neurologists have a number of other less conventional methods in their arsenal to help prevent seizures, even in those with epilepsy disorder.

“We’ve discovered, especially with kids, that a ketogenic diet is very helpful in helping to abate epilepsy,” observes Dr. de Leonni. “We also counsel our adult patients that carbs can make seizures worse. High-protein diets can help even in very severe genetic seizure disorders.

“The Academy of Neurology and the FDA have approved medical marijuana as a treatment in intractable epilepsy. And we’ve even been incorporating aromatherapy with our patients. These are multifaceted and complicated issues, and they require all of our efforts to help reduce seizure incidence.”

Seizures: A First-Person Account

Louann Carnahan, D.O., is a board-certified neurologist and a fellowship-trained Epileptologist treating adult patients at the Center for Neurosciences.

Here, she shares her experience with seizures related to a unique clinical syndrome called Myoclonic Epilepsy with Ragged Red Fibers.

had my first generalized convulsive seizure when I was 17 years old, during a high school calculus test, in a classroom full of students and everything!

What is it like to have a seizure? Some people, like myself, have no warning, it’s just boom — I lost consciousness.” — Louann Carnahan, D.O.

“I took the seizure in stride, and went about my business, not too concerned about having another. The second one occurred nine months after the first while I was on a plane going to Indonesia. We were over the ocean when it struck. I was with my brother, and because he knew my history he got on the phone back home, and they got hold of a neurologist. By the time we landed in Japan, my family had arranged for a doctor to meet the plane. I spoke with a young doctor for a quick assessment, and my home neurologist already had shipped my medicine to Indonesia, so it was there when we finally arrived.

Dr. Louann Carnahan points out an area of interest on a brain scan. Photo by Kris Hanning

“The cause of my seizures is a bit more complicated than traditional epilepsy. It’s part of a syndrome of mitochondrial disorders — a systemic disorder that can affect multiple parts of the body. It is called Myoclonic Epilepsy with Ragged Red Fibers, or MERRF syndrome. Ragged Red Fibers pertains to the microscopic muscle cell appearance, and it causes weakness and nervous system issues that started to affect me a few years later when I was beginning medical school.

“A doctor asked me later if I’d ever had any jerks or twitches in my arms, and I’d actually had them all the time since I was 14. That is textbook for my kind of epilepsy, and those were myoclonic seizures, which is a common presentation.

“What is it like to have a seizure? Some people, like myself, have no warning, it’s just boom — I lost consciousness. My classmates and, later, the people on the plane, witnessed my stiffening and convulsions. Seizures by their classical definition, are very short — a couple of minutes or less on average.

“Relatively speaking, I’m very lucky that I’ve had only three seizures in my life. My third one occurred during medical school the morning of an exam! I woke up on the floor, and discovered I was on the phone with my classmate. He knew I was in the habit of sleeping in, so he had called to make sure I made it to the test. I was confused and had a huge headache, I’d bitten the inside of my mouth pretty badly, and all I could think was, “I’ve got to get to that test! I did end up passing it….

“So I ended up back in the neurologist’s office in a new city. He was the first physician to put together that my epilepsy syndrome was consistent with the myoclonic type.

“I got on the proper medication, have had no further arm jerks or generalized convulsions, and I’ve passed my 12-year anniversary of being seizure-free.

“The Center for Neuroscience treats both children and adults, but I am an adult neurologist. Treatments are the same for kids and adults, and seizure activity is the same in terms of the electrical storm in the brain … it’s the same pathophysiology.

“The majority of patients, 65-70 percent, can be controlled with medication if they take it as prescribed, and follow up with their doctor. I’d say successful treatment relies half on medical treatment and half on self care of the patient. Many times, the struggle is the patient being noncompliant. In my own situation, the seizure I had in medical school led me to realize how very disruptive my epilepsy was. I couldn’t drive for six months, and I hated that. So, I finally complied, and took my meds.

“Symptomatic management and treatment of epilepsy is largely the same as it has been: medications and Vagus nerve stimulation.

Deep Brain Stimulation modulation recently has been approved in the U.S.; it was approved in Europe going on 10 years, but wasn’t FDA approved. They had Deep Brain Stimulation for intractable movement disorders such as Parkinson’s, but the approval never crossed over to the area of epilepsy. Experts are still learning the correct amount of stimulation for epilepsy, so this is still on the horizon for generalized use.

“Quite honestly, I’ve never looked on the epilepsy part of my condition as a disability. I just take my pill and forget about it.

“Statistically speaking, the majority of patients who are controlled go on to live normal lives.

“There are triggers that can cause a breakthrough seizure, such as sleep deprivation, stress (the top two triggers), illness or running out of meds. Lifestyle management is important.

“The seizures were what sparked my interest in neurology. I already had an interest in becoming a doctor and thought I wanted to become a surgeon, but during my med student rotations when I got to neurology I loved it!

“The other side of my condition, the Ragged Red Fibers, started manifesting early in medical school, and that causes a visible, physical disability from muscle weakness. I’ve had to use electric mobility aids. When I started my clinical rotations, my legs were too weak to walk the entire distances. It has been a challenge, and I’ve been fortunate that my advisors and co-workers have been willing to work with me to develop accommodations for my muscle weakness, such as electric scooters. I was introduced to people who understand, because I chose the field of neurology.

“My goal is that my patients return to normal life, that they’re seizure-free, able to drive and work where they wish. Understanding, education and awareness are key for patients being treated for epilepsy. When dealing with patients who won’t take their medication, I’ll ask them, ‘How much do you want to live confidently? What is it worth to you?’”

Editor’s Note:
This article is by no means meant to be an exhaustive study on, or medical advice for, seizures and epilepsy.
Readers always should obtain medical help immediately if they suffer a seizure
. 

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