It’s Sleep Apnea in Disguise
Generally, the symptoms of obstructive sleep apnea (OSA) are different in adults than they are in children1. Some of the symptoms include behavioral changes; adults with inadequate exhibit characteristics of sleepiness2, whereas children reflect hyperactivity3.One type of attention-deficit hyperactive disorder (ADHD)4 also involves an ongoing pattern of hyperactivity. Though both disorders share behavioral symptomology, there is a clear distinction between the two: OSA is a physiological disorder5, whereas ADHD is a neurobiological disorder6. Unfortunately this differentiation is not always made, and many children are following an ADHD treatment pathway, instead of a sleep-breathing disorder treatment pathway. If the child has OSA, but is treated for ADHD, then they will not only experience the ill effects of misdiagnoses—often involving prescription medication, but the OSA worsens because the underlying cause is left unaddressed7
Why is obstructive sleep apnea a big deal?
Obstructive sleep apnea8 is a respiratory disease9 that involves repeated pauses in
breathing while sleeping. Airway restriction prevents airway clearance for appropriate
gas exchange thereby causing a deficit in oxygenation and carbon dioxide elimination.
The imbalance deoxygenates the tissues10, and sets the stage for a myriad of diseases to
co-evolve. Locations of sleep apnea airway obstruction may stem from overly relaxed
throat muscle (causing snoring), disproportionally large tonsils, and adenoids (making it
hard to swallow), a small airway/nasal passages (making it hard to breathe), or an
underdeveloped jaw (making it hard to close the mouth in a balanced fashion). Wisely,
the body interprets snoring and sudden gasps11 as a direct threat, and switches the
automatic nervous system (ANS) from a state of equilibrium (parasympathetic mode)
into a continual state of “fight-or-flight” (sympathetic mode) placing the body in a state
of chronic stress12, which may explain some of the unexpected behavioral changes such
as hyperactivity13. Knowing the indicators of OSA will help determine if your child
is suffering from a respiratory disease.
Indicators of Obstructive Sleep Apnea
- Habitual snoring
- Long pauses in breathing while sleeping
- Night terrors, or sleep walking
- Hyperactivity, or inattention
- Mouth breathing (as opposed to nasal breathing)
- Restricted growth
What are the effects of untreated obstructive sleep apnea?
Oxidative stress is unsustainable. Airway obstruction places great strain on the body as a
whole and may lead to comorbid metabolic syndromes14 (MS) such as cardiovascular
disease, and type II diabetes. The interaction between OSA and MS is a recipe for
disaster. Understanding that OSA impacts the brain, heart, skin, immune system, blood
vessels, lungs, eyes, etc. will increase the immediacy for seeking treatment. For example,
the part of the brain involved in learning, thwarts cognitive function15 and lowers
academic performance. In addition, sleep apnea can alter normal growth patterns and can
contribute to childhood obesity16, as fatigued children are likely to seek carbohydraterich,
high-calorie food. A clinical sleep evaluation17 is highly recommended.
Why is misdiagnosis occurring?
There are a variety of reasons why misdiagnoses occurs. One reason may stem from the
overlapping symptomology of various disorders, as many of them are multi-factorial in
nature and therefore the root cause is not always easy to determine. A secondary cause
might simply involve the way the western medical system is set up; each type of doctor
focuses on various aspects of the body and mind, which compartmentalizes each field and
creates sub-sets of opinions, philosophies, methods, and treatments. A third reason
involves the lack-of sleep-medicine education offered in school. Unless someone
specifically goes to school with the intent of becoming a sleep doctor, they must
voluntarily advance their level of education by taking additional classes and exams
(termed as a subspecialty), otherwise they will know very little about the world of sleep
and the associated diseases and conditions. Fortunately, the medical world is waking up
to the affects of sleep-breathing disorders, and is taking active steps in learning more
about the conditions.
How can I get my child tested for obstructed sleep apnea?
The American Academy of Sleep Medicine (AASM) sets the gold standard for patient
care, and offers accredited nation-wide sleep clinic locations where you will be able to
obtain a clinical sleep assessment. You may find a nearby location by visiting:
What are the recommended treatment options for obstructive sleep apnea?
Treatment is heavily dependent on diagnosis. If your professional health care team
determines non-surgical routes are sufficient in treating your child’s OSA, then you have
the option between a CPAP (continuous positive airway pressure mask), which
mechanically pushes pressurized air to keep an airway open, or a MAS (mandibular
advancement split), which prevents the tissue of the upper airway from vibrating by
advancing the mandible forward. Together, you and your professional health team can
decide on the best option.
*Supplemental treatment includes: orofacial myofunctional therapy, yoga breathing, and
sleep hygiene. To learn more, visit: http://www.cortesadvanceddentistry.com/
To avoid unwanted outcomes of incorrect misdiagnosis, sleep-breathing specialists
strongly recommend that parents have their child take a sleep study, which will determine
if they are suffering from respiratory distress, and steer them toward the best course of
Clinic, M. (2016). Mayoclinic. Retrieved from http://www.mayoclinic.org/diseasesconditions/obstructive-sleep-apnea/home/ovc-20205684
Foundation, N. S. (2017). Sleep study for a child. Retrieved January 11, 2017, from
Owens, J. A. (2009). A clinical overview of sleep and attention-deficit/Hyperactivity
disorder in children and adolescents. , 18(2), . Retrieved from
Morin, A. (2014). A Timeline of learning and attention issues. Retrieved January 17,
2017, from https://www.understood.org/en/learning-attention-issues/getting-started/whatyou-need-to-know/a-timeline-of-learning-and-attention-issues
Thanks To the CEREC Machine, You Can Get Same Day Dental Restorations at Cortes Advanced Dentistry
Get it done. Your oral health is important, and if the slightest ailment is ignored it can snowball into a mess of problems. For instance, did you know that gum disease has been linked to:
- Chronic kidney disease
- Heart attacks
The link derives from the higher levels of bacteria caused by gum disease which can travel via your bloodstream and cause the above mentioned problems. Gum disease can also cause tooth loss.
Get Same Day Restorations at Cortes Advanced Dentistry…
Think about the convenience of it: just one visit to the dentist and you’re done. At Cortes Advanced Dentistry we use the CEREC machine for same day restorations. CEREC stands for Chair-side Economical Restoration of Esthetic Ceramics and can be used to create:
- Porcelain Veneers
Porcelain veneers are ultra-thin porcelain shells that are attached to the front of your teeth. Veneers are a great way to cosmetically enhance your smile as they look just like your natural teeth.
- Porcelain Crowns
Porcelain veneers are a great way to strengthen a damaged or decayed tooth. Porcelain crowns are often needed after a root canal, particularly bad filling or damage sustained from an injury.
Aesthetically speaking, crowns are great because they look and feel just like your natural tooth. Functionally, they can be a long-term solution that covers the entire tooth like a cap.
- Porcelain Inlays and onlays
Porcelain inlays and onlays have replaced the old amalgam fillings. Porcelain inlays and onlays are safer, stronger and better for your health than amalgam fillings.
Inlays and onlays are better for your health because they:
- Don’t contain mercury
- Cover and fill the entire tooth: with amalgam fillings there was always the chance of decay forming under the filling. This does not happen with porcelain restorations.
- Amalgam expands and contracts due to temperature changes in the mouth: amalgam fillings have been known to crack teeth. Porcelain restorations do not have this problem.
The only difference between an onlay and an inlay is the area of treatment: both are aesthetically pleasing options for oral restorations.
Get It Done in One Easy Appointment…
All you have to do is sit there, while a Cortes Advanced Dentistry dentist takes an impression of your tooth with a camera. Once the impression has been taken the restoration is prepared, designed and milled in-office.
The benefits of the CEREC machine are:
- save time: only takes one appointment
- save money: see above
- no strange unpleasant putty placed in the mouth to get a mold
- no fragile temporary cap placed while you wait for a lab to make your restoration
- a same day porcelain restoration will fit and feel like a natural tooth
Cortes Advanced Dentistry has your dentistry solution…
At Cortes Advanced Dentistry we use the latest technology in dentistry to give you the best treatment available. Whether you need porcelain restorations, are suffering from TMJ dysfunction (TMJ is temporomandibular joint) or are after general dental solutions we have the answer.
For more information on our same day porcelain restorations, or to book an appointment at our conveniently located dental practice in Manhattan, please do not hesitate to contact us.
The confusion of the two conditions overlap where they show similar symptoms, however the medicine used to treat ADHD may be exacerbating the issue!
It has been found by the Centers for Disease Control and Prevention that the diagnosis of attention hyperactivity disorder (ADHD) among children has increased dramatically over the years, as much as 22% from 2003 to 2007! But what if your child is suffering a different problem, one that is much more difficult to diagnose?
The symptoms of sleep apnea and ADHD overlap. Where children do not gain enough sleep, they become twitchy, energetic and obstinate – which results in trouble focusing, sitting still and paying attention for long periods of time; all common symptoms of ADHD.
A recent study has only proven this theory, where researchers followed 11,000 British children over a period of six years. It was found that those who were affected by breathing problems such as snoring, mouth breathing or apnea, were from 40% to 100% more likely to develop behavioral issues that resemble ADHD.
To discover more about this issue and for further reading, please click here.
At Cortes Advanced Dentistry we are committed to helping you achieve a restful night’s sleep…
If you or your children suffer from fatigue, snoring and poor concentration, you may be suffering from sleep apnea! If you feel yourself, your partner or your child may be suffering while you sleep, it is important to book an appointment at our Manhattan dental practice as soon as possible so Dr. Cortes can assess, diagnose and treat sleep apnea.
Sleep Apnea is associated with a number of potentially life-threatening diseases, including; high blood pressure, stroke, heart failure, heart attack, pulmonary hypertension, type II diabetes, depression, memory loss and numerous other health problems. This is why it is important to seek professional care as soon as possible.
The symptoms of sleep apnea…
If you, your partner or your child suffers from:
- Loud and chronic snoring
- Long pauses in breathing
- Morning headaches
- Difficulty concentrating
- Daytime sleepiness
- Waking up with a dry mouth
- Restless or fitful sleep
- Waking up feeling short of breath
- Choking, snorting, or gasping during sleep
- Moodiness, irritability, or depression
- Hyperactivity or inattention
- Developmental and growth problems
- Irritable, angry, or hostile behavior
- Breathing through the mouth instead of nose
It is possible your excessive daytime drowsiness and other issues can be linked back to your sleep patterns and ultimately, sleep apnea.
There are distinct links between the health of your teeth and your general health
We all remember our parents drilling into us that we need to brush our teeth before we go to bed. Hopefully this has engrained a strict oral hygiene routine in your life and you still have a healthy set of natural teeth that are both hygienic and look beautiful. Having hygienic teeth is not just a recommendation; it is a necessity when combatting various periodontal diseases as well as preventing general health complications. Dr Martha Cortes of Cortes Advanced Dentistry in Manhattan is here to help you advance your dental hygiene regime and improve the health of your pearly whites.
Bad oral hygiene can cause a myriad of complications in the body
By not maintaining a strict and rigorous oral health regime you are putting your body and mind at risk of various complications including:
- Heart Disease
- Bone Loss
- Rheumatoid Arthritis
- Lung Complications
- Sleep Apnea
- TMD (Temporomandibular Joint Disorder)
These are all very serious health conditions which can affect your quality of life and even cause death in some cases. Oral cancer is also another common issue which can be caused by ignorance to dental hygiene. Oral cancer can occur with symptoms such as lumps in the mouth, cheek or throat as well as tooth decay, gum bleeding and pain.
Drop the cigarettes and tobacco to increase your health
Tobacco and alcohol have been found to be common contributors to the occurrence of oral cancer. According to a recent study 42,000 people in America will be diagnosed with oral cancer or pharyngeal cancer In this year alone. Out of these 42,000 it is said that 19% of individuals will die, as oral cancer kills approximately one person every 60 minutes. Tobacco not only puts you at risk of death in more ways than one it can also compromise the overall look of your teeth including an increased risk of tooth decay and a yellowed or discolored tooth complexion.
How do I maintain my oral health?
Maintaining your oral health is relatively simple. The easiest ways to maintain or improve your dental hygiene is to brush your teeth twice a day and visit your dentist at Martha Cortes Advanced Dentistry at least twice a year. You should also refrain from using your teeth as ‘tools’ which can cause them to wear down in a similar way to grinding. If you notice anything abnormal about your teeth such as pain, crookedness or functional problems please visit our dental practice in Manhattan, New York for a check-up.
Another significant dental complication that can affect your dental health is sleep apnea
Sleep apnea is most commonly caused by an obstruction of the airway. This obstruction involves excess throat tissue blocking the airways which makes it difficult to breathe causing snoring, gasping and choking while asleep. Throat tissue can sometimes rest in the wrong position while you’re asleep due to incorrect oral posture which can be trained with the use of one of our DNA appliances. If you or someone you know has been diagnosed with sleep apnea, please don’t hesitate to contact Dr. Martha Cortes. You can also purchase a hardcover of her book to learn more about the health implications that sleep apnea can cause.
Porcelain inlays or fillings are often sought after due to the alleged toxicity of amalgam fillings
Recent studies have shown that amalgam fillings may potentially damage the body due to their high mercury content. Amalgam fillings have been used for decades as a long-lasting way to remedy the pain of cavities in the teeth. This particular type of tooth restoration is often referred to as a ‘silver filling’ and is the most cost effective option to fill in a cavity or deep crevice. However, a cheaper filling does come with a price as studies have shown that amalgam fillings can increase your mercury concentration which can cause a myriad of general health and dental complications. Here at Cortés Advanced Dentistry located in Manhattan we always want to be have high quality standards of dental health, and when it comes to amalgam fillings this means being ‘better safe than sorry’ when considering possible the side effects of these mercury-filled inlays.
What is really in an amalgam filling, inlay or onlay?
An amalgam filling is made up of various types of metal including: copper, silver tin alloy and mercury. It is a scientific fact that this type of filling releases colorless and odorless mercury vapor into the body which raises the neurotoxicity of the blood. Unfortunately it is very easy to aggravate the release of mercury vapor into the body as it can be provoked by trivial tasks such as brushing your teeth or chewing food. The side effects of mercury fillings are still under deliberation by the dental community as it hasn’t been determined if these concentrations are large enough to cause negative long-term changes within the body. If the concentration of mercury is found to be severely damaging to general health then over 100 million Americans could be suffering from the detrimental side effects of amalgam. Here at Cortés Advanced Dentistry located in Manhattan we believe in prevention rather than later treatment and that’s why we offer tooth-coloured fillings to replace amalgam fillings, after all it’s better to be safe than sorry!
Is it worth swapping my amalgam or ‘silver’ fillings for tooth-coloured fillings?
White or tooth-coloured fillings have both practical and cosmetic value. Not only do they fill in cavities in the teeth which can be painful and uncomfortable they also improve the aesthetic look of the teeth by eliminating unsightly metal. When you smile with amalgam fillings it is common to see flashes of unattractive silver which can detract from the power of your smile and decrease your confidence in front of the camera.
Have any of your patients seen a change after swapping to white inlays?
Yes. We have seen a number of patients return happier than ever about the health of their bodies after having their amalgam fillings removed. In the past our patients have raised concerns about amalgam or mercury fillings, claiming that they have suffered:
- Acid reflux
- Sweet tooth cravings
- Lack of energy and vitality
- Reduced activity of their digestive system
Once these patients had their amalgam fillings removed they experienced a total transformation of all of these problems. They experienced decreased acid reflux and cravings as well as a feeling of reinvigoration when it came to their diet, lifestyle and motivation to exercise. We also regularly receive a number of happy patients thanking us for transforming their smile that was once ridden with unsightly silver into one that is purely white and camera-ready.
A Breakthrough Technique to Treat Symptoms Relating to Breathing Problems, TMJ , Headaches and Other Common Ailments
By Dr. Mercola.
Orofacial myofunctional therapy is a profoundly useful treatment that may help treat the symptoms of a a wide variety of health issues, from opening airways to headaches, temporomandibular joint disorders (TMJ), to poor digestion, just to name a few. It may be the most profound therapy available for the treatment of mild to moderate sleep apnea, which is a pervasive problem that affects many.
Myofunctional therapy is the “neuromuscular re-education or re-patterning of the oral and facial muscles1.”
The therapy includes facial and tongue exercises and behavior modification techniques to promote proper tongue position, improved breathing, chewing, and swallowing. Proper head and neck postures are also addressed. There are good studies to substantiate that it may resolve jaw problems and orthodontic relapse working in a multi-disciplinary team.
It may also be an alternative or adjunctive treatment to facial plastic surgery, to help get rid of lines and saggy facial muscles, which is exciting. In fact, in Brazil, some myofunctional therapists work with plastic surgeons.
Joy Moeller, whom I had the good fortune of meeting as a result of an earlier interview with Carol Vander-Stoep (author of the book Mouth Matters), is a leading expert in this form of therapy in the US.
At the end of that interview with Carol, we discussed the issue of being “tongue tied,” and she happened to look into my mouth. A large population of Americans are estimated to have health problems related to poor orofacial function, and the vast majority have no idea their problems stem from the dysfunction of their mouth (primarily the tongue), breathing habit, and forward head and neck muscle function. Turns out I was one of them.
As a result, I got on a treatment plan with Joy, who is the premier expert on myofunctional therapy in the US. We’ve been doing regular Skype sessions for about the last six months, and not only am I making great progress in resolving my tongue tie, it’s had a profoundly beneficial effect on my posture and amount of deep sleep as well.
This is a “green” treatment, which your patients will love. They want this treatment because they actually have an active role in correcting the problem, which is proactive in preventing major issues and in treating orofacial myofunctional problems when they do occur.
The purpose of this article is to give you an overview of oral myology, which is the critical missing element to complete patient care. You can find a qualified therapist in your area by visiting the directory page on www.iaom.com. The interdisciplinary approach to patient wellness is important because the teeth, the bones and the muscles must work in harmony to attain occlusal stability.
The goals of oral myology are.
- Promoting a lip seal.
- Promoting a palatal tongue rest position.
- Promoting a posterior, tooth together swallow.
- Facilitating bi-lateral chewing and correct drinking.
- Keeping hands and objectives away from the face.
- Facilitating nasal breathing.
- Developing a harmonious peri-oral muscle pattern.
- Correcting dysfunctional habit patterns.
Myofunctional therapy, also called orofacial myology, is the neuromuscular re-education or re-patterning of the oral and facial muscles. It might include muscle exercises, which create a normal freeway space dimension. Therapists are trained to eliminate negative oral habits through behavior modification techniques and promote positive growth patterns. We train people to breathe through their noses if their airways are not compromised, and if the oral breathing is an acquired habit; we teach people how to properly position their tongue at rest; we teach how to chew and swallow correctly, and we emphasize the importance of proper head and neck posture patterns.
Obesity is one of the top health health concerns for Americans today. A staggering one-third of the U.S. population is affected by what is now considered a chronic disease…
In the 2013 January/February issue of General Dentistry, a feature article states that those who suffer from obesity are also at increased risk of periodontal disease.
Dr. Martha Cortes based in Manhattan, NY is an expert on recent studies…
“Researchers have known that people with gum disease also show a higher level of inflammation in their blood. Inflammation is now well known to be a risk factor for certain types of cancer, as well as heart disease, diabetes and many other health conditions.”
The studies show that individuals with obesity produce higher level of proteins, such as cytokines, which increase inflammation. Chief author of the article in General Dentistry, Charlene Krejci, DDS, MSD explains that, “These cytokines may directly injure the gum tissues or reduce blood flow to the gum tissues, thus promoting the development of gum disease.”
According to The American Academy of Periodontology an estimated 75 percent of Americans have some form of gum disease. Problems with periodontal disease constitute an array of conditions that endanger the supporting and surrounding areas at the base of teeth. A unique strain of cytokines are produced exclusively by periodontal disease unto itself, which induces an increased level of inflammatory proteins that affect the entire bloodstream. This can lead to a series of inflammatory diseases that affect the whole body.
Helping to decrease potential development of this dangerous chain reaction in her patients, Dr. Cortes offers only the latest in periodontal treatments at her Manhattan practice, Cortes Advanced Dentistry.
Only 100 qualified dentists in the United States perform LANAP™ certified periodontal Laser therapy, Dr. Cortes is proud to be one of them.
These treatments are clinically proven to be substantially more effective than traditional deep cleaning. Methods in which precision metal instruments are used kill only 60 percent of bacteria found in periodontal pockets, and surrounding areas. But by comparison, the periodontal Laser procedures used here at Cortes Advanced Dentistry will eliminate up to 99 percent of bacteria. LANAP™ Laser treatments zero in on the affected gum tissue and vaporizes it, leaving only healthy gum structure to thrive.
In the article, Samer G. Shamoon, DDS, MAGD and Spokesperson for AGD (Academy of General Dentistry) indicates that, “Whether one condition is a risk factor for another or whether one disease directly causes another has yet to be discovered.” He asserts that, “What we do know is that it’s important to visit a dentist at least twice a year so he or she can evaluate your risks for developing gum disease and offer preventive strategies.” He continues to say that, “A dentist can design a personalized program of home oral care to meet each patient’s specific needs.”
What’s most unfortunate is that this dangerous disease relationship is particularly affecting our future generation. Further data from a study conducted by Case Western Reserve University in Cleveland shows that researchers discovered “prevalence of periodontal disease among obese young adults (aged 18-34 years) was 76 percent higher than that among normal weight young adults. They also found an association between being underweight and a decreased prevalence of periodontal disease in this age group.”
At Cortes Advanced Dentistry in Manhattan, Dr. Martha Cortes can recommend a tailored oral care system for you and your family at home.
She offers exceptional general dentistry services to cater to all oral health care needs of everyone in your family. Minimizing the risk of periodontal disease means keeping up with regular brushing, flossing, rinsing to remove the daily build-up of plaque. In addition, scheduling a professional laser cleaning treatment with Dr. Martha Cortes can virtually eliminate the potential of severe periodontal related health problems in the future.
To learn more about your periodontal health and risks, or to book an appointment, visit us at Cortes Advanced Dentistry located in Manhattan, NY. We look forward to helping you and your family achieve and maintain stunningly healthy smiles.
A Japanese Dentist who pioneered the practice of snaggled-tooth smiles has formed a pop group
A dentist in Japan has for nearly two years now been providing his clients with crooked smiles – at their request! First making headlines in 2011 this procedure has since grown exponentially in popularity. So much so that the dentist who started it is offering discounts to high school students!
The dentist who pioneered the surgery formed a girl group who all have the snaggletooth look and turned the look into a true phenomenon. And even though they were not the first Japanese celebrities with crooked teeth, they certainly are the ones who have turned the look into a trend.
But it does not look like this trend will spread overseas. A survey performed in America shows that the majority of Americans would not date a person with crooked teeth. At Cortes Advanced Dentistry in Manhattan we believe in giving our patients the best in dental care and a snaggled-tooth look is definitely not the best in dental care!
At Cortes Advanced Dentistry in Manhattan we provide our patients with the best in dental care…
Our patient’s oral health is always the most important thing, which is why we believe in giving our patients all the information they require upfront so you can make an informed decision before treatment.
Your Smile is one of the greatest representations of you…
It has been proven in surveys that the overall health and look of your teeth does affect your social and work life. Poor oral health can also have psychological effect: a person with a clean, white and straight smile is much more likely to be employed than someone who has poor dental health.
There is also a health issue: crooked, uneven teeth also affects the structure of your face and the overall posture of your body. With the use of aesthetic dentistry at Cortes Advanced Dentistry in Manhattan we will be in a position to revitalize the appearance of your smile. This will enable you to have a beautiful, youthful smile.
Our oral restoration services allow you to retain that healthy looking smile without anyone noticing the difference.
The porcelain services we provide…
- Porcelain veneers:Porcelain veneers are a non-invasive dental treatment. Porcelain veneers are attached straight to the tooth’s surface and made from ceramic materials. The wonderful thing about this particular treatment is that veneers have the ability to look exactly like your natural teeth.
- Porcelain crowns:The benefits of crowns are similar to veneers in that they look just like your natural teeth. Porcelain crowns are a permanent solution to fix those seriously damaged or decayed teeth. Crowns cover the entire tooth, which helps the tooth both structurally and aesthetically.
- Porcelain inlays and onlays:A safe, non-toxic and more sustainable alternative to amalgam fillings these ceramic Inlays and Onlays are different only in which part of the mouth they treat. Both Inlays and Onlays are an aesthetically and functionally pleasing oral restoration.
At Cortes Advanced Dentistry in Manhattan we endeavor to nullify the harmful effects of oral issues that can have an impact on the body as a whole.
It has been clinically proven that sub-par dental treatment can increase the risk of disease. Your oral health is linked with the rest of your body which is why we at Cortes Advanced Dentistry in Manhattan we combine the knowledge of your dental and overall health in order to make an assessment of what your dental needs are without affecting your overall health.
For more information on our aesthetic dentistry, or to book an appointment at our Manhattan practice please do not hesitate to contact us.