Obesity and Periodontal Disease

Obese patients at higher risk of perio disease

By Rabia Mughal, Associate Editor

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February 24, 2011 -- A recent study conducted by researchers from the University of North Carolina found that dentists are interested in helping patients with serious weight issues but are afraid of offending them and appearing judgmental.

A large number of dentists would be more willing to have such discussions if obesity were definitively linked to oral disease, the study authors noted.
Now researchers from the University of Pittsburgh have found a positive association between periodontal disease and obesity, according to data from a study to be presented next month at the International Association for Dental Research (IADR) conference in San Diego.
"The prevalence of obesity is the public health challenge of our time as it can damage quality of life, boost medical costs, and is recognized as a predisposing factor to major chronic diseases ranging from cardiovascular disease to cancer," the study authors noted.
They hypothesized that the prevalence of periodontal disease would be greater in obese individuals and used electronic health records from the University of Pittsburgh School of Dental Medicine to retrospectively identify 4,537 unique individuals (2,445 female, 2,092 male, average age 54). The patient records documented weight, height, age, sex, type 2 diabetes status, and periodontal evaluation.
Periodontal disease was classified as periodontal pocketing of 4 mm or greater. Body mass index (BMI) was calculated, and patients with a BMI of 30 or higher were classified as obese, while those with a BMI below 30 were classified as nonobese.
"Statistical analysis of the retrospective data collected established that periodontal disease is more prevalent in obese individuals," the authors noted.
Systemic condition?
Obesity might represent a systemic condition influencing onset and progression of periodontal disease through the gateway of metabolic syndrome, the proinflammatory state characterized by insulin resistance and oxidative stress, in a bidirectional relationship, the researchers added.
"Obesity is an obvious national problem and is increasingly a global problem as well, affecting societies that never before were necessarily affected by obesity," study author Pouran Famili, DMD, a professor and chair of the department of periodontics and preventive dentistry at the University of Pittsburgh School of Dental Medicine, told DrBicuspid.com. "Not much has been done about it and its relation to dental issues."
While not surprising, the findings do indicate that more research regarding the relationship between obesity and periodontal disease needs to be conducted, she added.
Positive associations are repeatedly demonstrated between prevalent periodontal disease and obesity, but establishing any physiological mechanism behind this relationship will require well-designed prospective research, Dr. Famili and her colleagues concluded.
Other studies have come to similar conclusions.
Dentists in clinical practice can expect a higher prevalence of periodontal disease among obese adults, although the evidence pointing to a direct link between obesity and periodontal disease is limited, according to a recent study in the Journal of Periodontology (December 2010, Vol. 81:12, pp. 1708-1724).
"This positive association was consistent and coherent with a biologically plausible role for obesity in the development of periodontal disease," the authors of that study concluded. "However, with few quality longitudinal studies, there is an inability to distinguish the temporal ordering of events, thus limiting the evidence that obesity is a risk factor for periodontal disease or that periodontitis might increase the risk of weight gain."
Robert Genco, DDS, PhD, a distinguished professor of oral biology and microbiology at the State University of New York at Buffalo School of Dental Medicine, has conducted similar research (Journal of Periodontology, November 2005, Vol. 76:11-s, pp. 2075-2084). He noted that while there is no new information in this new study, the findings are "confirmatory."
In addition, he said, it is possible that inflammatory cytokines produced by adipose tissue could increase the inflammatory response to periodontal bacteria.
"The dentist can better understand why obese individuals may be at greater risk for periodontal disease, let the patient know this, and encourage weight loss as part of management of periodontal disease," he concluded.

For more information about periodontal disease and its treatment www.scottsdalelanap.com or www.drjamesmiller.com/lanap.html

Is Europe Preparing to Ban Amalgam?

Is Europe looking to ban dental amalgam?

By Rob Goszkowski, Assistant Editor
At present, the EC's position is that dental amalgams and various alternative materials are considered effective and safe to use, based on a 2008 assessment by the Scientific Committees on Emerging and Newly Identified Health Risks (SCENIHR) and the Scientific Committee on Health and Environmental Risks (SCHER).
February 14, 2011 -- Fresh challenges to the use of dental amalgam in Europe may arise following the release next month of a new European Commission report that is expected to recommend a phase out of amalgam. Some countries are already moving in that direction.

But in a preliminary report published online in July, Bio Intelligence Service (BIOIS) -- the French environmental and health consulting firm tasked with producing the EC report to be released in March -- recommended phasing out mercury amalgam dental restorations throughout Europe.

“There is no project aimed at banning dental amalgams so far.”
— Julie Aurnaud, European
     Commission press officer

Even so, "There is no project aiming at banning dental amalgams at the European level so far," Julie Aurnaud, press officer for the French representation of the EC, told DrBicuspid.com in an e-mail. "The commission will take a position on dental amalgams once the results are analyzed."
Currently in the EU, Denmark and Sweden have banned dental amalgam altogether, and Germany and Norway have restricted its use. The U.K. and France have done neither, although the new EC report could change France's position on the restorative material since it is already viewed unfavorably by many there, according to a recent article in the Guardian.
"France's 40,000 dentists use it less and less for two reasons: The fuss about mercury has made them cautious, but also for reasons of appearance," Michel Goldberg, spokesman for the French Dental Association, told the Guardian.
Mercury phase down
The EC has been working to reduce mercury exposure to humans since the completion of a 2005 Extended Impact Assessment by the EC's Directorate-General Environment of the Commission Services. That report contained a 20-point plan for limiting emissions, reducing supply and demand, protecting people from exposure, developing a better understanding of the problems mercury poses, and promoting international action.
More recent reports on the matter call for greater use of amalgam separators and more research into the impact of amalgam on health. BIOIS' preliminary report does acknowledge SCENIHR/SCHER's opinion that amalgam is safe. However, BIOIS also proposes a ban as a potential action and suggests that the conclusions of the SCENIHR/SCHER report could be revised and reassessed to support such a ban. It also notes the importance of taking into account information gaps highlighted in the 2008 assessment.
In its preliminary report, BIOIS weighed the potential impact of legislation banning dental amalgam on providers and patients, including costs, the life span of alternative restoratives, and environmental concerns. Ultimately, it sees caries prevention as a key strategy going forward.
BIOIS also referenced a December 2008 EC study, Options for reducing mercury use in products and applications, and the fate of mercury already circulating in society, conducted by Consultancy within Engineering, Environmental Science and Economics (COWI). According to BIOIS, COWI concluded that there is "sound basis for concluding that dental amalgam ... should be seriously considered for further restrictions."
BIOIS also believes that changing the guidelines for the exportation of elemental mercury should be considered. The EU is the world's largest exporter of mercury, and although a ban on exportation begins on March 15, 2011, an exception for medical usage exists for amalgam. There is concern that in some countries it is purchased under the guise of medical use and diverted to small-scale mining, BIOIS noted. Extending the ban to medical usage is suggested as an option, the organization concluded.

Dr. James Miller is a Family and Cosmetic Dentist located in Scottsdale, AZ.  His website is located at www.drjamesmiller.com or www.scottsdalelanap.com

Tongue Piercings: An Expensive Habit

Tongue Piercing: An Expensive Hobby

By Arthur Perry, MD, FACS

Do you have your tongue pierced? Sure, it only cost you $40, and that includes the jewelry. But in the end, it might just be the most expensive hobby you have. It turns out that the gums of people with piercings are exposed to high amounts of all sorts of bacteria, and that causes the gums in the front teeth to recede, leading to something called periodontal disease. As if that’s not enough of a problem, half of people with piercings wind up with chipped teeth, mostly in the back of the mouth. Dentistry to salvage your teeth can dwarf the cost of the initial piercing, even if you have a diamond stud.

Whether you care about the appearance of your teeth or not, piercings will eventually make your gums bleed and become sore – that’s called gingivitis. And when the roots of the teeth are exposed, they become sensitive to cold and heat and eventually lead to tooth loss.

But that’s not the only problem associated with tongue piercings. It turns out that bacteria love the channel that traverses your tongue. And these germs set up little communities called biofilms on the surface of the studs. The bugs create little fortresses that make the bacteria resistant to mouthwash and even antibiotics. Studs made of stainless steel make the best homes for these colonies of bacteria and ones made of the plastic called polypropylene make the worst. Bacteria in your mouth cause increased inflammation in your body. Many doctors think that this type of inflammation can lead to all sorts of problems, including heart disease.

So, the simple act of piercing your tongue, seemingly so cool to 17-year-olds, can lead to all sorts of dental and medical problems.

Think about this: the next time you pucker up and kiss your pierced mate, as you entwine your tongues, you will be visiting the 80 or more different species of bacteria that call that piercing “home."

Dr. James Miller is a Scottsdale Arizona Family and Cosmetic Dentistry. His website is www.drjamesmiller.com

US Regulators Call For Less Fluoride in Drinking Water

U.S. regulators call for less fluoride in drinking water

January 7, 2011 -- Americans are getting fluoride from a variety of sources that did not exist in the 1940s, when community water fluoridation first got under way. Water consumption patterns have changed too.

So, while continuing to stress the benefits of fluoride, officials from the U.S. Department of Health and Human Services (HHS) have proposed that the recommended level of fluoride in drinking water be set at the lowest end of the current optimal range to prevent tooth decay. At the same time, officials from the U.S. Environmental Protection Agency (EPA) announced they are initiating a review of the maximum amount of fluoride allowable in drinking water.
In a joint statement released January 7, officials from both agencies framed the actions as a way of maximizing the health benefits of water fluoridation to Americans by continuing to prevent tooth decay while reducing the possibility of ill effects.
"One of water fluoridation's biggest advantages is that it benefits all residents of a community -- at home, work, school, or play," said HHS Assistant Secretary for Health Howard Koh, MD, MPH, in the statement. "And fluoridation's effectiveness in preventing tooth decay is not limited to children but extends throughout life, resulting in improved oral health."
EPA Assistant Administrator for the Office of Water Peter Silva stressed that the agencies are reviewing fluoride levels in response to "the most up-to-date scientific data."
"EPA's new analysis will help us make sure that people benefit from tooth decay prevention, while at the same time avoiding the unwanted health effects from too much fluoride," he said.
Fluoride occurs naturally in drinking water, but levels vary from low to high in different regions of the U.S.
Lifestyle changes
At what are considered optimum levels, public health officials and the ADA have long promoted fluoride as a way of reducing dental caries. But research has also found that consumption at excess levels may cause fluorosis and skeletal deformities (Journal of the American Dental Association, November 2008, Vol. 139:11, pp. 1457-1468; October 2009, Vol. 140:10, pp. 1228-1236; January 2011, Vol. 142:1, pp. 79-87).
For the past 65 years, communities across the country have been supplementing naturally occurring fluoride in their water supplies to reach a level considered sufficient to promote oral health, especially among children. The fluoride level long recommended by health officials to prevent caries has been set at a range of 0.7 to 1.2 milligrams per liter (mg/L) of water. The HHS is now proposing the level be set at 0.7 mg/L of water.
The reassessment was initiated in part due to new research into changes in diet and lifestyle, as well as regional water consumption patterns seen over time, officials said. The old range was in part based upon differences in regional climate and water consumption that have become somewhat outdated with the advent of air conditioning. In addition, Americans have access to more sources of fluoride than in the past. Besides water, other sources of fluoride include dental products such as toothpaste and mouth rinses, prescription fluoride supplements, and fluoride applied by dental professionals.
The findings are also being used to guide the EPA in making a determination of whether to lower the maximum amount of fluoride allowed in drinking water. Under the Clean Water Act passed by Congress in 1974, the EPA must determine the level of contaminants in drinking water at which no adverse health effects are likely to occur. The EPA has set the maximum contaminant level goal for fluoride at 4.0 mg/L, based on the best available science to prevent potential health problems.
But in 2006, an analysis by the National Research Council concluded the EPA's drinking water standard was too high to protect against adverse health effects.
And the National Academy of Sciences reviewed new data on fluoride and issued a report recommending that EPA update its health and exposure assessments to take into account bone and dental effects and to consider all sources of fluoride.
Any formal change to the drinking water regulation would be made only after a formal proposal, public comment period, and finalization process.
As of 2008, 195.5 million Americans, or 72.4 % of the population on public water systems, had access to optimally fluoridated water, according to the most recent statistics available from the Centers for Disease Control and Prevention, which has hailed the fluoridation of drinking water as one of the 10 great public health achievements of the 20th century.
Opposition and support
In some communities, however, efforts have met continued resistance from opponents who contend that fluoridation amounts to forced medication or an unwanted intrusion of government into private life.
Fluoridation opponent Paul Connett, PhD, who heads the Fluoride Action Network, dismissed the January 7 announcement as "spin and collusion" between federal health officials and the dental establishment to continue fluoridation, which he argues is dangerous, especially to children.
"It's a stupid bloody practice," Connett said. "Once you put a medicine in the water, you can't control the dose."
The ADA commended the move by health officials to revisit fluoride guidelines and standards.
"As a science-based organization, the ADA supports the Department of Health and Human Services' recommendation," the ADA said in a statement. "This adjustment will provide an effective level of fluoride to reduce the incidence of tooth decay while minimizing the rate of fluorosis in the general population."
ADA President Raymond Gist, DDS, called the HHS recommendation "a superb example of a government agency fulfilling its mission to protect and enhance the health of the American people."
Shelly Gehshan, director of the Pew Children's Dental Campaign, praised the actions of the HHS and EPA.
"These announcements show that federal health officials are carrying out their proper role and relying on the best science to do so," she told DrBicuspid.com. "The public can feel reassured that optimally fluoridated water is a safe, effective way for people of all ages to prevent tooth decay."
The notice of the proposed recommendation will be published in the Federal Register soon, and HHS will accept comments from the public and stakeholders on the proposed recommendation for 30 days at CWFcomments@cdc.gov. HHS is expecting to publish final guidance for community water fluoridation by spring 2011.
Copyright © 2011 DrBicuspid.com
By: Mary Otto, DrBicuspid.com contributing writer
Dr. James Miller is a Scottsdale, Arizona family dentist. www.drjamesmiller.com

Medicine and Oral Health Screenings

Many physicians still resist doing oral health assessments

December 30, 2010 -- It's been 10 years since the U.S. surgeon general's report on oral health in America, which among other things advocated interdisciplinary training between medical and dental providers. But current research shows that primary medical care providers are still not comfortable performing basic oral health assessments, and many consider oral health outside their realm of practice.

"The time has arrived for each profession to recognize the benefit of coordinated treatment plans to better manage patients," Charles Cobb, DDS, PhD, professor emeritus at the University of Missouri-Kansas City School of Dentistry and co-author of a new study that used the theory of planned behavior to examine nurse practitioners' understanding of the link between periodontal disease and systemic health (Journal of Periodontology, December 2010, Vol. 81:12, pp. 1805-1813).
The researchers surveyed 200 primary care providers about practice behaviors, attitudes, opinions, and knowledge regarding the periodontal disease-systemic link and used 137 partially and fully complete questionnaires for their data analyses. Of the 137 questionnaires, 123 were completed by nurse practitioners.
Dr. Cobb and colleagues found that 22% of the respondents reported they always or routinely screen for periodontal disease. Using the theory of planned behavior -- which explains behavior as a function of intent, including such factors as attitudes, social norms, and perceived control -- they found that the likelihood of screening increased if the providers felt confident in their training (attitude), felt like it was within their scope of practice (social norm), and felt that they had control over office protocols (control).
"A change in professional and peer expectations about periodontal assessments would be an important factor in improving rates of screening," said Dr. Cobb. Limited time and concerns over reimbursement were also found to be factors.
Interdisciplinary/interprofessional education
In addition to recognizing the importance of the oral and systemic health link, primary medical care providers are being asked to assess oral health to help overcome disparities in access to care. Low-income and minority children, the elderly, people with developmental disabilities, and adults with less than a high school education are at particular risk for limited access to oral health services and a shortage of dental providers, according to the U.S. Centers for Disease Control and Prevention.
To address these disparities, health personnel who encounter patients without oral healthcare need to be able to perform simple assessments (Journal of Dental Education, May 2004, Vol. 68:5, pp. 505-512). Personnel also need to be aware of oral health resources in the community that will take patients on referral. In the case of infants and young children in the U.S., 95% have a physician but very few have a dentist, the researchers noted.
Other studies have shown that pediatric residents receive little training before completing their programs. When 661 pediatric graduating residents were surveyed in 2006, 35% of respondents stated they received no oral health training during residency (Pediatrics, August 2008, Vol. 122:2, pp. e465-e471). Of those who did receive some training, 73% had less than three hours of training and only 14% had clinical observation time with a dentist.
Similarly, a survey sent to 1,618 postresidency fellows of the American Academy of Pediatrics found that while more than 90% of pediatricians said they should examine their patients' teeth for caries and educate families about preventive oral health, in practice only 54% reported examining the teeth of more than half of their 0- to 3-year-old patients (Academic Pediatrics, November-December 2009, Vol. 9:6, pp. 457-461). In addition, the survey found that less than 25% of pediatricians had received oral health training.
Primary care training for adults fared no better. In a survey issued to incoming internal medicine trainees, 82% of the 115 respondents reported they never asked patients if they had been diagnosed with periodontal disease, and 90% reported not receiving any training about periodontal disease in medical school (J Periodontol, March 2010, Vol. 81:3, pp. 359-363). Nearly 70% reported that they were not comfortable "at all" doing a simple periodontal exam, 46% felt that discussing/screening for periodontal disease was outside their role as physicians, and 23% said they never referred patients to dentists.
"Somehow, there must be a recognition of value to doing even a 'tongue blade' visual examination of the oral cavity to determine obvious signs of inflammation," says Dr. Cobb. "Currently, such a visual examination is not part of the routine in medicine and nursing."
However, the "historic separation" of medicine and dentistry have kept the systems of education and training, financing, and service delivery separate, noted Wendy Mouradian, MD, MS, professor of pediatric dentistry and pediatrics at the University of Washington Schools of Dentistry and Medicine and co-author on the 2009 Academic Pediatrics and 2004 Journal of Dental Education papers.
"While microorganisms know no such barriers, health professional education and primary care practice lags behind today's science," she told DrBicuspid.com. "What is needed are cultural changes within medicine and dentistry and practical strategies to ensure better communication between practitioners and integration, or at least coordination, of health services."
Improving education
Efforts are under way to address these disparities. A 2003 Institute of Medicine (IOM) report, "Health Professions Education: A Bridge to Quality," concluded that all health professionals should be educated to:

• Provide patient-centered care
• Work in interdisciplinary teams
• Employ evidence-based practice
• Apply quality improvement approaches
• Utilize informatics

Using the IOM report as a guide, and as part of a study initiative called "New Models of Dental Education" funded by the Josiah Macy Jr. Foundation, three panels were convened to discuss the future of dental education. Panel 2 of the Macy Study, held in December 2006 and co-sponsored by the American Dental Education Association (ADEA) and the Association of American Medical Colleges (AAMC), discussed education and clinical training of both dentists and physicians (J Dent Educ, February 2008, Vol. 72:2 Suppl., pp. 73-85).
The panel concluded that medical providers would best be trained in oral health using a "spiral curriculum" on oral-systemic health in five key areas: caries, periodontal disease, dental public health issues, oral cancer, and the oral-systemic health relationship. Optimally, content from each of these five areas would be interspersed throughout medical training, starting in basic science courses and then reinforced at higher educational levels and in clinical rotations.
The 19th-century distinction between medicine and dentistry is becoming obsolete as the relation between oral and systemic health blurs, the Macy Panel 2 noted. To integrate new knowledge across the research literature, the panel recommended that clinicians become "sophisticated users of science and technology and avid consumers of interdisciplinary research to best implement the latest in evidence-based practice."
Building on this work, the AAMC will be mounting an effort to expand and disseminate curriculum resources available to medical schools through a cooperative agreement awarded by the Maternal and Child Health Bureau of the Health Resources and Services Administration (HRSA), Dr. Mouradian noted. This award reflects a new focus on oral health within the federal government. Both HRSA and the U.S. Department of Health and Human Services have identified the integration of oral health into primary care as strategic priorities.
"All this will take time and work," Dr. Mouradian said. "But without such efforts, we will be seriously hampered in our ability to address the profound oral health disparities identified by the surgeon general."
Copyright © 2010 DrBicuspid.com
By: Erin Archer, R.N., DrBicuspid.com contributing writer
Dr. James Miller is a Scottsdale Arizona family dentist. His website is http://www.drjamesmiller.com/

Pomegranite Mouthrinse Effective Against Plaque

December 29, 2010 -- Pomegranate mouth rinse should be explored as a long-term antiplaque rinse with prophylactic benefits, according to a new study in Quintessence International (January 2011, Vol. 42:1, pp. 29-36).

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The study authors divided 30 periodontally healthy volunteers into three groups and randomly assigned three different mouth rinses: pomegranate, chlorhexidine, or distilled water (placebo) twice daily.
The subjects' plaque index (PI) was assessed at days 0 and 5. Pomegranate extract was tested against Aggregatibacter actinomycetemcomitans (A.a.), Porphyromonas gingivalis (P.g.), and Prevotella intermedia (P.i.).
Results from the study included the following:

• Use of the pomegranate mouth rinse resulted in no adverse effects.
• There was a statistically significant difference between the chlorhexidine and placebo rinses and the pomegranate and placebo rinses, but no statistically significant difference was found between the chlorhexidine and pomegranate rinses with respect to PI.
• Pomegranate extract showed inhibition of all three strains of periodontopathogens at various concentrations.

"These results indicate that the pomegranate mouth rinse has an antiplaque effect," concluded the study authors. "Pomegranate extract is efficacious against A.a., P.g., and P.i. strains in vitro."
Copyright © 2010 DrBicuspid.com
By: DrBicuspid Staff

Dr. James Miller is a Scottsdale AZ Family dentist http://www.drjamesmiller.com/

Silver Fillings To Be Re-examined By FDA

U.S. FDA to re-examine metal dental fillings

December 10, 2010 -- WASHINGTON (Reuters) - U.S. health regulators are seeking a second opinion on whether mercury-containing dental fillings pose a risk to dental patients, especially children and pregnant women.

Food and Drug Administration officials said that while there are no new scientific findings on such silver-colored cavity fillings, it wants feedback on methods it used to weigh available data and decide last year that the metal alloy is safe.
In documents released on Friday ahead of a public meeting on the issue, the agency said it would ask its panel of outside experts to assess how much mercury dental patients are exposed to and how much exposure is acceptable.
The FDA in July 2009 declared the fillings, known as dental amalgam, posed no risk. A year earlier, it had cautioned against their use in certain more vulnerable people such as pregnant women and children, noting mercury's risks.
The agency is revisiting the issue after four groups questioned its assessment and petitioned for a second look. On Tuesday and Wednesday next week, the panel of outside experts will consider available data as well as the agency's interpretation before offering recommendations.
"Based on its own review and feedback from the panel, FDA will decide whether to make changes to its regulation," Nancy Stade, deputy director of policy for the FDA's device center, told reporters on Thursday. "At this time, the FDA is not modifying its existing recommendations to consumers."
Mercury is a known toxin, and at issue is whether the vapors released from mercury in dental fillings are enough to cause harm such as brain or kidney damage.
While some experts and advocacy groups say mounting data show a clear link between mercury and side effects and that dental fillings are no exception, industry groups and dentists say the evidence shows dental amalgam is safe.
FDA could decide to continue backing the metal fillings, again urge more cautious use, or ban the products.
The American Dental Association said earlier this month "there is no scientific reason to revisit" FDA's 2009 ruling and that the data has not changed since then.
But various groups are planning to hold protests outside the meeting and want such fillings banned. The controversial issue is also expected to draw four hours of public comments during the two-day meeting.
"Amalgam is a primitive, polluting, pre-Civil War device which no modern dentist uses," Charles Brown, the lawyer for the Consumers for Dental Choice advocacy group, told Reuters. But, he added, "we're actually pleased to see such serious questions" will be posed to the FDA's panel.
FDA released its questions to its advisers and other documents on its website at http://link.reuters.com/tyw59q.
While it now backs the fillings, FDA has changed how it regulates them. Products must carry warnings against use in poorly ventilated areas or in patients with mercury allergies.
About 50% of an amalgam contains mercury, while the rest is silver and other metals. Millions of Americans have such lower-cost fillings to patch cavities in their teeth. Other options include tooth-colored composite resins, although there is also some concern they can contain bisphenol A (BPA), a chemical used in plastics that has raised unease.
Last Updated: 2010-12-10 12:47:04 -0400 (Reuters Health)
By Susan Heavey
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By: Reuters Health