J. Peter St. Clair, DMD Blog

If you missed Part 1 and/or 2 of this series, you can find it at www.thetowncommon.com.

I have been talking the past couple weeks about the continual growing evidence that links oral and systemic disease and the need for more collaboration between dentists and physicians. All of this, of course, is in the best interest of the patient.

The discussion has been primarily about gum disease and its relationship with systemic disease. We know that the elbow bone is attached to the shoulder bone – everything is connected. In addition to the need for dentists and MD’s to collaborate more on the oral/systemic connection, we also need to collaborate better about our patient’s sleep problems.

Since I have taken an interest in screening for and treating some sleep problems, it amazes me how many people have issues with their sleep. It amazes me even more when I learn that many of these people have never even had a conversation with their doctor about sleep. However, according to experts in sleep medicine, there is room for expansion of knowledge amongst dentists and many physicians about the many types of sleep issues.

Periodontal issues and sleep are just two areas where more information should be shared between dentists and physicians. We have to be open to the fact that everything is connected and needs to be taken into consideration when we are trying to diagnose, monitor, or solve our patient’s problems.

For example, I had a patient in last week who has been a patient of mine for about 7 years. After the hygienist was done, I went into the room for the typical dentist 2-3 minute exam. I noticed in the patient’s notes that bruxism/grinding had been discussed at most hygiene appointments in the past due to the noticeable wear patterns on the patient’s teeth. There was also a quote in the notes several times stating that the patient would never wear a dental appliance at night.

As I did my exam I kept thinking to myself that there must be more to the story behind this patient’s dental issues. It happened to be around our lunch break so I asked the patient if she had a few minutes for us to talk. I photographed her teeth to compare them with photos taken 7 years ago. We talked for an hour.

Aside from learning that the patient was on 7 medications for the past SEVEN years and had never reported any of them to us, I also learned that the reason she was also resistant to wearing something to protect her teeth at night was because she had sleep issues and felt there was no way she could handle the extra stuff in her mouth. Oh…..and I learned that both of her parents are treated for sleep apnea.

So, here are some bullet highlights from the past 3 weeks:

1. Periodontal (gum) disease is bad. Just because it doesn’t hurt doesn’t mean you don’t have a problem. If you care about your general health, you must take care of your mouth.

2. Delaying taking care of dental problems always leads to more treatment and more cost.

3. Don’t leave information out when discussing your health with your doctors. Everything is important.

4. For better patient care, doctors and dentists should have more collaboration

5. Time is the most precious gift a health care provider can give their patients.

Are you one of the countless people who’s always attempting to lose “those last 10 pounds?” If so, you’ve probably tried all the usual things: eating less and moving more, adding more protein to your diet and eating lots of veggies. So, what gives? It’s one thing if you can’t lose weight because you’re not doing the right things, but it’s especially frustrating when the scale won’t budge even after you’ve put the effort in. If you can relate to this, there may be one thing you haven’t thought of – sleep apnea. It’s estimated that 22 million Americans have obstructive sleep apnea, or OSA, with 80% of them being undiagnosed! If you’d like to know more about this sneaky risk factor for weight gain, keep reading to learn more about what researchers are saying.

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If you missed Part 1 of this series, you can find it at www.thetowncommon.com.

I ended last week with a statement that I have used numerous times before – just because it doesn’t hurt doesn’t mean there isn’t a problem. We keep learning more and more about the link between the mouth and the rest of the body. It is essential that dentists and physicians do a better job at co-managing patients, and learn more about the relationship between oral and systemic disease.

It is clear that if you want to take better care of yourself, you need to take better care of your mouth. Familial history is very important. If you know of any family history of dental problems, you are at higher risk. Higher risk individuals need to be treated differently and may need a more aggressive preventive protocol to help ward off progression of disease. In addition, an otherwise healthy person who presents with a sudden increase in gum inflammation should possibly be evaluated by their physician to rule out any systemic causes if there is not a simple explanation for the change.

The connection between oral health and systemic health is well-established and ever-evolving. One thing we know for certain, we are living longer but with more chronic diseases and medication than ever before. It is exciting that there are so many things on the horizon when it comes to detection, prevention, and treatment.

Among the tools being researched to help determine the particular disease path that a person is on are salivary biomarkers. Although not routinely available yet, this precision approach to the prevention and treatment of periodontal disease accounts for variability in a person’s genes, environment, and lifestyle. Because it is more personalized to the individual, it results in more accurate treatment planning as well as improved outcomes for the patient.

Considering the aging population, periodontal (gum) disease has the potential to become the most prevalent dental disease in the near future. It is more important than ever for dentists to take the time to develop and incorporate a comprehensive periodontal examination and treatment protocol for adults.

As with most diseases, delaying the treatment of periodontal disease until the advanced stages results in treatment that is more expensive, more complex, and less predictable. Most early to moderate stage disease can be treated in a general dental office if the inflammation is easy to control and the patient doesn’t have numerous systemic issues. Otherwise, it may be in the patient’s best interest to be referred to a like-minded periodontist.

When half of the US population is still affected with periodontal disease despite decades of research and treatments, something is still missing. That missing key is a more collaborative approach involving, dentists, periodontists and physicians.

To be continued.

The connection between oral health and systemic health is well-established and ever-evolving. One thing we know for certain, we are living longer but with more chronic diseases and medication than ever before.

The latest statistics are alarming. Forty-seven percent of US adults who are age 30 or older – an estimated 64.7 million Americans – have either mild gum disease (8.7%), moderate gum disease (30%) or severe gum disease (8.5%). As the population ages, the prevalence rises with 70% of individuals over the age of 65 exhibiting some level of gum disease. And, since we are on statistics, by 2030, it is estimated that the number of people over 70 years of age will have doubled from 35 million to 71 million.

So, as we age, our risk of developing disease increases. Interestingly, there is also a direct correlation between the regions of the US with the greatest concentration of gum disease and those that have a high incidence of cardiovascular disease and diabetes. Although a direct cause-and-effect link is still in the works of being established between gum disease (periodontitis) and other systemic diseases, inflammation is often a common denominator. And, it is always important to remember that the mouth is the gateway to the rest of the body.

We used to think that if people didn’t brush their teeth well or didn’t visit a dentist often they would automatically get gum disease. However, there are patients who have poor home care who never develop gum disease, and there are also patients who have great home care and visit a dentist regularly and continue to experience breakdown from gum disease – albeit at a slower rate than they would if they had poor habits.

We now know that managing gum disease and other chronic inflammatory diseases like cardiovascular disease, diabetes, respiratory disease and arthritis are more patient specific based on an individual’s “inflammatory mediators”. These are molecules released by immune cells and are largely responsible for individual responses to disease susceptibility and progression. This is why probiotics are likely to play a significant role in treatment of chronic inflammation in the future.

As we wait for research development of different ways to combat chronic inflammation, it is without dispute that people should do all they can to minimize inflammation in the mouth. The mouth is very accessible and with proper training, coaching and monitoring, a healthy mouth is better for your whole body.

Although some may say that the associations between gum and systemic diseases are statistical by nature, not causal, the data is fairly strong that there is a link between gum disease and cardiovascular disease – such as heart infarction and stroke. This supports diagnosing and treating oral infections, including lifelong professional maintenance and good home care.

Remember – just because it doesn’t hurt doesn’t mean there isn’t a problem. More next week.

One of my dental hygienists recently informed me of a new series on the Investigation Discovery cable channel called “Deadly Dentists”. Apparently there are enough stories out there about dentists to make a series.

I looked the series up online and despite my pre-conceived notion about what the content would be, the first episode is about a dentist who is killed by his wife’s boyfriend. I’ll probably stick to watching the Bruins and hope I am never in an episode.

However, the title of the series did remind me about stories of people dying in the dental office and how important it is to be ready for medical emergencies. A couple years ago I remember a dentist who was charged in the death of a patient in Connecticut after 20 extractions and implants placed in the same visit. The patient was sedated by a method many dentists (general and specialists) use called conscious sedation. It is a very safe method of sedation that usually combines a couple of different oral medications. Since respiration can be affected with conscious sedation, it is vital to measure oxygen saturation and have the proper equipment and plan in place in case of an emergency.

It took a year for the charges to be filed against the dentist. Apparently, the Connecticut State Dental Commission initially found that the dentist was practicing within the standard of care and didn’t immediately revoke his license. The allegations now are that the dentist ignored warning signs of the patient and also ignored warnings from staff members to continue on with treatment.

Most people cannot fathom having 20 teeth pulled and implants placed all at one visit. However, it is a relatively common procedure and the service is growing. So, in case you were wondering whether the dentist was doing too much at one time, the answer is that it depends who you are doing it on.

“The commission also found that [the dentist] should not have attempted to perform so many procedures on [the patient] in one office visit given that her medical history included a heart attack six months before the visit, two strokes within the last two years and medication that could have affected her response to the sedation.”

Do we assume the dentist knew about all these circumstances that made this patient a high risk to treat? Let’s assume the patient divulged all necessary medical information. It is up to the dentist to decide whether to treat or refer to a specialist that can provide more options for sedation and monitoring of vitals. It is essential for the provider and the patient to go over medical history and concerns in detail. The best interest of the patient should be the forefront of that discussion.

This same dentist also allegedly violated care standards a year before when another patient under conscious sedation to have teeth extracted inhaled a piece of gauze that was intended to prevent things from going down the throat. The patient was rushed to the hospital and recovered.

Both of these situations are unfortunate. Many people were affected and one life was lost. While it is impossible to determine a definitive decision based on the information available, it will be important for the dentist to show proper planning and reaction to incidents.

Medical histories are very important. Make sure to report all information, including any medications and supplements. And, if you are a medically compromised person and need significant dental surgery, consider a specialist.

Patients often ask about whether there are any new technologies on the horizon, or currently in use, to help with different dental problems. There are many concepts being developed that could revolutionize the way care is delivered. My favorites are those that help prevent things, such as root canals.

Many people have felt the jolting sensation of a sharp pain in a tooth after drinking cold beverages. A tooth is made up of tubules, microscopic channels that extend from the inner layer of tooth called dentin, all the way to the center of the tooth containing the nerve. The sensation comes from the temperature travelling through open tubules, either from damaged dentin caused by decay or exposed dentin from recession of the gums.

If the sensation goes away in a split second the diagnosis is called reversible pulpitis (inflammation in the nerve of the tooth). If the pain lingers for more than a few seconds the diagnosis may be irreversible pulpitis and the treatment sometimes requires a root canal procedure to remove the damaged nerve.

Research being conducted at the University of Maryland School of Dentistry could provide dentists with a much less invasive treatment for pulpitis. Researchers are developing a new, patent-pending technique to deliver medication directly to the center of a tooth. The technique uses strong magnetic fields to move microscopic particles through the tooth’s dentin and into the pulp.

The research uses the tubules of the tooth as a vehicle to deliver medication that could reduce inflammation or treat infection. The technique would attach medication to nanoparticles. By creating the nanoparticles out of a magnetic substance, such as iron, the researchers can use a magnetic field to push those particles, and the attached medication, through the tubules and into the pulp.

Delivering steroid medication using these magnetic nanoparticles could treat inflammation in the pulp. An antibiotic could also be delivered to reduce the infection, or a local anesthetic could be used to anesthetize a tooth.

The research has shown that, even though the nanoparticles are tiny, they are able to deliver a large enough dose for medications to be effective. Studies are currently being conducted on extracted human teeth to determine the optimal size for the nanoparticles and the most effective biocompatible coating. By covering the particles with a biocompatible substance, starch for example, the body’s immune system won’t attack the nanoparticles.

Dentists have been treating inflammation of the pulp the same way for a long time, which is to remove the pulp of the tooth. When the pulp of the tooth is removed, the space the nerve occupied has to be filled with a material to prevent bacterial growth. Although effective, this devitalizes the tooth and comes with its own set of potential problems over time. These problems include a weakened tooth with a higher potential for fracture, as well as a much higher risk for recurrent infection.

This new research is a possible contemporary solution to an age-old problem. By delivering medication directly to the area of the tooth that gives the tooth its vitality, it could prevent the need for many root canals.

There are a lot of things that happen to the body during pregnancy. The oral cavity, the gateway to the rest of the body, is part of that. In a recent survey conducted by an insurance company, it was found that more than 75% of pregnant women and new mothers experience an oral health problem. The survey also found that almost half of the surveyed women did not visit the dentist during pregnancy despite having dental problems.

The researchers cited cost as one of the main reasons why pregnant women do not go to the dentist, and they found that women without dental benefits were twice as likely as those with benefits to not visit the dentist during pregnancy. However, their conclusion was that healthcare professionals may be able to increase the amount of women who prioritize oral health by simply talking to women about the importance of visiting the dentist.

It is important for pregnant women to visit the dentist because all infections, including ones in the oral cavity, may impact the health of their baby. In addition, according to the study, hormonal changes throughout pregnancy can increase the risk for periodontal disease.

I remember when I decided to go to dental school, my grandmother told me that she had all of her teeth at 82, except for the four she lost – one for each of her pregnancies. Now, I’m not sure what her frequency was back in those days of visiting a dentist, but the mere fact that she could correlate tooth loss with pregnancy always stuck in my head.

She, and the medical community, did not know back then that the risk for gum disease increased during pregnancy. We also did not know what effects this increase in inflammation did to the rest of the body, including the developing baby. We know more now.

For pregnant women, any infection, including tooth decay and gum disease, has the added possibility of affecting the baby’s health. Healthcare providers need to spend more time explaining the connection between oral health and overall wellness before, during, and after pregnancy.

While it is important to acknowledge the frequent reasons for avoiding the dentist and offer insight into overcoming potential barriers — such as providing details about what services are covered under a preventive visit and upfront communications about treatment costs for restorative services — educating about the potential consequences of failure to control dental problems should be first and foremost.

The takeaway is to “bring oral health into the conversation about overall health during preventive checkups,” the survey authors concluded. “Educating patients regarding the importance of regular dental exams, home care, and the potential impact of oral health on overall health as often as possible will have an incremental positive effect on the patient.”

It is clear from this study that cost is an issue for pregnant women (it is for the general population too) when it comes to getting dental care. If finances are the barrier, talk to your dental office to see how they can make it work for you. Don’t let lack of “insurance” be a barrier. Be an advocate for yourself. I’ll have more on this in future columns.

Last week I talked about a sometimes not so silent epidemic – sleep apnea. This week’s epidemic is much quieter but shares the general idea of decreasing the quality of life.

With more than 24 million diabetics and 57 million pre-diabetics in the United States, there are a lot of people affected by diabetes. That’s nearly a quarter of the nation’s population. The most up to date research shows the connection between dental health and diabetes has never been more critical.

As an indication of our general health, the rapidly rising rate of diabetes should be ringing alarm bells everywhere. The litany of health implications from diabetes is a long and grisly list. It is the sixth leading cause of death in the U.S. That is probably vastly understated because as many as 65% of deaths from diabetes are attributed to heart attack and stroke. People with diabetes have about twice the overall risk of death as those who don’t have the disease.

Complications from diabetes cut years off productive lives and interfere with the quality of those lives through a host of debilitating health effects. Heart disease and stroke rates are as much as four times higher among diabetics. Nearly three-quarters of diabetics have high blood pressure. Each year, diabetes causes blindness in as many as 24,000 Americans. It is the leading cause of kidney failure, nervous system disease, amputations – the list goes on.

The facts about the connections between oral health and diabetes are even more alarming than those about diabetes alone. Here are just a few:
Diabetics are twice as likely to develop gum disease. This is especially true if your diabetes is not under control. The gum disease then worsens your diabetes through an automatic response that your body uses to fight the infection.

People with gum disease are 270% more likely to suffer a heart attack than those with healthy gums.

People who have diabetes and severe gum disease have a premature death rate nearly eight times higher than those who do not have periodontal disease.

Those who have gum disease and diabetes together are more than three times more likely to die of combined heart and kidney failure.
In people who have type 2 diabetes, gum disease is a predictor of end-stage kidney disease.

In people who have pre-diabetes – blood glucose levels that are higher than normal but not in the diabetic range – gum disease makes it more likely that they will become diabetic.

Once established in a person who has diabetes, the chronic infection that causes gum disease makes it more difficult to control diabetes, and increases damage and complications in blood vessel disease.

These are simply the facts and, yes, they are sobering. If you have diabetes or are pre-diabetic, make sure you are doing all you can to control these diseases. These two diseases can twist each other into a tight downward spiral of amplifying negative health effects. Unless they are halted by your physician and your dentist working in tandem as a health care team, together with your commitment to hold up your end of the bargain, these effects can continue to compound.

Your dentist is here to address the greatest debate of our time: manual vs. electric toothbrushes. The choice between old school and new school dental care is in your hands, but do you know which is best for you? Learn more about your toothbrush options here!

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In March I completed a “mini-residency” program at Tufts in dental sleep medicine. In a nutshell, dental sleep medicine is the dentist’s participation in the treatment of sleep breathing disorders such as obstructive sleep apnea. Although the concept seemed relatively simple to me at the beginning of my journey, there is always more to the story.

About 7 years ago, I took a one-day class in dental sleep medicine. I found it intriguing how many signs and symptoms dentists see on a daily basis which could be relative to possible sleep breathing issues. For most of us, when we are “asleep”, we are unconscious and have no idea what is going on behind the scenes. However, a lot can be learned by observation and some simple questions.

The more I learned, the more I had trouble ignoring the many red flags I was seeing in patients. Wanting to delve deeper, I signed up for the program at Tufts. The program consisted of a rather intense literature review of the subject and many hours of lectures by both dentists, who have been in the field of dental sleep medicine since its start about 30 years ago, as well as sleep medicine physicians. Many sleep medicine physicians are ENTs or pulmonologists. Since the program at Tufts, I have also joined a national dental sleep medicine mentoring group to continue to learn more.

Incorporating what I have learned to help patients has been slow. Dentists and physicians don’t typically have a lot of interactions together. However, the relationship between the two is very important in the treatment of obstructive sleep apnea.

Obstructive sleep apnea is a medical problem and needs to be diagnosed by a physician. Of the many things I have observed in my short time treating patients in this arena, one thing is clear: patients do not talk to their doctors or dentists about sleep very often. Many of the issues that people live with (snoring, fatigue, grinding/clenching, hypertension, TMJ issues, etc.) deserve a conversation in relation to sleep.

When I ask patients about snoring, for example, I often hear, “I don’t think I snore but my husband/wife snores like crazy”. Just because you and/or your spouse snores, does not mean you have sleep apnea. Benign snoring is simply fluttering of soft tissue in the back of the throat with no obstruction of the airway space. However, it still is a medical diagnosis and in most cases cannot be established unless some form of sleep monitoring is done. Both sleep apnea and benign snoring are treatable….and it should be treated because it is disrupting to others.

Witnessed apnea events, on the other hand – that is a person visually and/or audibly witnesses a bed partner pause breathing during sleep – are a significant sign that there very well may be a sleep breathing disorder. Oxygen to the body may be depleted during these events. This should be discussed with your physician.

The key takeaway this week is to have a conversation with your doctor if you don’t feel you are sleeping well. If your bed partner is consistently snoring loudly or pauses breathing during sleep, have a conversation with your bed partner and decide if this is an issue which should be addressed. If there is no one sleeping in the room with you, email me and I’ll give you an app to evaluate how much noise you are making.

Sleep breathing issues are very much underdiagnosed, can be dangerous, and are very treatable. Talk to your physician and dentist about it.