Periodontics & Dental Implants Blog

Perio treatment reduces medical bills for diabetics
By Rabia Mughal, Contributing Editor Dr Bicuspid

April 9, 2012 — Medical costs are significantly lower for people with diabetes who receive treatment for periodontal disease, according to a new study presented at the American Association for Dental Research annual meeting in Tampa, Florida.
The research, which was funded by United Concordia, found that treating periodontal disease in diabetics saved the healthcare system an average of $1,814 per patient in a single year.
Study author Marjorie Jeffcoat, DMD, professor and dean emeritus of the University of Pennsylvania dental school, presented the findings at the meeting.
“I am interested in both the efficacy and cost-effectiveness of dental care as it relates to systemic disease,” Dr. Jeffcoat told DrBicuspid.com.
Large-scale study
She and her colleagues conducted the study on a very large scale, collecting data from an insurance database that contained information on more than 1.6 million patients. Of that group, 91,454 patients had diabetes, and those are the ones the authors studied.
“Our results are robust.”
— Marjorie Jeffcoat, DMD
All study participants had Highmark medical insurance and United Concordia dental insurance.
The longitudinal study compared medical costs for diabetic subjects diagnosed with periodontal disease who received periodontal treatment (773) versus controls (60,706) who chose not to get treatment over a three-year period starting in 2007.
The average age of patients in the treatment group was 48 years; 55% were male and 45% were female. The no-treatment group was the same as the treatment group in terms of age; 53% were male and 47% were female.
The periodontal treatment group was treated for the disease in 2007 and received regular maintenance after that. The control group received incomplete periodontal therapy prior to the study and did not receive regular maintenance during the study.
At the end of the study the researchers reported that the mean number of hospital admissions for the treatment group were 5.9, while mean hospital admissions for the control group were 9. Mean medical visits in the treatment group were 16.4 compared to 19 in the control group.
Hospitalizations and physician visits were reduced by 33% and 13%, respectively, in the subjects who received periodontal care when compared to controls, noted the authors.
In addition, medical costs were reduced by $1,814 per subject per year, with mean medical costs for the treatment group being $5,522 compared to $7,335 for the control group.
“While savings have been previously reported, the large number of patients studied makes us quite sure of the results,” said Dr. Jeffcoat. “Our results are robust, save medical costs, and permit patients with diabetes to spend more time at work.”
Three-year follow-up
The amount of individuals’ data in this study makes it the largest of its kind and clinically significant, she added. Also of significance was the three-year follow-up period; other similar studies did not follow their patients over such long a period of time after dental treatment, the researchers noted.
“It is really a landmark study because of its size and three-year duration,” agreed James Bramson, DDS, chief dental officer for United Concordia.
As a result of the study’s findings, United Concordia will offer UCWellness, a disease-specific program that provides 100% coverage for maintenance following periodontal treatment, certain surgical procedures that treat gum disease and removal of plaque and tartar in patients with periodontal disease. An important component of UCWellness is targeted education geared toward covered members with diabetes.
United Concordia is the first to offer this type and level of coverage to people with diabetes, noted F.G. Merkel, United Concordia president and chief operating officer.
This study is the first in a series of findings that will analyze the relationship between diabetes and other chronic diseases and conditions, such as heart disease, strokes, and pregnancy with pre-term birth, said Dr. Jeffcoat.

A common oral bacteria, Fusobacterium nucleatum, acts like a key to open a door in human blood vessels and leads the way for it and other bacteria like Escherichia coli to invade the body through the blood and make people sick, according to dental researchers at Case Western Reserve University.

Yiping Han, professor of periodontics at the Case Western Reserve School of Dental Medicine, made the discovery in her continued work with the Fusobacterium nucleatum bacterium, one of the most prevalent of the more than 700 bacteria in the mouth.

She found the gram-negative anaerobe has a novel adhesin or bonding agent she’s named FadA that triggers a cascade of signals that break the junctures in an interlocking sheath of endothelial cells on blood vessel’s surface just enough to allow F. nucleatum and other bacteria into the blood.

A description of bond-breaking process was described in the Molecular Microbiology article, “Fusobacterium nucleatum adhesin FadA binds vascular endothelial cadherin and alters endothelial integrity.”

The microbiologist at the dental school has studied the oral bacteria over the past decade and was the first to find direct evidence that linked it to preterm labor and fetal death. But its presence is found in other infections and abscesses in the brain, lungs, liver, spleen and joints.

After finding and genetically matching the oral bacteria in the fetal death, she began to unravel the mystery of how an oral bacterium can be found throughout the body and jumps the blood-brain and placental barriers that usually block disease-causing agents.

Through years of lab work, her research led to the vascular endothelial (VE)-cadherin, cell-cell junctures that link the endothelial vascular cells together on the blood vessels.

These junctures are like a hook and loop connection, but for some unknown reason when F. nucleatum invades the body through breaks in the mucous membranes of the mouth, due to injuries or periodontal disease, this particular bacterium triggers a cascade of signals that causes the hook to recede back into the endothelial cell. The oral bacterium leads the way with any other harmful invaders following along.

This “deceding” was observed by confocal microscopy when Han used cells from human umbilical cords. The researchers introduced F. nucleatum and demonstrated the VE-cadherins break on bonds on the endothelial cells and creating enough space in the endothelium for the invaders to move in.

Lab tests included introducing F. nucleatum with and without other bacteria. When E. coli alone was introduced, the bond did not break. But when F. nucleatum was introduced first, the bond broke, and the E. coli bacteria were able to move through the otherwise intact cell layers.

“This cascade knocks out the guard on duty and allows the bacteria to enter the blood and travel like a bus loaded with riders throughout the system. Whenever the F. nucleatum wants to get off the bus at the liver, brain, spleen, or another place, it does,” Han said.

When it disembarks from its ride through the blood, it begins to colonize. The colony of bacteria induces an inflammatory reaction that has a range of consequences from necrosis of tissue to fetal death.

The National Institutes of Health recommends that anyone age 45 or older consider getting tested for diabetes. However, if you answer yes to any of these items, you may be vulnerable. A fasting blood glucose test or an oral glucose tolerance test from your doctor is all it takes to measure your glucose levels.

My body mass index is 25 or higher (23 or higher for Asian Americans and 26 or higher for Pacific Islanders). Find out your BMI here.
I have a parent, brother, or sister who has diabetes.
I have had gestational diabetes while pregnant, or I gave birth to a baby weighing 9 pounds or more.
I have been told that my blood glucose levels are higher than normal.
My blood pressure is 140/90 or higher, or I have been told I have high blood pressure.
My HDL cholesterol (“good” cholesterol) is less than 35 mg/dL, or my triglyceride level is higher than 250 mg/dL.
I am physically active fewer than 3 times a week.
I have been told I have blood vessel problems affecting my heart, brain, or legs.

Dog ate your statins?
I’ve heard some pretty extraordinary excuses for not exercising, losing weight, taking medications, or practicing other heart-healthy habits. Although the reasons are often couched in some rather creative language, I’ve become adept at cutting through the veils of self-deception and steering my patients onto a more healthful path. Here are the five most common excuses I hear in my practice and how I typically respond.

1. “There’s nothing I can do to lose weight.”
The cardiologist says: In my experience, this is true for only 10 to 15% of people. These are the “fat and fit” who truly are limited by genetics. But for the majority of overweight Americans, significant weight loss is possible. Here’s the test: If you’ve lost weight before, even short-term, you can do it again and keep it off. The key to success is thinking of your new eating plan as a permanent lifestyle change rather than a temporary diet.

2. “But I eat out a lot.”
The cardiologist says: I have an overweight, diabetic friend who’s a gourmand—he likes to dine out at fancy restaurants almost every night of the week. He recently broke his leg and had to stay home for 6 weeks. Just by cooking for himself, he lost 25 pounds and reversed his diabetes. When you eat in restaurants, you forfeit control of ingredients as well as portion size. Unfortunately, my friend is back to eating out again. I tell him that if his health deteriorates, I’m breaking the other leg.

3. “I don’t have time to work out.”
The cardiologist says: I used this one a lot myself until I discovered interval training, a technique used by elite athletes that can work for anyone. It has helped me reduce my elliptical trainer workout from 45 to 20 minutes while actually increasing the benefits. Here’s what I do:

3-minute warm-up

Ten 60-second intervals ((alternating 30 seconds fast pace with 30 seconds normal pace)

Eight 30-second intervals (alternating15 seconds at an even faster pace with 15 seconds normal pace)

3-minute cool-down

Whatever your activity (walking, treadmill, elliptical machine, biking), try doing intervals. They strengthen your heart and burn more calories and fat than steady-state exercises, and they take less time. A bonus is that this kind of intense activity is good for brain health.

4. “I don’t want to take Rx meds.”
The cardiologist says: Patients often ask for natural alternatives when prescribed medication—particularly statins, which I believe are heart savers. But many “natural” supplements either are chemically derived or contain chemicals themselves. Plus, there’s less quality assurance in the manufacturing of supplements than there is with prescription medications. I’ve been prescribing statins for 20 years, and their safety record has been consistently impressive. Why experiment with something you saw advertised in a magazine or read about while surfing the Internet? Trust your doctor.

5. “I’m too old to change.”
The cardiologist says: Whenever I hear this excuse, I say, “Look around. Why are there so many 70-, 80-, and even 90-year-olds who look and feel so great?” The answer is simple: Because they exercise regularly, eat well, and follow their doctor’s advice. They’re living proof that simple changes are tremendously and instantly effective. And it’s never too late to start.

Cut Heart Disease by 92%! 28 Days to a Healthier Heart

When you look in your mouth you may see teeth that need whitening, but a dentist may see signs of heart disease. A study published in the Journal of Dental Research found that many dental problems can be signs of serious health complications. University of Washington School of Dentistry professor Philippe P. Hujoel, DDS, PhD, says the sugar and carbohydrates in food, known as “fermentable carbohydrates,” are to blame. Found in sugary drinks, snack foods like potato chips, and simple grains like white bread and corn, these carbs are fermented by bacteria in your mouth, which produces the acids that cause tooth decay. “Those dental diseases are a marker for an unhealthy diet, and an unhealthy diet may predict future health complications,” Dr. Hujoel notes.

#1: Obesity
“If a kid has tooth decay and cavities, he probably has high exposure to fermentable carbs,” Dr. Hujoel says. “He’s really having too many snacks and candy, and this may very well be the kid that ends up obese.” For adults, too, an increase in cavities could mean you’re eating too many unhealthy foods, which also puts you at risk for obesity. A dentist who knows your medical history may ask about your eating habits, but you should feel free to ask if what’s happening to your teeth might be a sign of other problems.

#2: Cardiovascular disease
The same carbs in snack foods and sugary drinks that get dentists drilling are often found in the company of unhealthy ingredients like trans fatty acids. While trans fats themselves don’t cause cavities, they’re often used in foods with high amounts of cavity-causing fermentable carbs, and they have been associated with an increase in cardiovascular disease. Whenever you can, replace processed, packaged food with fruits, vegetables, and whole grains. For those sweet treats you can’t give up, check the labels to make sure they’re trans fat free.

It’s also possible for cavities themselves to threaten your heart, if the bacteria that produce them find their way into your cardiovascular system. Bacteria associated with tooth and gum disease may also be involved in stroke, diabetes, and respiratory problems—so brush and floss every day.

#3: Diabetes
The fermentable carbohydrates in sugary drinks and snacks loaded with carbs increase your blood sugar level drastically, raising the risk of type 2 diabetes, Dr. Hujoel says. Which is one more reason to switch to a diet that produces fewer cavities. “Lifelong usage of high fermentable carbohydrates first leads to dental disease, and then, long-term, leads to other health outcomes,” Dr. Hujoel adds.

#4: Cancer
Not only does a tooth-unhealthy diet put you at risk for obesity, which is a risk factor for certain cancers, harmful lifestyle habits like smoking can produce tooth discoloration and periodontal destruction. Abnormalities in your mouth, including bleeding gums and cavities, should be a natural alarm bell, Dr. Hujoel says. So always ask your dentist if your tooth problems could point toward a wider problem.

#5: Alzheimer’s disease
In a study just published in The Journal of the American Dental Association, people who lost most of their teeth were more likely to develop dementia problems, such as Alzheimer’s disease, later on. It will take more research to clarify what the connection between tooth loss and brain health may be. But is seems that keeping your teeth as healthy possible has benefits that go far beyond your mouth.

Diabetes and the periodontal patient

What you should know about the relationship between these two conditions.
by Dr. Mark Ryder

“The relationship between diabetes and periodontitis has been well established. As other variables, such as obesity, are introduced into the equation this relationship becomes more dynamic and complex. In this excellent review, Dr. Ryder highlights some key aspects and definitions in this area. Because new information is constantly surfacing, clinicians need to stay current on the scientific literature to be able to provide optimal care. As the epidemic of obesity and diabetes escalates, so will the role of the dental clinician in overall patient care,” Dr. Peter Cabrera, Team Lead
It is now well known in the health professions and in the general media that diabetes is one of the major public health concerns in the United States. While the general prevalence of Type I (insulin dependent) diabetes has remained essentially stable over the past several decades, the incidence and prevalence of Type II (non insulin dependent) diabetes has steadily risen, with 20-25 million Americans now affected. This is argely because of changes in dietary habits, with an accompanying rise in obesity, which is a major risk factor for Type II diabetes.

While Type II diabetes has been characterized by a later onset in life, more recently, there has been an alarming increase in Type II diabetes in children, and that partially can be attributed to an increase in childhood obesity. Currently, while the prevalence of Type I diabetes is approximately 5% of all diabetes cases, the prevalence of Type II diabetes is about 95%. This dramatic increase in diabetic patients has had a major impact on dental practice, particularly when it comes to diagnosing and treating periodontal diseases.

A two-way relationship

The traditional view of diabetes and periodontal disease was as a “one-way” relationship in which poor glycemic control (blood sugar levels) in the diabetic patient went hand-in-hand with an increased severity of periodontal disease and with poorer responses to treatment. Over the past decade there has been a decrease in the prevalence of more severe forms of periodontal diseases in the United States, in part because of decreased smoking rates and better public awareness. However, the increase in the numbers of Type II diabetics, and in particular the large proportion of Type II diabetics who are not aware of their condition and have poor glycemic control, gives one pause to consider the possibility of an increase in the incidence of periodontal diseases and their accompanying management issues in the near future. Furthermore, over the past decade new insights have developed for the influence of periodontal diseases on the diabetic patient. Specifically, as one of the most common inflammatory diseases and microbial infections, periodontal diseases may have a significant influence on a diabetic patient’s glycemic control (glucose levels). Thus we have come to realize that the relationship between periodontal diseases and diabetes is a “two-way” relationship.

This article briefly summarizes the impact of this two-way relationship, as well as future directions in understanding periodontal disease and diabetes.

The influence of diabetes on periodontal diseases

Regardless of whether the dentist is dealing with a diabetic patient with Type I or Type II diabetes, the levels of glucose and control of those levels of glucose is of critical importance for the influence of diabetes on periodontitis. It is now well known that patients with either Type I or Type II diabetes have a 2.5-3.5 fold greater risk in developing periodontal diseases. This places diabetes as one of the major risk factors for the development of periodontal diseases. In addition the diabetic periodontal patient with poor glycemic control (a fasting glucose more than 125 milligrams per decaliter of blood, a non fasting glucose level more than 200 milligrams per decaliter of blood, and/or a glycosylated hemoglobin level of more than 8% of the total hemoglobin) will respond less favorably to the full range of periodontally related therapies, including subgingival debridement, soft and hard tissue periodontal surgery, and implants.

The underlying reasons for this adverse effect of diabetes on periodontal tissues include an impaired ability to combat bacterial infection, an impaired wound healing, an impaired ability to regenerate tissue, an increase in destructive inflammatory substances in the response to infection, and perhaps most importantly, the multiple damaging effects of the combination of glucose to a variety of proteins, termed advanced glycation end products (AGEs). These AGEs can cause local tissue damage by stimulating release of destructive inflammatory products, damaging the terminal circulation to the periodontal tissues, and stimulating alveolar bone resorption. As similar mechanisms of damage occurs in other parts of the body, some now consider periodontitis the sixth cardinal sign of diabetes, which also includes vision loss, kidney failure, damage to the nervous system, cardiovascular diseases and general impaired wound healing.

To prevent this chain of destructive periodontal events, it is important for the dental clinician to ensure the patient has acceptable glycemic control, particularly when performing the full range of periodontal procedures.

The influence of periodontal diseases on diabetes

In the diabetic patient, the presence of any chronic or acute infection and/or inflammatory disease can exacerbate the diabetic condition. Bacterial products and inflammatory products from diseased periodontal tissues can enter the bloodstream and induce greater insulin resistance in a variety of tissues in the body. With this impaired ability to respond to insulin to store glucose, periodontal diseases can further elevate levels of glucose and glycosylated hemoglobin. Additional support for the role of periodontal diseases in glycemic control comes from recent studies on the beneficial effects of a variety of periodontal treatments that reduce clinical periodontal inflammation, including debridement of bacterial deposits with or without antibiotics. These studies have shown that such conventional periodontal treatments can lower levels of glycosylated hemoglobin by an average of approximately 0.8%. While this number may not seem significant when compared with reductions in glycosylated hemoglobin with insulin injections for Type I diabetes, this improvement is comparable to reductions seen with many of the oral medications used in the treatment of Type II diabetes.

Future directions

While the appreciation of diabetes and periodontal diseases as a “two-way” relationship has been an important new development, with impact on all dental practices, there is probably more to this story. In particular, the mutual influence of obesity on both periodontal diseases and diabetes, making this a “three-way” relationship, has received considerable recent attention. All three conditions are linked by inflammation and infection. With the increase of the prevalence of obesity in the United States, Type II diabetes, and combinations of these conditions into metabolic syndromes, the dental practitioner will continue to play a pivotal role in both the oral health of these patients, as well as the overall health of the patient.

A bacterium that has been associated with the development of periodontal disease has been detected in colon tumors, according to new research that suggests it may set the stage for colorectal cancer (Genome Research, October 18, 2011).

Scientists at the Dana-Farber Cancer Institute and the Broad Institute found an abnormally large number of Fusobacterium in nine colorectal tumor samples, a sign that it might contribute to the disease and potentially be a key to diagnosing, preventing, and treating it. While the spike does not necessarily mean the bacterium helps cause colorectal cancer, it offers an enticing lead for further research, according to the study authors.

A confirmed connection between Fusobacterium and the onset of colorectal cancer would mark the first time any microorganism has been found to play a role in this type of cancer, which is the second-leading cause of cancer deaths in the U.S.

The discovery was made by sequencing the DNA within nine samples of normal colon tissue and nine of colorectal cancer tissue, and validated by sequencing 95 paired DNA samples from normal colon tissue and colon cancer tissue, the researchers explained. Analysis of the data turned up unusually large amounts of Fusobacterium’s signature DNA in the tumor tissue.

While the relationship — if any — between colorectal cancer and Fusobacterium is unclear, there are intriguing hints that the bacterium may play a role in the cancer, according to senior study author Matthew Meyerson, MD, PhD, co-director of the Center for Cancer Genome Discovery at Dana-Farber and a professor of pathology at Harvard Medical School. Previous studies have suggested that Fusobacterium is associated with inflammatory bowel diseases such as ulcerative colitis, which can raise people’s risk of developing colon cancer.

“At this point, we don’t know what the connection between Fusobacterium and colon cancer might be,” Meyerson stated in a news release. “It may be that the bacterium is essential for cancer growth, or that cancer simply provides a hospitable environment for the bacterium. Further research is needed to see what the link is.”

Reported by Dr Bicuspid on October 18, 2011

Oral bisphosphonates may up risk of esophageal cancer
By DrBicuspid Staff

July 21, 2011 — The U.S. Food and Drug Administration (FDA) is continuing to review data from published studies to evaluate whether the use of oral bisphosphonates is associated with an increased risk of esophageal cancer, the agency said in a safety announcementtoday.
There have been conflicting findings from studies evaluating this risk, the agency noted.

In January 2009, a case series was published describing reports submitted to the FDA of esophageal cancer in patients prescribed oral bisphosphonates (New England Journal of Medicine [NEJM], January 1, 2009, Vol. 360:1, pp. 89-90).
Since then, several epidemiological studies looking at the association between oral bisphosphonates and esophageal cancer have been published, with discrepant findings. The two largest published studies used data from the U.K.’s General Practice Research Database.
One compared the rate of esophageal cancer in patients taking an oral bisphosphonate to patients not taking an oral bisphosphonate and found no increase in the risk of esophageal cancer (Journal of the American Medical Association, August 11, 2010, Vol. 304:6, pp. 657-663).

However, using the same database, a second study found a doubling of the risk of esophageal cancer among patients who had 10 or more prescriptions of oral bisphosphonates or who had taken the drugs for three years (British Medical Journal, September 11, 2010, Vol. 341:7772).

Other investigators are researching this issue. In a large cohort of Danish patients with fractures, investigators found that bisphosphonate users (who had taken them for a median of 1.5 years) had a significantly reduced risk for esophageal cancer compared to patients with fractures who had not taken any bisphosphonate (NEJM, April 23, 2009, Vol. 360:17, pp. 1789-1792).

Longer-term follow-up of alendronate (Fosamax) users and nonalendronate users showed that alendronate users had a higher frequency of endoscopic examination of the esophagus, no greater incidence of esophageal cancer, and no increase in esophageal cancer deaths (3rd Joint Meeting of the European Calcified Tissue Society and the International Bone and Mineral Society, May 2011).

“Differences in methodologies in these studies may account for the discrepant findings,” the FDA noted. “Also, since these studies are observational rather than randomized, they are subject to bias and confounding.”

For example, it is possible that the gastrointestinal side effects of bisphosphonates increase a patient’s likelihood of undergoing an endoscopy, which could lead to earlier detection of a cancer or drug discontinuation, the agency said, adding that a present there is not enough information to make definitive conclusions about a possible association.

“At this time, FDA believes that the benefits of oral bisphosphonate drugs in reducing the risk of serious fractures in people with osteoporosis continue to outweigh their potential risks,” the FDA stated.

FDA’s review is ongoing, and the agency has not concluded that patients taking oral bisphosphonate drugs have an increased risk of esophageal cancer.
FDA will continue to evaluate all available data supporting the safety and effectiveness of bisphosphonate drugs and will update the public when more information becomes available.

What a wonderful Mother’s Day. Having my son graduate from Carolina Law and having all of my children with me for a very Special day.