In Search of ... a Connection

By David G. Jones

Researchers are working to find something that has eluded medical science for generations -- a possible link between oral disease and systemic health problems in other parts of the human body.

If that link is discovered, implications could be enormous.

Scientists at the State University of New York, Baffalo, and at the University of North Carolina in Chapel Hill are searching for a connection between periodontal disease and serious medical conditions, including heart disease and stroke. The research is being funded by a $1.2 million grant from the National Institutes of Health.

"The current studies are setting out to confirm if there's an association between periodontitis and heart disease, and if there is, to try to determine the mechanism of what might be causing the problem," says Dennis Mangan, director of infectious diseases program of the National Institute of Dental Research, a division of the U.S. Public Health Service in Bethesda, Md.

Mangan said that the research is based on different hypotheses of what may cause the problems.

"Both are controlled studies, comparing patients with periodontal disease with those who don't, with the goal of trying to find a correlation between periodontitis and myocardial infarction," Mangan says. "It will be fully another two years before the data are analyzed."
The new study involves 1,000 people who have survived a first heart attack, and 2,250 people who have never had a heart attack. Researchers will maintain contact with study participants to determine the incidence of heart attack among participants with periodontitis.
If a link can be discovered between oral health and systemic medical problems, antibiotic intervention may be possible, but probably not soon, according to one expert.

"People have spent many millions of dollars looking for a causal organism for periodontal disease, and that's been elusive," says Steve Sonis, DMD, MS, chair of Harvard School of Dental Medicine's Department of Oral Medicine and Diagnostic Sciences. "In the '70s and '80s, there was a great hope, and there's still work being done, but the probability is low, at least in the near term, that an effective vaccine can be developed."

As the studies move forward, their momentum must be tempered with scientific deliberativeness, says a California-based expert.

"We have to take this one step at time, investigate thoroughly, do good science, and see what the relationship is, if any," says Thomas J. Pallasch, DDS, MS, professor of pharmacology and periodontics at the USC School of Dentistry. "After all, this could be a case of 'much ado about nothing.' "

Sonis, echoing Pallasch's concern, says, "The major issue (in the study) is whether there's a causal relationship, or is this a coincidental incidence?"

And that's the sort of question medical science has long faced.

Medical people have for centuries wondered if dental infections could cause problems in other parts of the body, or whether coincidence was a factor. In the 18th century, Dr. Benjamin Rush, a Pennsylvania doctor and signer of the Declaration of Independence, reported that some people suffering from arthritis found relief after infected teeth were extracted.

Since 1989, several studies have found that people with periodontal disease have an increased risk of heart disease and stroke. The evidence alone did not prove cause and effect, but it did suggest that periodontal disease might increase the risk of cardiovascular disease.

And in February, the results of another study provided more tantalizing evidence. Research done in Minneapolis at the University of Minnesota, concentrated on Streptococcus sanguis, the predominant bacterium in dental plaque, considered harmless, a normal inhabitant in a healthy mouth. But the researchers found that when they mixed the bacteria with human blood in test tubes, clots formed, the pivotal event in most heart attacks and strokes. The findings were presented at a meeting of the American Association for the Advancement of Science in Philadelphia.

Periodontal disease is the No. 1 chronic infectious disease in the world, and the most common cause of tooth loss in adults. If an association between periodontal disease and other medical conditions can ever be found, it could provide a chance for both dentistry and patients to benefit directly.

"If a dentist tells patients that their periodontal disease could lead to more risk of stroke and heart attack, that would be a tremendous motivator for patients to minimize their risk of periodontal disease," Sonis says. "It would not only impact on their dental health, but on their longevity. That would be very good for dentistry and patients alike."

Even if no association is proven, the net effect of the research is already helping dentistry gain ground in the total health care industry.

"The barrier between oral health and systemic health is slowly blurring," Mangan says. "The oral dentist of yesterday is becoming an integral part of the overall health care of the individual, and the medical community is becoming more interested in what's going on in the mouth."

Asset Protection Can Be a Matter of Trust

Mouth-Watering Treatment

A pharmaceutical product designed to treat dry mouth symptoms caused by Sjogren's syndrome has been approved for marketing by the U.S. Food and Drug Administration.
Developed and produced by MGI Pharma Inc., the pills relieve the symptoms caused by Sjogren's, an autoimmune disease that damages the moisture-producing glands throughout the body, including the salivary glands in the mouth. They are available only by prescription.
Named Salagen Tablets, the pills feature as its active ingredient pilocarpine hydrochloride, a naturally occurring substance produced from the leaves of a plant grown in South America call the pilocarpus jaborandi.

Pilocarpine is a cholinergic agonist that stimulates the exocrine glands, including salivary glands, to produce more moisture. As prescribed, patients take Salagen Tablets daily. The effect of one 5 mg tablet lasts three to five hours.

Study results showed that Salagen in many patients can improve the overall feeling of dry mouth as well as improved specific symptoms of dry mouth, including: severity of dry mouth and mouth discomfort; the ability to speak, sleep and swallow food without drinking; and a decreased use if saliva substitutes.

The most common side effects related to the drug are sweating, increased urinary frequency, chills and flushing.

Salagen Tablets were introduced in 1994 to relieve dry mouth in head and neck cancer patients undergoing radiation therapy, which often damage salivary glands in addition to eradicating tumors.

An Atrocious Dental Pun

The following dental tale was sent to the Journal of the California Dental Association by longtime CDA member Dr. Marvin H. Leaf, so blame him.

A man went to his dentist because he felt something was wrong in his mouth. The dentist examined him and said, "That new upper plate I put in for you six months ago is eroding. What have you been eating?"

The man replied, "All I can think of is that about four months ago my wife made some asparagus and put some stuff on it that was delicious -- hollandaise sauce. I loved it so much that I now put it on everything -- meat, toast, fish, vegetables, everything."

"Well," said the dentist, "that's the problem. Hollandaise sauce is made with lots of lemon juice, which is highly corrosive. It has eaten away your upper plate. I'll make you a new plate, and this time, I'll use chrome."

"Why chrome?" asked the patient.

"It's simple," the dentist replied. "Everyone knows that there's no plate like chrome for the hollandaise."

After-Hours Club

Treating emergency patients after hours can be considered a fine service and an avenue toward making new, potentially long-lasting dentist-patient relationships, but that treatment requires thoughtful consideration.

Cindy L. Hutcheson, CDA, CDPMA, BS, writing in the September/October edition of The Dental Assistant, offers these guidelines:

* Make a decision. The dentist and team should decide whether they will treat patients after hours and if they will limit treatment to patients of record or accept new patients. Many loyal patients begin as emergency cases that no other dentist could or would see.

* Let others know. Specify whether emergency care is available to existing patients only or to the community in general.

* Is it an emergency? Providing 24-hour emergency care is not the same as being open for business 24 hours a day, Hutcheson writes. A true emergency is usually of sudden onset. A patient with a real emergency will appear at your instruction and not attempt to dictate a convenient time.

* Who is the person? Emergency patients should be instructed to bring photo identification and to provide the license number of the vehicle they will drive to the appointment. Explain that the police patrol the parking lot and need to be aware of the vehicle's legal presence.

* Expect payment. Most dentists and physicians charge an extra fee for after-hours work. Estimate the charge, and accept only cash or credit card. If an estimate cannot be made, instruct the patient with no credit card to bring $100 cash. If the charge is less, make change; if it is more, bill the balance.

* You have a life. Don't try to repair years of neglect at an after-hours visit. Get the patient out of pain and temporized, then schedule a new-patient visit. Explain that the emergency treatment is temporary, and stress the importance of keeping the appointment.

* Protect yourself. Never treat a patient alone. An auxiliary in the office -- preferable in the treatment area -- will safeguard against physical harm and the potential for litigation.

* Protect your patients. Arrive before the patient to make sure the parking area and door are well-lighted. After the appointment, walk the patient to the car. For safety, both doctor and staff should leave at the same time.

Getting Down to Basics

Simply put, students who decide to make a career in dentistry do so because it's a well-thought-of profession that pays well. Those aren't the only reasons, according to the results of a study published in the October 1997 issue of Journal of Dental Education, but they factor in significantly.

The study was done by Dan Zakik, DMD, MPH; Revital Gilad, DMD; and Benjamin Peretz, DMD, and was undertaken to assess the reasons for choosing dentistry as a career and to evaluate the perception of applicants and preclinical students regarding some of the aspects that characterize the dental profession.

The study group comprised 168 people and was restricted to applicants and students in the first three preclinical years of study to avoid direct contact with the clinical teachers who may be long-time practitioners and may unintentionally communicate their views and biases to the students.

"Professional standing" and "financial security" were the two dominant reasons given by both applicants and students for choosing dentistry as a career. Few participants indicated "manual skill required" and "opportunity to help people" as major reasons for entering dentistry.

As far as participants' perception of the profession, highest scores were given to "contact with people," "caring profession," "professional status," "responsible job," "be your own boss" and "financial security."

"Financial security," which was important even with the applicants, was more frequently indicated by advanced students. The authors suggest that the ambience of the dental school may change the freshmen's perception of the profession to a more money-oriented view, as compared with the relative naivete of applicants.

Not only was "helping people" not a significant motivation for embracing dentistry as a career, it bore the lowest priority. This seems to contradict the image of dentistry as a "caring profession." The authors suggest that this aspect was only marginally important in the decision-making process, while categories such as "be your own boss" and "financial security" carried more weight.

According to the authors, a basic issue is whether applicants are really aware of the nature of the profession they wish to enter. The authors suggest that a bias may exist between the perceptions of the profession prior to admission and the reality young graduates face early in their careers.

The authors suggest recruitment programs that present a realistic picture of the profession might bring forth a more serious and in-depth search for suitable candidates to dental schools.

ADA Award Entries Sought

The ADA Council on Access, Prevention and Interprofessional Relations is seeking entries for the 1998 Geriatric Oral Health Care Award and Community Preventive Dentistry Award programs. Entries for both awards programs must be postmarked by May 15.

The Geriatric Oral Health Care Award program is for any individual or organization responsible for creating or implementing an oral health care program using unique equipment, settings or innovative modes of delivery that improve the oral health of older Americans.

The first-place award winner receives $2,500, a wall plaque, and a trip to the ADA Annual Session in San Francisco. A meritorious award of $500 also may be bestowed to another entrant.

The award is sponsored by ADA through the ADA Health Foundation with the support of the Warner-Lambert Company Consumer Health Products Group.

The Community Preventive Dentistry Award program, which recognizes significant preventive dentistry projects, is for any individual or organization responsible for creating or implementing a community program concerned with some aspect of preventive dentistry. Appropriate community activities may involve members of the dental team and include school programs, programs for special populations and high-risk groups, media public information programs, and private practitioners' community education activities or treatment programs.

The award is sponsored by ADA through the ADA Health Foundation with the support of Johnson & Johnson Professional Division, a division of Johnson & Johnson Consumer Products Inc.

The first-place winner receives $2,000, a wall plaque and a trip to the ADA Annual Session in San Francisco. Three runners up will receive $300 each.

For more information on either program or to obtain entry forms, contact Jane McGinley, coordinator of Council on Access, Prevention and Interprofessional Relations programs, using the toll-free number. Ask for Ext. 2858. Or dial direct at (312) 440-2858.

Upcoming Meetings

1998
April 3-7 American Society for Laser Medicine and Surgery Annual Meeting and Courses, San Diego, Calif. (715) 845-9283
April 16-19 California Dental Association Spring Scientific Session, Anaheim, Calif. (916) 443-3382, Ext. 4470.
April 23-25 British Dental Association's National Dental Conference, Harrogate, Yorkshire, England 0171 935 0875, Ext. 286/233
April 23-26 24th Annual Meeting and Exhibition of the Society for Biomaterials, Minneapolis, Minn. (612) 927-8108
April 30 - May 2 American Academy of Periodontology's Periodontal and Restorative Conference, Chicago (312) 573-3243
May 6-10 American Association of Endodontists 55th annual session, New York (312) 266-7255, Ext. 3006
June 18-21 Infection Control in the Information Age: Access and Integration, Providence, R.I. (800) 298-6727
Sept. 11-14 Sixth Oral Health 2000 Consortium, San Diego (312) 836-9900
Sept. 16-19 American College of Prosthodontists Annual Session (800) 378-1260
Oct. 1-3 14th Annual Scientific Session of the Academy of Surgical Research (612) 927-6707
Oct. 9-13 ADA Annual Session, San Francisco (312) 440-2500
Nov. 19-21 International Dental Showcase, NEC Birmingham, U.K. 01722 335599

1999

April 8-11 California Dental Association Scientific Session, Anaheim, Calif. (916) 443-3382, Ext. 4470
April 13-17 International Dental Show, Cologne, Germany, http://www.koelnmesse.de/ids
To have a meeting included on this list, send the information to Upcoming Meetings, CDA Journal, P.O. Box 13749, Sacramento, CA 95853 or fax the information to (916) 443-2943.