Current News Relevant to Dentistry


Osteonecrosis of the Jaw


If you use a bisphosphonate medication-to prevent or treat osteoporosis (a thinning of the bones) or as part of cancer treatment therapy-you should advise your dentist. In fact, any time your health history or medications change, you should make sure the dental office has the most recent information in your patient file. Here's why:

Some bisphosphonate medications (such as Fosamax, Actonel, Boniva) are taken orally (swallowed) to help prevent or treat osteoporosis and Paget's disease of the bone. Others, such as Aredia, Bonefos, Didronel or Zometa, are administered intravenously (injected into a vein) as part of cancer therapy to reduce bone pain and hypercalcemia of malignancy (abnormally high calcium levels in the blood), associated with metastatic breast cancer, prostate cancer and multiple myeloma.

In rare instances, some individuals receiving intravenous bisphosphonates for cancer treatment have developed osteonecrosis of the jaw, a rare but serious condition that involves severe loss, or destruction, of the jawbone.

Symptoms include, but are not limited to:

  • pain, swelling, or infection of the gums or jaw
  • gums that are not healing
  • loose teeth
  • numbness or a feeling of heaviness in the jaw
  • drainage
  • exposed bone

If you receive intravenous bisphosphonates (or received them in the past year) and experience any of these or other dental symptoms, tell your oncologist and your dentist immediately.

More rarely, osteonecrosis of the jawbone has occurred in patients taking oral bisphosphonates.

Most cases of osteonecrosis of the jaw associated with bisphosphonates have been diagnosed after dental procedures such as tooth extraction; however the condition can also occur spontaneously. Also, invasive dental procedures, such as extractions or other surgery that affects the bone can worsen this condition. Patients currently receiving intravenous bisphosphonates should avoid invasive dental procedures if possible. The risk of osteonecrosis of the jaw in patients using oral bisphosphonates following dental surgery appears to be low.

Am I at Risk?

Because osteonecrosis of the jaw is rare, researchers can not yet predict who, among users, will develop it. To diagnose osteonecrosis of the jaw, doctors may use x-rays or test for infection (taking microbial cultures). Treatments for osteonecrosis of the jaw may include antibiotics, oral rinses and removable mouth appliances. Minor dental work may be necessary to remove injured tissue and reduce sharp edges of damaged bone. Surgery is typically avoided because it may make the condition worse. The consensus is that good oral hygiene along with regular dental care is the best way to lower your risk of developing osteonecrosis.

Cancer Treatment and Oral Health

Dental care is an important element of overall cancer treatment. As soon as possible after cancer diagnosis, the patient's treatment team should involve the dentist. Individuals who will undergo cancer treatment should:

  • Schedule a dental exam and cleaning before cancer treatment begins and periodically during the course of treatment.
  • Tell the dentist that he or she will be treated for cancer.
  • Discuss dental procedures, such as extractions or insertion of dental implants, with the oncologist before starting the cancer treatment.
  • Have the dentist check and adjust removable dentures as needed.
  • Tell the dentist and physician about any bleeding of the gums, or pain, or unusual feeling in the teeth or gums, or any dental infections.
  • Update a medical history record with the dentist to include the cancer diagnosis and treatments.
  • Provide the dentist and oncologist with each other's name and telephone number for consultation.
  • Maintain excellent oral hygiene to reduce the risk of infection.

Drinking Soda will Damage Teeth

Soda has emerged as one of the most significant dietary sources of acid capable of producing demineralization of tooth enamel.

There are two significant threats posed by soda. The sugar content fuels the bacteria that produce acidic by-products. Soda also exerts a profound deleterious effect by bathing the teeth in acid that also is capable of producing demineralization. Depending on the kind and brand, soda may contain carbonic, phosphoric, malic, citric and tartaric acids. The more acidic the soda, the more rapid and profound the demineralization of the enamel. Brands of soda that contain artificial sweeteners still pose a significant threat because the acid that they contain will contribute to the demineralization of enamel.

Soda is most commonly sweetened by adding sucrose or high-fructose corn syrup. This yields the equivalent of 10-12 teaspoons of sugar in the typical 12 ounce can of naturally sweetened soda. These sugars fuel the metabolism of bacteria that produce the acids which demineralize tooth enamel. The greater the exposure to these sugars, the more acid produced by the bacteria and the greater the chance of demineralization. Demineralization of the enamel of teeth will lead to the development of tooth decay.

Recently the American Academy of Pediatrics published a position paper to inform the public about the dangers posed by the ever-increasing amounts of soda consumption. Between 56%-85% of school age children consume at least one serving of soda each day. At least 20% of school age children consume a minimum of four soda servings every day.

The increase in soda consumption leads people to drink less milk. Milk contains calcium lactate, which stimulates remineralization of tooth enamel.

Toothbrushes can spread disease

Researchers have found that streptococcus, staphylococcus, influenza and herpes simplex 1, among other pathogens can survive on toothbrushes. The American Dental Association advises replacing your brush at least every three to four months. But microbes can make it their home long before then.

Bacteria and viruses on one brush can easily spread to another. Sharing your brush with someone else has been shown to cause sickness.

Bacteria prefer places that are warm, dark and moist, like a medicine cabinet, so Dr. R. Tom Glass at Oklahoma State University recommends keeping your brush out in the open near a bedroom window. Motorized brushes attract more germs. Instead use a manual brush with a small clear head. Replace it every two weeks, Dr. Glass said, or more often if you are sick. People recovering from an illness can reinfect themselves by using the same toothbrush.

Toothbrushes are the perfect environment for germs and should be replaced often.

If you can't think of a good reason to brush, floss, and seek regular dental maintenance visits to maintain a healthy mouth, how about a recent study linking periodontal disease as a contributing factor in heart disease?

A recent study by researchers at the University of Minnesota found evidence linking the bacteria found in dental plaque with the formation of blood clots which block arteries and trigger heart attacks and strokes. These findings were presented at the annual meeting of the American Association for the Advancement of Science.

A great deal is known about risk factors in heart disease, which include high blood cholesterol levels, lack of exercise, and smoking. Researchers detected evidence that a bacteria called Streptococcus sanguis (a component of dental plaque) could contribute to blocking of coronary arteries by causing blood platelets to form blood clots.

Periodontal disease (gum disease) is one of the most common infections. This initial study provides evidence of the possible link between oral health and cardiovascular health. Further research in this area is currently underway and being funded by the National Institutes of Health.

New Cold Sore Remedy

A few words about cold sores: Cold sores, also known as fever blisters, are caused by the herpes simplex virus. Once contracted, the virus can cause blister-like lesions commonly found on and around the mouth. Affected people may feel a tingling, itching or burning sensation beneath the skin's surface before the blister appears. An outbreak may be accompanied by flu-like symptoms, a low-grade fever or swollen lymph nodes in the neck. Once the cold sore heals the virus remains dormant in the body. Reoccurring episodes are common.

Abreva is a new over-the-counter medication for treating cold sores (recurrent herpes simplex labialis). This is the first drug approved by the FDA for such treatment. Prescription drugs are impractical for many cold sore sufferers. Most people have outbreaks just two or three times a year, not often enough to prompt them to seek a prescription. Furthermore prescription drugs work best at the first sign of tingling, before the blister appears. In the time it takes to make a doctor's appointment and fill a prescription, most outbreaks are well under way.

It's possible the FDA will never approve prescription cold sore treatments for over-the-counter use. In March 2000, the FDA issued a guidance paper advising the pharmaceutical industry that if antiviral agents were approved for over-the-counter sale to treat cold sores, they could be misused, resulting in a resistant strain of the herpes virus. This could jeopardize the usefulness of an entire class of agents for treatment of serious and life-threatening herpes infections.

Abreva, unlike antiviral medications, doesn't attack the virus directly, so the virus doesn't have the opportunity to mutate into a resistant strain. Instead it is believed to alter the skin cells, essentially creating a barrier that prevents the virus from doing its damage. Abreva contains docosanol, a common ingredient used to add body to lipsticks and other cosmetics.

American Dental Association Statement on Water Fluoridation Efficacy and Safety

The American Dental Association has endorsed fluoridation of community water supplies as safe and effective for preventing tooth decay for more than 40 years. Fluoride is nature's cavity fighter, occurring naturally in the earth's crust, in combination with other minerals in rocks and soil. Small amounts of fluoride occur naturally in all water sources, and varying amounts of the mineral are found in all foods and beverages. Water fluoridation is the process of adjusting the natural level of fluoride to a concentration sufficient to protect against tooth decay, a range of from 0.7 parts per million to 1.2 ppm.

"Water fluoridation has been recognized by the Centers for Disease Control and Prevention as one of the 10 great public health achievements of the 20th Century," said ADA President Richard F. Mascola, D.D.S. "Fluoride's benefits are particularly important for those Americans, especially children, who lack adequate access to dental care. It is safe, effective and by far the best bang for the nation's public health buck."

Thanks in large part to community water fluoridation, half of all children ages 5 to 17 have never had a cavity in their permanent teeth. According to the April 2000 Journal of Dental Research, the use of fluoride in the past 40 years has been the primary factor in saving some $40 billion in oral health care costs in the United States.

In addition to the ADA, nearly 100 national and international organizations recognize the public health benefits of community water fluoridation for preventing dental decay. They include the World Health Organization, the U.S. Public Health Service, the American Medical Association, the American Academy of Pediatrics, the American Academy of Family Physicians, the International Association for Dental Research, the National PTA and the American Cancer Society. And just last month, Surgeon General David Satcher wrote in his report, Oral Health in America, "Community water fluoridation is safe and effective in preventing dental caries in both children and adults. Water fluoridation benefits all residents served by community water supplies regardless of their social or economic status."

Unfortunately, despite overwhelming evidence of fluoridation's safety and efficacy, more than 100 million Americans still do not benefit from fluoridated water. The ADA, along with state and local dental societies, continues to work with federal, state and local agencies to increase the number of communities that benefit from community water fluoridation.

The ADA's policies regarding community water fluoridation are based on generally accepted scientific knowledge. This body of knowledge is based on the efforts of nationally recognized scientists who have conducted research using the scientific method, have drawn appropriate balanced conclusions based on their research findings and have published their results in refereed (peer-reviewed) professional journals that are widely held or circulated. Confirmation of scientific findings also reinforces the validity of existing studies.

Dry mouth, a common side effect of some medications, can cause serious tooth decay. Drugs used for treating depression, anxiety and hypertension are the most common sources of drug induced xerostomia (dry mouth). In the absence of saliva, which has potent antibacterial properties, bacteria in the mouth can run rampant, causing decay. Users of medications causing dry mouth have ten times the bacteria in their mouths as non-medicated people.

More than five hundred drugs list dry mouth as a potential side effect. The biggest culprits are psychiatric drugs, such as Prozac, Paxil, Zoloft, Xanax, and Valium; and blood-pressure medicines, such as Lopressor and Vasotec. Antihistamines, the new stop-smoking drug Zyban, and even some acne medications can also cause dry mouth. The effect of these drugs on the sensitive salivary glands, is to block the body's signal to produce saliva.

A study by Dr. Pappas, a professor at Tufts University School of Dental Medicine, presented at the International Association of Dental Research, reported that 170 patients on certain medications had nearly three times the rate of tooth decay as the control group. Patients who were taking psychiatric medicines such as antidepressants and antianxiety drugs had almost four times the rate of decay.

Dry mouth seems to have a higher prevalence among the aging populations. A University of Toronto study found dry mouth in twenty percent of the elderly patients it surveyed. Another study of 600 elderly Floridians found thirty-nine percent complaining of dry mouth.

Dry mouth sufferers can get relief from water, ice chips, or sugarless gum or one of several new therapeutic gums, such as Arm & Hammer and Trident Advantage. Foods that are sour or bitter can also stimulate saliva flow. Sufferers should avoid sugar, especially in the form of chewing gum and candies that are sucked on or sticky, as this exposes the teeth to bacterial attack for extended time periods. Also to be avoided are irritants such as tobacco and alcohol.

More serious dry mouth can be treated with over-the-counter or prescription saliva substitutes. A saliva-inducing drug called Saligen may be prescribed, but it has its own side effects, including excessive sweating.

The most important advice for anyone taking a medication that lists dry mouth as a side effect is to make more frequent visits to the dentist. A fluoride tooth paste and fluoride rinses are also helpful to ward off the effects of bacteria causing tooth decay.

The American diet over the last two decades has increased in the consumption of sugar by almost 30 percent. The average American now consumes more than 20 teaspoons of added sugars a day. This is twice the amount recommended by health experts. This is not only bad news for one's teeth but also for overall well-being.

By squeezing out more nutritious foods like fruits, vegetables, whole grains, and low-fat dairy products that can help to prevent disease, a high-sugar diet may be making an important contribution to health problems like osteoporosis, cancer, high blood pressure, diabetes, and heart disease. The association between high-sugar diets and tooth decay is a well-documented fact.

In recent years sugar has become a pervasive added ingredient to many processed foods. Sodas are the largest single source of added sugars at 33 percent of the total. One 12-ounce can of soda supplies 160 sweet calories, or 40 grams of sugar. Nearly a tenth of the calories consumed by American teenagers come from nutritionally empty soda. Soda has taken the place of milk and fruit juices, substituting empty calories for calcium and vitamins, which are necessary for maximum bone growth and general overall health.

A nutritionally sound diet should derive no more than 10 percent of its calories from added sugar. The average teenager derives 19 percent of calories from added sugar. Adolescents between the ages of 6 to 11 get 18 percent of their calories from added sugars.

Sugars that are naturally present in foods come along with many essential ingredients for a healthy diet. The added sugars come with nothing but empty calories. If enough added sugar calories are present, there is less room for the nutrient-rich foods that can help prevent serious chronic diseases. Two recent Harvard studies have linked diets high in sugars and refined starches to an increased risk of developing diabetes.

One should limit the amount of added sugar consumed in the diet and substitute foods that have naturally occurring ingredients with essential nutrients such as calcium, protein, and vitamins. One should not be fooled by claims of "all natural" sweeteners. Added ingredients such as brown sugar, raw sugar, fruit sugar, high-fructose corn syrup, honey, or maple syrup are treated no differently from table sugar by the body.

Despite the dramatic decline in dental caries following the widespread use of fluoridation, tooth decay remains a major public health problem. By the age of 17, 84% of US adolescents have experienced tooth decay in their permanent teeth. About 25% of children account for 80% of all decayed teeth. Disadvantaged children and adults have a higher rate of cavities than their wealthier counterparts.

The results of a recent study published in The Journal of the American Medical Association suggests that environmental lead exposure may explain the disproportionately high rate of decay among the disadvantaged. High Blood levels of lead are often found in people living in buildings with chipping and peeling paint, older outdated plumbing, and in areas of industrial pollution.

Three different mechanisms can be hypothesized concerning lead exposure and dental caries:

  1. Salivary gland function: Exposure to lead during salivary gland development may have adversely affected the ability of the gland to produce adequate amounts of saliva. Saliva has several protective properties that operate against decay.
  2. Enamel formation: Lead that is incorporated into the tooth structure before the teeth erupt into the mouth may result in defective enamel, making the teeth more susceptible to decay.
  3. Interference with fluoride in saliva: Lead, by binding to fluoride ions in saliva and plaque will reduce the preventive capacity of fluoride to remineralize tooth enamel.

This implication of this study shows the need to broaden the focus of health intervention for dental caries beyond modifying dietary habits, improving personal oral hygiene behavior, and increasing fluoride exposure to include environmental exposures to lead and possibly other factors as well.

Two new studies published in the Journal of the National Cancer Institute reinforce the ill effects of smoking.

Cigars and pipes increase the risk of lung cancer

After declining steadily from the mid-1970s to the early 1990s, the popularity of cigar smoking has recently been surging. The safe image cigars and pipes might have in some peoples minds is only delusional. A recent study shows people who smoke only cigars or cigarillos have nine times the risk of developing lung cancer as compared to nonsmokers; pipe smokers have nearly eight times the risk. In contrast, cigarette smokers have about 15 times the risk of developing lung cancer compared to nonsmokers.

The lower overall risk of lung cancer among smokers of cigars and pipes as compared with cigarette smokers might be due to lower consumption of tobacco in the former group of smokers. The risk seen in this new study are higher than those in previous reports. An editorial by Dr. Howard Koh of the Massachusetts Department of Public Health in Boston states, "these troubling conclusions clearly need confirmation in follow-up studies."

Smoking moms expose fetus to carcinogen

Analysis of the first urine from newborns shows that mothers who smoke during pregnancy expose their unborn children to a known carcinogen.

The study found that 71 percent of the newborns of mothers who smoked contained two metabolites of a carcinogen called NNK, which is found in tobacco. In contrast, these metabolites were not found in any of infants of nonsmoking mothers. NNK may induce lung cancer in smokers.

The results of this study demonstrated that uptake of NNK or its metabolites by nonsmokers begins before birth. Most women who smoke during pregnancy will continue smoking after the birth of their children, and additional exposure to tobacco smoke carcinogens will occur.

Three new products that have the potential to help in treatment of periodontal disease have recently come on the market. Each of the therapies is considered as an adjunct to scaling and root planing. The U.S. Food and Drug Administration have deemed all effective.

Two of the treatments, Atridox and Perio Chip, deliver antimicrobial agents directly to the periodontal pocket around the tooth. By placing these agents directly in the pocket a high concentration of the therapeutic agents can be delivered to the site where it is most needed.

Atridox is an antibiotic gel composed of doxycycline which is released over seven days. Perio chip is a biodegradable gelatin strip that delivers high concentrations of chlorhexidine (a product that has been used in mouthwash for fifty years) over a ten day period to the periodontal pocket.

Periostat is a pill, unlike Perio Chip and Atridox, which is composed of doxycycline hyclate. When periodontal disease occurs, the host releases large amounts of a naturally occurring enzyme called collagenase. In a healthy mouth, collagenase works to dissolve aging collagen. But in the presence of a bacterial infection, production of the enzyme is prolific. It overpowers natural inhibitors that act to keep it in check and consequently begins to destroy healthy tissue. Periostat blocks the production of collagenase and this reduces the destruction of the disease.

A patent was recently issued to Dr. Kleinberg, chairman and professor of oral biology and pathology at the School of Dental Medicine at the State University of New York. The patent is for a compound called Cavistat that will be added to toothpaste. The therapeutic effect of this product is to neutralize bacterial acids and restore calcium to the teeth.

Cavities occur when sugars from food interact with bacteria in the mouth and create acids which remove calcium phosphate from the teeth. An amino acid found in human saliva called arginine works to neutralize these acids. Cavistat combines arginine with calcium to mimic saliva's ability to neutralize acids and restore calcium to the teeth.

The product has been licensed to Ortek Technologies, which plans to begin clinical trials in the near future for Food and Drug administration approval. We will have to await the results of the clinical trials to determine how effective this product will be.

Arriving soon on a shelf at the local pharmacy and grocery store will be a new product--a gum that claims to reduce plaque and clean your teeth.

Don't be led into a false sense of security that you can revise your normal preventive oral health regime. Chewing one of these gums will not eliminate the need to floss and brush your teeth.

It is important to note that none of these new products has the approval of the FDA or the American Dental Association to be an effective, therapeutic oral hygiene product. Chewing gum of any kind can reduce plaque by increasing salivary flow which in turn lowers the acidity inside the mouth. This reduction, however, is not considered a significant therapeutic level.

These new gums contain xylitol, a natural sweetener. In Europe and Asia xylitol is marketed as a cavity fighter, but the Food and Drug Administration has not allowed this claim to be made in the United States. Several of these gums use baking soda, which acts as a mild abrasive and is believed to neutralize plaque acids. Others list chlorophyll, aloe vera, vitamin E, and dicalcium phosphate as ingredients.

The push to sell these gums is mainly a marketing gimmick and the consumer should beware. If you normally chew gum, by all means consider one of these products. If chewing gum is not something you would normally do, there is no reason to start.

A study published in the Journal of Periodontology suggests that untreated periodontal disease may account for a large share of low-weight premature births for which there is no other explanation.

The research team, composed of periodontists, obstetrician-gynecologists, and epidemiologists, emphasized that their findings, based on a detailed analysis of 124 births, were preliminary. They estimated from their findings that periodontal infection might be responsible for as much as 18 percent of the 250,000 premature babies that are born each year in the United States weighing less than 5.5 pounds .

Other bacterial infections and pneumonia have been shown to increase the risk for premature births, so it shouldn't come as too much of a surprise that periodontal infections would also place one at risk.

Any infection in pregnant women should be a concern. When periodontal disease is present, bleeding gums can release bacteria and their toxins into the bloodstream.

Rather than directly attacking the fetus, the bacteria appear to release toxins into the woman's bloodstream that reach the placenta and interfere with fetal development.

In the study the researchers concluded that, after taking other possible causes of prematurity into account, the risk of having a premature baby of low birth weight was at least 7.5 times higher for women with severe periodontal disease than it was for women with a lesser degree of periodontal infection.

Dr. Roberto Romero, chief of perinatal research for the National Institute of Child Health and Human Development, said that if periodontal disease increased the risk of prematurity by seven times, "it could be one of the most important identifiable risk factors for preterm birth," which he said occurred in 5 percent of pregnancies and cost the country 5.7 billion dollars a year.

Since periodontal disease is both identifiable and treatable, early detection can have a significant impact on the health of the mother and fetus. Preventive dental care is an important step in reducing the risk of contracting periodontal disease and establishing a healthy oral environment.

British scientists recently reported that they've developed a vaccine to prevent tooth decay.

The new vaccine is a plant-based substance that is painted on teeth and allegedly produces antibodies that prevent harmful bacteria from sticking to teeth and causing cavities. The vaccine was developed by California-based Planet Biotechnology and tested at Guy's Hospital in London.

According to the researchers, a mouth rinse was first used to reduce the levels of bacteria in the volunteers to zero. Then they applied a control, or placebo, solution to some patients and the vaccine to others. Within two months the bacteria returned to normal in the mouths of the control group while those who received the vaccine were reportedly protected for up to four months. The scientific trials were reported in the May, 1998 issue of Nature Medicine.

The initial research results appear promising, but additional long-term studies to validate the reported results will be needed. It should be noted that a variety of research endeavors have been underway to explore the possibility of developing a caries vaccine for more than twenty years. Planet Biotechnology is hoping to have the vaccine available for consumers in about four years, according to news reports.

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