Wednesday, September 16, 2009

US Health Care Debate MIsses the Point

There is little argument that the US health care model needs to be changed. But up to this moment, the arguments going on in congress make me think we are missing the boat entirely. What they are debating is changing how health care will be paid for, and how health care will be distributed. What we need is a fundamental redesign of our health care model, starting with the first day of medical school.

Considering how many years of their young lives they give up, in my opinion, physicians are some of the most under-compensated people in our society, right along with teachers. It takes until the early to mid thirties before a physician finally gets into practice. In the mean time, most of their college classmates have been out earning a living for a decade, investing in their retirement, buying houses, having nice vacations, while the medical residents are subsisting at near minimum wage, barely making ends meet.

And some of their years of training are brutal. During my one year of internship, I had two surgical interns as roommates. They would typically sneak moments of sleep in the hospital for two full days, before coming home for a good night’s sleep (maybe six hours) on the third night.

When I was in college in the 1970’s, the best and brightest of the college students were pre-med. There was a promise of a good income to all who could beat out the fierce competition to get into medical school (less than one in ten would succeed), and put in all the hard years of work to become a trained physician. But for decades now, the insurance companies have been dictating compensation to the doctors, who almost all have to sign on or go out of business. Become a member of their panel of doctors, and they will send you plenty of insured patients, but the doctor will work for what the insurance company determines is fair. The result has been a steady drop in the relative incomes of the very people whom we trust to keep us healthy.

But even worse, is the way that doctors are compensated in our current economy. Doctors are paid for doing procedures. Pap smears, X-rays, tonsillectomies, vaccinations, exams, crowns, root canals. It is way more lucrative to treat a heart attack victim than it is to prevent the heart attack. And that is just wrong.

But insurance companies are only one of the major forces that are influencing our health care system. Let us not forget the influence of the drug companies. The drug companies hit the jackpot when they create a drug to handle the symptoms of a chronic disease that is affecting millions of people. It is way more lucrative to manage the symptoms than it is to cure the disease. When you are cured, you no longer have a need for their drugs.

Monday, September 14, 2009

Could Diabetes be Caused by Periodontal Pathogens

We know that diabetes is multi-factorial. We have known since at least the 1970’s that diabetes and gum disease are related. We see more gum disease in diabetics and more diabetes in people with gum disease. A diabetic has a poorer healing response, so it would seem to follow that people with diabetes would defend themselves against gum disease wounds with less success than a non-diabetic. And dentists have been comfortable enough in that belief to treat diabetics more aggressively when the signs of gum disease appear.

But isn’t it possible that the insulin insufficiency diabetes, (the pancreas does not produce enough insulin), is being CAUSED by the same pathogens that might be causing pancreatic cancer, perhaps a less virulent strain? Remember the spirochetes that Dr. Nordquist implicated in coronary artery disease? Isn't it possible that another species of spirochetes could be attacking the pancreas? Shouldn't we be treating periodontal disease as if we could prevent chronic diseases of the rest of the body? It would seem to me that we should.

Gregory L Sawyer DDS

Thursday, September 10, 2009

Oral/Systemic Connection

There are two books that have made significant impact in my thinking process about the connection between gum disease and other systemic diseases. In Plague Time, the author, Paul Ewald postulates that the majority of chronic diseases that plague mankind are really chronic transmissible infections. We all know acute transmissible infections, the cold and flu being the most common. They attack us shortly after we have been exposed, and generally run their courses in a matter of a week or so. But chronic transmissible infections are different. These infections can wait for years or even decades to attack us, and all the while we can be spreading them without knowing we are infected. Dr. Ewald gives multiple examples in his book, but the one that jumped out at me was a cancer pathogen in Japan that is spread from mother to daughter in breast milk that does not manifest until the fifth or sixth decade of life, by which time the daughter has already passed the pathogen to the grand-daughter.

What is difficult for us to imagine, is that there are chronic diseases such as cancers that have a pathogen as the cause because we don’t know or can’t find what the actual pathogen is. The invention of the microscope allowed mankind to look at one celled animals first the first time, but their existence had already been postulated if not yet well understood by the infectious disease specialists at the time.

Wouldn’t a transmissible pathogen explain the breast cancer cluster in Marin County of California? Researchers have looked at the air, the water, the high power lines and who knows what else in Marin without an explanation of the breast cancer cluster there.

Wouldn’t a sexually transmitted pathogen explain the fact that a man’s risk for prostate cancer is exactly in line with the number of sex partners? The fact that we don’t know what that pathogen is does not diminish the likelihood of its existence.

What does all of this discussion have to do with our oral health? Well, I asked Dr. Ewald if he thought that the route of entry to the body of some of these pathogens might be through the bleeding gums. He told me that he thought it was not only possible but likely.

Which brings me to the other book that has had a major effect on my thinking. Stealth Killer, by WIlliam Nordquist. Dr. Nordquist is also a dentist, who had noticed the presence of spirochetal bacteria in the biofilms of the plaques of gum disease. These spirochetes worry me, because they are related to the bacteria that cause Syphilis and Lyme disease, which are truly dread diseases with no known cure if they aren’t defeated soon after infection. They worried Dr. Nordquist even more (and sooner), so he began studying them.

When a mature spirochete is attacked by antibiotics, it rolls its body up into a little ball that resembles a spore. The spores are impervious to any known attack that we can mount against them, and they can live for decades in the tissue of the body waiting for a signal to attack the host. Dr. Nordquist identified that presence of these spores in the bacterial plaques that had occluded the coronary arteries of recent heart attack victims. How did those spores get there? Since the exact same spores can be found in the plaques around the teeth under the gums, it would certainly follow that these are getting access to the bloodstream via the bleeding gums. The bacteria can be as small as 1 micron, and the red blood cells that we are seeing are between 70-100 microns in size. Isn’t it likely that these bacteria are getting access back through the damaged blood vessel wall in the gums and attacking the blood vessel walls around the heart? And when we use an antibiotic, these spores defend themselves from the attack by rolling up into the defensive spores that we see in the coronary arteries of recent heart attack victims and the gums of periodontal patients.

I am tired of the hedging of all the doctors that are saying that gum disease MAY be related to other diseases such as coronary artery disease. Isn’t it time that we stop the hedging and say that the bacteria from bleeding gums create the bacterial plaques that CAUSE heart attacks? The evidence here is nearly as strong as the evidence that HIV causes AIDS, and we can’t prove that either. Why can’t we prove HIV causes AIDS? Do you want to volunteer for the study to be inoculated with HIV and wait to see if you develop AIDS? Me neither.

And what about pancreatic cancer? What is the cause? We will admit that it MAY be related to gum disease again. What about Alzheimer’s disease? Renal (kidney) Insufficiency? Preterm births? Ischemic stroke? What else?

Gregory L Sawyer DDS

Wednesday, September 9, 2009

Risk Assesment cont.

I have seen older people who have started taking medicines for chronic illnesses that dry up the protective saliva. This has become so common that it has been called, MIX, for medicine induced xerostomia (dryness of the mouth.) When you eat, your mouth becomes acidic (low pH) as the beginning of the digestive process. The saliva buffers the pH of the mouth, so that in a normal mouth, the pH returns to normal within about a half hour of a meal. But in a person with a dry mouth, it can take hours. Indeed for the person with a dry mouth, the mouth can live in a highly acid environment from breakfast until hours after bedtime, because by time the limited saliva has had a chance to buffer the mouth from the last meal, the person has eaten again.

Type of bacteria and saliva amount (and pH) are predictors of risk for cavities. It is possible for dentists to evaluate you for that risk by testing the saliva. And it is possible to treat the saliva of those people determined to be at risk for cavities to reduce the risk, before the damage is done to the teeth. This is done with a series of mouth rinses that over a period of time lower the acidity of the saliva.

Risk for gum disease can likewise be assessed by determining the bacterial make up of the fluid next to the teeth at the deepest invaginations of the gums. The unhealthy bacteria, are anaerobes, or bacteria that prefer an environment that is without oxygen. The bacteria can be observed and generally identified as unhealthy with the use of a microscope. The exact make up of the gum disease-causing bacteria and the approximate numbers can be determined by a test called DNA-PCR, (DNA-polymerase chain reaction)

The presence of the unhealthy bacteria can be determined before the damage has started from the inflammatory process that results from gum disease. And science is finding that the damage to the body goes well beyond the teeth and gums.

Monday, September 7, 2009

The traditional dental exam, is a recording of historical damage; recent history in the case of those who visit the dentist regularly, or accumulated damage in the case of those who avoid the dentist for long periods of time. The exam is usually done with an explorer, a sharp instrument that allows a dentist to envision breaches in the continuity of the surface of the tooth, for the purpose of creating a plan of action to repair the damage.

There are some dentists who look beyond the teeth at the gums and surrounding structures in the mouth. The examination of the gums is usually done with a notched probe, and the invagination of the gums around the teeth is measured in millimeters. This gives a look at the historical damage to the gums and supporting bone for a plan of the repair.

But the pursuit of understanding of the microbiology of the disease processes can lead us to an examination process that can anticipate the damage before it has been done. This can be thought of as disease risk assessment and management.

The diseases that dentists deal with are intimately transmissible, bacterial infections. What you think of as dental diseases such as cavities or bleeding gums, are really the result of the disease process, not the diseases themselves. The disease is the bacterial infection, the hole in the tooth is only the symptom. If you repair the damage without treating the cause, the damage will recur. Those people think of themselves as “cavity prone.” There is an inherited host resistance component, but the occurrence of genuinely soft teeth is rare. Most people who have soft teeth, have softened them by diet to help make themselves cavity prone.

Regular risk assessment is important, because the risk changes throughout a lifetime. A baby’s risk of dental decay is transmitted directly from the mother. I witnessed just last night a loving mother feeding her one year old from her own soup bowl in a restaurant. One bite for mommy, one bite for baby. It was a joyous moment for the happy family, but the dark side of the ritual is the transmission of decay producing bacteria from the mother to the baby.

It is not uncommon for me to see a pre-teen girl who has been cavity-free all of her life, show up in my office with a mouth full of cavities. She had made it this far disease-free because she had not had the bacteria that caused cavities in her mouth. (Mommy either didn’t share her spoon, or didn’t have the bacteria) But as soon as she is inoculated with cavity causing bacteria by her first boyfriend, the cavities follow. Her risk for cavities has changed.

Sunday, September 6, 2009

If you must drink carbonated drinks

I am finally going to bite the proverbial bullet and begin writing down all these random thoughts that I have to share. A blog just seems like the best way to get the thinking out. I welcome your comments, and I promise to be controversial. While the blog is intended for the public, it will have topics that will appeal to fellow dentists. Please forgive me if I don't write to the level of an eighth grader. Some of this thinking will be well above the heads of an eighth grader.

I saw a presentation two weeks ago at the World Congress of Minimally Invasive Dentistry on the relative risks to the teeth from decay of drinking various popular drinks. The teeth are continuously demineralized from the food and drink and remineralized from the saliva in a process that repeats every time food or drink passes the lips. The teeth decay when they are attacked by the decay causing bacteria after they have been weakened by demineralization.

I have always recommended avoiding sodas because of the high acidity of the drink caused by the carbonic acid that makes the bubbles. There is no surprise that Coca Cola is bad for your teeth. Some time ago I found that sports drinks like Gatorade without bubbles have even higher acidity than sodas.

Dental research designed a study to see how the various drinks affect the demineralization of the teeth. And not surprisingly, Coca Cola did not do well, but it was not the worst. Mountain Dew was responsible for the most tooth structure dissolving with time of any of the drinks tested.

The biggest surprise for me, was A & W root beer, which is also carbonated with carbonic acid. But the study showed that A & W root beer was the closest to water in low potential for damage to the teeth. As a matter of fact, it helped remineralize the teeth.

So if you must drink soda, drink root beer. It has been shown to be the least destructive to the teeth of any of the popular sodas.