My Health

Tooth or consequences: The costs of poor dental fitness

February 25, 2008 on 11:09 pm | In Uncategorized | Comments Off A few years ago, an extremely sick, 2½-year-old boy came to the Houston office of pediatrician Ray Wagner, MD, with a 105-degree temperature. The illness, which required five days of hospitalization and a course of intravenous antibiotics, got its start in an infected tooth; which, in turn, resulted from poor dental hygiene and a lack of dental care. Dr. Wagner, who was then an assistant professor at the University of Texas Medical School, decided to use this case as a hook for an educational session on oral health.

"We discovered that early childhood caries [tooth decay] was the most common chronic disease of children," he said. "We were all shocked."

Now a staff physician at El Rio Community Health Center in Tucson, Ariz., he is one of more and more physicians who are looking at patients' mouths and teeth before moving on to their throats. These doctors are motivated by both firsthand experiences and the scientific literature documenting that health in this area makes a difference to the whole body.

An increasing number of physicians are educating patients on cleaning teeth and gums and advising parents on reducing the risk of transmitting cavity-causing bacteria from their own mouths to their children's. Fluoride varnishes are being applied to teeth in doctor's offices, and dentists are being added to the list of specialists consulted as needed.

"The mouth is part of the body," said Wanda Gonsalves, MD, associate professor of family medicine at the Medical University of South Carolina in Charleston. She began her career as a dental hygienist. "I'd really like dentists and physicians to co-ordinate more and not have the mouth treated as a totally separate entity."

The American Medical Association and other medical organizations have supported water fluoridation, but a movement is now emerging to have physicians more involved in mouth health. This interest had its start with the release of the surgeon general's 2000 report, "Oral Health in America." It pushed the message that oral health means more than teeth, is an integral part of wellness, and nondentists need to be involved.

"You can't be healthy if you don't have good oral health," said David Satcher, MD, PhD, who was surgeon general at the time of the report's release and is now director of the Center of Excellence on Health Disparities and the Satcher Health Leadership Institute at Morehouse School of Medicine in Atlanta.

Children's health

Physicians have since taken this report and applied it in various ways. The American Academy of Pediatrics published policy in the May 2003 Pediatrics urging pediatricians to start evaluating oral health at six months of age. Revised guidelines are expected before the end of this year. Also, a major educational session on the subject is being planned for the organization's annual meeting in October.

"We have to help physicians make [oral health] doable and make it easy, so it becomes second nature and no different than when you check the fingernails or the eyes or the ears," said Martha Ann Keels, DDS, PhD, chair of AAP's section on pediatric dentistry and head of pediatric dentistry at Duke University in Durham, N.C.

An estimated 51 million school hours are missed annually because of health problems affecting the mouth.

The U.S. Preventive Services Task Force recommended in April 2004 that primary care physicians prescribe fluoride supplements to preschoolers who primarily drink unfluoridated water. The Society of Teachers of Family Medicine launched "Smiles for Life," a curriculum designed to educate medical students and residents on oral health, in October 2005. A second edition will come out this summer. The New York Academy of Sciences hosted a symposium on this subject in January.

"Because of the historical separation of medicine and dentistry, there is a framework of thinking which separates dental care and oral health from medical care and general health. [The NYAS meeting] was one of many efforts to reconnect the mouth to the body," said Burton Edelstein, DDS, MPH, professor of clinical dentistry, health policy and management at Columbia University and a member of the event's planning committee.

These actions also were taken because, although overall dental health has improved, statistics related to children suggest the future may not be so bright. Dental caries is five times more common in children than asthma. An estimated 51 million school hours are missed annually because of health problems affecting the mouth. Data released by the Centers for Disease Control and Prevention's National Center for Health Statistics in April 2007 indicated that tooth decay in ages 2 to 5 increased for the first time in years.

"We as pediatricians haven't done a very good job of preventing disease in those youngest children," said David Krol, MD, MPH, chair of the pediatrics department at the University of Toledo's College of Medicine in Ohio and a member of the AAP's Oral Health Initiative Steering Committee. "Our previous policy in pediatrics was that we don't need to send a child to the dentist until they're age 3. By default, we were taking responsibility for those children's oral health."

Experts are particularly concerned because having bad teeth is a problem that goes far beyond the aesthetic and can become more serious as a child grows into adulthood.

"We are understanding more and more that having early childhood caries invariably sets you up to develop tooth decay of the permanent teeth," said Dr. Wagner. "Once the bacteria are well established in your mouth, they persist, and they're very hard to get rid of. Early oral disease predicts lifelong oral disease."

The mouth-body connection

And this circumstance can have implications beyond the mouth. The first signs of some diseases such as osteoporosis or HIV infection can show up in the mouth, but poor oral health can also cause damage to the rest of the body. Over the past decade, published studies have linked tooth loss to dementia and associated it with poor pregnancy outcomes. Dental plaque can be a source of ventilator-associated pneumonia among intensive care patients. Tooth decay may increase the risk of heart disease. Diabetes can increase the risk of gum disease, and, conversely, leaving this problem untreated can make blood sugar control next to impossible.

While significant data has tied such conditions to periodontal disease, attempts to improve them by going for the teeth have had mixed results. A study in the Nov. 2, 2006, New England Journal of Medicine reported that treating periodontal disease in pregnant women had no impact on the risk of preterm birth, although related research is continuing.

Tooth decay is 5 times more common in children than asthma.

Other studies have been more positive. One in the March 1, 2007, issue of the same journal found that treating periodontitis could improve endothelial function. Others also documented that caring for the teeth can improve glycemic control in diabetics.

"In general the field is comfortable with the finding that treating periodontal disease in a diabetic will contribute to their glycemic control," said Robert Genco, DDS, PhD, distinguished professor of oral biology and microbiology at the State University of New York at Buffalo, who has authored numerous studies on this subject. "It probably wouldn't hurt [for physicians] to say this is a possible complication and you should see your dentist. People see their dentist anyway, but we have found that if the primary care physician makes a recommendation like that, the patients oftentimes will listen to that carefully and act on it."

Although physicians are getting more involved in oral health because of the science, the lack of access to dental care faced by so many patients -- in part because there are far fewer dentists than physicians -- also is an important factor driving their interest and involvement.

"There aren't enough dentists in this country. We really do need primary care physicians jumping on board," said Catherine Hayes, DMD, DMSc, chair of the Dept. of Public Health and Community Service in the School of Dental Medicine at Tufts University in Boston, who is investigating the impact of poor oral health on children's growth.

Patients also have more difficulty financing dental care. Far more lack dental than medical insurance. Medicare does not cover most dentistry. Medicaid dental coverage for adults is optional, although quite a few states do provide this benefit to some degree. Children on Medicaid have coverage, but because of low reimbursement rates and other issues associated with the program or with living in poverty, they can have a very difficult time finding a dentist who will see them. These realities mean disparities in oral health generally run directly along economic lines. According to data from the Agency for Healthcare Research and Quality, released in September 2007, 26.5% of those in poor families saw a dentist annually, while 57.9% of those from high-income families did.

"This is a problem that doctors have to grab hold of if we're really going to make inroads here," said Alan Douglass, MD, associate director of the family medicine residency program at Middlesex Hospital in Middletown, Conn., and co-chair of the STFM's oral health workgroup. "This can't just be relegated to dentists. There are just too many linkages to overall health, and the reality is that while most patients in the United States have access to some form of medical care, many fewer have access to dental care."

And the consequences of not being able to access care can be catastrophic. Last year, newspapers were filled with stories of 12-year-old Deamonte Driver of Prince George's County, Md., a Washington, D.C., suburb, who died of a brain infection caused by untreated dental disease. On and off Medicaid and occasionally homeless, he was not able to get care.

"Deamonte Driver's inability to obtain timely oral health care treatment underscores the significant chronic deficiencies in our country's dental Medicaid program," said Kathleen Roth, DDS, during a March 27, 2007, congressional hearing held in response to the incident. She was president of the American Dental Assn. at the time. "Fundamental changes to that program are long overdue, not simply to minimize the possibility of future tragedies, but to ensure that all low-income children have the same access to oral health care services enjoyed by the majority of Americans."

A bill was subsequently introduced in the U.S. House calling for increased funding of federally qualified health centers for dental services and training of more pediatric dentists. The proposal is currently in committee.

Flu activity up; vaccine not as protective as hoped

February 25, 2008 on 11:09 pm | In Uncategorized | Comments Off One component of the 2007-08 influenza vaccine is providing protection against the variant of the flu virus causing nearly 40% of illnesses this season, but the other two are not good matches for circulating strains. Thus, if a patient contracts one of those viruses, this immunization may lessen the illness's impact rather than prevent it from occurring.

"These data suggest that protection against the H3N2 and B virus strains in the community may not be optimal ... [but] the effectiveness of the vaccine may not be completely compromised," said Joe Bresee, MD, chief of the epidemiology and prevention branch in the Centers for Disease Control and Prevention's influenza division.

The vaccine has been well-matched to circulating strains 16 out of the past 19 years, and public health officials are stressing the importance of receiving it as well as taking other protective measures to prevent infection and spread.

These steps include more frequent hand washing, antiviral medications as appropriate and good coughing etiquette. The need for these actions is particularly acute, because rates of influenza cases increased sharply as of Feb. 9, with all states reporting at least local activity. The full magnitude of this season will not be known until its conclusion.

"Whether this year ends up being a severe season, a moderate or a mild season I think can't be predicted with certainty at this point," Dr. Bresee said.

Vaccine has been plentiful this time around, with up to 132 million doses expected. Medical societies and public health agencies have been working for several years to create a more stable influenza vaccine supply.

In preparation for the 2008-09 flu season, the National Influenza Vaccine Summit, organized by the American Medical Association and CDC, will hold its annual meeting in May in Atlanta. Several vaccine manufacturers also are taking orders for next season.

Study says table salt may not have as much iodine as labeled

February 25, 2008 on 11:09 pm | In Uncategorized | Comments Off The iodine content in table salt may not match its label, and amounts may vary throughout the container, according to a study published in the Feb. 15 Environmental Science & Technology.

"There's a problem here," said Purnendu K. Dasgupta, PhD, lead author and chair of the chemistry department at the University of Texas at Arlington.

Iodization of table salt, considered one of the great public health achievements of the 20th century and widely supported by the American Medical Association as well as many other public health organizations, is common but not mandated. Much of the salt used in processed food may not have this additive, and, according to the study, more than half of table salt samples did not contain enough of it. In response to these data and the fact that the average American diet is composed of an increasing amount of processed food, the authors are calling for all salt to be iodized.

"If you iodize all the salt then you would automatically increase iodine consumption without increasing salt consumption," said Dr. Dasgupta. "We need to have legislative action."

This perspective is also in response to concerns that iodine levels in the U.S. diet have diminished. Centers for Disease Control and Prevention statistics indicated that consumption of the mineral declined by more than 50%, based on comparisons between the 1971 to 1974 National Health and Nutrition Examination Survey and the one conducted from 1988 to 1994. Subsequent surveys found the number had stabilized, and public health officials and advocates of appropriate iodine consumption are continuing to monitor the situation.

"If it continued to drop, that would not be a good thing," said Jonathan Borak, MD, clinical professor of epidemiology and public health at Yale University in New Haven, Conn.

Iodine deficiency during pregnancy can affect fetal and newborn development.

Worry is particularly acute with regard to pregnant women because deficiency of the mineral can affect fetal and newborn development.

For example, a study in the May 2007 Journal of Clinical Endocrinology & Metabolism found 47% of women who were breastfeeding were producing milk that did not have enough iodine for their infant.

The American Thyroid Assn. issued policy in April 2004 calling for pregnant women to take prenatal vitamins that include the mineral.Experts increasingly are calling for these products to always contain it, because not all do.

"This is when you need it the most, but you may not be getting it," said Elizabeth Pearce, MD, lead author on that paper and assistant professor of medicine at Boston University.

This phenomenon may be the result of educational efforts to reduce overall salt intake because of the cardiovascular risk associated with ingesting large amounts of sodium, as well as changes in food production that mean iodine is not as present as it used to be. In addition, people are more likely to get their salt from processed food, in which salt is not always iodized, than from table salt, which usually is iodized.

"I suspect that iodized salt is not the primary way we get iodine in our diet any more," said Dr. Pearce. "And we cannot count on salt as the sole source of dietary iodine."

But those who work in the salt industry doubt that the reductions in iodine in the American diet are the result of the varying levels in table salt found by this study and questioned the soundness of the researchers' methods.

"There's absolutely no chance that our salt is not within the Food and Drug Administration specifications for iodine," said Richard L. Hanneman, president of the Salt Institute.

Also, although consumption of iodine has gone down, there are no data that the general population has actually become deficient in this substance. A paper published by FDA researchers online last month in the Journal of Exposure Science & Environmental Epidemiology concluded that iodine intake was high enough.

Data on glycemic control differ in 2 trials

February 25, 2008 on 11:09 pm | In Uncategorized | Comments Off Washington -- Interim findings released Feb. 13 regarding a large international type 2 diabetes study contradict those released a week earlier showing that patients receiving intensive treatment to lower their blood glucose levels were more likely to die.

Data from the 11,140-patient Action in Diabetes and Vascular Disease: Preterax and Diamicron MR Controlled Evaluation (ADVANCE) trial did not show any evidence of increased deaths among participants who received aggressive treatment to lower their blood glucose levels to an A1c of 6.5% or less, which is below recommendations in some clinical guidelines.

Researchers from the National Heart, Lung and Blood Institute's Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial halted an arm of that study on Feb. 6. A data review revealed 54 more deaths occurred among patients treated to reduce A1c levels to less than 6% than in the study's standard treatment arm, which had a goal of 7% to 7.9%.

The ADVANCE trial has not yet ended. But, according to Principal Investigator Stephen MacMahon, DSc, PhD, director of the George Institute for International Health in Sydney, researchers decided to check data early after the ACCORD findings were announced.

The American Diabetes Assn. cautioned against making treatment changes based on the two studies' early findings. "There is insufficient evidence from what we've heard so far," said Richard Kahn, PhD, ADA's chief scientific and medical affairs officer.

The number of deaths in the discontinued arm of the ACCORD trial -- 14 per 1,000 patients -- also is much lower than that seen in the regular population of diabetics, about 40 or 50 per 1,000, demonstrating that driving down blood glucose levels could well be beneficial, noted Dr. Kahn. "All the more reason not to change therapeutic regimens."

Meanwhile, the ADA said it was awaiting full reports for the ACCORD and ADVANCE studies as well as the VA Diabetes Trial, which also examined the relationship between intensive glycemic control and cardiovascular outcomes in type 2 diabetes. All data are expected to be available later this year.

Down syndrome is the target of ambitious NIH research initiatives

February 18, 2008 on 11:02 pm | In Uncategorized | Comments Off Washington -- Down syndrome is a familiar condition, affecting about one in every 800 children born in the United States. Although it is the most frequent genetic cause of mild to moderate mental retardation and it is associated with numerous other medical problems, much about it remains unknown.

The National Institutes of Health proposes to change that with an ambitious research agenda intended to advance understanding and speed treatments.

The agenda, released Jan. 22, sets out objectives for the next 10 years that cover disease progression, diagnosis and screening as well as treatment and management. It also includes medical, cognitive and behavioral conditions that occur more frequently in people with Down syndrome, such as leukemia, heart disease, sleep apnea, seizure, stomach disorders and mental health problems.

Most frequently, the syndrome results from an extra copy of chromosome 21 in all of an individual's cells. In a small number of cases, the extra chromosome 21 is present in some cells. Also in a few cases, individuals have the normal number of chromosomes but carry portions of material from chromosome 21 on other chromosomes.

The effects of this aberration are registered in many parts of the body. In addition to affecting physical appearance, the syndrome can cause hearing loss, heart malformations, hypertension, digestive problems and vision disorders.

The agenda was established by representatives from several NIH institutes and led by the National Institute of Child Health and Human Development. The group also identified the need to study whether aging has a greater impact on mental processes in people with the syndrome. Congress had asked last year that the NIH explore this issue.

Down syndrome can cause hearing loss, heart malformations, hypertension, digestive problems and vision disorders.

Roger Reeves, PhD, a Down syndrome researcher and professor of physiology at Johns Hopkins University School of Medicine in Baltimore, applauded the NIH initiative. "It's a really important step in dealing with a syndrome that affects so many different aspects of people who have an extra copy of chromosome 21."

A challenge, as Dr. Reeves sees it, will be for all the institutes to find ways to interact with one another. "Each institute lists different kinds of projects in Down syndrome, each focused, unsurprisingly, on their own missions." Targeted areas range from improving animal models to studying real-world outcomes for Down syndrome families.

The involvement of NIH Director Elias Zerhouni, MD, could provide needed leadership, Dr. Reeves said.

"Through the years, the NIH research effort has led to increased understanding of Down syndrome. We are now poised to capitalize on these advances and improve the health of people with Down syndrome," Dr. Zerhouni said during his announcement of the agenda.

A variety of agendas

The agenda was assembled at the urging of advocates for people with the syndrome who caught the attention of Congress, said Brian Skotko, MD, a pediatrician at Children's Hospital in Boston and a long-time advocate for people with the syndrome, including his sister.

"Down syndrome is the most common chromosomal condition that mankind has, yet surprisingly, the NIH, the [Centers for Disease Control and Prevention] and the national Down syndrome movement have never had a focused research agenda," he said. This circumstance has occurred despite the fact that other disability and medical conditions that occur in far fewer people have such agendas, he added.

Down syndrome is the most common chromosomal condition.

Now it appears that the syndrome will have three separate research agendas as the NIH effort is expected to be joined shortly by a CDC agenda and one developed by the Down Syndrome Research Coalition, an assembly of advocacy groups and physicians, Dr. Skotko said. He worked on developing the CDC agenda.

The challenge, similar to that described with the NIH agenda, will be to reconcile the different approaches recommended by the three organizations, he said.

The NIH agenda focuses on the scientific and the molecular underpinnings of the syndrome while the CDC will focus on the public health ramifications, the epidemiology and the statistics, he said. The agenda being developed by the National Down Syndrome Society and the National Down Syndrome Congress will include all of the above plus whatever the advocacy groups identify as the research gaps, said Dr. Skotko, who serves on the NDSS board.

Dale Ulrich, PhD, professor of kinesiology and director of the Center for Motor Behavior and Pediatric Disability at the University of Michigan in Ann Arbor, called the NIH agenda a "critical first step." He also would like to see a focus on recruiting more researchers to work in this area.

Funding an issue

But the funds needed to carry out these agendas are missing, all concurred. NIH funding for Down syndrome research has decreased from $23 million in fiscal 2003 to $17 million in 2008, Dr. Skotko noted. In comparison, autism research, which should remain intact, he stressed, is funded at $128 million for this year.

In addition to the lack of funds, the lack of a national registry of people with Down syndrome also is obstructing progress, Dr. Skotko said. "No one is stepping up to the plate. The NIH doesn't identify the national registry as a priority, the CDC will mention it in a preamble when its agenda is released and the national Down syndrome groups don't have the funds for it."