Inflammatory Diseases: It’s Not Just Perio Anymore

Inflammatory Diseases: It’s Not Just Perio Anymore

February 5, 2010MOHC

Lory Laughter, RDH, BS

February 5, 2010MOHC

Lory Laughter, RDH, BS

Credentials

• Clinical RDH – 16 years experience

• Columnist for RDH Magazine – 4 years

• Corporate Consultant – 2 years

• National Speaker – 3 years

Disclosures

• Hygiene Specialist – Orapharma

• Dental Relations Manager – Nuvora Inc

Course Disclosure

• List of diseases is not complete

• Information changes often

• Stay current

Inflammation

• A localized protective reaction of tissue to irritation, injury, or infection, characterized by pain, redness, swelling, and sometimes loss of function.

• Inflammatory disease is one of a number of diseases characterized by inflammation

INFLAMMATORY RESPONSE

When bacteria invade tissue WBC are dispatched to destroy the threat.

The WBC devour the foreign cells (bacteria) and secrete oxidants and cytokines to signal for more WBC.

Cytokines and your Heart

• Proinflammatory cytokines – reduce infection and increase inflammation

• Antiinflammatory cytokines – may be increased by Vitamin D.

• Suggested link between impaired Vit. D and chronic heart disease.

Ray Sahelian, M.D

Inflammatory Response

• Systemic response to inflammation

• Liver produces C-Reactive Protein

• White blood cells

• Dilation of blood vessels

C- Reactive Protein

• Measured in blood to detect infection

• Produced by liver

• High levels in blood associated with Cardiovascular events, stroke and diabetes

Sed Rate

• Measures how quickly erythrocytes settle in a vial of blood

• High levels suggest inflammation

• Not site specific and can be elevated by other causes such as fatigue and diarrhea

Systemic Response

• Immune response is essentially the same regardless of the location of inflammation.

• Often difficult to isolate the cause of inflammation – diagnosis of inflammatory diseases is often complicated.

• Inflammatory diseases can/do co-exist

INFLAMMATORY RESPONSE

Prolonged high levels of CRP signal a chronic inflammatory state

Women's Health Initiative states:increased levels of CRP are linked to cardiovascular diseases

INFLAMMATORY RESPONSE

Women with increased CRP

5 times the risk for cardiovascular disease

7 times the risk for Heart Attack

PAD: Peripheral Arterial Disease

• Narrowing or blockage of arteries that results in poor blood flow to the arms and legs

• Can cause painful cramps when walking or exercising

Possible Causes of PAD

• Build up of plaque inside the walls of the arteries – atherosclerosis.

• Gradually develops over a lifetime.

• High cholesterol, high blood pressure, and smoking contribute to atherosclerosis and peripheral arterial disease.

Possible Causes of PAD

• In some cases, peripheral arterial disease can be unrelated to atherosclerosis and caused instead by inflammation of the blood vessels (vasculitis) and old injuries that damaged blood vessels.

• Decrease in blood flow ‘starves’ tissues and muscles in the lower body

Risk factors for PAD

• High LDL Cholesterol

• High Blood Pressure

• Smoking

• Diabetes

• High Homocysteine levels

Symptoms of PAD

• Weak or tired legs• Difficulty walking or balancing• Cold/numb feet or toes• Sores that are slow to heal• Foot pain while at rest – advancing

disease• Erectile dysfunction• Often NO symptoms until very advanced

Treatment for PAD

• Diet to lower cholesterol and BP

• Low impact exercise

• Angioplasty

• Medications

Medications for PAD

• Antiplatelets – Plavix or aspirin

• Cilostazol – serious side effects

• Statins – lower cholesterol

• HBP medication

Oral Complications of PAD

• Slow healing– Tissue trauma from smoking or biting

• HBP Meds – Dry mouth– Tooth decay– Gingival hyperplasia

Dental Treatment Considerations

• Periodic position changes

• Lesions may heal slower

• pH concern from dry mouth

• Increased decay rate

Colitis

• Inflammation of the large intestine and colon

• Bacterial imbalance

• Can be spread from person to person

Causes of Colitis

• Clostridium difficile

• Antibiotic therapy

• Infected by another person

• Inadequate immune system

Symptoms of Colitis

• Diarrhea

• Cramping

• Fever

• Blood in stool

• Possible abnormal heart beat

Oral Complications

• Periodontal inflammation

• Yeast infections

• Erosion from nausea and/or vomiting

• Will not see during acute disease

Treatment for Colitis

• Vancomycin and/or metronidazole

• Fluids and electrolytes

• Blood transfusion if severe anemia occurs

• Possible surgery to remove area of perforations

Dental Treatment Considerations

• Repair areas of erosion

• Neutralize pH of oral cavity

• Treat infections locally and early

• May not absorb vitamins/minerals well

Dental Treatment Considerations

• Judicious use of systemic medications

• Systemic Flouride not recommended

• Be aware of complexion

• Check with MD during steroid treatments

Rheumatoid Arthritis

• Inflammation in the tissue lining the joints

• Over time destroys tissue in joints and limits movement

• 2 -3 times more common in women

• Symptoms often begin at 40 -60

Causes of Rheumatoid Arthritis

• Exact cause is not known

• Autoimmune disease

• Appears to be some genetic tendencies

Symptoms of Rheumatoid Arthritis

• Pain, Stiffness and Swelling of joints

• Affects both sides of the body

• Rarely affects eyes, lungs, heart and nerves

Symmetrical Symptoms

Affects small and large joints in symmetry

Risks for Rheumatoid Arthritis

• Genetic predisposition

• Female

• Between age of 40 – 60

• Cracking your knuckles does NOT cause or increase symptoms

Treatment for Rheumatoid Arthritis

• Disease-modifying antirheumatic drugs (DMARDs)

• Corticosteroids

• Weight control / exercise / adequate rest

Other Treatments for RA

• Physical Therapy

• Biofeedback

• Breathing exercises

• Acupuncture

Oral Complications of RA

• Stiffness of TMJ

• Medication side effects– Mouth sores – often wide spread and painful– Dry mouth– Vomiting – erosion of enamel

Dental Treatment Considerations

• Bite block and rest periods

• Higher decay rate

• Warm blanket or pillow around joint

• Short appointments not first thing in day

• May be slow to heal from tissue trauma

MSRA

• methicillin-resistant Staphylococcus aureus

• Can cause infection of skin, heart, blood and bones

• Can be spread person to person

• Can be hospital acquired – esp post surgery

Causes of MSRA

• Over population of Staphylococcus

• Injudicious use of antibiotics

• Unsterile surgical environment

• Person to person spread

Symptoms of MSRA

• Skin infection that will not heal

• High fever

• Pain and/or edema

• Drainage from wound – not healing

• Fainting

Treatment for MSRA

• Antibiotics – intravenous common

• Debridement of wound

• NSAIDs

• Long term monitoring – CRP and Sed Rate

Dental Treatment Considerations

• Resistant to antibiotics

• No treatment when CRP is high

• Susceptible to oral inflammation

• Dry Mouth/ sores from NSAIDs

Dental Considerations

• Clinician/patient should not be in the office if MSRA is active

• If outward skin lesions are present, avoid person to person contact

• No office personnel in office when lesions are present – not even at desk jobs

Periodontitis

• Inflammatory Disease– Infection– Not a disease of calculus

• Increased CRP levels

• Often undiagnosed in early stages

Causes of Periodontitis

• Periodontal disease is a bacterial infection, specifically, red complex bacteria (RCB).

• The bacteria associated with periodontal disease reside within biofilms above and below the gingival margin.

• Biofilms are dense mixtures of organisms resistant to natural antibodies and proteins that the body uses to fight infection.

INFLAMMATORY RESPONSE

• Cytokines in Periodontal Disease most often represented as IL-1 (interleukin 1)

• Additional biomarkers in Periodontal Inflammation: ICTP (cross-linked carboxy- terminal telopeptide type 1 collagen)

Treatment for Periodontitis

• Mechanical debridement of infected sites– Scaling and Root Planing (non-surgical

therapy)

• Site specific antibacterial agents– Arestin/Atridox/Periochip– Subgingival Irrigation

• Maintenance and monitoring

Treatment for Periodontitis

• Systemic anti-inflammatory – Periostat (low dose doxycycline)

• Occasionally systemic antibiotics– Stop the inflammatory cascade– Potent and short-term

ARESTIN

Distributed by OraPharmaMinocycline hydrochloride1 mg prefilled carpuleAdjunct to Scaling and Root PlaningEasy application

Treatment for Periodontitis

LAA Facts

•

The LAA ARESTIN®

(minocycline hydrochloride) Microspheres, 1 mg

can help eliminate the

bacteria that SRP can leave behind including:

–

P gingivalis–

T denticola

–

T forsythia2 x as effective as SRP alone in reducing

RCB

Bacterial Reduction with LAA

In a recent microbiological study of patients with moderate-to-severe periodontitis, ARESTIN®

+ SRP:

significantly reduced the quantity of red complex bacteria VS SRP alone.

Citations

•

Williams RC, Paquette DW, Offenbacher S, et al. Treatment of periodontitis by local administration of minocycline microspheres: a controlled trial. J Periodontol 2001;72:1535-1544

•

American Academy of Periodontology Research, Science, and Therapy Committee. Guidelines for periodontal therapy. J Periodontol 2001;72:1624-

1628.

ATRIDOX

Doxycycline hyclate 10%Flexible dosing –

treat multiple

teethGel that flows into pocket

May not completely dissolve

-

Tolmar/Zila

ATRIDOX

•

An important option in the treatment of chronic adult periodontitis.

-

Flows to the bottom of pocket, readily adapting to root morphology

-

Controlled release of doxycycline for a period of 7 days

-

Bioabsorbable-

removal may still be needed

-

Takes only minutes to prepare and administer

ATRIDOX

Solidifies to a wax-like substance in minutes -

Patient friendly -

no anesthesia required

Provides dosing flexibility. -

Can effectively treat multiple sites with a

single syringe.

www.atridox.com

PERIO CHIP

Chlorhexidine gluconate 2.5 mg in amatrix of hydrolyzed gelatin/glutaraldehyde

Broad spectrum anti microbial

Single dose chip placed in pocket

Perio Chip at 9 month check

•

Twice as many patients (30.3%) receiving PerioChip and SRP, had a PD reduction of 2mm or more (vs. control: 13.5%)

•

Control = SRP alone (or with Placebo chip) vs. SRP & PerioChip.

•

Chip was placed 1 hour

after Scaling and Root Planing, and repeated at 3 and/or 6 months if PD remained 5mm or more.

SUBGINGIVAL IRRIGATION

Place antimicrobial solution into pocket-

blunt end syringe

-

endo type syringe-

powered irrigation device

+ allows for pulsating action+ cannulas to reach deeper

Inflammatory Diseases and Women

• Be an advocate for early detection

• Insist on testing for unhealed or slow healing lesions or edema

• Encourage the women in your life to be proactive

IBC

• Often misdiagnosed as skin infection

• Systemic complications from inflammation

• Lowest 5 year survival rate

• Insist on testing for unhealed skin lesions

Pelvic Inflammatory Disease

• Infection of uterus, fallopian tubes and other reproductive organs

• Serious complication of some STDs

• Inflammation often goes undiagnosed for years – patients don’t seek medical care

PID in the United States

• 1million women experience acute PID yearly in the US alone

• 100,000 become infertile each year from PID

• 150 women die yearly from PID complications

PID

• Associated with gonorrhea and chlamydia

• Many sexually transmitted bacteria can lead to PID

• Number of sex partners associated with PID - both of the woman and her partner

PID Symptoms

• Unrecognized by health care professionals 2/3 of the time

• Abdominal pain• Discharge• Foul odor• Irregular vaginal bleeding

PID Diagnosis

• Ultrasonic evaluation

• Bacterial testing – blood and discharge

• Laprascopy often required

PID Treatment

• At least two antibiotics simultaneously

• Woman and her partner both treated

• Surgery for abscesses or scarring occurs

PID Consequences

• In untreated can lead to– Ectopic pregnancy – Severe Pain– Internal bleeding

– DEATH

Inflammatory Diseases

• Localized manifestation of systemic condition

• Often undiagnosed until later stages

• Increased risk for cardiovascular events

Our Role

• Health Care Provider

• Screenings provide valuable information– BP– Oral Cancer Screening

• Recommend further evaluation

Where to Look

• PubMed

• Web MD

• Kaiser – www. kp. org

• Amy’s List– AmyRDH.com

Questions