12/8/2010 Journey thru the GI tract—practical pearls The Teeth for the healthcare professional • Tooth loss and heart disease • Periodontal disease, subclinical vasculitis and coronary plaque development • State with the least teeth is the state with the most heart disease Barb Bancroft, RN, MSN, PNP Chicago, IL www.barbbancroft.com Oral bacteria and coronary artery Floss disease • 4 bacteria are implicated—Tannerella forsythia, • “Floss only the teeth you want to keep…” Porphyromonas gingivalis, Actinobacillus actinomycetemcomitans, Treponema denticola. • Enter the bloodstream via small ulcers that develop in the gum tissue of patients with periodontal disease • MINUTIAE: On average, each person uses 54 • Contribute to plaque formation via inflammation; induce feet of dental floss every month or about 1.5 platelet aggregation and clot formation feet of floss per day which equals 548 feet of • Depending on the bacterial concentration, the increased risk of heart attack in persons with one or another of these dental floss per year. bacteria ranges from 200-300 percent, compared to people with no evidence of the bacteria Drugs used for osteopenia and Osteoporosis and tooth loss osteoporosis—the bisphosphonates • Osteoporosis of the mandible and maxilla on • Alendronate (Fosamax), risendronate dental X-rays—loss of trabecular bone (Actonel), ibandronate (Boniva) for PMF • Women who do NOT take estrogen have fewer • Pamidronate (Aredia), zolendronic Acid natural teeth (Zometa) for cancer—doses are 4-12 x higher than doses to prevent osteoporosis—inhibit osteoclastic production of calcium and • The bisphosphonates and osteonecrosis of the therefore treat the hypercalcemia of jaw malignancy (multiple myeloma , breast cancer metastases to bone, etc.) 1 12/8/2010 Osteonecrosis of jawbone (2/3 are Osteonecrosis of the jaw bone mandible) • Less than 1 / 100,000 patient years in people • 95% of cases are taking IV Aredia or Zometa to who take Fosamax for osteoporosis stop bone resorption in certain cancers (breast and multiple myeloma) • More common with IV bisphosphonates such • Incidence—1.3-7% as pamidronate (Aredia) and zolendronic acid • Discuss risks of dental complications and (Zometa) perform dental procedures BEFORE starting these drugs • Hard to treat—stopping therapy does little good because these drugs are metabolized slowly and stay in bone for many years (especially alendronate/Fosamax) The teeth--meth mouth Forensics and meth mouth • 22 y.o. meth user; snorted and/or injected meth x 2 • Changes in teeth w/ meth mouth—cannot years • Denied use of any other drugs recognize dental prints • Drank 2-3 liters of carbonated drinks each day • Problem when meth labs blow up and the because of a dry mouth; rampant dental caries human remains are incinerated at the scene because of acidic environment • How addicting is methamphetamine? Dopamine and addiction • (British Journal of Medicine 2006;333:156) Speaking of…forensic odontology Forensic odontology--January 15, 1978 • “Listen my children and you shall hear…” • Two girls attacked at the Chi Omega sorority house in Tallahassee FL; both girls were strangled and beaten, and one was raped. No fingerprints were left at the • Dental records—the first forensic dentist in crime scene, but the killer did leave one identifying mark—he bit one of the girls twice on the left the U.S. was none other than the famous Paul buttock. Revere who was known for his identification • The impression was clean enough to make a match of fallen Revolutionary soldiers via dental with the dental impression—his bite mark bore an records uneven alignment and several chips giving the forensic odontologist two good impressions to work with 2 12/8/2010 1st case in FL history to convict a killer via dental forensics—Ted Bundy Bites… • As a general rule in the world of biology, If it bites, it’s female…the exception to this rule— sexual predators such as Bundy and Dahmer Bites and child abuse 3 characteristics/components of bite marks • When seen on a living child, have a high index 1) the bite mark is an ovoid area with teeth of suspicion indentations; shape and size are significant • May signal escalating danger 2) the suck mark—caused by pulling of the skin • Sign that the child will most likely be further into the mouth, creating a negative pressure— abused and fatally injured in the future if the resembles a contusion in the middle of the abuse is not stopped bite 3) the thrust mark—caused by the tongue as it pushes against the skin Child abuse Bite marks • Bite marks on the tongue of a child with no • From another child? Adult? Animal? A teeth diameter of greater than 3 cm between • Suspicious? cuspids is human • Bite mark from the abuser shows a curve in • Human bites—crescent; usually 2 opposing the direction opposite the child’s dental arch semicircles which may be incomplete; individual teeth marks may be visible or the dental arch may be represented by a continuous line • DOGS vs. CAT bites 3 12/8/2010 Dogs tear vs. cats puncture Dog bites • Cats cause puncture wounds with those little • 2-5 million Americans bitten by dogs every fangs year • Dogs rip a major portion of skin off • Arms and legs in young adults; face in children • • Pasteurella and necrotizing fasciitis (the flesh- More than 50% occur in kids under age 12 eating disease) • Most nonrabid bites are provoked • • Antibiotics for cat bites Dog bites comprise 80-90% of all animal bites requiring medical care • TETANUS shots for all bites! Myth: A dog’s mouth is cleaner than a human mouth… The immunocompromised patient • Fact: Despite being able to lick body parts that • Candida albicans (inhaled steroids in no human has the capability of licking, Fido’s asthmatics) mouth is often touted as scientifically more • Diabetics with hyperglycemia sterile. Truth be told, oral bacteria are so • Fungal infections and TNF-α antagonists species-specific that one cannot be considered (infliximab/Remicade; adalimumab/Humira; “cleaner” than the other, just different. certolizumab/Cemzia etanercept/Enbrel)* (LiveScience.com) • Kaposi’s sarcoma • HPV • HIV (TB) The diabetic mouth Dental care and diabetes • In addition to uncontrolled blood sugars and • 1 to 2 periodontal treatments per year an increased risk of yeast infections such as decreased diabetes costs by 11-12% candida, diabetics also have neuropathy that • Univ of Michigan School of Public Health can result in hyposalivation • Science Daily, January 8, 2009 4 12/8/2010 Herpes labialis – HSV-1 Active herpes and dental procedures… • Herpes Simplex Virus-1 and 2, VZV • Patients with active herpes lesions should avoid elective • Ophthalmic, maxillary or mandibular root of the trigeminal dental treatment; it’s easy to spread the virus in the dental nerve setting • Tend to not “jump” roots • Recent studies have shown taking antiviral medicine before • Can be in more than one root certain dental procedures can help decrease recurrent HSV outbreaks. • The first time children are infected, they may have a fever, a • sore mouth, and red and inflamed gums. Dental extraction has been reported as triggering event. • • Adults who are infected for the first time may exhibit a sore In surgical procedures involving the trigeminal nerve root, throat or tonsillitis and occasionally some sores in the mouth. HSV reactivation occurs in up to 50 % of the patients (Haydeir LE) Recurrent herpes labialis (RHL)—16-38% of the population The “herpes family”… • HSV-1—herpes labialis/genitalia, Bell’s palsy (VII)—mucous • Patients with a previous history of RHL seem to be at membranes higher risk. It is not clear whether RHL is linked to the • HSV-2—herpes genitalia/labialis—mucous membranes procedure itself, to the anesthetic procedure or both. • VZV—varicella-zoster-virus--airborne • Prophylactic antiviral treatment in RHL patients who • CMV—cytomegalovirus—shed throught epithelial cells are undergoing extractions. Increased awareness of • EBV (Epstein-Barr virus)—MONO--the “kissing” disease—how this potentially severe post-extraction long does EBV live in saliva? Posterior cervical nodes complication—some patients have been hospitalized • HHV-6—roseola, ?MS for IV acyclovir therapy • HHV-7 • KSHV (HHV-8)—Kaposi’s sarcoma herpes virus (STD) The antiherpetics—the “cy{i}clovirs” Treating shingles • Acyclovir (Zovirax) • Acyclovir (Zovirax)(4000/d) • • Famciclovir (Famvir) Famciclovir (Famvir)(750/d) • Valacyclovir (Valtrex)(3000/d) • Valacyclovir (Valtrex) Tx must be started within 48-72 hours after the first • Ganciclovir (Cytovene)– CMV retinitis in HIV signs of a rash appear. patients; CMV pneumonitis in transplant • +Prednisone patients PREVENTION--Zostavax 5 12/8/2010 What is the hardest thing to Say “ah”…what are we looking for? swallow?… • Soft palate and uvula • Relationship of the pharyngeal musculature • Clear fluids such as water with CN IX (Glossopharyngeal) and X (Vagus) • Stroke patients • Ya’ can’t size it, ya’ can’t shape it… • Swallowing (brainstem {bulbar} vs. hemispheric stroke)(25-50%)(swallowing center is in the brainstem • Post polio syndrome—bulbar muscle dysfunction—25-30 years after Back to CN IX and X Causes of nasal speech • The gag reflex • Cleft palate (folic acid) • CN IX and X close off the nasopharynx • Guillain-Barré Syndrome (GBS)—what is the • Head injured patients (and surgical) lose their gag #1 cause of GBS in U.S. today? reflex and have a high risk of aspiration pneumonia • Lou Gehrig’s (ALS) disease • Open your mouth and pant like a dog • “K, K, K, K, K” • Glossopharyngeal nerve palsy