New York Times, May 6, 2013 excerpt

Since 2006, a few state organizations and dental associations have issued practice guidelines declaring that dental care is safe and effective at any stage of pregnancy, including diagnostic X-rays, cavity restorations and root canals.

OB-GYNs should check for bleeding gums or oral infection and refer a patient to a dentist if her last visit was longer than six months ago, according to the first national consensus statement on dental care during pregnancy (see below), published in September by the National Maternal and Child Oral Health Resource Center at Georgetown University.

The statement advised dentists to provide emergency care in any trimester. OB-GYNs can be consulted, as necessary, if a pregnant patient is diabetic or hypertensive, or if general anesthesia is required.

Oral Health Care During Pregnancy: A National Consensus Statement (PDF) presents a consensus statement that resulted from an expert workgroup meeting convened by the Health Resources and Services Administration in collaboration with the American College of Obstetricians and Gynecologists and the American Dental Association held on October 18, 2011, in Washington, DC. The consensus statement provides guidance on oral health care for pregnant women for both prenatal care health professionals and oral health professionals, pharmacological considerations for pregnant women, and guidance for health professionals to share with pregnant women.

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American Academy of Pediatrics
For Release:  May 6, 2013

Parents use a variety of methods to clean a baby’s pacifier: rising it in tap water, boiling it, or putting it in their own mouth and sucking on it before giving it back to the baby. According to a new study, parents who “clean” their child’s pacifier by sucking on it can also protect their infant from developing allergies. The study, “Pacifier Cleaning Practices and Risk of Allergy Development,” in the June 2013 issue of Pediatrics (published online May 6), examined 184 infants at 18 and 36 months of age for clinical allergy symptoms and sensitization to food and airborne allergens. Researchers found that children whose parents sucked on their pacifiers to clean them had one-third the risk of developing eczema (the most common early manifestation of allergy), at 18 months of age, compared to children whose parents did not use this cleaning practice. Development of eczema up to 36 months of age was significantly lower in children whose parents sucked on their pacifiers during the first 6 months of life. Additionally, infants who were vaginally delivered and experienced parental pacifier sucking also had a reduced incidence of eczema at 18 months of age. Study authors conclude that early exposure to parental saliva may help stimulate the baby’s immune system, resulting in a reduced risk of allergy development.

Pacifiers: Are they good for your baby?
MayoClinic.com

The decision to use a pacifier — or not — is up to you. Consider the do’s and don’ts of giving your baby a pacifier, and how to help him or her break the habit.

Kelly Kennedy, USA TODAY, April 9, 2013: Study: Younger patients more likely to skip medications

People younger than 65 are twice as likely to skip medications than older Americans, according to a study released today by the federal Centers for Disease Control and Prevention (click here for the study – PDF: “Strategies Used by Adults to Reduce Their Prescription Drug Costs”).

from the CDC study
Key Findings: Data from the National Health Interview Survey, 2011

• Adults aged 18–64 and those aged 65 and over were equally likely to have asked their doctor for a lower-cost medication to save money on prescription drugs (19.8% and 20.3%, respectively).
• Adults aged 18–64 were twice as likely to not have taken medication as prescribed to save money (12.6%) compared with adults aged 65 and over (5.8%).
• Among adults aged 18–64, uninsured adults (23.1%) were more likely than those with Medicaid (13.6%) or those with private coverage (8.7%) to not have taken medication as prescribed to save money.
• Among adults aged 65 and over, those with only Medicare coverage were more likely to ask their doctor for a lower-cost medication to save money (24.9%) compared with those who had private coverage (20.1%) and those with Medicare and Medicaid (14.7%) coverage.

The new CDC study found that about 13% of the Americans younger than 65 did not take their medications as prescribed to save money, while 6% of the older group skipped medications. About 6% of both groups tried alternative therapies to avoid prescription drug costs. Researchers used data from the 2011 National Health Interview Survey, a survey that has gone out through the U.S. Census since 1956.

Not taking medications as prescribed can lead to poorer health or emergency-room visits, according to the CDC report, a finding backed by other recent studies. In fact, the New England Healthcare Institute found that non-adherence to prescriptions costs Americans as much as $290 billion a year.

Read more …

Dr. Van der Bilt at the Department of Head and Neck in the Wageningen University Medical Center Utrecht (The Netherlands) studies the neuromuscular elements of chewing. You often hear about the impressive power of the jaw muscles. In terms of pressure per single burst of activity, these are the strongest muscles we have. But it is not the jaw’s power to destroy that fascinates Dr. Van der Bilt; it is its nuanced ability to protect. Dr. Van der Bilt isn’t a dentist, however. He is an oral physiologist.

Some interesting points of the article (in ‘The Marvels in Your Mouth’, NYTimes, March 25, 2013 by Mary Roach): 

• The way you chew, for example, is as unique and consistent as the way you walk or fold your shirts.
• Teeth and jaws are impressive not for their strength but for their sensitivity, Dr. Van der Bilt has found. Human teeth can detect a grain of sand or grit 10 microns in diameter. A micron is 1/25,000 of an inch.
• Round foods are particularly treacherous because they match the shape of the trachea. If a grape goes down the wrong way, it blocks the tube so completely that no breath can be drawn around it. Hot dogs, grapes and round candies take the top three slots in a list of killer foods published in the July 2008 issue of The International Journal of Pediatric Otorhinolaryngology.
• Those who can chew want to chew. We especially enjoy crunch. A colleague of Dr. Van der Bilt, Ton van Vliet, has spent the past seven years figuring out just how crunch works.

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On March 12, 2013, the U.S. Food and Drug Administration (FDA) issued a warning that the antibiotic azithromycin (Zithromax® or Zmax™) can lead to a potentially fatal irregular heart beat. According to the FDA, patients with existing QT interval prolongation, low levels of potassium or magnesium, or a slower than normal heart rate are at particular risk, as are those using certain drugs to treat arrhythmias.

Understanding the risk v. benefit is something that is very important, and should not frighten people from appropriate use of antibiotics. From the original article in the New England Journal of Medicine the risk to people taking azithromycin of cardiovascular death appears to be relatively low – 1 in 11,655* (odds of dying from: heart disease 1 in 5, cancer 1 in 7, motor vehicle accident 1 in 100, assault by firearm 1 in 325, drowning 1 in 8,942, air travel incident 1 in 20,000, tornado 1 in 60,000).

* During matched 5-day intervals among persons who did not take antibiotics, there were 41 cardiovascular deaths (29.8 per 1 million periods), and for those taking 5-day course of azithromycin (hazard ratio=2.88 > 85.8 per 1 million periods = 1 in 11,655).

Groups at higher risk include:

• Patients with known prolongation of the QT interval (1 in 10,000 individuals), a history of torsades de pointes, congenital long QT syndrome, bradyarrhythmias, or uncompensated heart failure
• Patients on drugs known to prolong the QT interval
• Patients with ongoing proarrhythmic conditions such as uncorrected hypokalemia or hypomagnesemia, clinically significant bradycardia, and in patients receiving Class IA (quinidine, procainamide) or Class III (dofetilide, amiodarone, sotalol) antiarrhythmic agents.

Elderly patients and patients with cardiac disease may be more susceptible to the effects of arrhythmogenic drugs on the QT interval.

The FDA-approved indications for azithromycin include:

• Acute bacterial exacerbations of chronic pulmonary disease
• Acute bacterial sinusitis (possible use in dentistry)
• Community-acquired pneumonia
• Pharyngitis/tonsillitis
• Uncomplicated skin and skin structure infections (possible use in dentistry)
• Urethritis and cervicitis
• Genital ulcer disease

Azithromycin (Z-Pak) is useful in the treatment of acute bacterial sinusitis for tooth pain caused by the sinusitis (not the tooth). Z-Pak (2-250 mg azithromycin tabs day one, 1-250 mg tab the following 4 days) is effective for a number of reasons: limited doses per day* (compared to 10-day, 3 times a day Augmentin [amoxicillin+clavulanate]), faster clinical cure, better drug tolerance, fewer adverse events, lower cost, and fewer relapses.

* Completion of therapy, i.e. taking the antibiotics as prescribed, is significantly higher when people take the medication less frequently: 80% for once-daily regimens but falling to 60% for twice-daily and 38% for three-times-daily regimens.

So … it is important to have an accurate health history for everyone to be able to best help you with your conditions and medications. Please don’t hesitate to ask me questions about any prescription I may write for you.

In December 2012 the American Dental Association (ADA) and the American Academy of Orthopaedic Surgeons (AAOS) released a co-developed guideline, “Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures,” a systematic review of existing clinical research published in peer-reviewed journals to determine the correlation between dental procedures and prosthetic joint infection (PJI).

The new ADA and AAOS guideline has three recommendations (below) and replaces the previous AAOS Information Statement “Antibiotic Prophylaxis for Bacteremia in Patients with Joint Replacement.” The guideline is careful to state that it is “not a stand-alone document”, but rather “an educational tool to guide clinicians through treatment decisions.”

Evidence Insufficient to Recommend Routine Antibiotics for
Joint Replacement Patients Who Undergo Dental Procedures

The following statements from the AAOS press release may be helpful for people in their decision:

• …  ”in this analysis is that there is no conclusive evidence that demonstrates a need to routinely administer antibiotics to patients with an orthopaedic implant, who undergo dental procedures.”
• “The research showed that invasive dental procedures, with or without antibiotics, did not increase the odds of developing a prosthetic joint infection.”

 If you have a total joint replacement, and you have any question at all whether you should take an antibiotic for dental visits, please contact your orthopedic surgeon or family physician to advise you.  

This summary of recommendations is not intended to stand alone. Treatment decisions should be made in light of all circumstances presented by the patient. Treatments and procedures applicable to the individual patient rely on mutual communication between patient, physician, dentist and other healthcare practitioners.

The Guideline Recommendations:

1. The practitioner might consider discontinuing the practice of routinely prescribing prophylactic antibiotics for patients with hip and knee prosthetic joint implants undergoing dental procedures.

Strength of Recommendation: Limited

A Limited recommendation means the quality of the supporting evidence that exists is unconvincing, or that well-conducted studies show little clear advantage to one approach versus another.

Practitioners should be cautious in deciding whether to follow a recommendation classified as Limited, and should exercise judgment and be alert to emerging publications that report evidence. Patient preference should have a substantial influencing role.

2. We are unable to recommend for or against the use of topical oral antimicrobials in patients with prosthetic joint implants or other orthopaedic implants undergoing dental procedures.

Strength of Recommendation: Inconclusive

An Inconclusive recommendation means that there is a lack of compelling evidence resulting in an unclear balance between benefits and potential harm.

Practitioners should feel little constraint in deciding whether to follow a recommendation labeled as Inconclusive and should exercise judgment and be alert to future publications that clarify existing evidence for determining balance of benefits versus potential harm. Patient preference should have a substantial influencing role.

3. In the absence of reliable evidence linking poor oral health to prosthetic joint infection, it is the opinion of the work group that patients with prosthetic joint implants or other orthopaedic implants maintain appropriate oral hygiene.

Strength of Recommendation: Consensus

A Consensus recommendation means that expert opinion supports the guideline recommendation even though there is no available empirical evidence that meets the inclusion criteria.

Practitioners should be flexible in deciding whether to follow a recommendation classified as Consensus, although they may set boundaries on alternatives. Patient preference should have a substantial influencing role.

It’s still time to think about getting a flu shot, which is generally offered between September and mid-November - typically before the late-fall to early-winter start of flu season. It takes up to two weeks to build immunity after a flu shot.

• A seasonal vaccine is distributed routinely every year.
• While there are many different flu viruses, the flu vaccine protects against the three viruses that research suggests will be most common.
  • The 2012-2013 flu vaccine will protect against A/California/7/2009 (H1N1)-like virus, A/Victoria/361/2011 (H3N2)-like virus, and the B/Wisconsin/1/2010-like virus. While the H1N1 virus is the same as what was included in the 2011-2012 influenza vaccines, this year’s influenza H3N2 and B viruses differ from those in the 2011-2012 influenza vaccines.
• Everyone 6 months of age and older should get vaccinated against the flu as soon as the seasonal vaccine is available.
• People at high risk of serious flu complications include young children, pregnant women, people with chronic health conditions like asthma, diabetes or heart and lung disease and people 65 years and older.
• Vaccination of high risk persons is especially important to decrease their risk of severe flu illness.
• Vaccination also is important for health care workers, and other people who live with or care for high risk people to keep from spreading flu to high risk people.
• Children younger than 6 months are at high risk of serious flu illness, but are too young to be vaccinated. People who care for them should be vaccinated instead.

Cold or Flu?

It’s important to know the difference between flu and cold symptoms. A cold is a milder respiratory illness than the flu. While cold symptoms can make you feel bad for a few days, flu symptoms can make you feel quite ill for a few days to weeks. The flu can also result in serious health problems such as pneumonia and hospitalizations. With the flu, you may feel very weak and fatigued for up to two or three weeks. You’ll have muscle aches and periods of chills and sweats as fever comes and goes. You may also have a stuffy or runny nose, headache, and sore throat.

Compare Flu and Cold Symptoms 

The following chart (from WebMD) can help you compare flu symptoms with cold symptoms – similarities and differences. Then, if you get flu symptoms and they persist, you might call your physician and ask about an antiviral drug.

It is important to note that both the cold and flu are viruses. Antibiotics are effective against bacteria, not viruses.

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It doesn’t take much to help others during the holiday season.

Share your good will and good fortune with other local families: food, personal care items, cleaning supplies, new and gently-used clothing – cleaned (especially coats), and financial contributions.

Local organizations:

• Koinonia, and
• Food for Others, via Network for Good click here 

It’s almost that time again. Insurance open season, when you have an opportunity to change your insurance to better fit your life. But … it can be a puzzle. Which insurance plan is right for you? How is that company to work with? How is their coverage? Is dental separate from medical.

Federal open season runs from November 12 – December 10, 2012. Many other companies have a similar period at year’s end when you can change plans / coverage.

When it comes to dental insurance there are a few things to look at:

• Let’s be practical – do you need dental insurance? Do you have many large old fillings, then yes. Do you have almost no fillings, then maybe no. Do you clean your teeth real effectively, brushing and flossing? Do you hardly every floss?
• Depending on the types of dental treatment you might anticipate, fillings, only checkups, crowns – look at what a particular policy covers.
• Are you concerned about if you can stay with me / our office? We accept virtually all standard dental insurance, but no HMO plans. You can usually use your PPO plan with us, unless you sign up for an ‘in-network only’ plan. Usually even ‘in-network’ plans cover out-of-network, but on a slightly different fee schedule.

If you have questions about choosing between a couple plans, speak with Pat or Mariela to see if they are familiar with them to help you choose.