C214                  TREATING PATIENTS WITH CARDIOVASCULAR                  DISEASE                  JAMES LICHON, RPH, D...
Chicago Dental Society                                                     MWM & REGIONAL MEETING COURSE EVALUATIONSpeaker...
James F. Lichon RPh,DDS,NCCM                                            Risk Factors That Weaken                          ...
ADVERSE EFFECTS OF STENTS                                               (24-48 hours)                                     ...
Valve replacement—no appointment for                                                 Patients who stop taking aspirin are ...
Ankle-brachial index test for               More women die from CVD then from all                                         ...
Inflammatory Cells                                                                   Monocytes, Macrophages,              ...
IS PERIODONTAL DISEASE                                 Rheumatoid Arthritis and the AN AUTOIMMUNE DISEASE?                ...
Factors That Affect Your                                  Fewer than half the adults diagnosed with high           Cholest...
“All substances are poisons, there is none      which is not a poison. The right dose       differentiates a poison from r...
Caution with Calcium Channel Blockers (3A4)       What Can I Prescribe When Taking Zocor,     (Diltiazem, Verapamil, Felod...
Drug-Induced Gingival Hyperplasia                                                        NEW REVISED GUIDELINES FORCalcium...
Do not prescribe NSAIDs during the                                        NSAIDs (not aspirin)     last 6 to 8 weeks of pr...
325mg            500mg           650mg50% of all sudden (acute) liver failure in UScaused by Tylenol--ck pt for liver dise...
No drug produces reliable               NEW ANTICOAGULATION DRUGS    pain relief in every patient               TO REPLACE...
LOWERS TRIGLYCERIDES                                                                                                 HOMER...
OMEGA 3 AND PERIODONTAL DISEASE                           OMEGA 3 AND PERIODONTAL DISEASE9182 adults aged 20 years or olde...
PHYSICIAN HEALTH STUDY-2                         MULTIVITAMIN USE AND RISK OF       PRIMARY PREVENTION                    ...
Causes of vitaminB12 deficiency                                                 Symptoms of vitamin                       ...
BURNING MOUTH SYNDROME                                                           VITAMIN D Iron Zinc B vitamins—B1, 2, ...
VITAMIN D and BALANCE                             Vitamin D is now recognized as important                                ...
PROSTATE CANCER AND                                                         ANDROGEN DEPRIVATION THERAPY VITAMIN D AND PRO...
CALCIUM                                        CALCIUM                                                    Found naturally ...
WOMAN’S HEALTH INITIATIVE               CALCIUM INTAKE: MORE IS NOT BETTER                                              Ca...
A Manual of              Physical activity and eating a proper diet can                      Laboratory and           miti...
ORAL MANIFESTATIONS OF                      Let Them Eat Dirt:     How Clean Environments                                 ...
Cold Cereals                       Hot Cereals                  Mostly refined                       Mostly refinedWhole g...
Benefits of Exercise                                         Women who walk 2 or more hours a                             ...
Primary and secondary prevention              Exercise does not have to be a workout at the gym    of hormone driven cance...
PROCRASTINATION   PERSEVERANCE                    jclichon@aol.com                                       29
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C214 treating patients with cardiovascular disease

  1. 1. C214 TREATING PATIENTS WITH CARDIOVASCULAR DISEASE JAMES LICHON, RPH, DDS, CCL FRIDAY, FEBRUARY 22DISCLAIMER: This work, audio recordings and the accompanying handout, are the intellectual property of the clinician, and permission hasbeen granted to the Chicago Dental Society, its members, successors and assigns, for the unrestricted, absolute, perpetual, worldwide rightto distribute solely as an educational material at the scientific program being presented at the 2011 Midwinter Meeting. Permission has beengranted for this work to be shared for non-commercial education purposes only. No other use, including reproduction, retransmission in anyform or by any means or editing of the information may be made without the written permission of the author. The Chicago Dental Societydoes not assume any responsibility or liability for the content, accuracy, or compliance with applicable laws, and the Chicago Dental Societyshall not be sued for any claim involving the distribution of this work.
  2. 2. Chicago Dental Society MWM & REGIONAL MEETING COURSE EVALUATIONSpeaker: Date:Subject: Number of attendees:PLEASE RATE YOUR SPEAKER AS TO: Excellent Good Fair Poor N/A • Subject selected................................. 4 3 2 1 0 • Timeliness of subject ......................... 4 3 2 1 0 • Comprehensiveness........................... 4 3 2 1 0 • Meeting your expectations ................ 4 3 2 1 0 • Content level...................................... 4 3 2 1 0 • Delivery .............................................. 4 3 2 1 0 • Voice quality....................................... 4 3 2 1 0 • Holding your interest ......................... 4 3 2 1 0 • Appropriate audiovisuals ................... 4 3 2 1 0 • Effective audiovisuals ........................ 4 3 2 1 0 • Overall evaluation of speaker ............ 4 3 2 1 0 • Overall evaluation of program........... 4 3 2 1 0Should this speaker be invited for future meetings? Yes q No qWhat topics of interest would you like to see covered in the future?Comments (use reverse if you need additional space):Name (requested but not required—please print):RETURN EVALUATION CARD TO: DO NOT FOLD CARD. FOR CDS PERMANENT FILES.Chicago Dental SocietyAloysius F. Kleszynski, DDS401 N. Michigan Ave., Suite 200, Chicago, IL 60611-5585
  3. 3. James F. Lichon RPh,DDS,NCCM Risk Factors That Weaken The Endothelium and the Fibrous Cap Diabetes High Toxic Mechanical Food Sedentary Cholesterol (nicotine) (hypertension) choices lifestyle RUPTURE OF PLAQUE The more risk factors, the faster the development of the plaque What Increases the Strength of the CORONARY ARTERY SPASM Endothelium and the Fibrous Cap MAGNESIUM DEFICIENCY COCAINE –AMPHETAMINES Cholesterol, diabetes, and blood HEART CATHETERIZATION pressure medicine CIGARETTE SMOKING COLD No smoking STRESS Exercise Good diet 1
  4. 4. ADVERSE EFFECTS OF STENTS (24-48 hours) Acute access site pain with hypotension Thrombus (blood clot) Coronary artery spasm Arrhythmias Heart attack—4% Cardiac mortality—1% Bypass Surgery ADVERSE EFFECTS OF BYPASS SURGERY Cognitive Impairment-short term memory loss, depression Stroke or MI—5%-6% Death—3% Insomnia Flashbacks InfectionNeither coronary angioplasty, Dental Implications for Patientsstents, nor cardiac bypass surgery with Stents and Bypass Surgeryis curative for coronary arterydisease. They do relieve symptomsbut do not treat the cause. JAMA, NOV. 10, 2010-Vol 304, No.18 INR < 3 Do Not Stop Taking Medication Without a Cardiologist Approval 2
  5. 5. Valve replacement—no appointment for Patients who stop taking aspirin are at a6-12 months significantly increased risk of MI than those who continue treatment.Stents and open heart surgery—no British Medical Journal July 19, 2011appointment for 6 monthsContact cardiologistfor an update Depression SUDDEN CARDIAC DEATH15% to 20% of post heart attack, stent, bypasspatients have major depression65% have one symptom of depressionUnder diagnosed--only 20-30% diagnosedDepression and heart diseaseare a lethal combinationDental Implications Excess plaque Tardive Dyskinesia SUDDEN CARDIAC DEATH IN SUDDEN CARDIAC DEATH IN YOUNG ATHLETES YOUNG ATHLETES Congenital Coronary Artery Anomaly 3
  6. 6. ISCHEMIC STROKE CAROTID EXAM COROTID DOPPLER EXAM PERIPHERAL VASCULAR DISEASE Often Underdiagnosed WHO IS AT RISK FOR PERIPHERAL LOWER EXTREMITY VASCULAR VASCULAR DISEASE DISEASE QUESTIONNAIRE• SMOKERS Do your calves, thighs, or buttocks get• DIABETIC cramped, painful, heavy or tired when you• OVERWEIGHT walk, and does the pain stop with rest?• NOT EXERCISING Do you have leg pain mostly at rest or when• OVER AGE OF 50 standing for long periods?• HIGH CHOLESTEROL Do you have pain, numbness, or tingling in the• HIGH BLOOD PRESSURE toes?• THOSE WHO HAVE EXISTING CVD Do your toes ever become blue, black or red?• FAMILY HISTORY OF HEART DISEASE Do you have sores on your legs or feet that heal slowly or do not heal? 4
  7. 7. Ankle-brachial index test for More women die from CVD then from all cancers combined. peripheral vascular disease Women schedule mammograms but skip lipid (cholesterol) profiles and blood- pressure checks Treatment with exercise (walking), aspirin, statins, stents, or surgeryHEART DISEASE SYMPTOMS IN WOMEN 2/3 of the deaths from heart attacks occur among those women who have no symptoms or don’t recognize the symptomsChest pain, but less severe then menNeck, shoulder, upper back discomfort Diagnostic tests in women not as accurateLightheadedness or dizziness as those in menShortness of breathUnusual fatigueSweatingNauseaWomen may have less blockage in main WHITE BLOOD CELLSarteries but more in small vessels called All white blood cells are known as LEUKOCYTES “microvascular disease”Shortness of breath Leukocytes are divided into 3 classes: 1. Granulocytes-Neutrophils, eosinophils, basophilsUnusual fatigue 2. Monocytes-evolve into macrophages 3. Lymphocytes-2 kindsLack of energy A. B cells—produce antibodies B. T cells—help destroy infected cellsNeck, shoulder, back discomfort 5
  8. 8. Inflammatory Cells Monocytes, Macrophages, Lymphocytes Cytokines-- pro inflammatory IL-1, IL-6, IL-8, TNF-1, Interferon CYTOKINES MMP(matrix metalloproteinase) Cytokines-- anti-inflammatory IL -4, IL-10, IL-11, IL 13, TNF-2, MMP-1 SELF AND NON-SELF CYTOKINES AND PERIODONTAL DISEASECYTOKINES AND RHEUMATOID ARTHRITIS EXAMPLES OF AUTOIMMUNE DISORDERS Addisons disease Celiac disease - sprue Dermatomyositis Graves disease Hashimotos thyroiditis Multiple sclerosis Myasthenia gravis Pernicious anemia Reactive arthritis Rheumatoid arthritis Sjogren syndrome Type I diabetesEMBREL, REMICADE, HUMIRA , ACTEMRA 6
  9. 9. IS PERIODONTAL DISEASE Rheumatoid Arthritis and the AN AUTOIMMUNE DISEASE? Temporomandibular Joint SJOGREN SYNDROME CHOLESTEROL• A chronic autoimmune inflammatory connective tissue disease• Majority of people with SS are middle-aged women ALWAYS in Animals• Dry eyes, dry mouth and lips, swallowing complaints, fatigue, tongue changes, and overgrowth of Candida NEVER in PlantsOther causes of dry mouth antidepressants antipsychotics antihypertensives antihistamines Venus Williams Why is Cholesterol Good? For normal structure, function and repair of cell membranes For nerve conduction and brain function Precursor for steroid hormones, e.g. testosterone, estrogens Precursor for bile acid Precursor for Vitamin D Heredity 7
  10. 10. Factors That Affect Your Fewer than half the adults diagnosed with high Cholesterol Levels cholesterol knew whether they had ever been tested for thyroid disease, despite the well- Sedentary lifestyle documented connection between the two conditions Diet American Association of Clinical Endocrinologists January, 2011 Weight Symptoms of Hypothyroidism Diabetes Weight gain Fatigue Heredity Depression Dry skin Feeling cold Muscle cramps, joint pain FAMILIAL HYPERCHOLESTEROLEMIADisorder of high LDL (bad) cholesterol that is passed downthrough families. Can cause heart attacks at an early ageand premature death. Blood tests may show: Total cholesterol > 300mg/dl in adults LDL levels > 220mg/dl in adults IT’S IN THE GENES, NOT THE DIET Very common disorder: 1 in 300-500 (heterozygous) ONLY 15% DIAGNOSED Stormie Jones • Age 6 diagnosed with HFH, “homozygous familial hypercholesterolemia” –TC 1200 mg/dl (less then 160) –TG 150 mg/dl –LDL 1130 mg/dl (normal 120 g/dl) –Progressive xanthomas • Age 6 yr 6 mo. Angina and double coronary bypass • Age 6 yr 8 mo. Second bypass • Age 6 yr 9 mo. Heart failure • Age 6 yr 9 mo. Combined heart and liver transplant –TC dropped to about 250 mg/dl 8
  11. 11. “All substances are poisons, there is none which is not a poison. The right dose differentiates a poison from remedy.” Paracelsus, 1493-1541“the precursor of chemical pharmacology and therapeutics” www.scientificamerican.com DRUG INTERACTIONS WITH BELOW PRODUCTS STATIN SIDE EFFECTS WHEN TAKING ZOCOR, LIPITOR AND MEVACOR *CRESTOR, FLUVASTATIN, PRAVASTATIN, AND• Muscle pain or damage LIVALO OK• Liver damage• Low testosterone levels• Increased blood sugar or type 2 diabetes• Neurological side effects Headaches GI distress Myopathy Rhabdomyolysis DRUG INTERACTION WITH BELOW PRODUCTS WHEN TAKING ANTIARRHYTHMIC MEDICATIONS (AMIODARONE, DIGOXIN, BETAPACE, ETC) P450 3A4 Ventricular arrhythmia Sudden death Cytochrome P450 3A4 9
  12. 12. Caution with Calcium Channel Blockers (3A4) What Can I Prescribe When Taking Zocor, (Diltiazem, Verapamil, Felodipine, Nifedipine) Lipitor, Mevacor, antiarrhythmic medications when prescribing or CCB? Biaxin, Ketek Amoxil--amoxicillin Keflex--cephalexin Ventricular arrhythmias Cleocin--clindamycin Sudden death Vibramycin--doxycycline Edema Flagyl--metronidazole YEAST (FUNGAL) INFECTIONS OF MUCUS MEMBRANE • Amoxicillin (Coumadin) Drug interactions of Diflucan, Sporanox, or Nizoral (3A4) • Keflex--Cephalexin when taking Zocor, Lipitor, Mevacor, CCB • Cleocin—Clindamycin or antiarrhythmic medications • Erythromycin (Coumadin) (Crestor, Lescol, Pravachol OK) • Z-Pak—Azithromycin (Coumadin) • Biaxin—Clarithromycin (Coumadin) • Vibramycin-Doxycycline (Digoxin, Sun, Vit A, Amoxicillin, Methotrexate, Coumadin) • Periostat (low dose doxycycline-20mg) • Flagyl--metronidazole (Coumadin, alcohol) ---------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------- Mycelex troche (clotrimazole-4-5x/d) Nystatin S&SFactors Predisposing To Candida albicans ORAL SIDE EFFECTS-STATINS(KNOW THE CAUSE) Angioedema—Crestor, Lipitor, Zocor,Dentures Lescol, Mevacor Also from antibiotics, BP medicines (AceAntibiotics inhibitors & renin inhibiting agents), insectSteroids bites, food (shellfish, nuts)SmokingDiabetesXerostomia Dysfunction of certain cranial nervesRadiation Alteration of taste, impairment of extraocularHIV-AIDS movement, facial paresisNutritional deficiencies (iron, folate, B12) 10
  13. 13. Drug-Induced Gingival Hyperplasia NEW REVISED GUIDELINES FORCalcium Channel Blockers Amlodipine (Norvasc) ASPIRIN –PRIMARY PREVENTION Nifedipine (Procardia) Verapamil (Calan) Aspirin—uncertain value for primary prevention except for high risk patients.Antiseizure Drugs (HTN, smoking, diabetes) Phenytoin (Dilantin) Carbamazepine (Tegretol) Always check with your doctorImmunosuppressive Agents Cyclosporine (Neoral) NEW REVISED GUIDELINES FOR NARCOTICS ASPIRIN –SECONDARY PREVENTION Vicodin —Hydrocodone/Tylenol—5/500Patients with prior history of CVD, or Vicodin ES—Hydrocodone/Tylenol7—7.5/500ischemic stroke should be Vicoprofen—Hydrocodone/Ibuprofen—7.5/200on aspirin Tylenol with Codeine—#3 and #4 (300mg Tylenol) Fiorinal with Codeine-(butabarbital, aspirin 325mg, caffeine, codeine 30mg)Always check with your doctor Percodan—Oxycodone/Aspirin—5/325 Percocet—Oxycodone/Tylenol—2.5/325, 5/325, etcPhysicians’ Health Study showed that Demerol—Meperidine 50,100mgtaking aspirin every other day also works CAUTION--NARCOTIC SIDE NSAIDs Nonsteroidal Anti-Inflammatory Drugs EFFECTS WITH: Aspirin—81mg, 325mg, 500mg, 650mg Antidepressants: Elavil, Wellbutrin, Celexa, Lexapro, Zoloft, Serzone, Effexor, Prozac, etc. Ibuprofen (Motrin—Advil) 200mg OTC--400, 600, 800mg Rx Antipsychotics: Clozaril, Holdol, Lithium, Abilify, Seroquel, Zyprexa, Thorazine, etc. Naproxen (Aleve) 220mg OTC--250, 375, 500mg Rx *20-30% develop upper GI bleeding Symptoms: slow heart rate, confusion, respiratory depression, etc. 11
  14. 14. Do not prescribe NSAIDs during the NSAIDs (not aspirin) last 6 to 8 weeks of pregnancy Nonsteroidal anti-inflammatory drugs 1. Increase CV events and stroke September 8, 2010 – European Society of Cardiology Prolonged gestation 2. Exacerbation of heart failure Premature closure of ductus arteriosus 3. Effect on kidneys and salt retention Cause maternal and fetal complications 4. Increase BP and worsen control of HTN Miscarriage Tylenol and Codeine is safe during pregnancy BLACK BOX WARNING DENTAL IMPLICATIONS WHEN PRESCRIBING NSAIDs Cardiovascular Risk NSAIDs may cause an increased risk of serious cardiovascular thrombotic events, myocardial In patients with prior heart attack, most infarction, and stroke, which can be fatal. This risk may (NSAIDs), not aspirin, even when taken increase with duration of use. for as little as one week, are associated with an increased risk of death and Gastrointestinal Risk recurrent heart attack. NSAIDs cause an increased risk of serious May 9, 2011 Circulation gastrointestinal adverse events including bleeding, ulceration, and perforation of the stomach or intestines, which can be fatal. Naproxen may be best choice Elderly patients are at greater risk for serious gastrointestinal events. DENTAL IMPLICATIONS WHEN DENTAL IMPLICATIONS WHEN PRESCRIBING NSAIDs PRESCRIBING NSAIDs Caution when prescribing---- Caution when prescribing---- Patients taking Methotrexate (kidney & bone• Patients taking ACE inhibitors (Vasotec, Zestril) marrow toxicity, stomatitis, fatality)• Patients taking ARB (Atacand, Cozaar)• Patients taking CCB (Norvasc, Cardizem) Patients taking anticoagulants (Coumadin,Plavix)• Patients taking Diuril, Laxix (renal function) Rx—Tylenol with Codeine or Vicodin• Patients taking Digoxin (irregular heartbeat) Patients taking aspirin-- increased risk of GI• Patients taking Lithium ( tremors, confusion, bleeding and decreases the cardio protection of muscle weakness) aspirin (naproxen does not interfere with aspirin) 12
  15. 15. 325mg 500mg 650mg50% of all sudden (acute) liver failure in UScaused by Tylenol--ck pt for liver diseaseMaximum adult dose = 3000 mg/day New FDA Limits on Maximum dose of Study: Tylenol and Ibuprofen May Acetaminophen Cause Hearing Loss in WomenThe FDA announced new limits on the dosage of Taking ibuprofen or acetaminophen regularlyacetaminophen (Tylenol) because of serious liverimpairment. FDA limits drugs containing Tylenol to was associated with increased risk oflimit dosage to 325 mg in prescription medicine. hearing loss in women, and the risk generally increased with the frequency of use J of EpidemiologyVolume 176 Issue 6 September 15, 2012Issued February 9, 2011Deadline January 2014 HEART-FRIENDLY MEDICINES TYLENOL (ACETAMINOPHEN) 500MG MOTRIN OR ADVIL (IBUPROFEN) 200MG 13
  16. 16. No drug produces reliable NEW ANTICOAGULATION DRUGS pain relief in every patient TO REPLACE COUMADIN Rivaroxaban—Xarelto (3A4) Apixaban—Eliquis (3A4) Dabigatran—Pradaxa (renal) *Check with physician Caution with aspirin, ibuprofen, naproxen, Z-Pak Ketek, Biaxin, itaconazole, ketoconazole (3A4) OMEGA 3 FATTY ACIDS Essential fatty acids Mayoclinic.com Epocrates (downloadable app) The 2 Active Components in The 2 Active Components in Omega 3 Omega 3 are DHA and EPA are DHA and EPA• •• 1300mg 600mg•• 14
  17. 17. LOWERS TRIGLYCERIDES HOMER 2752 mg CARDIOVASCULAR HEALTH OMEGA-3 AND DEPRESSION SECONDARY PREVENTION American Psychiatric AssociationSystematic reviews of EPA + DHA found concluded there is evidence for EPA-that dietary supplementation reduced DHA based on DBRCT as an adjunctivethe risk of cardiovascular deaths, therapy for major depressive and bipolarfibrillation, and non fatal cardiovascular disordes.events. *Check with your doctor Freeman MP et al J Clin Psychiatry 2006 Archives of General Psychiatry Feb.2010 Clin Cardiol. 2009 Jul:32(7)365-72 HFSA Scientific Meeting Sept20, 2010 Mayo Clin Proc.2011:86(7):626-632 RHEUMATOID ARTHRITIS MACULAR DEGENERATION Studies (2500 patients – 7 years) shows Trials have demonstrated a range of that omega-3 fatty acids slows the benefits in patients with RA that progression of vision loss from age- include reducing joint pain when used related early macular degeneration and as an additive with NSAIDs (ibuprofen, reverses the signs of dry eye syndrome. naproxen, aspirin). SanGiovanni JP Arch Ophthalmol. 2008 Sep:16 Arch Ophthalmol. 2011 July, Vol 129, No. 7 Calder PC, Proc Nutr Soc. 2008 Nov:67 15
  18. 18. OMEGA 3 AND PERIODONTAL DISEASE OMEGA 3 AND PERIODONTAL DISEASE9182 adults aged 20 years or older The result of this clinical study suggest thatConclusion: higher intakes of DHA/EPA dietary supplementation with Omega 3 maywere associated with lower prevalence of provide a sustainable, low-cost interventionperiodontal disease. to augment periodontal therapy. Sharkawy H, J.Periodontol. 2010 Nov:81(11):1635-43 Kaye, E. J Am Diet Assco. 2010 Nov:110 (11) 1650-52 SIDE EFFECTS OF FISH OIL Heart Health: 1000mg-1200mg DHA+EPAIncreased risk of bleeding—minimal –ck coumadin High Triglycerides: 4000mg DHA+EPAHeavy metals and other pollutants-China and IndiaIncrease in LDL and total cholesterol Rheumatoid arthritis: 2500mg DHA+EPAStomach upset Children (1-5 yrs): 300mg-400mg DHAAfter taste Mental Health: 1-2000mg EPA or EPA+DHABurping Prenatal: 250-350mg DHADiarrhea Vision: 800mg DHA or 1000mg DHA+EPATo minimize: Periodontal disease: 1-2000mg EPA+DHA• Take with meals• Start with low dose• Keep in refrigerator MULTIVITAMINS A 4 billion dollar businessLots of Types Consumers Lab (June 2011)Lots of Confusion 10 of 38 multivitamins tested contained either more or less of what the label indicated 16
  19. 19. PHYSICIAN HEALTH STUDY-2 MULTIVITAMIN USE AND RISK OF PRIMARY PREVENTION CANCER AND CARDIOVASCULAR DISEASE IN WOMEN’S HEALTH 1997-2007, 15,000 physicians INITIATIVE COHORTS (1997-2005) Results— Vit.E and Vit.C no effect on 8 YEARS, 66,000 POSTMENOPAUSAL WOMEN CVD, prostate or total cancer MULTIVITAMIN USE HAS LITTLE INFLUENCE ON THE RISK OF COMMON CANCERS, CVD, The multivitamin component will OR TOTAL MORTALITY. continue for a few more years. ARCHIVE INTERNAL MEDICINE, 2009 $625 million NIH Multiple Vitamins (may benefit) Those who have chronic gastrointestinal disorders Those who fail to get the right amount and type of We found no evidence to support food for proper nutrition antioxidant supplements for primary or People with a chronic illness secondary prevention. Vitamin A, beta- Women who are pregnant carotene, and vitamin E may increase Alcoholism mortality. January 20, 2010 PRENATAL VITAMINS DEFICIENCIES AS WE AGE VITAMIN B12Folic acid (B9)in prevention of neural tube or spinal defects Vitamin B12 (cobalamin) deficiency is particularly common in elder adultsPrevention of low birth weight Development of RBC Development of nerve cellsHelps support growth of placenta Aid in production of DNA and RNAVitamin B12 deficiency may be Aid in production of cause of infertility or neurotransmitters spontaneous abortion 400mcg/day 17
  20. 20. Causes of vitaminB12 deficiency Symptoms of vitamin B12 deficiency• Abdominal or intestinal surgery• A diet low in vitamin B12 (a strict vegetarian diet) Anemia, fatigue, tiredness• Chronic alcoholism Neurologic (muscle weakness, unsteady gait,• Crohn’s disease, atrophic gastritis, Celiac disease, numbness or tingling in fingers or toes—DM or B12) hypothyroidism (40%), Metformin (Glucophage) for type Psychiatric symptoms (dementia, cognitive 2 diabetes impairment, psychoses, depression)• PPI (Nexium, Prilosec, Prevacid) acid blocking medication Dental (bleeding gums, sore mouth and tongue)• Elderly people (common deficiency 15-20%) Lab test—methyl malonic acid ATROPHIC GLOSSITIS (Smooth Tongue) ANGULAR CHEILOSIS Nutritional deficiencyNutritional deficiency • Vit B12• Vit B12 • Folic Acid (B9)• Folic Acid (B9) • Riboflavin (B2)• Riboflavin (B2) • Niacin (B3)• Niacin (B3) • Iron• Iron • Celiac Disease• Celiac Disease--1 in 133 (gluten intolerance) BLEEDING GUMS-poor oral hygiene or….. RECURRENT APHTHOUS ULCERS  Vitamin B12  Vitamin K Nutritional deficiency  CCB (Norvasc, Cardizem) • Vit B12  Pregnancy • Folic Acid (B9)  Blood thinners (Coumadin) • Riboflavin (B2)  Chemotherapy agents • Niacin (B3)  Leukemia  Birth control pills • Iron  Immunosuppressant drugs (Cyclosporin) • Celiac Disease  Antidepressants (Zoloft, Celexa, Lexapro + NSAID) 18
  21. 21. BURNING MOUTH SYNDROME VITAMIN D Iron Zinc B vitamins—B1, 2, 6, 9, 12 ACE inhibitors---Lisinopril Diabetes Allergies Hypothyroidism Hormonal imbalance---menopause Check “mayoclinic.com” DEFICIENCY OF VITAMIN D Use of sunscreen Liver or kidney problems Aging-decrease provitamin D because of thin skin (75%) . GI disorders—Crohn disease, ulcerative colitis, Celiac disease (gluten induced) Hyperthyroidism and hyperparathyroidism No sun—Northern climate MUSCLE SORENESS* Low vitamin D—muscle pain- fall rates Statins (Zocor, Lipitor, etc--10%-15%) Peripheral vascular disease Vitamin B12 (low) Magnesium (low) Celiac Disease Hypothyroidism If your shadow is longer than you are Bisphosphonates tall, you are not making any vitamin D Drug combinations 19
  22. 22. VITAMIN D and BALANCE Vitamin D is now recognized as important for cardiovascular health and its deficiency .Can present as severe bone pain, muscle as a potential risk factor for several weakness (hard to get off chair or climb up stairs), and increased body sway that can lead cardiovascular disease processes. Am J Cardiology 2010; 106: 798-805 to falls and hip fractures. J Amer Col Cardiology July 2011; 58: 186-192 MACULAR DEGENERATION High serum 25 (OH) D concentrations may protect against early age-related macular degeneration in women younger Vitamin D in the form of vitamin D3 than 75 years. seems to decrease mortality in Arch Ophthalmol. Apr 13,2011:129(4):481-489 predominantly elderly women (mean age- 74 years). Cochrane Database Syst Rev 2011 Jul 6; CD007470 VITAMIN D AND CANCER Mayo Clinic and Collaborators Find16 year study, 88,000 women, found higher Vitamin D Levels are Associated withintakes of vitamin D associated with lower Survival in Lymphoma Patientsbreast cancer risk in premenopausal women Patients with deficient vitamin D levels had a 1.5-fold greater risk of diseaseBreast cancer--women with deficient progression and a twofold greater risk ofvitamin D levels (less then 20ng/ml) had a dying, compared to patients with optimal60% increased risk of development of vitamin D levelsmetastatic disease Dec. 5, 2009 Journal Clinical Oncology, Vol 27, Page 3757-2009 20
  23. 23. PROSTATE CANCER AND ANDROGEN DEPRIVATION THERAPY VITAMIN D AND PROSTRATE CANCER To reduce levels of male hormones (testosterone) which stimulate the growth of prostate cells and fuels the growth of cancerLaboratory and population-based Within 4 years of starting androgen therapy, 50% of men willresearch suggest that adequate levels of have osteoporosisvitamin D reduce the risk of developing More likely to have periodontal disease and osteoporosisprostate cancer J Urology-2007 Mar, 177(3): 921-4 Johns Hopkins July 2009 Need to change lifestyle - Smoking cessation - Alcohol consumption - Resistance exercise - Calcium and vitamin D supplements *Depends on lab test of Calcium and Vitamin DVITAMIN D AND PERIODONTAL DISEASE VITAMIN D AND PERIODONTAL “a low vitamin D concentration was DISEASE independently associated with periodontal An observational study in the U.K. involving post- disease.” menopausal women with osteoporosis found PD Cleveland Clinic Journal of Medicine Aug 2009 “is more common in women with osteoporosis and is associated with lower vitamin D and higher concentrations of two cytokines, RANKL and MMP J Periodontal Research. 2011 Feb VITAMIN D VITAMIN D Dose: 1000 to 2000 IU/day depending on lab Do not take if have studies Liver disease Kidney disease Lab studies range (Mayo Clinic): Hypoparathyrodism 10 ng/mL—severe deficiency Hyperparathyrodism 10-30 ng/mL—mild to moderate Sarcoidosis 30-80 ng/mL—optimum *Always check with your doctor first 21
  24. 24. CALCIUM CALCIUM Found naturally in dairy products, leafyBuilds strong structure of bones and teeth green vegetables, beans, and meat.Muscle and blood vessel contractionSecretion of hormones and enzymes May also need supplements since theTransmit impulses thru the nervous system body cannot make calcium CALCIUM SUPPLEMENTS CALCIUM SUPPLEMENTS Take with magnesium if blood test shows it is low Calcium carbonate Least expensive Do not take with thyroid, Dilantin, cortisone, Must be taken with food bisphosphonates, thiazides, Vibramycin/Periostat (take 4hours before or 4 hours after taking Ca) Calcium citrate Best if have low gastric acid Those who have liver disease, kidney disease, production and those taking high or low parathyroid levels, talk with Dr. first Nexium, Prevacid, Prilosec, to block stomach acid Do not need to take with food NEW DATA, MORE DEBATE CALCIUM SUPPLEMENTS MAY BE BAD FOR YOUR HEARTNew studies linking calcium supplements to: Those who consumed 820mg/day had a 31%• Increased risk for heart attack and stroke lower risk of heart attacks then those who• Vascular calcification consumed less from their diet.• Kidney stones Those who got calcium from BMJ APRIL 2010 supplements were twice as likely to have a heart attack as OhMyGosh those who took no supplementsI have been taking to much 24,000 people for 11 years Heart: May 23, 2012 22
  25. 25. WOMAN’S HEALTH INITIATIVE CALCIUM INTAKE: MORE IS NOT BETTER Calculate how much you are eatingWomen who took 1000mg of calcium daily through food and balance off the rest withhad 17% more kidney stones then those supplements so it equals 1,200 milligramswho got a placebo of calcium a day for women older than 50.36,000 women/ 15 yearsCaveat –women were allowed to eat their usual diet, so calcium intake was unknown RISK FACTORS FOR OSTEOPOROSIS DRUGS ASSOCIATED WITH LOW BONE MINERAL DENSITY• Aging and estrogen deficiency Steroids• Smoking, alcohol Antiepileptic drugs (Dilantin, Tegretol, Neurotin)• Sedentary lifestyle Nexium, Prilosec, Pepcid, Zantac• Low vitamin D Coumadin Actos or Avandia• Gastric bypass• Type 1 diabetes ACTONEL, BONIVA, FOSAMAXCalcium and vitamin D supplementationhad a modest positive effect on periodontal Arthritis of the joints (primarily in thehealth on those subjects receiving jaw) has been reported in patients takingperiodontal maintenance therapy. bisphosphonates.J Periodont 2011:82:25-32 Bisphosphonates may cause bone, joint, and muscle pain. 23
  26. 26. A Manual of Physical activity and eating a proper diet can Laboratory and mitigate progression of chronic disease and in fact Diagnostic Tests reverse existing disease by Frances Fischbach Lab Tests • Vitamin B12 • Vitamin D • Calcium • HgA1c • Iron • tTGA Whole grains contain the germ, bran, and endosperm. Refined grains retain only the endosperm Gluten is the protein part of the endosperm (83% of the kernel) *cause of celiac disease CELIAC DISEASE an ORAL MANIFESTATIONS OF AUTO IMMUNE DISEASESymptoms CELIAC DISEASE• Stomach pain • Recurrent aphthous ulcers• Diarrhea • Atrophic glossitis• Depression • Oral lichen planus• Fatigue • Cheilosis• Weight loss• Osteoporosis• Mouth sores• Muscle cramps• No symptoms 80% not diagnosed 1 out of 133 people 24
  27. 27. ORAL MANIFESTATIONS OF Let Them Eat Dirt: How Clean Environments May Set Up Kids for Immune Problems CELIAC DISEASE Enamel Defects in Children WHOLE GRAINS WHITE OR WHEAT FLOUR • Rolled oats • Whole wheat flour BRAN AND GERM OUT • Whole ryeTHIAMIN (B1), RIBOFLAVIN (B2), NIACIN (B3) • Brown riceZINC, FOLIC ACID, MANGESIUM, COPPER • Wild rice • Whole cornmealPHOSPHORUS, IRON, CALCIUM,SODIUM, • PopcornAMINO ACIDS, ANTIOXIDANTS, FIBER, PLUS • Barley15 MORE • Quinoa • Spelt INTO THE BREAD • Couscous • AmaranthVITAMIN B1, B2 , B3, IRON, FOLIC ACID • Wheat berries (Molasses or Carmel)WHOLE GRAINS REDUCEHEART DISEASESTROKECANCER Wheat flour Durum wheatDIABETES Unbleached flour Enriched flour Semolina MultigrainOBESITY Cracked wheat DON’T BE TRICKED THESE ARE NOT THE SAME AS “WHOLE WHEAT” or “MULTI-GRAIN WHOLE GRAIN” 25
  28. 28. Cold Cereals Hot Cereals Mostly refined Mostly refinedWhole grain Whole grain grain grainCheerios Basic 4 Oat bran Cream of riceGranola or muesli Corn flakes Oatmeal Cream of wheatGrape-Nuts Frosted Flakes Quaker Multigrain GritsNutri-Grain Just Right Ralston High • FiberRaisin bran Kix, Corn Pops Roman Meal •Shredded wheat Product 19 WheatenaTotal Puffed wheatWheat germ Rice KrispiesWheaties Special K • 51 51 Gm Sugar=17 packetsIF YOU WANT TO BE FUNCTIONAL See a physical therapist first if you AT 80 have joint problems YOU NEED TO START AT 50 Don’t compare yourself with others Keep track of your progress Be realistic. Set goals loosely Forget the past Check with your Dr. 26
  29. 29. Benefits of Exercise Women who walk 2 or more hours a week, especially at a brisk pace, areImproves• Mood significantly less likely to experience• Self confidence any type of stroke than women who do• Sense of well-being• Have a better sex life! • Post surgical not walk. recovery is faster • Increases weight loss Woman’s Health Study 4-13-2010 • Emphysema Reduces 39,315 women, 45 years or older • Increases joint • Stress function-arthritis • Depression • Anxiety Decreases • Blood pressure • CHD by 30% • Blood sugar • Stroke by 30% • Bone mineral • Type II Diabetes by 30% loss • Medication dosage Pedometer Benefits of using Pedometers Helps you realize just how active you are (or are not) in your everyday life Gives you a visible cue to see how far you are walking Acts as a motivator Inspiration on a daily basis Impact of Physical Activity on Cancer EXERCISE AND BREAST CANCER PRIMARY PREVENTION Accelerates movement of food through intestine, Increasing physical activity, even if reducing time bowel lining is exposed to mutagens. started later in life, reduces overall risk of developing breast cancer by 20%. Reduce risk of colon, breast, C Brown et at M.C. Anderson Cancer Center 2009 prostate, and other cancers 27
  30. 30. Primary and secondary prevention Exercise does not have to be a workout at the gym of hormone driven cancers Health clubs provides instruction, supervision, equipment, and motivationExercise The key is doing some type of moderate exerciseVitamin D routinely--time of dayGood dietLose weight 9 MONTHS!!!!! A Dip in the Pool Does an AgingBy the age of 65, many seniors have Body Goodlost 30-40% of their muscle mass Swimming reduces blood pressure, improves artery health and boosts endurance in COPD in elderly adults American Journal of Cardiology July, 2011 Aging Exercise is MedicineProgressive weight gainDecreased metabolismLoss of muscle massDecrease in pancreatic beta-cell functionAdverse distensibility of the arterial tree With No Side Effects 28
  31. 31. PROCRASTINATION PERSEVERANCE jclichon@aol.com 29