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  • 1. 9/19/2011 BIO4360       Oral Medicine Etiology of Pathologies II Monday, Sept. 19th, 2011Algonquin College Oral Medicine BIO4360 © Dr. Jim Panchuk 2011 ‘MIND’ Algorithm Metabolic Inflammatory Neoplasms Developmental Metabolic a) Hormonal b) Nutritional c) Compromised Organ Systems Inflammatory a) Trauma b) Infection – viral, fungal, bacterial c)Immunologic - autoimmuneAlgonquin College Oral Medicine BIO4360 © Dr. Jim Panchuk 2011 1
  • 2. 9/19/2011 ‘MIND’ Algorithm Inflammatory – c) immunologic i) immune response to body’s own antigens (autoimmune) -pemphigus, pemphigoid ii) allergic reaction to external antigen - cinnamon, toothpaste, medications, etc.Algonquin College Oral Medicine BIO4360 © Dr. Jim Panchuk 2011 ‘MIND’ Algorithm Inflammatory – c) immunologic i) immune response to body’s own antigens (autoimmune) -pemphigus, pemphigoid ii) allergic reaction to external antigen - cinnamon, toothpaste, medications, etc. Inflammatory – d) reactive -body’s response to chronic, physical irritation -papillary hyperplasia, pyogenic granuloma, epulis fissuratumAlgonquin College Oral Medicine BIO4360 © Dr. Jim Panchuk 2011 2
  • 3. 9/19/2011 ‘MIND’ Algorithm Neoplasms – benign, premalignant, malignant -usually some change in surface colour &/or texture - +or- swelling &/or pain -usually one location and enlarges from that point -risk factors (tobacco &/or alcohol)Algonquin College Oral Medicine BIO4360 © Dr. Jim Panchuk 2011 ‘MIND’ Algorithm Neoplasms – benign, premalignant, malignant -usually some change in surface colour &/or texture - +or- swelling &/or pain -usually one location and enlarges from that point -risk factors (tobacco &/or alcohol) Developmental -genetic – Basal Cell Nevus (mole), Macule -acquired – cleft palate -other – geog. tongue, leukodemaAlgonquin College Oral Medicine BIO4360 © Dr. Jim Panchuk 2011 3
  • 4. 9/19/2011 12 Questions to Ask “Listen to your patient and the patient will give you the diagnosis” Sir William OslerAlgonquin College Oral Medicine BIO4360 © Dr. Jim Panchuk 2011 12 Questions to Ask 1) How long has the problem been present? -if <2-3 weeks more likely inflammatory etiology -less likely developmental, neoplasm, metabolic -if > 5-6 wks poss. of neoplasm 2) Has it happened previously, and, if so, did it go away completely? -if occurred before and healed completely chance of neoplasm is minimal -inflammatory more likely -infectious (herpes, recurrent fungal infection) -immunologic (apthous ulcer, lichen planus)Algonquin College Oral Medicine BIO4360 © Dr. Jim Panchuk 2011 4
  • 5. 9/19/2011 12 Questions to Ask 3) Is it happening (has it occurred) in other locations in your mouth -multiple locations almost always rule out neoplasms - likelihood of trauma -location also important ex: attached vs. unattachedAlgonquin College Oral Medicine BIO4360 © Dr. Jim Panchuk 2011 12 Questions to Ask 3) Is it happening (has it occurred) in other locations in your mouth -multiple locations almost always rule out neoplasms - likelihood of trauma -location also important ex: attached vs. unattached 4) Does it hurt? And if it does, chose one word to describe the pain. -one of 4 aspects of inflammation -‘burning’ more chance of fungal etiology ***important to let patient chose word***Algonquin College Oral Medicine BIO4360 © Dr. Jim Panchuk 2011 5
  • 6. 9/19/2011 12 Questions to Ask 5) Has it grown/become worse/spread to other spots? +ve response (along with location) will affect prob. of metabolic etiolology -or neoplasm, esp. malignancy which will grow in size but seldom spread Remember….all questions build on each other Must link info gained from various questions Ex: pain for 4 weeks, several locations, pain is more ‘burning, seems to be spreading slightly….. Likelihood of fungal infection is fairly highAlgonquin College Oral Medicine BIO4360 © Dr. Jim Panchuk 2011 12 Questions to Ask 6) What can you do/have you done that makes it better or worse? -if stopped using product and it resolved…immunologic -hypersensitivity/allergic rxn -improves with salt water, worsens with orange juice -ulceration/erosionAlgonquin College Oral Medicine BIO4360 © Dr. Jim Panchuk 2011 6
  • 7. 9/19/2011 12 Questions to Ask 6) What can you do/have you done that makes it better or worse? -if stopped using product and it resolved…immunologic -hypersensitivity/allergic rxn -improves with salt water, worsens with orange juice -ulceration/erosion 7) Does it come and go/change during the day? -if rapid change…….trauma related -if stress related…..less in morning, worse later in day -around mealtime?Algonquin College Oral Medicine BIO4360 © Dr. Jim Panchuk 2011 12 Questions to Ask 8) Do you remember injuring the area of the lesion? -identify trauma or recurrent traumaAlgonquin College Oral Medicine BIO4360 © Dr. Jim Panchuk 2011 7
  • 8. 9/19/2011 12 Questions to Ask 8) Do you remember injuring the area of the lesion? -identify trauma or recurrent trauma 9) Do you have any lesions on other parts of your body? -increased potential for immunologic cause -auto-immune diseases with dermatologic symptoms -some developmental lesions also have skin changes (café au lait spots)Algonquin College Oral Medicine BIO4360 © Dr. Jim Panchuk 2011 12 Questions to Ask 8) Do you remember injuring the area of the lesion? -identify trauma or recurrent trauma 9) Do you have any lesions on other parts of your body? -increased potential for immunologic cause -auto-immune diseases with dermatologic symptoms -some developmental lesions also have skin changesAlgonquin College Oral Medicine BIO4360 © Dr. Jim Panchuk 2011 8
  • 9. 9/19/2011 12 Questions to Ask 10) Do other people in your family have anything similar? -family Hx points to developmental problem (usually)Algonquin College Oral Medicine BIO4360 © Dr. Jim Panchuk 2011 12 Questions to Ask 10) Do other people in your family have anything similar? -family Hx points to developmental problem (usually) 11) How is your general health? Other than the oral problem, do you feel medically well? -if ‘yes’ less likely due to metabolic or systemic diseaseAlgonquin College Oral Medicine BIO4360 © Dr. Jim Panchuk 2011 9
  • 10. 9/19/2011 12 Questions to Ask 10) Do other people in your family have anything similar? -family Hx points to developmental problem (usually) 11) How is your general health? Other than the oral problem, do you feel medically well? -if ‘yes’ less likely due to metabolic or systemic disease 12) Are you taking any medication for any reason currently or were you taking medication recently? -verifies info about general health -oral effects of medsAlgonquin College Oral Medicine BIO4360 © Dr. Jim Panchuk 2011 12 Questions to Ask REMEMBER: -intra-oral exam is NOT all that’s required to arrive at diagnosis -need to combine with info gained from questioning -either confirm Dx or lead to next step in tmt plan -biopsy, drug therapy, or ‘watchful waiting’ depends on suspected etiologyAlgonquin College Oral Medicine BIO4360 © Dr. Jim Panchuk 2011 10
  • 11. 9/19/2011 12 Questions to Ask -some conditions have multiple etiologies Ex: AIDS, Leukemia are Metabolic (compromised organ system -but oral problems typically of the Inflammation category (infection) -MIND does not include conditions secondary to psychologic problems -anxiety, phobias, self-inflicted traumaAlgonquin College Oral Medicine BIO4360 © Dr. Jim Panchuk 2011 Available OnlineAlgonquin College Oral Medicine BIO4360 © Dr. Jim Panchuk 2011 11
  • 12. 9/19/2011 BIO4360       Oral Medicine Herbal Products and Supplements Monday, Sept. 19th, 2011Algonquin College Oral Medicine BIO4360 © Dr. Jim Panchuk 2011 Come One, Come allAlgonquin College Oral Medicine BIO4360 © Dr. Jim Panchuk 2011 12
  • 13. 9/19/2011 Come One, Come allAlgonquin College Oral Medicine BIO4360 © Dr. Jim Panchuk 2011 Come One, Come allAlgonquin College Oral Medicine BIO4360 © Dr. Jim Panchuk 2011 13
  • 14. 9/19/2011 Disclaimer The products and the claims made about specific products on or through this site have not been evaluated by Herbal Remedies or the United States Food and Drug Administration and are not approved to diagnose, treat, cure or prevent disease. The information provided on this site is for informational purposes only and is not intended as a substitute for advice from your physician or other health care professional or any information contained on or in any product label or packaging. You should not use the information on this site for diagnosis or treatment of any health problem or for prescription of any medication or other treatment. You should consult with a health care professional before starting any diet, exercise or supplementation program, before taking any medication, or if you have or suspect you might have a health problem.Algonquin College Oral Medicine BIO4360 © Dr. Jim Panchuk 2011Algonquin College Oral Medicine BIO4360 © Dr. Jim Panchuk 2011 14
  • 15. 9/19/2011Algonquin College Oral Medicine BIO4360 © Dr. Jim Panchuk 2011Algonquin College Oral Medicine BIO4360 © Dr. Jim Panchuk 2011 15
  • 16. 9/19/2011Algonquin College Oral Medicine BIO4360 © Dr. Jim Panchuk 2011 Beliefs -Canadian studies have shown herbal medicines being used by 30-35% of people “Patients often believe that herbs are natural alternatives to prescription medications, and do not recognize that herbs are composed of bio-active chemicals which may be toxic and can interact with other medications” Arch Fam Med 1998;7(6):523-36 "Better Living Through Chemistry"Algonquin College Oral Medicine BIO4360 © Dr. Jim Panchuk 2011 16
  • 17. 9/19/2011 Beliefs -Canadian studies have shown herbal medicines being used by 30-35% of people “Patients often believe that herbs are natural alternatives to prescription medications, and do not recognize that herbs are composed of bio-active chemicals which may be toxic and can interact with other medications” Arch Fam Med 1998;7(6):523-36 "The miracles of science"Algonquin College Oral Medicine BIO4360 © Dr. Jim Panchuk 2011 Ethnobotany Botany + AnthropologyAlgonquin College Oral Medicine BIO4360 © Dr. Jim Panchuk 2011 17
  • 18. 9/19/2011 Ethnobotany Botany + AnthropologyAlgonquin College Oral Medicine BIO4360 © Dr. Jim Panchuk 2011 Ethnobotany Botany + Anthropology Phillippus Aureolus Paracelsus 1493-1541AD “It’s the dose that makes the poison”Algonquin College Oral Medicine BIO4360 © Dr. Jim Panchuk 2011 18
  • 19. 9/19/2011 Ethnobotany Poisonous plants are medicinal plants & Medicinal plants are poisonous plants Herbal medications are importantAlgonquin College Oral Medicine BIO4360 © Dr. Jim Panchuk 2011 Ethnobotany Poisonous plants are medicinal plants & Medicinal plants are poisonous plants Herbal medications are importantAlgonquin College Oral Medicine BIO4360 © Dr. Jim Panchuk 2011 19
  • 20. 9/19/2011 Herbal based Medicines -1900’s – herbal supplements hallmarks of pharmaceutical industry -67% of all medicine listed in US Pharmacopeia were botanicals……now only 2% - >1/2 of “modern” prescription & OTC drugs have botanical origins (aspirin, caffeine, cyclosporine, digoxin, quinine)Algonquin College Oral Medicine BIO4360 © Dr. Jim Panchuk 2011 Herbal based Medicines -1900’s – herbal supplements hallmarks of pharmaceutical industry -67% of all medicine listed in US Pharmacopeia were botanicals……now only 2% - >1/2 of “modern” prescription & OTC drugs have botanical origins (aspirin, caffeine, cyclosporine, digoxin, quinine) -ethnobotany very important - < 0.5% of the world’s vanishing tropical plant species have been investigated for their medicinal qualitiesAlgonquin College Oral Medicine BIO4360 © Dr. Jim Panchuk 2011 20
  • 21. 9/19/2011 Herbal Medicine ~7000 plants have medicinal applications -75% of world’s pop’n rely on plants for health care -in NA most use for prevention and health maintenance -pharmaceuticals target symptomatic/curative medicine -majority of knowledge on plant derived medicine is traditional -Herbals reputation hampered by: -lack of standardization -lack of clinically verifiable safety and efficacyAlgonquin College Oral Medicine BIO4360 © Dr. Jim Panchuk 2011 Definitions Dietary Supplement (DSHEA): a product (other than tobacco) that: -Is intended to supplement the diet -Contains one or more dietary ingredients or their constituents -Is intended to be taken by mouth -Is labeled as being a dietary supplement.Algonquin College Oral Medicine BIO4360 © Dr. Jim Panchuk 2011 21
  • 22. 9/19/2011 Definitions Herbal supplements: -are one type of dietary supplement -An herb is a plant or plant part (leaves, flowers, seeds, roots) that is used for its flavor, scent, and/or therapeutic properties -"Botanical" is often used as a synonym for "herb." -may contain a single herb or mixtures of herbs.Algonquin College Oral Medicine BIO4360 © Dr. Jim Panchuk 2011 Regulations (USA) -US Dietary Supplement Health and Education Act (1994) -compromise -exempts vitamins, minerals, & botanical products from meaningful FDA regulationAlgonquin College Oral Medicine BIO4360 © Dr. Jim Panchuk 2011 22
  • 23. 9/19/2011 Regulations (USA) -US Dietary Supplement Health and Education Act (1994) -compromise -exempts vitamins, minerals, & botanical products from meaningful FDA regulation -burden of proof? -2006 – Changes to Federal food, Drug and Cosmetic Act -require industry to report all serious dietary supplement related adverse drug effects to the FDA -2007-10 – manufacturers must test for purity, -ensure no contaminants -verify contents match labeling informationAlgonquin College Oral Medicine BIO4360 © Dr. Jim Panchuk 2011 Regulations (USA) -Labeling according to the DSHEA: -prevents use of therapeutic claim ex: “for treatment of hypertension” -must be labeled as dietary supplement -CAN contain claims of effect on structure or function of body (ex: increases immunity)Algonquin College Oral Medicine BIO4360 © Dr. Jim Panchuk 2011 23
  • 24. 9/19/2011Algonquin College Oral Medicine BIO4360 © Dr. Jim Panchuk 2011 Regulations (USA) -Labeling according to the DSHEA: -prevents use of therapeutic claim ex: “for treatment of hypertension” -must be labeled as dietary supplement -CAN contain claims of effect on structure or function of body (ex: increases immunity) -info does not have to be scientific, but cannot be false or misleading (responsibility in hands of FDA) Multiple violations / near violationsAlgonquin College Oral Medicine BIO4360 © Dr. Jim Panchuk 2011 24
  • 25. 9/19/2011 Regulations (USA) … your webpage …. bears the following claim: "[F]our recent studies in people at risk for coronary disease have shown a significant cholesterol lowering effect from tea or tea flavonoids ... One of these studies, on post-menopausal women, found that total cholesterol was lowered by 8% after drinking 8 cups of green tea daily for 12 weeks ....“ The therapeutic claims on your website establish that the product is a drug because it is intended for use in the cure, mitigation, treatment, or prevention of disease.Algonquin College Oral Medicine BIO4360 © Dr. Jim Panchuk 2011 Regulations (USA) Your Sparkling Green Tea Ginger Ale bears the claim, "ENHANCED WITH 200 mg OF ANTIOXIDANTS FROM GREEN TEA & VITAMIN C**" with the double asterisk referring to the statement, "* *Each 8 oz serving contains 200 mg of antioxidants from Green Tea Flavonoids and Vitamin C" on the principal display panel of the product label. In the context of this label the term "enhanced" is an unauthorized synonym for a "more" nutrient content claim. FDA has defined the nutrient content claim "more" and its authorized synonyms in 21 CFR 101.54(e).Algonquin College Oral Medicine BIO4360 © Dr. Jim Panchuk 2011 25
  • 26. 9/19/2011 Regulations (USA) -Labeling according to the DSHEA: -prevents use of therapeutic claim ex: “for treatment of hypertension” -must be labeled as dietary supplement -CAN contain claims of effect on structure or function of body (ex: increases immunity) -info does not have to be scientific, but cannot be false or misleading (responsibility in hands of FDA) -information can be physically separate from the product (ie: product on one shelf, info in another isle) HUH?????Algonquin College Oral Medicine BIO4360 © Dr. Jim Panchuk 2011 Regulations (Canada) Canada: Natural Health Product Regulations (2004) -allowed for sale of products otherwise not allowed under the Food and Drug Regulations -pre-2004 natural health products either drugs, or foods (Food and Drug Act)Algonquin College Oral Medicine BIO4360 © Dr. Jim Panchuk 2011 26
  • 27. 9/19/2011 Regulations (Canada) Canada: Natural Health Product Regulations (2004) -allowed for sale of products otherwise not allowed under the Food and Drug Regulations -pre-2004 natural health products either drugs, or foods (Food and Drug Act) -different sets of reg’s for cosmetics, foods, drugs, etc. -burden of proof variesAlgonquin College Oral Medicine BIO4360 © Dr. Jim Panchuk 2011 Regulations (Canada) Canada: Natural Health Product Regulations (2004) -allowed for sale of products otherwise not allowed under the Food and Drug Regulations -pre-2004 natural health products either drugs, or foods (Food and Drug Act) -different sets of reg’s for cosmetics, foods, drugs, etc. -burden of proof variesAlgonquin College Oral Medicine BIO4360 © Dr. Jim Panchuk 2011 27
  • 28. 9/19/2011 Regulations (Canada) Canada: Natural Health Product Regulations (2004) Natural health products (NHPs) are defined as: -vitamins and minerals, -herbal remedies (ex: St. John’s Wort), -homeopathic medicines ** -traditional medicines (Traditional Chinese Medicines), -probiotics,Algonquin College Oral Medicine BIO4360 © Dr. Jim Panchuk 2011 Regulations (Canada) Canada: Natural Health Product Regulations (2004) Natural health products (NHPs) are defined as: -vitamins and minerals, -herbal remedies (ex: St. John’s Wort), -homeopathic medicines ** -traditional medicines (Traditional Chinese Medicines), -probiotics,Algonquin College Oral Medicine BIO4360 © Dr. Jim Panchuk 2011 28
  • 29. 9/19/2011 Regulations (Canada) Canada: Natural Health Product Regulations (2004) Natural health products (NHPs) are defined as: -vitamins and minerals, -herbal remedies (ex: St. John’s Wort), -homeopathic medicines ** -traditional medicines (Traditional Chinese Medicines), -probiotics, -other products like amino acids and essential fatty acids.Algonquin College Oral Medicine BIO4360 © Dr. Jim Panchuk 2011 Canadian DatabaseAlgonquin College Oral Medicine BIO4360 © Dr. Jim Panchuk 2011 29
  • 30. 9/19/2011 Labeling Requirements (Can) Brand Name Product/Herb Name Structure/Function Claims Disclaimer Number of Product and Net Weight of Each Directions for use Supplement Facts Manufacturer’s or distributor’s name, city, state, zip code Expiration dateAlgonquin College Oral Medicine BIO4360 © Dr. Jim Panchuk 2011 Energy Drinks -call for Health Canada to get involved with regulating -if considered ‘foods’ only have to list ingredients -talks about natural product not having to label caffeine containing herbal ingredients -if ‘natural health products’ also have to have appropriate warnings packs 505 mg of caffeine and 5000 mg of taurine Beverage…..or drug delivery systems??Algonquin College Oral Medicine BIO4360 © Dr. Jim Panchuk 2011 30
  • 31. 9/19/2011 Energy Drinks -call for Health Canada to get involved with regulating -if considered ‘foods’ only have to list ingredients -talks about natural product not having to label caffeine containing herbal ingredients -if ‘natural health products’ also have to have appropriate warnings packs 505 mg of caffeine and 5000 mg of taurine Beverage…..or drug delivery systems??Algonquin College Oral Medicine BIO4360 © Dr. Jim Panchuk 2011 Energy DrinksAlgonquin College Oral Medicine BIO4360 © Dr. Jim Panchuk 2011 31
  • 32. 9/19/2011 Energy DrinksAlgonquin College Oral Medicine BIO4360 © Dr. Jim Panchuk 2011 Energy DrinksAlgonquin College Oral Medicine BIO4360 © Dr. Jim Panchuk 2011 32
  • 33. 9/19/2011 Alcoholic Energy DrinksAlgonquin College Oral Medicine BIO4360 © Dr. Jim Panchuk 2011 Alcoholic Energy DrinksAlgonquin College Oral Medicine BIO4360 © Dr. Jim Panchuk 2011 33

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