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  1. 1. ADA 2003 How to Get Patients to Say Yes to Periodontal TreatmentDear Colleagues - A Reminder: PLEASE get the research to your patients, all day, every day, every way.Include information in your newsletter and add patient education to your statements. Be sure to haveinformation in reception, at the desk and in all treatment rooms. Check your local newspapers forarticles relating to dental health, perio, appearance - related dentistry. Consider offering your servicesto the local paper and write articles as well as radio and TV spots. It is important that patients receivedental information from their dental health care professional (that’s us!) It is important and it works……OUR DENTAL TEAM IS COMMITTED TO STAYING ABREAST OF CURRENT RESEARCH INDENTISTRY. IN THE INTEREST OF GOOD HEALTH, PLEASE BE AWARE OF THE LATESTRESEARCH REGARDING PERIODONTAL DISEASE, HEART DISEASE, CHRONIC INFECTIONS &OTHER RELATED H E A L T H I S S U E S ……… RECENT AND RELEVANT RESEARCH Published by the American Heart Association The Journal STROKE (1997,28:1724) Chronic infections such as dental infections or chronic bronchitis may more than double the risk of stroke, The findings are consistent with earlier reports of a link between chronic infections and atherosclerosis. A study reported at the University of North Carolina showed increased risk of heart disease and stroke in people with periodontal disease. (Beck, Garcia, Heiss, Offenbacher, Vokonas: J of Periodontology 67:1123, 1996) People with heart disease or primary cardiac event are now being referred to their dentists to “get their mouth cleaned up”. Patients with frequent bouts of bronchitis in preceding two years have a greater risk for stroke and TIAS. In addition, those with poor dental status, linked to gum disease, were at a 2.6 times greater risk for stroke or TIAS. Dentists are reporting: “Before we could tell people to brush and floss or you might lose your teeth. But now we are saying to brush and floss, it COULD SAVE YOUR LIFE.” Study: Inflammation Worst Heart Attack Risk Associated Press November 2002 BOSTON A landmark study offers the strongest evidence yet that simmering, painless inflammation deep within the body is the single most powerful trigger of heart attacks, worse even than high cholesterol. The latest research is likely to encourage many doctors to make blood tests for inflammation part of standard physical exams for middle-age people, especially those with other conditions that increase their risk of heart trouble. The study, based on nearly 28,000 women, is by far the largest to look at inflammations role and it shows that those with high levels are twice as likely as those with high cholesterol to die from heart attacks and strokes. Over the past five years, re- search by Dr. Paul Ridker of Bostons Brigham and Womens Hospital has built the case for the "inflammation hypothesis." With his latest study, many believe the evidence is overwhelming that inflammation is a central factor in cardiovascular disease, by far the worlds biggest killer. "I dont think its a hypothesis anymore. Its proven," said Dr. Eric Topol, chief of cardiology at the Cleveland Clinic. Inflammation can be measured with a test that checks for C- re- active protein, or CRP, a chemical necessary for fighting injury and infection. The test typically costs between $25 and $50. Diet and exercise can lower CRP dramatically. Cholesterol- lowering drugs called statins also reduce CRP, as do aspirin and some other medicines. Doctors believe inflammation has many possible sources. Often, the fatty build-ups that line the blood vessels become inflamed as white blood cells invade in a misguided defense attempt. Fat cells are also known to turn out these inflammatory proteins. Other possible triggers include high blood pressure, smoking and lingering low-level infections, such as chronic gum disease. Inflammation is thought to weaken the fatty build-ups, or plaques, making them more likely to burst. A piece of plaque can then lead to a clot that can choke off the blood flow and cause a heart attack. For the first time, Ridkers study establishes what level of CRP should be considered worrisome, so doctors can make sense of patients readings. ……please help us help you…… Call to schedule your dental appointment today
  2. 2. RECENT AND RELEVANT RESEARCH Published by the American Heart Association The Journal STROKE (1997; 28: 1724-1729) Chronic infections such as dental infections or chronic bronchitis may more than doublethe risk of stroke, according to a report in the journal Stroke. The findings are consistent withearlier reports of a link between chronic infections and atherosclerosis. A study reported atthe University of North Carolina showed increased risk of heart disease and stroke in peoplewith periodontal disease. People with heart disease or a primary cardiac event are now beingreferred to periodontists to "get their mouth cleaned up." A new study in Germany byneurologist Dr. Armin Grau of Heidelberg University compared the rate of dental and otherchronic infections .Those patients with frequent bouts of chronic bronchitis in the preceding two years had a 2.2times greater risk for stroke or TIAs. In addition, those with poor dental status (linked to gumdisease) were at a 2.6 times greater risk for stroke or TIAs. "Chronic infection is a treatablecondition and for preventive purposes, it appears important to elucidate its role as a potentialstroke risk factor," Grau and his colleagues conclude. "Before, we could tell people to brush and General dentists are now stating:floss or you might lose your teeth. But now we are saying brush andfloss, it could save your life." From the desk of Annette Ashley Linder, B.S., R.D.H. A hygienist from a “new” client office called to report the following because she was so excited. Thispractice is a mature 25 year fine practice in a major northeast city. Three mature and tenuredhygienists with the senior hygienist of over 20 years experience working full time and two (long term)hygienists working part time to fill the week. Marie has been with the practice for almost 15 years andthe others for 8 and 10 yrs. Their concerns were similar to yours. “What to say to the long term patientsand those difficult ones.” Marie called to tell me the following experience: Patient of record, difficult patient, hard to get in, always in a hurry when he does get in,busy and successful businessman-type. (Sound familiar? We all know and have these patients).He “just wanted his teeth cleaned - in a hurry today - no time for perio exam” Marie proceeded withroutine prophy and continued to discuss perio / his bleeding tissues, etc. She had placed currentresearch article (perio systemic) in the clear Lucite File holders they have on the wall. The patientnoticed the heading about perio and heart disease - took the article with him to read when “hegot back to the office.” Patient called the office later the same day with a complete change of heart..was very concerned and immediately scheduled a return appointment for examination. Inaddition, and this really excited the entire team, when he called the office to schedule he askedthe scheduling coordinator if there was more that he could do to “keep his mouth clean” until he gotback into the dental office!! All 3 hygienists, doctor and the entire team are so excited and pleasedwith the positive responses they are receiving from the patients of record. Incidentally, in the first month since working with this team, hygiene increased 47%(from 13,000 to over 21,000 in the month.) Small physical office space, 4 tx rooms, 2assistants and 1.5 business staff. They have barely begun to go with the new format buthygienists and Doctor report how much better they all feel about their work and how easy to getpatients involved using my Co-Examination format.
  3. 3. Records Update #456 Office Use Only MEDICAL HISTORY UPDATE SINCE YOUR LAST DENTAL APPOINTMENT: CONTACT PHONE NUMBERS: WORK________________ HOME __________________CELL ___________PAGER__________Email_______ Tobacco Y_____N_____ Date of last visit to physician_______________________ For what purpose______________________ Have there been any changes in your health history, new allergies? No _________ Yes __________________ Please list current medications including aspirin, vitamins, herbals__________________________________ ________________________________________________________________________________ Have you been hospitalized? No__________ Yes, for what purpose_________________________________ Please list any and all surgeries, specific replacement (knee, hip) ____________________________________ _________________________________________________________________________________ Are you required / did you / take medication (as prescribed by American heart Assoc) prior to treatment? Yes _____ No__ Date Signature SINCE YOUR LAST DENTAL APPOINTMENT: CONTACT PHONE NUMBERS : WORK________________ HOME __________________CELL ___________PAGER__________Email_______ Tobacco Y_____N_____ Date of last visit to physician_______________________ For what purpose______________________ Have there been any changes in your health history, new allergies? No _________ Yes __________________ Please list current medications including aspirin, vitamins, herbals__________________________________ ________________________________________________________________________________ Have you been hospitalized? No__________ Yes, for what purpose_________________________________ Please list any and all surgeries, specific replacement (knee, hip) ____________________________________ _________________________________________________________________________________ Are you required / did you / take medication (as prescribed by American heart Assoc) prior to treatment? Yes _____ No__ Date Signature SINCE YOUR LAST DENTAL APPOINTMENT: CONTACT PHONE NUMBERS : WORK________________ HOME __________________CELL ___________PAGER__________Email_______ Tobacco Y_____N_____ Date of last visit to physician_______________________ For what purpose______________________ Have there been any changes in your health history, new allergies? No _________ Yes __________________ Please list current medications including aspirin, vitamins, herbals__________________________________ ________________________________________________________________________________ Have you been hospitalized? No__________ Yes, for what purpose_________________________________ Please list any and all surgeries, specific replacement (knee, hip) ____________________________________ _________________________________________________________________________________ Are you required / did you / take medication (as prescribed by American heart Assoc) prior to treatment? Yes _____ No__ Date Signature Patient completes “short form” health history during intervening visits (typically hygiene- recall appt).
  4. 4. Your office letterhead IMPORTANT INFORMATION FOR OUR PATIENTS REGARDING PERIODONTAL DISEASEDATE____________ PATIENT_____________________________________________Periodontal disease is a bacterial infection of the gums and bone caused by the bacteria found indental plaque. If the plaque is allowed to remain and grow on the teeth, an inflammation of thegums called GINGIVITIS occurs. It is estimated to affect 4 out of every 5 people. As the diseaseprogresses the pockets of bacteria deepen, destroying the bone that holds the teeth in themouth. This results in tooth loss. Unlike most diseases that give us early warning signs, gumdisease (periodontal disease) may progress silently, often without pain or overt symptoms thatwould alert you to its presence. It may develop slowly or progress very rapidlyOf great concern to the dental community is the most recent research that demonstrates a linkbetween periodontal disease and chronic infections, cardiovascular diseases and low birthweight babies. With this in mind, please be aware of the following signs and symptoms andcheck if you are aware of any of these symptoms in your mouth: VISIBLE SIGNS • Gums that bleed when you brush your teeth. • Gums that are red, swollen, or tender. • Gums that have pulled away from your teeth. • Permanent teeth that are loose or separating. • Changes in the way your teeth fit together when biting. • Any changes in the fit of partial dentures. • Pus between your teeth and gums. • Chronic bad breath or bad taste. INVISIBLE SIGNS1. Abnormal spaces (periodontal pockets) developing between the teeth and gums.2. Loss of the bone and connective tissue that normally surrounds and supports the teeth.We are committed to your good health. If you or anyone you know is experiencing thesesymptoms, call our office immediately so that we may arrange an appointment for a periodontalscreening examination. Thank you.Source: American Dental Association • THIS FORM IS GIVEN TO THE PATIENT UPON ENTRY TO THE PRACTICE • COMPLETED IN RECEPTION • HYGIENE PATIENTS AND NEW PATIENTS  ERIODONTAL   ESEARCH   PDATE   KEY   OINTS     TOPICSP   R    U :     P     &      
  5. 5. I. BACTERIAL INDUCED INFECTION Host Mediated • Presence of Pathogens - over 350 species in the oral cavity, 192 sites, 12 to 15 periodontal pathogens, as perio markers, microbial complexes found in subgingival BIOFILM AA P. gingivalis P. intermedia B. forsythus, Wolinella Rectus T. denticola • Endotoxin, LPS - lipopolysaccharide produced by gram negative bacteria is toxic to living tissue; destroys cell walls; may aid in triggering over response of immune system • Genetic testing, DNA, chairside tests for enzyme and antibody levels • Incurable but controllable (non-refractory diseases) chronicII. HOST IMMUNE RESPONSE IMMUNO - INFLAMMATORY Inadequate and/or unregulated immunological response Impaired neutrophils Asynchronous Burst Theory Episodic, site specific Medical comparable: arthritis, TB, connective tissue Host containment systemIII. RISK FACTORS IDENTIFIED INNATE & ACQUIRED   LOCAL SYSTEMIC Restorative needs Age, ethnicity, health, chronic illnesses Furcations, mobility Diabetes, radiation or chemotherapy, meds Occlusion, tooth position Hormonal and genetic factors (PST) Root morphology, heavy calculus and plaque Deficiency diseases, aids, SMOKING #1 Which of these can we control? CLINICAL DIAGNOSTIC SIGNSIn early stages of the disease the destructive inflammatory process occurs without signs orsymptoms. Once the clinical signs or discomfort is present, the disease process may be wellunder way Bleeding upon Probing Tissue Health, tone form, color, texture þ Pocket depths Attachment Loss þ Furcations / Exudate Active infection þ Pocket Microflora Volatile Sulfur Compounds Microscopy þ Mobility Radiographs - Bone Loss RATIONALE FOR TREATMENT• Long term research supports non-surgical intervention for Case Types I, II, III successful• Debridement, deplaquing, detoxifying of root surface and pocket environment. The critical mass concept implies that if the quantity of pathogenic stimuli such as plaque or calculus is maintained below the hosts reparative ability, then healing takes place. Root planing is effective technique for debridement and detoxifying of root surfaces and remains the most important aspect of periodontal therapy for maintenance of attachment levels and control of plaque induced diseases. THERAPEUTIC GOALS• Attain TISSUE HEALTH, a shallower pocket through shrinkage of the soft tissue wall, clinical gain in attachment levels, or a combination of both• Reduction of the inflammatory process in the surrounding tissues with the elimination of bleeding. Consistent absence of bleeding is 99% predictive of inactivity Lang JPerio 1994 / 1998• Conversion of pathogenic flora in the pocket to those compatible with health• Attain a root surface that is biologically compatible with maintenance and reformation of a healthy and functional attachment Your Office Letterhead
  6. 6. PERIODONTAL INFORMATION AND TREATMENT RECOMMENDATIONSPATIENT__________________________________ DATE_______________I have been advised on this date of the results of my periodontal evaluation:__ GENERALIZED GINGIVITIS __ EARLY ADULT/SLIGHT PERIODONTITIS__ MODERATE ADULT PERIODONTITIS __ SEVERE PERIODONTITISI have been advised that periodontal disease is an infection and that bleeding gums and periodontalpockets are clinical indicators of the disease. I have been advised that periodontal disease is chronic,progressive, inflammatory and episodic. If the condition remains untreated the infection may spreadto the bone, the teeth become loose and slowly detach from the supporting structures. This mayresult in acute infection and/or loss of teeth. I have been advised that proper daily bacterial plaqueremoval is critical to treat the disease. Health, medications, nutrition, genetics and smoking arefactors implicated in successful treatment.I have been advised that treatment includes: 1. NECESSARY RADIOGRAPHIC EXAMINATION (AS NEEDED) 2. PERIODONTAL DEBRIDEMENT , DEPLAQUING , PERIODONTAL INSTRUMENTATION INCLUDING SCALING / ROOT PLANING 3. ANTIMICROBIAL THERAPIES AND CHEMOTHERAPEUTICS (AS NEEDED) 4. DETAILED AND SPECIFIC INSTRUCTIONS FOR PROPER DAILY BACTERIAL PLAQUE CONTROL 5. RE-EVALUATION , ONGOING AND CONTINUOUS SUPPORTIVE PERIODONTAL THERAPYFollowing the completion of initial therapy, a re-evaluation will be performed to determine iffurther treatment and/or referral to a periodontist is necessary. At this time the doctor willdetermine an appropriate interval for ongoing care. Evaluation procedures will be repeatedperiodically in order to monitor the progress of the disease. As prescribed by the AmericanAcademy of Periodontology: "An interval of three months between Supportive PeriodontalTherapy appointments is generally required for effective control and monitoring of the patientsperiodontal status. The interval may vary depending on the individual patient and the clinicaljudgment of the dentist."In advance we would like to thank you for your cooperation. The goal of periodontal therapy isto control disease progression since it cannot be cured. Keeping scheduled appointments andfollowing our instructions are instrumental in our joint effort to obtain a successful result.Please do not hesitate to call us at any time should you have any further questions.Once again, we thank you!Patients Treatment Choice:ACCEPTS TREATMENT ____________________________ FEE___________DECLINES TREATMENT_________________________________________________SIGNATURE_______________________________________ DATE _____________COMMON PERIODONTAL CODES ADA CDT-4 Jan 2003
  7. 7. 0180 Comprehensive Periodontal Evaluation, new or established; This procedure is indicated forpatients showing signs and symptoms of periodontal disease AND for patients WITH RISK FACTORSsuch as smoking or diabetes. It includes: evaluation of periodontal conditions, probing and charting,evaluation and recording of the patients medical and dental history and a general health assessment.4341 Periodontal SCALING & ROOT PLANING FOUR OR MORE continguous teeth or bundled teeth spaces4342 Periodontal SCALING & ROOT PLANING ONE to THREE TEETH, per quadrant4355 FULL MOUTH DEBRIDEMENT TO ENABLE COMPREHENSIVE EVALUATION The removal of subgingival and / or supragingival plaque and calculus. This is a preliminaryprocedure and does not preclude the need for other procedures. This procedure may be necessary morethan once and may require multiple visits to complete.RX Narrative: Patients last dental visit was 5/93: full mouth debridement w/ultrasonics and anti microbial agents was required; pt to return for evaluation4910 SUPPORTIVE PERIODONTAL THERAPY follows 4341; after completion of activeperiodontal therapy (surgical or non-surgical) and continues at varying intervals, determined by theclinical diagnosis of the dentist, for the life of the dentition. Includes removal of supra and subgingivalmicrobial flora and calculus, site specific scaling and root planning where indicated, and / or polishingthe teeth. When new or recurring periodontal disease appears, additional diagnostic and treatmentprocedures must be considered. NOTE: does not include periodic exam; performed and chargedseparately. This procedure DOES include periodontal evaluation (do not charge 0180 for exam)RX Narrative: Patient completed active periodontal therapy on (date) and now receives periodic ongoing treatment [as recommended by the American Academy of Periodontology]4381 LOCALIZED DELIVERY CHEMOTHERAPEUTICS Subgingival localized delivery of _____agent with sustained release. Site /s unresolved, bacterial infection remains active following periodontal scaling and root planing, tooth ##1330 ORAL HYGIENE INSTRUCTIONS Personalized instructions in daily periodontal care to control causative bacterial etiology9630 OTHER DRUGS & MEDICAMENTS BY REPORT Subgingival delivery of chemotherapeutic agent ___ to control bacterial Infection and promote healing1204 FLUORIDE, TOPICAL APPLICATION Adult - separate from prophy does NOT include rinses or swishes4999 UNSPECIFIED PERIODONTAL PROCEDURE BY REPORT Patient presented with generalized gingivitis, all quadrants; therapeutic scaling and placement of medicaments __ required to remove bacterial infection9910 DESENSITIZING AGENTS9951 OCCLUSAL ADJUSTMENTS0415 BACTERIOLOGIC STUDIES TO DETERMINE PATHOGENIC AGENT  Patient Letter SPT give to patient at final therapy apptDear Patient!
  8. 8. Thank you for your efforts during the active phase of initial periodontal treatment. You are nowready for the important MAINTENANCE PHASE in order to monitor and stabilize yourperiodontal health.WHAT IS THE IMPORTANCE OF MAINTENANCE THERAPYPeriodontal disease can easily recur. The bacteria that caused the infection are present in your mouth andare ready to attack the teeth, bone and gum tissues. Supportive Periodontal Therapy is an absolutenecessity to insure that the periodontal infection does not re-activate. Supportive therapy continues atvarying intervals and is an extension of active periodontal treatment. There is significant scientificevidence stating that the most important aspect of periodontal treatment is ongoing maintenance therapy.According to the American Academy of Periodontology, "Following a course of active periodontal treatment, periodic ongoing care at regularly prescribed intervals is essential. Although the standard of care recognizes that these intervals may vary due to the nature of of microbial plaque, calculus formation and host factors, a 3 month time interval for periodontal maintenance therapy remains the most generally accepted. The majority of clinical studies have shown that 3 months is most effective in controlling disease."EVERYONE RESPONDS DIFFERENTLY TO TREATMENT AND THE SEQUENCE FOR PERIODONTAL MAINTENANCE APPOINTMENTSDEPEND ON SEVERAL FACTORS :1. Clinical signs of control of the infection2. Degree of residual pocket depth, clinical attachment and bone loss3. Bacterial plaque control effectiveness4. Individual susceptibility, host immune response system5. Health, medications, age, other risk factors including smoking, diet and nutritionMost people have a varying resistance to periodontal disease at different times in their lives. A personsresistance may be normal for years and then resistance may diminish, because periodontal disease iscontrollable but not curable. The host immune response, medical and other mediating factors contributeto the health risk.BUT EVERYTHING FEELS FINE TO ME... When active periodontal disease recurs followingtreatment, it may do so without any clinical symptoms and often progresses much more rapidly anddestructively. If the patient waits for discomfort before returning to the dentist, many times the problemis beyond successful treatment.WHAT OCCURS DURING PREVENTIVE MAINTENANCE THERAPY APPOINTMENTS?Evaluation of the health of your gum tissues will be performed. Clinical evaluation for any signs ofdisease recurrence through comprehensive periodontal examinations, appropriate occlusal analysis,necessary periodontal instrumentation, periodontal debridement, deplaquing and antimicrobial therapies.Evaluation of disease control efforts, bacterial and plaque control and review and recommendations forimprovement. Provide you with dental aids to assist you in your daily homecare efforts. Perform ageneral health assessment, medical records update, necessary radiographic update and all oral healthexaminations including oral cancer examination, and. Thank you for your continued commitment to good oral health! We look forward toserving your dental needs. Please do not hesitate to call if you have any questions. We welcomethe opportunity to continue to serve you, your family and friends in providing optimum oralhealth.Additional patient education re: perio and systemic healthPERSONAL HEALTH: Flossing Protects Far More Than Teeth and Gums By Jane Brody NY TimesI suspect that my most egregious lapse in healthful living is widely shared: Knowing that I might lose my teeth incoming decades is not enough to get me to floss every night. I do endure thrice yearly periodontal cleanings andadmonishments to do a better job on a daily basis, but still that 18 inch strip of string does not always find its proper
  9. 9. mark. Even watching the misery my husband suffered in adjusting to dentures was not enough to sustain a nightlyhabit of flossing.But I recently learned that there is a lot more than tooth preservation to worry about. Recent findings indicate thatperiodontal disease may precipitate or aggravate health problems elsewhere in the body. Perhaps the emerginginformation about the relationship between periodontal disease and these serious, sometimes fatal ailments willmotivate more of us, including yours truly, to pay more attention to the health of the gums and bones that supportour teeth.INFECTIONS GO BODYWIDEMore than 400 species of bacteria live in the human mouth, where some can infect the gums andunderlying bone that support the teeth. Gingivitis, an infection that sometimes renders the gums tenderand susceptible to bleeding when they are irritated, is generally the first stage of periodontitis, a diseasethat afflicts millions of Americans. As many as half of all high school students have gingivitis. Gradually,as infected gums pull away from the teeth , ever-deepening pockets form that allow the infection tospread and eat away at the bone, causing teeth to loosen in their sockets. About 15% of American adultshave advanced periodontitis and are in danger if losing their teeth. In fact, most adults over age 60 inthis country have lost all their teeth, primarily due to periodontal disease.But recent studies show that teeth are not the only organs endangered by this oral disease. Infections in the tissues ofthe mouth are easily spread into the bloodstream. Even brushing, flossing and chewing can prompt bodywideinvasion when periodontal disease is advanced. “People think of gum disease in terms of their teeth, but they don’tthink about the fact that gum disease is a serious infection that can release bacteria into the bloodstream,” said Dr.Robert Genco, editor of the Journal of Periodontology and professor of oral biology at State University of New York atBuffalo. “The end result could mean additional health risks for people whose health is already affected by otherdiseases – or lead to serious complications like heart disease.”SERIOUS CONSEQUENCESA century ago, a spurious link between periodontal disease and rheumatoid arthritis prompted dentists to extract allof a persons’ teeth in the hopes of curing the arthritis. This mistaken belief virtually halted for many decades anyserious research into the relationship between periodontitis and other diseases. But its recent revival is yielding somefrightening links to such problems as HEART DISEASE, STROKES, DIABETES, PNEUMONIA AND PREMATUREBIRTHS AND LOW BIRTHWEIGHT BABIES.HEART DISEASE – All other things being equal, people with periodontal disease are one and a half to two times aslikely to suffer a fatal heart attack and nearly three times as likely to suffer a stroke as those without this oral disease.The association with heart disease is especially strong in people under 50. Studies have indicated that chronic oralinfections can foster the development of clogged arteries and blood clots. Substances produced by oral bacteria thatenter the bloodstream can precipitate a chain of reactions that result in a build-up of arterial deposits. And severalcommon oral bacteria can initiate the formation of blood clots and disrupt cardiac function.DIABETES—It has long been known that diabetes predisposes people to bacterial infections, including infections oforal tissues. But recent studies strongly indicate that periodontitis can make diabetes worse. Diabetic patients withsevere periodontitis have greater difficulty maintaining normal blood sugar levels, and treatment of periodontitisoften results in a reduced need for insulin.. Experts now urge that periodontal inflammation be treated andeliminated in all people with diabetes, especially since such treatment may reduce the risk of injury to the retinal andarteries that is a common consequence of diabetes.PNEUMONIA—Bacterial pneumonia results when bacteria that live in the mouth and throat are inhaled into thelungs where immune defenses fail to wipe them out. Several agents that cause pneumonia can thrive in infected oraltissues of people with periodontal disease. And, other respiratory diseases, like chronic bronchitis and emphysema,may be worsened by oral infections when the invading bacteria are inhaled.PREMATURE BIRTH — It has been known that infections of the pelvic organs can precipitate premature labor andthe birth of small babies. Infections lead to high levels of substances like prostaglandin E-2 that can induce labor.There is increasing evidence that oral infections too, can induce premature labor. Periodontal bacteria producemolecules that also prompt the release of labor-inducing substances like prostaglandin. One small study found thatmothers of prematurely born small babies were seven times more likely to have advanced periodontal disease asmothers whose babies were normal weight at birth, even though all mothers in the study were not otherwise at risk ofhaving a premature baby.. What is needed is a study to determine whether treatment of periodontal disease inpregnant women can reduce the risk of premature birth.INFECTIONS —People with artificial joints and heart valves are at increased risk of suffering a serious infectionwhen periodontal bacteria enter the bloodstream. For those with artificial heart valves, the infection can be fatalunless promptly and thoroughly treated with antibiotics. This is why dentists routinely prescriptive antibiotics tosuch patients before initiating dental work.WHAT YOU CAN DOOf course, prevention is always the best bet. It starts with building and protecting one’s bones.. This means havingenough calcium in the diet to maximize bone development before age 30, when gradual bone loss begins. People withosteoporosis lose bone in the mouth as well as the hips and spine, and postmenopausal women who do not take
  10. 10. hormone replacement have a greatly increased risk of periodontal disease. Prevention also means establishing aroutine of daily brushing and flossing and a professional periodontal cleaning at least once a year—or more often, ifyour mouth readily forms dental plaque. Keep in mind that early stages of periodontal disease often produce nosymptoms.The American Academy of Periodontology provides information about the link between gum disease and otherdiseases through a toll-free number, (800) 356-7736, and on its Web site—www.perio.org. An academy periodontistwill answer questions.STUDY: GUM DISEASE RAISES DEATH RISK IN DIABETICS: Severe gum diseasemay hasten death in people with diabetes, new study findings suggestReuters Health News July 2003"Diabetic people with periodontal disease had increased death rates due to cardiovascular diseaseand renal (kidney) failure, which are two major complications of type 2 diabetes," said studyauthor Dr. William C. Knowler. The findings underscore the need for good oral hygiene indiabetics (news - web sites), who are particularly prone to periodontitis, or gum disease,Knowler said in an interview with Reuters Health.Gum disease, characterized by red, swollen gums, is caused by a bacterial infection. And studieshave indicated that infections and inflammation can promote blood-vessel damage in the heartand kidneys, said Knowler, chief of the diabetes and arthritis epidemiology section of theNational Institute of Diabetes and Digestive and Kidney Diseases in Phoenix. While gumdisease might not be diagnosed until mid-life or later, infection with the bacteria that cause it canoccur decades earlier. Combined with years of inadequate oral hygiene, infection can result ingingivitis, an early form of gum disease characterized by inflamed gums that often bleed easily.This form of the disease can usually be reversed with more careful brushing and flossing. Butas the more aggressive periodontitis develops, the gums and bone surrounding the teeth canbecome seriously damaged, and teeth may loosen or fall out. The new study involved 549 PimaIndians ages 45 or older with type 2 diabetes, the most common form of the disease. At thebeginning of the study, the prevalence of severe gum disease, marked by the loss of bone andoften teeth, was roughly 60 percent. During a follow-up period of about 10 years, 172participants died of natural causes, according to findings presented at a recent meeting of theAmerican Diabetes Association in New Orleans. Overall, the rate of death from natural causeswas 42 per 1,000 people per year among participants with severe gum disease, compared with26.6 per 1,000 people per year among those who did not. The extra deaths among those withsevere gum disease were due to heart disease and diabetic nephropathy, and not to other causessuch as cancer or liver disease.After adjusting for factors such as age, sex, duration of diabetes, obesity and cholesterol levels,the researchers found that diabetics with severe gum disease were twice as likely as thosewithout it to die from either heart disease or kidney failure.

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