Medical History...

Dr. Pietrini writes a monthly column for Fra Noi, an Italian newspaper. Articles related to the topic of Medical History are featured below. Click here to view this month's article

The Romantic Type by Dr. Pietrini
When I was in dental school, I overheard a friend of mine taking a patient's medical history. He asked the patient if he ever had a rheumatic heart. The man's response was "I'm not the romantic type." In my office, each new patient is required to complete a medical history form, which is reviewed before the initial examination and is updated at follow up visits. Occasionally, patients will question why it is necessary for them to reveal such information. I explain that the same blood that flows through your heart, lungs, liver and kidneys also flows through the structures of your mouth. It is very important for the dental team to know what illnesses the patient currently is being treated for or may have had in the past.

A complete list of all medications that the patient is currently taking is essential to provide safe and effective treatment. Occasionally, medications that were taken years earlier can have long-term affects on the health of the patient for example; certain dietary supplements have been linked to heart conditions. If a patient was given certain types of antibiotics as a young child, it may have resulted in misshapen teeth or discolorations such as tetracycline staining.

Subacute bacterial endocarditis (SBE) is a relatively uncommon life-threatening disease, which can be prevented with the proper precautions. Some dental and surgical procedures can cause a transient bacteremia (a temporary contamination of the blood with bacteria). Patients with a history of certain cardiac conditions, such as advanced congenital heart disease, rheumatic fever, mitral valve prolapse or other problems or surgeries of the heart valves must be given a prophylactic dosage of antibiotics one hour prior to any dental treatment, which can cause bacteria to enter the bloodstream. For patients with no history of allergies to antibiotics, it is essential to take 2000mg of Amoxicillin one hour prior to their dental visit-even before routine dental cleanings. Patients, who have had joint replacement surgery within the past two years, also require pre-medication.

It is not uncommon for some patients to be taking medications, which have been prescribed by two or more doctors. Adverse drug interactions may occur when patients take certain combinations of medications. In some cases, certain nutritious foods that are eaten daily by millions of people may affect the way drugs are absorbed. Grapefruit juice may inhibit certain digestive enzymes, so that more of the medication you take will get out of your digestive tract into the rest of your body frequently leading to a drug overdose. One glass of grapefruit juice can inactivate these enzymes for up to 36 hours.
A significant number of commonly prescribed drugs may be affected by ingestion of grapefruit:
· Some psychiatric medications
· Certain cardiac medication, such as calcium channel blockers or antiarrhythmics
· Some immune-system suppressants
· Some cholesterol-lowering drugs, hormones, sedatives and anti-anxiety drugs

Make sure to keep an accurate list of all of your medications and review their uses each time you see your physician or dentist.

Where There Is Smoke, There Is Fire by Dr. Pietrini
While most people recognize that smoking cigarettes has been proven to be harmful to their health, until recently the effects of cigar and pipe smoking, as well as using smokeless tobacco was not known. In 1999, an article in The Journal of the American Dental Association indicated that cigar and pipe users might be puffing away their chances of maintaining healthy teeth and gums. The article pointed to a study at Boston University Goldman School of Dental Medicine showing that men who smoke cigars or pipes have a greater risk of early loss of their teeth, even if they do not inhale. They can increase their risk of developing cancer of the mouth or throat by as much as six times that of non-smokers.

All tobacco products increase your risk of developing periodontal disease (gum disease} and oral cancer. Smoking chewing tobacco can contribute to a build-up of tartar and stain on your teeth. It damages your gums by affecting the attachment of the soft tissue and bone around your teeth. As the bone and gums recede, it exposes the root surface of the tooth increasing the risk for decay and sensitivity to hot and cold.

According to the U.S. Department of Health, since 1993 cigar sales have increased by fifty percent. In the past, cigar smoking was associated with older men. Today both men and women are smoking cigars. In 1996, more than twenty-five percent of high school students reported smoking at least one cigar.

The use of smokeless tobacco has become increasingly popular with young men. Like cigars and cigarettes, at least 28 toxic chemicals associated with cancer are found in smokeless tobacco products. Sugar is often added to enhance the flavor of chewing tobacco, which might increase the risk of tooth decay. The greatest concern is the development of lesions of the lining of the mouth called leukoplakia. The American Cancer society reports that five percent of the lesions are cancerous or exhibit changes that progress to cancer within ten years if not properly treated. A study conducted by the US Air Force showed that approximately ten percent of twenty-year-old trainees used smokeless tobacco. Forty percent of them had leukoplakia. Some reports indicate an increase of oral and throat cancer among young people using smokeless tobacco, even when these products were used for less than ten years. If they stop using all tobacco products for at least six weeks, most mouth lesions will disappear.

As early as 1964, the American Dental Association (ADA) first adopted policies to discourage the use of tobacco products and encouraged dentists to educate their patients. More information about the effects of smoking and other topics related to dentistry can be found at the ADA web site (www.ada.org).

Sometimes Less is More by Dr. Pietrini
As I write this month's column, my wife and I are about to leave on a long awaited trip to Italy. The first week will be spent with a number of close friends aboard a barge on the Po River. All the usual temptations will be there for overeating and drinking a little too much vino. When it comes to good, healthy living, often times "less is more."

In the office we are confronted with two types of dental infections-chronic and acute. An example of a chronic infection would be periodontal (gum) disease. Usually the patient has no discomfort and the only symptoms might be puffy, bleeding gums. An acute infection usually has symptoms, such as pain, swelling and fever. Recently, I had a patient come into the office with an acute dental infection. She told me that she had started taking an antibiotic, which had been prescribed for a previous ailment. Not only was she taking too large a dosage, but also I discovered that her physician had prescribed another medication, which could have caused an adverse reaction. I changed her medication to one that was more compatible and at the proper strength. For chronic periodontal disease, your dentist might choose to prescribe a low dose of antibiotic, which will not be strong enough to kill bacteria, but will inhibit the bacteria from producing an enzyme that causes disease of the gums and underlying bone.

For more than forty years, the American Dental Association (ADA) has endorsed fluoridation of community drinking water. Fluoride occurs naturally in most water sources; however, it can be present in varying concentrations. The optimal level should range from .7 to 1.2 parts per million. In communities where the fluoride levels are too high, patients will exhibit signs of fluorosis (mottled enamel), where the teeth become stained with a mixed brown and white pattern. If the community water is not fluoridated, dietary supplements are available by prescription. It is important for your dentist or physician to prescribe the correct dosage of fluoride for your child. Because fluoride may present in varying concentrations in prepared foods, juices, bottled water and tap water, dietary supplements should be prescribed by following the recommended schedule approved by the ADA.

Many of our patients take vitamins and other supplements. Again, taking the proper dosages is imperative. Vitamins are either water or fat-soluble. Some people advocate taking large amounts of Vitamin C. Since this is a water-soluble vitamin, your body can only retain a certain level. The excess is eliminated in the urine. Fat-soluble vitamins taken in excess will be stored in the body and can be toxic.

It is important to constantly review your medications and dosages with your dentist and physician.

Dental Myths and Wives Tales by Dr. Pietrini

During the 6^th century B.C., the Greeks had an intellectual awakening referred to as the “emancipation of thought from myth”. By the next century, Hippocrates, the father of medicine, was proposing theories related to medicine and dentistry. Despite the new logical approach to treating patients, some bazaar and worthless ideas and concoctions of medicines were suggested. The philosopher, Aristotle, made the incorrect observation that men had more teeth than women. In the early days of the Roman Empire many Christians became martyrs. Apollonia refused to deny her Christian faith and had her teeth broken by an angry mob. Legend has it that before she was to be burned at the stake, she threw herself into the flames and shouted that all those who suffered from toothaches should invoke her name. Eventually, she was canonized becoming St. Apollonia the patron saint of dentistry. Today, despite the fact that consumers have been bombarded with information about dental care, many myths and wives tales exist.

At one time, women were told that they could count on losing one tooth for every child they bore. One common misconception was that the baby would drain calcium from the mother’s teeth.  It is not uncommon for expectant mothers to experience pregnancy gingivitis, especially during the first trimester. While hormonal changes affect this condition, a more significant factor is that women suffering from morning sickness may have difficulty maintaining good oral hygiene. If the patient keeps up with her routine dental cleanings and continues to brush and floss properly, she will reduce her risk of dental problems. It is very important to maintain a well balanced diet during pregnancy, because at three months the fetus begins to develop tooth enamel.

Most people realize that babies should not be given a bedtime bottle containing anything other than water. Even milk can contribute to a condition called “nursing bottle caries”. The milk breaks down into sugars and combines with the bacteria to from acids that cause the teeth to decay. I have seen 2 and 3 year old children with most of their teeth destroyed from extensive caries. Letting your baby sleep with a clean, well-designed pacifier is a good alternative. A word of caution—if you give your children filtered or bottled water; it may not contain the optimal level of fluoride necessary to protect their teeth from future breakdown.

Some patients believe that they cannot get cavities under teeth that have been capped. If the teeth have been prepared properly and all of the original decay has been removed, less surface area is exposed to dental plaque reducing the chances of future fracture and decay. Regular professional care and oral hygiene maintenance are necessary to prevent future cavities and/or periodontal disease. We recommend that patients use brushes with soft bristles and polished tips. If the bristles are too stiff, the teeth and gums can become abraded. If you have any questions about your dental health, ask your dental staff for additional information.

Getting the General Idea by Dr. Pietrini

Recently, a new patient an Army, World War II veteran came to our office to have a fractured tooth repaired. When one of my staff members asked how he found out about our office, he stated that he found our listing in the Yellow Pages. With his dry sense of humor he related that he knew we were a high-quality practice because we performed “General Dentistry.” He commented that he still had “iron” fillings in his teeth, which were placed by an Army dentist in 1942. There are several special areas of dental practice. Sometimes, patients are confused as to which dentist can perform each of these services.

The dental schools in the United States offer two types of dental degrees, either a Doctor of Dental Surgery (DDS) or a Doctor of Medicine in Dentistry (DMD). Both are equivalent degrees and are accepted by all state licensing boards. Dentists who hold one of these degrees are referred to as “GENERAL DENTISTS”. The American Dental Association (ADA) recognizes nine dental specialties. A dentist must take 2-4 additional years of education and training to become board-eligible for a specialty certificate.

During their four years of dental school, general dentists receive education and practical training in all aspects of dentistry. They learn how to place fillings, prepare teeth for crowns and bridgework, extract teeth, perform root canals, treat gum disease, construct full and partial dentures and treat a variety of other aliment for adults and children. While the Academy of General Dentistry offers Fellowship and Mastership programs, currently, there is no board certification of general dentists.

Frequently the general dentist feels that a patient would be better served if they were referred to a Board Certified Specialist. The specialists most commonly used are:

• ENDODONTISTS: who perform root canal therapy and related surgical services.
• ORAL AND MAXILLOFACIAL PATHOLOGISTS: who analyze biopsies and other tests to help determine a dental diagnosis.
• ORAL AND MAXILLOFACIAL SURGEONS: who perform dental extractions, placement of implants and bone grafts, treat jaw fractures and jaw defects, remove tumors and a variety of other surgical services.
• ORTHODONTISTS: are specialists who correct conditions related to malformed jaws and malpositioned teeth. They place braces on children and adults.
• PEDIATRIC DENTISTS: who specialize in all types of treatment necessary for infants, children and adolescents, including fillings, pulp treatments, extractions, minor tooth movement and injuries.
• PERIODONTISTS: are specialists who treat all forms of gum disease both surgically and non-surgically. They frequently perform bone and tissue grafting procedures and place dental implants.
• PROSTHODONTISTS: who specialize in placement of crowns and bridgework, full and partial dentures. They frequently make prosthetic appliances for patients who have suffered injuries, those who have congenital defects or have had cancer surgery.

A Joint Venture by Dr. Pietrini

This year, nearly half a million total joint replacements will be performed. The American Dental Association (ADA) and the American Academy of Orthopaedic Surgeons have developed guidelines that are designed to assist patients and health care practitioners in making decisions about the use of preventive antibiotics prior to dental treatment. These guidelines are not a standard of care or a substitute for the practitioner’s clinical judgment. Health care providers must exercise their own clinical judgment in determining whether or not preventive antibiotics are appropriate. Pediatric (children’s) dosages may be different. Thanks to the ADA for their permission to reprint these recommendations for distribution to patients. 

For the first two years after a joint replacement, all patients may need antibiotics for all high-risk dental procedures.

The bacteria commonly found in the mouth may travel through the bloodstream and settle in your artificial joint. This increases your risk of contracting an infection. Ask your dentist about preventive antibiotics for all dental procedures with high risk of bleeding or producing high levels of bacteria in your blood. Your dentist and your orthopaedic surgeon, working together, will develop an appropriate course of treatment for you.

You may need preventive antibiotics before all high-risk dental procedures if:

• you had a joint replacement less than two years ago
• you’ve had previous infections in your artificial joint
• you have an inflammatory type of arthritis, type I diabetes or hemophilia
• you have a suppressed immune system or are malnourished
• you have a history of prior or present malignancy

These procedures have a high risk of bleeding or producing high levels of bacteria in your blood:

• all dental extractions
• all periodontal procedures
• dental implant placement and replantation of teeth that were knocked out
• some root canal work
• initial placement of orthodontic bands (not brackets)
• certain specialized local anesthetic injections
• regular dental cleanings (if bleeding is anticipated)

One of these preventive antibiotics may be prescribed for you:

• if you are not allergic to penicillin: 2 grams of amoxicillin, cephalexin or cephradine (orally) OR 2 grams of ampicillin or 1 gram of cefazolin (intramuscularly or intravenously) 1 hour before the procedure.
• if you are allergic to penicillin: 600 milligrams of clindamycin (orally or intravenously) 1 hour before the procedure.

When a toothache becomes a headache by Dr. Pietrini

When a patient complains that all of their back, upper teeth ache, it is often related to a cold, allergy or sinus infection. The roots of the upper teeth are located near the nasal and sinus passages. There are seven different sinus cavities. The maxillary sinuses are located in the cheekbones above the back teeth. Inflammation or infection of these sinuses can mimic dental pain, often with accompanying headache. Patients will frequently mention that they were not sure if they should have made an appointment with their physician or me for diagnosis and treatment.

 Nasal congestion and discharge, fever, foul odor and tenderness in the area over the sinuses are common symptoms. Diagnosis and appropriate treatment can be difficult, because the infection can be viral or bacterial. Sinusitis can be acute or chronic. Patients with acute infection usually require antibiotics, especially if the symptoms have persisted for several days. Chronic cases (those that reoccur frequently) may require consultation with an ear, nose and throat specialist (ENT) or an allergist.

A thorough examination and several different tests may be necessary to determine if the pain is dental or sinus in origin. If the source of the pain is a dental abscess, the pain and swelling is usually above one specific tooth. Tooth vitality can be determined by using an electronic pulp tester, gently tapping on the teeth or by applying heat and ice. Several types of dental x-rays can be used. Small films of the individual teeth or a panoramic view can be used to rule out dental disease. With sinusitis, generally the swelling and tenderness radiates over a broader area. Various types of sinus imaging will help to determine if there is congestion or disease present in the nasal or sinus passages.

Most sinus infections, like the common cold are caused by viruses and do not require the use of antibiotics. Decongestants taken orally or in spray form will relieve the symptoms in most cases. If allergies are suspected, an antihistamine will work best. Sometimes it is advisable for your physician to perform a test to culture the bacteria present in the sinus, because bacteria can develop a resistance to antibiotics if they are prescribed too frequently. In some cases of chronic sinusitis, surgery is necessary. Modern surgical techniques are often less invasive, allowing patients to recover more rapidly.

Studies show that more than 30 million Americans suffer from sinusitis. When your dental team reviews your medical history be sure to mention if you have ever been treated for allergies or sinusitis.

Adverse Drug Reactions By Dr. Dennis R. Pietrini

Millions of patients may be putting themselves at risk for serious drug interactions. Many people fail to inform their physician or dentist of medications, which they have purchased over-the counter, including herbal medications and dietary supplements. While the Food and Drug Administration (FDA) regulates prescribed medications, hundreds of medications sold by pharmacies and health-food stores are available without restrictions. Besides conventional medications, patients and healthcare providers need to be aware of the actions and side effects of these medications to avoid adverse drug reactions.

Physicians and dentists need to modify the way they obtain the health history of their patients. It is important for doctors to take a non-judgmental approach with their patients to be able to obtain accurate information about their medications. Because the use of some alternative medications may be considered controversial, patients might be tempted to withhold informing their doctors about non-prescription drugs that they use.

For nearly fifty years, the Physicians Drug Reference (PDR) has been the bible for healthcare workers. Dentists and physicians use this book as a source for valuable information about the actions, indications, dosages and side effects of prescription drugs. Other additions are now available, which cross-reference interactions with non-prescription drugs, herbal preparations and dietary supplements.

The following are some examples of various possible adverse interactions:

• An herbal medication, St. John’s Wort used for depression, may react with tetracycline, an antibiotic frequently used to treat acne, causing severe sunburn.

Kava-Kava an herb used to promote mental alertness when taken with Xanax, commonly prescribed to prevent panic disorders, may cause a patient to go into a coma.

•  People consuming three or more alcoholic drinks per day should avoid using Tylenol —there is an increased risk of abdominal bleeding or liver damage.
• Certain diuretics (water pills), which help the patient eliminate water and certain minerals, may actually block the kidney’s ability to excrete potassium possibly causing heart palpitations or an irregular heartbeat. Patients need to reduce intake of foods high in potassium, such as green leafy vegetables, bananas and oranges.
• Drinking alcohol while taking beta-blockers, such as Inderal or Lopressor, actually lowers the blood pressure too much.
• Patients taking the anticoagulant Coumadin need to limit their consummation of foods high in vitamin K like cauliflower, spinach, broccoli and brussel sprouts. Many patients take vitamin E (an antioxidant), which is known to prolong clotting time, thereby increasing the risk of bleeding.

 These are just an example of some of the potentially dangerous combinations of drugs, foods and supplements. I have many patients who daily take ten or more medications. The risk of adverse reactions cannot be overlooked.

Your Heart In Your Mouth By Dr. Dennis R. Pietrini

When someone encounters a frightening experience, they may comment that, “I had my heart in my mouth.” Despite all the advances in technology and patient care, a visit to the dentist may still elicit fear in some people. The biggest concern that adult dental patients should have is that evidence continues to build about the possible relationship of poor oral health and cardiovascular disease (CVD).

Hardening-of-the-arteries or atherosclerosis essentially is an inflammation of the muscular lining of the wall of the arteries. Scientists believe that infectious agents in the body cause injury to the wall of the artery and produce the inflammation. We are all aware of the multiple factors related to CVD, such as family history, a diet that is high in fats and cholesterol and smoking. A lot of time and energy has been spent worrying about a patient’s cholesterol level; however, it is advisable to also check the levels of homocystin and C-reactive protein (CRP). A diet low in vitamin B6 may lead to increased production of homocystin, which contributes to the hardening of blood vessels. High levels of CRP could be an indication of infectious agents in the blood such as those produced when patients have untreated periodontal (gum) disease. 

Periodontal disease is a chronic condition that may affect heart disease in several ways. In the absence of good homecare and lack of professional dental treatment, bacteria-laden plaque builds up resulting in inflammation of periodontal tissues. Periodontal pockets form when the inflamed tissues separate from the underlining tooth and bony structures. Increasing numbers of bacteria grow within the pockets producing destructive toxins. As gum tissues break down, these toxins are released into the bloodstream and may trigger an inflammatory response affecting the lining of the arteries. 

In addition to good brushing and flossing, several types of dental therapy and preventive products are available to assist in better oral health:

·        Periodontal therapy—surgical and/or non-surgical

·        Laser therapy to reduce inflammation and bacteria

·        Oral disinfectants

·        Medications that are placed in the periodontal pockets

·        Toothpastes containing antibacterial agents

·        Low-level doses of antibiotics that prevent bacteria from producing toxins

See your dentist to evaluate the state of your periodontal health and to design a preventative program that will be the most beneficial for you.