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Blood Levels in Fat Cells May Help Predict Migraine

Posted on 10. May, 2014 by .

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A new study appearing in the journal Headache: The Journal of Head and Face Pain, looks at people experiencing two to twelve migraine headaches a month. In this study researchers found that measuring a fat-derived protein called adiponectin before and after migraine treatment is useful in revealing if headache patients felt pain relief or not. The researchers of the study are hopeful that finding this potential biomarker for migraine of adiponectin may be used for developing new and better migraine treatment options.

Finding better treatment options for migraine sufferers is lucrative because roughly 36 million Americans suffer from migraine headaches which can last longer than 4 hours at a time. Women are three times to get migraines when compared to men.

In the study the researchers collected blood from 20 women who visited 3 different headache clinics for an acute migraine attack during a period of a few years. The women had their blood taken before treatment with sumatriptan or naproxen sodium or a placebo. The researchers drew blood at 30, 60, and 120 minutes after the drug was given. The researchers then looked at blood levels of adiponectin along with two subtypes or fragments of total adiponectin in circulation: 1)  low molecular weight (LMW)-adiponectin and high molecular weight (HMW)-adiponectin.

The researchers found that when all 20 women in the study had levels of LMW that increased, the severity of their pain decreased.  Further, when the ratio of HMW to LWM increase, the pain severity increased. The researchers believe that reducing levels of adiponectin or targeting the 2 subtypes of adiponectin may be a useful strategy for a new medication that can be helpful for those who suffer from migraine.

Of course also looking at potential other causes for LMW to increase can also be useful for migraine suffers.

Source: B. Lee Peterlin, Gretchen E. Tietjen, Barbara A. Gower, Thomas N. Ward, Stewart J. Tepper, Linda W. White, Paul D. Dash, Edward R. Hammond, Jennifer A. Haythornthwaite. Ictal Adiponectin Levels in Episodic Migraineurs: A Randomized Pilot Trial. Headache: The Journal of Head and Face Pain, 2013; 53

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Ingestion of Foreign Body During Dental Procedures

Posted on 03. May, 2014 by .

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In the complications of wisdom teeth page on this site http://www.teethremoval.com/complications.html I have discussed cases of teeth being displaced into various places of the body. A tooth can also either be aspirated and end up in the respiratory tract or ingested and likely pass several days after being swallowed. Dental instruments can also break off during surgery and end up in various places of the body.

Some recent studies and cases have emerged for other dental procedures where foreign bodies were ingested. An article titled ” Precautions for accidental ingestion of a foreign body,” appears in J Can Dent Assoc 2013;79:d5, located over at http://www.jcda.ca/article/d5. This article describes a case where a 58 year old man underwent treatment for a dental crown and accidentally ingested a 20 mm stainless steel post intended to support the prosthesis. An imaging study revealed the post in the mid-abdomen and the patient, since he was not in distrust, was told to monitor for it to be passed. The patient never saw the post pass in his GI tract but subsequent imaging studies did not reveal it so it is presumed to have passed. This of course, opens up the possibility that maybe there is a better way to monitor a foreign body if it has been ingested to make sure it passes in the GI tract. This article cites another study conducted in 2011, Obinata K, Satoh T, Towfik AM, Nakamura M. An investigation of accidental ingestion during dental procedures. J Oral Sci. 2011;53(4):495-500.

This article presents 23 cases of accidental ingestion of foreign bodies occurring during dental procedures at the Center for Dental Clinics of Hokkaido University Hospital between 2006 and 2010. The authors found that most cases occurred when practitioners had less than 5 years of experience. Some of the cases of accidental ingestion presented include a scaler tip, a metal core, a metal crown, a metal onlay, and a bur. Three (3) of the 23 cases had to be retrieved by endoscopic procedures whereas the remaining 20 cases of passed through the GI tract within 10 days with no adverse events. It appears one case involved a wisdom tooth but it is not clear if it was being extracted or some other type of treatment was performed.

The authors mention that the incidence of accidental ingestion during dental procedures was found to be 0.0041% and 0.0044% at 2 prior dental colleges in Japan. In this study the number was found to be 0.0037% (case/patients) per year of accidental ingestion.  The authors state

“Moreover, the occurrence (cases/dentists) per year was 0.018, being very close to the figure of 0.021 reported from 2 French insurance companies representing 24,651 French general dental practitioners over an 11-year period (1994-2004).”

Near the end of the study the author state

“In the treatment of molars, the present authors suggest inclining the head of the patient to one side to help catch objects in the buccal pouch. However, the best countermeasure is still meticulous care to fix burs tightly and to use dental instruments in the properly prescribed way. Additionally, practitioners can make patients aware of the possibility of dental objects dropping in such cases, and instruct them to spit out any dropped objects.”

It appears that more foreign bodies are accidental ingested than aspirated. Further, most foreign bodies that are accidentally ingested are safely passed through the GI tract with 7 to 10 days.

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Is Creative Diagnosis on the Rise in Dentistry?

Posted on 26. Apr, 2014 by .

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A very interesting MyView column by the American Dental Association (ADA) is titled “Creative Diagnosis” by Jeffrey Camm, D.M.D. located over at http://www.ada.org/9151.aspx and published October 21, 2013. In the column the author touches on an issue he faces as a dentist where he has patients who have seen other dentists who were likely unethical in their treatment (and treating when it is not warranted) – a term he calls creative diagnosis. Of course one can ask, what is the motivation for creative diagnosis and one would answer money and staying afloat.

Essentially the author describes several cases he has dealt with at his practice:

  1. A 16 year old patient who graduates from his pediatric practice and sees a new dentist who then says she has 16 cavities. The patient and her mother of course are upset and he reviews her teeth. He then asks 5 other dentists to review the radiographs and finds a diagnosis of between 0 and 4 cavities. (suggesting the new dentist was practicing creative diagnosis)
  2. In another case he sees a 2 year old who comes in with a full mouth series of radiographs. He says a child that young has no business having a full mouth series. (suggesting the other dentist was practicing creative diagnosis)
  3. He also describes how his practice gets a lot of referrals for general anesthesia and second opinions on anesthesia. However, in many of these cases he doesn’t agree with the treatment plan as the patients have minimal or no decay. (suggesting possible creative diagnosis and difference of opinion in treatment)

The author further states

“The difficult task for me with all this creative diagnosing is trying to explain to the parent why my treatment plan is hundreds (thousands?) of dollars different than someone else’s treatment plan. I can only cover up so much with my explanation of different treatment criteria, sharper explorers, conservative vs. more aggressive therapy, blah, blah, blah.”

In another post I have touched on whether or not dentists are ethical, see http://blog.teethremoval.com/are-dentists-ethical-or-scam-artists/. It seems to be the case that some dentists are not being ethical and this can’t be explained by either a more conservative or more aggressive treatment, it simply is a matter of economics. However, in other cases some dentists do disagree on certain aspects of care particularly with regards to how many cavities are present. The take home message for patients seems to be, it is beneficial to get several opinions on any treatment plans you are suspicious or have hesitations about. It is also useful to do some research online or elsewhere if able. Of course, seeing several dentists to decide on a treatment plan is not covered under usual aspects of normal care. It seems like it should be…

Further, many dentists are facing financial pressures due to increasing student loans. For example see the post http://blog.teethremoval.com/lets-give-our-kids-a-chance-to-succeed/. It is important that these loans do not continue to increase substantially in the future so that dentists in the future are not further pressured into even more creative diagnosis. This does not benefit patients.

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How to Manage Pain Patients in Dental Practice

Posted on 19. Apr, 2014 by .

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An interesting article appears in J Can Dent Assoc 2012;78:c83 titled “Neuropathic Orofacial Pain Patients in Need of Dental Care,” written by Gary D. Klasser and Henry A. Gremillion. It was posted online on August 17, 2012, over at http://www.jcda.ca/article/c83. The abstract of the article states

“Dental pain is a common complaint among the general population. Most pain is a result of traumatic injury or bacterial infection in pulpal and periapical tissues, and dental practitioners are successful at diagnosing these conditions and providing prompt relief. However, in some cases, patients continue to complain of persistent pain, which may be categorized as neuropathic. These people may avoid or neglect routine dental treatment or interventions to prevent precipitation, perpetuation or exacerbation of their pain condition, and practitioners may have to modify their procedures when managing the dental needs of this unique population.”

The article mentions that most dental pain is the result of traumatic injury or bacterial infection and classified as nociceptive or inflammatory. A description of the differences between nociceptive and inflammatory pain is provided. The article states that dental practitioners are very succesful at recognizing and treating these types of pain. The article then goes on to say

“However, in some cases, those who have undergone dental treatments that have been considered both clinically and radiographically successful continue to complain of persistent pain. These people may be experiencing neuropathic pain.”

The article then goes on to state that neuropathic pain may have not have a demonstrable lesion or disease and then becomes classified as dysfunctional pain. The differences of neuropathic pain compared to the two other types of pain are then described.

Neuropathic pain can sometimes lead to what is known as a phantom toothache where a patient complains of pain which they may believe be in a tooth yet the dental practitioner can’t find a clear source of this pain.

The authors then go on to describe the pathophysiology of neuropathic pain and state that complex peripheral and central mechanisms are involved which are not yet fully understood. The authors state that the initiating event is often uknown

“… although it is probable that some form of mechanical trauma, metabolic disorder, neurotoxic chemicals, infection (bacterial, viral, fungal) or tumour invasion causes a release of neurochemicals and inflammatory mediators from the peripheral tissues, primary afferent nerve endings or both. This can increase membrane excitability and decrease the activation threshold of peripheral nociceptors (a process referred to as peripheral sensitization) increasing nociceptive input into the central nervous system (CNS). This bombardment of the CNS induces synaptic plasticity characterized by spontaneous activity, expansion of receptive fields, lowering of activation thresholds, hyperexcitability of neurons in the CNS, anatomic alterations to inhibitory neurons and other neural tissues and genetic alterations (a process referred to as central sensitization).”

The article goes on to describe how when people with neuropathic orofacial pain see a dentist the treatment performed may exacerbate the pain due to a hyperexcitable trigeminal nociceptive system. This can lead to further dental treatments which may or may not be successful.  The authors state that dentists should take a comprehensive history and clinical and imaging examinations in order to rule out other potential causes of pain which includes pain from a psychologic origin.

The authors go on to state that local anesthesia should be carefully considered in patients with neuropathic orofacial pain. This is certainly an interesting article and as the authors state in the conclusion all dentists should be aware of neuropathic orofacial pain and able to recognize it. The authors argue that these patients require a team based approach with open communication between all parties.

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High-Level Evidence to Identify Diseases and Disorders Associated with Periodontal Disease

Posted on 19. Apr, 2014 by .

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An interesting article appears in J Can Dent Assoc, 2012, 78:c25, titled ” Separating Fact from Fiction: Use of High-Level Evidence from Research Syntheses to Identify Diseases and Disorders Associated with Periodontal Disease,” by Amir Azarpazhooh and Howard C. Tenenbaum. The article describes how it is known that periodontitis has been correlated with several diseases and attempts to look at the more robust associations.

In the risks of keeping wisdom teeth page http://www.teethremoval.com/risks_of_keeping_wisdom_teeth.html this has been mentioned and several studies are cited. This page states

“These potential systemic diseases that may be associated with periodontal disease include premature delivery of low-birth weight infants, coronary artery disease, coronary heart disease, renal vascular disease, stroke, diabetes, bacterial pneumonia, chronic obstructive lung disease, and Alzheimer’s disease.”

The article discussed above uses meta-analyses and systematic reviews available up to June 2011. This article states

“This high-level evidence indicates that individuals with periodontitis have a significantly higher risk of various other problems, including cardiovascular disease, diabetes mellitus, respiratory disease and preterm low-birth-weight deliveries….The diseases for which an association with periodontitis has been reported include cardiovascular disease (CVD), stroke, respiratory disease, rheumatoid arthritis, pancreatic cancer, diabetes mellitus (types 1 and 2), preterm delivery, low-birth-weight delivery, preeclampsia, osteoporosis and osteoarthritis. On the basis of an initial scan of the literature for high-level evidence, data were analyzed for only a selection of these conditions: CVD, diabetes, adverse outcomes of pregnancy, preeclampsia and respiratory disease.”

The author then goes into a more detailed analysis of 1) cardiovascular disease, 2) diabetes mellitus, 3) adverse outcomes of pregnancy, 4) preeclampsia, and 5) respiratory diseases. Many articles and possible implications are discussed in brief.

The author concludes by saying

“..it remains important to recommend periodontal treatment for all patients, whether or not they have other established general health problems, primarily to improve periodontal health in its own right. Despite some evidence for reversibility, it cannot be guaranteed that treatment of periodontitis will reduce patients’ risk for other diseases. However, the role of periodontal disease as a “risk indicator” or “marker” should not be ignored, since the presence of this condition may serve as a warning to the dentist or dental hygienist that the patient is at risk for other diseases, especially CVD, diabetes, respiratory disease and preterm and/or low-birth-weight delivery.”

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