Relief for Patients with Chronic Dry Mouth

XyliMelts Help Relieve Dry Mouth Overnight

By Rabia Mughal

November 10, 2011 -- A self-adhering, slowly dissolving disk that releases xylitol, cellulose gum, and mild mint flavor has been found to be effective in relieving dry mouth during prolonged periods of sleep, according to a small study in the International Journal of Dental Hygiene (October 31, 2011).

Many patients have a sensation of dry mouth (xerostomia) while they are awake, which generates serious complaints, but there are consequences of dry mouth during sleep that are much more serious, according to study author Jeff Burgess, DDS, the director of Oral Care Research Associates, which provides research consulting services to commercial and educational clients.

“Any product that can reduce these consequences is worthy of investigation.”
— Jeff Burgess, DDS

Dry mouth is worst while sleeping, when saliva flow is lowest for everyone, and this can disturb sleep, according to Dr. Burgess. It can also cause an increase in levels of bacteria that cause caries, periodontal disease, and halitosis.

While daytime dryness is easily managed in most individuals, there is no product lasting longer than an hour that can be used at night to reduce the perception of oral dryness while sleeping, the study authors noted. To date, no research has supported the use of time-release oral-adhering disks for managing symptoms of nighttime dry mouth, they added.

This led them to study XyliMelts for Dry Mouth (OraHealth), disks which are designed to adhere to gingiva and/or molars in the buccal region and time release 500 mg of xylitol, cellulose gum, and a mild mint flavor.

"Any product that can reduce either of these serious consequences is worthy of investigation," Dr. Burgess said.

5 disks a day

To study this product, the authors recruited 15 subjects who identified themselves as having morning oral dryness. The study was conducted as a nonblinded case series with self-reported measures before treatment and self-reports of measures during and after one week of treatment. Subjects also completed a health history questionnaire that detailed medical problems.

Initial and follow-up questions included endorsement of two 100-mm visual analog scales (anchored by dryness/wetness and comfortable/uncomfortable) defining the perceived level of mouth moisture and the level of oral discomfort upon waking in the morning. The study participants were also asked about sleep problems and night awakenings related to dry mouth.

Each subject was asked to use one XyliMelts disk 30 minutes after breakfast, 30 minutes after lunch, and 30 minutes after dinner and two before going to bed.

Among the study findings:

• Initial self-assessed oral wetness upon waking ranged from 3 to 50 (mean = 22.2). Self-assessed oral wetness upon waking after one week of using two disks at bedtime and three more during the day ranged from 32 to 92 (mean = 67.80).
• Initial self-assessed discomfort upon waking ranged from 22 to 92 (mean = 65.23) with post-treatment discomfort ranging from 6 to 55 (mean = 27.63).
• Several subjects reported less sleep disturbance associated with nighttime oral dryness.

"When the subjects in this study used two XyliMelts disks while sleeping, they reported their mouths were more moist upon waking in the morning, showing that the product reduces the sensation of dryness all night long," Dr. Burgess said. "They also reported that the flavors of xylitol and mint were still present in their mouths upon waking in the morning, showing that the time-release aspect of the product worked all night long."

To the researchers' knowledge, no remedy for xerostomia has previously been shown to be effective for a substantial period of sleep, and, as a consequence, to reduce the morning sensation of dryness and reduce sleep disturbance, he added.

"Dentists have many patients who suffer from xerostomia for a variety of reasons, and it is worst for them while sleeping," Dr. Burgess concluded. "This study shows that these patients can benefit from XyliMelts for Dry Mouth."

Oral Cancer Screenings Now Considered Standard of Care in Dentistry

October 13, 2011 -- LAS VEGAS - The statistics are chilling: Oral cancer now kills nearly three times as many people as cervical cancer. Every hour, someone dies from the disease. This year, 37,000 Americans will be diagnosed with oral cancer, and 25% of them will die of it.

So it is crucial that dentists check their patients for it regularly, according to John Flucke, DDS, a general dentist from Lee's Summit, MO, who writes a technology blog and lectures regularly about dental technologies.

"It's under the radar," he said, referring to the fact that the rising occurrence of oral cancer has not been widely reported.

In a presentation on oral cancer at the ADA annual session this week, Dr. Flucke stressed the importance of dentists incorporating oral cancer screening into their regular practice routines.

“Dentists really are oral physicians.”
— John Flucke, DDS

Since dental professionals have been trained to spot unhealthy characteristics in the mouth and many medical doctors often don't check the oral cavity, dentists should make it part of routine exams, he said.

"Dentists really are oral physicians," Dr. Flucke said.

Only 20% of the U.S. population gets annual oral cancer screenings, according to the National Cancer Institute.

Incidence of the disease is growing, especially among those who don't fit the traditional profile. Instead of older people who drink and smoke, oral cancer has become more common among people between 25 and 50 years old. Studies show it is increasingly being linked to human papillomavirus (HPV) 16 and 18 among people who have had more than three sex partners, Dr. Flucke said.

He starts oral cancer screening of patients when they are 15 years old and repeats it every six months. Such screening only takes three to five minutes for a visual exam and physical palpation, Dr. Flucke said.

HPV-related oral cancers generally occur in the posterior regions of the mouth, including the pharyngeal tonsil, he noted.

Most oral cancers are survivable if detected early. However, most are not found until the disease is in the later stages, when five-year survival rates drop to 20% to 30%.

"I tell patients if they have trouble swallowing for prolonged periods to get it checked, or if they notice anything lumpy, bumpy, or that feels out of place," Dr. Flucke advised.

Suspicious lesions or inflamed areas could result from injuries, so dentists should do follow-up checks 10 days later, he recommended.

The escalating incidence of HPV-related oral cancers, particularly after actor Michael Douglas' battle with oropharyngeal cancer, has increased awareness among medical professionals and the public about the disease.

The incidence in oral cancer patients younger than age 40 has increased nearly fivefold, with many patients having no known risk factors, according to the ADA. Only 57% of all oral cancer patients will still be alive five years after their diagnosis, according to the American Cancer Society.

Staff training, especially with hygienists, and discussing new protocols for oral cancer screening is important, Dr. Flucke said.

If dentists are sufficiently concerned to refer a patient to an oral surgeon for biopsy, he advised practitioners to assure the patient that it does not mean they have oral cancer, just that it is important to be cautious.

As part of his oral cancer screenings, Dr. Flucke uses DentalEZ's Identafi device, which uses fluorescent technology to detect mucosal abnormalities. The small, cordless device uses a combination of white, violet, and green-amber multispectral wavelengths to find suspicious lesions.

Oral Cancer Linked to Virus

Increase in Oral Cancers Linked to HPV

The human papillomavirus is contributing to the growing number of  head and neck cancers in the United States, according to a new study Monday in the Journal of Clinical Oncology.

The study found that the number of cases of oropharyngeal cancer - cancers of the tonsil, back of the mouth (throat) and base of the tongue - has been on the rise since the mid-1980s.  The study suggests that one reason could an increase in the number of people having oral sex resulting in oral human papillomavirus  exposure.

Researchers say these cancers fall into two categories–those caused by tobacco and alcohol and those caused by the sexually transmitted virus, HPV. They now believe approximately 70% of all oropharyngeal cancers are caused by HPV infection.

"We used to think of oropharyngeal cancer as one cancer," said senior author Dr. Maura Gillison, The Ohio State University Comprehensive Cancer Center in Columbus. "Now we know the disease is comprised of two biologically and epidemiologically distinct cancers. This new understanding will increasingly enable us to improve and better personalize care for patients with each form of the disease."

Researchers tested cancer tissue samples from almost 6,000 patients in Hawaii, Iowa and Los Angeles between 1984 and 2004. They found the HPV-positive cancers increased 225% while HPV-negative oropharynx cancers dropped 50%–most likely because of a reduction in smoking and tobacco use. Even so, patients with HPV-positive cancers live longer.

"Patients with HPV positive cancers have better survival rates," said principal investigator Dr. Anil Chaturvedi of the National Cancer Institute. "The precise reasons for the survival benefits are not clear, but tumors in HPV-positive patients tend to have less genetic damage. Because of that, they are more responsive to cancer therapies like radiation treatment."

"The HPV status of a patient's tumor is the single greatest determinant of whether a person lives or dies after a diagnosis of local-regionally advanced oropharynx cancer," Gillison said. "HPV-positive patients have an approximate 60% reduction in risk of death after their diagnosis when compared to HPV-negative patients."

Gillison says about 95% of the HPV-positive oropharynx cancers were caused by HPV16, a strain targeted by Gardasil and Cervarix, the two vaccines currently on the market to prevent cervical cancer. Gardasil is manufactured by Merck & Co. and Cervarix is made by GlaxoSmithKline.

Gardasil was approved in 2006 for use in females  ages 9-26 to help prevent cervical cancer and genital warts. It was approved in 2009 for  males9-26 to reduce the risk of genital warts. It has not been recommended for use in preventing HPV-associated cancers, according to the National Cancer Institute. Cervarix was approved in 2009 for use in females 10-25. It is not approved for males.

The findings are important because the increase in these cancers has been relatively rapid compared with other HPV associated cancers like cervical cancer, Chaturvedi says. With cervical cancer, incidence rates have declined over time because of screening, but currently there is no screening in place for oropharyngeal cancers.

"Should the observed declines in cervical cancer and the observed increases in HPV positive oropharyngeal cancers continue into the future," Chaturvedi said.  "HPV positive oropharyngeal cancers will be the leading HPV associated cancers over the next decade–by around 2020."

There were almost 35,000 new cases of oral and oropharyngeal cancers this year, according to the American Cancer Society. While about 7,000 Americans will die this year, death rates associated with these cancers has actually been declining over the last 30 plus years.

"The burden of invasive HPV-caused cancers will shift from women to men in the US, largely due to the rise of HPV-positive oropharynx cancers among men," Gillison said. "HPV infection and its consequences have long been considered a women's problem, and women will continue to bear the brunt of the morbidity associated with the infection. However, gender equity is being achieved with regard to the burden of HPV-caused cancers. HPV infection is therefore a problem for both men and women."

Using Infrared Cameras to Search for Breast Cancer

Here is How They Work:

A cell puts out energy as it grows and divides into multiple cells. The faster this growth occurs, the higher is the energy output. This energy output increases the heat; that is, a breast cancer is, among other things, a severe inflammation that does not respond to normal anti-inflammation drugs, whether they are OTC or prescription. 

This increase in energy production has been known for a very long time. In the 1960s and 1970s, Xerography was used, but the printouts of the pictures taken of the breast hot spots took the form of a series of life-size pictures on sheets of computer paper that might be yards long. The sheer inconvenience of Xerographic heat detection made it impracticable and eventually it was largely though not totally abandoned. What we now know as traditional mammography, which is radiation-based and was in use before Xerography was tried, took its place. 

But problems with mammography abound. There are many false positives, which must be ruled out by biopsy, and much more serious, there are many false negatives. Breast cancer is the second leading malpractice-related condition with most lawsuits arising out of misdiagnosis and delayed treatment. One problem is that a mammogram may be negative, even for women with a breast lump, but a negative mammogram does not definitively rule out breast cancer. Further tests are necessary. Another problem is that women under 50 can get breast cancer, but many doctors will assume a diagnosis of breast fibrocystic disease because of their age. 


It is in that area of women under 50 years old that infrared camera, viewing their digital images on computer screens rather than yard-long paper, are the most useful. Although fibrocystic breast disease puts out some heat, it does not involve the very rapid cell growth and proliferation seen in cancer. For that reason, an infrared camera will show a much hotter image on a cancer than on a cyst or fibroid. This lowers the likelihood of a false positive and a false negative. According to a brochure on Breast Health, infrared screening is especially appropriate for younger women (30 to 50) whose denser breast tissue makes it more difficult for mammography to be effective. 

However, infrared cameras also have limitations. The most important one is that infrared cameras do not have the penetrating effectiveness of radiology. Therefore, a cancer an inch from the skin will almost certainly be picked up by infrared photography, but a cancer clinging to the back of the breast wall will be missed. This cancer will probably be missed by traditional mammography as well. 

Ultimately, the responsibility for breast cancer detection falls to each individual woman. She must see to it that the early detection guidelines are followed.  Annual Infrared Imaging (thermography) screening for women of all ages.  Mammography, when considered appropriate for women who are aged 50 or older. A regular breast examination by health professional Monthly breast self-examination. Personal awareness for [sic] changes in the breast.  Readiness to discuss quickly any such changes with a doctor. 

That last is critically important. Most women quickly become aware of changes in their breasts, but all too many women won't report the changes to their doctors because they are afraid they have breast cancer and somehow convince themselves that if they don't have the cancer confirmed medically it will go away. The best technology in the world will not save a woman from a breast cancer if she won't allow to be diagnosed or treated.

by Anne Wingate, Ph.D

About the Author

My first mammogram, when I was in my late 20s, was a Xerograph. I still remember how LONG that sheet of paper was. My mother and her mother both died of breast cancer. Last year I was on an every three months mammography schedule, but after one last month they put me back on an every six month schedule. I have read every book on breast cancer I could get my hands on, including some from the University of Utah's medical school library.

Whitening Toothbrush Maker Responds to Criticism

J&J to Modify Some Toothbrush Whitening Claims

September 9, 2011 -- The National Advertising Division (NAD) of the Council of Better Business Bureaus has recommended that Johnson & Johnson Healthcare Products modify certain claims for its Reach Total Care + Whitening toothbrush to clarify that the brush whitens teeth through the abrasive action rather than through bleaching.

As part of its routine monitoring program, NAD -- the advertising industry's self-regulatory forum -- requested substantiation for express claims that included the following:

• "Ordinary toothbrushes clean teeth. Reach whitens them."
• "At the core of this revolutionary toothbrush Reach has engineered a unique row of bristles infused with calcium carbonate microwhitening technology. That means each time you brush, you're whitening teeth and removing stains.*" (*in lab tests)

NAD also examined the implied claim that the Reach Total Care + Whitening toothbrush has been proven to actually whiten teeth when used in the same manner as an ordinary toothbrush.

According to Johnson & Johnson, the toothbrush, launched in 2010, was designed with bristles embedded with calcium carbonate, recognized by the U.S. Food and Drug Administration as an abrasive used in fluoride toothpastes.

In support of its claims, Johnson & Johnson provided NAD with evidence that demonstrated that bristles infused with calcium carbonate do, in fact, provide statistically significantly better stain removal than brushes with ordinary bristles. The company also provided testing to demonstrate that its advertised toothbrush provided significantly better plaque removal than the other two ordinary toothbrushes tested. In addition, Johnson & Johnson's evidence demonstrated that the difference in whitening and stain removal was meaningful to consumers, according to NAD.

Following its review of evidence, NAD determined that Johnson & Johnson could support the claim that "[o]rdinary toothbrushes clean teeth. Reach whitens them."

However, NAD recommended that the company modify the claims "whitens and removes stains" and "each time you brush you're whitening and removing stains" to ensure that consumers are aware that stain removal is accomplished extrinsically, through the stain-removing abrasive action of the bristles, not intrinsically through bleaching.

According to NAD, Johnson & Johnson said it is disappointed with the NAD recommendation, "given the industry practice of making unqualified whitening claims based on data showing extrinsic whitening only. Nevertheless, we understand NAD's recommendations and will take them into consideration in future advertising."

      - Dr. Green's sidenote


Patients often ask me for product recommendations (the best toothpaste, toothbrush, etc.) that they can use at home.   We evaluate 100s of products every year to make these recommendations.  Johnson & Johnson is one of the leading manufacturers of these at-home products and to be fair, I will say that the vast majority of their products are excellent and safe.  By posting this article I am in no way suggesting to my readers that they should ban J&J products from their household.  The objective of this post is to educate my readers on the potential dangers of store-bought whitening products.
When I recommend any product to my patients, I always consider it's method of action (how it does what the manufacturer claims it does).  With whitening toothpaste or toothbrushes the method of action usually involves the removal of surface staining rather than through the whitening of the tooth enamel (which is how whitening solutions and gels work).  This is accomplished through the use of coarse abrasives, not whitening solutions.

The best analogy I can use would be to compare toothbrushing to sanding a piece of wood.  In order to take raw wood from being splintery and rough to a smooth surface that's ready to stain, a carpenter will start with a fairly coarse grit of sandpaper and use progressively finer grits until the board is smooth.  When you brush your teeth you are basically doing the same thing-you use a toothbrush and toothpaste containing a minty abrasive to remove the plaque and food debris from your teeth.  I always recommend the use of a soft or ultra-soft bristled toothbrush and a traditional toothpaste (non-whitening and non-tartar control) for my patients.  This will do more than enough to clean your teeth on a daily basis - without damaging or removing the protective enamel.  If you have issues with stain accumulation related to heavy coffee consumption, smoking or drinking colas or red wines, that's where we come in.

Regular visits to a dental hygienist are always essential to maintaining optimum dental health, especially if you accumulate stain easily! 

Limitations Suggested for Osteoporosis Medications

FDA advisers consider time limit for bone drugs

By Reuters Health

September 9, 2011 -- ADELPHI, Md. (Reuters) - U.S. health advisers are considering a time limit for taking a class of drugs used by millions of women to prevent bone fractures, due to concerns over unusual fractures linked to the medicines and possible higher cancer rates.

Two U.S. Food and Drug Administration advisory panels were jointly meeting on Friday over whether to recommend a "drug holiday" or otherwise clarify how long people should take a class of osteoporosis drugs known as bisphosphonates.

These drugs include Merck & Co's Fosamax, Warner Chilcott's Actonel, Roche's Boniva, and Novartis' Reclast.

Widely taken by women after menopause to prevent osteoporosis, drugmakers told the advisers that a sweeping imposition of an interruption in treatment may leave patients vulnerable to more fractures.

FDA staff said rare femur fractures appear to be associated with use of the drugs, and the risk of jaw bone death may increase the longer people take them orally. But they said the evidence for an increased cancer risk was inconsistent.

No advantage exists in staying on the drug beyond five years, FDA researchers said.

"In light of the risk-benefit challenges, the available data suggest that therapy can be safely discontinued without the loss of efficacy," said Dr. Marcea Whitaker, an FDA medical officer from the reproductive and urologic drugs division. "However, additional data are needed to further define an appropriate duration of drug cessation."

Some 4.5 million Americans over the age of 55 filled prescriptions for bisphosphonates in 2009. The medicines are commonly taken for osteoporosis, a progressive bone-thinning condition that typically causes bone fractures in the hip, wrist, or spine.

Boniva is available as either an injection or a tablet, Reclast is an injection, and the other drugs are taken orally.

Since Merck's Fosamax became the first bisphosphonate to get approval for osteoporosis in 1995, the labels for the drugs of this class have undergone multiple reviews and changes.

In 2005, a warning of higher risk of osteonecrosis of the jaw was added to labels, and in 2009, a caution about adverse gastrointestinal reactions. Earlier this year, the labels added a warning of atypical femur fractures and Reclast's label was changed to highlight a higher risk of kidney failure.

Just last month, a federal judge threw out part of a bellwether lawsuit against Merck, but said the plaintiff could pursue her claim that Merck's Fosamax had a design defect and caused her jawbone tissue to die.

Still, bisphosphonates remain a widely-used treatment option for women facing a risk of bone fractures.

"I have to tell my patients that we have no magic bullet, that our drugs decrease the risk of fracture but we have nothing that eliminates fracture," said Dr. Robert Adler, an invited speaker at the advisory meeting and endocrinology professor at the Virginia Commonwealth University.

"Despite rare side effects, those patients who take bisphosphonates have fewer fractures and lower mortality, and these findings need to be shared with our patients," he said.

Makers of the drugs emphasized that studies have not directly linked or explained the connection between their medicines and adverse side effects. They voiced concerns about the lack of data on what happens to patients who go off treatment and suggested "drug holiday" decisions are best done for each patient individually.

"A drug holiday may be appropriate for some patients, but that decision should be based on an individual risk-benefit basis, and a physician is in the best position to make that decision overall," said Joseph Kohles, international medical leader for Boniva at Roche.

Whitening - How to Reduce Sensitivity & Damage to Your Teeth

Can Remineralizing Agents Mitigate Whitening Side Effects?

September 14, 2011 -- Teeth whitening is one of the most popular cosmetic procedures today, but it can have negative side effects. For example, some studies have reported that whitening agents containing carbamide peroxide or peroxide may soften dental hard tissues.

But a new study has found that adding a remineralizing agent such as casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) to the bleaching agent could mitigate this effect (Operative Dentistry, August 5, 2011).

"I decided to conduct this research since there is still a debate over whether carbamide peroxide- or peroxide-containing agents can soften dental hard tissues," said lead study author Boniek Castillo Dutra Borges, DDS, an assistant professor at the school of dentistry at Potiguar University, in a DrBicuspid.com interview. "We were surprised to find that the use of a CPP-ACP paste (MI Paste, GC America) with carbamide peroxide bleaching agents increased the bleached enamel's microhardness and did not have an influence on whitening efficacy."

“CPP-ACP-containing paste with carbamide peroxides could protect enamel against the demineralization. ...”
— Boniek Borges, DDS

Although a large body of scientific evidence demonstrates that CPP-ACP could promote the remineralization of even enamel subsurface caries lesions, this study is the first to analyze the effect of MI Paste in conjunction with carbamide peroxides on bleached enamel microhardness, the study authors noted.

To evaluate the efficacy of an at-home bleaching technique using 10% or 16% carbamide peroxide modified by CPP-ACP and its influence on the microhardness of bleached enamel, the researchers studied 40 bovine incisors that were stained using a mixture of red wine and tea.

The samples were divided into four groups of 10 each and stored in artificial saliva for a 14-day bleaching regimen. The four groups were bleached using the following:

• 10% carbamide peroxide only
• A blend of 10% carbamide peroxide and a CPP-ACP paste
• 16% carbamide peroxide only
• A blend of 16% carbamide peroxide and a CPP-ACP paste

For two of the 10% and 16% peroxide groups, the peroxides were mixed with MI Paste by combining 1 mL of the bleaching gels with 1 mL of MI Paste until a homogeneous paste was obtained, which was then inserted into a 5-mL syringe. In addition, the peroxides alone were put into 5-mL syringes.

The researchers assessed the microhardness and color of the teeth at baseline and immediately after the 14-day bleaching regimen using a microhardness tester and a spectrophotometer. The degree of color change was determined by the Commission Internationale de l'Eclariage (CIE) L*a*b* system and Vita shade guide parameters.

Among the study's findings:

• The teeth that were bleached with a blend of peroxide (10% or 16%) and the CPP-ACP paste presented increased microhardness values after the bleaching regimen compared with the baseline measurements, whereas the samples that were bleached with peroxide only did not show any differences in their microhardness values.
• All the bleaching agents were effective at whitening the teeth and did not show a statistically significant difference using the CIE L*a*b* system or the Vita shade guide parameters.

Even though the concentration of carbamide peroxides was reduced to half after mixing them with MI Paste, this was not sufficient to affect color change after a 14-day bleaching regimen, the authors wrote.

"The use of a casein phosphopeptide-amorphous calcium phosphate (CPP-ACP)-containing paste with carbamide peroxides could protect enamel against the demineralization caused by these bleaching agents," Dr. Borges said. "This improves safety and might even reduce in vivo tooth sensitivity during the bleaching process."

The authors did note, however, that more studies are needed to evaluate how long this microhardness increase could last. Other bleaching peroxides should be tested in association with the CPP-ACP paste because the results of this study are not applicable to all types of bleaching systems, they added.