April is Oral Cancer Awareness Month

This month marks 13th year for raising oral cancer awareness

The Oral Cancer Foundation (OCF) is encouraging the dental community to get involved in Oral Cancer Awareness Month this April 2012 by offering free oral cancer screenings to the public in an effort to raise awareness of this disease across the U.S.

Oral cancer screening for side of tongue

OCF is asking dental and medical professionals nationwide to act as the first line of defense against oral cancer through the process of early discovery, and to raise public awareness of this cause by opening their doors for at least a half-day, during the month of April, to screen members of their community.

Oral cancer is one of the few cancers that are on the rise in the U.S. When found early, oral cancers have an 80% or better survival rate. Unfortunately, most oral cancers are found in late stages, when the five-year survival rate plummets to about 30%. Late-stage diagnosis can be greatly reduced through increased public awareness of these facts, and OCF believes that a national program of opportunistic screenings is the best means of creating that awareness.

In April 2012, OCF will again join forces with both professional societies and private sector companies who are stakeholders in this disease. The ADA, the American Academy of Oral and Maxillofacial Surgery, the Academy of General Dentistry, and the American Academy of Oral Medicine form the core of the professional society sponsorship.

OCF has also aligned with Henry Schein, LED Dental, and Bristol-Myers Squibb, who are asking their customers to be active in this April's endeavor. In addition, the 21 treatment facilities with head and neck departments that participated in 2011's effort are expected to participate again in 2012.

With the help of these partners in 2011, OCF was able to create more than 2,000 screening sites/events, according to the foundation. These events, combined with seven major walk/run awareness events coordinated by OCF, resulted in more than 50,000 individual screenings for oral cancer during April alone.

Cancer-causing Agent Identified in Smokeless Tobacco

Oral carcinogen shown to induce cancer for snuff/chew users

April 2, 2012 -- A chemical present in smokeless tobacco products is a strong oral carcinogen, according to research being presented this week at the American Association for Cancer Research's annual meeting in Chicago.

Although smokeless tobacco products have long been linked with certain cancers, including those of the oral cavity and esophagus, this is the first study to identify a specific chemical present in smokeless tobacco products that induces oral cancer in animals, according to Silvia Balbo, PhD, research associate at the Masonic Cancer Center of the University of Minnesota.

"(S)-N'-nitrosonornicotine, or (S)-NNN, is the only chemical in smokeless tobacco known to cause oral cancer," Balbo said in a press release.

Balbo and colleagues administered (S)-NNN and (R)-NNN to four groups of 24 rats. The rats were given either (S)-NNN alone, (R)-NNN alone, a combination of both, or tap water. The total dose was approximately equivalent to the amount of (S)-NNN to which a smokeless tobacco user would be exposed from chronic use of these products.

All rats assigned to (S)-NNN alone or the combination of the two began losing weight after one year of exposure and died by 17 months. Rats assigned to (R)-NNN or tap water were terminated at 20 months.

All rats assigned to (S)-NNN had esophageal tumors and demonstrated 100% incidence of oral tumors, including tumors of the tongue, buccal mucosa, soft palate, and pharynx. In contrast, researchers found oral tumors in only five of 24 rats given (R)-NNN and esophageal tumors in only three of 24 rats assigned to (R)-NNN.

Twelve rats given the combination of (S)-NNN and (R)-NNN had 153 esophageal tumors and 96 oral tumors.

Since the U.S. Food and Drug Administration regulates tobacco products, Balbo hopes the results of this study will inform regulatory decisions. Moving forward, she and her colleagues hope to identify other chemicals that may be carcinogens in smokeless tobacco and to understand what level of these chemicals is present in smokeless tobacco products.

CEREC Outshines The Competition

Chairside all-ceramic restorations shine in long-term study

A study of 1,335 all-ceramic restorations placed between 1987 and 2009 has found that they are both predictable and reliably successful, with a 93.5% probability of survival over a 10-year period (International Journal of Prosthodontics, January/February 2012, Vol. 25:1, pp. 70-78).

Only glass ceramic restorations placed between 1987 and 2009 were evaluated in the study, which was conducted by members of the clinical department of restorative and prosthetic dentistry at Medical University Innsbruck.

Cases involving bruxism, nonvital teeth, and specific cementation agents created significantly increased rates of failure. Yet even when failures occurred, patients overwhelmingly reported "excellent" satisfaction.

"The purpose of this clinical retrospective study was to evaluate the clinical quality, success rate, and estimated survival rate of silicate glass-ceramic restorations in both dental arches over a 20-year period," the authors wrote. They also examined patient- and restoration-specific variables to see which could predict a ceramic restoration failure.

Study methodology

A total of 302 patients (120 men and 182 women) participated in the study. They were examined at the university during regularly scheduled visits for maintenance. Patient-specific data about sex, age, tooth sensitivity, smoking, and bruxism were noted, as well as self-reported data regarding their level of satisfaction with their restorations: excellent, good, medium, or none. The restorations were categorized by region as well, into anterior, premolar, and molar regions.

All 1,335 silicate ceramic restorations had been placed at the university between November 1987 and December 2009. Of these restorations, 451 were observed over a 10-year period, 84 for 15 years, and 24 over 20 years.

Clinical examinations were carried out by two dentists between March and July of 2010. One dentist had placed most of the restorations, whereas the other had placed none of them. California Dental Association/Ryge criteria were used to rate each ceramic restoration as a success if it received an alpha or bravo grade, or as a failure if it received a charlie or delta grade.

Any restorations that had severe enough issues to necessitate replacement were deemed an absolute failure. If a finishing procedure or polishing could correct the issue, the restoration was labeled a relative failure.

Survival rates

Only 95 restorations were rated as failures, 79% of which were absolute. Most failures occurred in the anterior region, with 65, while 19 occurred in premolars and 11 occurred in molars.

Success rates remained strong over time. The estimated survival rate was 97.3% at five years, 96% at eight years, 94% at 10 years, 85.8% at 15 years, and 78.5% after 20 years. Nearly half of the failures occurred in the first eight years, the researchers noted.

While the entire study included 1,335 all-ceramic restorations, 69 failures took place prior to the 2010 examination, so 1,266 were considered. Of these, 26 were rated not acceptable and unsatisfactory when evaluated.

The most frequent reason for failure was fracture of the ceramic, according to the researchers, followed in order by cracks in the ceramic and secondary caries.

Interestingly, "comparing the type of restoration and all-ceramic material as a predictor for failure, no significant differences were found," they added.

Nonvital teeth and patients with bruxism displayed significantly higher failure rates (p < 0.0001 and p = 0.0045, respectively). The choice of luting agent also was relevant. Cementation using Variolink (Ivoclar Vivadent) showed significantly fewer failures than Optec cement (Pentron, p = 0.0217) and Dual cement (Ivoclar Vivadent, p = 0.0099), the researchers noted.

Patient satisfaction

Patient responses to questions about satisfaction were quite positive, with 96% rating it as "excellent" and 4% rating it as "good." Not a single respondent rated his or her satisfaction as "medium" or "none."

"All of the patients, even those who had ceramic failures, regarded the all-ceramic restorations as an ideal type of dental restoration and would bear the time and costs of the all-ceramic procedure again," the researchers wrote.

However, because of the higher occlusal forces present in molar teeth, "the dentist has to be especially careful of ceramic material selection depending on indication, the extent of the defect, and the patient," they added.

Dental Visits Critical for Smokers

CDC report: More smokers avoid the dentist

Adult tobacco smokers are four times more likely to develop oral health problems but much less likely than nonsmokers to go to the dentist regularly, according to a report released February 7 by the U.S. Centers for Disease Control and Prevention (CDC).

The study, which included more than 16,000 adults between the ages of 18 and 64 who participated in the 2008 National Health Interview Survey, also found that although more than a third of smokers included in the report said they have three or more dental problems, 20% said they had not been to a dentist in at least five years. Among nonsmokers and former smokers, 10% had stayed away that long.

Cost was cited as the main reason that most adults with an oral health problem did not see a dentist in the past six months; 56% of current smokers, 36% of former smokers, and 35% of never smokers said they could not afford treatment or did not have insurance.

"Overall, current smokers had a poorer oral health status and more oral health problems than either former smokers or never smokers," the report authors noted. "However, current smokers were more likely to think that their oral health problem was important."

The evidence for an association between tobacco use and oral diseases has been clearly shown in every U.S. surgeon general's report on tobacco since 1964. Tobacco use is a risk factor for oral cancers, periodontal diseases, and dental caries, among other diseases.

reported by DrBicuspid.com, Feb 2012.

Dr. Notes:

Because cost is cited as a major factor for smokers and their reluctance to visit the dentist for regular check-ups, I thought I would present some facts.

The average cost for a pack of cigarettes in the state of Minnesota is $6.53.  That’s 33¢ per cigarette.  According to the American Lung Association, the average smoker inhales 3/4 pack, or 15 cigarettes, per day.  After doing the math you'd find that the annual cost for a smoker’s habit totals $1787 plus change.

Now consider this.  The average annual cost of routine dental care (includes 3 cleanings, exams and routine radiographs) would be around $275.  Again, if you crunch the numbers you would find that if the average smoker were to reduce cigarette consumption by 3 cigarettes per day, they could easily afford the out-of-pocket expense of routine dental care.  And these numbers don’t consider the inclusion of dental insurance, which 80% of smokers have, yet don’t utilize.

Our job as a dental office is to address and treat oral health.  We don't give lectures and we don't judge people based on their choices in life, especially their decision to smoke.  But we will provide guidance and advice for those who do.  Regular dental care is crucial for smokers if they wish to minimize the long term effects of their smoking habit.  Routine cleanings and exams can do a lot to help prevent a wide range of problems that smokers are predisposed to and help proactively identify the development of long-term complications that can result from oral tobacco use.

What Does Your Mouth Have to Say About Your Health?

Oral Health Can Provide Clues to Total Body Wellness for Patients

Cardiologists might not check your teeth and gums, but maybe they should start. Mounting evidence suggests a quick peek in the mouth may reveal a whole lot about your general health.

PICTURES: Foul mouth: what yucky signs say about your health

The lips, mouth, teeth and breath can signal medical problems and diseases beyond the plaque, gum disease and gingivitis diagnosed in the dentist's chair. Plaque buildup between teeth due to lax brushing and flossing is very different from plaque that builds up in arteries and causes heart attacks - but the toxins in mouth plaque stimulate a chronic inflammatory response linked to diseases like heart disease.

"The mouth is the gateway to the heart and there's clearly a link between poor dental health and cardiovascular conditions," says Dr. Kevin Marzo, Chief of Cardiology at Winthrop University Hospital in Mineola, New York. For example, he says, cardiac medications you put under your tongue travel quickly through the bloodstream. That means bacteria can too.

"The bacteria that cause dental plaque may promote inflammation in the body beyond the mouth including the lining of the blood vessels, increasing the risk for cardiovascular disease including heart attacks," says Marzo.

Research has shown when people with active gum disease are treated, their arteries actually get healthier. Some experts suggest managing inflammation in the mouth may reduce other inflammatory-related health issues, including arthritis - even wrinkles and aging. Besides heart disease, gum disease has been linked to respiratory diseases, stroke, and osteoporosis.

The mouth can also give doctors clues about a person's sexual health. Warts in the mouth that resemble cauliflower clusters may signal the human papillomavirus, or HPV, one of the most common sexually transmitted infections.

"I see them on the lips, tongue or roof of the mouth," says Dr. Susan Pugliese, Clinical Assistant Professor Division of Oral Medicine and Dentistry Department of Surgery at SUNY Downstate. "And I'm seeing them more frequently in patients over 50 who are dating." Pugliese says this age group may not connect what's going on in their mouth to their sex lives.

HPV is also a driver of oral cancer: the National Cancer Institute, estimates 65 percent of the approximately 8,000 cancers of the tonsils and base of the tongue seen in the U.S. in 2010 were from HPV infections; 80 per cent were in men. Cancers may appear as ulcers on the lips, inside of the cheeks, tongue or back of throat that don't heal, or white patches that don't slough off. A biopsy is typically recommended for suspicious warts or lesions in the mouth and throat.

HIV is often first detected in the mouth, as a bright red outline around the teeth, or as a white coating that can be scraped off the tongue, known as thrush. The coating signals an overgrowth of Candida, the same fungus that causes yeast infections in women and jock itch in men. The white coating can also signal glucose levels are out of whack, poorly managed diabetes or fluctuating hormones. It can also be harmless, signaling a sensitivity to additives in toothpaste, such as tartar control agents. Dentists may recommend an HIV test for young patients presenting with Candida who have other risk factors.

A person's breath also provides health clues. Bad breath may signal serious conditions that require medical attention such as respiratory infections, diabetes, acid reflux and kidney and liver problems. Dry mouth? That's sometimes caused by medications, such as antidepressants, anti-inflammatories, and heart drugs. Drinking water or chewing on fibrous foods such as celery may help.

Good oral hygiene is the best way to prevent gum disease and keep your mouth healthy. Healthy gums hug the teeth and don't pull away, have bounce, and don't bleed from brushing or flossing.

But while a clean, well-cared for mouth can promote good health, it can also disguise serious health problems... so don't skip regular visits to the doctor, and dentist.

Minnesota Taxpayers Suffer As Insurance Carriers Reap Rewards of Government Oversight

Minn. Medicaid under fire for alleged overpayments

March 13, 2012 -- The federal government is investigating whether Minnesota is overpaying the nonprofit healthcare plans that administer its Medicaid programs.  The issue arose after UCare, one of the managed care plans that subcontracts with Medical Assistance (the state Medicaid program), unexpectedly returned to the state $30 million in excess reserves last year when lawmakers were facing huge deficits.

Three other managed care companies -- Blue Plus, Medica, and HealthPartners -- refused to make similar "donations," even though these plans had higher Medicaid operating margins than UCare in 2010, according to Allan Baumgarten, an independent research consultant and author of Minnesota Health Market Review.

In February, Minnesota Department of Human Services (DHS) Commissioner Lucinda Jesson told lawmakers that federal authorities had contacted her last summer about the investigation. But she could not say which federal agency was involved or the scope of their queries.

Dental carriers, too?

As part of the Medicaid program, UCare and the other managed care plans subcontract to four dental carriers, including Delta Dental of Minnesota, which administers the bulk of the state's Medicaid dental benefits. In January 2011 Jesson initiated 1% profit caps and competitive bidding for the health plans, but the possible effect this will have on the dental care subcontractors is yet to be determined.

Joe Lally, vice president for strategic planning at Delta Dental of Minnesota, which supports Medicaid dental services through Medica, Blue Plus, and Metropolitan Health Plan, noted that his company is not part of the federal investigation.

"It is not a risk arrangement; it's a self-insured arrangement," he told DrBicuspid.com. "We're simply paid for the services we provide in terms of getting the network together, processing claims, and providing customer service."

In addition to the federal investigation, Sen. Chuck Grassley (R-Iowa) has launched a separate inquiry into Minnesota's management of the Medical Assistance programs -- a $3.7 billion-a-year business for the health plans the state pays to manage care for public patients. Grassley has sent requests for information to the Minnesota DHS and officials in 49 other states.

Lally had heard from lawmakers that the investigation is likely focusing on the profits that the healthcare plans are making from public health programs.  "I think the concern in some discussions in the Capitol is that people are making money from public programs as opposed to breaking even or having a slight margin or loss," Lally said.

“The states should not make it possible for HMOs to make higher profits on Medicaid plans than they're making on employer group plans.”

— Allan Baumgarten, Minnesota Health Market Review

In 2010, Minnesota paid an average of $441 per month per Medicaid managed-care enrollee, to Medica, Blue Plus, HealthPartners, and UCare, according to DHS. In Michigan, the average monthly amount paid to big plans was $283, according to Baumgarten, and in Wisconsin, the amount was $298 in 2009.

There was also a striking difference in the annual profits that the plans made on Medicaid programs. In 2010, the average annual profit margin in Minnesota was 8.9%; Michigan's 2010 average was 2.4%, and Wisconsin's 2009 average was 2.6%.

Step in the right direction

In an opinion piece in the Star Tribune, Julie Brunner of the Minnesota Council of Health Plans wrote that Minnesota often provides more extensive benefits than other states, which "greatly influences" costs. She also pointed out that profits vary from year to year. The average profit over the past five years for all of Minnesota's public programs was 1.6% of revenue -- less than the margins for both Michigan and Wisconsin.

"I do know the health plans have lost a lot of money in certain years, and in other years they've come out ahead," said Delta's Lally. "So it depends on the year.”  The profit caps and competitive bidding for the health plans initiated by Jesson are steps in the right direction, according to Baumgarten.

"It's probably something the state should have done long ago, but better now than never," he told DrBicuspid.com. "Through competitive bidding or better analysis of data on care being delivered, the state should be able to reset rates paid to HMOs to cover necessary care while carrying a reasonable margin, which is not 8.9%. The states should not make it possible for HMOs to make higher profits on Medicaid plans than they're making on employer group plans."

Competitive bidding saved about $175 million this year, and reforms to managed care are expected to save a total of $242 million, according to Jesson.  "Looking ahead, we intend to move to more performance-based purchasing, creating incentives for quality and efficiency in both managed care and fee for service," she said in a statement to DrBicuspid.com.

This spring her office will begin a demonstration project to contract directly with providers, which will give them flexibility and provide the opportunity to share in the savings they create, she added.

A 2010 report [PDF] from the U.S. Government Accountability Office found inconsistent federal oversight of states' payments to managed-care organizations. A bill calling for an independent audit is being considered in the Minnesota legislature.

Snoring Tied to Kids' Risk of Behavioral Problems

Regular dental visits can help identify problems at an early stage

By Reuters Health

March 7, 2012 -- Young children who snore a lot or have other breathing problems at night may have a heightened risk of behavioral and emotional problems later on, a new study suggests.

The study, published in the journal Pediatrics, is not the first to link behavioral issues to so-called sleep-disordered breathing.

"We didn't invent the association," noted lead researcher Dr. Karen Bonuck, of the Albert Einstein College of Medicine in New York.

But, she said, this is the largest study yet to look at the question, following more than 13,000 children from infancy to the age of seven.  Of those kids, 45% remained free of nighttime breathing problems, based on parents' reports. The rest had symptoms at some point during infancy or early childhood.

Eight percent of the children fell into what the researchers dubbed the "worst case" group; they had breathing symptoms that peaked between the ages of two and three and then persisted.

Overall, Dr. Bonuck's team found, children with sleep-disordered breathing at any time were more likely to develop symptoms of behavioral or emotional disorders -- like attention deficit hyperactivity disorder (ADHD) or anxiety -- by age seven.

About 13.5% had such symptoms at age 7, versus just over 8% of kids who'd been free of sleep-disordered breathing.  And the biggest risk was seen in the worst-case group. By age 7, nearly 18% of those kids had possible behavioral or emotional disorders.

The researchers can't say for sure whether all of those children had outright disorders, such as ADHD. Their results are based on a screening questionnaire given to parents.  What's more, it's not certain that the breathing problems are directly to blame.  But, Dr. Bonuck said, the researchers did control for a range of variables that could help account for the link -- like parents' income and education, race, birth weight, and whether moms smoked during pregnancy.

"Even considering all those variables, overall, sleep-disordered breathing seemed to have the strongest effect," Dr. Bonuck said.

Among the "worst case" kids, for example, sleep-disordered breathing was linked to a 72% increase in the risk of behavioral and emotional symptoms at age seven -- even with other factors considered.

"This provides strong evidence that the (breathing) symptoms we looked at could promote these behavioral and emotional symptoms," Dr. Bonuck said.

Still, she stressed, no one is saying sleep-disordered breathing is the whole story. "Certainly, emotional and behavioral disorders are multi-factorial," Dr. Bonuck said.

"What [the study] found is intuitively what we'd expect to see," said Dr. Sanjeev V. Kothare, interim medical director of the Center for Pediatric Sleep Disorders at Children's Hospital Boston.

Dr. Kothare noted that the American Academy of Pediatrics (AAP) already recommends that pediatricians should screen all children for snoring and, if needed, refer them to a sleep center for further evaluation.

In many kids, especially 3- to 6-year-olds, sleep-disordered breathing is caused by enlarged tonsils or adenoids, and removing the tissue can improve nighttime breathing -- as well as daytime symptoms, Dr. Kothare noted.  For other children, excess pounds feed the nighttime breathing problems and most will improve if they shed the extra weight, according to the AAP.