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Ce 330 - aging, systemic disease and oral health: implications for women worldwide (part ii)

Aging, Systemic Disease and Oral Health:
Implications for Women Worldwide (Part II)
Pam Hughes, RDH, MS
Continuing Education Units: 3 hours Part one of this two-part series on Women, Aging and Oral Health appears in the CE library and introduced the global prevalence and risk factors of three common health conditions among aging women: cardiovascular disease, diabetes and osteoporosis. The aim of the course was to provide dental professionals prevention and treatment approaches, information on connections to oral health and specific treatment plans for each condition. Conflict of Interest Disclosure Statement
• The author has done consulting work for P&G.
The Procter & Gamble Company is an ADA CERP Recognized Provider.
ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry.
Concerns or complaints about a CE provider may be directed to the provider or to ADA CERP at: This course will review the worldwide prevalence, trends and risk factors identified in three medical conditions affecting the health in aging women: stroke, rheumatoid arthritis and depression. A number of health conditions are more prevalent in women than men, requiring different treatment approaches and protocols. Some medical conditions may cause different symptoms in women, ultimately affecting women Crest Oral-B® at Continuing Education Course, Revised February 21, 2012 differently than men. Oftentimes, women are at greater risk for specific medical conditions and are simply unaware.
Knowledge of a condition's symptoms, risk factors, and prevention approaches can assist the dental professional in being more informed. From preventive care to treatment strategies and options, medications and resources, the dental professional is challenged to stay informed as women's medical needs, especially during their adult years, are continually changing.
Upon completion of this course, the dental professional should be able to: • Identify three women's health concerns observed worldwide.
• Discuss prevalence, risk factors, common treatment and prevention strategies and oral connections for each disease.
• Outline home care strategies to help patients with these diseases improve oral hygiene.
100 years later, this portion of the population • Demographic Trends has grown to almost 35 million or just under 13% • Stroke in Women of the American population.1 By the year 2030, when the baby boom generation reaches senior Stroke Conditions status, more than 70 million Americans will be 65 Risk Factors in Women and over, comprising between 19%-20% of the Prevention and Treatment Measures total population (Figure 1).1 Worldwide, similar Oral Connections demographic trends are being observed. The • Rheumatoid Arthritis World Health Organization (WHO) reports women age 60+ comprise more than half of the women in Global Trends and Statistics the world.2 Those residing in developing regions total 198 million compared to the 135 million in developed regions.2 By the year 2025, the life Prevention and Treatment expectancy above 80 years will be represented Surgery and Long-term Prognosis in 35 countries around the world, and about Oral Connections 800 million (one in ten) persons will be 65+.3 In fact, evidence indicates that women on average are outliving men by six to eight years in the developed nations and women are the fastest Other Risk Factors growing population among the 85+ group in the Types of Depressive Disorders US as well as many other countries.4 Signs & Symptoms The impact from these demographic trends Medications/ Prescription Trends may indicate women living longer; however, a Oral Connections longer life does not guarantee a healthier one • Final Thoughts and Home Care free from disease. The fact women are living longer does not guarantee they are enjoying the quality of their life. The likelihood of women suffering from chronic diseases increases with • About the Authors age5, and recent studies linking periodontal health to the progression of systemic conditions Demographic Trends
demonstrate the need to understand women's In 1900, people over 65 accounted for aging complexities even greater. As the numbers approximately 4% of the United States population, of aging women increase worldwide, dental less than one in twenty-five.1 Today, more than professionals face significant challenges and Crest Oral-B® at Continuing Education Course, Revised February 21, 2012 opportunities in recognizing gender specific health people worldwide experience stroke and five concerns that ultimately impact the overall well- to seven million die yearly.11 It is estimated being of their patients.
that 60,000 more American women than men experience stroke, contributing to 60% of total This course will focus on three common stroke deaths evidenced in women.9 Differences conditions women may potentially experience in contributing factors generally indicated at as they age: stroke, rheumatoid arthritis, and the time women experience a stroke than men depression. It will further discuss risk factors are advancing age and poorer health.12 African- and research based approaches to treatment American women average higher blood pressure protocols and prevention. Oral health care levels than white Caucasian women, represent treatment guidelines, and home care products a 1.5 times greater risk in having a stroke, and specifically tailored to promote oral health will be are 1.3 times more likely to die from a stroke than Caucasian women.13 The American Heart Association reports 22% of women who survived Stroke in Women
a first stroke are more likely to suffer a second within a five year period9 and more likely suffer poorer outcomes than men.14 Stroke has become a worldwide health concern for women. Traditionally, it was viewed as a American women numbering more than three man's disease; however, the reality is that stroke million have suffered a stroke. Strokes are accounts for higher death rates among women considered to be the leading cause of the than men (11% versus 8.4%).6 The Office of nation's long-term disability, and the cause Women's Health at the Centers for Disease of dementia in 25% of its survivors.15 Women Control and Prevention identifies stroke as the 65+ represent the largest number of stroke third leading cause of death among American survivors16, and considering their longer life women, claiming 100,000 lives yearly, behind expectancy, among those survivors women will cardiovascular disease (CVD) and cancer7 and more likely live alone than men. Subsequently, it ranks third in cause of death in developed a woman's hospitalization will be longer than countries worldwide.8 Cancer is still believed a man's, and women will less likely go home to be more of a threat in the minds of women; or to a rehabilitative facility, yet they are more however, twice as many American women will die likely to be transferred to chronic care facilities17 from heart disease, stroke or other cardiovascular ultimately affecting their quality of life and future diseases than from all forms of cancer9, and independence. Witnessed in both developing only 13% of American women understand heart and developed countries worldwide, stroke has disease and stroke to be their greatest health become one of the five most important causes risk.10 Hence, the knowledge of stroke risk factors, of disability18 leaving five million permanently prevention and treatment is critically important.
Stroke has several modifiable risk factors allowing Worldwide, stroke among the 60+ age group is it to be preventable, yet an estimated 16 million the second leading cause of death after CVD Crest Oral-B® at Continuing Education Course, Revised February 21, 2012 and fifth leading cause in ages 15-59 (Figure 2).8 Whereas, with damage to the frontal lobe and Without worldwide interventions, it is estimated left side of the brain, a woman would be unable by 2030 there will be 7-8 million deaths from 23 to articulate speech even though understanding million strokes yearly.11 The incidence of stroke what was being communicated and knowing has been declining in many developed countries; what she desired to say. With damage to the however, the actual number will increase due to left temporal lobe, comprehension of language aging populations8, and worldwide projections would be impossible, even though she would be indicate stroke becoming the second cause of able to articulate words. To better understand the death following ischemic heart disease among effects of a stroke, it is important to understand these aging populations.18 the location of damage in the brain. When one hemisphere of the brain suffers from a stroke, consequently, the opposite side of the body's Cerebrovascular accident (CVA) commonly functioning becomes impaired. When a stroke known as stroke, is a sudden interruption of occurs in the right hemisphere of the brain, vision oxygenated blood to the brain, resulting in may be impaired in both eyes, and difficulty can brain cell death.24 Ischemic strokes account occur in lifting the left arm or smiling from the left for 85% of all strokes, resulting from a blocked side of the mouth.
artery insufficiently supplying the brain with necessary oxygen and nutrients. Hemorrhagic A stroke, depending on the location of brain strokes, responsible for 15% of strokes, occur damage, can produce weakness or paralysis from ruptured blood vessels leaking blood in or on one side of the body, muscle spasticity, around surrounding areas of the brain.25 The difficulty in coordinating movement, and trouble cells that die can leave a woman with the inability swallowing. Numbness, ongoing aches and to speak, feel, think, move or even recognize pain and sensory changes may be produced. family and friends. It is estimated that two-thirds Difficulties can occur in expressing oneself in of the survivors have to pursue rehabilitative words as well as understanding speech. Memory measures in order to regain abilities, learn how loss, impaired thinking, disorientation, inability to to compensate for those lost and develop new complete tasks along with denial of disabilities are cognitive problems, if left untreated, can potentially undermine any rehabilitation.24 The effects from a stroke are determined by the location of damage within the brain (Figure 3). Risk Factors in Women
When cell death occurs in the cerebellum (the While men and women share similar risk factors lower back portion of the brain), coordination, for stroke as with other chronic conditions, stroke movement, reflexes and balance are affected. is often caused from a combination of factors Crest Oral-B® at Continuing Education Course, Revised February 21, 2012 and gender-specific risk factors do exist. Oral risk for hemorrhagic strokes.27 High blood pressure contraceptive use combined with smoking has is considered one of the major risk factors for demonstrated higher stroke and heart attack heart attacks and the most critical factor leading risks than in non-smokers using birth control to strokes. Obese women pose a high risk for protection.9 In 2002, the Women's Health blood pressure concerns, thus placing them at an Initiative trial of hormone replacement therapy increased risk for strokes.9 Strokes occur twice (estrogen-plus-progestin) was discontinued as often in diabetics with hypertension than those due to CVD incidences and increased risk for with hypertension alone.28 Adults with diabetes strokes among women participating. The current have two to four times greater death rates than recommendation for hormone therapy is at the adults without. Diabetics often exhibit elevated lowest effective dose and for short-term relief. If blood pressure levels, cholesterol, and obesity and consideration for its use is necessary, the benefits overweight concerns posing them at greater risks and risks should be discussed with a physician.15 for CVD conditions9 and six times greater risk for stroke than those without diabetes.29 Controlling Stroke risk increases after age 55, and a and maintaining blood pressure levels can reduce woman's risk more than doubles each decade risks of strokes by 30-40%.15 following.26 Ethnicity represents a risk factor. African-American women exhibit an increased Reported data from the Women's Health Study risk for stroke and heart attack more than white indicated abnormal cholesterol levels doubled risk Caucasian women, and compared to white factors for ischemic strokes in healthy women. Caucasian, African-American women and men The results were from one of the first studies to are more likely to die from stroke.9 Risk factors confirm a link between stroke risks in women increase if a family history of stroke exists, with no prior CVD conditions. Additionally, the especially with a first-degree relative, a personal study provided supporting data from clinical trials history, heart attack or heart related conditions. demonstrating statin medications reducing stroke Having experienced a transient ischemic attack risk.30 Studies have indicated women's cholesterol (TIA), known as a mini-stroke, increases the risk levels tend to be higher than men's from age ten-fold regardless of gender and age.26 Elevated 55+. Research has indicated low levels of HDL blood pressure levels are responsible for 50% cholesterol (the good cholesterol), and higher of ischemic strokes and potentially increase the triglyceride levels in women appear as stronger Crest Oral-B® at Continuing Education Course, Revised February 21, 2012 risk factors for stroke and heart disease than equivalent to someone who never smoked.15 observed in men. Smoking remains one of the major causes of CVD among women.9 Smoking According to the American Heart Association, can double the chances of ischemic strokes a woman with more risk factors increases her and hemorrhagic stroke risk quadruple from chance of experiencing a stroke or heart attack. tobacco use.29 Tobacco usage can elevate blood Many of the identifiable risk factors (Table 1) pressure, damage the lining in blood vessels, cannot be modified such as: family health history, increase risk for blood clots, and lower beneficial race, increasing age and gender. Yet, many of HDL cholesterol - all serious risk factors for the modifiable factors: high cholesterol, high blood potential strokes. Data from The Nurses' Health pressure, diabetes, obesity, (Figure 4), lack of Study indicated women who quit smoking lowered exercise and smoking can be treated or controlled their stroke risk by 25% within a one to two by medication along with making positive changes year period, and after five+ years, the risk was in lifestyle habits.9 Crest Oral-B® at Continuing Education Course, Revised February 21, 2012 After suffering from a stroke, odds can be HDL above 50 mg/dL; LDL below 100 mg/dL; reduced in having another by necessary and triglyceride levels below 150 mg/dL. It is medications, altering diets, and implementing necessary to implement lifestyle changes including healthy habits. Reducing the risk of ever having a healthy diet, reduction of salt intake, regular a stroke starts with healthy lifestyles, regular exercise, and weight reduction in order to reduce medical examinations detecting at-risk conditions, and maintain blood pressure and cholesterol and positive steps towards controlling any one of levels. Fortunately, there are preventive treatment the risk factors.
measures and lifestyle recommendations emphasizing healthy eating patterns low in According to the Women's Health Study, saturated fats, and avoiding trans fats, each monitoring 38,000 participants for 10 years assisting in cardiovascular benefits. Suggestions proved that risk factors really matter. The study for a healthy diet are listed in Table 2.
indicated women with the greater number of healthy habits, BMI scores less than 22, who In addition to following a healthy diet, losing weight never smoked, ate a diet high in fiber, omega-3 and regular exercise, medications, if necessary, fatty acids, folic acid, low in trans fat, saturated have also been used to lower blood pressure, fat and refined carbohydrates, had four to 10 alcoholic beverages weekly, and exercised four or • Angiotensin-converting enzyme (ACE) inhibitors more times weekly were 71% less likely to suffer from an ischemic stroke.15 • Angiotensin-receptor blockers• Beta blockers or alpha blockers Prevention and Treatment Measures
Understanding risk factors and how to minimize
The formation of blood clots can occur from an their likelihood is a necessary first step towards abnormal heart rhythm, and with clot breakage, making significant impacts in stroke prevention. ischemic strokes potentially occur. Anticoagulants When blood pressure readings are 140/90 such as warfarin (Coumadin) or aspirin assist mmHg or higher, and 130/80 mmHg or higher reducing the potential for blood platelets to form in diabetics, yearly monitoring is recommended. clots. Blood clotting medications have shown a Monitoring can occur every two years if normal 68% reduction of risk for ischemic strokes.
levels of 120/80 mm Hg exist. Cholesterol levels should be checked every five years using Medications are often recommended if target a fasting lipoprotein profile. According to the cholesterol and triglyceride levels have not been American Heart Association, women should achieved after three months of lifestyle changes, maintain total cholesterol below 200 mg/dL; LDL cholesterol levels are 190 mg/dL+, and/or Crest Oral-B® at Continuing Education Course, Revised February 21, 2012 personal history identifies one or more risk factors What to do regarding smoking? Avoid smoking (e.g., heart disease, diabetes, prior stroke, low and second-hand smoke. Research studies have HDL's, and high triglycerides). Such options are: indicated a three-step approach to quitting along with smoking cessation programs encompassing • Statins, Niacin, and Fibrates all used to reduce the following suggestions: triglyceride and LDL levels and raise HDL's.
• Chew nicotine gum or wear a nicotine patch• Learn techniques to remove thoughts of Statin medications are recommended beyond smoking and activities that trigger such behavior their cholesterol-lowering effects and are • Seek professional counseling and become commonly prescribed for ischemic stroke patients active in support groups.
upon discharge from the hospital.15 Studies have (Smoking cessation programs are available indicated patients discontinuing statins one to two online and free of charge) months post-hospitalization increase their risk of dying from a stroke within one year.31 Exercise at least 30 minutes most days and with longer exercising or greater intensity, increased A daily low dose aspirin has been shown to benefits can be achieved. Moderate-intensity reduce risk for a second stroke in women who exercise such as walking, swimming, and bicycling have suffered either an ischemic stroke or heart can assist in recovering from a stroke and reduce attack; however, evidence is mixed regarding the risk for another CVA event. Utilize a physical a daily low dose aspirin for healthy women.15 therapist to design a tailored program if a stroke- According to the 2005 Women's Health Study, related disability has occurred.15 healthy women taking a low dose aspirin every other day showed a risk reduction for ischemic strokes by 24%, yet the risk for hemorrhagic The potential for active periodontal inflammation strokes rose by 24%. The CVD benefits for to affect overall health, including cardiovascular women age 65+ taking daily aspirin demonstrated disease and stroke, has initiated research to a 34% reduction in heart attacks and fewer further study linkages between oral health and ischemic strokes by 30%. The Women's Health systemic disease. A special report published Study further reported that healthy women under in Scientific American and a supplement to the age 65 may suffer greater side effects such as Journal of the American Dental Association gastrointestinal bleeding, bruising, and increased explored potential links between oral infections risk for hemorrhagic strokes versus modest and systemic relationships; however, the causality benefits from daily aspirin use. Furthermore, of the relationship has yet to be fully determined. healthy women 65+, and younger women Such potential relationships afford unprecedented with family history of CVD should consult their opportunities for dental professionals to collaborate physician regarding a low dose aspirin therapy with the medical profession in addressing the (81 mg baby aspirin).15 management of systemic disease.
Crest Oral-B® at Continuing Education Course, Revised February 21, 2012 Associations between hyperlipidemia, involving the destruction of bone and cartilage. hyperglycemias, and periodontal disease Inflammation can create swollen, tender, stiff and CVD and stroke have been recently and often permanently deformed joints resulting documented.32,33 Patients susceptible to heart in decreased movement and even loss of func- disease have been shown in recent studies to tion. Fingers can exhibit a deviated, unnatural also be susceptible to periodontal disease.34 shape spanning towards the little finger (Figure 5). Researchers suggest specific bacterial Typically after waking, an increased stiffness can inflammatory responses trigger CVD and CVA occur, identified as a prominent feature lasting as events. From a recent meta-analysis, the long as one hour.37 relationship between periodontal disease and CVD has been reported to be stronger for stroke RA has been classified as a systemic disorder than coronary disease.35 meaning the immune system attacks the body's tissues leading to destruction and inflammation While precise links and causal factors spreading to systems and tissues known as extra- between CVD, stroke and periodontal disease articular conditions or "outside the joints" existing continue to be researched, oral concerns in approximately 15% of those diagnosed with commonly associated with medications are RA.38 Lymph nodes may become inflamed, and well-documented.36 With numerous reports in in aggressive systemic conditions nodules can medical and dental journals substantiating a occur under the skin and around joints, which are periodontal-systemic relationship, the role of associated with a poor prognosis. It has been dental professionals to risk assess patients reported approximately 40% with RA also suf- demonstrating inflammatory burdens, recognize fer with pericarditis affected by the inflammatory oral adverse reactions often encountered from process.39 According to the European League medications, and educate patients about the Against Rheumatism in Paris, those with RA had a benefits from daily self-care regimens will improve doubled risk of suffering a stroke or heart attack.37 oral health outcomes and further establish oral Over one-third of deaths with RA were attributed health as an essential component necessary to a cardiovascular condition identifying cardiovas- for overall health. With a yearly estimate of 16 cular disease as a major factor in the increased million people worldwide suffering from stroke, mortality among those with RA.37 recognition and treatment for gingival and inflammatory periodontal diseases can potentially Global Trends and Statistics
minimize further risk for systemic disorders.
RA may or may not produce noticeable clinical manifestations, is unpredictable in duration and Rheumatoid Arthritis
is incurable. It is estimated around 2.1 million, Rheumatoid Arthritis (RA) is an autoimmune dis- about 1% of the US adult population have RA with ease from unknown reasons resulting in chronic it occurring in two to three times as many women inflammation affecting synovial joints in the fin- than men,40 and the prevalence and incidence gers, hands, and feet. Larger joints in the knee rises with advancing age. It peaks around age 70, and shoulder can also be affected and condi- then declines.41 Its prevalence has been reported tions will vary among individuals. The inflamma- with few cases in developing countries and no tion is often found in multiple joints, usually, yet cases reported from South African surveys.42 not always occurring in a symmetrical pattern However, among Native American groups, the prevalence rates are 5-6%; with lower rates documented in the regions of the Caribbean.43 A prevalence study among white Europeans was equal to South African urban blacks, while lower rates were noted among South African rural blacks.42,44 It has been challenging for most countries to conduct incidence and prevalence studies on RA due to limited health data systems and sampling size.41 Crest Oral-B® at Continuing Education Course, Revised February 21, 2012 In some countries, such as Sweden and Finland, factor such as cigarette smoking.48 In fact, registrars collect data based on medication smokers are four times more likely to exhibit RA and diagnostic criteria representative from conditions than non-smokers.43 community-based surveys. In the United Kingdom, a network of physicians document Individuals with autoimmune disorders suffer from reason for medical consultations; however, some the inability to recognize foreign invaders from diagnoses could be viewed as biased.41 The their body's own. Clusters of genetic markers, World Health Organization (WHO) in joint efforts HLA-DR4/DR1 occur in 90% of those with RA, with the International League of Associations allowing susceptibility through genetic factors for Rheumatology (ILAR) have developed and infectious episodes triggering autoimmune community studies to determine prevalence and risk factors and to educate health care providers in the area of prevention and treatment based Research has suggested complex interactions on RA symptoms and complaints.45 Over two exist between RA and estrogen and female sex decades of results are available from Thailand, hormones as influencing risks. The onset of RA Pakistan, China, India, Kuwait, Brazil, Vietnam, is rare during pregnancy, can often return post- Mexico, Chile, Australian Aboriginals and delivery, and is more common among nulliparous Australian Caucasians with additional studies women. Oral contraceptive medications and ongoing.41 The prevalence varied among the unidentified factors associated from their use can industrialized countries between 0.3 and 1%; interfere with severe RA by protecting against with an overall 0.8% for adults over age 15. In its development. Nulliparity, frequency of oral developing countries, some studies reported contraception use, and breast-feeding may all lower prevalence rates while others were similar influence the epidemiology of RA.39,50 to levels in developed countries. With worldwide demographic trends demonstrating an aging population, an increase in RA is expected Diagnosing RA is challenging even during its over the next 10 years in North America and early stages due to the variety of symptoms; Europe, yet prospective studies are suggested to many appearing similar to other arthritic disorders characterized with intense pain. A rheumatologist, specializing in diseases of Risk Factors
connective tissue and joints typically is the one to Environmental, genetic and hormonal factors diagnose and prescribe long-term management having an association with the immune system's approaches.37 A physical examination, discussion attack on body joints have been speculated as of symptoms, x-rays (Figure 6) and a blood potential risk factors for RA.39 Since specific test comprise an essential diagnostic work-up.39 causative agents have yet to be identified, X-rays may not clearly identify bone changes in suppressed immune systems, and infections early stages; whereas ultrasound and magnetic serve as contributing factors in some individuals. resonance imaging (MRI) provides greater Inflammation affecting organ systems contributes sensitivity in detecting early joint damage and to systemic manifestations.46 Evidence is erosions.51 Immunological testing determines the mounting around infectious agents, such as presence of a specific antibody, rheumatoid factor bacteria or viruses triggering RA conditions in (RF), identified in approximately 80% suffering susceptible individuals.39 The Human Herpes Virus 6 (HHV-6) and Epstein-Barr virus (EBV) have been confirmed in epidemiological studies to have potential associations.47 RA is familial with a 2-3% prevalence rate for first-degree relatives, and a genetic disease component with identical twins is approximately at 15-20%.43 Genetic components demonstrating positive RA factors have been associated with disease severity and may interact with a well defined environmental Crest Oral-B® at Continuing Education Course, Revised February 21, 2012 with RA after one year.52 Not all individuals resting. Cold or hot applications have assisted present with an indicator of disease. Some with in palliative treatment measures used prior or the RF may never be diagnosed with RA and after exercise therapy. Occupational therapists others with RA may never exhibit the RF.39 can provide helpful alternatives in reducing joint stress while performing daily activities with devices RA is a disabling disease with most daily assisting in writing, lifting objects and eating.39 activities impaired. At least 50% of those diagnosed ten years from onset are unable to maintain full time employment. Those diagnosed A broad range of medications have been before age 45 encounter greater disabilities than FDA approved to treat RA. They vary in cost, those diagnosed at 70+.53 The American College effectiveness and side effects. Some physicians of Rheumatology (ACR) collectively defines the recommend supplements, yet little evidence is following as criteria used in classifying RA and available to qualify their effectiveness. Some states a minimum of four are necessary to be met research studies indicate omega-3 fatty acids, those for classification. They are as follows: in plant seed oils and certain fish, can potentially 1. Arthritis along with soft-tissue swelling in >3 reduce inflammation, yet the recommended dose of 14 joints/or groups of joints for a minimal for positive effects appears too difficult to tolerate. duration of six weeks.
If supplements or herbal remedies are considered, 2. Arthritis in hand joints for a minimal duration of the physician should be consulted as many medications can interact negatively.39 3. Specific places with subcutaneous nodules.
4. Morning stiffness of six weeks and > one hour Medications fall into several categories, each on most mornings.
requiring careful monitoring with periodic blood 5. Six week duration of symmetrical arthritis.
screening tests. (Table 4) Analgesics and anti- 6. Joint erosion identified radiographically.
inflammatory agents assist in relieving stiffness, 7. RH factor level > 95 %.
pain and inflammation; however, they do not slow disease progression or prevent joint damage.39 According to the ACR, criteria were designed Documented long-term effects from cortisone to categorize research and further establish therapy have been determined undesirable; epidemiological associations for those with RA.54 nevertheless, cortisone injections used adjunctively in treatment regimens have proven valuable.55 Prevention and Treatment
Unfortunately, there is no cure for RA. The key
Disease modifying anti-rheumatic drugs (DMARDs) to maintaining a quality of life while living with RA are prescribed for altering the disease course while is determined by the management of treatment. preventing joint and bone damage occurring from In order to reduce inflammation, relieve pain secondary inflammatory responses. They have and improve function, the following treatment been used separately or in combination with other suggestions include: medications with results reported as early as one • Lifestyle modifications through proper and month and up to six months from initial treatment. Early treatment with one effective DMARD, methotrexate, has shown favorable outcomes in RA years afterwards. Those prescribed with methotrexate continue with treatment regimens longer than other medications due to lessened side Exercise and learning how and what techniques effects, effectiveness in controlling symptoms, and to use becomes a vital skill for those with RA. its ability to work in combination with biological Personalized exercises can be designed by a agents. Immunosuppressant medications are used physical therapist to assist in maintaining muscle for those co-existing with systemic disease.41,51,56 strength and flexibility without overusing joints. Swimming is ideal, as this exercise avoids stress The latest category of medications are biological being placed on joints. Splints are recommended response modifiers (BRMs) known as biologics, in order to immobilize and support joints while and are used to treat aggressive and debilitating Crest Oral-B® at Continuing Education Course, Revised February 21, 2012 cases when standard methods from one or more the injection site. Since BRMs suppress immune DMARDs have shown unfavorable responses. system functions, those individuals with active The BRMs target against cytokines triggering infections, including tuberculosis, or those prone inflammation and approximately 70% of patients to infection (e.g. diabetics) should be screened report improvement within the first two weeks by their physician prior to treatment. Annual from initial therapy. Their continued use is expenses for BRMs range from $17,000 to necessary in order to maintain results. When $25,000 with varying degrees of health insurance BRMs are combined with DMARDs, specifically methotrexate, greater efficacy has been indicated. BRMs exhibit few adverse reactions, Surgery and Long-term Prognosis
unlike DMARDs yet side effects from long-term Orthopaedic surgery such as joint replacement use remain unclear. BRMs are either injected has offered relief from severely damaged joints, or infused and mild skin irritations can occur at including alleviating constant pain, and enhancing Crest Oral-B® at Continuing Education Course, Revised February 21, 2012 Crest Oral-B® at Continuing Education Course, Revised February 21, 2012 mobility and function. Reconstructive hand and periodontal disease.62 Each disease exhibits surgery is used to straighten deformed fingers dysfunctional immune systems, genetic risk and seeks to restore their function.39 Individuals factors and inflammatory mediators compounding either in the second or third decade of RA who susceptibility; suggesting a co-existing relationship are severely disabled achieve particularly great is probable.63 Chronic inflammation has been success from surgical interventions in addition to defined as a common link supporting systemic oral medications. Lifestyle modifications along manifestations and risk factors for various medical with physical therapy may assist in reducing the conditions.5 Research studies continue to explore burden of disability. It is estimated a 25% further co-existing factors and their relationships between reduction in RA disability can occur in developed RA and periodontal disease. A recent study countries with proper treatment management published in the Journal of Clinical Periodontology being optimally utilized. Research studies have found RA patients were nearly eight times more indicated using methotrexate may potentially likely to have periodontal disease compared to reduce mortality.58 Orthopaedic surgery and oral the control subjects.64 A study in 2005 conducted medications may not be available in low-income by Al-Shammari and colleagues65 reported tooth countries, and steroid therapy is offered too loss from periodontitis and risk factors for severe freely and possibly used indiscriminately. In such periodontal disease shared RA as the strongest regions, if medical advice and interventions were risk indicator for periodontally-induced tooth loss. available, an estimated 40% reduction in RA Independent of other risk factors, the mechanism disability could occur.41 by how RA creates the increased risk remains unknown. Early recognition of risk factors and According to the National Rheumatoid Arthritis proper treatment protocols are essential in any Society in the UK, factors associated with higher disease management.
mortality rates include: conditions of severe RA; involvement in organs other than synovial joints; Depression
co-morbidity conditions; hospitalization stay; and extensive damage observed on x-rays.59 Life-shortening effects from RA vary, with some Depression affects men and women of all ages; studies indicating a lifespan reduction by five to it can be disabling, interfere in daily activities, ten years.59 In a 2005 study, the Mayo Clinic limit normal functioning, and potentially lead discovered RA patients suffer from a doubled risk to suicide. Worldwide, it has been estimated for cardiovascular disease60; independent from 340 to 360 million people suffer from major risk factors such as diabetes, alcohol abuse and depressive disorders with 18 million represented elevated body mass index, blood pressure, and in the United States.66 According to the National cholesterol. It remains unknown why RA creates Institute of Mental Health (NIMH), 12 million such risk; contributing factors have suggested the US women yearly are affected by depressive presence of chronic inflammation.61 The impact disorders.67 It has been estimated one in 33 from inflammation should not be overlooked and children and one in eight adolescents have been especially when treating patients with impaired diagnosed with depressive disorders and most immune systems.
likely numerous cases go undetected.66 Studies have demonstrated depression occurring twice as frequently in women than in men, and 25% of all RA has been defined as a chronic disease linked women sometime during their life will suffer from with inflammatory factors resulting in destruction a major depressive disorder.68 of connective tissue and bone deterioration.39 Those well defined characteristics are also No single cause of depression has been distinguishing features defining periodontal identified; however, studies indicate combinations disease. With each condition, inflammation of factors are likely to exist. Since women are appears to separate diseased conditions from being diagnosed more than men, research is health. Numerous research studies have currently exploring factors associated with their suggested relationships may exist between RA increased risk for depression. Social, genetic, Crest Oral-B® at Continuing Education Course, Revised February 21, 2012 hormonal, biological and chemical factors unique Risk Factors
to women are being examined as potential links to depression.67 Coexistence with Illnesses & Other Conditions
Unfortunately, depression can be misdiagnosed,
Depressive illnesses have been characterized under treated, misunderstood and overshadowed as brain disorders; magnetic resonance imaging by medical complexities. Illnesses, especially in (MRI) has demonstrated brain matter in those women often co-exist with depression. They may with depression appear differently than in precede or follow depression, or even be identified those where no depression has occurred.67 as the cause or consequence.67 Depression Neurotransmitters, chemicals used for brain cell often coexists with medical conditions such as communication appear unbalanced as well as stroke, heart disease, diabetes, cancer, HIV/AIDS, mood and appetite regulators seem to improperly Parkinson's disease, and multiple sclerosis; often function in the brains with depressive illnesses.67 worsening symptoms of the illness.70 Studies have indicated those suffering from depression Depressive episodes can last several in addition to serious medical conditions exhibit months or up to one year depending on the increased symptoms from each illness.71 Adapting individual's family support system and access to medical conditions becomes a greater to treatment. Depression has been shown to challenge for those suffering from depression; influence subsequent episodes. Recurrent proper treatment for depression and coexisting episodes can vary among women and years medical condition(s) can alleviate burdens may lapse between occurrences; however, as associated from each.71 women age the frequency of episodes tends to increase.69 Studies have indicated at least Especially among women, depression has been 60% of those suffering their first depressive diagnosed in those with eating disorders, bulimia episode will typically encounter a second and nervosa and anorexia nervosa. Post-traumatic those experiencing two episodes will have a 70% stress disorders (PTSD), panic disorders, chance to suffer a third.69 Five to ten percent obsessive-compulsive disorders (OCD) and of those with a single depressive episode will anxiety disorders often coexist with depression.72,73 develop manic disorders, changing their initial Women are more prone to depression after diagnosis to a bipolar disorder.69 encountering a PTSD, and Kessler and colleagues74 report more women than men In some individuals, depressive disorders can experience these coexisting disorders.
start as young as 15 years of age. This early onset has been associated with family histories Other Risk Factors
of mood disorders. An early onset in women has Family histories of depression may place a been associated with low self-esteem and poor woman at greater risk for developing disorders; school grades.66 Such patterns of depression however, depression can also exist in women are being classified as progressive and lifelong where no genetic links have been identified.75 Those with relatives suffering from major depressive illnesses are likely to have a 1.5 to 3.0 Data extrapolated from remission studies times greater chance of developing depression one year post diagnosis reported only 40% than the general census.69 From genetic research of individuals achieve partial remission, 30% data, the influence from multiple genes linking achieve full remission, and 30% were resistant with a combination of factors has suggested risk to treatment. Unfortunately, evidence is showing for depression.76 Children in households with more women than men not seeking treatment adults suffering depressive disorders represent for their depression, even though in severe an increased risk of attention-deficit/ hyperactivity depressive conditions, women have shown some disorders (ADHD) or anxiety disorders.69 improvement from treatment measures.67 Crest Oral-B® at Continuing Education Course, Revised February 21, 2012 According to Burt77, "trauma suffered by a other women may suffer serious conditions woman early in childhood places her at risk for requiring emotional support and therapy. Munk depression later in life." Any history of domestic and colleagues84 have noted an increased risk violence, abuse, victim of incest or the loss of a for mental disorders to occur and last several parent during childhood can influence depression months postpartum. Others have suggested in later years.69 women suffering postpartum depression possibly suffered depression during pregnancy which Women are more likely to suffer from was undiagnosed. Studies have concluded with psychosocial stressors than men; increasing their recommendations indicating women should be likelihood for depression.78 Stress encountered screened for depression during pregnancy as well from work, family or marital relationships has as during the postpartum period.75,76 triggered depressive episodes, as well as divorce, death and personal trauma. Caring for Depression has not been associated with the aging parents and children along with additional normal aging process; however, evidence suggests household or work responsibilities can create older women experience more depression than stressful situations eliciting depression. It has older men; even though rates decrease in women been reported women respond differently to after menopause.85 The transitioning phases stressful events than men, and for unknown between pre-menopause and menopause indicate reasons their prolonged responses to the fluctuations in hormonal changes; mood changes stress actually place them at higher risk for may not be experienced by all women, while others depression than men.79 Studies have provided may demonstrate increased risks for depression. no explanation as to why some women faced These depressive illnesses have been noted without with similar challenges experience no depressive prior histories86,87 while other studies have shown depression in post-menopausal women occurring in those with prior histories of depressive disorders. Hormonal factors unique to women have Older women tend not to express or discuss feelings been researched as probable risks linking of sadness, and demonstrate less than obvious women to higher rates of depression. Since symptoms resulting in physician's being less likely to hormones directly affect the brain's ability to diagnose a depressive disorder.67 control moods and emotions, scientists have examined the influence of hormones during Types of Depressive Disorders
specific times in a woman's lifecycle; puberty, There are many classifications of depression and menses, pregnancy, postpartum, pre and post- major depressive disorders along with dysthymic menopause.80 One week prior to menstruation, disorders are the most commonly identified.67 anxiety, mood swings, irritability and depression • Major depressive disorders are also known as have each been observed in women suffering major depression; collectively symptoms impact from a severe type of premenstrual syndrome one's ability to function, work, and enjoy life. known as premenstrual dysphoric disorder This type of depression becomes disabling; (PMDD).81 Those debilitated with PMDD exhibit it may occur only once or recur throughout a different responses to hormonal changes; demonstrating greater sensitivity possibly linked • Dysthymic disorders are typically characterized to histories of mood disorders, or unidentified as lasting two or more years; altering normal differences in brain chemistry. Researchers functioning, yet not totally creating disability. are currently examining the cyclical periods of Episodes involving major depression tend to estrogen affecting the brain that potentially have occur often during a lifetime.67 associations with depression.80,82,83 Other characteristics of depression are classified as: Postpartum depression is common for many • Postpartum depression can be diagnosed one women. From the numerous physical and month after a new mother delivers a baby.67 hormonal changes occurring during and Altshuler and colleagues88 report 10-15% of after pregnancy, episodes of depression can women suffer with this depressive episode after exist. While for many they will be temporary Crest Oral-B® at Continuing Education Course, Revised February 21, 2012 • Psychotic depression represents a form symptoms will vary based on individual types of of psychosis; delusions and hallucinations disorders. (Table 5) usually coexist with severe depression.67 • Seasonal affective disorder (SAD) can be Additional signs and symptoms may include: characterized by depression experienced psychosomatic complaints with increased visits to during the winter season. Oftentimes, medical doctors; difficulty in maintaining personal light therapy is used in combination relationships; phobias; frequent change and/ with antidepressant medications and or loss of employment; and addictive behaviors psychotherapy to reduce SAD symptoms.89 to substance abuse and gambling. Suicide • Bipolar disorders are also known as manic- attempts and family histories of completed depressive illnesses and appear not as suicides represent severe symptoms requiring common as major depressive disorders. immediate medical attention. When impairments They are characterized by mood swings are so significant that normal functioning is halted, with extreme highs known as mania to very specialized psychotherapy must be initiated.69 extreme lows classified as depression.67 Signs & Symptoms
A loss of interest in almost all activities, daily and
consecutively for two weeks is a strong sign of a Severe cases of depressive illnesses can major depressive disorder. Persistent aches and be treated and the earlier the treatment, the pains that do not change even after treatment greater the success and less likely a chance for are often described by older women rather than recurrence. The first and most important step is sadness.69 Often, the individual's demeanor, to seek medical care. Emergency room doctors facial expressions and anxious feelings are can assist with temporary care and further advise used to describe behavioral characteristics where to seek additional treatment. Psychiatrists, observed in depression.69 Not all express or social workers, psychologists, community mental experience similar symptoms; with each gender health centers, hospital outpatient psychiatry the frequency, severity and duration of signs and centers, state hospital outpatient clinics, private Crest Oral-B® at Continuing Education Course, Revised February 21, 2012 clinics, local medical and psychiatric societies can While antidepressants have been shown to be each assist in offering care and guidance towards helpful, there is some concern they are being the appropriate treatment based on individual overused. The U.S. Centers for Disease Control and Prevention (CDC) reported a 48% increase in the use of antidepressants in the US during Consulting a physician is necessary in ruling out 1995-2002. Among the 2.4 billion prescription potential thyroid conditions, viral infections or medications written in the US in 2005 the CDC previously treated medical conditions creating identified 118 million as antidepressants.91 depressive adverse reactions. Laboratory testing A 2007 study surveyed 8,098 Americans, and physical examinations are necessary along from which it was reported 25% were over with psychological evaluations to determine diagnosed for depression, regardless of medical history of symptoms, duration, severity, alcohol or intervention.92 The use of antidepressants in the substance use, thoughts of suicide and/or death.67 United Kingdom (UK) was reported at a 234% Once an individual is diagnosed, treatment increase during a ten year period until 2002.93 methods such as psychotherapy and medications are typically introduced.
In a 2002 survey conducted in France, it was reported 3.5% of the people had been prescribed antidepressants, in comparison to a 1.7% When mild to moderate depression is diagnosed, prescription rate in a 1992 finding. The results psychotherapy has demonstrated successful further indicated the antidepressants were not treatment regimens consisting of short-term being used for depressive disorder symptoms, (10-20 weeks) cognitive-behavioral therapy and the prescriptions were not in accordance with (CBT) and/or interpersonal therapy (IPT) based specific guidelines identified to treat depressive on individual needs. CBT assists in altering illnesses.94 In British Columbia during 1996- behaviors and negative thoughts that potentially 2004, the use of antidepressants increased contribute towards depression, while IPT from 3.4% to 7.2%.95 In the Netherlands during focuses on working out difficult relationships 1992-2001, an increased rate of prescriptions triggering depressive symptoms.67 Alternative for antidepressants was recorded along with therapies often recommend a positive state increased periods of treatment necessary to treat of well-being emphasizing good nutrition, depressive illnesses.96 exercise, social support groups, and the avoidance of drugs, cigarettes, and alcohol Studies indicate an increased use of use are strongly encouraged.66 Studies have antidepressants particularly in the developed shown the combination of psychotherapy and countries, due to the commercialized promotionals medications to be effective treatment approaches and availability of the latest classifications of in treating older adults, with results indicating antidepressants.97 A UK survey reported more less recurrences after two years of combination male physicians prescribing antidepressants than female physicians.98 Medications/ Prescription Trends
In 2006 (Zoloft), (Lexapro) and (Prozac), each The use of antidepressant medications has selective serotonin reuptake inhibitors (SSRI) demonstrated success in working to calm were listed as the most commonly prescribed neurotransmitters, (brain chemicals such as medications in the US for depression; with 28, 26, norepinephrine and serotonin), while other and 21.7 million prescriptions respectively.99 antidepressant medications focus on dopamine, which is responsible for controlling mood To fully understand how antidepressants work and instabilities. Studies have indicated combination the specific classifications of each is significant therapy - psychotherapy and medications - to be when trying to avoid side effects, negative effective in at least 80% of patients versus 40% interactions from other prescriptions, over- who receive only single phase treatment, and the-counter medications, herbal nutriceuticals, 15% who receive no treatment.67 and nicotine replacements. The awareness of Crest Oral-B® at Continuing Education Course, Revised February 21, 2012 coexisting medical conditions, recognition of medications; alerting patients and health clinical signs and symptoms, and a history of any care professionals to the increased risk of depressive disorders and/or treatments aide in suicide and suicidal attempts in children and determining the best antidepressant based on the adolescents taking such medications. The individual's disorder.67 FDA in 2007 extended the "black box" warning to include young adults through age 24. The There are numerous classifications of "black box" warning represents the gravest antidepressant medications with the latest and of warnings on any prescription labeling. most commonly used antidepressant's falling Close monitoring is necessary for those into two classifications: selective serotonin patients taking antidepressants; any unusual reuptake inhibitors (SSRI) and serotonin and behaviors, worsening depression or suicidal norephinephrine reuptake inhibitors (SNRI).67 behaviors should be reported to their physician SSRI's include: fluoxetine (Prozac); citalopram (Celexa); sertraline (Zoloft); paroxetine (Paxil); and escitalopram (Lexapro). Examples of SNRI's are venlafaxine (Effexor) and duloxetine Patients suffering with depressive symptoms and undergoing specialized treatments require detailed oral hygiene care. Oftentimes, their Fewer side effects have been reported from depression may have led them to consume non- SSRIs and SNRIs than tricyclics and tetracyclics, nutritious diets consisting of highly cariogenic older classifications of antidepressants such as drinks, snacks, and retentive fermentable (Elavil) and (Pamelor) and monoamine oxidase carbohydrates, all contributing factors for inhibitors (MAOI) such as (Nardil) and (Marphan). dental caries. Dietary inadequacies have been Not all medications will prove effective and associated with depressive mood disorders.67 some may produce intolerable side effects; Preventive dietary care is certainly recommended consequently, physicians will alter between along with specialized oral hygiene instructions. categories of antidepressants, or prescribe Medications used to treat depression often create antipsychotic medications that potentially improve xerostomia; additional oral manifestations such the efficacy of the antidepressant.67 as burning mouth syndrome and candidiasis67 can potentially develop requiring detailed home care Those taking MAOIs require a thorough measures. Xerostomia can intensify gingival, understanding of the medications ability to periodontal and caries progression requiring interact negatively with certain foods; particularly specialized home care products tailored to the chemical, tyramine found in wines, pickles address specific needs. Signs and symptoms and many cheeses, and over-the-counter (OTC) consistent with depressive disorders typically medications such as decongestants.67 For display low motivation for self-care or total example, Wellbutrin, a commonly prescribed rejection of any health interest. Sensitive care antidepressant used to treat SAD symptoms and stress-free appointments are suggested when should not be taken while using Zyban or other treating these individuals in order to respect their nicotine replacement alternatives intended for well-being and emotional status. Any abnormal use in smoking cessation protocols. Wellbutrin is behavior, distraught or angry feelings should be not advised for those with eating disorders or in shared with their care provider immediately.
combination with a MAOI; negative interactions can increase blood pressure and potential stroke Final Thoughts and Home Care
conditions can develop.67 Recommendations
The preceding sections of this course have
It is vitally important that all health care highlighted research related to women and stroke, professionals understand the potentially fatal rheumatoid arthritis and depression. Women interactions between antidepressants and have shown disproportionate outcomes from prescription medications. The Food and Drug medical conditions in measures of diagnosis, Administration (FDA) in 2005 established prevalence, incidence as well as response to "black box" warning labels on all antidepressant treatments. Their culture, education, and most Crest Oral-B® at Continuing Education Course, Revised February 21, 2012 importantly access to care have placed female meeting selection criteria were evaluated. Seven populations worldwide at potential risk for adverse studies compared the rotating oscillation action disease outcomes.
and side-to-side (sonic action) technologies. The outcome stated in the Cochrane review Oral risk assessments, screening, education, provides evidence that when independent, highly referrals and treatment planning are essential regarded third parties evaluate performance, the components necessary for comprehensive oscillating-rotating power toothbrush technology dental care; providing dental professionals the was consistently top ranked.103 Flossing and opportunity to identify early stages of disease, interproximal aides are additional home care determine patient compliance, and tailor oral care methods necessary to mechanically remove recommendations based on need. The dental plaque; each removing plaque biofilm below professional can directly influence the patients' the gingival margin along with the interproximal oral health status, educate them about systemic regions. Patients have opportunities to select relationships linked to oral health concerns, and from numerous interproximal brushes, varieties help them embrace whole body health as total of floss, floss picks, and floss holders allowing ease and compliance in accomplishing necessary interdental care.
Educational materials for patient information and videos are available from numerous Chemotherapeutic dentifrices and rinses help organizations. The American Dental Association inhibit plaque biofilm and are important home care (ADA) and the American Dental Hygienists' products that should be recommended based on Association (ADHA) have online patient individual patient needs. Dentifrices, containing information ( and active ingredients such as stannous fluoride and provides the latest or triclosan are used to inhibit plaque regrowth up-to-date customized patient education available between brushings, reduce gingival inflammation for print in 17 languages.
and bleeding. A significant difference between the two ingredients found in over-the-counter Home care regimens including specialized dentifrices is that only stannous fluoride products to improve gingival and periodontal additionally offers protection from sensitivity104,105 health are particularly significant when treating as well as caries and gingival health benefits.106 these patients. Dental professionals should When recommending a stannous fluoride consider the complex needs reported in dentifrice, it is important the product contain relationships to prevalence when recommending stabilized stannous fluoride (Crest® Pro-Health™), home care products for these conditions.
which provides greater product efficacy than unstabilized formulations.107,108 An advanced Products to enhance mechanical plaque regimen including (Crest® PRO-HEALTH® Clinical removal are fundamental to a good oral Gum Protection™), a dentifrice demonstrating hygiene regimen. The oscillating-rotating reduced gingival inflammation, bleeding and power toothbrush technology has demonstrated plaque along with daily use from an oscillating- increased efficacy in plaque removal over rotating toothbrush and floss provides strong manual brushes.101,102 Some models offer evidence that it is beneficial in addressing the compliance-enhancing features such as timers, necessary components for optimum gingival multiple brushing modes, and visual pressure sensor indicators which help motivate patients to brush with good technique. According to Whether rinses are prescription or over-the- the Cochrane Database of Systematic Reviews counter versions, they can serve as effective 2010, "brushes with a rotation oscillation action and successful adjuncts to patients' daily reduced plaque and gingivitis more than those hygiene routines. Chlorhexidine rinses have with a side-to-side action in the (4-12 weeks)". been viewed as the gold standard due to their The systematic review further detailed 398 substantivity and efficacy (and now it is available studies compared power technologies to each in an alcohol-free formula); however, these other, and 17 trials including 1369 subjects rinses are limited to a short-term use due to Crest Oral-B® at Continuing Education Course, Revised February 21, 2012 some extrinsic staining and patient compliance caries, due to a lower oral pH.112 Various forms of concerns. Over-the-counter options include specialized rinses, dentifrices, liquid moisturizers, chemotherapeutic rinses with cetylpyridinium salivary stimulants, sugar-free chewing gum are chloride (CPC), a broad-spectrum antimicrobial marketed to assist with symptoms and protect agent available in an alcohol-free formula. against xerostomic conditions.
Alcohol-free formulas are recognized as providing pleasurable rinsing experiences; especially Each day dental professionals are challenged ideal for those patients already experiencing to provide the best treatment and home care xerostomia and/or oral manifestations induced recommendations to assist patients in achieving from medications, necessary for treating a myriad optimal oral health. Resources currently available of medical conditions. Essential oils rinses are with valid and credible research findings can also over-the-counter, yet contain alcohol. It assist dental professionals to better understand is important to know that research findings the oral-systemic relationships challenging have indicated CPC and essential oils rinses worldwide populations. Aging and gender-specific when formulated properly have demonstrated concerns represent unique health concerns significant and comparable reductions in plaque requiring specialized care and awareness. As and gingivitis.110,111 we better understand this plethora of information before us, we will continue to address the ever In-office or take-home fluoride products are challenging needs facing our patients, recommend available to treat those patients requiring the latest evidence-based technology, and we too additional fluoride assistance, such as the aging will evolve just as the research unfolds additional population experiencing an increased rate of oral discoveries and causal relationships in the root caries. It has been estimated that about systemic diseases impacting our oral health and one-fifth of the aging patients report xerostomia, whole body wellness.
increasing their risk for plaque, gingivitis, and Crest Oral-B® at Continuing Education Course, Revised February 21, 2012 Course Test Preview
To receive Continuing Education credit for this course, you must complete the online test. Please go to and find this course in the Continuing Education section.
The latest and most commonly used classifications of antidepressant medications are:
a. Serotonin norephinephrine reuptake inhibitors (SNRI)
b. Tetracyclics and tricyclics
c. Beta blockers
d. Biological Response Modifiers
In 2006, three SSRI antidepressant medications were listed as the most commonly
prescribed medications used in the US for treating depression. They were:
a. Zoloft, Cymbalta and Lexapro
b. Zoloft, Lexapro and Prozac
c. Zoloft, Effexor and Prozac
d. Zoloft, Paxil and Effexor
The single cause for depression demonstrated in women has been identified as:
a. Hormonal
b. Smoking
c. Genetic
d. Not one single cause, possible combinations of factors.
The following categories of medications have been used to treat rheumatoid arthritis, except
one, what is the exception?
a. Immunosuppressants
b. Steroids
c. Biological response modifiers
d. Angiotensin-converting enzyme (ACE) Inhibitors
Stroke and heart attack share similar risk factors, except one, what is the EXCEPTION?
a. Obesity
b. Diabetes
c. Physical inactivity
d. Low triglyceride levels
A specific antibody can be identified from immunological testing in most patients that fully
confirms the presence of rheumatoid arthritis in the body.
a. True
b. False
Numerous factors (hormonal, genetic and environmental) have been speculated as risk
factors affecting the body's immune system attacking multiple joints and placing one at risk
for rheumatoid arthritis.
a. True
b. False
Crest Oral-B® at Continuing Education Course, Revised February 21, 2012 According to the American Heart Association, women should maintain total cholesterol
below 200 mg/dL and HDL levels should be above 50 mg/dL and the LDL levels and
triglyceride levels should be:
a. LDL levels at 175 mg/dL and triglycerides at 200 mg/dL
b. LDL levels at 150 mg/dL and triglycerides at 150 mg/dL
c. LDL levels below 100 mg/dL and triglycerides below 150 mg/dL
d. LDL levels above 125 mg/dL and triglycerides above 150 mg/dL
The Office of Women's Health at the Centers for Disease Control and Prevention identifies
stroke as the 2nd leading cause of death among American women, behind cancer deaths.
a. True
b. False
10. All of the following are modifiable risk factors for stroke except one, what is the
a. Physical inactivity
b. Elevated triglyceride levels
c. Personal history of stroke
d. Smoking when combined with oral contraceptives
11. The American College of Rheumatology uses all the following criteria in classifying
rheumatoid arthritis except one, what is the exception?
a. Morning stiffness of 7 days and > one hour upon waking.
b. Joint erosion identified radiographically.
c. Specific places with subcutaneous nodules.
d. Six week duration of symmetrical arthritis.
12. To understand the effects of a stroke, it is important to first understand the location of
damage in the brain.
a. True
b. False
13. All the following statements are true EXCEPT:
a. Oscillating-rotating power toothbrushes have demonstrated increased efficacy in plaque removal over manual brushes.
b. Some power brush models offer timers and pressure sensors.
c. Interproximal floss aids can reduce compliance.
d. Flossing helps remove plaque below the gumline.
14. The active ingredient available in an alcohol-free over-the-counter chemotherapeutic rinse
for the treatment of plaque-induced gingivitis is:
a. Baking soda
b. Essential oils
c. Cetylpyridinium chloride
d. Chlorhexidine
15. The cure for rheumatoid arthritis involves a series of complex medications, physical therapy
and surgery to correct the joint deformity.
a. True
b. False
Crest Oral-B® at Continuing Education Course, Revised February 21, 2012 References
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112. The Oral Cancer Foundation. Xerostomia information for dentists. Retrieved July 10, 2008. Additional Resources for Heart Disease and Stroke
1. The Atlas of Heart Disease and Stroke
2. World Heart Federation:
3. American Heart
4. American Stroke Association:
5. World Health Organization:
6. The Journal of Contemporary Dental Practice: www.
Additional Resources for Rheumatoid Arthritis

National Institute of Arthritis and Musculoskeletal and Skin Disease (NIAMS) American Autoimmune Related Diseases Association (AARDA), Inc. The Arthritis Foundation Additional resources for Depression

National Alliance for the Mentally Ill Toll-free, 24-hour hotline of the National Suicide Prevention Lifeline at 1-800-273-8255; 1-800-799-4889 for a trained counselor at a suicide crisis center.
Food and Drug Administration- Crest Oral-B® at Continuing Education Course, Revised February 21, 2012 About the Authors
Pam Hughes, RDH, MS
Pam has lectured internationally and throughout the United States on such topics as oral risk assessment, advances in therapeutic oral care products, women's aging complexities with oral health impacts, and clinical challenges observed in patients with erosive decay and xerostomia. She is a past President of the California Dental Hygiene Educators' Association and California Dental Hygienists' Association. Pam has over 30 years of clinical practice in general and periodontal practice settings and holds a faculty position at the Ostrow School of Dentistry of University of Southern California in the Department of Periodontology, Diagnostic Sciences and Dental Hygiene.
Email: [email protected] Crest Oral-B® at Continuing Education Course, Revised February 21, 2012



Undersökning av spill och läckage vid hantering av antibiotika inom sjukvården Slutrapport AFA-projekt 07-0043 Olle Nygren och Roger Lindahl Gruppen för Arbetsmiljökemi Miljö- och Biogeokemi Kemiska Institutionen Umeå Universitet Projektet, som redovisas i denna rapport, är ett tillämpat projekt med syfte att dels beskriva omfattningen av det spill och läckage av antibiotika, som förekommer vid svenska sjukhus, dels att ta fram exempel och förslag på åtgärder som kan vidtas för att minska omfattningen och spridning detta spill och läckage. En viktig del av detta projekt är därför en återkoppling av resultat till den undersökta och berörda målgruppen. Denna rapport utgör en viktig del av denna återkoppling.

Cardiovascular and Cerebrovascular Effects in Response to Red Bull Consumption Combined With Mental Stress Erik Konrad Grasser, PhD, MD, Abdul G. Dulloo, PhD, and Jean-Pierre Montani, MD The sale of energy drinks is often accompanied by a comprehensive and intense marketingwith claims of benefits during periods of mental stress. As it has been shown that Red Bullnegatively impacts human hemodynamics at rest, we investigated the cardiovascular andcerebrovascular consequences when Red Bull is combined with mental stress. In a randomizedcross-over study, 20 young healthy humans ingested either 355 ml of a can Red Bull or waterand underwent 80 minutes after the respective drink a mental arithmetic test for 5 minutes.Continuous cardiovascular and cerebrovascular recordings were performed for 20 minutesbefore and up to 90 minutes after drink ingestion. Measurements included beat-to-beat bloodpressure (BP), heart rate, stroke volume, and cerebral blood flow velocity. Red Bull increasedsystolic BP (D7 mm Hg), diastolic BP (D4 mm Hg), and heart rate (D7 beats/min), whereaswater drinking had no significant effects. Cerebral blood flow velocity decreased more inresponse to Red Bull than to water (L9 vs L3 cm/s, p <0.005). Additional mental stressfurther increased both systolic BP and diastolic BP (D3 mm Hg, p <0.05) and heart rate(D13 beats/min, p <0.005) in response to Red Bull; similar increases were also observed afterwater ingestion. In combination, Red Bull and mental stress increased systolic BP by about10 mm Hg, diastolic BP by 7 mm Hg, and heart rate by 20 beats/min and decreased cerebralblood flow velocity by L7 cm/s. In conclusion, the combination of Red Bull and mental stressimpose a cumulative cardiovascular load and reduces cerebral blood flow even under a mentalchallenge.