Thursday, September 29, 2011

Dental care in Behcet's General concepts

Regarding Behcet's and dental care, here are my thoughts.

Do all the preventative things possible:

1) Brush and floss always. The basic most important thing you can do.
2) Use an ultrasonic toothbrush. It will clean beyond where you touch the brush, many times better than you can with a manual toothbrush. Sonicare
3) Prevident or some other kind of prescription flouride. It will help remineralize teeth, strengthening them every day.
4) No sodium lauryl sulfate in toothpaste. Biotene, and Rembrandt make a tooth paste specifically without this. This can help cut down the number of sores in the mouth.
5) Regular cleanings. You clean the plaque every time you brush and floss, but tartar build up cannot be brushed off. It is much like a hard water deposit on your sink, it is harder to remove. It is very rough and porous so it harbors a lot of bacteria that causes inflammation and infection.
6) Use mouthwashes without alchohol, like Crest ProHealth. Scope, Listerine etc, are good at killing bacteria, but the alchohol dries your mouth which is bad for Behcet's sores, both sores already present and in helping to generate more.
7) Dry Mouth? Use saliva substitutes. Biotene, Oasis, Spry, Breath Rx and others. There are sprays, gels, mints, lozenges, rinses. Use what works in your lifestyle best. Decreased saliva causes increased cavities and gum disease. Make sure you are not wetting your mouth with things with sugars in them.
8)Eliminate colas. Coke, Pepsi, Mtn.Dew, Dr.Pepper, generic colas have phosphoric acid in them. (Look on the ingredients on the label). This etches and weakens the teeth. (I use phosphoric acid to etch the teeth to roughen the surface before doing a filling so the filling will bond to the tooth better.) They will weaken and wear down your teeth.
9) Don't postpone the crown on the tooth with the big filling in it. (I am hearing "teeth breaking off in chunks" over and over here.) A crown will protect you from that.
10) Arestin, Perio chip, etc. (Antibiotics placed in the gums next to the teeth) are a good idea where there periodontal pockets. For sure for pockets, 6mm and greater. Good for 5mm pockets if you can afford it. It puts antibiotics where needed for periodontal disease where the blood stream can't reach.
11) Disclaimer: this is my own personal theory, not yet fully studied and tested:
Painful teeth: Consider a root canal with a teeth that are not presenting with the "classic symptoms" for a tooth abscess. For example: Pain to cold that develops several minutes after a cold drink, ice cream etc. then worsens the more time passes and the pain lingers for several hours or even a day or more. / Exquisitely sensitive or painful to touch or bite. It hurts as much to push the tooth side to side as it does to tap or touch the top of the tooth. Tooth pain that increases and decreases coinciding with your "flares". This can happen even in the abscence of anything showing on an xray.
Also, getting proper treatment for the Behcet's can stop the tooth problems. I have seen it happen.
12) Eliminate all rough spots, overhangs or any other irritants on the teeth.
13) Denture wearers - Ill fitting dentures should be replaced or relined to fit better. Loose movement on a denture creates friction, inflammation and thus more Behcet's sores. It also increases bone resorption of the ridges under the denture. (It does that, Behcet's or not)
14) Be vigilant. Remember, in Behcet's, inflammation in the mouth increases inflammation everywhere else.
Periodontal (Gum) disease is a chronic, inflammatory infection. Generalized 6mm pocket periodontal disease is the equivalent of having a 2 square inch sore anywhere else. If you had a bed sore, 2 square inches in size, you wouldn't ignore it, don't ignore periodontal disease.

I hope this helps.

David Petersen DDS

Silver fillings and Behcet's (don't worry about them, they are fine!)

The silver fillings debate rears its ugly head on a fairly regular basis. As a dentist, I solved that debate very easily in my practice by not doing silver fillings for the last 12 years. You can request to have the white composite fillings and don't need to have them in silver, thus eliminating the potential for you personally (Actually they are silver amalgam fillings and the controversy is over the mercury that is in the fillings. Mercury makes the filling material soft so it is able to be packed into the cavity. When it hardens it is because of the chemical bond that takes place between the silver, mercury and a few other metals that are mixed together. Being chemically bound is what makes it unable to be free to get into your body and cause problems.)

As far as silver fillings you already have: They are safe, in my opinion. This is also the official word from the American Dental Association. The other side of the debate would have you think that the ADA and dentists in general are just saying that because it is self serving to the dentists. That is just simply not true. But there are many other scientific sources that have research to support the opinion of it's safety also that is independent from the dental community.

One of the most convincing things for me on this subject, however, happened several years ago. The TV show 20/20 (or one of the shows like that) ran a story saying that silver amalgam fillings cause or exacerbate Multiple Sclerosis (MS). They had testimonials from people with MS that they had had miraculous remissions of their MS symptoms after having all of their silver fillings removed. And of course they found various "experts" to support their claims. What happened after the show, however, was the most interesting part.

The MS Society came down hard on 20/20 saying: How dare you put this kind of story out there to MS sufferers. It is unsubstantiated and false information and is giving out false hope to people that already have many challenges in life to deal with. This kind of report will encourage MS sufferers to have unnecessary and expensive dental work done that will place an uncalled for financial burden on people that are already saddled with high medical bills from their appropriate treatment. It was irresponsible reporting and they demanded a retraction, which 20/20 did issue a retraction and an apology. 20/20 is not the kind of show that issues a retraction easily. (This is not an exact quote from the MS society, but the general idea that I remember from watching the show about 10 years ago, so if you look this up and it is not 100% exact, forgive me.)

What my thought is what I have said many times here and will say again. In autoimmunity, inflammation in one part of the body causes inflammation every where else there is inflammation from the disease. So these people that had these miraculous recoveries probably really did have help from having the fillings replaced. But not because of the silver amalgam, but because in having them done they removed inflammation from the mouth. They probably had over hangs on the fillings removed. Some of those fillings probably had a bit of decay under them that feeds the inflammation in the gums and that was removed. A very big side effect of having dental work done is that you become aware of things that you may have ignored for years. So those people, whether they realized it or not, probably started to brush and floss better and more consistently thus reducing their periodontal disease. This is the part of the story that doesn't get told. I would bet you $1000 that the people they quoted on that show had periodontal disease before starting in on removing all of those "evil fillings" and that their periodontal condition was greatly improved by the time they were done with the fillings. Their great improvements in their MS were from removing inflammation from their mouths, not from having the silver removed. (In my humble but very passionate and biased opinion based on 4 years of study, observation and consistent thought on this concept. Sarcasm intended towards the 20/20 reporters).

So if you want to remove the silver filling to make it look better, great! Go ahead. If you want to take it out to help your Behcet's get better, don't count on it, you are wasting your money, in my opinion (And that is coming from someone who makes a living and has financial gain from taking fillings out and replacing them).

David Petersen DDS

TMJ syndrome, Behcet's disease and this dentist's point of view

TMD (Temporomandibular disorder, also commonly known as TMJ syndrome) problems can cause the following symptoms:

Ringing in the ears (Tinnitus)
Muscle tension in the head and neck
Interrupted sleep
Wear on the teeth
Popping in the joint
Pain in the teeth (cold sensitivity, pain to biting)
Loose teeth due to bone and periodontal involvement

I Behcet's you can have many of these things from other sources also, but many or all of these can potentially be helped with treatment for the TMJ problems.

The problems stem from the joint being pulled out of position by the teeth being in the wrong position. This can be treated by wearing a proper fitting hight guard (big emphasis on proper, the boil and bite kind will not help and can potentially make it worse). OR -- An equilibration which is a balancing of the teeth to position the condyle of the mandible in the right place. You will find dentists on both sides of the debate as to which is better. Simply put, they both work if done correctly. Neither work very well if not done correctly. So it is important to go to someone who has some experience with it and has had years of confirmed success.

Now the Behcet's part of it-------------- This is my theory/hypothesis. I have some practical, clinical experience with this, but I will be up front in saying that there is not any research yet to back this up.

The autoimmune part of Behcet's attacks the mucous membranes of the mouth and gut selectively more than anywhere else in the body. Thus the 100% of Behcet's sufferers that have apthous ulcers in their mouth at least some time during the course of their Behcet's if not constantly for decades. If you look at where tissues originate from, embryonically, there are various extensions from the mouth and gut that have the same origin and thus the same marker that the autoimmunity does the search and destroy on. One surface of the temperomandibular joint (TMJ) is lined with an epithelial layer. Embryonically, that epithelial layer is the same or very similar to the epithilium in the mouth. So my theory is that there is inflammation in the TMJ due to the autoimmune activity of Behcet's. The TMJ is unique in this way from any other joint in the body. So where the average person gets TMD because of the mal-position of the teeth and resultant muscle tension, someone with Behcet's has an added component.

You can get the teeth perfectly balanced and in the right position and then inflammation in the joint from a Behcet's flare can change that in a day. The problem is that if you re-balance the teeth to that position and the inflammation subsides, then all of a sudden the teeth are in the wrong place again and you have just undone the good that was done previously. So you adjust again and again if you don't recognized what is happening. With a night guard, you go though a cycle of it working and then not working, you get fed up and just stop using it all together because it is so frustrating.

My recommendation:

Do the equilibration (balancing of the teeth ) by someone with successful experience in doing that. Then know that that point is your solid, stable point and do no change it. When there is a flare and your bite changes due to swelling in the joint, you have a thin soft "night guard" that you wear will you sleep. It is essentially the same as a soft tray that is used for bleaching your teeth. It is there only to cushion you bite during the flare. It does not reposition your bite and it is not treatment. It will just minimize the damage done during the flare. But as the flare subsides, you will return to your home base of a solid stable position that will always be there. (At least usually). Without recognizing this issue, you become like a dog chasing it's tail. You will never find a stable place or a night guard that works long term because you will constantly be changing it.

My "Embryology Theory" in Behcet's (not an official term, just something to put a name to my thoughts about this concept) goes to other parts of the body too. The eustachian tube to the ear and part of the inner ear has that same epithelial lining in it, often causing hearing problems that come and go with flares. The thyroid is also an embyologic evagination from the gut. As is the anterior part of the pituitary. That is part of my theory/hypothesis of why there are so many endocrine problems associated with Behcet's.

Feed back would be appreciated of experiences regarding this. I think the more information that is passed back and forth the more we help each other.

David Petersen DDS

Thursday, January 6, 2011

Behcet's disease NIH (National Institute of Health)

Connections made at the April 2010 ABDA conference has lead to participation in a study on Behcet's disease conducted at the NIH in Bethesda, Maryland. The study will help in establishing a more complete understanding of all of the symptoms caused by Behcet's. There are several other diseases being studied, but I was told that the response of Behcet's patients wanting to participate was much larger than any of the other diseases. This interest makes me feel that there is a need that is being inadequately met in the treatment of Behcet's patients. I will post more of what is being done at the NIH to help after our experience there.

Friday, April 30, 2010

American Behcet's Disease Association 2010 conference

I had the pleasure of speaking at the ABDA 2010 conference. In addition to speaking, Sharon, my wife, and I attended all 3 days to listen to the other speakers and learn from their knowledge and experience.

There have been many advances in the research, study and treatment of Behcet's disease since we attended the last ABDA conference in 2007. There will be a survey posted soon on the website regarding dental concerns in Behcet's.

At the conference there were patients and physicians. Trying to address both audiences presented a challenge for me that left me feeling that my message to both was diluted. The ABDA Board said that they will put an article I write in their next newsletter. In that way I will be able to better address the things that I feel are important for each.

At the conference, the informal poll taken showed approximately 30% of the patients present having root canals done that the patient's dentist had a hard time explaining why the tooth was dead. In conversations at the conference, many spoke to me of this kind of problem happening. One shared that they had 24 root canals and 4 teeth extracted. I looked back at things that I wrote at the 2007 conference. A similar informal poll at that time yielded approximately 20 % showing this symptom. It is significant enough to merit research into this area.

Sunday, October 4, 2009

Questions posed on Behcet's and dental involvement

Again, on dentaltown, these questions were posed in response to my comments on Behcet's and dental involvement.

If nothing else, it sure sounds like you have done your research on this topic! I can certainly follow the logic of your argument which leads me to think you might be on to something. Just a couple of questions from someone who is being exposed to this idea for the first time:
1. Is the symptomology of a Bechet's patient generally the same as a patient with a classical presentation of periapical pathology? i.e., do they go through the stages of cold/hot sensitivity followed by a total loss of sensation once the tooth has become necrotic?
2. Is the radiographical presentation the same? Does the lesion have the same classical appearance, or is there something that might distinguish it from the classical presentation?
3. Is there an increased rate of other dental related issues other than endo present in this population of patients, such as higher caries risk, malocclusion, etc? Given the description of the etiology of the disease you provided (circulatory issues, etc.), I would tend to think that these patients might have issues with gingival health-just speculating.Anyhow, I think the topic is certainly worthy of discussion.

And my response:

Good questions.
To # 3. There is a lot of literature out there on the increase in periodontal disease in Behcet's. That is well documented. The same with the classic DMFT (decayed, missing, filled teeth) that is used in dental research. In reading these studies, the assumption is made that the missing component is due to the increased periodontal disease and/or decay due to decreased oral hygiene. That coming from the fact that it is painful to brush and floss when there is a crop of ulcerations present. That is all very true. My feeling is that the Missing component is partly due to the root canal issues. People with this disease have huge medical bills. One study says that there is an average of 7 years of dealing with the disease before they come to a diagnosis because there is no marker for this that you can test to give a diagnosis. It is arrived at by the process of elimination. They also have huge pain issues in many parts of their body. If they can eliminate on pain by just pulling a tooth, its done. Plus the cost is prohibitive at a time when they are already faced with many medical bills.Also, with Behcet's, inflammation anywhere in the body will tend to ramp up the inflammation and cause more sores in the classic Behcet's sore locations. This too is very well documented and discussed in reference to periodontal disease. When I have a patient without Behcet's with an asymptomatic abscess, I talk to them about how that is a drain on their immune system. There is a lot of literature out there about how the inflammation of perio contributes to heart disease, stroke and PAD.
My feeling is that if necrotic pulps are treated earlier, not only will they save more teeth, but it can reduce inflammation that will also help with the overall inflammatory process of the disease systemically.

Which brings me to #1 and #2(A preface to this answer first - My experience with Behcet's and root canals consists of a sample of 2 patients, so it is not like I have done a large sampling of research on this. It is hard enough to get any research done on Behcet's from the medical side because the rarity (3 in a million) makes it an orphan disease. But those 2 patients were my wife and her sister, so I was able to see the progress of their problems like no other researcher would ever be able to see.)
#2 They can have the classic radiolucency of any abscess, but more often than not, there is little to no radiolucency present. So that is the first difference that would make a dentist reluctant to proceed with a root canal. I was reluctant on my own wife at first to do root canals because it didn't fit the normal sequence of events in the death of a tooth. We went through checking all the different non dental origins of pain possible with no results. The clincher for me was when after a long line of physicians and tests, I would open up a tooth with no decay or no radiolucency and the pulp chamber was dry with just powder present and after the root canal the pain subsided.
#1 Some did the classic stages, cold/hot sensitivity, loss of sensation then big pain suddenly. But like the answer to #2, more often than not it is not like that. What I saw diffuse generalized pain in the area of the affected tooth/teeth. There was sensitivity to cold, but early on it would be a delayed sensitivity 5 to 10 minutes after something like eating ice cream. But then the pain would linger for several hours and actually increase over time before it started to decrease. Pain to percussion or biting only came after delayed cold sensitivity had been around for weeks. But, when the pain finally started in earnest, it was constant, relentless and intense. (10 of 10 on the pain scale) Then later, there was large amounts of swelling and inflammation in the surrounding soft tissue. This was often without radiolucencies present. I fully expected to see draining sinus tracts and pockets of pus to drain. When an endodontist did some apicoectomies on teeth that continued to hurt after RCT, there was no apparent infection. And yet the apicos relieved the pain. There was one huge swelling in the maxilla. After several oral antibiotics that were ineffective, our physician went as far as to do IV antibiotics before having an oral surgeon go in to drain the area. When he got there, there was nothing to drain. It was inflammation out of control from the vasculitis caused by the Behcet's. At some point in all of this it was shown that the WBC count was not elevated during this time.

This scenario was part of what lead us to the diagnosis of Behcet's in the first place. If it wasn't an infection, then what in the world was it? That lead me to vasculitis possibilities. The other systemic conditions fit also and then we came to the Behcet's diagnosis.

At a conference of the American Behcet's Disease Association in 2007 they allowed me to get up in front of the conference to ask about dental related problems. In a very un-scientific poll there, about 20% of the Behcet's sufferers reported similar experiences with their teeth.

One has always stood out in my mind.
He was an ex Navy Seal. (no wussy whiner here) His wife had divorced him over issues created by the Behcet's. He had custody of his kids. He talked to me after bringing up the dental issues at the conference. He told me that the only reason why he hadn't put a gun his head because of the pain in his head is that he knew that he had to be there for his kids. He was planning on having all his teeth pulled and getting full dentures because he couldn't stand the pain any more. He let me examine his teeth. He did have some decay and periodontal disease present, but not in all of them. The degree of pain expressed by Behcet's patients is not the same as the average patient. Again, this makes me feel that it is at least worth investigating to help give relief to these people.
This is a note to the dentists on dentaltown about why there is not much research done on Behcet's and particularly on the relationship of Behcet's to dentistry.

There was one study done a while back on Sickle Cell Anemia and pulpal necrosis. It was done by some doctors in Turkey. I emailed him and said that he is trying to do a similar study with Behcet's. (Behcet's is many times over more common in Turkey than in the US) He had recently changed universities where he is working and is trying to talk them into getting the necessary equipment. But it sounded like it will be quite a way in the future. The lack of research on this has several reasons.
1.Behcet's is rare. There not that much research done on the disease in general. It is hard to get a large population and there is not much money in it. Orphan diseases have a hard time getting funding.
2. Physicians don't work with dentists in research much. Recently that gap has started to be filled with the heart disease, stroke and periodontal health connection. But millions of people have perio and heart attacks and strokes are easy to get people concerned about.
3.When ever there is a new concept presented in science, medicine, or dentistry that is unproven, there is questioning and skepticism. And rightfully so. The line between a quack and a pioneer in medicine and dentistry is a fine line. But hey, the famous Mayo Clinic partly got its start from practicing that radical idea that you should wash your hands between surgeries.

I don't know if I am right or not. I just think that with the experiences that I have had that it would be well worth looking into or at least just considering and noticing what your patients with autoimmune diseases say about their teeth.