DISCLAIMER: This work, audio recordings and the accompanying handout, are the intellectual property of the clinician, and permission hasbeen granted to the Chicago Dental Society, its members, successors and assigns, for the unrestricted, absolute, perpetual, worldwide rightto distribute solely as an educational material at the scientific program being presented at the 2011 Midwinter Meeting. Permission has beengranted for this work to be shared for non-commercial education purposes only. No other use, including reproduction, retransmission in anyform or by any means or editing of the information may be made without the written permission of the author. The Chicago Dental Societydoes not assume any responsibility or liability for the content, accuracy, or compliance with applicable laws, and the Chicago Dental Societyshall not be sued for any claim involving the distribution of this work.

C214TREATING PATIENTS WITH CARDIOVASCULARDISEASEJAMES LICHON, RPH, DDS, CCLFRIDAY, FEBRUARY 22

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RETURN EVALUATION CARD TO: DO NOT FOLD CARD. FOR CDS PERMANENT FILES.Chicago Dental SocietyAloysius F. Kleszynski, DDS401 N. Michigan Ave., Suite 200, Chicago, IL 60611-5585

1

James F. Lichon RPh,DDS,NCCM

Diabetes

High

Cholesterol

Toxic

(nicotine)

Mechanical

(hypertension)

Food

choices

Sedentary

lifestyle

RUPTURE OF PLAQUE

Risk Factors That Weaken

The Endothelium and the Fibrous Cap

The more risk factors, the faster the

development of the plaque

Cholesterol, diabetes, and blood

pressure medicine

No smoking

Exercise

Good diet

What Increases the Strength of the

Endothelium and the Fibrous Cap

CORONARY ARTERY SPASM

MAGNESIUM DEFICIENCY

COCAINE –AMPHETAMINES

HEART CATHETERIZATION

CIGARETTE SMOKING

COLD

STRESS

2

ADVERSE EFFECTS OF STENTS

(24-48 hours)

Acute access site pain with hypotension

Thrombus (blood clot)

Coronary artery spasm

Arrhythmias

Heart attack—4%

Cardiac mortality—1%

Bypass Surgery

ADVERSE EFFECTS OF BYPASS

SURGERY

Cognitive Impairment-short term memory

loss, depression

Stroke or MI—5%-6%

Death—3%

Insomnia

Flashbacks

Infection

Neither coronary angioplasty,

stents, nor cardiac bypass surgery

is curative for coronary artery

disease. They do relieve symptoms

but do not treat the cause.

JAMA, NOV. 10, 2010-Vol 304, No.18

Dental Implications for Patients

with Stents and Bypass Surgery

INR < 3

Do Not Stop Taking Medication Without a

Cardiologist Approval

3

Valve replacement—no appointment for

6-12 months

Stents and open heart surgery—no

appointment for 6 months

Contact cardiologist

for an update

Patients who stop taking aspirin are at a

significantly increased risk of MI than

those who continue treatment.

British Medical Journal July 19, 2011

Depression 15% to 20% of post heart attack, stent, bypass patients have major depression

65% have one symptom of depression

Under diagnosed--only 20-30% diagnosed

Depression and heart disease are a lethal combination

Dental Implications

Excess plaque

Tardive Dyskinesia

SUDDEN CARDIAC DEATH

SUDDEN CARDIAC DEATH IN

YOUNG ATHLETES Congenital Coronary Artery Anomaly

SUDDEN CARDIAC DEATH IN

YOUNG ATHLETES

4

ISCHEMIC STROKE

CAROTID EXAM

COROTID DOPPLER EXAM PERIPHERAL VASCULAR DISEASE

Often Underdiagnosed

WHO IS AT RISK FOR PERIPHERAL

VASCULAR DISEASE

• SMOKERS

• DIABETIC

• OVERWEIGHT

• NOT EXERCISING

• OVER AGE OF 50

• HIGH CHOLESTEROL

• HIGH BLOOD PRESSURE

• THOSE WHO HAVE EXISTING CVD

• FAMILY HISTORY OF HEART DISEASE

LOWER EXTREMITY VASCULAR

DISEASE QUESTIONNAIRE Do your calves, thighs, or buttocks get

cramped, painful, heavy or tired when you

walk, and does the pain stop with rest?

Do you have leg pain mostly at rest or when

standing for long periods?

Do you have pain, numbness, or tingling in the

toes?

Do your toes ever become blue, black or red?

Do you have sores on your legs or feet that heal

slowly or do not heal?

5

Ankle-brachial index test for

peripheral vascular disease

Treatment with exercise (walking),

aspirin, statins, stents, or surgery

More women die from CVD then from all

cancers combined.

Women schedule mammograms but skip

lipid (cholesterol) profiles and blood-

pressure checks

HEART DISEASE SYMPTOMS IN WOMEN

Chest pain, but less severe then men

Neck, shoulder, upper back discomfort

Lightheadedness or dizziness

Shortness of breath

Unusual fatigue

Sweating

Nausea

2/3 of the deaths from heart attacks occur

among those women who have no

symptoms or don’t recognize the symptoms

Diagnostic tests in women not as accurate

as those in men

Women may have less blockage in main

arteries but more in small vessels called

“microvascular disease”

Shortness of breath

Unusual fatigue

Lack of energy

Neck, shoulder,

back discomfort

WHITE BLOOD CELLS

All white blood cells are known as LEUKOCYTES

Leukocytes are divided into 3 classes:

1. Granulocytes-Neutrophils, eosinophils, basophils

2. Monocytes-evolve into macrophages

3. Lymphocytes-2 kinds

A. B cells—produce antibodies

B. T cells—help destroy infected cells

6

CYTOKINES

Inflammatory Cells

Monocytes, Macrophages,

Lymphocytes

Cytokines-- pro inflammatory

IL-1, IL-6, IL-8, TNF-1, Interferon

MMP(matrix metalloproteinase)

Cytokines-- anti-inflammatory

IL -4, IL-10, IL-11, IL 13,

TNF-2, MMP-1

SELF AND NON-SELF CYTOKINES AND PERIODONTAL DISEASE

CYTOKINES AND RHEUMATOID ARTHRITIS

EMBREL, REMICADE, HUMIRA , ACTEMRA

EXAMPLES OF AUTOIMMUNE

DISORDERS Addison's disease

Celiac disease - sprue

Dermatomyositis

Graves disease

Hashimoto's thyroiditis

Multiple sclerosis

Myasthenia gravis

Pernicious anemia

Reactive arthritis

Rheumatoid arthritis

Sjogren syndrome

Type I diabetes

7

IS PERIODONTAL DISEASE

AN AUTOIMMUNE DISEASE?

Rheumatoid Arthritis and the

Temporomandibular Joint

SJOGREN SYNDROME

• A chronic autoimmune inflammatory connective tissue

disease

• Majority of people with SS are middle-aged women

• Dry eyes, dry mouth and lips, swallowing complaints,

fatigue, tongue changes, and overgrowth of Candida

Other causes of dry mouth

antidepressants

antipsychotics

antihypertensives

antihistamines

Venus Williams

CHOLESTEROL

ALWAYS in Animals

NEVER in Plants

Heredity

Why is Cholesterol Good?

For normal structure, function and repair of cell membranes

For nerve conduction and brain function

Precursor for steroid hormones, e.g. testosterone, estrogens

Precursor for bile acid

Precursor for Vitamin D

8

Factors That Affect Your

Cholesterol Levels

Sedentary lifestyle

Diet

Weight

Diabetes

Heredity

Fewer than half the adults diagnosed with high

cholesterol knew whether they had ever been

tested for thyroid disease, despite the well-

documented connection between the two

conditions

American Association of Clinical Endocrinologists January, 2011

Symptoms of Hypothyroidism

Weight gain

Fatigue

Depression

Dry skin

Feeling cold

Muscle cramps, joint pain

FAMILIAL HYPERCHOLESTEROLEMIA

Disorder of high LDL (bad) cholesterol that is passed down

through families. Can cause heart attacks at an early age

and premature death.

Blood tests may show:

Total cholesterol > 300mg/dl in adults

LDL levels > 220mg/dl in adults

Very common disorder: 1 in 300-500

(heterozygous)

IT’S IN THE GENES, NOT THE DIET

ONLY 15% DIAGNOSED

Stormie Jones • Age 6 diagnosed with HFH,

“homozygous familial hypercholesterolemia”

–TC 1200 mg/dl (less then 160)

–TG 150 mg/dl

–LDL 1130 mg/dl (normal 120 g/dl)

–Progressive xanthomas

• Age 6 yr 6 mo. Angina and double coronary bypass

• Age 6 yr 8 mo. Second bypass

• Age 6 yr 9 mo. Heart failure

• Age 6 yr 9 mo. Combined heart and liver transplant

–TC dropped to about 250 mg/dl

9

“All substances are poisons, there is none

which is not a poison. The right dose

differentiates a poison from remedy.”

Paracelsus, 1493-1541

“the precursor of chemical pharmacology and therapeutics”

www.scientificamerican.com

STATIN SIDE EFFECTS

• Muscle pain or damage

• Liver damage

• Low testosterone levels

• Increased blood sugar or type 2 diabetes

• Neurological side effects

Headaches

GI distress

Myopathy

Rhabdomyolysis

DRUG INTERACTIONS WITH BELOW PRODUCTS

WHEN TAKING ZOCOR, LIPITOR AND MEVACOR

*CRESTOR, FLUVASTATIN, PRAVASTATIN, AND

LIVALO OK

Cytochrome P450 3A4

Ventricular arrhythmia

Sudden death

DRUG INTERACTION WITH BELOW PRODUCTS WHEN

TAKING ANTIARRHYTHMIC MEDICATIONS

(AMIODARONE, DIGOXIN, BETAPACE, ETC)

P450 3A4

10

Caution with Calcium Channel Blockers (3A4)

(Diltiazem, Verapamil, Felodipine, Nifedipine)

when prescribing

Biaxin, Ketek

Ventricular arrhythmias

Sudden death

Edema

What Can I Prescribe When Taking Zocor,

Lipitor, Mevacor, antiarrhythmic medications

or CCB?

Amoxil--amoxicillin

Keflex--cephalexin

Cleocin--clindamycin

Vibramycin--doxycycline

Flagyl--metronidazole

• Amoxicillin (Coumadin)

• Keflex--Cephalexin

• Cleocin—Clindamycin

• Erythromycin (Coumadin)

• Z-Pak—Azithromycin (Coumadin)

• Biaxin—Clarithromycin (Coumadin)

• Vibramycin-Doxycycline (Digoxin, Sun,

Vit A, Amoxicillin, Methotrexate, Coumadin)

• Periostat (low dose doxycycline-20mg)

• Flagyl--metronidazole (Coumadin, alcohol)

YEAST (FUNGAL) INFECTIONS OF MUCUS MEMBRANE

Drug interactions of Diflucan, Sporanox, or Nizoral (3A4)

when taking Zocor, Lipitor, Mevacor, CCB

or antiarrhythmic medications

(Crestor, Lescol, Pravachol OK)

Mycelex troche (clotrimazole-4-5x/d)

Nystatin S&S

----------------------------------------------------------------------------------------------------------------------------------------

----------------------------------------------------------------------------------------------------------------------------------------

Factors Predisposing To Candida albicans

(KNOW THE CAUSE)

Dentures

Antibiotics

Steroids

Smoking

Diabetes

Xerostomia

Radiation

HIV-AIDS

Nutritional deficiencies (iron, folate, B12)

ORAL SIDE EFFECTS-STATINS

Angioedema—Crestor, Lipitor, Zocor,

Lescol, Mevacor Also from antibiotics, BP medicines (Ace

inhibitors & renin inhibiting agents), insect

bites, food (shellfish, nuts)

Dysfunction of certain cranial nerves

Alteration of taste, impairment of extraocular

movement, facial paresis

11

Drug-Induced Gingival Hyperplasia

Calcium Channel Blockers

Amlodipine (Norvasc)

Nifedipine (Procardia)

Verapamil (Calan)

Antiseizure Drugs

Phenytoin (Dilantin)

Carbamazepine (Tegretol)

Immunosuppressive Agents

Cyclosporine (Neoral)

NEW REVISED GUIDELINES FOR

ASPIRIN –PRIMARY PREVENTION

Aspirin—uncertain value for primary

prevention except for high risk patients.

(HTN, smoking, diabetes)

Always check with your doctor

NEW REVISED GUIDELINES FOR

ASPIRIN –SECONDARY PREVENTION

Patients with prior history of CVD, or

ischemic stroke should be

on aspirin

Always check with your doctor

Physicians’ Health Study showed that

taking aspirin every other day also works

NARCOTICS

Vicodin —Hydrocodone/Tylenol—5/500

Vicodin ES—Hydrocodone/Tylenol7—7.5/500

Vicoprofen—Hydrocodone/Ibuprofen—7.5/200

Tylenol with Codeine—#3 and #4 (300mg Tylenol)

Fiorinal with Codeine-(butabarbital, aspirin 325mg,

caffeine, codeine 30mg)

Percodan—Oxycodone/Aspirin—5/325

Percocet—Oxycodone/Tylenol—2.5/325, 5/325, etc

Demerol—Meperidine 50,100mg

CAUTION--NARCOTIC SIDE

EFFECTS WITH:

Antidepressants: Elavil, Wellbutrin, Celexa,

Lexapro, Zoloft, Serzone, Effexor, Prozac, etc.

Antipsychotics: Clozaril, Holdol, Lithium,

Abilify, Seroquel, Zyprexa, Thorazine, etc.

Symptoms: slow heart rate, confusion,

respiratory depression, etc.

NSAIDs Nonsteroidal Anti-Inflammatory Drugs

Aspirin—81mg, 325mg, 500mg, 650mg Ibuprofen (Motrin—Advil) 200mg OTC--400, 600, 800mg Rx Naproxen (Aleve) 220mg OTC--250, 375, 500mg Rx

*20-30% develop upper GI bleeding

12

Do not prescribe NSAIDs during the last 6 to 8 weeks of pregnancy

Prolonged gestation

Premature closure of ductus arteriosus

Cause maternal and fetal complications

Miscarriage

Tylenol and Codeine is

safe during pregnancy

NSAIDs (not aspirin) Nonsteroidal anti-inflammatory drugs

1. Increase CV events and stroke September 8, 2010 – European Society of Cardiology

2. Exacerbation of heart failure

3. Effect on kidneys and salt retention

4. Increase BP and worsen control of HTN

BLACK BOX WARNING

Cardiovascular Risk

NSAIDs may cause an increased risk of serious

cardiovascular thrombotic events, myocardial

infarction, and stroke, which can be fatal. This risk may

increase with duration of use.

Gastrointestinal Risk

NSAIDs cause an increased risk of serious

gastrointestinal adverse events including bleeding,

ulceration, and perforation of the stomach or

intestines, which can be fatal.

Elderly patients are at greater risk for serious

gastrointestinal events.

DENTAL IMPLICATIONS WHEN

PRESCRIBING NSAIDs

In patients with prior heart attack, most

(NSAIDs), not aspirin, even when taken

for as little as one week, are associated

with an increased risk of death and

recurrent heart attack. May 9, 2011 Circulation

Naproxen may be best choice

DENTAL IMPLICATIONS WHEN

PRESCRIBING NSAIDs

Caution when prescribing----

• Patients taking ACE inhibitors (Vasotec, Zestril)

• Patients taking ARB (Atacand, Cozaar)

• Patients taking CCB (Norvasc, Cardizem)

• Patients taking Diuril, Laxix (renal function)

• Patients taking Digoxin (irregular heartbeat)

• Patients taking Lithium ( tremors, confusion, muscle weakness)

DENTAL IMPLICATIONS WHEN

PRESCRIBING NSAIDs

Caution when prescribing----

Patients taking Methotrexate (kidney & bone

marrow toxicity, stomatitis, fatality)

Patients taking anticoagulants (Coumadin,Plavix) Rx—Tylenol with Codeine or Vicodin

Patients taking aspirin-- increased risk of GI

bleeding and decreases the cardio protection of

aspirin (naproxen does not interfere with aspirin)

13

325mg 500mg 650mg

50% of all sudden (acute) liver failure in US

caused by Tylenol--ck pt for liver disease

Maximum adult dose = 3000 mg/day

New FDA Limits on Maximum dose of

Acetaminophen The FDA announced new limits on the dosage of

acetaminophen (Tylenol) because of serious liver

impairment. FDA limits drugs containing Tylenol to

limit dosage to 325 mg in prescription medicine.

Issued February 9, 2011

Deadline January 2014

Study: Tylenol and Ibuprofen May

Cause Hearing Loss in Women

Taking ibuprofen or acetaminophen regularly

was associated with increased risk of

hearing loss in women, and the risk generally

increased with the frequency of use J of EpidemiologyVolume 176 Issue 6 September 15, 2012

TYLENOL (ACETAMINOPHEN) 500MG

MOTRIN OR ADVIL (IBUPROFEN) 200MG

HEART-FRIENDLY MEDICINES

14

No drug produces reliable

pain relief in every patient

NEW ANTICOAGULATION DRUGS

TO REPLACE COUMADIN

Rivaroxaban—Xarelto (3A4)

Apixaban—Eliquis (3A4)

Dabigatran—Pradaxa (renal)

*Check with physician

Caution with aspirin, ibuprofen, naproxen, Z-Pak

Ketek, Biaxin, itaconazole, ketoconazole (3A4)

Mayoclinic.com

Epocrates (downloadable app)

OMEGA 3 FATTY ACIDS Essential fatty acids

The 2 Active Components in

Omega 3 are DHA and EPA

•

• 1300mg

•

•

The 2 Active Components in Omega 3

are DHA and EPA

•

600mg

15

2752 mg

LOWERS TRIGLYCERIDES

HOMER

CARDIOVASCULAR HEALTH

SECONDARY PREVENTION

Systematic reviews of EPA + DHA found

that dietary supplementation reduced

the risk of cardiovascular deaths,

fibrillation, and non fatal cardiovascular

events.

*Check with your doctor Clin Cardiol. 2009 Jul:32(7)365-72

HFSA Scientific Meeting Sept20, 2010

Mayo Clin Proc.2011:86(7):626-632

OMEGA-3 AND DEPRESSION

American Psychiatric Association concluded there is evidence for EPA-DHA based on DBRCT as an adjunctive therapy for major depressive and bipolar disordes.

Freeman MP et al J Clin Psychiatry 2006

Archives of General Psychiatry Feb.2010

RHEUMATOID ARTHRITIS

Trials have demonstrated a range of

benefits in patients with RA that

include reducing joint pain when used

as an additive with NSAIDs (ibuprofen,

naproxen, aspirin).

Calder PC, Proc Nutr Soc. 2008 Nov:67

MACULAR DEGENERATION Studies (2500 patients – 7 years) shows

that omega-3 fatty acids slows the

progression of vision loss from age-

related early macular degeneration and

reverses the signs of dry eye syndrome.

SanGiovanni JP Arch Ophthalmol. 2008 Sep:16

Arch Ophthalmol. 2011 July, Vol 129, No. 7

16

OMEGA 3 AND PERIODONTAL DISEASE

9182 adults aged 20 years or older

Conclusion: higher intakes of DHA/EPA

were associated with lower prevalence of

periodontal disease.

Kaye, E. J Am Diet Assco. 2010 Nov:110 (11) 1650-52

OMEGA 3 AND PERIODONTAL DISEASE

The result of this clinical study suggest that

dietary supplementation with Omega 3 may

provide a sustainable, low-cost intervention

to augment periodontal therapy. Sharkawy H, J.Periodontol. 2010 Nov:81(11):1635-43

SIDE EFFECTS OF FISH OIL Increased risk of bleeding—minimal –ck coumadin

Heavy metals and other pollutants-China and India

Increase in LDL and total cholesterol

Stomach upset

After taste

Burping

Diarrhea

To minimize:

• Take with meals

• Start with low dose

• Keep in refrigerator

Heart Health: 1000mg-1200mg DHA+EPA

High Triglycerides: 4000mg DHA+EPA

Rheumatoid arthritis: 2500mg DHA+EPA

Children (1-5 yrs): 300mg-400mg DHA

Mental Health: 1-2000mg EPA or EPA+DHA

Prenatal: 250-350mg DHA

Vision: 800mg DHA or 1000mg DHA+EPA

Periodontal disease: 1-2000mg EPA+DHA

MULTIVITAMINS

A 4 billion dollar business

Lots of Types

Lots of Confusion

Consumers Lab (June 2011)

10 of 38 multivitamins tested contained

either more or less of what the label

indicated

17

PHYSICIAN HEALTH STUDY-2

PRIMARY PREVENTION

1997-2007, 15,000 physicians

Results— Vit.E and Vit.C no effect on

CVD, prostate or total cancer

The multivitamin component will

continue for a few more years.

MULTIVITAMIN USE AND RISK OF

CANCER AND CARDIOVASCULAR

DISEASE IN WOMEN’S HEALTH

INITIATIVE COHORTS (1997-2005)

8 YEARS, 66,000 POSTMENOPAUSAL WOMEN

MULTIVITAMIN USE HAS LITTLE INFLUENCE

ON THE RISK OF COMMON CANCERS, CVD,

OR TOTAL MORTALITY.

ARCHIVE INTERNAL MEDICINE, 2009

$625 million NIH

We found no evidence to support

antioxidant supplements for primary or

secondary prevention. Vitamin A, beta-

carotene, and vitamin E may increase

mortality.

January 20, 2010

Multiple Vitamins (may benefit)

Those who have chronic gastrointestinal disorders

Those who fail to get the right amount and type of

food for proper nutrition

People with a chronic illness

Women who are pregnant

Alcoholism

PRENATAL VITAMINS

Folic acid (B9)in prevention of

neural tube or spinal defects

Prevention of low birth weight

Helps support growth of placenta

Vitamin B12 deficiency may be

cause of infertility or

spontaneous abortion 400mcg/day

DEFICIENCIES AS WE AGE

VITAMIN B12

Vitamin B12 (cobalamin) deficiency is

particularly common in elder adults

Development of RBC

Development of nerve cells

Aid in production of DNA and RNA

Aid in production of

neurotransmitters

18

Causes of vitamin

B12 deficiency

• Abdominal or intestinal surgery

• A diet low in vitamin B12 (a strict vegetarian diet)

• Chronic alcoholism

• Crohn’s disease, atrophic gastritis, Celiac disease, hypothyroidism (40%), Metformin (Glucophage) for type 2 diabetes

• PPI (Nexium, Prilosec, Prevacid) acid blocking medication

• Elderly people (common deficiency 15-20%)

Symptoms of vitamin

B12 deficiency

Anemia, fatigue, tiredness

Neurologic (muscle weakness, unsteady gait,

numbness or tingling in fingers or toes—DM or B12)

Psychiatric symptoms (dementia, cognitive

impairment, psychoses, depression)

Dental (bleeding gums, sore mouth and tongue)

Lab test—methyl malonic acid

ATROPHIC GLOSSITIS

(Smooth Tongue)

Nutritional deficiency

• Vit B12

• Folic Acid (B9)

• Riboflavin (B2)

• Niacin (B3)

• Iron

• Celiac Disease--1 in 133

(gluten intolerance)

ANGULAR CHEILOSIS

Nutritional deficiency

• Vit B12

• Folic Acid (B9)

• Riboflavin (B2)

• Niacin (B3)

• Iron

• Celiac Disease

RECURRENT APHTHOUS ULCERS

Nutritional deficiency

• Vit B12

• Folic Acid (B9)

• Riboflavin (B2)

• Niacin (B3)

• Iron

• Celiac Disease

BLEEDING GUMS-poor oral hygiene or…..

Vitamin B12

Vitamin K

CCB (Norvasc, Cardizem)

Pregnancy

Blood thinners (Coumadin)

Chemotherapy agents

Leukemia

Birth control pills

Immunosuppressant drugs (Cyclosporin)

Antidepressants (Zoloft, Celexa, Lexapro + NSAID)

19

BURNING MOUTH SYNDROME

Iron

Zinc

B vitamins—B1, 2, 6, 9, 12

ACE inhibitors---Lisinopril

Diabetes

Allergies

Hypothyroidism

Hormonal imbalance---menopause

Check “mayoclinic.com”

VITAMIN D

DEFICIENCY OF VITAMIN D

Use of sunscreen

Liver or kidney problems

Aging-decrease provitamin D because of

thin skin (75%) .

GI disorders—Crohn disease, ulcerative

colitis, Celiac disease (gluten induced)

Hyperthyroidism and hyperparathyroidism

No sun—Northern climate

If your shadow is longer than you are tall, you are not making any vitamin D

MUSCLE SORENESS*

Low vitamin D—muscle pain- fall rates

Statins (Zocor, Lipitor, etc--10%-15%)

Peripheral vascular disease

Vitamin B12 (low)

Magnesium (low)

Celiac Disease

Hypothyroidism

Bisphosphonates

Drug combinations

20

VITAMIN D and BALANCE

.Can present as severe bone pain, muscle

weakness (hard to get off chair or climb up

stairs), and increased body sway that can lead

to falls and hip fractures.

Vitamin D is now recognized as important

for cardiovascular health and its deficiency

as a potential risk factor for several

cardiovascular disease processes. Am J Cardiology 2010; 106: 798-805

J Amer Col Cardiology July 2011; 58: 186-192

MACULAR DEGENERATION

High serum 25 (OH) D concentrations

may protect against early age-related

macular degeneration in women younger

than 75 years. Arch Ophthalmol. Apr 13,2011:129(4):481-489

Vitamin D in the form of vitamin D3

seems to decrease mortality in

predominantly elderly women (mean age-

74 years).

Cochrane Database Syst Rev 2011 Jul 6; CD007470

VITAMIN D AND CANCER

16 year study, 88,000 women, found higher

intakes of vitamin D associated with lower

breast cancer risk in premenopausal women

Breast cancer--women with deficient

vitamin D levels (less then 20ng/ml) had a

60% increased risk of development of

metastatic disease

Journal Clinical Oncology, Vol 27, Page 3757-2009

Mayo Clinic and Collaborators Find

Vitamin D Levels are Associated with

Survival in Lymphoma Patients

Patients with deficient vitamin D levels

had a 1.5-fold greater risk of disease

progression and a twofold greater risk of

dying, compared to patients with optimal

vitamin D levels

Dec. 5, 2009

21

VITAMIN D AND PROSTRATE CANCER

Laboratory and population-based

research suggest that adequate levels of

vitamin D reduce the risk of developing

prostate cancer Johns Hopkins July 2009

PROSTATE CANCER AND

ANDROGEN DEPRIVATION THERAPY

To reduce levels of male hormones (testosterone) which

stimulate the growth of prostate cells and fuels the growth of

cancer

Within 4 years of starting androgen therapy, 50% of men will

have osteoporosis

More likely to have periodontal disease and osteoporosis

J Urology-2007 Mar, 177(3): 921-4

Need to change lifestyle

- Smoking cessation

- Alcohol consumption

- Resistance exercise

- Calcium and vitamin D supplements

*Depends on lab test of Calcium and Vitamin D

VITAMIN D AND PERIODONTAL DISEASE

“a low vitamin D concentration was

independently associated with periodontal

disease.”

Cleveland Clinic Journal of Medicine Aug 2009

VITAMIN D AND PERIODONTAL

DISEASE An observational study in the U.K. involving post-

menopausal women with osteoporosis found PD

“is more common in women with osteoporosis and

is associated with lower vitamin D and higher

concentrations of two cytokines, RANKL and MMP

J Periodontal Research. 2011 Feb

Do not take if have

Liver disease

Kidney disease

Hypoparathyrodism

Hyperparathyrodism

Sarcoidosis

*Always check with your doctor first

VITAMIN D VITAMIN D

Dose: 1000 to 2000 IU/day depending on lab

studies

Lab studies range (Mayo Clinic):

10 ng/mL—severe deficiency

10-30 ng/mL—mild to moderate

30-80 ng/mL—optimum

22

CALCIUM

Builds strong structure of bones and teeth

Muscle and blood vessel contraction

Secretion of hormones and enzymes

Transmit impulses thru the nervous system

CALCIUM

Found naturally in dairy products, leafy

green vegetables, beans, and meat.

May also need supplements since the

body cannot make calcium

CALCIUM SUPPLEMENTS

Calcium carbonate

Least expensive

Must be taken with food

Calcium citrate

Best if have low gastric acid

production and those taking

Nexium, Prevacid, Prilosec, to

block stomach acid

Do not need to take with food

CALCIUM SUPPLEMENTS Take with magnesium if blood test shows it is low

Do not take with thyroid, Dilantin, cortisone, bisphosphonates, thiazides, Vibramycin/Periostat

(take 4hours before or 4 hours after taking Ca)

Those who have liver disease, kidney disease,

high or low parathyroid levels, talk with Dr. first

NEW DATA, MORE DEBATE

New studies linking calcium supplements to:

• Increased risk for heart attack and stroke

• Vascular calcification

• Kidney stones BMJ APRIL 2010

OhMyGosh

I have been taking to much

CALCIUM SUPPLEMENTS MAY BE

BAD FOR YOUR HEART

Those who consumed 820mg/day had a 31%

lower risk of heart attacks then those who

consumed less from their diet.

Those who got calcium from

supplements were twice as

likely to have a heart attack as

those who took no supplements

24,000 people for 11 years

Heart: May 23, 2012

23

WOMAN’S HEALTH INITIATIVE

Women who took 1000mg of calcium daily

had 17% more kidney stones then those

who got a placebo

36,000 women/ 15 years

Caveat –women were allowed to

eat their usual diet, so calcium

intake was unknown

CALCIUM INTAKE: MORE IS NOT BETTER

Calculate how much you are eating

through food and balance off the rest with

supplements so it equals 1,200 milligrams

of calcium a day for women older than 50.

RISK FACTORS FOR OSTEOPOROSIS

• Aging and estrogen deficiency

• Smoking, alcohol

• Sedentary lifestyle

• Low vitamin D

• Gastric bypass

• Type 1 diabetes

DRUGS ASSOCIATED WITH LOW

BONE MINERAL DENSITY

Steroids

Antiepileptic drugs (Dilantin, Tegretol, Neurotin)

Nexium, Prilosec, Pepcid, Zantac

Coumadin

Actos or Avandia

Calcium and vitamin D supplementation

had a modest positive effect on periodontal

health on those subjects receiving

periodontal maintenance therapy.

J Periodont 2011:82:25-32

ACTONEL, BONIVA, FOSAMAX

Arthritis of the joints (primarily in the

jaw) has been reported in patients taking

bisphosphonates.

Bisphosphonates may

cause bone, joint, and

muscle pain.

24

A Manual of

Laboratory and

Diagnostic Tests

by

Frances Fischbach

Lab Tests

• Vitamin B12

• Vitamin D

• Calcium

• HgA1c

• Iron

• tTGA

Physical activity and eating a proper diet can

mitigate progression of chronic disease and in fact

reverse existing disease

Whole grains contain the

germ, bran, and

endosperm.

Refined grains retain only

the endosperm

Gluten is the protein part

of the endosperm

(83% of the kernel)

*cause of celiac disease

CELIAC DISEASE an

AUTO IMMUNE DISEASE Symptoms

• Stomach pain

• Diarrhea

• Depression

• Fatigue

• Weight loss

• Osteoporosis

• Mouth sores

• Muscle cramps

• No symptoms

80% not diagnosed 1 out of 133 people

ORAL MANIFESTATIONS OF

CELIAC DISEASE

• Recurrent aphthous ulcers

• Atrophic glossitis

• Oral lichen planus

• Cheilosis

25

ORAL MANIFESTATIONS OF

CELIAC DISEASE

Enamel Defects in Children

Let Them Eat Dirt: How Clean Environments

May Set Up Kids for Immune Problems

WHITE OR WHEAT FLOUR

BRAN AND GERM OUT

THIAMIN (B1), RIBOFLAVIN (B2), NIACIN (B3)

ZINC, FOLIC ACID, MANGESIUM, COPPER

PHOSPHORUS, IRON, CALCIUM,SODIUM,

AMINO ACIDS, ANTIOXIDANTS, FIBER, PLUS

15 MORE

INTO THE BREAD

VITAMIN B1, B2 , B3, IRON, FOLIC ACID

(Molasses or Carmel)

WHOLE GRAINS

• Rolled oats

• Whole wheat flour

• Whole rye

• Brown rice

• Wild rice

• Whole cornmeal

• Popcorn

• Barley

• Quinoa

• Spelt

• Couscous

• Amaranth

• Wheat berries

WHOLE GRAINS REDUCE

HEART DISEASE

STROKE

CANCER

DIABETES

OBESITY

Wheat flour Durum wheat

Unbleached flour Enriched flour

Semolina Multigrain

Cracked wheat

DON’T BE TRICKED THESE ARE NOT THE SAME AS

“WHOLE WHEAT” or “MULTI-GRAIN WHOLE GRAIN”

26

Cold Cereals Hot Cereals

Whole grain Mostly refined

grain Whole grain

Mostly refined

grain

Cheerios Basic 4 Oat bran Cream of rice

Granola or muesli Corn flakes Oatmeal Cream of wheat

Grape-Nuts Frosted Flakes Quaker Multigrain Grits

Nutri-Grain Just Right Ralston High

Fiber

Raisin bran Kix, Corn Pops Roman Meal

Shredded wheat Product 19 Wheatena

Total Puffed wheat

Wheat germ Rice Krispies

Wheaties Special K

•

•

• 51

51 Gm Sugar=17 packets

IF YOU WANT TO BE FUNCTIONAL

AT 80

YOU NEED TO START AT 50

See a physical therapist first if you

have joint problems

Don’t compare yourself with others

Keep track of your progress

Be realistic. Set goals loosely

Forget the past

Check with your Dr.

27

Benefits of Exercise

Improves

• Mood

• Self confidence

• Sense of well-being

• Have a better sex life!

Reduces

• Stress

• Depression

• Anxiety

• Blood pressure

• Blood sugar

• Bone mineral

loss

Decreases

• CHD by 30%

• Stroke by 30%

• Type II Diabetes by 30%

• Medication dosage

• Post surgical

recovery is faster

• Increases weight

loss

• Emphysema

• Increases joint

function-arthritis

Women who walk 2 or more hours a

week, especially at a brisk pace, are

significantly less likely to experience

any type of stroke than women who do

not walk.

Woman’s Health Study 4-13-2010

39,315 women, 45 years or older

Pedometer Benefits of using Pedometers

Helps you realize just how active you are (or are not) in your everyday life

Gives you a visible cue to see how far you are walking

Acts as a motivator

Inspiration on a daily basis

Impact of Physical Activity on Cancer

Accelerates movement of

food through intestine,

reducing time bowel lining is

exposed to mutagens.

Reduce risk of colon, breast,

prostate, and other cancers

EXERCISE AND BREAST CANCER

PRIMARY PREVENTION

Increasing physical activity, even if

started later in life, reduces overall

risk of developing breast cancer by

20%.

C Brown et at M.C. Anderson Cancer Center 2009

28

Primary and secondary prevention

of hormone driven cancers

Exercise

Vitamin D

Good diet

Lose weight

Exercise does not have to be a workout at the gym

Health clubs provides instruction, supervision, equipment, and motivation

The key is doing some type of moderate exercise routinely--time of day

9 MONTHS!!!!!

By the age of 65, many seniors have

lost 30-40% of their muscle mass

A Dip in the Pool Does an Aging

Body Good

Swimming reduces blood pressure, improves

artery health and boosts endurance in COPD in

elderly adults American Journal of Cardiology July, 2011

Aging

Progressive weight gain

Decreased metabolism

Loss of muscle mass

Decrease in pancreatic beta-cell function

Adverse distensibility of the arterial tree

Exercise is Medicine

With No Side Effects

29

PROCRASTINATION PERSEVERANCE

jclichon@aol.com