Bisphosphonate Drugs And Their Potential Effect On Periodontal Health

Dr. Elle Kheirkhahi-Love DDS. MSD 

You may have heard recent reports about bisphosphonate drugs and their potential effect on periodontal health. These reports can be alarming and even misleading, especially for those taking bisphosphonates. The information below explains what bisphosphonates are, how they are related to periodontal health, and how bisphosphonates may impact your periodontal treatment.

Bisphosphonates, also known as bone-sparing drugs, are used to treat and prevent osteoporosis, and are also prescribed to patients diagnosed with certain bone cancers. Bisphosphonates can be administered in two ways: orally and intravenously (IV). Oral, or tablet, bisphosphonates (common names include Fosamax, Boniva, and Actonel) are usually prescribed for osteoporosis, while IV bisphosphonates (common names include Aredia and Zometa) are typically prescribed for patients with advanced bone cancers to help decrease pain and fractures.

In rare instances, some people that have been treated with bisphosphonates, especially the intravenous form, develop a rare condition called osteonecrosis of the jaw (ONJ), which can cause severe, irreversible, and often debilitating damage to the jaw. ONJ can be worsened by invasive dental procedures such as tooth extractions or dental implants. People may not have symptoms in the early stages of ONJ, but pain can gradually develop as the condition progresses.

Symptoms of ONJ include:

• Loose teeth
• Numbness or a feeling of heaviness in the jaw
• Pain, swelling, or infection of the gums or jaw
• Gums that do not heal
• Exposed bone

Currently, there is no treatment that definitely cures ONJ. However, antibiotics and anti-inflammatory drugs may help relieve some of the pain associated with ONJ. Most people diagnosed with ONJ will also need surgical treatment.

If your physician prescribes a bisphosphonate, especially IV bisphosphonates, it is very important to tell your dental professional, because your dental treatment plan may be affected. There have been other risk factors associated with ONJ including age, gender, and other medical conditions, so it is important to share all health information with our our periodontal office.

It is also important to maintain your oral health if you are taking bisphosphonates. Even though the risk of developing ONJ while taking a bisphosphonate remains very small, if you need periodontal surgery, your dental professional may recommend that you interrupt your bisphosphonate therapy prior to, during, and/or after your procedure. Be assured that both the medical and dental communities are studying ways to ensure the safest outcomes for patients taking bisphosphonates who require invasive dental procedures.

Osteoporosis and Tooth Loss
Osteoporosis is a condition that causes low or decreasing bone mass. Untreated osteoporosis can often lead to tooth loss, mainly because the disease diminishes the density of the bone supporting the teeth. Since both osteoporosis and periodontal disease have shared risk factors such as tobacco use and age, and because both can result in bone loss, an association between the two diseases has been difficult to prove. However, if you are at risk for or being treated for osteoporosis, it is still important to keep your oral health at its best. Be sure to brush your teeth at least twice every day, floss at least once every day, and see our office every six months.


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Why You Should Choose An Periodontist To Place Your Dental Implants

Dr. Elle Kheirkhahi-Love DDS, MSD

Dental implants have become the clear choice for replacing single or multiple missing teeth. Although the procedure is extremely technical, when performed by an experienced periodontist, the results are typically very predictable. As you begin to explore your options with dental implants in Palm Springs/Rancho Mirage, you can be confident that our office in Ranch Mirage has the expertise to permanently restore your smile.

The dental implant procedure is an amazing combination of science and cosmetics. After extensively reviewing your medical history, your periodontist will implant a surgical grade titanium post into your jaw bone. Using state of the art imaging technology, the periodontist can evaluate the anatomical curvatures of your bone in order to identify the exact location for your implant.

When the jaw bone is not dense enough to support an implant, your periodontist may suggest a bone grafting procedure to improve stability.

During the planning and placement of your implant, the periodontist will pay particular attention to the esthetic aspects of the procedure. How will the implant be angled to align with the neighboring teeth? How is the jaw bone shaped near the implant? Does the gum tissue look healthy and natural around the implant? These aspects are just as important as the clinical success of the implant. You deserve a tooth replacement solution that is both strong and beautiful.

By trusting our office to restore your smile, you have access to a specialist who possesses a wealth of knowledge. With surgical expertise, an periodontist is the most likely specialist to deliver superior implant dentistry.

Maybe you have been curious about the ways that dental implants can improve your smile. Perhaps you have questions about how to proceed with your choice to replace your missing teeth. If so, then call our dental implant team at (760) 836-1809 to schedule a consultation today.


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Stress May Leave Your Mouth A Mess

Dr. Ellie Kheirkhahi-Love DDS,MSD

A literature review published in the August 2007 issue of the Journal of Periodontology (JOP) saw a strong relationship between stress and periodontal diseases; 57% of the studies included in the review showed a positive relationship between periodontal diseases and psychological factors such as stress, distress, anxiety, depression and loneliness. Literature Review Abstract 

“More research is needed to determine the definitive relationship between stress and periodontal diseases” said study author Daiane Peruzzo, PhD. “However, patients who minimize stress may be at less risk for periodontal disease.”

Researchers speculate that the hormone cortisol may play a role in the possible connection between stress and periodontal diseases. A study in the July issue of the JOP* found that increased levels of cortisol can lead to more destruction of the gums and bone due to periodontal diseases. It is well known that periodontal diseases left untreated can ultimately lead to bone loss or tooth loss.

“Individuals with high stress levels tend to increase their bad habits, which can be harmful to  periodontal health. They are less attentive to their oral hygiene and may increase their use of nicotine, alcohol or drugs,” explained Preston D. Miller, DDS and AAP president. “Patients should seek healthy ways to relieve stress through exercise, balanced eating, plenty of sleep and maintaining a positive mental attitude.”


Patients should to also keep in mind their “pocket size guide” to periodontal health; periodontal probing depths of one to two millimeters with no bleeding are not a concern but probing depths of three and four millimeters may need a more in depth cleaning called scaling and root planing. Probing depths in excess of 5mm may require more advanced treatment and patients should consult with our office.

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The Link Between Gum Disease & Rheumatoid Arthritis

Dr. Ellie Kheirkhahi-Love DDS, MSD

Research is increasingly pointing towards a link between gum disease & rheumatoid arthritis. Rheumatoid arthritis, more than 1.3 million Americans suffer from this condition, and it’s been discovered by German researchers in Berlin, that patients with this condition can have a higher prevalence of periodontal disease. In fact a study of 57 rheumatoid arthritis patients and 52 healthy controls discovered that people with this condition are nearly eight times as likely to have periodontal disease

The study determined the oral health of rheumatoid arthritis patients and the healthy controls, and took into account demographic and lifestyle characteristics such as gender, age and tobacco use. It’s been found that treating periodontal disease can lessen the degree of arthritic pain and stiffness in sufferers. 

To some extent the diseases can be considered similar; both conditions are systemic inflammatory disorders that destroy hard and soft issues through inflammation caused by bacterial infection. 

One particular toxin from inflamed areas in rheumatoid arthritis sufferers is called tumor necrosis factor-alpha (TNF- α), and is a marker found in the bloodstream where inflammation is present. It can initiate new infections or aggravate existing infection sites by promoting inflammation, pain and swelling. 

A study of 40 patients suffering from both rheumatoid arthritis and moderate to severe periodontal and disease was conducted by Askari and Bissada. The participants were divided into four groups, two of which were prescribed a new type of drug which blocks the production of TNF- α, while two groups didn’t receive this medication.

One half of each of the two groups received standard, non-invasive periodontal treatment, while the remaining half didn’t receive any treatment until the study was completed. Patients who received standard periodontal treatment saw their rheumatoid arthritis symptoms improve, regardless of whether they received anti- TNF- α medication or not. Those receiving the medication showed significantly improved results over those not receiving the drugs.

The connection between these two conditions has been suspected for a long time. Results of studies into the link between rheumatoid arthritis and periodontal disease should encourage rheumatoid arthritis sufferers to be vigilant about their oral hygiene routine. Anyone suffering from this condition should have an excellent daily oral hygiene routine, and should see a dental professional at least twice a year, this will help ensure appropriate action is taken to achieve the best levels of oral and general health.

To read more about how gum disease, please click here.

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Children's Oral Health, Periodontal Disease

Dr. Ellie Kheirkhahi-Love DDS, MSD

Many people think of periodontal disease as an adult problem. However, studies indicate that nearly all children and adolescents have gingivitis, the first stage of periodontal disease. Advanced forms of periodontal disease are more rare in children than adults, but can occur. Below are types of periodontal diseases in children:

Chronic gingivitis is common in children. It usually causes gum tissue to swell, turn red and bleed easily. Gingivitis is both preventable and treatable with a regular routine of brushing, flossing and professional dental care. However, left untreated, it can eventually advance to more serious forms of periodontal disease.

Aggressive periodontitis can affect young people who are otherwise healthy. Localized aggressive periodontitis is found in teenagers and young adults and mainly affects the first molars and incisors. It is characterized by the severe loss of alveolar bone, and ironically, patients generally form very little dental plaque or calculus.

Generalized aggressive periodontitis may begin around puberty and involve the entire mouth. It is marked by inflammation of the gums and heavy accumulations of plaque and calculus. Eventually it can cause the teeth to become loose.

Periodontitis associated with systemic disease occurs in children and adolescents as it does in adults. Conditions that make children more susceptible to periodontal disease include:

• Type I diabetes
• Down syndrome
• Kindler syndrome
• Papillon-Lefevre syndrome

Four Basic signs of periodontal disease

Bleeding Bleeding gums during tooth brushing, flossing or any other time	Puffiness Swollen and bright red gums	Recession Gums that have receded away from the teeth, sometimes exposing the roots
Bad breath Constant bad breath that does not clear up with brushing and flossing

Periodontal Disease Runs in the Family

Periodontal disease may be passed from parents to children and between couples. Researchers suggest that the bacteria which causes periodontal disease may be passed from one person to another though saliva. This means that the common contact of saliva in families puts children and couples at risk for contracting the periodontal disease of another family member.

Genetics may also play a major role in the onset and severity of periodontal disease. Researchers found that Up to 30% of the population may be genetically susceptible to developing severe periodontal disease. Therefore, if one family member has periodontal disease, it is a good idea for all family members to see a dental professional for a periodontal disease screening.


Adolescence and oral care

Evidence shows that periodontal disease may increase during adolescence due to lack of motivation to practice oral hygiene. Children who maintain good oral health habits up until the teen years are more likely to continue brushing and flossing than children who were not taught proper oral care.

Hormonal changes related to puberty can put teens at greater risk for getting periodontal disease. During puberty, an increased level of sex hormones, such as progesterone and possibly estrogen, cause increased blood circulation to the gums. This may cause an increase in the gum's sensitivity and lead to a greater reaction to any irritation, including food particles and plaque. During this time, the gums may become swollen, turn red and feel tender.

As a teen progresses through puberty, the tendency for the gums to swell in response to irritants will lessen. However, during puberty, it is very important to follow a good at-home oral hygiene regimen, including regular brushing and flossing, and regular dental care. In some cases, a dental professional may recommend periodontal therapy to help prevent damage to the tissues and bone surrounding the teeth.


Advice for parents

Early diagnosis is important for successful treatment of periodontal diseases. Therefore, it is important that children receive a periodontal examination as part of their routine dental visits. Be aware that if your child has an advanced form of periodontal disease, this may be an early sign of systemic disease. A general medical evaluation should be considered for children who exhibit severe periodontitis, especially if it appears resistant to therapy.

Many medications can dry out the mouth or pose other threats to oral health. Be sure to tell your dental professional about any medications your family members are taking.

Monitor your family to see if anyone has the habit of teeth grinding. Grinding can increase the risk of developing periodontal disease, in addition to causing cracked or chipped teeth. Dentists can make custom-fitted night bite guards to prevent teeth grinding at night.

Researchers suggest periodontal disease can pass through saliva. This means that the common contact of saliva in families may put children and couples at risk for contracting the periodontal disease of another family member. If one family member has periodontal disease, all family members should see a dental professional for a periodontal evaluation.

The most important preventive step against periodontal disease is to establish good oral health habits with your child. There are basic preventive steps to help your child maintain good oral health:

• Establish good oral health habits early. When your child is 12 months old, you can begin using toothpaste when brushing his or her teeth. However, only use a pea-sized portion on the brush and press it into the bristles so your child won't eat it. And, when the gaps between your child's teeth close, it's important to start flossing.
• Serve as a good role model by practicing good oral health care habits yourself.
• Schedule regular dental visits for family checkups, periodontal evaluations and cleanings.
• Check your child's mouth for the signs of periodontal disease, including bleeding gums, swollen and bright red gums, gums that are receding away from the teeth and bad breath.

If your child currently has poor oral health habits, work with your child to change these now. It's much easier to modify these habits in a child than in an adult. Since your child models behavior after you, it follows that you should serve as a positive role model in your oral hygiene habits. A healthy smile, good breath and strong teeth all contribute to a young person's sense of personal appearance, as well as confidence and self-esteem.

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New Swedish Study Links Periodontitis To Breast Cancer

Dr. Ellie Kheirkhahi-Love DDS, MSD

Since the early 1990’s, a number of systemic maladies have been associated with chronic periodontitis.  Initially, these reports were greeted skeptically.  Many suspected no pathophysiological relationships, and questioned if the correlations were just coincidence or were indicative of etiologically unrelated co-morbidities.  Such doubts were sensible given the possibility that data mining may have biased early reports.  Nevertheless, others were spurred to perform additional studies that uncovered additional associations, etiologic explanations and assessed the effects of periodontal interventions on systemic conditions.

Years later, it’s now thought the systemic inflammatory burden incurred by those with periodontitis, along with the seeding of oral pathogens via the circulation to other sites, represent plausible pathophysiological explanations underscoring the potential for periodontitis to aggravate or even help induce certain systemic conditions.

Yet, the most definitive question for practitioners remains the same now as it was fifteen years ago, namely does periodontal therapy beneficially affect those systemic diseases to which periodontitis has been linked? Unfortunately, the effects of periodontal therapy on various systemic maladies have not been well-elucidated, partly because clinical studies are expensive.  In this context, two prospective clinical trials funded by the (U.S.) National Institutes of Health failed to uncover statistically significant improvements in birth outcomes when pregnant women treated for periodontitis were compared with untreated controls. Yet, similar controlled trials have detected benefits, including one published in early 2010. 


Why such discrepancies?  It’s my opinion that NIH-funded studies were underpowered because they compared the effects of only one episode of scaling and root planing with non-treated controls.  In contrast, periodontal care in the 2010 study was provided to test subjects throughout their pregnancies.  As someone who spends much of my professional life assessing the design, quality and clinical meaningfulness of published evidence, many prospective controlled studies and even some systematic reviews come up short.  On the other hand, it’s clear from the science that those with Type II diabetes are better able to control their blood glucose if they optimize their periodontal health.  Moreover, those with diabetes who better control their serum glucose improve their periodontal health, thereby confirming the central role that inflammation – acting both locally and remotely – plays in both groups of diseases.

Recently signs of past and present oral infections were linked to an increased incidence of breast cancer in a Swedish study. Yet many questions remain yet to be answered regarding what may turn out to be a new perio-systemic link.  

For now, I believe that it’s reasonable to inform patients that this new study has reported that breast cancer incidence may be increased in patients with chronic periodontitis. We don’t know yet if treating periodontitis will have a beneficial effect in this context. More studies are needed. However, when one compares the costs of being wrong on either side of this question, getting treatment that one already needs for a host of other reasons seems to make good sense.

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New Study Shows Gum Disease Can Extend The Time That It Takes For A Woman To Become Pregnant

Dr. Ellie Kheirkhahi-Love DDS, MSD

The importance of maintaining a sound oral hygiene is often underestimated by women but new research has shown that presence of gum disease can by an average of two months extend the time that it takes for a woman to become pregnant. Researchers have for the first time been able to clearly demonstrate the significant impact of poor oral health on the time to pregnancy in women who are trying to conceive.

Speaking at the annual meeting of the European Society of Human Reproduction and Embryology, Professor Roger Hart informed that the ill effects of poor oral health on pregnancy are of the same degree as the effects ofobesity. He is the Professor of Reproductive Medicine at the University of Western Australia (Perth, Australia) and Medical Director of Fertility Specialists of Western Australia.

Periodontal disease is a chronic inflammatory disease that affects the periodontium, i.e., the tissues that surround and support the teeth. Periodontitis involves progressive loss of the alveolar bone around the teeth, resulting in the formation of periodontal pockets. If left untreated, it can lead to the loosening and subsequent loss of teeth. Periodontitis is caused by microorganisms that adhere to and grow on the tooth's surfaces, along with an overly aggressive immune response against these microorganisms.

The inflammation of the gums results in tissue destruction that can find its way into the blood circulation. Due to this, most forms of gum disease in earlier studies have been shown to play a significant role in heart disease, type 2 diabetes, respiratory and kidney disease, and problems in pregnancy such as miscarriage and premature birth. It is believed that about 10% of the general population suffer from gum disease which can easily be prevented by brushing teeth regularly and the use of dental floss.


Prof Hart said:

"Until now, there have been no published studies that investigate whether gum disease can affect a woman's chance of conceiving, so this is the first report to suggest that gum disease might be one of several factors that could be modified to improve the chances of a pregnancy."

Pregnancy planning and pregnancy outcome was analysed by scientists for 3,416 women out of a total of 3,737 who participated in the SMILE study, a study conducted in Western Australia.

They found that women with gum disease took an average of just over seven months to become pregnant - two months longer than the average of five months that it took women without gum disease to conceive.

The study also revealed that non-Caucasian women who had gum disease were at the highest risk of later conception and were more likely to take over a year to become pregnant compared to those without gum disease. Non-Caucasian women with gum disease faced an increased risk of 13.9% for later conception compared to only 6.2% for women who were free from gum disease. Caucasian women who had gum disease also took longer to conceive than those who were disease-free; however the difference was not statistically significant. 


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