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How to avoid tooth loss

Posted by medconsumers on August 18, 2010

An interview with Thomas Rams, DDS, clinical periodontist and Professor of Microbiology and Immunology, Temple University School of Dentistry by Maryann Napoli

MN: Like a lot of people, I was very interested in the Keyes technique back in the early 1980s and wrote about it as an alternative to periodontal (gum) surgery. Its self-care, inexpensive simplicity had wide appeal because it relied on daily applications of baking soda and hydrogen peroxide to prevent tooth loss due to periodontal disease. The technique, which reduced the bacteria that grow as dental plaque on tooth surfaces, was developed by a dentist at the National Institutes of Health named Dr. Paul H. Keyes (rhymes with skies).

Periodontal surgery, at the time, was a relatively new treatment, and I remember the pushback from periodontists who warned against the use of hydrogen peroxide as too abrasive to apply to the gums. There were also objections from dentists about Keyes’ use of systemic antibiotics in certain circumstances. The American Academy of Periodontology eventually took a stand against the Keyes technique. I haven’t thought about this controversy in years…that is, until I learned that you have the Paul H. Keyes Chair at Temple University School of Dentistry in Philadelphia. How did that come about?

TR: A wealthy New York woman named Claire Friedlander had ongoing problems with her teeth. Multiple periodontal surgeries didn’t work out, and she kept losing teeth. Eventually she found her way to Dr. Keyes who helped her keep her remaining teeth. She was upset that other dentists were bad-mouthing him and donated money for the Paul H. Keyes professorship in periodontology in 2004.

MN: What is the scientific basis for the Keyes technique?

TR: In the late 1970s and early ‘80s, there was a significant debate among periodontists largely initiated by the work of Dr. Keyes at the National Institutes of Health. It was about the surgical vs. non-surgical treatment of periodontal disease. Keyes was interested in treating severe disease with an anti-bacterial strategy.

MN: Was he the first to see periodontal disease as a result of bacterial growth on the teeth?

TR: No. It had been observed way back in the 1680s by someone named Antony van Leeuwenhoek in The Netherlands who invented a microscope. The first substance he looked at was dental plaque from his own teeth. And he saw various micro-organisms similar to what we see today. Van Leeuwenhoek wrote letters to a London scientific society about these micro-organisms, which became the first descriptions of bacteria in recorded history. He noticed that there were many more of these micro-organisms in the debris from the areas where his gums were bleeding. If he immersed the plaque in vinegar, they stopped moving. He couldn’t find the same micro-organisms in other substances like rain water. And when he rinsed his mouth out with vinegar solutions, the number of organisms would go down. He had already made a connection between inflammation and these micro-organisms. No one picked up on it.

MN: So, periodontally speaking, there was a long dry spell between the 17th century and Dr. Keyes.

TR: Dental plaque wasn’t given attention until the 1960s when Paul Keyes became the first to demonstrate that there are particular types of bacteria in dental plaque that were more pathogenic (infective). He was the first one to develop an animal model system to study periodontal disease. He was then at the University of Rochester and it was an important step forward. Instead of doing surgery, he did non-surgical scaling of the teeth and applied different antiseptics topically to the tissues and flooding the periodontal pockets as a way of killing bacteria. And also in certain circumstances, he used systemic antibiotics—short term use, that is.

MN: What about the hydrogen peroxide that got periodontists so exercised back in the 1980s?

TR: Peroxide was only a secondary part of the Keyes method. It was primarily the baking soda. While he was at the NIH, a woman in her mid-nineties came in as part of an aging study. She had all her teeth and allowed Keyes to take plaque samples. When she was found to have none of the pathogens implicated in periodontal disease, she was asked what she’d being doing. “I come from the Appalachian Mountains of West Virginia. During the depression we couldn’t afford tooth paste, and my grandma told me to brush my teeth with baking soda,” she answered. “I’ve done that my whole life.”

That started Dr. Keyes’s investigation of the anti-bacterial properties of baking soda. It turns out that the periodontal pathogens are highly sensitive to baking soda. Instead of using the dry powder, which is abrasive, you can make a paste with tap water. It then becomes non-abrasive but still retains its antibacterial properties. The addition of hydrogen peroxide just provided some foaming effect, but it’s not helpful in the mouth because it’s broken down by a number of enzymes in the saliva. In short, the baking soda was doing most of the (bacteria) killing, not the peroxide. Now people can buy baking soda toothpaste. [Note: Arm & Hammer, the baking soda company that also makes baking soda toothpaste, appears to be unaware of Dr. Keyes' work. The company lists baking soda as an inactive ingredient of its toothpaste.] I recommend the baking soda toothpaste because you can buy a version with fluoride added for anti-decay activity.

MN: What is the Paul Keyes legacy?

TR: He was right on target. We never knew back in the 1960s what good oral hygiene was. There was a study mentioned in the British journal The Lancet in the early 1990s that had followed people who at age 35 did not have periodontal disease. Fifteen years later, two-thirds of those who didn’t brush their teeth very well had periodontitis, compared with one in ten of those who had had good oral hygiene at age 35.

MN: What’s good oral hygiene today?

TR: Using an electric, or powered, toothbrush is much better than a manual toothbrush because it provides a tremendous disruption of the dental plaque from the tooth surfaces and around the teeth. Flossing is important and if you can’t floss they have what we call intra-dental brushes for patients with periodontal breakdown (inflamed gum tissue). Dental flossing is also important. I have my patients with severe periodontal breakdown use a Waterpik, or oral irrigator, to flush the area between and around the teeth with baking soda diluted water or a very highly diluted bleach. People who don’t floss very well can use an oral irrigator on a preventive basis. This device is also good for people with dental implants because it makes it easier to get around the restorations.

MN: How would a person know whether these self-care preventive practices are actually working?

TR:
The sad thing is you won’t. Periodontal disease is a relatively silent condition. Patients can develop relatively advanced lesions where they don’t suffer pain and have little awareness their mouth is deteriorating. They may see bleeding from gum tissue when they brush and floss their teeth. But a patient can’t usually tell just how serious it is. Loose teeth are usually associated with a rather advanced disease. Much of the detection, however, relies on a dentist taking a periodontal probe and advancing it around the tooth to see if there’s a loss of periodontal attachment to the tooth and considerable bleeding.

MN: The current use of antibiotics in the treatment of advanced periodontal disease seems like one sign that mainstream dentistry has accepted Dr. Keyes’s research demonstrating that periodontal disease is a bacterial disease.

TR:
Back in the early 1980s there were major objections—from periodontists in particular—about the so-called Keyes technique because, for certain patients, systemic antibiotics would be prescribed. It is ironic that, now 25 years later, the periodontal community has reached a consensus both here and in Europe about the use systemic antibiotics. Based on systematic literature reviews, commissioned respectively by the American Academy of Periodontology and the European Federation of Periodontology, both organizations concluded that for certain patients with severe periodontal disease, short-term systemic antibiotics, in combination with non-surgical scaling, are extremely valuable. As of about six years ago, this is the recommended approach.

MN: And it’s only recommended for people with severe disease.

TR: There’s little benefit to giving a systemic antibiotic to someone with gingivitis. Very little benefit for moderate periodontitis.

MN: How is the antibiotic chosen?

TR: That depends on the bacterial profile [of the patient]. Probably most widely used is the combination of two antibiotics—one is metronidazole and the other is amoxicillin—-for one week.

MN: What about the use of antibiotic gels that hygienists apply directly to the periodontal pockets?

TR: This has some benefit but not as profound as the systemic agents. It tends to get washed out.

MN: While preparing for this interview, I read that your dental school at Temple University has one of only three laboratories in the U.S. that cultures dental plaque. Is this routinely done for tough cases?

TR: The top of the line approach is to do microbiological testing as a means of selecting the best antibiotic regimen for a particular patient. This is endorsed by the American Academy of Periodontology. Otherwise dentists might select an inappropriate antibiotic where the target organisms are resistant. We have evidence that resistance to periodontal micro-organisms is increasing. Only a few dentists use microbiological testing unfortunately. And that’s too bad because they are making an informed guess.

MN: How would anyone know about where to send a plaque culture? Would the average dentist know about these labs?

TR: They can go to the Internet. Our dental school has a website that describes our lab. So do the University of Southern California and University of North Carolina [dental schools].

MN: Is there a role for periodontal surgery today?

TR: Yes, for esthetic reasons.

MN: Gum surgery for cosmetic reasons!

TR: Yes, for people with severe gingival recession of the front teeth that gives them an elongated look. And there are patients for whom non-surgical methods are not working sufficiently. Then by all means, go ahead have surgery, which has evolved differently since 30 years ago. One of the reasons why there’s a diminished debate about surgery vs. non-surgery for periodontal disease is so many of natural teeth are being extracted and replaced with implants today. Yet this doesn’t exactly solve the situation in that the person still has to maintain good oral hygiene. If you have periodontitis and you go through treatment, it’s important to get rid of the bacterial pathogens and if you don’t get rid of them, you will have recurrent breakdown. If you have dental implants, and your natural remaining teeth have periodontal pathogens on them, then these pathogens can spread from the natural teeth and can lead to a periodontal diseaselike breakdown that eventually causes loss of the dental implants. I can’t stress enough the importance of good oral hygiene [see part 1 of this interview].

MN: After the person with natural teeth and/or implants successfully gets rid of the pathogens, then what?

TR: Then benign bacteria begin to grow in your mouth. You don’t have a sterile mouth post-treatment. Some patients make the transition from pathogenic to benign; but for others, it’s a more difficult transition because periodontal disease persists or keeps coming back. In any case, this recolonization process had to take place on its own. Now for what’s new: We have known for about 25 years that there are certain benign bacteria that actually inhibit the periodontal pathogens. There are three particular streptococcal bacteria that don’t cause periodontal disease or tooth decay. If you grow them in culture with periodontal pathogens, they inhibit the growth of the periodontal pathogens. They are natural bacteria that grow in the dental plaque of people with healthy teeth and gums, and they secrete hydrogen peroxide. We always wanted to be able to promote those organisms to overgrow so they would block out the pathogens.

MN: And now you can?

TR: Yes, there’s a researcher who used to be at Harvard Dental School and then at University of Florida. Jeffrey Hillman, a periodontist with a PhD in microbiology, did some of the pioneering work on what is called bacterial antagonisms in the periodontal microflora. He discovered that if you take Streptococcal uberis and Streptococcal oralis that produce the most peroxide of any of the streptococci—they inhibit almost all of the periodontal pathogens. Dr. Hillman, now a retired professor emeritus, has come up with a lozenge that dissolves in your mouth and what comes out of the lozenge are millions of S. oralis and S. uberis that are alive. And there’s a third bacterium I’ll get to in a minute.

MN: So the lozenge contains probiotics.

TR: Yes, Evoraplus can be purchased over the Internet without a prescription. These lozenges can change the balance of the microbiology in the mouth towards one that is more conducive to maintaining periodontal stability.

MN: Is this product only for people who have had these pathogens cleared up? Can a person go wrong taking these lozenges without having his or her pathogens cleared up professionally?

TR: We don’t know that. If they have periodontal disease, this is not the only answer. They need to have their teeth scaled, good home care, etc. But if you can get these benign organisms to grow in your mouth before you get periodontal disease, you may never get it.

MN:
You’re suggesting this product could be preventive. Has this been proven?

TR: No, it hasn’t been studied well, but all the elements are there. There is no evidence that these bacteria can cause dental disease. In animal studies, they’ve shown that once these micro-organisms are introduced, the periodontal pathogens are prevented from getting back in.

TR: The third organism in this product is S. rattus, a very interesting bacterium. It’s similar to the bacterium that causes tooth decay, which is Streptococcus mutans. S. mutans will overgrow in a mouth when people eat a lot of sugar. It produces lactic acid that will start to degrade the tooth surfaces and cause tooth decay. By culturing out millions and millions of bacteria, Dr. Hillman found this unusual bacterium called S. rattus, which is similar to the one that causes tooth decay. But here’s the big difference: S. rattus gobbles up sugar without producing lactic acid. So if you can get S. rattus overgrowing in your mouth, you can block the introduction of the tooth-destroying S. mutans. Bacteria compete against each other, and sometimes one side gets the upper hand.

Dr. Rams said that he has no financial interest in this product.

Posted in Alternative Medicine, Chronic Conditions, Dental, surgery | Tagged: , , , , , , | 6 Comments »

Home Remedy and Antibiotics for Eczema

Posted by medconsumers on May 11, 2009

A small, preliminary study published in the journal Pediatrics showed a combination treatment can alleviate symptoms of the painful itchy skin disease called atopic dermatitis, which is the most common of the many forms of eczema. It combines a home remedy—soaking in bath water diluted with laundry bleach—and antibiotics.

Jennifer T. Huang, MD, and colleagues at the Northwestern University, Feinberg School of Medicine, Chicago, acknowledged that, along with other pediatricians, they had been advising the diluted bleach baths for some time because they appear to alleviate symptoms and cut down on infections. Their study is the first to include this home remedy.

In an effort to reduce the most troubling complication of atopic dermatitis, all 31 children with eczema who participated were given oral antibiotics for 14 days prior the start of the study. This was to combat the bacterial infection, most often staphylococcus, which can occur when children scratch themselves hard enough to draw blood.

The participants, ages 6 months to 17 years, were then randomly assigned to sit submerged in a bathtub full of water mixed with 1/2 cup of bleach for 5 to 10 minutes twice a week over three months, or a bathtub full of plain water. Only the children in the bleach-bath group were given an antibiotic ointment (mupirocin), which was applied intranasally.

At three months, the children in the bleach-bath group showed greater decrease in the severity in their symptoms and in symptoms of bacterial infections. Huang and colleagues wrote that the next research step should be more studies that assess the efficacy and long-term safety of diluted bleach baths without the addition of antibiotics.

Maryann Napoli, Center for Medical Consumers© May 2009

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Avoiding Alcohol While on Antibiotics—A Prevalent Myth

Posted by medconsumers on January 15, 2009

Yet another medical myth was explored in a recent issue of the British Medical Journal click here. The idea that alcohol should be avoided while taking antibiotics is prevalent, according to a survey of British patients. The advice also turned up frequently in a Google search of the Internet.

A research team led by J. Lwanga and colleagues at the Department of Genitourinary Medicine, Guy’s and St. Thomas’ Hospital in London, found there was no basis for this belief and no such contraindication is listed for antibiotics in the British National Formulary. Still, the researchers showed that 72% of patients who were treated at their clinic believed that drinking alcohol while on antibiotics would make them sick. And 81% thought that alcohol might stop the antibiotics from working properly. Despite the prevalence of these incorrect assumptions, the survey found they rarely led people to skip the antibiotics in order to drink.

Lwanga and colleagues could only speculate about their findings. “Prohibition of alcohol in people being treated for a sexually transmitted disease is a recognized historical fact and may have punitive origins.”

The first two rapid responses (electronic letters to editor) to this survey justified the avoidance of alcohol for people taking antibiotics for sexually transmitted diseases. One doctor wrote that sexual abstinence is essential until antibiotic therapy has been completed. Yet the disinhibiting effects of high alcohol consumption, especially binge drinking, might lead people to disregard the standard advice about sexual abstinence.

Maryann Napoli, Center for Medical Consumers©

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Sinusitis: Saline Irrigation Works

Posted by medconsumers on September 1, 2007

An Old Sinusitis Treatment Makes a Comeback: Nasal Saline Irrigation

Sinusitis sends millions of adults and children to the doctor each year. And many receive inappropriate treatment. Though studies show that viruses are by far the most frequent cause of a sinus infection, U.S. physicians reported that they prescribed antibiotics in 82% of visits nationwide for this condition. Despite contradictory results from studies exploring the efficacy of inhaled nasal corticosteroids, these drugs are also prescribed frequently.

These are some of the alarming findings from a study reported early this year in Archives of Otolaryngology. The authors, Hadley J. Sharpe and colleagues at the University of Nebraska Medical Center in Omaha, based their study on physician-generated information from two national surveys of patient data collected during visits for ambulatory care from 1999 to 2002. The misuse of antibiotics is of particular concern because it contributes to the increase in more virulent and drug-resistant bacteria.

“Watchful waiting, lavage with saline solution, and use of decongestants or proper antimicrobial agents are the treatments of choice,” wrote the University of Nebraska research team, referring to the steps doctors should go through in treating acute sinusitis. Acute rhinosinusitis, as it is also called, usually lasts less than four weeks, and a short-term antibiotic regimen can in fact provide relief to a minority with a bacterial infection. But the effects of antibiotics on chronic sinusitis, defined as symptoms lasting 12 weeks or longer, were described by the University of Nebraska researchers as questionable.

Enter Saline Irrigation

This study exposed the poor quality of sinusitis treatment in the U.S. Does it provide an impetus for increased use of a home treatment called nasal irrigation, which involves sending a buffered salt-water solution up one nostril and out the other? “Absolutely,” agreed Otolaryngologist Donald A. Leopold, MD, a co-author of the University of Nebraska study, in a telephone interview.

“90% of my patients are rinsing their noses. It’s so easy and inexpensive, and in many ways, solves the whole problem,” said Dr. Leopold, who is professor and chair of the department of otolaryngology-head & neck surgery at the University of Nebraska Medical Center, Omaha. “It’s the every day, and sometimes twice a day, use of this stuff that makes the difference. It’s something the patients have to do on an ongoing basis, and if they do, they get better.”

Nasal saline irrigation recently received validation from a Cochrane review of all relevant clinical trials. After noting that this treatment has its foundations in yogic and homeopathic traditions, the Cochrane review concluded, “There is evidence that [saline irrigations] relieve symptoms of chronic rhinosinusitis, help as an adjunct to treatment and are well tolerated by the majority of patients.”

Allergies can also be relieved with daily nasal saline irrigation, according to two studies involving children with seasonal allergic rhinitis. Those who were randomly assigned to nasal irrigation had a decrease in symptoms and a reduced intake of antihistamines.

Range of Products Available

In the practice of yoga, nasal irrigation involves the use of a neti pot, which can be purchased at most health food stores and resembles a teapot with a narrow spout. With the head tilted sideways, the salt-water solution is poured into one nostril and, in turn, goes down the other. Today nasal irrigation can be accomplished more conveniently while leaning over the bathroom sink and using one of the over-the-counter variations on a flexible plastic squeeze bottle.

Available at most pharmacies under such brand names as NeilMed Sinus Rinse™ and SinuCleanse,TM the products are sold with packets that combine sodium chloride (salt) and sodium bicarbonate (baking soda). The latter acts as a buffer against the stinging and burning sensation caused by salt water alone. These products make saline irrigation easy for children as well as adults.

Another product called Rhinotip™ is designed to fit over the jet tip end of most dental irrigators.

No independent head-to-head comparison study of these over-the-counter nasal wash products has been conducted to determine which is best in terms of ease of use and the reduction of symptoms and use of medications.

Whatever Works

“It’s up to the individual,” said Dr. Leopold when asked which product he recommends to his patients. “I will typically introduce all the different ideas [for nasal irrigation] and if a patient says, ‘I thought it was uncomfortable pressure,’ then I will switch them from a squeeze bottle to a neti pot, for instance. And some of my patients prefer a power wash with WaterPikR which is inserted a number of inches into the nose,” Dr. Leopold continued “Whatever product makes them comfortable and lets them do it on a regular basis is the one I would like to push. Most feel better after they’ve done it, especially if you have a cold, it’s the best way to make cold go away. A small minority feel irritated by [saline irrigation], but most want to do it all the time.”

The lead author of the Cochrane review about saline irrigation, otolaryngologist Richard Harvey, MD, Royal National Throat Nose and Ear Hospital in London, U.K., was asked by e-mail whether he advises his patients to do regular nasal saline irrigations and if so, which product is recommended. “While this is an area of ongoing research, my clinical judgement and experience from working with world leaders in nose and sinus care, suggests that squeeze bottles, such as NeilMed Sinus RinseTM, and pressurised sprays which can deliver high volumes, such as Physiomer (Goëmar Laboratories, France), under positive pressure are probably the most effective.”

In a telephone interview, K.C. Mehta, MD, the California-based lung specialist who developed NeilMed Sinus RinseTM, explained the importance of “positive pressure” and “high volume” in clearing out the nasal passages. “The key to symptom relief is to physically displace and wash away excess mucous and along with it allergens, such as grass and tree pollen, dust particles, pollutants and bacteria from the nasal passages. This in turn reduces inflammation of the mucosa membrane allowing you to breathe more normally.”

Dr. Mehta says that he suffered for years with sinus infection; had all types of treatments, including surgery; and finally decided that saline irrigation worked the best in terms of controlling symptoms. He went on to develop his own products that overcome the messiness of using the traditional neti pot and introduce the high-volume, positive pressure needed to wash out the excessive mucous and allergens. A step-by-step illustration of how to use the product can be found at http://www.neilmed.com. [Disclosure: The writer of this article has a friend who works for the company that makes NeilMed Sinus RinseTM.]

A Trend in the Works

Saline nasal irrigation appears to be catching on, and it is the ear/nose/throat specialists who are leading the way, rather than primary care physicians. The specialists first recommended the practice as aftercare for people who have had sinus surgery. Now, saline irrigation is becoming day-to-day standard care.

And according to Dr. Leopold, word of mouth from satisfied customers is also driving the trend. “People are becoming missionaries giving saline packets to their friends with sinus problems.” Consumer satisfaction is reflected in the sales of these saline irrigation products which have doubled annually for the last few years, according to the independent market data provided by A. C. Nielsen.

Role of Antibiotics

Given the fact that the University of Nebraska study found misuse of antibiotics to be common in the treatment of rhinosinusitis, Dr. Leopold was asked how people would know when antibiotics are appropriate. “If the person has a high fever, that could be an indication for an antibiotic,” he answered. “And if they have chronic respiratory problems like asthma, I typically tell them to take antibiotics early on. I’m aggressive up front with those folks.”

But the symptoms of a cold should be gone in two or three days in people without chronic respiratory problems who rinse their noses regularly, Dr. Leopold explained, and if they are still clogged up, then an antibiotic may be appropriate. He dismissed as “unreliable” the prevailing notion that greenish-yellow mucous always signals the need for an antibiotic.

The treatment of sinus infection seems to have come full circle where it concerns saline irrigation. “Medicine rolls in trends, just like fashion,” said Dr. Leopold. “Rinsing the nose had been a huge deal around the turn of the last century. There were a lot of articles back then about rinsing solutions and rinsing devices,” he explained, but interest died out once antibiotics, “the miracle drugs,” became available.

Now nasal saline irrigation is making a comeback.

Maryann Napoli, Center for Medical Consumers ©
September 2007

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Yogurt Drink Prevents Antibiotic-Induced Diarrhea

Posted by medconsumers on July 8, 2007

A yogurt drink sold in many supermarkets has been shown to reduce the risk of severe diarrhea that can occur after taking antibiotics. The study, published last month in the British Medical Journal Online First, was conducted at several hospitals, a setting where people are most likely to be exposed to drug-resistant strains of bacteria.

Of particular concern in most industrialized countries is the emergence of Clostridium difficile, an increasingly common, sometimes fatal, complication of antibiotic treatment, which occurs in about 5-25% of all hospitalized patients, usually two or three weeks after finishing antibiotic treatment.

Eating yogurt is now a standard way for people to protect themselves while on antibiotics. And to serve this expanding market, more and more yogurt products now feature the word probiotics on the label, claiming that they contain live cultures. Probiotics are defined as “live micro-organisms which when administered in adequate amounts confer a health benefit on the host.” Most probiotic products contain bacteria that help to balance the hundreds of different species of bacteria found in the human body.

Probiotics are gaining some research attention because of the overuse of antibiotics and the resulting increase in drug resistance. Probiotic-containing foods and capsules are consumed to overcome the tendency of antibiotics to kill the normal as well as the harmful bacteria. The problem with products claiming to contain probiotics or “live active cultures” is that they are unregulated, so it’s impossible to know whether they actually contain adequate amounts of live bacteria and the right strains of live bacteria.

British Hospital Study

The probiotic drink used in the newly published British hospital study was Actimel, sold as DanActive in the U.S. This study was partly funded by Danone, a French company that makes both products, which contain Lactobacillus casei, L bulgaricus and Streptococcus thermophilus. All three strains had already been evaluated for the prevention or treatment of diarrhea associated with antibiotic use and found to be safe, according to the British researchers led by Mary Hickson, Imperial College, London, England.

The researchers recruited patients from three London hospitals. All were asked to participate within 48 hours of taking their first dose of antibiotics prescribed for a variety of infections unrelated to any gastrointestinal ailments. The 113 patients (mean age, 74 years) who decided to participate were randomly assigned to drink either four ounces of Actimel or a placebo drink (milkshake).

All agreed beforehand to take the assigned drink twice a day during the course of antibiotics and for one week after completing the regimen. Neither the patients nor the hospital staff knew who was in the probiotics group and who was in the placebo (milkshake) group. When participants developed diarrhea, stool samples were analyzed for the potentially fatal Clostridium difficile toxin.

The hospital patients in the probiotics group fared much better than those in the placebo group. Hickson and colleagues concluded, “Consumption of a probiotic drink containing L casei, L bulgaricus and S thermophilus can reduce the incidence of antibiotic-associated diarrhea and C difficile-associated diarrhea. This has the potential to decrease morbidity, heath care costs, and mortality if used routinely in patients over age 50.”

Here are the results of the study: 12% of the hospital patients in the probiotic group developed diarrhea associated with antibiotic use, compared with 34% of the patients in the placebo group. No one in the probiotics group developed C difficile, but 9% of the patients in the placebo group developed this serious complication.

Cost Effective, Too

Hickson and colleagues provided this estimate of the cost savings in U.S. dollars. The average cost of the probiotics regimen in this study was $20 per patient. The cost of preventing one case of C difficile-associated diarrhea with probiotics was estimated to be $120, excluding dispensing and nursing costs. This is due to that fact that six patients were treated with probiotics for each case of C difficile prevented.

The $120 was then compared with the $3,669 it would cost in the U.S. to provide the standard medical treatment for one person with C difficile. The high cost is mainly due to the increased length of hospital stay required for people with C difficile and the use of a costly intravenous antibiotic called vancomycin, according to Hickson and colleagues.

Vaginal Infections

Something important to women was not addressed in the British study. Many eat yogurt while on antibiotics in order to avert another nasty side effect—vaginal infections. Will the yogurt drink used in this study have any preventive benefit for this infection? The answer is no, according to a leading probiotics expert not associated with the British study: Gregor Reid, PhD, Canadian Research and Development Centre for Probiotics in London, Ontario. “The product [Actimel/DanActive] is designed for intestinal benefits and not for the type of bacteria strains needed to promotevaginal health.”

There is, however, another product proven to reduce the risk of vaginal infections, called Fem-Dophilus (www.jarrowprobiotics.com), said Dr. Reid, who owns patents to the strains present in these capsules. As for the probiotic claims on numerous products sold in supermarkets and pharmacies: “It’s only a probiotic if the product formulation has been clinically tested. Many of them have not. At least, if they have the strains of probiotic in a suitable viable count as found in studies with other formulations, it is promising, but the real test is a human study with the formulation.”

Maryann Napoli, Center for Medical Consumers ©
July 2007

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Antibiotics Prior to Dental Procedures: Big Change in Recommendations

Posted by medconsumers on July 1, 2007

For over a half century, millions of Americans with common heart valve problems, such as mitral-value prolapse, were told to start taking preventive antibiotics prior to undergoing routine dental procedures. To ignore this standard recommendation is to risk a potentially life-threatening case of bacterial endocarditis triggered by the dental procedure. Or so went a widely held belief that has been revised recently by the American Heart Association.

The AHA now restricts its preventive antibiotics advice to a much smaller group of people—those with serious heart conditions. The new guidelines were published recently in the journal, Circulation, where the AHA acknowledged its longstanding policy was based on expert opinion rather than evidence.

The AHA appointed a writing group comprised of people selected for their expertise in the prevention and treatment of endocarditis. After reviewing all relevant studies, the AHA writing group concluded that the odds of suffering a serious adverse reaction to the antibiotics are higher for most people with heart conditions than their odds of getting endocarditis due to a dental procedure. In other words, endocarditis is a rare possibility. This is similar to the conclusion of a 2004 review of all relevant studies on this topic conducted by the Cochrane Collaboration.

Central to the now-outdated AHA recommendations was the concern that even the most routine of dental procedures, such as tooth scaling, could let loose bacteria into the bloodstream. Theoretically, the bacteria would lodge on abnormal heart valves or other damaged heart tissue and cause endocarditis, an infection of the heart’s inner lining (endocardium) Ironically, the AHA guideline writers said that the chances of developing endocarditis from the more mundane everyday activities, such as tooth brushing, flossing, and use of toothpicks, are higher than getting it during a dental procedure.

On another ironic note, the AHA writing group found that studies involving the antibiotics typically prescribed before dental procedures—penicillin or amoxicillin—failed to prove that either drug is effective in reducing the release of bacteria into the bloodstream. (The studies had compared drug-treated people with untreated people who underwent the same dental procedures.) Also, there is no evidence to show that amoxicillin, the antibiotic of choice since 1990, can reduce the risk of or prevent endocarditis.

The new AHA guidelines now confine preventive antibiotics to people at the very highest risk for endocarditis, including those who have had the disease, and those with a prosthetic heart valve, congenital heart disease, hypertrophic cardiomyopathy or cardiac valvulopathy (after heart transplant). A single antibiotic dose before the dental procedure is sufficient for people in these circumstances.

Mitral Valve Prolapse

People with mitral valve prolapse (MVP), estimated to be about 18% of the population, are now freed from the need to take preventive antibiotics. The AHA writing group noted that the incidence of endocarditis is extremely low in the entire population of people with MVP. Moreover, the disease does not have the same deadly consequences in people with MVP as it does for those with the above-mentioned highest risks.

Bottom Line: A 50-year-old health policy without much supporting evidence has been revised. For most people with heart valve problems, antibiotics before a dental procedure pose more of a threat to health than the rare possibility of developing endocarditis. Furthermore, there is no evidence to show that antibiotics can reduce the risk of endocarditis. The American Dental Association endorsed the new guidelines.

Maryann Napoli, Center for Medical Consumers ©
July 2007

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Probiotics: Research is Promising, But Few Products Can Be Trusted

Posted by medconsumers on January 1, 2006

Many people eat yogurt to protect themselves from antibiotics-induced diarrhea. Others swallow probiotic supplements for the same reason. Either way, the idea is to consume “good” bacteria in order to overcome the tendency of antibiotics to kill good, as well as harmful, bacteria in the gut, throat, and vagina. The public has caught on to the importance of eating microbe-containing foods, especially yogurt, as a way to prevent illness, such as traveler’s diarrhea, and as a way to maintain health. Now many yogurt containers proclaim the presence of “live active cultures,” and it is common to see probiotic capsules side by side with vitamins on the shelves of pharmacies and health food stores. Unfortunately, consumers may be wasting money because most of these products are untested and unproven to contain the necessary amounts of live microorganisms.

Consumer Reports

The problem was highlighted last year in the aftermath of a July 2005 Consumer Reports article featuring probiotics. It described several exciting areas of preliminary research that indicate probiotics could be beneficial to people with digestive disorders like irritable bowel syndrome and food allergies like atopic eczema. Other studies have suggested that probiotics may prevent respiratory infections, urinary tract infections, and precancerous changes that commonly occur in the large intestine. Such studies, however, prove only that one particular microorganism or a specific combination of microorganisms can provide this benefit. Unfortunately, some companies post these research findings on their Web sites implying that their untested products confer the same benefits.

As with all subjects taken on by Consumer Reports, the article ended with a list of products that passed the test-in this case, a list of yogurts, yogurt drinks, and supplements purportedly proven to contain the appropriate amounts of probiotics. But doubts were raised by Mary Ellen Sanders, PhD, president of the International Scientific Association for Probiotics and Prebiotics, in a letter to Consumer Reports (posted on www.isapp.net).

She objected to the article’s conclusion that 18 supplements and nine yogurt products actually contain one billion probiotic units, or colony forming units, the minimum needed for any meaningful health benefit, according to most researchers in this field. Furthermore, just having the right viable count doesn’t mean the product has been shown in a well-designed study to provide a health benefit.

While Consumer Reports was congratulated by Dr. Sanders for highlighting the potential value of consuming the right types of live bacteria and the importance of the dose delivered per serving, its testing methods were questioned. Dr. Sanders’s letter stated that many yogurts and probiotic supplements contain more than one type of bacterium and reporting the total may be misleading to consumers.

Consumer Reports had instructed readers “to pick a product with at least one billion probiotics units,” but that is actually the minimum for each strain of live bacterium in a product. Moreover, the magazine provided only sketchy information about the microbiological methods used to reach their conclusions about the recommended products. Unfortunately, this letter to the editor was not printed by Consumer Reports.

In a telephone interview, Dr. Sanders explained her frustrations with the products on the market that bill themselves as probiotics and/or carry the Live & Active Cultures seal of the National Yogurt Association (NYA). “The problem, in short, is this: with current labeling practices, consumers have no way of knowing if products contain the right number of efficacious probiotic strains. Even if the types are listed on the label, the names used may be inaccurate and the numbers may not sufficient or be what is claimed.”

In an effort to rectify the matter, Dr. Sanders met with officials at the U.S. Pharmacopeia (USP) in May, 2005 to see whether this public standards-setting authority would set the standards for probiotics. “As I understood it, the way the USP functions, it can only respond to a request from industry,” explained Dr. Sanders, “The USP needs a company to come to them and request verification.”

At this point, there is no incentive for a company to make such a request because they claim that consumers are not questioning what is written on the product label. “Things are not going to change until there is a demand from the marketplace,” she said. “What is needed is one or two companies to come forward and have their claims verified independently,” Dr. Sanders continued, suggesting that properly tested products might have a market advantage that would force all competitors to have their products tested.

Similar sentiments were expressed by researcher Gregor Reid, PhD, at the Canadian Research and Development Centre for Probiotics, University of Western Ontario . In a telephone interview he said, “The problem is the majority of the so-called probiotics products out there are unproven, though not harmful.” Even if companies meet the viable count standards that would allow them to be called yogurt, explained Dr. Reid, this would not be enough to call them probiotics. Rather, the specific live bacteria identified on the label must have been proven in a clinical trial to prevent or treat an illness or confer a defined health benefit, he explained. The live bacteria must also be at the same amounts used in the clinical trial.

Dr. Reid, a Professor of Microbiology and Immunology, and Surgery, is also concerned about the lack of incentive for companies to put out a high-quality product. Two companies in Canada pulled their products off the shelf, despite the fact that they had a proven benefit in clinical trials, Dr. Reid said, explaining that one company found it was cheaper to sell an inferior version of its own product. Can consumers trust any probiotic products that have been proven in studies to confer a health benefit? Dr. Reid answered in the affirmative, but the list* is short and none made it into the Consumer Reports article:

  • Culturelle with Lactobacillus GG , a supplement made by ConAgra, prevents and treats diarrhea;
  • VSL#3, made by VSL Pharmaceuticals, Inc. Fort Lauderdale , FL, keeps ulcerative colitis in remission;
  • Activia with Bifidus Regularis TM yogurt, made by Dannon, maintains regularity;
  • Florastor capsules and powder, made by Biocodex , France , maintains intestinal health and normal bowel function in infants, children, and adults;
  • Lactobacillus reuteri (capsules), made by Nature’s Way, treats diarrhea;
  • and Align containing Bifantis TM , made by Procter & Gamble, Cincinnati, Ohio, relieves abdominal pain/discomfort, bloating/distention, and bowel problems.

Dr. Reid has published numerous studies and commentaries about probiotics and owns patents on Lactobacillus strains GR-1 and RC-14. (Both strains are marketed in Europe to maintain the “balance of vaginal flora” under the brand name, Ombe, but this product is not yet available in the U.S. ) He has been working to improve quality and standards for products that claim to be probiotics. For example, the live bacteria in the products should be present for the length of shelf life. And the products should specify the exact strain of live bacteria, for example Lactobacillus acidophilus NCFM TM , as opposed to simply listing Lactobacillus acidophilus on the label.

It should be noted, however, that uncertainties about quality apply to all dietary supplements, including vitamins and herbal products, because this is an unregulated industry. One cannot be sure that any of these products contain what it says on the label because products classified as dietary supplements are not required by the FDA to undergo testing for safety or effectiveness.

When Dr. Sanders was asked what products currently on the market could be expected to be truly probiotics, she prefaced her answer by saying, “I’m not in any better position to answer that question than consumers because there is no third party verification.” Dr. Sanders did, however, single out three products-Culturelle supplements , DanActive TM yogurt drink, and Stonyfield Farm organic yogurt. (The last two products got the highest ratings by Consumer Reports.)

By way of disclosure, Dr. Sanders said that she serves on the scientific advisory board for Dannon, the company that makes DanActive TM , which claims to “naturally strengthen your body’s defense system.” Dr. Sanders points out that DanActive TM appropriately identifies the presence of 10 billion Lactobacillus casei cultures per serving on its label. [Editorial note: two other strains are listed on the label of DanActive TM without mention of the amount of cultures.] Dr. Sanders is not only a consultant for the probiotics industry but also an adjunct research professor at California Polytechnic State University .

While Stonyfield yogurt is one of Dr. Sanders’s three picks for products that appear to be probiotics, she expressed dissatisfaction about companies that do not inform consumers about the amount of live bacteria. “Stonyfield lists the six live active cultures on the label, but the company will not reveal the level of each strain or whether they are still active at the end of shelf life,” she said. “The company says it is proprietary information.”

Probiotics Research at a Turning Point

While there are plenty of reasons to be skeptical about the majority of probiotics on the market, there are also reasons to be optimistic. Dr. Reid spoke of a mindset in the mainstream research establishment that is dismissive of probiotics research and of his frustration about where the lion’s share of the research funding goes. “It’s drugs, drugs, drugs.” But he also reports a sea change in the last few years, much of it related to concerns about antibiotics. “Until a few years ago, we [probiotics researchers] were laughed at by our peers-both scientists and physicians. Now with the problem of resistant antibiotics, there is patient demand, and physicians are starting to pay attention.

” There are a number of reasons why probiotic research has become a hot topic. Despite over 50 years of antibiotics, infectious diseases remain a major cause of death, with gastroenteritis killing a child every 15 seconds. Antibiotics kill normal bacteria as well as good bacteria; hospital-borne infections are not declining; multiple-drug-resistant bacteria continue to emerge as the antibiotic pipeline dries up; pathogenic microbes are being linked with the induction or worsening of many chronic diseases.

“Add to this the pending threat of a deadly flu pandemic. All this has led to consideration of probiotics as one of the possible anti-disease countermeasures. Worried consumers, governments, scientists and industries are looking for new approaches to health restoration and retention. Probiotics have already been shown to alleviate some disease processes, so we need to explore their true potential, as well as understand their limitations.”

* All products can be purchased in the U.S. without a prescription. VSL #3 is available only at www.vslpharma.com or by calling 1(866-GET-VSL3).

Maryann Napoli, Center for Medical Consumers ©
January 2006

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Antibiotics Before Dental Procedures

Posted by medconsumers on April 1, 2005

Should People with Heart Valve Problems Take Antibiotics Before Invasive Dental Procedures?

People with heart valve problems are told to take antibiotics before certain dental procedures in order to prevent bacterial endocarditis. This disease can be triggered by bacteria disrupted by tooth scaling, dental implantation, and other invasive procedures. The bacteria goes into the bloodstream and become lodged in the innermost layers of the damaged heart valves. It is potentially fatal and can be well underway before symptoms ever appear. To treat after the fact might very well be too late. But antibiotic therapy in itself can cause harm. And some researchers have questioned the universal preventive antibiotics recommendation because bacterial endocarditis is an uncommon disease.

For a 2004 Cochrane* review entitled, “Penicillins for the prophylaxis of bacterial endocarditis in dentistry,” R. Oliver and colleagues searched the published medical literature to find studies that proved the benefits of preventive antibiotics outweigh the harm for high-risk people facing an invasive dental procedure. All that could be found was one case-control study conducted in The Netherlands, and its results are inconclusive.

The Cochrane reviewers also found a population study published in 2000 in the American cardiac journal, Circulation that quantified the risk of bacterial endocarditis and the risk of taking antibiotics. It estimated that people taking penicillin were five times more likely to die from an allergic reaction to this antibiotic than from endocarditis.

The Cochrane authors concluded: “There is no evidence about whether penicillin prophylaxis is effective against bacterial endocarditis in people at risk who are about to undergo an invasive dental procedure. There is a lack of evidence to support published guidelines in this area. It is not clear whether potential harms and costs of penicillin administration outweigh any beneficial effect. Ethically practitioners need to discuss the potential benefits and harms of antibiotic prophylaxis with their patients before a decision is made about administration.”

*The abstracts from all Cochrane reviews are available at http://www.thecochranelibrary.com . See “Penicillins for the prophylaxis of bacterial endocarditis in dentistry”.

Maryann Napoli, Center for Medical Consumers ©
April 2005

Posted in Drugs, Heart | Tagged: , , , | Leave a Comment »

 
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