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Good Health Requires a Healthy Mouth

A dog watching people go by at Echo Dale Park, Medicine Hat. (Dr. Noorali Bharwani)
A dog watching people go by at Echo Dale Park, Medicine Hat. (Dr. Noorali Bharwani)

An article in the Canadian Medical Association Journal (CMAJ September 2, 2014) titled, “Good health requires a healthy mouth: improving the oral health of Canada’s seniors” says one in six seniors decline recommended dental treatment because of cost.

The Canadian Health Measures Survey reported that one in six seniors aged 60 to 79 years in the community had untreated dental caries. More than half had periodontal disease, with 15 per cent having evidence of severe disease. About one in five had no remaining teeth.

Joan L Rush, Lawyer (retired) comments on the above article in the CMAJ. Rush’s letter is titled, “The dental profession fails those most in need.” She says more than 3.8 million Canadians are disabled, and 26 per cent of this group are defined to have very severe disabilities. These people face terrible barriers getting necessary dental treatment. This group is subject to inequality in oral health both in terms of prevalence of disease and unmet dental care.

As most of us know, dental and periodontal infection has serious health implications for all individuals but especially older people. Periodontal infection is associated with systemic diseases such as coronary artery disease, stroke and aspiration pneumonia. These are very serious conditions.

There is some evidence that dental disease has been linked with diabetes, rheumatoid arthritis and obesity, among other conditions, the strongest evidence for a relationship is found with cardiovascular disease, says the article.

Why do seniors have more dental problems?

Most seniors claim to brush and floss as regularly as younger people, says the article. But there are several factors contributing to an increased risk of poor oral health in this age group. For example, as the aging process proceeds, the salivary glands reduce the amount of saliva production and increase the bacterial load in the mouth.

Other oral issues, which may affect dental care in the seniors, are: attachment of gums to teeth loosens, mechanical difficulty with brushing and flossing, chronic diseases and poor nutrition contribute to reduced immunity against infection, leading to periodontal disease.

In Canada, only Alberta and Yukon Territories provide financial assistance for dental care to people over the age of 65 years who meet certain conditions. On retirement, most Canadians lose their dental benefits and many cannot afford private insurance. What is interesting is severe periodontal disease was most prevalent in those without health insurance. In fact, a lack of health insurance was the only factor that appeared to influence the prevalence of severe disease.

The authors of the article hope that the Canadian Dental Association will create a roadmap that will lead to tangible positive oral health outcomes for seniors. I wonder how long is that going to take. But there are measures that we can take to keep our teeth and gums healthy. Here is what the Mayo Clinic website recommends:
1. Brush your teeth at least twice a day.
2. Floss daily.
3. Eat a healthy diet and limit between-meal snacks.
4. Replace your toothbrush every three to four months or sooner if bristles are frayed.
5. Schedule regular dental checkups. Contact your dentist as soon as an oral health problem arises.

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Ebola Virus Disease has a High Fatality Rate

Robin building nest. (Dr. Noorali Bharwani)
Robin building nest. (Dr. Noorali Bharwani)

Ebola virus disease (EVD), as it is known now, was formerly known as Ebola haemorrhagic fever. It is a severe, often fatal illness in humans. It is a disease of the wild animals and then it is transmitted to people. It spreads in the human population through human-to-human transmission.

The Ebola virus causes an acute, serious illness, which is often fatal if untreated, says WHO website. Ebola virus disease first appeared in 1976 in two simultaneous outbreaks, one in Nzara, Sudan, and the other in Yambuku, Democratic Republic of Congo. The latter occurred in a village near the Ebola River, from which the disease takes its name.

Previously the disease was confined to small villages near tropical rainforests. The most recent outbreak in West Africa has involved major urban as well as rural areas. The case fatality rates have varied from 25 to 90 per cent in past outbreaks.

Controlling the disease has been difficult. According to the WHO website, community engagement is key to successfully controlling outbreaks. Good outbreak control relies on applying a package of interventions, namely case management, surveillance and contact tracing, a good laboratory service, safe burials and social mobilization.

Currently there is no licensed treatment for the disease. Treatment is base on providing rehydration with fluids and treat any other symptoms that the patient presents with. A range of blood, immunological and drug therapies are under development.

The current outbreak started in March 2014 in West Africa. WHO calls this the largest and most complex Ebola outbreak since the Ebola virus was first discovered in 1976. There have been more cases and deaths in this outbreak than all others combined. It has also spread between countries starting in Guinea then spreading across land borders to Sierra Leone and Liberia, by air (one traveller only) to Nigeria, and by land (one traveller) to Senegal. Latest report has confirmed a case in the US. By the time you read this the numbers may change.

How does a person get infected with Ebola virus?

It is thought that fruit bats of the Pteropodidae family are natural Ebola virus hosts. Ebola is introduced into the human population through close contact with the blood, secretions, organs or other bodily fluids of infected animals such as chimpanzees, gorillas, fruit bats, monkeys, forest antelope and porcupines found ill or dead or in the rainforest.

How does it spread among humans?

Ebola then spreads through human-to-human transmission via direct contact (through broken skin or mucous membranes) with the blood, secretions, organs or other bodily fluids of infected people, and with surfaces and materials (e.g. bedding, clothing) contaminated with these fluids.

WHO says people remain infectious as long as their blood and body fluids, including semen and breast milk, contain the virus. Men who have recovered from the disease can still transmit the virus through their semen for up to seven weeks after recovery from illness.

First symptoms are the sudden onset of fever fatigue, muscle pain, headache and sore throat. This is followed by vomiting, diarrhea, rash, symptoms of impaired kidney and liver function, and in some cases, both internal and external bleeding (e.g. oozing from the gums, blood in the stools). Laboratory findings include low white blood cell and platelet counts and elevated liver enzymes.

Confirming the diagnosis and providing treatment continues to be a challenge. There is lot more information available on the WHO website.

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Medications That Put Our Seniors in the Hospital

Summer Flowers (Dr. Noorali Bharwani)
Summer Flowers (Dr. Noorali Bharwani)

I covered this topic about three years ago. It is never too early or too late to review the subject again.

A study published in the New England Journal of Medicine says 40 percent of people over 65 take five to nine medications every day. What this means is that hospitalizations for accidental overdoses and adverse side effects are likely to increase among this group.

The study found that every year, about 100,000 people in the United States over age 65 are taken to hospitals for adverse reactions to medications. Most of the patients are there because of accidental overdoses. Sometimes the amount of medication prescribed for them had a more powerful effect than intended.

The four most common groups of medications putting seniors in hospitals are: warfarin (a blood thinner), insulin injections for diabetes, antiplatelet drugs to thin the blood and oral diabetes drugs.

Warfarin accounts for the most visits due to adverse drug reaction. It accounted for 33 percent of emergency hospital visits. Warfarin (Coumadin) is an anticoagulant – popularly referred to as a “blood thinner.” In reality, it does not make the viscosity of the blood thin. What it does is that it acts on the liver to decrease the quantity of a few key proteins in blood that allow blood to clot.

It was initially marketed as a pesticide against rats and mice. Later it was found to be effective and relatively safe for preventing blood clots in humans. It was approved for use as a medication in the early 1950s and now it is the most widely prescribed oral “blood thinner” drug in North America.

Insulin injections were next on the list, accounting for 14 percent of emergency visits. Insulin is a hormone central to regulating carbohydrate and fat metabolism in the body.

Insulin causes cells in the liver, muscle, and fat tissue to take up glucose from the blood, storing it as glycogen in the liver and muscle. When control of insulin levels fails, diabetes mellitus will result. Patients with type 1 diabetes depend on insulin injections.

Antiplatelet drugs like aspirin, clopidogrel (Plavix) and others that help prevent blood clotting were involved in 13 percent of emergency visits. An antiplatelet drug is a member of a class of pharmaceuticals that decrease platelet aggregations and inhibit clot formation. They are effective in the arterial circulation, where “blood thinners” have little effect.

Lastly, diabetes drugs taken by mouth, called oral hypoglycemic agents, which were implicated in 11 percent of hospitalizations. Anti-diabetic medications treat diabetes mellitus by lowering glucose levels in the blood. There are different classes of anti-diabetic drugs, and their selection depends on the nature of the diabetes, age and situation of the person, as well as other factors.

The authors of the article say that in order to reduce the number of emergency hospitalizations in older adults we should focus on improving the safety of this small group of blood thinners and diabetes medications, rather than by trying to stop the use of drugs typically thought of as risky for this group. And patients should work with their physicians and pharmacies to make sure they get appropriate testing and are taking the appropriate doses.

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Unused Prescription Drugs Should be Disposed of Carefully

A lonely tree. (Dr. Noorali Bharwani)
A lonely tree. (Dr. Noorali Bharwani)

It is a common dilemma in every household – what to do with expired and unused medications.

An article in the Canadian Medical Association Journal (CMAJ August 5, 2014) says unused prescription drugs should not be treated like leftovers and kept sitting in a closet for years to come.

On May 11, 2013, Public Safety Canada and the Canadian Association of Chiefs of Police coordinated the first National Prescription Drug Drop-Off Day, which resulted in the return of more than two tones of unused medications, says the CMAJ article. This initiative was repeated on May 10, 2014.

The whole idea of this exercise was to reduce the amount of unused prescription drugs in Canadian households and, ultimately, drug-related harm. Unused prescription drugs are common in most households.

Some individuals are reluctant to throwaway unused medications because they may be useful in the future. A good example is painkillers. A second example is antibiotics.

A review found that more than a third of patients did not complete their antibiotic course as prescribed, and unused antibiotics were taken by more than a quarter of the patients for new infections.

If you keep unused prescription drugs in the house then another member of the family may think that the same pills may be useful for his or her ailment.

Unused opioids, benzodiazepines and stimulants are major sources of misuse and diversion, says the article. Fifteen per cent of students in grades seven to 12 in Ontario reported using prescription medications (most often opioids and stimulants) for recreation in the preceding year. Most of these pills were prescribed to one of the parents or sibling.

Unused prescription drugs are sometimes brought to “pill parties” (also called “pharm” or “Skittles” parties), where adolescents experiment with pills they select from the pool of medications brought by partygoers, says the article. Some of the drugs can kill if mixed with other drugs or alcohol.

Self-medication with antibiotics, without proper professional diagnosis, is a common practice, most often for a sore throat and common cold.

What about our toddlers?

Between 2001 and 2008, more than 450 000 cases of poisoning in children less than six years of age were reported to US poison control centers. Of these, 95 per cent involved the ingestion of a prescription medication, which resulted in substantial morbidity and resource use (i.e., non-fatal injury, visit to the emergency department and admission to hospital), as well as 66 deaths, says the article.

To minimize these kinds of harm, there should be responsible disposal of unneeded or expired medications.

Health Canada recommends that unused medications be returned to local pharmacies or municipal waste disposal centers and should not be disposed off in the garbage or by flushing them down the toilet.

Flushing the pills down the toilet is not a bad idea although Health Canada does not like it. The US Food and Drug Administration recommends disposal in the garbage after the unused medications have been mixed with coffee grinds or cat litter to mask the drug or render it unpalatable. Not an easy disposable system.

The most important thing to remember is all medications should be stored in a secure place.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!