To Floss or Not To Floss? Making Recommendations Without Data

The U.S. Department of Health has announced that there is no data that flossing your gums has any benefit.  This has led to an Associated Press review of the paucity of randomly controlled trials with evidence that flossing is beneficial. The result is a new recommendation that flossing daily is not necessary. We are living in an era where the only justification for research and observational studies seems to be to justify saving money by not teaching patients something or encouraging them not to do something. Cost containment is the key as the US Government tries to lower the percentage of dollars spent on health care as a percentage of the Gross National Product.

Experts at the Cleveland Clinic spurred on by the “Bale and Doneen” philosophy that inflammation in arterial vessels leads to acute heart attacks and strokes have pushed for greater periodontal care and health. Flossing is part of that philosophy. Cleaning in-between your teeth with hand held pics or water pics provides cleaning of the gums and spaces between teeth as well.  There are few or any studies on this subject because the benefit is so obvious that there has been no need to perform them.  Dentists assure me that proper tooth and gum care is essential to your general health and wellbeing.  This is common sense like not crossing a busy street against the light, not drinking alcohol and driving a car or truck or not jumping out of an airplane without a parachute. It’s time for our dental schools to organize and perform these studies but I suggest you keep caring for your gums and teeth while the data is being accumulated.

Men’s Sexual Function Tied to Statin Use

Statins v2Statin medication has been used for years to lower cholesterol and reduce an individual’s risk and chances of having a heart attack, a stroke or symptoms of peripheral arterial vascular disease. The “off label” uses of statins have been noted by many practitioners and researchers as well. The Bale and Doneen research team have for years believed that statins stabilize soft lipid plaque in the wall of blood vessels and reduce sudden heart attacks and strokes by reducing inflammation. At the American College of Cardiology meetings recently a paper was presented and appeared in the online version of the Journal of Sexual Medicine hinting that statins improved erectile dysfunction. John Kostis, MD, of Rutgers Robert Wood Johnson Medical School in New Jersey said that statins improvement of erectile dysfunction was about 1/3 of what pills like Viagra, Levitra or Cialis can achieve but significantly better than placebo or life style improvements. He felt the improvement in erectile dysfunction was due to the medications lowering of lipid levels and to their improvement of the endothelial cells that line the inner walls of our blood vessels.

For many years erectile dysfunction was felt to be a marker for cardiovascular disease because it was felt that the ED reflected an inability to achieve adequate blood flow in the vascular tree of the genital organs. Testosterone, the male hormone, is a byproduct of cholesterol metabolism. It was originally felt that by lowering cholesterol you were indirectly lowering testosterone levels and this might affect your sexual performance. This study in 647 patients enrolled in 11 randomized studies with different statins would tend to reach a different conclusion that by lowering the lipids and maintaining the blood flow you can actually improve erectile function despite lowering the testosterone indirectly.

Dr. Kostis was quick to point out that statins should not be used as a sexual enhancing drug in men with normal or low cholesterol levels. He called for a larger study looking at multiple statins versus placebos and the current ED meds on the market.

Gum Health Associated With Carotids

GumsOver the years I have attended lectures led by Bradley Bale, MD and Amy Doneen, RN who promote the theory that inflammation is one of the major causes of acute heart attack and stroke.  They measure inflammation in men and women with normal lipid levels, normal blood pressure who are non-smokers and exercise but still have cardiovascular events such as heart attacks and strokes.  They talk about the formation of soft lipid plaque or foam cells forming in the walls of the blood vessels and then erupting into the lumen of the blood vessel under the influence of inflammation setting off a clotting cascade that leads to heart attacks and strokes acutely. They measure the degree of inflammation using a series of blood tests patented by the Cleveland Clinic and look for atherosclerosis by doing carotid ultrasounds in a special way to measure carotid artery intimae thickness which they believe correlates with the presence of atherosclerosis, soft plaque and the risk of an acute event.  When all traditional major  risk factors such as smoking, blood pressure, blood glucose level, high blood pressure , activity level and family history have been taken into account and treated there are individuals who still have inflammation and acute events.  They believe oral periodontal disease is the culprit and suggest treating it.

They receive confirmation of their theory in an online article in the Journal of the American Heart Association written by Moise Desvarieux, MD, PhD of Columbia University’s Mailman School of Public Health in NYC with his colleagues.  They demonstrated that by reducing periodontal disease over a three year period there was less progression of carotid artery intima media thickening.  As the gums improved and the oral microbes that are associated with periodontal disease decreased the progression of intimal thickness slowed.

It is clear that more research is needed but while it is ongoing simply seeing your dentist regularly and caring for your teeth and gums can go a long way to reducing your risk of a heart attack or stroke. The long hypothesized relationship between mouth disease and vascular disease has much stronger evidence after this study and it makes it necessary for those of us discussing prevention and risk factor reduction to ask you at your visits “are you up to date on your dental visits and dental hygiene?” It additionally adds clout to the argument that health insurance includes dental coverage as well!

Inflammation and Vascular Disease

Heart, stethescopeI was privileged to hear Bradley Bale, MD and Amy Doneen, MSN, ARNP talk about the development of coronary artery disease and cerebrovascular disease in patients with low or few cardiac risk factors.  They cited American Heart Association studies looking at groups of men and women between ages 45 and 65 who have their first heart attack or stroke despite being in compliance with suggested lipid and blood pressure guidelines. They pointed out that the first Myocardial Infarct or Stroke occurred in 88% of women who met lipid guidelines and 66 % of men.  These are people who do not smoke, do not have untreated or uncontrolled lipid levels, are not diabetics and who lead an active life style.  They asked “why”?

Dr. Bale and Ms. Doneen work with the well respected cardiovascular Center of Excellence at the Cleveland Clinic program in Ohio, and believe that inflammation is the root of the problem.  They believe that soft plaque composed of lipids and other cells lurks beneath the endothelial cells lining blood vessels. In the presence of inflammatory stimulants, this soft plaque ruptures suddenly through the endothelial level into the blood stream. When it comes in contact with the blood flowing through the vessels the body believes we are bleeding and cut and chemical mediators are released that initiate the formation of a clot. When this clot occurs in a small coronary artery we have a heart attack or myocardial infarction or precipitate a lethal irregular heartbeat. When this clot occurs in the blood vessels of the brain, we have an acute stroke or cerebrovascular accident.

The key to prevention in the so called low risk patient is to detect the inflammation in advance, and treat it. They are firm believers in performing B Mode Duplex ultrasounds of the carotid arteries in the neck to look for the presence of soft plaque beneath the endothelial cell lining. This soft plaque is distinctly different from the safe but calcified plaque we can see on CT scans used for cardiac scoring studies.  They couple this imaging study with a series of complex blood tests which identify inflammation. These include a myeloperoxidase level, the Lp-PLA2 level, the urine microalbumen to creatinine ratio, a F2-IsoPs level and the cardiac specific CRP level.

These tests and studies in combination with a traditional history and exam, sugar and lipid levels and EKG can help us identify those “low risk” patients who actually are high risk for a heart attack or stroke. The cause of the inflammation is often difficult to spot and may be in your mouth with dental or periodontal disease or in your joints with inflammatory arthritis.  Patients with excellent dental hygiene and normal appearing gums may harbor specific inflammatory bacteria that put them at risk. While this seems a bit forward thinking, remember we once questioned the research that showed that bacteria (H Pylori) caused gastric ulcers and intestinal bleeding.

I have begun instituting the inflammatory blood marker panels in my practice. Labs are sent to the Cleveland HeartLab for this purpose. I will be initiating periodic carotid ultrasound studies for the appropriate patients in the coming year.

It is often difficult for clinicians to distinguish snake oil sold for profit from cutting edge science. I have tried to spare my patients from worthless but profit driven products. I am convinced the Cleveland Clinic is just ahead of the rest of us in offering these services and I will make them available to the appropriate patients and will do it in a financially structured manner that does not add out of pocket cost to the patient. It’s not about adding another profitable income stream to the practice. It’s about identifying individuals who shouldn’t have a heart attack or stroke before they do.