Judy Foreman

Nationally Sindicated Fitness, Health, and Medicine Columnist

Advice for all ages: Don’t skip the dentist

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Earlier this month, a team of researchers from the University of Connecticut and London announced that aggressive treatment of gum disease can improve the function of blood vessel walls in the body, potentially reducing the risk of heart attacks.

A few weeks before that, researchers from the Harvard School of Public Health reported a study of more than 51,000 male health professionals, which showed that men who had gum disease, or periodontitis, were far more likely than those without it to get pancreatic cancer.

Other studies have shown links between gum disease and diabetes, heart disease, stroke and even — though this is more controversial — pregnancy problems such as low-birth-weight infants. The evidence is accumulating faster than you can say “don’t forget to floss” that taking good care of your teeth — and treating gum disease aggressively — may be one of the best things you can do not just for your mouth, but for your overall health. With pancreatic cancer, for instance, previous studies had suggested such a link, but those studies were muddied because many participants smoked, and smoking is a risk factor for both diseases. This time, even among never-smokers, gum disease was linked to a doubling of the cancer risk, said epidemiologist Dominique Michaud, the first author, of the Harvard School of Public Health. It’s still not clear, cautioned Michaud, whether that means the gum disease led to the cancer.

Chronic inflammation anywhere, including swollen gums, makes the body release nasty chemicals called cytokines that have been linked to many problems, including diabetes and heart disease. The crucial point, in other words, is that “oral infections have systemic effects,” said Dr. Thomas Van Dyke , a professor of periodontology and oral biology at the Boston University School of Dental Medicine.

In some cases, these systemic effects are probably linked to the direct spread of oral bacteria through the bloodstream to other parts of the body, but most

In other cases, oral bacteria have been found in plaques in artery walls, though it is not clear whether these bacteria are a cause of heart disease or merely incidental, said Dr. Bruce Pihlstrom , acting director of the center for clinical research at the National Institute of Dental and Craniofacial Research, part of the National Institutes of Health.

But most of the systemic problems linked to periodontitis, which affects millions Americans to varying degrees, are believed to be problems of chronic inflammation.

The clearest example of that is the association between periodontitis and diabetes, said Dr. Robert J. Genco , a periodontologist at the University of Buffalo. He and others have shown that people with diabetes have more severe periodontal disease and have it at an earlier age than non-diabetics. And it’s a two-way street: People with diabetes who also have periodontitis have more trouble controlling blood sugar than diabetics without periodontitis.

It makes sense. Cytokines, such as those generated in chronic gum inflammation, can disrupt the system by which insulin, the hormone that escorts sugar into cells, sends chemical signals inside cells. This can trigger insulin resistance, which often leads to diabetes.

And obesity — long known as a major cause of diabetes, in part because fat cells in the abdomen pump out so many cytokines — is also now seen as a direct risk factor for periodontitis, said Genco. (Like Van Dyke, Genco is a co-author of a special Scientific American publication on oral health paid for by Proctor & Gamble, makers of Crest toothpaste and Oral-B electric toothbrushes. It is available online at www.dentalcare.com/soap/products/index_promotion_sa.htm.)

Cytokines can also trigger inflammation in artery walls, raise blood pressure, worsen cholesterol profiles and increase the tendency for blood to clot, which can lead to potentially fatal heart attacks.

Animal studies have also shown that deliberately inducing periodontitis triggers plaque buildup in the coronary arteries, said epidemiologist Kaumudi J. Joshipura , director of the division of dental public health at the University of Puerto Rico in San Juan.

A large study published in 2003 in the on-line journal Stroke showed that people who had lost a lot of teeth were more likely to have both severe periodontal disease and clogged coronary arteries. Another study that year showed a direct link between periodontal disease and stroke in people who had never smoked. And a study published in 2005 in the journal Circulation showed that older adults with higher levels of periodontitis-causing bacteria in their mouths also had thicker arteries in the neck that supply the brain, a predictor of heart attack and stroke.

Pregnancy complications, too, have been linked to gum disease, perhaps because chronic inflammation leads to high levels of a hormone-like substance, called prostaglandin E-2, which can induce labor. But last year, a study in the New England Journal of Medicine of 823 women with periodontal disease showed that treatment did not lower the risk of premature or low birth-weight babies. A second government study of 1,800 more women is now underway.

Bottom line? “The associations between periodontitis and systemic disease are provocative and important,” said Pihlstrom of the national dental institute.

But even if there were no links to systemic health, “taking care of your mouth is important for its own sake,” Pihlstrom said. Regular brushing, flossing and visits to a dentist can help reduce the risk of periodontitis — and can help you keep your teeth as you get older.

Saliva May Replace Blood as Test for Disease

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Within two years, you may be able to go for a regular dental visit, spit into a cup and, before your appointment is over, find out from an analysis of your saliva whether you’re at risk for oral cancer. Currently, dentists have to do a thorough mouth exam to probe for oral cancer, which will strike more than 28,000 Americans and kill more than 7,000.Within a few more years, you may be able, with a fancier spit test, to find out if you’re at risk for a number of other diseases as well, including breast cancer, Type 2 diabetes, ovarian cancer, Alzheimer’s disease and rheumatoid arthritis.

If you’re among the avante garde, you might even have a tiny chip implanted in your cheek to monitor proteins in saliva such as CRP, a protein that is often linked to an increased risk of heart disease. With constant monitoring, the chip could sound an alarm – maybe a beep, maybe an electronic message to your doctor – whenever levels of a particular protein drift too high or too low.

Until a few years ago, the technology to analyze minute quantities of genetic material and proteins in saliva was simply not good enough for many of the tests doctors want to do or tests consumers could do in the privacy of their own homes, said Dr. David Wong,, associate dean of research at the UCLA School of Dentistry and co-director of head and neck cancer research program at the Jonsson  Cancer Center at UCLA.

In the brave new world of genomics and proteomics – the study of genes and the proteins they make – the best body fluid to analyze disease risk may soon be saliva, not blood. Saliva, the slippery fluid that helps moisten and digest food, is a medical goldmine because it is almost identical to the clear part of blood, but with everything, including infectious organisms, present in weaker concentrations.

Saliva testing is less invasive, less painful, less likely to cause infection and potentially cheaper than blood testing because there’s no need for a phlebotomist to draw blood. And because it’s so easy to test saliva repeatedly during the day, doctors believe they will be able to use saliva-based tests to keep track of real-time physiological changes such as how an infection is responding to antibiotics.

The idea of using saliva for detection is not new. Among ancient peoples, legend has it that saliva was used as a primitive lie detector test. A person accused of wrongdoing would be given a handful of rice and told to swallow it; if he couldn’t, it meant he was dry-mouth, nervous and guilty.

Medically, researchers have long been fascinated by what can be studied in saliva, and there are already saliva-based tests on the market to detect the presence of the AIDS virus, alcohol, illicit drugs, the influenza virus, hormones that signal premature labor or

Oral Cancer Poses Growing Threat

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Patrice Di Carlo’s ordeal with oral cancer just might be enough to scare anyone who still chews tobacco or smokes and drinks heavily out of denial forever.Di Carlo, 49, a former smoker who lives in Malden and works as a legal secretary at the Boston lawfirm, Ropes and Gray, discovered what she thought was a harmless canker sore on her tongue eight years ago. Her dentist thought it was nothing, too, which is not terribly surprising: Every year, thousands of people get funny little spots in their mouths that appear benign to the naked eye – even the naked eye of a trained dentist, though two new detection tests are beginning to make things easier.

But as month after month ticked by and Di Carlo’s spot did not go away, she decided to see another dentist. He immediately sent her to an oral surgeon who removed a sizable chunk of her tongue – a squamous cell cancer –  five days later.

Five and a half years later, Di Carlo developed a new primary tumor, as happens to one of every five people with oral cancer. 

So doctors removed more of her tongue, plus her salivary glands and, through an incision from her earlobe to her Adam’s apple, dozens of lymph nodes. Then came radiation therapy, which left her with mouth sores that felt like “being burnt with blisters,” she says. The sores made eating so painful that Di Carlo lost 75 pounds. Last summer: Yet another tumor, more surgery. This summer, same story.

Cancer of the oral cavity – the tongue, mouth, insides of the cheeks and pharynx (back of the throat) – kills more people every year than melanoma, cancer of the cervix, cancer of the uterus or certain subtypes of leukemia, including chronic lymphocytic leukemia, acute myeloid leukemia, chronic myeloid leukemia and others.

It’s a “very serious cancer because the oral cavity is where we eat, breathe and speak,” says Dr. Robert Haddad, an oral cancer specialist at Boston’s Dana-Farber Cancer Institute. Aggressive tumors “can grow within weeks – they can become symptomatic, meaning speech and swallowing are affected. I have patients who can’t swallow at all.”

Yet so few people even know about oral cancer – much less know when to worry about mouth lesions – that the American Dental Association and coalitions of dental schools in a handful of cities, including Boston, San Francisco, Kansas City and others, have all launched campaigns in the last year or so to raise public awareness.

Their message, and mine, is simple: Roughly 29,000 Americans, including 19,000 men, are diagnosed with oral cancer every year, according to American Cancer Society figures. About 7,400 die. The 5-year survival rate is only 54 percent, though it’s improving at major cancer centers.

The implications are clear: Don’t become one of these statistics. Which means ,don’t smoke, don’t chew tobacco and don’t drink heavily. Do see your dentist regularly.  If he or she doesn’t routinely feel the lymph nodes in your neck, move your tongue from side to side to look for lesions in your mouth and look at the back of your throat carefully, get a new dentist.

You can also monitor yourself, but early cancers can be hard to see. More advances lesions may appear as sores that bleed easily or do not heal; changes in the color of oral tissue; lumps or rough spots, or areas that are painful or numb anywhere in the mouth or lips. Suspicious lesions can be either red or white.

But, unfortunately, there’s more to it than that. As many as 25 percent of oral cancers seem to be caused by something other than smoking and drinking, and researchers aren’t sure what it is. The chief suspect is HPV-16, the same strain of human papilloma virus that causes cervical cancer.

So far, there is no proof that oral sex with an HPV-infected person causes oral cancer. But that is an obvious theoretical possibility and it might explain another worrisome observation: The growing numbers of young people with oral cancer. 

Some published data suggest there is “an increased incidence in young adults, patients between 20 and 39,” says Haddad of Dana-Farber. “Many of these people have never drunk except socially and they are not smokers.”

Indeed, even if people this young “smoked like fiends, they wouldn’t have enough time to make a cancer of the tongue,” agrees Dr. Barbara Conley, a head and neck cancer specialist and chief of the diagnostics research branch in the cancer diagnosis program at the National Cancer Institute.

Whatever the cause, the death rate from oral cancer has budged little in 40 years because many people “are being detected too late,” says Dr. Thomas Kilgore, professor of oral and maxillofacial surgery at the Boston University School of Dental Medicine.

When oral cancer is detected early, “it has an 80 percent cure rate,” Dr. Michael C. Alfano, dean of the New York University College of Dentistry, explains in an email interview. “Late diagnosis has a survival rate of only 20 percent.” 

“When a lesion is small,” Alfano adds, “it often looks like any benign minor irritation of the soft tissues of the mouth. Dentists are reluctant to biopsy these lesions since a conventional biopsy is invasive and requires both anesthesia and sutures, and because the lesions are usually benign.”

Recently, two new tests (and a third on the way) are beginning to help dentists sort out which patients need to have a surgical biopsy and which do not.

One test, a “brush biopsy” kit called OralCDx, appears to have helped identify more than 2,500 precancerous or cancerous lesions since it went on the market in January, 2000.  

In the brush biopsy, a dentist twirls a little stick with small brushes on top of the lesion to get a sample of cells. The cells are then sent to a lab where a computer scans them, picks out atypical cells and projects them onto a TV screen for a pathologist to read. If the pathologist confirms that the cells are abnormal, he or she tells the dentist, who orders a surgical biopsy. (A surgical biopsy is also needed if the cells are judged normal but the lesion persists for several weeks anyway.)

In a study published in October, 1999 in the Journal of the American Dental Association, the brush biopsy test was tried on 945 patients. It detected all the lesions that were subsequently identified as cancerous or precancerous by surgical biopsy; it also had few false positives – lesions incorrectly deemed to be dangerous. 

“This test is not a substitute for traditional surgical biopsy. It allows dentists to test harmless looking lesions that might not have been tested otherwise, and if the test comes back abnormal, to send that patient traditional biopsy,” says Dr. Drore Eisen, medical director of the company that analyzes the brush biopsy specimens, CDx Laboratories in Suffern, N.Y.

In another study of the brush biopsy kit published in March, 2002 in the same journal, nearly 1,000 dentists and dental hygienists were screened by the naked eye; nearly 10 percent, 93 people,  had lesions, which were then tested with brush biopsy. Three precancers were found. Without the brush biopsy test, all 93 might have been referred for traditional biopsy.

Another test called Vizilite, also approved by the US Food and Drug Administration, is a  chemiluminscent light that is shined in the mouth. A dentist can spot potentially dangerous lesions because, under this light, abnormal tissue glows differently from normal tissue, says Dr. Sol Silverman, professor of oral medicine at the University of California, San Francisco. The light makes lesions more visible, though can’t necessarily tell if they are potentially cancerous. The company that makes Vizilite, Zila, Inc. in Phoenix, AZ. is also working on a noninvasive dye (toluidine blue) that stains abnormal tissues.

Like diagnostics, treatments are getting better, too. Historically, side effects from surgery to remove all or parts of the tongue have proved so difficult for patients to live with that some “say they might have made other decisions, like not being treated,” if they had known, says Silverman.

Without a whole tongue, some patients can’t swallow, which means they must eat through a feeding tube. If the base of the tongue, which extends down to the voice box, must be removed, patients can’t speak either, except through an artificial larynx, nor can they breathe, except through a permanent tracheotomy.

But at major centers like Dana-Farber, which now claims a 5-year survival rate of 65 percent, the focus is not just on survival but on “organ preservation,” specifically, postponing tongue surgery until after chemotherapy and radiation to minimize the amount of tongue tissue to be removed. The emerging protocol is first chemotherapy, then chemotherapy plus radiation, then surgery of the tongue and, if necessary, the lymph nodes. Organ preservation is also improving because of better radiation techniques, including IMRT (intensity modulated radiation therapy), in which external beam therapy is precisely targeted only to the areas needed to spare surrounding tissues.

For Patrice Di Carlo, all this is promising, but sobering as well. Her latest surgery, in August, removed much of the base of her tongue and part of the back of her throat. The cancer now appears to be spreading. She can still swallow and speak. “Where I go from now ,I don’t know. How much can one person take. I am a fighter. But this time, I am having a very difficult time.” But it may be in her blood vessels. Her advice? If you have any spots in your mother that lasts longer than several weeks, she says, “get it checked out.”

Unnecessary Dentistry?

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He’s 81 now, this former Boston businessman, and when he retired to a southern state some years back, one of the most treasured things he left behind was his friend and dentist of 50 years, Dr. Wallace J. Gardner of  Cambridge.

In the south, the executive found a new dentist, who proposed a $5000 treatment plan involving multiple visits (including one 3-hour session) to replace some of his gold crowns and change his bite. The executive, who asked that his name not be used, was outraged. ” I had never had any trouble. I still had all my teeth.” “This really upset me very much,” says Gardner, waving the letter from his friend as he stood amid dozens of plaster casts of teeth in his workroom not long ago. Not only would the treatment the new dentist proposed be expensive, he says, “you should never put a dental patient in the chair and work on them for three hours at that age…. it’s too dangerous because of blood clots.”

Most dentists are honest, Gardner and many other dentists insist. But there are also cases like this one, Gardner says, in which proposed treatments are unnecessary – and possibly dangerous to boot.

Unnecessary dentistry is a touchy subject among the nation’s 155,000 dentists, who’ve already had more than enough bad press lately.

In August, Medicaid fraud investigators in Florida charged that criminals were snatching poor kids off street corners and delivering them to dentists for unneeded cleanings, X-rays and even extractions. The same week, the American Dental Association, huffy that the nation’s third largest dental insurer, Aetna, Inc. had claimed that certain dentists were overcharging patients, retaliated with a class action suit against the insurer.

In terms of outright fraud, the frequency is probably low. But more subtle things, like crowns that a person doesn’t really need? Routine removal of wisdom teeth in teenagers? Very frequent cleanings? In truth, there’s little hard data on these softer sins.

But the temptation for dentists to blur the lines between necessary procedures and those that are optional or cosmetic clearly exists.

A century ago, most Americans lost their teeth by middle age, according to last year’s Surgeon General’s report on oral health. Now, thanks to widespread fluoridation of the nation’s water supplies, most middle-aged Americans can expect to keep their teeth throughout their lives, and many kids have few or no cavities.

Indeed, this dramatic improvement in oral health is one of the 10 greatest public health advances of the last century, notes Dr. Raul Garcia, chairman of health policy and health services research at the Boston University School of Dental Medicine.

But with fewer cavities to fill,  dentists have had turn to other procedures to boost their incomes, says Dr. Marv Zatz, a New Jersey dentist who now works as a dental insurance consultant for Towers Perrin, a health, welfare and retirement consulting firm.

“Dentists have changed their whole paradigm,” he says. Today, “much of what they do is elective,” including tooth whitening, braces for adults and replacing dark fillings with white ones. 

Some dentists go so far as to urge patients to have their old, amalgam fillings (which contain tiny amounts of potentially toxic mercury) replaced, a practice that the National Institute of Dental and Craniofacial Research does not recommend.

One of the toughest critics of post-fluoride dentistry is Dr. Gordon Christensen, a Provo, Utah dentist who is on the editorial board of the Journal of the American Dental Association. In a recent issue of that journal, he blasted fellow dentists for “having a commercial, self-promotional orientation” and “planning and carrying out excessive treatment.”

Many dentists and plastic surgeons “may make something sound as though it’s absolutely necessary when in fact it’s elective,”  he added in a telephone interview. Since 50 percent of the average dentist’s income is now from cosmetic work,  he stressed, “people should be told what’s necessary…and what’s not.”

Making matters worse, other critics say, is that, compared to doctors, dentists have fewer national guidelines on specific practices and are more likely to work alone – with less professional scrutiny.

Take wisdom teeth, for example.

Many dentists believe that wisdom tooth extraction, for which Americans spend $2 billion a year, should be done in teenagers to avoid cysts or infections that might develop around the teeth in the future. Moreover, they say, young people heal so much more quickly than older ones that it makes sense to extract the teeth in late adolescence.

But no one really knows how much long term benefit, if any, there is to routine extraction of wisdom teeth that have not yet caused problems. The most recent government recommendations on the subject are 22 years old, which means they don’t include more recent data from studies that question routine extraction.

One relatively recent study, for instance, published in 1990 in the International Journal of Technology Assessment in Health Care suggested that instead of routinely pulling healthy wisdom teeth, it might make more sense, in terms of both economic costs and disability, to extract only those teeth that are impacted (emerging crookedly or stuck partway out of the gums) and clearly causing problems.

A British analysis published last year in Health Technology Assessment reviewed 40 other studies and came to a similar conclusion – that routine removal of wisdom teeth to prevent future problems is often not justifiable.

In the US, oral surgeons, whose income depends heavily on wisdom tooth extraction, are currently conducting their own, multi-center study on the issue, says Dr. Louis Rafetto, a Wilmington, Delaware oral surgeon and spokesman for the American Association of Oral and Maxillofacial Surgeons.

But those results are several years away, which means patients are on their own trying to assess a dentist’s advice.

One Framingham woman, who asked that her name not be printed, feels that both her daughters, now in their 20’s, were “railroaded” into wisdom tooth extractions. “Nobody was willing to even consider whether it was necessary to take them all out,” she says.

And then there’s the issue of how often people need to have their teeth professionally cleaned. The dental association says that’s a judgment call best done case by case, says Dr. Matthew Messina, a Cleveland dentist and ADA spokesman.

But the recommended interval between seems to keep getting shorter. Traditionally, dentists said professional cleanings were needed every six months to prevent periodontal disease, an inflammatory response to bacterial infection that destroys the gums and bones around teeth. Seeing a dentist that often is a also good way to detect cavities or other problems, they argue.

But that 6-month interval has “transmigrated” into cleanings every three or four months for many people, says Dr. Richard Beyers, a dentist in Kitchener, Ontario and author of a recent paper in the Journal of the Canadian Dental Association.

That may make sense for people who are too physically or mentally impaired to brush and floss regularly.  Short intervals may also be essential for people who naturally  “form calculus very fast,” says Dr. Glenn Clark, a specialist in hard-to-diagnose oral medicine at the UCLA School of Dentistry. (Calculus is the mineral gunk on teeth that bacteria feed on, triggering periodontal disease.)

But in actuality, there’s so little evidence on the right interval for cleaning that the authors of a 1994 study in the Journal of Dental Education concluded  “it may be time to call all clinical dogma regarding treatment of adult periodontitis into question.”

So, what’s the answer? As the bumper stick says, “question authority.” If your dentist recommends a procedure that strikes you as overly expensive or invasive, ask whether you really need it. If you’re not convinced, get a second opinion.

And if you do go for a second opinion, take your X-rays with you. There’s no point in subjecting yourself to the extra (albeit low dose) radiation that X-rays entail, or to the expense.

SIDEBAR

If you want a second opinion on a dental procedure and don’t know where to turn, try calling a local dental school. Most states have at least one. In Boston, Harvard, Tufts and Boston University all run dental schools.

Procedures that you may want a second opinion on include the following:

  • Crowns: These can run $600 or more. Crowns are made of porcelain or plastic and are usually put on a tooth that has broken or in which a cavity is too large for a simple filling. Sometimes, they are used to provide a better contour for the tooth. If a crown is purely to change the appearance of a tooth, that’s an elective procedure. If it’s to enable you to chew better, it’s probably not elective.
  • Bonding:  This is a procedure in which the dentist etches the surface of the tooth and then covers it with a tooth-colored plastic material to provide a better appearance. It is often an elective procedure.
  • Deep scaling: This probing around the gums to remove debris is necessary – and therefore not elective – if you have periodontal disease, but is usually not necessary if you don’t. Whether or not you really need it is a judgment call by the hygienist and dentist.
  • Implants: These are permanent replacements for lost teeth. They consist of anchors that are surgically placed deep in the jawbone, to which posts, and then crowns, are attached. They are not usually considered elective.
  • Replacement of black fillings with white ones. If the old fillings are still functional, this is primarily a cosmetic procedure, therefore elective. Filling very tiny cavities – as opposed to watching and waiting to see if they get worse – is also often elective.

‘Deep pockets’ that nobody wants

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It was the “Floss or Die” poster that got to 54-year-old Jack Kelsch of Wareham.

Kelsch works as a grants administrator at the Harvard School of Dental Medicine, where the perils of periodontal disease are standard water cooler fare and “deep pockets” means gum disease, not money.But as Kelsch discovered, that poster was no joke.

Most people know gum disease can lead to tooth loss, or, as some put it, “Ignore your teeth and they’ll go away.” But can it also lead to heart disease? Stroke? Death from all causes?

Yes, according to a growing body of evidence showing that infections in the mouth – notably periodontal disease in the “pockets” where the teeth meet the gums – can indeed have a major impact on health.

Luckily, this gloomy picture is offset by more upbeat news: A number of new treatments for periodontal disease have been approved by the US Food and Drug Administration in recent months.

Periodontal disease is a serious problem for 29.6 million Americans, according to the American Academy of Periodontology. (Others say as many as 67 million Americans – one in three adults – have it to some degree.)

It all starts when bacteria – a strain different from those that cause tooth decay – take up residence in the gums. White blood cells from the blood then flock to the area to fight the infection, triggering inflammation.

At first, this just results in gingivitis – swelling and redness of the gums, says Dr. Nadeem Karimbux a periodontist at the Harvard Dental Center. But when chronic inflammation destroys gums and bone around teeth, it’s periodontitis.

Periodontal infection is troublesome enough in the mouth. But it can be even more serious if it spreads.

Several years ago North Carolina researchers showed that periodontal disease in pregnant women was associated with an increased risk of low birth weight babies.

In 1993, a study of 7,610 Americans published in the British Medical Journal showed that men and women with periodontal disease had a 25 percent higher risk of coronary heart disease and a 46 percent higher risk of death from all causes than those without gum disease.

Last summer, newly-published data on more than 1,000 Boston men showed that those with the worst periodontal disease were twice as likely as those with the least to die of heart disease, and three times as likely to suffer stroke, even when other factors such as smoking and cholesterol were accounted for.

In fact, the deeper the pockets of infection, the greater the risk of death from all causes, says the author of that study, Dr. Raul Garcia, director of the Veterans Affairs Dental Longitudinal Study at the Boston VA Outpatient Clinic and a health policy professor at Boston University School of Dental Medicine.

These findings fit, somewhat, with those from a 1996 Harvard study of more than 44,000 male health professionals. That study didn’t find a link between periodontal disease per se and heart disease, but did find a link between heart disease and the main consequence of gum disease: tooth loss. Another Harvard study of 22,037 doctors, on the other hand, found no such link.

The apparent link between periodontal disease and other health problems may be explained by recent studies showing that oral bacteria can indeed become travelling troublemakers.

When bacteria from the periodontal pockets enter the bloodstream, notes Garcia, they may contribute to the formation of plaque on artery walls. This leads to blood clots that can cause heart attacks and strokes. In fact, several recent studies have found bacteria from the mouth in parts of the brain damaged by strokes and in diseased coronary arteries.

Bacteria from the mouth can also directly cause infections in other parts of the body. That’s why the American Heart Association has long recommended that certain heart patients undergoing dental procedures take antibiotics to prevent a heart infection called bacterial endocarditis.

If your dentist or hygienist discovers, by poking around with a probe, that your pockets are deeper than four or five millimeters and you’re starting to lose bone around the teeth, you’re probably a candidate for scaling and root planing. This is a deeper cleaning process than the one we’re all supposed to have every six months. It involves scraping bacteria off tooth roots, under local anesthesia, and can take up to an hour for just one quadrant of the mouth.

If that doesn’t do the trick, surgery is often required – opening the gums, cleaning tooth roots and the jawbone of bacteria, then stitching the gums together tightly to reduce the pockets.

Oral antibiotics might seem a logical solution for periodontal disease, but they’re not. They cause side effects and can create resistant strains of bacteria.

But new ways of delivering antibiotics and other germ-killing drugs just to the gums, not the whole body, and a new understanding of how some antibiotics work, hold promise.

In recent years, periodontists have been using Actisite, a plastic fiber impregnated with antibiotics that is placed in the gums. So far, though, there’s no proof that five years after treatment, it’s better than scaling and root planing alone, says Karimbux of Harvard.

A newer approach to local control of disease is PerioChip, developed in Israel and marketed in this country by Astra Pharmaceuticals, Inc. It was approved in May by the FDA.

The chip, which Jack Kelsch had implanted last month, is about the size of a baby’s fingernail. Inserted into pockets after scaling and root planing, it releases a bacteria-killing chemical, chlorhexidine, over a week.

Yet another new local treatment is Atridox, made by Atrix Laboratories, Inc. Approved by the FDA in September, this gel is injected into the pocket, where it solidifies and releases an antibiotic, doxycycline, also over about a week.

The latest remedy, Periostat, approved just last month, is also based on doxycycline. It acts not by killing bacteria, as the antibiotic usually does, but by attacking an enzyme called collagenase, a tissue-destroying substance pumped out by white blood cells, including those that flock to the gums.

A decade ago, researchers showed that low doses of doxycycline can reduce levels of collagenase, says Brian Gallagher, CEO of CollaGenex Pharmaceuticals, Inc., which makes Periostat.

Studies show that Periostat, a twice-a-day pill, increases the attachment of gums to teeth, when used with scaling and root planing. This makes it a useful adjunct to current treatment “but not a magic bullet,” says Dr. Robert S. Schoor, president of the American Academy of Periodontology.

If you have a deep pocket and scaling reduces it by one millimeter and Periostat by a half-millimeter, “that’s a 50 percent improvement” over scaling alone, he says. “But you still have a deep pocket and you haven’t cleaned the roots of poison.”

Other researchers are investigating ways to use bone grafts – either synthetic or from cadavers – to combat the bone loss that leads to tooth loss in severe periodontal disease.

Used alone, none of these treatments is likely to reverse periodontal disease, but used with existing treatments they should help.

Prevention, of course, is also key – brushing, flossing, and professional cleaning.

Remember the poster: “Floss or die.”

Signs to watch for

The American Dental Association and the American Academy of Periodontology recommend that you see your dentist if you have any of the following symptoms. It is also possible to have periodontal disease without these signs:

  • Gums that bleed easily, or are red, swollen or tender.

  • Gums that have pulled away from the teeth.

  • Pus between the teeth and gums when the gums are pressed.

  • Persistent bad breath or bad taste.

  • Permanent teeth that are loose or separating.

  • Any change in the way your teeth meet when you bite.

  • Any changes in the fit of partial dentures.

To keep teeth and gums healthy, you should brush twice a day and floss once. And have regular dental checkups.

Dental lasers – are they the safest way to fill your cavity?

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They might fix your phobia but are they the safest way to fill your cavity? 

Until recently, Glenn Gustafson, a 56-year-old Boston man who manages a Weston country club, was your basic dental phobic.

It used to take him weeks to make an appointment, says Gustafson, whose fear of needles and drills mirrors that of 7 to 10 percent of the population. And once he did commit to going, he says, he would be a wreck by the time he got there.No more.

Gustafson was among the first patients to have his cavities removed with a laser instead of the standard drill. And he’s a convert: “I didn’t feel a thing. There was no Novocain. . .it’s amazing.”

In Sweden, meanwhile, about 1,000 drill-haters have tried a different option, a new gel called Carisolv designed to dissolve tooth decay in minutes with less pain than drilling.

Going to the dentist will probably never be anybody’s idea of a good time. But a number of new developments may make it distinctly less miserable, if more expensive.

Last May, the US Food and Drug Administration approved the first dental laser, made by Premier Laser Systems, Inc. in Irvine, Calif., for treating tooth decay. Although dental lasers have been used for 10 years to cut soft tissue like gums, when the FDA approved the Premier laser, the agency raved in a press release that laser dentistry “is medicine for the 21st century.”

Another California company, BioLase Technology, Inc. in San Clemente, is now working on a competing product.

The laser creates a beam of light that is all of the same wavelength and that can be tightly focused. The energy from this light rapidly vaporizes water in decaying parts of teeth, causing microscopic explosions. Scientists think that since decaying tissue contains more water than healthy tissue, the laser has a selective effect that mainly vaporizes decay.

The Premier laser, so far sold to only about 60 dentists around the country, is expensive – $45,000 – and patients who opt for laser treatment may pay 50 percent more, says Dr. James M. Stein, one of two Boston-area dentists using the machine.

But for people like Gustafson, it’s worth it. There’s no pain so “there’s no shot, which causes anxiety, and you don’t have to listen to the noise of the drill,” says Stein, also a lecturer at the Harvard School of Dental Medicine.

In one clinical study of 500 decayed teeth reviewed by the FDA, there was no sign of damage to the tooth’s nerve and blood supply. In another study of 125 patients with decayed teeth, the erbium-YAG laser proved as safe and effective as drilling.

Dr. G. Lynn Powell, a laser researcher at the University of Utah in Salt Lake City, said in a telephone interview that in his study, less than 3 percent of patients having the laser treatment asked for anesthesia, while “almost everybody gets it” in routine practice. Powell also spoke last week at the Yankee Dental Congress in Boston, which draws thousands of dentists.

But many dentists – and the American Dental Association – aren’t convinced.

“We still have concerns,” says Dr. Dan Meyer, associate executive director for science at the association, among them the possibility that the laser might cause heat damage to the delicate inner tooth pulp despite a built-in water spray designed to keep things cool.

The laser also doesn’t provide dentists the tactile feedback of high-speed drills, which allows them to “feel” how the procedure is going. “We are guardedly optimistic,” says Meyer, but the laser has not yet won the ADA’s “seal of acceptance.”

Dr. Harvey Wigdor, a dentist at the Ravenswood Hospital Medical Center in Chicago and an adjunct associate professor of biomedical engineering at Northwestern University, is also skeptical.

The erbium-YAG laser “will not take the place of the drill,” he says, arguing that it is under-powered, doesn’t remove enamel well and works satisfactorily only on very small cavities.

Based on his research, however, Wigdor does not think the laser’s heat damages tooth pulp. But he is skeptical that the laser treatment is painless, because many cavitites on which lasers have been used are so shallow that drilling would be painless, too.

Wigdor does agree with the laser’s fans that the energy of the laser helps kill bacteria. But lasers can also create “noxious toxins, fumes or molten metals” if used to remove old fillings. “I don’t see the rationale for using a laser if you are going to have to use a high-speed drill for part of the procedure, such as removing a silver filling.”

As for Carisolv, the Swedish chemical decay remover, the product, which is not yet available in the this country, “sounds promising, but we’re waiting to see the data,” says Kenneth Burrell, senior director for the scientific council at the American Dental Association.

Carisolv is a mixture of three amino acids and sodium hypochlorite that dissolves decay with minimal pain, says Irene Hermann, a dentist and manager for clinical research at MediTeam, Inc. in Gothenburg.

“Sometimes, if the cavity is between two teeth or underneath an old filling, you might have to drill to open up, because Carisolv does not act on old fillings or intact enamel,” she says. After the decay is dissolved, the residue is scraped away and the procedure is repeated until the tooth is free of cavities – in about the same amount of time as drilling.

Data from the first multi-center study of 130 patients who tried Carisolv has been submitted for publication by a scientific journal, she adds.

But the ADA worries the gel might not get rid of all decay and might irritate tooth roots. A decade or so ago, another decay-dissolver called Caridex seemed promising, then fizzled. The Swedish developers say Carisolv is more effective.

The bottom line on all this toothy wizardry is this: Beware of anything that sounds too good to be true. And before you sign up, ask what experience your dentist has with any new procedure or device. And ask to speak to patients who’ve tried it. Previous “Health Sense” columns are available through the Globe Online searchable archives at http://www.boston.com. Use the keyword columnists and then click on Judy Foreman’s name.

Do-it-yourself whitening discouraged

Tooth whitening, a popular option for people whose teeth have become dingy from age or medications, has become big business for dentists, who often charge hundreds of dollars per patient when the procedure is done in their offices. To avoid those costs, which are not covered by insurance, many people turn instead to do-it-yourself tooth bleaching – to dentists’ dismay.

The American Dental Association is “against all home whitening except under a dentist’s supervision,” says Kenneth Burrell, senior director for the ADA’s scientific council, because the bleaching agents can be corrosive to the gums.

The January issue of the Mayo Clinic Women’s HealthSource, similarly advises against over-the-counter whitening kits, noting that the one-size-fits-all trays used to hold the bleaching solution can fit poorly, allowing the bleaching agent to leak out, irritating gums and other soft tissues. Like whitening at the dentist’s, home bleaching can also leave teeth sensitive to hot and cold, adds Dr. Ned Van Roekel, a Mayo dentist.

Home kits, which cost $ 20 or so, contain a 10-percent solution of carbamide peroxide gel (equivalent to a 3-percent solution of hydrogen peroxide.) The bleaching kits used in dental offices are 30 percent hydrogen peroxide or stronger.

In some cases, dentists will make a customized tray to hold the bleaching agent for home use.

Even dentists who support it say there is only a cosmetic, not a medical, justification for bleaching. So far, there’s no evidence that it damages teeth, but most studies have lasted less than 10 years.

When dentists bleach your teeth, they protect the gums with surgical wax or dental dams. They may also use heat sources, including lasers, to activate the bleach.

One of the first dentists nationwide to use lasers for tooth whitening was Canton dentist Konstantin Ronkin, who has employed the BriteSmile laser system on 300 patients so far. The system, developed by Ion Laser Technology in Salt Lake City and being used by 130 dentists nationwide, uses an argon laser to activate a 50 percent solution of hydrogen peroxide, then a carbon dioxide laser to seal the surface.

The process takes two to three hours, costs $ 900 and is especially useful for stains caused by the antibiotic tetracycline, he says.

If you decide to whitenen your teeth at home, talk to your dentist first. Fillings or caps will not change color, so you may end up with a worse aesthetic problem than you started with.

And remember that even some whitening toothpastes can be abrasive, as can plain old baking soda. None of the over-the-counter whitening kits or whitening toothpastes carries the dental association’s seal of acceptance.

And read product labels carefully. One home kit developed by BioLase Technology, Inc. is called a “LaserBrush” for use with a whitening toothpaste. Despite its name, there’s no laser.

Implants? chew on this first

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Last Friday, Ed Pearson, a 45-year-old computer programmer from Charlestown, climbed into the dentist’s chair for what has become almost routine for him: dental implant surgery.

At roughly $2,000 per implant, not counting the crown that goes on top, Pearson wasn’t thrilled – who would be? But he was upbeat. The two implants he’s had before caused little pain, except to the wallet, and look good – “like having real teeth again.”Besides, he says, “You have to have a mechanism to eat.”

Dental implants have improved markedly since half a century ago, when dentists sliced open the gum, carved a groove in the jaw, inserted a crude screw, “loaded” it with false teeth – and hoped the whole thing wouldn’t wiggle.

The big breakthrough came in the early 1980s, when Swedish researchers announced they could boost the success rate by avoiding high speed drills – which burned the bone so severely it did not regrow around the implant – and began using slower drills instead. Switching to pure titanium instead of steel or other metals also helped, because it allowed the bone to grow more tightly around the implant.

Since then, implants have become a badge of dental derring-do, at least among the well-to-do.

A 1993 estimate showed Americans were getting 300,000 implants a year, according to the American Academy of Implant Dentistry. That figure is now believed to be more than 450,000, though millions more get permanent bridges or removable dentures.

But implants – which run $50,000 to $60,000 for a full set of teeth for the totally edentulous, or toothless – are not always the best solution.

For one thing, many insurers still consider them experimental and won’t pay. For another, there are other options, like removable dentures that cost from a few hundred to a few thousand dollars, and fixed bridges that can cost roughly $10,000 for each jaw. Both options are often covered by insurers, at least partially, and thanks to advances in restorative dentistry, may in some cases be better choices.

Still, there’s no doubt that “implants have really revolutionized dentistry,” says Hans-Peter Weber, head of the department of restoration dentistry at the Harvard School of Dental Medicine.

They are especially good for people who are born missing a tooth or two, he says, for those who have no teeth and hate their dentures, and for some people who have had jaw cancer.

Others, like Dr. Arthur Falvey of Newton, agree that implants “are great things when used in the right place.”

But the more prosthodontists, periodontists, oral surgeons and general dentists work with implants, the more they are fine tuning their sense of who should, and shouldn’t, get them.

Implants are primarily used to replace missing teeth – either those you never had or those you lost.

In the standard procedure, an implantologist opens the gum, drills away a precise spot of jawbone, taps or screws an anchor in place, then stitches the gum closed over the implant. If a number of adjacent teeth are missing, several implants can be inserted during one procedure, though it’s not necesssary to replace each tooth with an implant.

After this surgery, which takes from one to several hours and can be done in the office under local anesthesia, the patient must wait three to four months for the bone to heal in the lower jaw and five to six months in the upper jaw, says Dr. Paul A. Schnitman, former chairman of implant dentistry at Harvard and now in private practice in Wellesley Hills. Because of this lengthy healing process, implants take roughly four times longer to complete than bridges or dentures.

After the healing comes a second surgery, in which the dentist slices open the gum again to insert a post into the implant. After the patient heals – in 2 to 4 weeks – a restoration specialist (not necessarily the same person who performed the surgery) makes a false tooth or crown that goes on top of the post. Many people wear temporary dentures during the months of healing and crafting of the crown, which can also take a month or more.

Some dentists now use a one-step procedure, in which the anchor is inserted so that it sticks up vertically through the gumline, says Dr. Michael DiPace, a Brookline periodontist who favors this approach. The implant is covered with a temporary cap, then after the patient has healed, a post is screwed into the implant and a crown made, without further surgery.

The downside of this is that the implant may not work as well as when it is buried below the gum, says Schnitman, who is also president of the American Board of Oral Implantology.

But there’s something else to chew on if you’re considering an implant: the dicey issue of bone grafting.

If the jawbone into which the implant would go is too shallow or too narrow, as is often the case, you may need bone grafts before the implant, says Dr. Gary Rogoff, a maxillofacial surgeon at the Tufts University School of Dental Medicine.

Because it takes six to nine months for grafts to heal, it may be nearly a year before you can start the implant process.

Sometimes, bone is harvested from the chin and packed into the jawbone in the dental office. But if you don’t have enough to spare in your chin or other areas in your mouth, bone may be taken from your hip – in a hospital operating room.

Cadaver grafts are a safe alternative, though some patients worry about the very remote chance of catching a transmissible disease. And other materials may work, too.

If, knowing all this, you want to go ahead with an implant, there’s still something else to consider. Implants can fail – necessitating bridges or dentures or another attempt at implantation, and much of this depends on where in the mouth they are placed.

In the lower jaw in the chin area, implants have a documented success rate of more than 95 percent at 5 years, and this appears to hold at 10 years, too. In the upper jaw under the nose, it’s 90 percent. But the odds drop to 85 percent for the lower back jaw and to 70 to 75 percent for the upper back jaw.

“People should be very cautious about implants in the upper back part of the jaw,” says Schnitman. “This is a real iffy place” because the bones abut the sinuses and are often weak.

The type of implant may matter, too. Anchors with a roughened surface often work better in soft bone because they provide more surface for the bone to grow into.

(The American Dental Association reviews data on implant devices and gives its approval only to those whose failure rate is less than 85 percent. The US Food and Drug Administration classifies most implants as Class III devices for which there is insufficient data to evaluate safety and efficacy, although a panel met last week to begin reconsidering this.)

And there are other risks, too, notably that the implantologist may inadvertently nick a nerve in your jaw while inserting the implant – which would leave you with a numb lip.

In general, implants don’t make sense if you have untreated periodontal disease, uncontrolled diabetes (which can retard healing) or a weakened immune system (because of the increased risk of infection). People with other medical conditions that affect blood or bone may also be ruled out, though many people with osteoporosis can get implants. Heavy smokers and drinkers are also at higher-than-normal risk of implant failure.

And if you’re fussy about esthetics, you should know that an implant may be visible where it joins the artificial tooth, especially if you have a “high smile” or receeding gumline.

All that said, implants can be a good solution if you’re in good health and have, say, knocked out a tooth or two playing sports, says Dr. John Da Silva, a prosthodontist at the Harvard Dental Center, part of the Harvard School of Dental Medicine.

In this situation, an implant makes sense because the alternative is a permanent bridge, which, at least in the past, has involved filing down to stumps the adjacent teeth to support the bridge – damaging two healthy teeth to restore one.

Recently, though, dentists have begun using newer materials to prepare adjacent teeth for a bridge with minimal damage, says Dr. Jamie Wong, a Brookline dentist.

In the future, bone growth factors may make all this less daunting, if, as researchers hope, new drugs can truly spur growth of the jawbone and speed the healing process.

But for the moment, it’s wise to consider all the options and shop around before deciding on an implant.

Says Schnitman, the Wellesley Hills implantologist: “Sometimes you don’t need all these exotic procedures, so patients should be cautious.”

Don’t be afraid of . . . your Dentist

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You’d rather face the IRS than the dentist? Relax, there are ways to fight the phobia;

Michele DerVartanian, a 25-year-old student in Medford, says she was 10 when she learned to fear the dentist.

She had a very sore, abscessed tooth, and “I had to have it pulled immediately,” she recalls. The whole family had plane tickets to Florida that they would have had to cancel unless her tooth was treated right away, she says.”From there on, it was downhill,” says DerVartanian, who adds that she’s “not completely” dental phobic, but does “get really stressed when I have something done to my teeth.”

For Amy Rothstein-Teehan, a 30-year-old sales rep from Randolph, the trouble began nine years ago when a dentist jabbed a needle in the roof of her mouth prior to wisdom tooth surgery.

“My feet literally went up in the air,” she recalls.”It’s the worst place to have a needle.”

She was left so frightened that when she later needed periodontal surgery, she delayed it for months, a pattern of avoidance that Jean, a 37-year-old Winchester mother, knows all too well.

“People think I’m nuts,” says Jean, who did not want her last name used, “but I’d rather have a child than go to the dentist. I just don’t like the needles. The smell alone gags me.”

If you hate going to the dentist and don’t go even when you should, you may have dental phobia.

And plenty of company.

Rationally, of course, we all know that we should brush and floss every day to get rid of the bacteria that can invade not just the teeth, but gums and the bones beneath them.

We all know, too, that we’re supposed to see a dental hygienist every six months. And that if we mess up on this basic stuff, the dental gods have ways of punishing us – like making our gums rot and our teeth fall out.

We even know, the cagey among us, that we can offer realistic-sounding excuses for skipping appointments, like the fact that dentistry can be very expensive – $ 47 to fill a cavity, according to national averages, $ 500 for a crown, $ 250 and up, up, up for a root canal.

The fact that most of us don’t have dental insurance – and that prices in Boston are higher than the national average – doesn’t help.

And then there’s always the old “if it ain’t broke, don’t fix it” rationale, which the American Dental Association says half of us use to justify going anywhere but the dentist’s.

Yet for all this, the fact remains that for many of us, it’s cold, sweaty fear that really keeps us away from the dentist, sometimes with unpleasant consequences.

An estimated 7 to 10 percent of adults feels “very afraid” to “terrified” of going to the dentist, says Tracy Getz, a psychologist and researcher at a place where they actually study such stuff, the Dental Fears Research Clinic at the University of Washington in Seattle. Another 13 to 20 percent feel “somewhat fearful” or “scared,” he says.

More than 90 percent of the time, these fears result from a bad experience at the dentist, often during childhood, though this pattern of fear, dentists hope, may get better as fluoride treatments, dental sealants and better dental hygiene keep more and more children from having cavities.

Typically, dental phobias start with fear of pain, then expand to become all-encompassing, says Dr. Michael Krochak, who runs the Dental Phobia Clinic at Mt. Sinai Hospital in New York.

A person “might have initially feared the pain. Over time, he says, ‘I should go,’ and now he fears, ‘The dentist will yell at me for not having gone.’ So the fear of embarrassment almost supersedes the actual fear of physical trauma.”

But recently, researchers have begun to recognize another significant cause for dental phobia as well – sexual abuse.

Childhood sexual abuse is an “identifiable factor” in dental phobia in about 7 percent of cases, says Getz, a co-author of a study on abuse and women’s dental fears published in April in Journal of the American Dental Association.

“Some women with early experiences of forced oral sex may have difficulty later with oral health care because of a symbolic re-creation of the experience,” his team wrote.

Adding to some patients’ fears is “the intimacy in the way you are positioned” in the dental chair, says Dr. Howard Howell, associate dean for dental education at the Harvard School of Dental Medicine.

“The patient is in a seated or supine position where they can’t get up and get out of the office. They feel trapped. And most of what goes on around them is in the region of the head and mouth, so they may feel suffocated by having people that close to them,” he says.

Nor are our cultural anxieties assuaged by the fact that we use root canals as a metaphor for any number of horrific things, says Dr. Robert Amato, an endodontist at Limited to Endodontics in Boston.

“You hear it all the time – ‘I’d rather have a root canal than see my accountant or pay my taxes.’ It’s almost a universal term for something people perceive as unpleasant,” he says.

Yet increasingly, dental work – including root canals and gum surgery – is much less painful than many patients think, in part because drugs for local anesthesia have gotten better and in part because dentists are getting better at dealing with patients’ fears and pain.

Many dentists now pinch the lip on the opposite side from where the anesthesia needle will be placed to distract the nervous system from the sting of the needle. Many dentists also routinely use topical anesthesia – a painkilling gel – on the gums before the needle goes in.

If you’re really scared, dentists may also suggest nitrous oxide, or “laughing gas,” before work begins. This short-acting gas can dramatically relieve anxiety.

But behavioral tricks – both yours and the dentist’s – may in some cases do the most to offset fears. For instance:

–     Consider using the initial appointment just to talk. Phobia specialist Krochak says the interview process “serves as a catharsis, a release of angst, of anxiety.” While some clinics have psychologists talk to scared patients, he believes it works better for patient and dentist to discuss fears directly.

–     Consider having a nurse in the room at all times, especially if you’ve been sexually abused. “I don’t even talk to patients without a nurse in the room,” Krochak says.

–     A process called systematic desensitization may also calm fears. This involves calming the patient with techniques such as deep breathing, muscle relaxation and guided imagery, then gradually exposing him or her to the feared stimulus, such as the sound of the drill, and then the drill itself.

–     If you fear gagging – such as when the dentist makes an impression of your teeth by putting trays of puttylike material in your mouth – you may feel better if you sit up straight and keep your chin tucked in. It may also help to have the dentist count off the minutes aloud as the impression is made.

–     Distraction also helps. Some patients listen to music. Others watch tiny TVs placed near their eyes.

–     If you hate the smell of dental offices, ask your dentist to use a bit of “aromatherapy” – scented candles and essential oils may mask medicinal odors.

–     Consider having a few short visits instead of one long visit, to minimize anxiety, suggests Susan Cottrell, a hygienist at the Harvard School fo Dental Medicine.

–     It can also help to work out in advance a system – such as raising one hand – to flag your dentist’s attention if you want him or her to stop, says Howell. Some dentists also make it a point to stop every few minutes and ask how you are doing.

–     Many patients also feel reassured if the dentist talks to them as he or she works, explaining each step of the procedure.

Former dental phobics like Amy Rothstein-Teehan have their own hard-won advice. In her case, talking through her fears with Howell of Harvard helped substantially.

“He knows how to relax someone who’s nervous,” she says. “He walked me through the whole thing and said, ‘You can stop at any point.’

She has also learned not to listen to other people’s “horror stories . . . That makes you more nervous than you have to be.”

Michele DerVartanian is similarly grateful fo endodontist Amato because “he just totally took care of me.”

“He was wicked nice,” she says, adding a heartfelt, “and he was fast.”

The dire consequences of dental phobia

Although some people seem able to neglect their teeth and get away with it, at least for a while, for many others, avoiding basic care at home and at the dentist’s office can have dire consequences. The reason is bacteria.

Bacteria on the surface of teeth use sugars from food to produce an acid that weakens teeth by taking the minerals out of tooth tissue, says Dr. Howard Howell, associate dean for dental education at the Harvard School of Dental Medicine.

Initially, the result is tooth decay and cavities, which can be fixed by drilling away damaged parts of the tooth and filling the hole with silver or plastic materials. In recent years, campaigns to put fluoride in water supplies and in mouthwashes and toothpaste have greatly reduced the incidence of decay.

If decay is severe and the infection has invaded the nerve of the tooth, a root canal may be necessary, says Dr. Robert Amato, an endodontist at Limited to Endodontics in Boston and an assistant clinical professor at the Tufts University School of Dental Medicine. A root canal involves removing the inflamed tissue from deep inside the tooth under local anesthesia.

But as tooth decay has declined in recent years and more people are keeping their teeth, the unintended effect has been that periodontal disease in the gums and jaw bones has soared.

Periodontal disease begins with a bacterial infection in the gums, called gingivitis. You’re likely to notice gingivitis first when specks of blood appear during flossing or brushing.

Each side of the tooth surface may be home to a different strain of bacteria. Usually, the bacteria congregate in a kind of pocket called the sulcus where the gum meets the tooth.

Brushing and flossing – once a day is enough if you do it thoroughly – gets rid of most bacteria mechanically, by dislodging it so you can rinse it out with water. Listerine – and a slew of other mouthwashes that also carry the American Dental Association seal of acceptance – have also been shown to get rid of bacteria, as do prescription mouthwashes such as Peridex or PerioGard.

But home care is often not enough, which means you should see a dental hygienist at least every six months. The hygienist’s job is to measure the depth of the pockets around your teeth and remove bacteria, plaque (bacterial deposits) and calculus (a calcified layer of plaque) from the pockets.

If gingivitis is not taken care of, it can turn into periodontal disease, which can destroy the gums, ligaments and bones that support teeth, ultimately causing teeth to fall out. Periodontitis is not caused by bacteria per se, but by the body’s attempt to fight this infection – the inflammatory response which brings huge numbers of white blood cells to the area. Recent research suggests low doses of non-steroidal anti-inflammatory medications like ibuprofen may slow this process.

Sometimes, periodontal disease can also be controlled by scaling or root planing – deep cleaning of the teeth under local anesthesia. In severe cases, surgery may be necesssary to remove inflamed gum tissue and reconstruct damaged bone.

Bone grafts may also help. When she was 10, Michele DerVartanian of Medford had a bad experience with a hasty tooth extraction, and 15 years later she still finds going to the dentist stressful. 3. Dr. Howard Howell engages a patient in conversation to ease her fears about a dental procedure.

Fear of aids is no reason to avoid dentist

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At 2:30 on a Monday afternoon in the summer of 1989, James Sharpe, a convenience store owner from Northampton, settled back in the dentist’s chair to have three teeth extracted.

AIDS was, presumably, the last thing on his mind, and he certainly had no risk factors for the disease.His dentist, Dr. Anthony E. Breglio, was not infected with the AIDS virus, quite unlike Dr. David Acer, the Florida dentist who was infected and passed the virus to six patients.

Furthermore, no other patients Breglio had treated earlier that day are known to have had AIDS.

Breglio practiced the type of infection control that most dentists used at the time – soaking his drills and other similar tools in chemicals, says Dr. Alfred De Maria, director of communicable disease control for Massachusetts, who looked into the case in 1991.

Today, Sharpe has AIDS, and he blames it on poor sterilization of dental equipment by Breglio, whom he is suing in Hampshire County Superior Court. Seven weeks after his dental visit, Sharpe developed flu-like symptoms; when other tests came back negative, he had an AIDS test. It was positive.

Whatever the outcome of the Sharpe case, which is expected to go to the jury this week, it has revived one of the nagging fears of the AIDS epidemic: that you can catch it just by going to the dentist.

How realistic are those fears?

Not very, say many infection-control specialists. And whatever the odds were in 1989, they are even tinier today.

In fact, if you’re looking for an excuse to avoid the dentist, you’d be better off with the old “My dog ate the appointment card” line.

But fear is a notoriously stubborn thing, and in the case of invasive medical procedures, not irrational. So like a diligent dentist picking around with that nasty little “explorer” tool, let’s take a close at the evidence.

With the Sharpe case still unresolved, there has been not one documented case in which a person has caught AIDS from dental equipment, even though Americans make nearly 500 million dental visits a year. If you want to calculate the risk ratio since the AIDS epidemic began in 1981, that’s zero cases over a denominator in the billions.

In fact, even if all 32,381 AIDS cases in which the mode of infection is unknown were actually caused by dental equipment – which is unlikely – the risk would still be vanishingly small.

Furthermore, Acer’s six patients are the only documented cases of AIDS transmission from a dentist infected with HIV. Federal health officials have never been able to pinpoint whether Acer cut himself and then accidentally exposed patients to his blood, failed to sterilize his equipment properly or infected his patients intentionally.

“There were some problems with his infection-control methods,” acknowledges Dr. Harold Jaffe, associate director for the HIV-AIDS National Center for Infectious Diseases at the federal Centers for Disease Control in Atlanta. “But we didn’t prove the route of transmission.”

The Acer case aside, there have been zero – count ’em, zero – documented cases of HIV transmission from infected health care workers to patients. And this holds true even after “look-back” studies involving 22,000 patients, though critics note that there were some methodological flaws in these studies.

By contrast, at least 40 health care workers have been infected by patients.

Still, there’s no question that, under pressure from nervous patients, dentistry been getting safer.

In 1989, when Sharpe believes he was infected, American Dental Association guidelines recommended sterilization by autoclave (which uses intense heat and steam under pressure), but said disinfection with chemicals, a less surefire germ-killing method, was also adequate, says Dr. Richard Price, a Newton dentist and ADA spokesman.

In 1992, the ADA toughened its stance, recommending that all metal instruments, including drills, be heat-sterilized after each use by autoclave, dry heat or chemical vapors. It also said chemical disinfection was no longer adequate.

This proved difficult, however, because many handpieces had to be taken apart to be sterilized or could not withstand heat, prompting some dentists to continue using chemical disinfectants instead.

Even today, some dentists don’t heat-sterilize as they should. The ADA’s own survey last year found that 92.5 percent of dentists heat-sterilize handpieces before each use – up from 25 percent in 1990 – but that still leaves 12,000 who don’t.

And some specialists, like David Lewis, a microbial ecologist at the University of Georgia, contend that only 50 to 80 percent of dentists heat-sterilize tools after each patient.

The technology has improved so much that dentists “can sterilize handpieces in toto now, without taking them apart, because manufacturers have made all the components heat-resistant,” says Price.

In 1993, the CDC issued its own infection-control guidelines, which don’t carry the force of law but are generally followed. These call for sterilizing with an autoclave, dry heat or chemical vapor all instruments that penetrate soft tissue or bone, like the burs used for drilling, as well as instruments that contact oral tissues, like mirrors.

Because the internal surfaces of high-speed handpieces and other devices can become contaminated, the CDC concluded that “soaking in liquid chemical germicides” is not acceptable infection control.

In practice, though, some dentists still use chemicals to sterilize equipment that is not heat-resistant, like the tabs that hold X-ray films.

“Cold sterilization with chemicals obviously only works for surfaces that the chemicals can reach – not for instruments with tiny nooks and crannies or hollow tubes – but it does work well for these solid surfaces,” insists Price of Newton.

“But things are evolving even as we speak, and as of this week, because of questions remaining in patients’ minds, I am doing away with cold sterilization myself.”

Increasingly, he adds, dentists are turning to materials they can use once and throw away, like devices used to polish teeth and the tubes that suck saliva out of the mouth.

So does this mean all risk of AIDS in dentistry is gone?

Not quite. A small risk will remain as long as there is any dentist out there who does not heat-sterilize or throw away after use everything that goes in your mouth.

That’s because, as Lewis showed in studies published in 1992 in the journal Lancet and last year in Nature Medicine, the AIDS virus can get into dental equipment and survive “up to several days” in the lubricating fluids inside the instruments.

Lewis, who testified last week for Sharpe, took blood from AIDS patients and mixed it with lubricants, then immersed the lubricants in a 2-percent solution of glutaraldehyde, a disinfectant. The virus survived.

“And if glutaraldehyde couldn’t kill the AIDS virus, then no chemical disinfectant used would be effective. Only heat effectively kills the AIDS virus in dental devices,” he said in a telephone interview. “But if the equipment is properly sterlized, there should be no concern.”

Dr. Sanford F. Kuvin, who also testified for Sharpe last week, charging that “dirty dentistry” was involved, agrees “there is no risk if the dentist or other invasive dental health care worker is HIV-negative and if sterilization is proper.” If not, he said, “there is a risk that’s somewhere between infinitessimal and small.”

So how can you tell if your dentist is doing the right thing?

“Ask questions and don’t stop until you’re satisfied,” advises Price, though for many patients, that’s easier said than done, especially with a mouth full of dental hardware.

Still, you could start by asking how much your dentist has spent to meet infection-control guidelines, including guidelines to protect dental employees. Many dentists have spent $ 24,000 a year to comply and may be quite happy to tell you so.

Ask if your dentist uses an autoclave, and if you’re in doubt, ask to see it. Then ask how often your dentist checks to be sure it’s working.

After that, you might as well relax because, as Price puts it, “There’s got to be some trust.”

Dr. Martin Hirsch, director of clinical AIDS research at Massachusetts General Hospital, agrees.

“I hate going to dentists,” says Hirsch, “but I think the risk of spread of HIV is infinitessimally low in that setting and people shouldn’t avoid dentists for that reason.”

 Look and ask questions

Things to look for and ask about at the dentist’s office:

  • Is the room clean and orderly, and do surfaces and equipment appear clean?
  • Is the staff willing to answer your questions?
  • Do the dentist and other dental workers practice “universal precautions,” including wearing gloves and other protective gear during your treatment?
  • Are needles and other sharp items disposed of in special puncture-resistant containers?
  • Is everything that goes in your mouth heat-sterilized or disposable? (If you’re worried about non-heat-resistant items like the gadgets that hold X-rays, ask. American Dental Association guidelines say it’s acceptable, though not preferred, to use chemicals to sterilize these.)
  • How often is the autoclave machine checked? (Federal guidelines say it should be checked at least weekly.)

    If you’re still worried, call the state Board of Registration in Dentistry (617-727-7368 begin_of_the_skype_highlighting              617-727-7368      end_of_the_skype_highlighting).