James "Jim" Ross DDS MS

One of our founding partners, James “Jim” Ross passed away this past Friday evening after a long battle with cancer. Many of you will remember Jim as one of our leaders in the Memphis Dental Society. He served as President of Memphis Dental Society and on many committees of Tennessee Dental Association (TDA). He was also president of the Tennessee Society of Periodontics, and someone who carried the flag of Periodontics. He was from East Tennessee (Elizabethton), graduated from the University of Tennessee College of Dentistry, served in Military after Dental School, and practiced General Dentistry before graduating from The Ohio State University in Periodontology in 1970. He was Board Certified in Periodontics.

He practiced Periodontics in the state of Washington before returning to Tennessee as a faculty member in the Department of Periodontology in 1972 at UT College of Dentistry. He served as Clinical Director of Periodontics before entering full time Practice Limited to Periodontics in 1976. He continued teaching part time for many years.  He practiced with Ed Lane,Sr., P.D. Miller, Les Binkley and Roger Craddock.  Jim retired in 1999 from practice but not from his motel business and helping his son in the trucking business. Later he turned his attention to writing books. He authored three books, which are great reads, since he was a great story teller. He and his wife Lucy spent many hours in the garden together. In retirement, Jim and Lucy enjoyed their grandchildren and two sons, Richard and Glenn and their lovely daughters-in-law.  Jim never lost his love of travel and his wonderful sense of humor. I hope you will remember Jim’s family in your prayers.

Jim and Lucy’s home address:  534 Bray Station Rd., Collierville, TN  38017

A Memorial Service will be held this Sunday March 4^th at 2pm at Collierville Methodist Church.  Please note there will be no visitation.  A Reception will follow the Memorial Service.

This summer our office added the “My Perio Path” test from Oral DNA Labs to our tool kit for improving our ability to diagnose and treat periodontal diseases.   Oral DNA also offers “My Perio ID PST” for genetic testing of the patient’s risk for periodontal disease, as well as “ORARISK HPV’ testing to detect the human papilloma virus which can increase cancer risk.

We use “My Perio Path” for a baseline and then as a follow up test after treatment to determine our progress in controlling the bacteria that cause periodontal disease.   While there are well over 500 bacterial species that can call the mouth home, only about a dozen are well documented to cause periodontal disease.   Because the bacteria are anaerobic (don’t need oxygen to live or even may be killed by it), they are notoriously difficult to collect and grow in lab culture.  Oral DNA Labs has developed very sensitive tests of the bacteria’s own DNA that can tell us if these bacteria are present and in what numbers.  The sample is collected by swishing a small amount of salt water for 30 seconds.   Sounds like the TV show CSI right?  The bad guys here are bacteria, though.   We use the test results to help shape our treatment plan and to select the most appropriate antibiotics for use in treatment.

Periodontal Associates is pleased to announce that Dr. Tom Nabors, the founder of Oral DNA Labs will join us on Monday, November 7, to speak to our Hygiene Study Club.

For more information, go to www.OralDNA.com or www.PerioMem.com.

Busy Germantown office looking for a reg/cert dental assistant. Experience preferred but not necessary.

Must be able to work at a fast pace and be open to flexible hours. Office hours are Monday thru Thursday 7:45am to 5:00pm and Fridays 7:45am to 2:00pm.
Please fax resume to 901-754-2447. (This post will be removed once the position is filled).

Thank you,
Rebecca

Patrick Kutas Family Dentistry
7512 Corporate Center Drive
Germantown,TN 38138

September is Prostate Cancer Awareness Month!

Ladies, in general you are more in “tune” with your bodies than the men in your lives. Please remind the men to see their physician regularly for check-ups and blood tests.

Prostate Cancer is a serious disease but it is treatable with early detection. After Skin Cancer, Prostate Cancer is the #2 cancer in men.

A simple blood test called a PSA (prostate specific antigen) can help detect prostate cancer early. Physicians also perform a palpation test to check for prostate enlargement.

This is a good time to remind everyone the risk of Prostate Cancer is higher in males with gum disease. So treating gum disease may help to decrease your risk of prostate cancer as well as other diseases. For more info check out this link.

Prostate Cancer Awareness month is here, but we should make every month just as important in raising awareness for prostate cancer.

Our next Hygiene Study Club will be Monday September 19th. We will have an evening with Sonicare. We are excited to have Tracey with us. See her info below. She will discuss the two below topics.

You’ve Been Slimed! Emerging Biofilm Science and Therapeutic Decisions. What if the use of a power toothbrush could change the composition of dental biofilm to benefit the patient’s oral health? Dental biofilms are one of the major contributing factors for both periodontal diseases and caries infections. Through emerging research, we now know not all dental biofilm is bad. Novel and compelling science from Philips Sonicare demonstrates the ability of Sonicare* to transition the biofilm composition from a pathogenic state towards a benign state and
eventually to a beneficial state.
In addition, the potential of Sonicare to enhance the delivery of chemotherapeutics into biofilm, such as fluoride from toothpaste, will be explored. These research findings could significantly impact self-care regimens and long-term oral health.

*Note: Sonicare is a sonic powered toothbrush manufactured and distributed
by Philips Oral Healthcare

Customized Care Program for Healthy Patients and a Healthy Practice: This high-energy, practical, “how-to” program will explore the benefitsof using a “Customized Care Program” for patient care. According to the ADA, a patient assessment should be done on each patient at every appointment. This course will teach participants how to integrate five time-efficient comprehensive clinical screenings to improve restorative/
esthetic identification and perio therapy enrollment. Periodontal therapy referral to support restorative treatment plans will be outlined.
Strategies for effectively discussing the emerging science of the oral systemic link will also be discussed compelling patients to want the dentistry they need. Dental professionals are moving beyond a “mouth-only” approach toward whole-body wellness through a customized care approach.

Tracey Jacobs, BSDH, RDH
Manager, South Professional Education
Philips Sonicare Global Profession Education
Tracey.Jacobs@Philips.com
Territory: AL, FL, GA, KY, LA, MS, TN
Tracey is a graduate of the University of Alabama School of Dentistry with a Bachelor’s of Science in Dental Hygiene.
She is a member of the American Dental Educators Association and the American Dental Hygienists’ Association. Serving several leadership positions including President of the Florida Dental Hygiene Association, she is most noted for her dedicated service as the FDHA Event Planner since 1996.
Tracey manages seven states within the South region for Philips Sonicare and presents a variety of educational programs nationwide. With 20 years of clinical experience, she continues to practice dental hygiene part-time in Central Florida.
Tracey enjoys photography, power yoga, and coordinating family celebrations. She resides with her family in Orlando.

If anyone knows a dental assistant looking for a part time job (preferably Wed and Thur), please contact Janie at Dr. Tommy Shipmon’s office (901) 767-3603. This would be great place to work.

Job Opportunity! Dr. John Whittemore at Germantown Dental Group is looking for a treatment plan coordinator. This requires someone who enjoys talking with and helping people and to whom people enjoy talking, but also dots their i’s and crosses their t’s (a tough combination to find!). This would be a fun and rewarding place to work. Compensation will be at the absolute top of the market for this type of position. If you know of someone who could help, please contact John at DrW@GermantownSmiles.com or (901) 754-0540.
Thanks.
Periodontal Associates of Memphis.

This is from our friends at LexiComp. Our recommendation is to have all dental treatment prior to cancer treatment. This should help avoid the below problems.

Bevacizumab (Avastin®): Another Drug Associated With Osteonecrosis of the Jaw

First it was the intravenous bisphosphonates, zoledronic acid (Zometa®) and palmidronate (Aredia®), then the oral bisphosphonates (the Fosamax® family of drugs), then the anti-RANKL drug, denosumab (Prolia®, Xgeva®). Now it’s a human monoclonal antibody known as bevacizumab (Avastin) that is associated with osteonecrosis of the jaw (ONJ) syndrome.

Bevacizumab (Avastin) belongs to a class of drugs known as antiangiogenic agents, used with increasing frequency in treating cancer. Bevacizumab is indicated for the treatment of metastatic colorectal cancer, and metastatic nonsquamous, nonsmall cell lung cancer. Angiogenesis in tumor cells involves the formation and growth of new blood vessels which help tumor growth. Bevacizumab acts to block angiogenesis through inhibition of cell proliferation and vessel sprouting, as well as by decreasing circulating vascular endothelial growth factor (VEGF) levels. This action is similar to the antiangiogenic action ascribed to the bisphosphonates. There are literature reports on patients receiving bevacizumab who developed ONJ. These reports are described in this month’s newsletter.

A case of ONJ associated with bevacizumab exposure was reported in a letter to the editor in 2008 (Greuter S, Schmid F, Ruhstaller T, et al, “Bevacizumab Associated Osteonecrosis of the Jaw,” Ann Oncol, 2008, 19(12):2091-2).

A 63-year old woman was treated for breast cancer. Bone scans were normal and she had never taken bisphosphonates. While being treated with liposomal doxorubicin and bevacizumab, the patient experienced left-sided maxillary pain after one-month therapy. A tooth infection was diagnosed and numbers 25 and 26 were extracted. One month later, a mouth-antrum fistula was surgically revised and occluded. Soon afterward, the patient suffered from a trigeminal neuralgia. Imaging showed maxillary sinusitis and signs of ONJ. The jaw lesion was extirpated and the sinus drained. Histology verified the clinical diagnosis of ONJ and an infiltration from the cancer was excluded. At 3 months of follow-up, the patient remained free of lesions and symptoms.

The authors commented that bevacizumab acts to block angiogensis through inhibition of cell proliferation and vessel sprouting, as well as by decreasing circulating vascular endothelial growth factor (VEGF) levels. This action is similar to the antiangiogenic action described for the bisphosphonates.

The authors stated that this was the third published case of ONJ associated with bevacizumab therapy. The doxorubicin the patient was taking is an anthracycline antineoplastic agent that has been on the market for many years and has never been known for causing ONJ. The authors suspected that bevacizumab, which hampers wound healing and possibly bone remodeling, was the causative agent in this case.

The other two published cases were included in a report by Estilo, et al (Estilo CL, Fornier M, Farooki A, et al, “Osteonecrosis of the Jaw Related to Bevacizumab,” J Clin Oncol, 2008, 26(24):4037-8).

A 51-year-old female with a history of infiltrating ductal carcinoma of the right breast was diagnosed in late 2001 and treated with mastectomy in 2002. She subsequently underwent treatment with chemotherapy, doxorubicin, cyclophosphamide, and letrozole for various cycles over a 3-year period. Since 2006, she underwent additional chemotherapy, capecitabine therapy, and radiation. In late December 2006, she was started on bevacizumab at a dose of 15 mg/kg every 3 weeks for a total of 8 doses, the last dose given in May 2007. Six weeks after the last dose, the patient presented with a 2-month history of complaints of lower jaw discomfort and protruding bone in the lower jaw. Examination revealed an area of bone exposure in the left posterior lingual mandible approximately 1 X 1 mm in diameter. The area appeared necrotic. The surrounding tissue had no evidence of infection. The exposed bone was smoothed with a bone file and the patient prescribed chlorhexidine 0.12% oral rinse. The bevacizumab and capecitabine were then discontinued. The area of exposed bone had resolved within a few weeks. The overlying mucosa appeared normal. At that time, a new area of exposed bone appeared in the right posterior lingual mandible of 1 X 1mm in area. Histology showed devitalized necrotic bone with a scalloped “moth eaten” appearance. Bacterial colonies occupied the demineralized areas.

The other case was a 33-year-old woman with a history of glioblastoma multiforme diagnosed in November 2006. She underwent surgery followed by radiation therapy and temozolomide from December 2006 through January 2007. The patient started bevacizumab therapy in Feb 2007 at a dose of 10 mg/kg every 2 weeks. Thirteen weeks later, she was referred to the dental clinic for evaluation of a 2-week history of spontaneous mucosal breakdown overlying her right mandible. The patient complained of gingival pain. On examination, there appeared a 1 X 2 cm dehiscence at the junction of the unattached/attached gingiva in the mucobuccal fold overlying the lower right first and second premolar and first molar teeth. There was exposed necrotic bone visible through the dehiscence extending inferiorly and posteriorly. There was no evidence of infection. Other than that, the oral mucosa appeared healthy with intact dentition. The patient continued on biweekly bevacizumab. In August 2007, she returned with a small mucosal defect posterior to the original lesion. There was soft tissue dehiscence with no evidence of exposed bone.

The authors commented that the clinical features of bone exposure in the two cases were compatible with ONJ in patients exposed to bisphosphonate therapy. The two patients had no history of bisphosphonate use. The authors suggested that bevacizumab contributed to the oral mucosal breakdown with exposed necrotic mandibular bone in the two patients. The antiangiogenic property of bevacizumab could compromise microvessel integrity in the jaw and lead to subclinical compromise of the osteonecrosis. Trauma from tooth brushing or chewing could also increase the demand on this compromised bone to repair itself and result in localized bone necrosis, periosteal death, and eventual exposed necrotic bone.

Estilo et al went on to explain that angiogenesis is a critical step in tumor growth, invasion, and metastasis. VEGF is a family of cytokines that exert important functions in tumor angiogenesis. VEGF is overexpressed in various human tumors and overexpression of VEGF is associated with tumor progression. VEGF is also essential for osteogenic differentiation and bone formation. Thus bevacizumab, used as a VEGF inhibitor to suppress tumor progression, could also suppress the osteogenic differentiation and bone formation. This could result in failure to repair bone trauma.

In the two patients described, additional factors possibly contributing to the development of ONJ were the advanced cancer and chemotherapy. The authors cautioned that clinicians involved in the care of patients treated with bevacizumab should be aware of the potential complication of ONJ.

Antiangiogenic Agents and the Risk of ONJ

Christodoulou et al reported that a combination of bisphosphonates and antiangiogenic factors induces ONJ more frequently than bisphosphonates alone (Christodoulou C, Pervena A, Klouvas G, et al, “Combination of Bisphosphonates and Antiangiogenic Factors Induces Osteonecrosis of the Jaw More Frequently Than Bisphosphonates Alone,” Oncology, 2009, 76(3):209-11). Their introduction in the report stated that antiangiogenic agents may add to the risk of ONJ, especially when used in combination with bisphosphonates. The purpose of the study was to do a back review of data of patients receiving bisphosphonates with or without antiangiogenic factors for osseous metastases from various tumors between June 2007 and June 2008.

Among 116 patients being treated for various malignancies, 25 received concurrent treatment with antiangiogenic agents at some point. Twenty-two were taking bevacizumab, two were taking a drug called sunitinib, and one was taking a drug called sorafenib. The median duration to exposure to bisphosphonates was 28.5 months for the 25 patients taking the antiangiogenic drugs and 24 months for those not taking any antiangiogenic drugs. There were no significant differences between the two groups regarding treatment duration with the bisphosphonate.

Of the 25 patients receiving concurrent treatment with bisphosphonates and the antiangiogenic drug, 4 developed ONJ (incidence of 16%). Of the 91 patients receiving bisphosphonates without antiangiogenic factors, 1 developed ONJ (incidence 1.1%). This difference was statistically significant.

In this study, the diagnosis of ONJ was according to the clinical diagnoses made by dentists specializing in treating cancer patients and consisted of pain in the jaw with exposed, necrotic bone, some with purulent discharge. The authors commented that bisphosphonates have also been reported to possess antiangiogenic activity, particularly zoledronic acid (Zometa®) — a widely popular bisphosphonate used as an adjunct agent in cancer treatment.

Greuter et al (above) summed it up best by stating “if more cases of bevacizumab-associated ONJ are reported, special dental management (jaw x-ray, optimal dental health, and good oral hygiene) should become standard before patients start bevacizumab.”

Dental Management to Reduce the Risk of ONJ

The importance of special dental management to reduce the risk of ONJ in patients taking bevacizumab was shown in a recent report (Francini F, Pascucci FF, Francini E, et al, “Osteonecrosis of the Jaw in Patients with Cancer Who Received Zoledronic Acid and Bevacizumab,” J Am Dent Assoc, 2011, 142(5):506-13). They looked at cancer patients on zoledronic acid and chemotherapy combined with bevacizumab who underwent a dental exam before starting treatment. They found that none of the patients developed ONJ.

The study included 59 patients with either breast cancer or nonsmall cell lung cancer who received 4 mg zoledronic acid I.V. every 4 weeks and 15 mg per kg bevacizumab every 3 weeks. The median time of receiving zoledronic acid was 18 months and the median time of receiving bevacizumab was 16 months. All subjects received a dental exam and panoramic x-rays before starting treatment and every three months thereafter until the patient died or was lost to follow-up. If needed, patients received periodontal disease treatment and underwent tooth extraction before they received any drug.

None of the patients required dentoalveolar surgery while undergoing cancer treatment. After a median follow up of 19.7 months, none of the participants developed ONJ. The conclusion was that a bisphosphonate combined with an antiangiogenic drug did not predispose to ONJ in participants with cancer that metastasized to the bone, who underwent a baseline dental examination and preventive dental measures.

Indications for Bevacizumab (Avastin®) Approved by FDA:

Treatment of metastatic colorectal cancer; treatment of unresectable, locally advanced, recurrent or metastatic nonsquamous, nonsmall cell lung cancer; treatment of metastatic HER-2 negative breast cancer (who have not received chemotherapy for metastatic disease); treatment of progressive glioblastoma; treatment of metastatic renal cell cancer (not an approved use in Canada).

Note: For the treatment of metastatic breast cancer, effectiveness is based on improvement in progression-free survival; not indicated for the treatment of breast cancer with metastatic disease that has progressed following anthracycline and taxane treatment. For the treatment of glioblastoma, effectiveness is based on improvement in objective response rate.

Unlabeled/Investigational Use:

Treatment of recurrent ovarian cancer; recurrent cervical cancer; soft tissue sarcomas (angiosarcoma or hemangiopericytoma/solitary fibrous tumor); age-related macular degeneration (AMD).

Recommendations from Periodontal Associates of Memphis

Our recommendation is to have all dental treatment prior to cancer treatment. This should help avoid the above problems.

Many patients have had difficulty affording dental treatment. Dental insurance has not increased the maximum benefit since the 1970’s. The maximum in the 1970’s was $1000 to $2000. Obviously this allowed much dental care in the 1970’s. Today this does not pay for much more than preventive care and maybe a crown a year. Using flexible spending accounts helps patients pay for dental care without paying tax on the money. This can be a significant savings. See below for the info on legislation that should make this easier.

Paulsen Bill Picking Up Steam

Rep. Erik Paulsen’s (R-Minn.) Patients’ Freedom to Choose Act (H.R. 605), a bill to repeal the Affordable Care Act’s $2,500 limit on flexible spending accounts, is picking up momentum in the House, with 101 cosponsors.

Earlier this month, ADA president Dr. Raymond Gist wrote to Rep. Paulsen to express the association’s support:

“Too many Americans families have either inadequate dental coverage or no coverage at all. Flexible spending accounts can help them get the dental care that will make the difference between constantly fighting oral disease and obtaining good oral health. We applaud the sponsors of H.R. 605, who are working to fully restore this critical resource for our citizens, who realize and will fully utilize its value, to keep their families healthy.”

Some observers believe the bill will pass the full House by the August recess.

Sen. Orrin Hatch, ranking member of the Senate Finance Committee, introduced a companion bill (S. 312).

CareCredit

Another option which helps patients afford dental care is CareCredit.

The American Dental Association (ADA) is not just about teeth. Jaw bone is important to help preserve facial structures and to help anchor teeth. So the ADA is sponsoring bone research. Without good bone, you would lose your teeth and smile.

The ADA pushes for Bone Health Research by recently announcing support for S. 966, the Bone Health Promotion and Research Act. Introduced by Sen. Kirsten Gillibrand (D-N.Y.), the bill would strengthen federal support for bone disease research through grants to independent facilities and at the National Institutes of Health.

The bill also would enhance the public health infrastructure for monitoring, preventing, and controlling bone-related maladies through the Centers for Disease Control and Prevention. It would also support a national awareness campaign that could be used to educate the public about enamel erosion, periodontal disease, osteonecrosis of the jaw, and other bone-related conditions of the oral cavity. The ADA’s letter of support is available here.

Bone is important to anchor teeth and preserve your facial appearance. Regrowing bone also helps to support teeth and dental implants to replace teeth.