The Medical News Report #71
Subjects for December, 2017
Pearl Harbor Attack by the Japanese, December 7, 1941—NEVER FORGET!
A. Gabapentins and opioids-a potential lethal combination
Gabapentins (Neurontin and Lyrica) are being prescribed for many types of pain, however, there has been little value in patients with neuropathy pain from diseases like diabetes and for chronic low back pain. The gabapentins are fairly successful in treating neuropathy! In an attempt to reduce the number of opiate prescriptions, physicians have been prescribing the gabapentins in combination with opiates (smaller doses—hydrocodone, etc.) with little success in controlling many types of chronic pain.
Both have been found to depress respiration, and if taken together in higher doses, can potentially cause death. Studies recently have reported that gabapentins are of little value in treating many types of pain. Since these patients have long term pain, they are at high risk for narcotic abuse, which creates a real challenge for physicians. Side effects of dizziness and sedation can also be multiplied when gabapentins are taken in combination with opiates.
Discuss this with your doctor if you are being prescribed both a gabapentin and an opiate and beware of the increased danger. Ref. NEJM, Apr. 15, 2017; JAMA-Neurology, July 1, 2017
B. Does Zinc shorten a cold?
Since 1968, there have been studies that suggest zinc may help shorten the length of a cold. Recent studies say it may help but by only 24 hours (as a lozenge or syrup). Zinc sprays can permanently damage the smell nerves, so it is suggested that patients not use the spray. Most colds are caused by the rhinovirus, and it is theorized that a lozenge or syrup may coat the throat preventing invasion of the virus. Taken at the onset of symptoms may help slightly. The evidence is not strong. Mayo Clinic
C. New evidence on the occurrence of colorectal cancer in younger people
Some of you know I have been volunteering for 39 years for the American Cancer Society (Florida President, National Board of Directors, Screening Guidelines Committee, Survivorship Committee, etc.) and we are about to finish our results to be published in cancer journals on colorectal cancer screening guidelines revision.
I was privileged to be present for a presentation on some changing trends in colorectal cancer that I can share.
Colorectal cancer is increasing especially in younger people before age 50 (especially 45-49), even though the majority of the cancers occur later. The reason is increasing numbers of colon adenomas (polyps) that are occurring younger in life which become malignant over about a 10 year period. These polyps seem to be getting more aggressive in their growth pattern in younger people.
The occurrence of rectal cancer is increasing in even higher numbers. The reason is increasing rates of obesity, lack of exercise, and poor nutrition. Mortality is also rising for younger men 50 and under because of these colorectal cancers. This age group is not being routinely screened since most current guidelines recommend routine screening to start at age 50 (unless there are symptoms or there is a positive family history). Some national organizations have already starting recommending earlier screening.
Colorectal cancer is now the number one cause of cancer death in men 50 and under (surpassing lung cancer in the age group 45-49).
I hope to share those guideline revisions soon from the American Cancer Society.
I have written extensively on colorectal cancer www.themedicanewsreport.com/57/58
Below is a chart showing the rates of colorectal cancer by sex:
2-5% of Americans fit the criteria for the diagnosis of the hoarding syndrome. This may be surprising to some. We all hold on to memorabilia, and “stuff” we think we might wear or use sometime in the future. But hoarders keep almost everything cluttering their homes to the max. It is often a true health issue as clutter accumulates mold, rodents, etc. potentially creating illness. It causes great family discourse.
It was thought to be form of a compulsive disorder in the past, however, more recently it is felt to be linked with anxiety, depression, dementia, social phobias, attention deficit syndrome, and even schizophrenia.
Compulsions may, however, play a role in hoarding disorder. These people cannot let go of material goods , not because they rationalize they might use it, rather they literally cannot part with material objects. It is a true emotional attachment to “stuff” and would feel an emotional loss if they were removed. These are not objects most of us would understand why the person is keeping them. These people do not see it as a problem, which makes it difficult to treat. Social isolation can also occur to prevent people from ridiculing them.
When parts of the house normally intended for normal use are used to store magazine, old newspapers, books, cosmetics, clothes, worn out or unusable equipment, there is a problem. Clutter does not even come close to what these people’s homes look like. Hoarding can even include excessive numbers of pets.
70% report their hoarding started between the ages of 12-21. Some relate the beginning of this syndrome linked to a trauma at home, forced intercourse, a history of forceful removal of objects from them, or being abused.
There is a difference in the frontal lobes of these individual’s brains. This is the part of the brain that processes rationale, weighing options, and consideration of others. It is thought that these people use that part of the brain differently.
These people do not seek help. Their family may bring them to the doctor’s or there may be fear of eviction that pushes them, but they come in reluctantly. You may have seen TV programs on this subject. This is fascinating to viewers, but not to the families of these people.
This is a very difficult disorder to treat and create change in behavior since most sufferers do not believe they have a problem. Treating underlying psychological issues may really be more productive. Ultimately, cognitive therapy to work on understanding how to look at objects and make better decisions about retaining objects may be of some value. They must realize that the underlying psychological problem frequently triggers hoarding behavior and the cycle must be broken. They also must understand the hazards of hoarding (health, fire, vermin, threats to exiting in an emergency, etc.).
Nagging by family members will not be successful and will even evoke more underlying anxiety and or depression. Support from family and friends will assist these patients in reinforcing certain goal behavior to let go of objects with little value for the immediate future even if a little at a time.
WebMD, Mayo Clinic
W.C. Fields (early Hollywood)
This common skin disorder plagues men and women ages 30-50 usually fair skinned and blue eyed. Normal teenage acne is called acne vulgaris.
This is an inflammatory skin disease characterized by facial redness, dilated blood vessels, and sometimes pimples (acne). It occurs on the face, neck, and back most often. There can be symptoms of stinging, burning, tightness, swelling, and tingling. This disease affects people’s quality of life because of the eruptions, inflammation, and disfigurement.
There are triggers that can aggravate this disease (heat, stress, hot beverages, spicy foods, ultraviolent sun rays, alcohol, and smoking). There is redness, flushing, papules (bumps) and pustules, abnormal blood vessel formation (telangiectasia), burning, stinging, and dryness of the skin, which creates peeling and scaling. Thickening of the skin over the tip of the nose is common (called rhinophyma).
There is a growing body of evidence that this is an immune disease. The skin reacts to a bacterium called Bacillus olerenius. A protein called cathelcidin, which normally protects the skin from infection, overreacts and leads to redness and swelling. There is also an organism called Demodex folliculorum, which is a mite that infests the skin in these patients. Whether it is causal or not is unknown.
There are other diseases to rule out when diagnosing rosacea (acne vulgaris, lupus, flushing disorders, other forms of dermatitis).
There are 4 types of acne roseacea
1- erythematotelangictatic--redness, dilated blood vessels, and flushing. Rule out lupus vulgaris (lupus of the skin)!
2-papulopustular—redness and pimples with pustules
3-phymatous rosacea--rhinophyma—bumpy thick red skin over the nose (W.C. Fields’ nose)
Before and after photo using dermabrasion
Having performed this procedure many times, this excessive tissue can be planed down using dermabrasion (a sanding procedure) with amazing results. The before and after photo (above) is typical of the results that can be obtained. There are other methods such as laser and loop cautery.
4-ocular-redness, swelling, and small pustules along the lid margin are the hallmarks of this disease.
An ophthalmologist should evaluate and assist the dermatologist and must rule out other eyelid diseases.
There is no cure, but control of the redness, dilated blood vessels, flushing, acne, and swelling can be successful with medication (oral and topical creams) and prevention.
Education about the disease and its triggers, skin care, and medical management are staples in the management.
Benzoyl peroxide cleansing of the areas is a recommended daily therapy for most patients just as with acne in teenagers.
Treatment should begin with topical prescription medications.
The medications to treat the inflammation are from the tetracycline family (minocycline, clindamycin), and erythromycin. Oral and topical antibiotics are commonly used in combination. The newer ones are very expensive, therefore, using less expensive generic treatments first should be considered, and if they are not effective, proceed to the more expensive brands.
Another option is metronidazole (Flagyl, Metrogel) in both oral and topical preparations. Others are azelaic acid (Finacea) and ivermectin, sodium sulfacetamide, and permethrin cream. Oral isotretenoin (in the family of the Retin-A) is also effective, but not to be used by pregnant women because it may cause birth defects. Birth control methods and frequent pregnancy tests are recommended. All these options should be discussed with the dermatologist.
For ocular rosacea, careful cleansing of the eyelid margin with cotton balls and warm water twice a day and the use of artificial tears are recommended. For more severe cases metronidazole or oral doxycycline may be helpful. Also topical cyclosporine drops are very helpful. Off-label use of topical azithromycin (Azacite) may be helpful since it is FDA approved for bacterial conjunctivitis.
The newer topical preparations can cost as much as $500 per tube.
Flushing may be controlled by beta blockers (used in hypertension). There is a topical medication called brimonidine (Alphagan) (an alpha adrenergic drug that causes vasoconstriction of dilated blood vessels). It can also be used as a drop in the eye. Another is oxymetazoline gel mentioned as a common treatment. As a nasal spray, it is called Afrin, a strong nasal decongestant.
Laser and light based therapies are commonly used to treat the redness, dilated blood vessels, and early rhinophyma.
I am a great believer in estheticians (specially trained cosmetologists in skin care). All of my cosmetic surgery patients were encouraged to go regularly to provide maximum cleansing, clearing of pores, and protection before and after facial surgeries. Facials by experts are worth every dime. Patients with skin issues of all kinds will benefit greatly.
I mentioned dermabrasion is very effective for rhinophyma to smooth the thick bumpy skin over the nose.
Alcohol, heat, sun exposure, and stress all aggravate acne rosacea. Artificial tears are valuable but if one has the ocular type, be sure other diseases of the eye are not present by seeking consultation with an ophthalmologist. Most patients need to be treated by dermatology. NEJM,
Pedophilia is a psychiatric disorder and a disorder of sexual preference that is unusual ( a type of paraphilia). Pedophiles are defined as at least 16 years of age and be at least 5 years older than those they are attracted to. Although most commonly diagnosed in men, women can have the disorder as well. Less than 5% of the population carries this diagnosis either formally or in secret.
Symptoms emerge during puberty. Pedophiles often suffer from other psychiatric disorders (anxiety, depression, and personality disorders). These individuals are shy, over sensitive, socially withdrawn, and depressed. Thoughts of suicide are common (46% in one survey).
Relationship with child pornography
Consumption of child pornography correlates better than with child molestation, as there are non-pedophiles that molest children. Most of these people have huge collections of photos described as their prize possessions. These pedophiles are not uncommonly in underground clubs sharing photos and communications.
There are 2 distinct groups of people who have sexual interests in children—those who have a history of sexual abuse against children, and those who have sexual interests but do not act on their impulses. Co-existing psychiatric disorders may push those not acting on their impulses into action.
Relationship to child molestation
Not all individuals who molest children are pedophiles. In fact, Psychology Today states that as many as 20% of American children have been sexually molested (most commonly by family members). There are many factors that may come into play including marital problems, alcohol or drug abuse, stress, the unavailability of an adult partner, anti-social behavior, or high sex drive. Pedophilia is less common in incest cases especially in fathers and step-fathers. One study cited 35% of child molesters are true pedophiles.
Pedophilia is not a legal term but certainly is the most stigmatized of all mental disorders.
Structural Brain Differences
Scientists in Germany (Journal of Translational Psychiatry-May, 2017) studied brain imaging in both groups. They found actual structural brain differences in the group who act on their impulses committing criminal acts of sexual abuse compared to normal individuals who were attracted to adults. There is less gray matter in the right temporal lobe, specifically the right amygdala. Affected areas are associated with empathy, sexual and social cueing, and behavioral inhibition. The MRI scans (below) demonstrate the area in yellow and green.
Other studies suggest less white matter of the brain than controls.
There appears to be no genetic differences in pedophiles although there is some familial tendencies. These people have normal IQs. But it has been suggested that there is a dysfunction at the cognitive stage of sexual arousal.
Behavioral inhibition therapy implies the ability to not act on impulses due to negative consequences. If this study can be repeated with similar results, it may help doctors prevent or treat this horrible disorder.
The diagnostic criteria for pedophilia include the presence of sexually arousing fantasies, behaviors or urges that include some kind of sexual activity with a prepubescent child usually below age 13 for six months or more or the individual has acted on those urges and feels distress for having these feelings. A subset of those committing incest may be included in this diagnosis. True pedophiles are sexually aroused only by pre-pubescent children while there are non-exclusive pedophiles can be aroused by adults and children but have a preference for the children. The diagnosis does not require an actual sexual act with a child.
Those that perform indecent exposure to children may or may or not fit the exact criteria for pedophilia, but certainly are suspect. There are voyeurs also that may be included (peeping Toms). Some studies cite as many as half of adult males have some of these tendencies or have acted on them at one time but did not continue.
There is disagreement between the American Psychiatric Association and other experts. Many want to simplify the criteria to include anyone who is sexually attracted to pre-pubescent children whether they act on their urges and fantasies or not.
If a child is the victim of or observer of inappropriate sexual behavior, they may learn to imitate such behavior and may be reinforced by these same behaviors in their future.
There is no cure for pedophilia. Treatment centers on helping these individuals not to act on their urges. Cognitive therapy emphasizes controlling (not curing) the disorder by reducing behaviors, beliefs, and attitudes that may influence having sexual activity with a child.
There are medications that can reduce the individual’s sex drive. Anti-androgens have been used to reduce testosterone levels in males but the evidence for successfully controlling pedophilic fantasy and behavior is still in question. Medroxyprogesterone (Depo-Provera) and cyproterone (Androcur) are the two most commonly prescribed. Lupron, which is also used to chemically castrate prostate cancer patients is also used with less side effects. All of these meds can cause weight gain, osteoporosis, breast development and liver damage. Medical treatment should always be combined with counseling and appropriate monitoring.
Because there has been observed different levels of serotonin (a brain hormone) in these individuals, somewhat higher doses of SSRIs (anti-depressants) have shown some success in treating their underlying depression (Zoloft, Celexa, Prozac, Paxil, and Luvox). These medications do not resolve the real sexual fantasy and urge issues. Anti-depressants are successful in decreasing sex drives in pedophiles as a side effect of SSRIs.
Aversive conditioning has been tried with some success. Remember the movie A Clockwork Orange? Watching video of sexual behaviors associated with a negative experience such as visualizing a painful experience with the genitals is an example of this conditioning technique.
Registry for sex offenders
A. Background and definitions
Last month, I reported on leukemia (acute and chronic). In addition to leukemia, lymphomas are cancers that involve the lymph system as well. The lymph system is intimately involved with the hematological system, but is actually part of the circulatory and immune system.
To discuss lymphomas, it is important to give you an idea about what the lymph system entails. The anatomy of the system is below, which includes lymphatic vessels (separate from blood vessels) which traverse the body connecting all the lymph nodes in a network. These vessels connect into a conduit called the thoracic duct in left lower neck which dumps the lymph fluid into a blood vessel (subclavian) for the lymph to be broken down by the liver.
B. Component of the lymph system
The lymph system also includes the bone marrow, tonsils, spleen, and thymus, as shown below. All these organs can be involved in lymphoma. I will explain what the spleen is and does immediately following this report.
C. Functions of the lymph system
The lymph system essentially filters the body’s tissues, removing toxins, excessive fluid in the body, poisons, and transports white blood cells to the blood to fight infections, and produces lymphocytes (T and B cell lymphocytes which produce antibodies) primarily in the lymph nodes.
These functions overlap with the hematologic system because the bone marrow is also part of the lymphatic system, where leukemia occurs. Leukemia can transform into lymphomas and vice-versa because the actual cancer cells (lymphocytes) are the same. Essentially, if the main disease is in the bone marrow, it is diagnosed as leukemia, and if primarily in the lymph nodes, it is diagnosed lymphoma.
Lymph nodes can enlarge with infections but also with cancers. These nodes are present in the neck, chest, abdomen, armpits, and groin. Every organ has lymph nodes that drain the tissue fluids away to be discarded.
Lymph nodes are the “policemen” of the body trying to limit spread of infection and cancers. But cancers can start in the nodes. If these nodes enlarge, doctors need to determine why they enlarge (infection, metastatic cancer, or lymphoma) with a biopsy.
Lymphomas are cancers of the lymph system, specifically the lymphocyte, a white blood cell that make antibodies.
D. Classification of lymphoma
Lymphomas account for 5% of all cancers according to the NIH (National Institutes of Health) and 55% of all blood cancers. There are dozens of subtypes of lymphomas, however, the two main categories include Hodgkins and non-Hodgkins lymphoma. Thomas Hodgkin described the disease in 1832. Internationally, multiple myeloma and myeloproliferative diseases (previously discussed) are included in blood cancers with leukemia and lymphoma. 90% of lymphomas are non-Hodgkins type.
E. Signs and symptoms
The primary symptom of lymphoma is swelling of the lymph nodes (i.e. see above drawing of the neck nodes).
Systemic symptoms include fever, night sweats, and weight loss. Others are fatigue, malaise, anorexia (loss of appetite), respiratory distress or shortness of breath, itching, and abdominal discomfort or swelling (the stomach is the most common intestinal organ to have a lymphoma although can occur in the colon). Stomach lymphomas occur outside of the lymph nodes and account for 1-4% of all intestinal cancers.
A biopsy of a lymph node is the primary method used to diagnose lymphoma wherever they are enlarged (neck, chest, abdomen, etc.). Analysis of the malignant cells is used to categorize the lymphoma using immunotyping, flow cytometry, and other tests. Flow cytometry can provide in-depth knowledge about the characteristics of a cancer cell. Bone marrow biopsy may be performed to see if the cancer cells are present in the bone marrow.
Lymphomas occur in the two types of lymphocytes--T-cell and B-cell. Since the treatments are somewhat different, it is crucial to know which type it is.
A special test to measure the level of LDH (lactic dehydrogenase) in the cancer cells can help predict outcome. Genetic analysis for mutations is also a predictor.
G. Staging (I-IV)
Imaging (PET and CT scan) is performed to see the extent of the disease and is instrumental in staging the disease, as is done in all cancers (localized, regional, and distant). Staging correlates with survival.
MRI scan with chest nodes; Chest X-ray with nodes
H. Grading of the cancer (low or high grade) of non-Hodgkins Lymphoma
The treatment differs between low and high grade lymphomas. Follicular lymphoma is the most common low grade (indolent) lymphoma which may not require treatment if there are no symptoms.
1- Non-Hodgkins Lymphoma-classification
-low grade/with symptoms and without symptoms
a) Low grade (indolent) lymphomas (most common is Follicular Lymphoma) grow and spread very slowly usually with few symptoms. Follicular lymphoma is derived from the B cell lymphocyte, usually diagnosed at 50 years of age or older. Although usually slow growing, they can become aggressive.
If asymptomatic treatment may be delayed because of the side effects of the treatment.
If symptomatic, there is still controversy over frontline therapy—options include bendamustine (Treanda), *CHOP, or **CVP with Rituxin or Gazyva. These acronyms are combination drugs (chemo) added to prednisone plus a biologic agent(Rituxin or Gayzva).
* CHOP therapy (C-Cytoxin, H-Doxirubin hydrochloride, O-Oncovin, P-Prednisolone;
**CVP therapy-C-Cytoxin, V-vincristine, P-prednisolone
b) High grade lymphomas (the most common is called diffuse B-cell lymphoma) quickly grows in the lymph nodes, spleen, liver, and bone marrow. They usually present with fever, sweats, and weight loss (called B symptoms). They can still be controlled but are treated aggressively with the same chemo agents previously mentioned. These usually recur within 2 years and will need even more aggressive chemotherapy and or stem cell transplants.
The FDA just approved the second gene therapy for these lymphomas when standard therapy fails(type of targeted therapy). The gene is called axicabtagene (Yescarta). This therapy involves extracting T-cells (CAR-T cells--immune lymphocytes) from the patient’s blood and genetically engineering them to recognize proteins on the lymphoma B-cells and targets them for destruction. These cells are then re-infused into the blood stream for them to do their work (Price of drug minus care-$393,000 and with care probably approaches $1 million. This is being studied in 22 hospitals (including Moffitt Cancer Institute in Tampa) and is very promising. These treatments are reserved for chemo failures. There are consequences (side effects) when manipulation of the immune system is performed, and that is why it is reserved for a select group.
J. Risk factors for developing lymphoma
Certain Groups of individuals
There are groups of individuals who are more likely to develop lymphoma. They are older people, male, white, those who have auto-immune diseases(rheumatoid arthritis, lupus, etc.), hereditary immune disorders (hypergammaglobulemia, etc.), HIV/AIDS, infection with Ebstein-Barr virus-i.e. infectious mononucleosis, H.pylori infections (causes peptic ulcers), or anyone taking immunosuppressive drugs for auto-immune diseases and organ transplants.
Some of the new anti-tumor necrosis factor agents (TNF-inhibitors) have created an increased risk for lymphoma. They are used in the treatment of rheumatoid and psoriatic arthritis and other immunologic diseases such as inflammatory bowel disease (Crohn’s, ulcerative colitis) such as infliximab (Remicade), adalimumab (Tremfya), and certolizumab (Cimzia). The risk is increased almost three times especially if the patient has also been treated with thiopurines (Imuran, Purinethol, Lanvis) as well for their inflammatory disease. Etanercept (Enbrel), another drug used to treat arthritis also causes an increase risk for lymphoma.
Counteracting inflammation in the body with immunosuppressive agents comes with a cost of serious side effects in a small percentage of patients including developing malignancy of the very blood cell (lymphocyte) that is responsible for creating the immune response in the body.
If the disease is localized to one area of the body, it can be treated with radiation therapy. If more extensive (in more than one area), the *ABVD method can be used. BEACOPP and the Stanford methods are also used.
*ABVD is a combination therapy consisting of Adriamycin, Bleomycin, Vinblastine, Dacarbazine
Options for Treatment
There are actually 10 types of treatment that can be used depending on the type, severity, relapse, etc. Rather than get specific with each of the many types of lymphoma, (and these options are available to most the blood cancers, I will quickly describe them.
1. Radiation-external, internal—using radioactive materials in wires, seeds, needles, and catheters, and external total body before stem cell transplants, 3. Chemotherapy-oral, intravenous, into the cerebrospinal fluid, in body cavities, or into an organ, 4. Immunotherapy-these immunomodulators stimulate the body’s own immune system to fight the cancer (Lenalidomide is used in lymphoma), 5. Targeted therapy-the most common are monoclonal antibodies (Rituximab, Yttrium Y 90 ibritumomab tiuxetan), proteosome inhibitor antibodies, and kinase inhibitors (idelasilsib) are all used in non-Hodgkins type, 6. Plasmapherisis—remove the plasma and then specifically remove unneeded plasma protein antibodies, 7. Surgery-to remove tumors especially in indolent types, and splenectomy, 8. Stem cell transplant, 9. Antibiotics-for infections, and 10. Watchful waiting in indolent asymptomatic lymphomas.
First time vs recurrent lymphoma
This is a difficult discussion and has many factors to consider, including what was used the first time. Stem cell transplants and biologic therapies (Retuxin, Gayzva) are part of the discussion. Also clinical trials should be considered.
Biologic therapy is a type of therapy that also attacks specific cells similar to immunotherapy. Vaccines are an example. These are being tested along with many new types of therapy in clinical trials. This could be an option when other therapies are ineffective.
Late effects of treatment
The chemotherapy and other forms of lymphoma treatment carry a price for multiple drug treatment. These chemo agents may cause heart problems, infertility, loss of bone density, neuropathy, and secondary cancers, but also bankruptcy (because of the enormous cost), prolonged depression, permanent pain, etc. I bring these last few items up because of the outrageous prices Big Pharma is getting away with. I recently wrote a report on this subject (September, 2017), but this is the latest:
Novartis pharmaceuticals just received FDA approval a new drug for treatment of leukemia and some lymphomas. The price of the drug alone is $475,000. They rationalize it is cheaper than the cost of a stem cell transplant. Wow!!
5 year survival rates and percent of the total number of cases by stage (note the percent who present with distant disease)
I—localized—26% of cases; 5 yr survival 82.3%
II—Regional—19% of cases; 5 year survival 78.3%
III--Distant—47% of cases; 5 year survival 62.7%
IV—Unknown—8% of cases; 5 year survival 68.6%
Lymphomas are not curable but very controllable. Almost half of the patients already have distant disease when first diagnosed although still do very well for prolonged periods of time. There will be relapses, usually within 2 years, therefore, treatment does not have to always be ongoing.
There are maintenance drugs for some lymphomas. Watchful waiting is a reality for very slow growing lymphomas (indolent) with no symptoms. This may seem odd to some, but considering the significant side effects and the fact that treating earlier does not change the course of the disease, it is a real option.
American Cancer Society- www.cancer.org/lymphoma
National Cancer Institute www.cancer.gov/lymphoma
Medicine.net, CDC, Mayo Clinic
I have talked about the spleen many times and have not explained what this organ is and what its functions are.
Anatomy and function
The spleen is an organ that sits up under the left ribs in the uppermost abdomen opposite from the liver which occupies the right upper abdomen. It is the size of a small fist (~4 inches long).
It is part of the hematological system/immune system that filters blood, gets rid of old red blood cells, can store blood in certain circumstances and even make blood cells (lymphocytes and red cells), especially when the bone marrow is not doing its job. It can also fight infections because the spleen contains a cell called a phagocyte which can engulf bacteria and destroy them. It also stores red cells and platelets (as much as 40% of platelets).
The spleen does not get much attention until it becomes enlarged and can rupture creating a true emergency (hemorrhage) requiring surgical removal since it can’t be repaired. It can rupture in a fall, a car accident, or from disease.
The spleen can enlarge from infectious mononucleosis, toxoplasmosis (parasitic disease), and endocarditis (infection in the heart), inflammatory diseases (rheumatoid arthritis, sarcoidosis), diseases of liver (pressure backs up from the liver in the veins—i.e. cirrhosis, cancers especially leukemia and lymphoma, and from trauma.
When the spleen becomes enlarged it can aggressively destroy blood cells necessitating its surgical removal. Therefore, in recent reports the spleen was discussed in the disorders of the red cells, white cells, and platelets.
The physician should not be able to feel this organ in the upper abdomen. If he or she can, it is considered enlarged and should alert the doctor for a workup looking for a cause.
Can you live without a spleen?
Yes, but the patient can be prone to infections from strept pneumonia (pneumococcal infections), Neisseria meningitides (meningitis), and Haemophilus influenza.
It is critical for patients who lose their spleen to stay up to date on the flu vaccine, and get the pneumococcal vaccine (pneumonia shot) (Prevnar 13). If the pneumonia shot is received before age 65, a booster is recommended in 5 years, however, if over 65, a booster is not necessary, according to the CDC.
I have two goals in writing this article:
I. Explain how inflammation plays a role in dental disease
II. How gum disease is one of the leading causes of inflammation and how it influences systemic disease
I. Inflammation and Disease
I have mentioned many times that the mouth, especially gum disease, contributes to chronic inflammation in the body and can aggravate many diseases. The mouth is a clear source for bacteria to enter the blood stream. Bacteria can be found in the blood stream after the teeth are brushed. Anytime there is a vulnerable area in the body, gum disease and its bacteria can attach to these areas, especially artificial or damaged organs such as a heart valve, a replaced joint, an artery with plaque in it, etc. causing severe consequences.
It is also known that inflammation in one area of the body can have deleterious effects on the inflammatory process in another part of the body. There are chemicals (cytokines, C-reactive protein, etc.) that are well known in the inflammatory process that create disease for vulnerable areas of the body, including organs such as the pancreas, and has long thought to be involved in contributing to type 2 diabetes. It is well known gum disease secretes these pro-inflammatory cytokines.
There are tests that when elevated indicate non-specific inflammation—one is called ESR—erythrocyte sedimentation rate and another is the C-reactive protein test. However, chronic inflammation can be present without these tests being elevated. An elevated test must be correlated with clinical findings to focus in on the site of inflammation. It should be noted that with gum disease and certain illnesses, there is an association not a causation with periodontitis and certain illnesses.
II. Periodontal (gum) disease
According the CDC, 47% of men and women over 30 years of age, and 70% over 65 have some degree of periodontal disease. It is no surprise, since only 64% of American adults see a dentist regularly. Without dental cleanings and professional examinations (along with twice daily brushing and flossing)the risk for dental and gum disease is very high.
Gum disease is PREVENTABLE with regular brushing using fluoride toothpaste, flossing, water pic use (my favorite), and regular checkups (including at least every 6 month dental hygiene cleanings).
B. Relationship to increased risk of cancer
A recent study of postmenopausal women with periodontal disease cited a 14% increased risk of certain cancers. These are observational studies but still legitimate. It is still unclear whether periodontal disease causes cancer, however, the same bacteria have been found in esophageal cancers. These women have an increase risk of cancers of the lung, esophagus, gall bladder, breast, oral cavity, and melanoma of the skin. A slight increase occurred with stomach cancer. Smoking history although often associated with periodontal disease and cancers still showed increased risks in non-smokers with periodontal disease.
C. What causes gum disease?
Gum disease begins because people are not following their dentist’s guidelines for dental disease prevention. Without daily brushing and flossing, deposits of bacteria begin to accumulate on the teeth especially between the teeth and gum line (plaque). As this process progresses, inflammation begins in the gums leading to gingivitis, periodontitis and ultimately loss of teeth.
D. Plaque and Tartar--definition
Bacteria fill the mouth of all people and form a sticky substance with mucus and other particles to create what is called plaque. Plaque that is not removed routinely will harden causing tartar. Once tartar is present, it may take a dental hygeinist to remove it. That is one of the main functions of a dental cleaning. Flossing (and water irrigations) can control plaque if routinely removed. Electric toothbrushes are more effective in removing plaque than regular brushes.
Interdental cleaning instruments
When plaque and tartar persist, it causes inflammation of the gums, which is called gingivitis. This is also a reversible process with proper dental care. Redness and easy bleeding of the gums are signs of gingivitis. It is time to see the dentist. No toothpaste (including parodontax) is going to substitute for seeing a dentist if gingivitis is present.
If gingivitis is not treated, the disease progresses to periodontitis, which means extended inflammation deep into the gums around the teeth. As the gum disease progresses, the gums pull away from the tooth creating pockets that become infected and go below the gum line. The body’s natural defenses and bacterial toxins try to dissolve these plaques and tartar, but in doing so, start breaking down the bone and connective tissue which holds the tooth tightly in place. When that occurs, the ultimate result is tooth loss.
G. There are risk factors that accelerate gum disease:
1. Smoking and chewing tobacco (this includes smoking pot regularly which is very drying to the mouth)
2. Hormonal changes in girls and women can make the gums more sensitive and more prone to gum disease.
3. Diabetes increases the risk of infections including gum disease.
4. Diseases that decrease the immune system, including autoimmune diseases (rheumatoid arthritis, lupus, MS, etc.), patients on immunosuppressant drugs, chronically ill patients, those with HIV-AIDS, and diseases of the salivary glands-- (i.e. *Mikulicz disease, Sjogrens disease, etc.), which decrease the amount of saliva predisposing to dry mouth syndrome (later explained in this report).
* Mikulicz and Sjogrens disease are characterized by swelling and pain the spit glands requiring antibiotics, etc.
5. Patients with cancer treated with chemotherapy and radiation especially head and neck cancer patients who have treatments of the mouth and throat (includes the jaws, teeth and gums).
6. Dry Mouth syndrome secondary to medications
There are hundreds of prescription and OTC medications that cause dryness of the mouth. (Expanded information in the January 2018 report)
7. Genetic predisposition to gum disease
H. Progression of periodontal disease
Recession of the gums leads to exposure of the deeper portions of the teeth as shown in the X-rays on the next page. As the gums recede, pockets form leading to bone loss around the teeth, which leads to loosening of the tooth and eventually tooth loss.
I. Symptoms of Gum disease
Bad breath, red, swollen, tender and bleeding gums, sensitive teeth, loose teeth, and receding gums (teeth look longer).
Note the recession of the gums exposing more of the teeth in the two images below.
(Good bone betweenteeth--arrow)
Bone loss between the teeth
J. Treating Gum disease
The goal of treatment is to control infection with comprehensive professional dental care (including deep cleanings) combined with daily home dental care. Home care should include using an irrigator to clean the pockets out that flossing cannot reach.
If a general dentist deems it necessary, referral to a periodontist should be entertained especially if treatment below the gum line gets fairly deep. If these gum pockets get too deep--5-10 mm (by measuring with a small dental probe), the tooth may need to be removed. Below is a dental probe checking for pockets.
Dental probe in a pocket
Probe in pocket seen below
Note tartar deposits at base of tooth
K. Scaling and root planing to remove plaque and tartar
The instruments are used to clean the tooth plaque and tartar even down below the gum line in these pockets.
L. The Dentist/Dental Hygienist team-their vital role
I cannot overemphasize the value of a dental hygienist and dentist to see people regularly. Patients tend to skip seeing their dentists when the budget gets tight. However, prevention of dental disease is a crucial healthcare concern and should be considered as vital as seeing the primary care physicians routinely. The dentist’s examination and X-rays can find early hidden disease and handled more easily and less expensive than waiting til there is a full blown issue is discovered. Prevention is the hallmark of dentistry as it is in medicine.
A special thanks from my personal dentist, Dr. Ray Gyselinck, in Dillard, Georgia, who reviewed this report and made important contributions.
Next month, I will report on the dry mouth syndrome and its serious effect on dental and gum disease, plus an extensive self help section.
THANK YOU FOR READING THE MONTHLY REPORTS. REMEMBER TO LET ME KNOW IF YOUR E-MAIL ADDRESS CHANGES, AND IF YOU EVER DON’T SEE THE REPORT ON THE FIRST OF THE MONTH, CHECK YOUR SPAM.
NEXT MONTH, JANUARY, 2018, THE SUBJECTS WILL BE:
1. Dry mouth syndrome is serious
2. Hereditary cancer syndromes
3. The use of estrogen after menopause
4. Social anxiety disorder
5. Ear wax—how to prevent and treat
6. Interstitial cystitis in women
Stay healthy and well, my friends, and merry Christmas and Happy Hanukkah, Dr. Sam