BIO4360 Lecture 2 Sept 19

BIO4360 Oral Medicine

Etiology of Pathologies II
Monday, Sept. 19th, 2011

Algonquin College Oral Medicine BIO4360 © Dr. Jim Panchuk 2011

‘MIND’ Algorithm
Metabolic
Inflammatory
Neoplasms
Developmental

Metabolic
a) Hormonal
b) Nutritional
c) Compromised Organ Systems

Inflammatory
a) Trauma
b) Infection – viral, fungal, bacterial
c)Immunologic - autoimmune


Inflammatory – c) immunologic

i) immune response to body’s own antigens
(autoimmune)
-pemphigus, pemphigoid

ii) allergic reaction to external antigen
- cinnamon, toothpaste, medications, etc.


Inflammatory – c) immunologic

i) immune response to body’s own antigens
(autoimmune)
-pemphigus, pemphigoid

ii) allergic reaction to external antigen
- cinnamon, toothpaste, medications, etc.

Inflammatory – d) reactive

-body’s response to chronic, physical irritation
-papillary hyperplasia, pyogenic granuloma, epulis
fissuratum


Neoplasms – benign, premalignant, malignant

-usually some change in surface colour &/or texture
- +or- swelling &/or pain
-usually one location and enlarges from that point
-risk factors (tobacco &/or alcohol)


Neoplasms – benign, premalignant, malignant

-usually some change in surface colour &/or texture
- +or- swelling &/or pain
-usually one location and enlarges from that point
-risk factors (tobacco &/or alcohol)

Developmental

-genetic – Basal Cell Nevus (mole), Macule

-acquired – cleft palate

-other – geog. tongue, leukodema


12 Questions to Ask
“Listen to your patient and the patient
will give you the diagnosis”
Sir William Osler


12 Questions to Ask
1) How long has the problem been present?

-if <2-3 weeks more likely inflammatory etiology
-less likely developmental, neoplasm, metabolic
-if > 5-6 wks poss. of neoplasm

2) Has it happened previously, and, if so, did it go away
completely?

-if occurred before and healed completely chance of
neoplasm is minimal
-inflammatory more likely
-infectious (herpes, recurrent fungal infection)
-immunologic (apthous ulcer, lichen planus)


12 Questions to Ask
3) Is it happening (has it occurred) in other locations in
your mouth

-multiple locations almost always rule out neoplasms
- likelihood of trauma
-location also important ex: attached vs. unattached


12 Questions to Ask
3) Is it happening (has it occurred) in other locations in
your mouth

-multiple locations almost always rule out neoplasms
- likelihood of trauma
-location also important ex: attached vs. unattached

4) Does it hurt? And if it does, chose one word to describe
the pain.

-one of 4 aspects of inflammation
-‘burning’ more chance of fungal etiology
***important to let patient chose word***


12 Questions to Ask
5) Has it grown/become worse/spread to other spots?
+ve response (along with location) will affect prob. of
metabolic etiolology
-or neoplasm, esp. malignancy which will grow in size
but seldom spread

Remember….all questions build on each other

Must link info gained from various questions

Ex: pain for 4 weeks, several locations, pain is more
‘burning, seems to be spreading slightly…..

Likelihood of fungal infection is fairly high


12 Questions to Ask
6) What can you do/have you done that makes it better or
worse?

-if stopped using product and it resolved…immunologic
-hypersensitivity/allergic rxn
-improves with salt water, worsens with orange juice
-ulceration/erosion


12 Questions to Ask
6) What can you do/have you done that makes it better or
worse?

-if stopped using product and it resolved…immunologic
-hypersensitivity/allergic rxn
-improves with salt water, worsens with orange juice
-ulceration/erosion

7) Does it come and go/change during the day?

-if rapid change…….trauma related
-if stress related…..less in morning, worse later in day
-around mealtime?


12 Questions to Ask
8) Do you remember injuring the area of the lesion?

-identify trauma or recurrent trauma


12 Questions to Ask


9) Do you have any lesions on other parts of your body?

-increased potential for immunologic cause
-auto-immune diseases with dermatologic symptoms
-some developmental lesions also have skin changes
(café au lait spots)


12 Questions to Ask


9) Do you have any lesions on other parts of your body?

-increased potential for immunologic cause
-auto-immune diseases with dermatologic symptoms
-some developmental lesions also have skin changes


12 Questions to Ask
10) Do other people in your family have anything similar?

-family Hx points to developmental problem (usually)


12 Questions to Ask


11) How is your general health? Other than the oral
problem, do you feel medically well?

-if ‘yes’ less likely due to metabolic or systemic disease


12 Questions to Ask


11) How is your general health? Other than the oral
problem, do you feel medically well?

-if ‘yes’ less likely due to metabolic or systemic disease

12) Are you taking any medication for any reason currently
or were you taking medication recently?

-verifies info about general health
-oral effects of meds


12 Questions to Ask
REMEMBER:

-intra-oral exam is NOT all that’s required to arrive at diagnosis

-need to combine with info gained from questioning

-either confirm Dx or lead to next step in tmt plan

-biopsy, drug therapy, or ‘watchful waiting’ depends on
suspected etiology


12 Questions to Ask
-some conditions have multiple etiologies
Ex: AIDS, Leukemia are Metabolic (compromised organ
system
-but oral problems typically of the Inflammation category
(infection)

-MIND does not include conditions secondary to psychologic
problems
-anxiety, phobias, self-inflicted trauma


Available Online


BIO4360 Oral Medicine

Herbal Products and Supplements
Monday, Sept. 19th, 2011


Come One, Come all


Disclaimer
The products and the claims made about specific products on or
through this site have not been evaluated by Herbal Remedies
or the United States Food and Drug Administration and are not
approved to diagnose, treat, cure or prevent disease. The
information provided on this site is for informational purposes
only and is not intended as a substitute for advice from your
physician or other health care professional or any information
contained on or in any product label or packaging. You should
not use the information on this site for diagnosis or treatment of
any health problem or for prescription of any medication or other
treatment. You should consult with a health care professional
before starting any diet, exercise or supplementation program,
before taking any medication, or if you have or suspect you
might have a health problem.


Beliefs
-Canadian studies have shown herbal medicines being used
by 30-35% of people

“Patients often believe that herbs are natural alternatives to
prescription medications, and do not recognize that herbs
are composed of bio-active chemicals which may be toxic
and can interact with other medications”
Arch Fam Med 1998;7(6):523-36

"Better Living Through Chemistry"


Beliefs
-Canadian studies have shown herbal medicines being used
by 30-35% of people

“Patients often believe that herbs are natural alternatives to
prescription medications, and do not recognize that herbs
are composed of bio-active chemicals which may be toxic
and can interact with other medications”
Arch Fam Med 1998;7(6):523-36

"The miracles of science"


Ethnobotany
Botany + Anthropology


Ethnobotany
Botany + Anthropology

Phillippus Aureolus Paracelsus
1493-1541AD

“It’s the dose that makes
the poison”


Ethnobotany

Poisonous plants are
medicinal plants
&
Medicinal plants are
poisonous plants

Herbal medications are
important


Herbal based Medicines
-1900’s – herbal supplements hallmarks of pharmaceutical
industry
-67% of all medicine listed in US Pharmacopeia were
botanicals……now only 2%
- >1/2 of “modern” prescription & OTC drugs have botanical
origins (aspirin, caffeine, cyclosporine, digoxin, quinine)


Herbal based Medicines
-1900’s – herbal supplements hallmarks of pharmaceutical
industry
-67% of all medicine listed in US Pharmacopeia were
botanicals……now only 2%
- >1/2 of “modern” prescription & OTC drugs have botanical
origins (aspirin, caffeine, cyclosporine, digoxin, quinine)
-ethnobotany very important
- < 0.5% of the world’s vanishing tropical plant species have
been investigated for their medicinal qualities


Herbal Medicine
~7000 plants have medicinal applications

-75% of world’s pop’n rely on plants for health care

-in NA most use for prevention and health maintenance

-pharmaceuticals target symptomatic/curative medicine

-majority of knowledge on plant derived medicine is traditional

-Herbals reputation hampered by:

-lack of standardization

-lack of clinically verifiable safety and efficacy


Definitions
Dietary Supplement (DSHEA):

a product (other than tobacco) that:
-Is intended to supplement the diet
-Contains one or more dietary ingredients or their
constituents
-Is intended to be taken by mouth
-Is labeled as being a dietary supplement.


Definitions
Herbal supplements:
-are one type of dietary supplement
-An herb is a plant or plant part (leaves, flowers, seeds,
roots) that is used for its flavor, scent, and/or
therapeutic properties
-"Botanical" is often used as a synonym for "herb."
-may contain a single herb or mixtures of herbs.


Regulations (USA)
-US Dietary Supplement Health and Education Act (1994)
-compromise
-exempts vitamins, minerals, & botanical products from
meaningful FDA regulation


Regulations (USA)
-US Dietary Supplement Health and Education Act (1994)
-compromise
-exempts vitamins, minerals, & botanical products from
meaningful FDA regulation
-burden of proof?
-2006 – Changes to Federal food, Drug and Cosmetic Act
-require industry to report all serious dietary supplement
related adverse drug effects to the FDA
-2007-10 – manufacturers must test for purity,
-ensure no contaminants
-verify contents match labeling information


Regulations (USA)
-Labeling according to the DSHEA:
-prevents use of therapeutic claim
ex: “for treatment of hypertension”
-must be labeled as dietary supplement
-CAN contain claims of effect on structure or function of
body (ex: increases immunity)


Regulations (USA)
-info does not have to be scientific, but cannot be false or
misleading (responsibility in hands of FDA)
Multiple violations / near violations


Regulations (USA)

… your webpage …. bears the following claim: "[F]our recent
studies in people at risk for coronary disease have shown a
significant cholesterol lowering effect from tea or tea flavonoids ...
One of these studies, on post-menopausal women, found that total
cholesterol was lowered by 8% after drinking 8 cups of green tea
daily for 12 weeks ....“

The therapeutic claims on your website establish that the product
is a drug because it is intended for use in the cure, mitigation,
treatment, or prevention of disease.


Regulations (USA)

Your Sparkling Green Tea Ginger Ale bears the claim,
"ENHANCED WITH 200 mg OF ANTIOXIDANTS FROM GREEN
TEA & VITAMIN C**" with the double asterisk referring to the
statement, "* *Each 8 oz serving contains 200 mg of antioxidants
from Green Tea Flavonoids and Vitamin C" on the principal display
panel of the product label. In the context of this label the term
"enhanced" is an unauthorized synonym for a "more" nutrient
content claim. FDA has defined the nutrient content claim "more"
and its authorized synonyms in 21 CFR 101.54(e).


Regulations (USA)
-info does not have to be scientific, but cannot be false or
misleading (responsibility in hands of FDA)
-information can be physically separate from the product
(ie: product on one shelf, info in another isle)
HUH?????


Regulations (Canada)
Canada: Natural Health Product Regulations (2004)
-allowed for sale of products otherwise not allowed under
the Food and Drug Regulations
-pre-2004 natural health products either drugs, or foods
(Food and Drug Act)


-allowed for sale of products otherwise not allowed under
the Food and Drug Regulations
-pre-2004 natural health products either drugs, or foods
(Food and Drug Act)

-different sets of reg’s for cosmetics, foods, drugs, etc.
-burden of proof varies



Natural health products (NHPs) are defined as:
-vitamins and minerals,
-herbal remedies (ex: St. John’s Wort),
-homeopathic medicines **
-traditional medicines (Traditional Chinese Medicines),
-probiotics,



Natural health products (NHPs) are defined as:
-vitamins and minerals,
-herbal remedies (ex: St. John’s Wort),
-homeopathic medicines **
-traditional medicines (Traditional Chinese Medicines),
-probiotics,
-other products like amino acids and essential
fatty acids.


Canadian Database


Labeling Requirements (Can)
Brand Name
Product/Herb Name
Structure/Function Claims
Disclaimer
Number of Product and Net Weight of Each
Directions for use
Supplement Facts
Manufacturer’s or distributor’s name, city, state, zip
code
Expiration date


Energy Drinks
-call for Health Canada to get involved with regulating
-if considered ‘foods’ only have to list ingredients
-talks about natural product not having to label caffeine
containing herbal ingredients
-if ‘natural health products’ also have to have appropriate
warnings

packs 505 mg of caffeine and 5000 mg of taurine

Beverage…..or drug delivery systems??


Energy Drinks


Alcoholic Energy Drinks


BIO4360 Lecture 2 Sept 19

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