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Linking oral health to diseases and optimal ageing

Numerous studies have found a correlation between oral health and optimal ageing and diseases, but why does this happen? And how does it work? 

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Numerous studies have found a correlation between oral health and optimal ageing and diseases, but why does this happen? And how does it work? 

Normally the body’s natural defences and good oral health care, such as daily brushing and flossing, keep bacteria under control. However, without proper oral hygiene, bacteria can reach levels that might lead to oral infections, such as tooth decay and gum disease.

Gum disease is where the gums becomes red, swollen and sore, and bleed. It’s very common, but it’s important to get it checked by a dentist. 

This disease is caused by a build-up of plaque on the teeth. If you don’t remove plaque from your teeth by brushing and cleaning in between them regularly, it builds up and irritates your gums.

Pete Williams, founder of Functional Medicine Associates, said: “If you look at the literature, it shows that over 50 per cent of the population over 30 in western societies have gum disease. It means that one in two patients are probably gonna have gum disease, and that’s problematic.”

Oral health is important for maintaining general health among patients and in particular the elderly.

Martijn Verhulst, Medical Liaison Manager at Sunstar, explained the relation between wellness in elderly adults and oral health: “A good example is how a gradual decline in oral function due to ageing can impact general well-being, and vice versa. Starting in Japan, the scientific community is more and more accepting that this gradual decline in oral function is part of a broader concept called physical “frailty”.”

Discussing issues. Cropped shot of a professional dentist showing jaws and teeth x-rays to his patient using a digital tablet technology gadget online

 

As explained by Dr. Williams, having a gum disease means having a barrier that’s been broken. If a patient’s gums are bleeding or if the patient has gum recession, there is a weakness in the barriers that protect them from the outside world.

As a consequence, the bacteria can slip in the body and cause problems. With bacteria always coming through the gum, there’s a constant response from the immune system, which damages other structures at the same time. 

“In addition to the effect of physical frailty on oral health, the reverse is also true,” said Verhulst. “Research has also shown a clear relationship between poor oral health and physical frailty. Problems such as losing teeth, deterioration of oral motor skills, chewing and swallowing issues, saliva disorders, and oral pain all contribute to becoming frail.

“And then finally, there’s the more patient-centred side of the relationship. Both oral and physical frailty are also associated with poor quality of life, as people start losing their independency and become less and less socially engaged due to their symptoms.”

Gum disease has also been found related to chronic diseases such as Alzheimer’s. Dr. Williams explained that what is important to understand is that a local problem becomes a systemic problem.

Therefore, an infection can travel from the mouth, possibly becoming a causative effect of what happens in the brain.

“There are some drug trials happening now, creating a drug that is an inhibitor for one of the toxic effects of the oral bacterias,” he said.

“If you control some of the pathogenic bacteria in the mouth you reduce the risk of Alzheimer’s.”

Martijn Verhulst explained that prevention is the most important thing to do. He added: “Efforts should be targeted at retaining as many teeth as possible by optimising oral hygiene and regular dentist visits. 

“If a full denture is needed, it’s better to go for an implant-supported one rather than a removable one. 

“When it comes to maintaining oral function, there are some studies showing that an oral and physical exercise program can improve oral hypo function. And finally, maintaining a healthy diet and an active social life are absolutely crucial for preventing oral frailty.”

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Palliative care beneficial to manage symptoms, improve quality of life for people with CVD

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Implementing patient-centered palliative care therapies, including prescribing, adjusting or discontinuing medications as needed, may help control symptoms and improve quality of life for people with heart disease, according to a new scientific statement from the American Heart Association.

Decisions about initiating, adjusting or discontinuing cardiovascular and other medicines should be patient-centered and include input from multiple specialties including cardiology experts in close collaboration with primary care professionals.

Evidence shows that adding palliative care interventions to standard cardiovascular care improves outcomes for patients with heart disease. However, the latest research indicates palliative care is underutilised, especially among people from underrepresented racial and ethnic groups who are affected by unfavourable social determinants of health and health inequities.

The American Heart Association’s statement, published in the Association’s journal, Circulation: Cardiovascular Quality and Outcomes, reviews current evidence on the benefits and risks of cardiovascular and essential palliative medications.

The statement provides guidance for health care professionals to incorporate palliative methods as part of holistic medication management at all stages of a patient’s health conditions, emphasizing the importance of shared decision-making and goal-oriented care.

Palliative care is specialised medical care that aims to relieve symptoms and enhance quality of life for people experiencing health-related issues due to serious illnesses. This approach may benefit patients with cardiovascular disease, including coronary heart disease, valvular heart disease, pulmonary arterial hypertension and heart failure. These conditions significantly reduce quality of life, require ongoing treatment, are usually progressive and are associated with high mortality rates. The progression of many conditions, from chronic to advanced and end-stage, may be unpredictable and marked by worsening symptoms that result in recurrent hospitalisation.

Palliative care complements standard cardiovascular care by reducing physical symptoms, managing emotional distress and assisting patients in making decisions that coincide with their goals of care. A palliative approach can be integrated into the medication management of patients at any stage of heart disease, from chronic, stable heart disease to advanced and end-stage cardiovascular disease. And, importantly, palliative care supports a more goal-oriented, patient-centered approach to treatment.

Previous studies have found that adding palliative care interventions to evidence-based care improved patients’ quality of life, functional status, depression, anxiety and spiritual well-being and reduced the risk of hospital readmission for patients with advanced heart disease compared to clinical care alone. Despite these benefits, fewer than 20% of people with end-stage heart disease receive palliative care.

In addition, despite significant progress in cardiovascular care, disparities in care and outcomes related to race, ethnicity, gender and social determinants of health persist. People with heart failure who are referred to palliative care are predominantly white, have higher socioeconomic status and are more likely to receive care at academic medical centers. Patients from underrepresented racial and ethnic groups are less likely to receive palliative care, which contributes to poorer outcomes and increased risk of early mortality.

“It is critical for patients to be fully informed about their diagnosis and how medication management may change throughout the disease progression so they have ample time to set and share their goals,” said Chair of the statement writing group Katherine E. Di Palo, Pharm.D., M.B.A., M.S., FAHA, senior director of Transitional Care Excellence at Montefiore Medical Center and assistant professor of medicine at Albert Einstein College of Medicine in New York City.

“These goals often include reducing symptoms such as shortness of breath, fatigue, and pain as well as improving sleep, mood and appetite.”

To achieve these goals, cardiovascular medications that provide symptom relief, such as diuretics to manage fluid retention in heart failure, should be prioritised in patients with advanced heart disease.

Adding palliative medicines to evidence-based cardiovascular therapies can be complementary to manage symptoms and optimise quality of life. Examples of common palliative medicines include antidepressants, opioids for pain relief and difficulty breathing, and anti-nausea medications.

“Given the complexities of medication management in people with heart disease, a team-based approach is urged. Collaboration between multidisciplinary clinicians across primary care, cardiology and palliative care is needed to deliver effective, person-centered care,” said Di Palo.

Because the health status of patients can change rapidly, it is crucial to have ongoing discussions to ensure that treatment plans align with the patient’s preferences and priorities. Clinicians should routinely evaluate — and clearly communicate — to patients and their families about the potential risks, benefits and expected time to benefit of each medication.

Deprescribing and de-escalating medications are also essential components of palliative medication management for people with heart disease. Deprescribing involves tapering, withdrawing or discontinuing a medication to improve outcomes. De-escalating medications focuses on reducing the dose or switching to another medication based on the patient’s response to the medicine.

“Deprescribing that targets medications with limited benefit or increased risk of adverse events can be done safely with patient permission,” Di Palo said.

The statement provides several examples where deprescribing medications may be appropriate to consider, such as when the time to benefit from the medication may be longer than the patient’s life-expectancy.

Anti-clotting medications (also known as anticoagulants) may be prescribed to reduce the risk of blood clots. However, some of these medicines may increase the risk of bleeding, especially in older patients over the age of 75 who are at increased risk of falls.

Discontinuing non-steroidal anti-inflammatories (NSAIDs) may also be considered in patients with end-stage heart disease due to increased risk of bleeding and fluid retention. Although beta-blockers are commonly prescribed for high blood pressure and heart failure, they may contribute to fatigue and functional decline in end-stage heart disease. A slow-tapering schedule can help to reduce the risk of rebound high blood pressure or withdrawal when large doses are abruptly stopped.

Other reasons to consider deprescribing medications include polypharmacy, defined as taking five medications or more daily. This increases the risk of adverse reactions or side effects, not taking medications as prescribed, hospital readmission and mortality. Excessive out-of-pocket medication costs may also prompt the need to deprescribe certain medications.

Future research is needed to determine the best ways to provide timely and targeted access to palliative medication management, particularly for patients with advanced heart disease from under-represented racial and ethnic groups who are less likely to receive palliative care or may face barriers to care.

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How the ketogenic diet improves healthspan and memory in aging mice

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The ketogenic diet has its fanatics and detractors among dieters, but either way, the diet has a scientifically documented impact on memory in mice.

While uncovering how the high fat, low carbohydrate diet boosts memory in older mice, Buck scientists and a team from the University of Chile identified a new molecular signalling pathway that improves synapse function and helps explain the diet’s benefit on brain health and aging.

Published in the June 5, 2024 issue of Cell Reports Medicine, the findings provide new directions for targeting the memory effects on a molecular level, without requiring a ketogenic diet or even the by-products of it.

“Our work indicates that the effects of the ketogenic diet benefit brain function broadly, and we provide a mechanism of action that offers a strategy for the maintenance and improvement of this function during aging,” said the study’s senior author, Christian González-Billault, PhD, who is a professor at the Universidad de Chile and director of their Geroscience Center for Brain Health and Metabolism, and adjunct professor at the Buck Institute.

“Building off our previous work showing that a ketogenic diet improves health span and memory in aging mice, this new work indicates that we can start with older animals and still improve the health of the aging brain, and that the changes begin to happen relatively quickly,” said John Newman, MD, PhD, whose laboratory at Buck collaborated with Dr. González-Billault on the study. Newman is both an assistant professor at the Buck Institute, and a geriatrician at University of California, San Francisco.

“It is the most detailed study to date of the ketogenic diet and aging brain in mice.”

More than a century ago, researchers observed that rats that consumed less food lived longer. “We now know that being able to manipulate lifespan is not about specifically eating less,” said Newman, but actually is related to signals inside cells that turn on and off specific pathways in response to available nutrients. Many of those pathways are related to aging, such as controlling protein turnover and metabolism.

Some of those signals are the ketone bodies, which consist of acetoacetate (AcAc), β-hydroxybutyrate (BHB) and to a much lesser extent, acetone. These molecules are routinely produced in the liver. They ramp up when glucose is in short supply, whether due to caloric restriction, intense exercise or low carbohydrate intake, such as with a ketogenic diet.

Seven years ago, Newman led a team that published the first proof of the concept that if a ketogenic diet exposes mice to increased levels of ketone bodies over much of their adult life, it helps them to live longer and age in a more healthy way. “The most striking effect on their health as they aged was that their memory was preserved; it was possibly even better than when they were younger,” he said.

The current study, designed to answer what part of the ketogenic diet was having the effect and how it was affecting the brain on a molecular level to improve memory, was led by González-Billault in a collaboration with scientists at the Buck. Mice on a ketogenic diet are fed a ratio of 90 percent calories from fat and 10 percent from protein, while mice on a control diet received the same amount of protein but only 13 percent fat. The test mice, of “advanced age” of more than two years old, received one week of the ketogenic diet, cycled with one week of the control diet, to keep the mice from overeating and becoming obese.

The benefits of the ketogenic diet, said, González-Billault, were demonstrated through neurophysiological and behavioural experiments with the mice that test how well the mechanisms involved in memory generation, storage, and retrieval function in aged animals. When these showed that the ketogenic diet appeared to benefit how well the synapses responsible for memory worked, they took a deep dive into the protein composition at these synapses in the hippocampus, in a collaboration with Buck professor Birgit Schilling, PhD, who directs the Proteomics and Mass Spectrometry Center.

“Surprisingly, we saw that the ketogenic diet caused dramatic changes in the proteins of the synapse,” said Schilling. Even more surprising, she said, was that the changes started after a relatively brief exposure to the diet (tested after only one week on the diet) and only became more pronounced over time (tested again after six weeks and a year).

Further testing indicated that in synapses, a particular signalling pathway (protein kinase A, which is critical to synapse activity) was activated by the ketogenic diet. In isolated cells, the team then showed that it appears that BHB, the main ketone body produced in a ketogenic diet, is activating this pathway. This leads to the idea, said González-Billault, that ketone bodies (specifically BHB) play a crucial role not only as an energy source, but also as a signalling molecule.

“BHB is almost certainly not the only molecule in play, but we think this is an important part of understanding how the ketogenic diet and ketone bodies work,” said Newman “This is the first study to really connect deep molecular mechanisms of ketone bodies all the way through to improving the aging brain.”

Looking forward, he said, the next step would be to see if the same memory protection could be achieved by using BHB alone, or possibly going even more targeted than that by manipulating the protein kinase A signalling pathway directly. “If we could recreate some of the big-picture effects on synapse function and memory just by manipulating that signalling pathway in the right cells,” he said, “we wouldn’t even need to eat a ketogenic diet in the end.”

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The impact of lifestyle intervention in rheumatoid arthritis

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Patients with rheumatoid arthritis have unique autoantibody patterns

A 16-week Plants for Joints trial investigated the effects of a multidisciplinary lifestyle intervention in people with rheumatoid arthritis (RA), as compared to usual care.

The intervention was based on a whole-food, plant-based diet – alongside physical activity and stress management. Previous reports showed this intervention significantly reduced the 28-joint disease activity score compared to usual care alone.

To expand on this, the researchers wanted to determine the long-term effectiveness of the intervention, specifically with regards to disease activity after two years.

After the initial 16-week randomised period, the control group also received the intervention, and participants were followed for 2 years with biannual visits and six adherence-promoting webinars annually. People with DAS28 <2.6 also received a protocol as a suggested approach to try tapering their antirheumatic medication – under the supervision of their rheumatologist – and any treatment changes were recorded.

In total, 62% of the original trial completers also completed the two-year follow-up. Those who discontinued most often indicated that this was because they were too busy, unreachable, or did not give permission for the second year of the extension study.

The long-term results showed that improvement in DAS28 was maintained for two years after completing the intervention – and was significantly lower compared to baseline. Tender joint count and general health components of the DAS28 also improved significantly, although there was no significant difference in the erythrocyte sedimentation rate and swollen joint count compared to baseline.

Results were similar in people who completing the two-year extension study versus those that discontinued prematurely.

Of the 39 participants who completed their follow-up and used disease-modifying antirheumatic medication, 44% were able to decrease or stop, 26% had stable usage, and 31% had increased medication. Of those with stable or decreased medication compared to baseline, 65% had improved DAS28.

After the two-year follow-up, HDL-cholesterol was increased and C-reactive protein (CRP) remained significantly lower compared to baseline values – although there was no longer a significant difference in weight, waist circumference, LDL-cholesterol, or HbA1c.

These findings indicate that intensive lifestyle modifications can be effective in the long term for people with RA.

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