Transcribed by Amit Amin [Organ Systems] [25] [GERD] by [Dr.

Spielman]

04/07/2014

[1] [Title] [Dr. Spielman] Today is actually an experiment that Im trying to figure out. How many have you seen Salman Khans TED conference? The one w/ Bill Gates at the end? So the idea of the Khan Academy was to change classroom activity and make it more interactive. They called it flip classroom. You post material ahead of time, students are to read, take a test, and then you come to class and you enhance the concepts you want the students to learn. Today is one of these experiments. You saw the module last September called the Case of Sensitive Teeth that was one of sixty-seven modules that are being developed. Im personally involved in twenty. They are all associated w/ a main disease, a symptom of something in the oral cavity, and then slices of science in regards to the disease. They type of activity you have done in GERD you will see in Obesity, Anemia, Osteoporosis, HIV, Hepatitis, CV problems, and other diseases. You will see 6-7 more modules next fall. Every time you have a patient that has this specific disease you should get a handle on how to handle this patient. So this module is a combination of what you retook (GERD module) as well as some of the things you have learned from it. [2] [Goal] [Dr. Spielman] The goal of today is to enhance these concepts and review those that you have seen and some that you havent seen and teach students some kind of strategy on how to figure out when patients come to you how to make sense? You will be faced w/ a range of symptoms (everything they complain about). You need to make sense of that. You need to figure out what counts and doesnt count. How do you connect the dots? Think about an analogy. I was reading an article about the 1840s in NYC. You remember that year in context of events like opening of first dental school. It was the year when flowing water and drainage was established. If I ask you to tell you everything about 1840 you would have trouble recalling all the events. Your brain does not synthesize the information. You read about things but when you are asked to put everything together you wont remember the anatomy, physiology, etc. of the stomach since they are taught in different courses. This module forces you to find the connections in these diseases. When you see your next patient w/ GERD you will know where to go. [3] [Patient] [Dr. Spielman] Here is a patient that happens to have the following symptoms. Tooth sensitivity, bad breathe, bitter taste, heartburn, and would like to have whiter teeth. First you think about acid reflux. [4] [Oral Symptoms] [Dr. Spielman] This is a symptom you might see. Soft enamel, brown teeth. They might not connect the dots. You have to do that. An esthetic concern could be an underlying problem. [5] [Oral Symptoms] [Dr. Spielman] This is a very specific image. What do you see that is alarming? Enamel erosion? What is the sign you are looking for? What specific feature in this image? You see dentin. How do you know its dentin? Its different from enamel. Its darker and brownish. What is this? Its the pulp chamber. Far less density and thats 1

Transcribed by Amit Amin

04/07/2014

where the pulse chamber shows through. Clearly you see the enamel all around. This can be easily missed. Thats why you need to take a careful look. Clearly there is sensitivity. Not ever patient complains about it. It happens gradually and it takes time for the tooth to get adjusted. Its not THE symptom all the time. Sometimes half the patients will only have it. [6] [Patient] [Dr. Spielman] These are the symptoms. How many of you would know if the patient says I have a pain and shows something on the body. How would you know where the cardia is? Let me bring it up and ask you to point it out. (He pulls up a website module). You have a number. This is a segment from an upcoming module Im working on. These are the preproduction versions. This is the type of tests you may have in 5 or 6 of them. Point to the area where the cardia, fundus, or heart is. This is something we dont teach you. If patient points to something you need to know what is there. Starting from the midline where would you put the cardia. Is it this point? This point? Ok well the vast majority said this. You see how misleading it could be (they got it wrong)? Take a look. Its actually close to the nipple. The stomach goes all the way up. People who eat a lot have the diaphragm push against the heart and you actually get palpitations. This is the actual place. Thats the where the cardia is. The stomach comes all the way up here and sits right below the diaphragm. The left ventricle sits on the stomach. Lets go back. This patient has heartburn. What kind of medications do you expect? Write it down on paper and lets talk about it. Think about it? Antacid. How many types can you have? There are different mechanisms. It should be a flag when the patient says Im taking these following medications. If you dont know the name you need to look it up. Antiacid neutralizes acid by taking carbonates. Is that a good mechanism? (student talking) What does it do? Any kind of side effects? Thats one thing. What about physical symptoms by taking bicarbonates? Whats the reaction thats taking place? Chemistry 101? Whats the product? CO2. What happens w/ CO2? Burping and bloating from water. Its not a good medication. Itll inhibit the burning sensation but its not a treatment. What other medications would you expect? Proton pump inhibitor. Why do you need that? Where is the pump? Lets take the pharmacology. You have taken the module but Im not sure you have a full picture (goes to another module again). The medications that the patient can take is a pump inhibitor and a H2 inhibitor. The problem w/ the H2 is that all three (histamine, muscarinic, and CCK receptors) are all channeling through the proton pump. If you inhibit antihistamine the other 2 pumps are still working. Gastrin can actually be inhibited but w/ a lot of side effects. Companies decide not to target gastrin or acethyocoline receptor since its so universal. Instead you target the common pathway (proton pump). Its a very important component. Let me show you a slide that will convince you (still on the module). This is a schematic diagram of a cell. These are the openings where HCL is secreted. This is the lumen. This is the basal lateral surface. All three of them are mediating through the same pathway to activate the proton pump. If you target this you pretty much shut down all of that. If you target only the H2 these two receptors are capable of still secreting. H2 targeting will only give you a partial shut down. Is that clear? OK. Lets go back a few slides. These are the two potential medications taken (H2 didnt work and now taking Prilosec). 2

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[7] [Patient (cont.)] [Dr. Spielman] What social factors would you expect to see that would aggravate HCl production. Coffee, chocolate, alcohol, and smoking (big deal). Smoking for 25 years, alcohol, and a couple daily coffee shots. Meat/ carbohydrate rich. Sometimes you know what to expect and you want to see upon questioning them. It will set you up at the end in terms of how you manage the patient. This patient will not be successful unless you tackle social factors and the medication background regardless of what you do w/ the teeth. Success relies on underlying problem being taken care of. [8] [Patient (cont.)] [Dr. Spielman] These are some of the symptoms. What other conditions could cause upset stomach? What else do you expect patient to have? Hiatal hernia. Whats the hiatus? An opening where esophagus goes into the abdomen. Whats an abdominal hernia? The abdominal wall has a musculature when weakened, has some parts of the cavity that goes through it. Weight lifters use belts to prevent hernias from happening. Need the extra protection. The same occurs to the hiatus. If the sphincter is weak, potions of the stomach can bud through next to the esophagus and go into the thoracic cavity. Let me show you an image of what it might look like. This is the diaphragm. Its like having a secondary stomach thats trapped. Theres an unrelated condition where the cardia is constricted or enlarged. In this situation it sits in this area and bulges. Its called mega-esophagus. Creates bad breath b/c it does not have the mucosa to keep the food or survive the acidity of the food. Its not an absorptive mucosa. This creates a similar feeling for patients. They cannot eat a lot, bad breath, regurgitation. This creates a favorable environment in which patients are going to suffer. This patient also happened to have a gastric ulcer. What would you expect to find in an ulcer besides discomfort. What causes it as of 2004? Bacteria. Thats actually what was the very intriguing discoveries. A group of Australian scientist came up w/ this idea (H. Pylori). Swallowed it, caused ulcers, took antibiotics and cured the ulcers. You should be able to identify H. Pylori by isolating the bacteria. Its transmittable by saliva. Mothers can pass it on to children and patients can give it to dentists. [9] [Patient (cont.)] [Dr. Spielman] We are moving along. How do you connect Aspirin and gastric bleeding? A lot of people take Aspirin that is coated. Why do you have to worry about it? Whats the mechanism? People get gastric bleeding by taking it. Why? It has a thinning mechanism (delays coagulation). What is Aspirin/ why are you taking it? Prostaglandin that helps w/ inflammation. Whats the deal w/ prostaglandins and gastric bleeding? You need to connect the dots (goes to previous slide). Prostaglandins have protective function for the mucosa. They induce bicarbarbonate secretion for certain cells. Bicarbonate and mucin secretion. That combined w/ others such as increased acid production you create an environment where gastric bleeding occurs. You want to find something that bypasses the stomach and gets to inflamed joints. Aspirin shuts down this mechanism and you get increased HCl production. [10] [Picture] [Dr. Spielman] skip 3

Transcribed by Amit Amin

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[11] [GERD] [Dr. Spielman] GERD is fairly common. 10% has some form at one point or another. Individuals who take a lot of this in their diet, you have an increase chance of suffering. [12] [Why acid does not affect the gastric mucosa, only the esophagus and the oral cavity?] [Dr. Spielman] This is something the patient says in the video. Why does it hurt my esophagus and not my stomach. Whats the answer. Whats the difference b/w the stomach and the esophagus. Its the protective mechanism. First its the mucous layer. It has a thick carbohydrate rich protein. Do you know where mucin is? Its in the oral cavity. Id like you to take your tongue and push it against the cheek. What you feel is salivary mucin. You feel carbohydrates w/ water attached to it. Its so water soaked that it feels like trying to swim w/ an open parachute. At a molecular protein you have a core protein w/ carbs on the side and water there. Its so thick that it creates this slippery feel. Imagine eating a piece of toast thats so hard you wouldnt be able to eat it w/o hurting the mucosa. Its covering the entire digestive system. Any patient w/ dry mouth will shut down the mechanism. You need to think of this layer as a protective mechanism. This layer also has bicarbonate secreted in it. pH of HCl is so low but how is the cell that secretes it is not digested? Once HCl is secreted the back diffusion is stopped b/c bicarbonates are there to protect it. This mechanism is not present in the esophagus. When you see the esophagus it has normal epithelium and thats why its very sensitive and hurts. Then you have the prostaglandins. The fourth element is the blood supply to the stomach. If you have a good blood supply the protons are removed. (goes back to the module). The mucin is secreted out and the acid secreting cells flow into an already protected layer so the cells next to it wont be affected. [13] [Picture] [Dr. Spielman] skip [14] [What is relevant?] [Dr. Spielman] One of the things you need to figure out is how to make sense of the ton of information you have. How do you connect the dots? What is important and whats not important? Why dont you turn to the right or left, talk it over and then well start. Any kind of strategy? Any clue on whats the first thing to look for? Time factor. You need to look for a cause effect relationship. Look for temporal coincidence and history. You need to ask question about when it happened. Cause/ effect relationship. You need to know something about the drugs and the habits. What would be the first thing you start looking at. Whats the oldest? Smoking. You would probably figure out that the gastric upset has to deal w/ some form (there has to be a time factor/ cumulative effect before you see an effect on the health). This happened 5 years ago but there were other things like diet, ulcer. What else do you think my have contributed? H. Pylori.- 10-year effect. Coffee and aspirin. You see the bleeding and the gastric upset. All of these have now called the symptoms (colored teeth/ heart burn). [15] [How do you establish cause- effect relationship?] [Dr. Spielman] skip [16] [What is relevant?] 4

Transcribed by Amit Amin

04/07/2014

[Dr. Spielman] This is one potential way of connecting the dots. This is what you need to look for. How would you treat something like this? I have dark colored teeth. How would you approach this? You could give a patient a $25,000 bill and say thats what Im going to do. You could pocket the money but its an ethical dilemma. You need to take care of the underlying issues first. Youll have patients come back w/ sensitive teeth. You will lose far more than reputation (goes to module again). Erosion of enamel, you need to make differential diagnosis. I remember I had one patient that had no enamel (melted away). This man was squeezing a galloon of freshly squeezed orange juice every day. Bathing his teeth in low acidic solution. Low acidity is very harmful. Buffering capacity can raise the ph. whats the critical pH of the enamel (5.5) and dentin are 6.5. Drinking coke dips it below 6 and dentin starts to erode. Whats the critical pH for FAP (4.5) there are two additional modules. One is oral management. You are responsible for the patient not just your pocketbook. You need to provide some kind of guidance. Need to treat GERD before you treat the patient. This shows professionalism. A nutritionist and a social worker are also important. If you dont think this is important as a dental professional would you be wanted to be treated this way? [17] [Management and Prognosis] [Dr. Spielman] Starts to go through practice questions? One exacerbating factor of acid reflux is: hiatal hernia. Acid reflux is due to: Weaker cardiac sphincter. Acid reflux is exacerbated by: Bending forward and alcohol. Gastric Acid secretion is controlled by: Acetylcholine, Gastrin, and Histamine. Most effective drug control: (didnt say on microphone) who should you first refer a patient w/ uncontrolled acid reflux to: Family physician. What are clinical symptoms? Dental hypersensitity and gingival burning sensation. [18] [Picture] [Dr. Spielman] skip [19] [What basic concepts are reinforced] [Dr. Spielman] skip [20] [What did we learn?] [Dr. Spielman] skip