Dr. Steinberg is clinical professor of surgery at Drexel University College of Medicine and adjunct associate professor of oral medicine at the University of Pennsylvania School of Dental Medicine.
Our vision for WDJ is to be the resource for the art and science of dentistry. We want to connect women through WDJ and talk about ways to achieve personal balance with our demanding professional lives, while focusing on different types of practices. This month, we focus on Dr. Barbara J. Steinberg's unique clinical practice in the hospital, combined with her academic practice and leadership role in women's health.
Integrating systemic and oral health
Dr. Margaret Scarlett — Your whole career has been involved with the integration of systemic and oral health, hasn't it?
Dr. Barbara Steinberg — Yes, even before we knew of these links.
Dr. Scarlett — Many people in the dental profession don't see patients who have medical, physical, and mental disabilities. How did you come to love working with those patients? And what kind of advice would you give to people who want to expand their practices to include these patients?
Dr. Steinberg — First of all, dentists are seeing people with medical problems. You can't help it. People are living longer with advanced medical interventions and new pharmacotherapeutic agents. While dentists are seeing more and more people with medical issues, they may not be treating people who are as compromised as those I'm seeing, because to receive care in a hospital, you have to be unable to receive treatment in a conventional setting. The patients who are referred to me absolutely cannot be treated in an outpatient environment.
Dental education at the undergraduate level exposes students to treating medically compromised patients. Students are gaining some experience in treating these kinds of patients and learning about these medical issues. More comprehensive medical training can be gained in a residency program.
They are also taught to know when they should not treat medically compromised patients in their office and when they need to refer to a hospital. When I lecture, it amazes me to hear a dentist who has been practicing for a long time say, "I never treat people in my practice with medical problems." When you probe further, you find out they are treating these people; they just don't know that they have medical problems. Usually that is because they haven't engaged in taking a good, comprehensive medical history to find out this information. Everyone in the profession is now treating people with medical issues. We need to take time to understand these medical concerns and address them appropriately.
Training in a hospital setting
Dr. Scarlett — I know you lecture at many conventions, providing training for people to be more comfortable treating patients with a variety of medical conditions and illnesses. If dentists and their team members want to get extra experience, are there other resources?
Dr. Steinberg — Yes, I lecture extensively on treatment of the medically compromised patient. There are others speaking on this topic as well. Participatory courses in a hospital environment are also offered; however, I am not aware of too many programs of this nature. There was a course in Seattle on providing care for the developmentally disabled.
Innovator in women's health
Dr. Scarlett — You've also been lecturing on women's health for a long time. What changes in emphasis on women's health have you seen over the years?
Dr. Steinberg — Yes, I began incorporating topics on women's health in my courses even before it was in the forefront. Our medical school, Drexel University College of Medicine, has a Women's Health Institute, which is on the cutting edge of new developments in women's health. In fact, today I am preparing a lecture on "Women's Oral Health Issues" to present to the physicians and staff at this Women's Institute.
Dr. Scarlett — So you're teaching physicians about oral health and the implications for women?
Dr. Steinberg — Yes, I'm giving a summary of the times in women's lives when hormonal changes may affect the oral cavity. I'm showing them oral manifestations associated with bulimia. I've included domestic violence and some of the oral injuries we may see associated with it.
Dr. Scarlett — Tell us a little bit about the hormonal changes affecting women throughout the life cycle.
Dr. Steinberg — Well, there are certain times in women's lives when there are hormonal surges and the gingival tissues are particularly sensitive to local factors; i.e., plaque. We think of this occurring at puberty, pregnancy, and during menses, as well as when taking oral contraceptives.
Pregnancy gingivitis is encountered most frequently. We encourage patients to seek dental care prior to becoming pregnant to minimize the risk of pregnancy gingivitis. This is especially important because of the association of periodontal infection and preterm birth.
Another example is menopause. For years, women have complained of various oral symptoms that occur during menopause. Some of the complaints include generalized oral discomfort, burning mouth, dry mouth, altered taste sensations, just to mention a few. Osteoporosis, a decrease in bone mass, is most prevalent in women after menopause. We may see this reflected in the jawbones as well. Women with osteoporosis tend to have a greater incidence of tooth loss and more severe periodontal disease.
Women have a predilection for certain conditions such as eating disorders, which primarily affect younger women. We may see telltale signs of bulimia in the oral cavity, such as enamel erosion. Victims of domestic violence, who are most often women, may sustain mouth injuries including fractured teeth. They may also present to us with fractured jawbones and other facial fractures.
Understanding domestic violence
Dr. Scarlett — Many state laws now require dental professionals to report or take continuing-education courses that focus on child abuse or domestic violence. Do you also teach men about these signs of domestic violence?
Dr. Steinberg — Yes. I was active on our hospital's Domestic Violence Task Force, which gave me the idea to incorporate the topic into my lecture on women's health. Domestic violence primarily affects women. In 95 percent of the cases, the woman is the victim.
While women comprise the majority of my audiences, there are also some men. I think it's important for everyone to know about domestic violence; all health-care professionals should incorporate this subject into their medical history. Ask, "Have you been involved in a relationship with someone who has caused you bodily harm?" We must explain to patients that we're asking this because violence is so prevalent today. We, as dentists, can provide a list of resources available in our community to help these victims.
Changing science for HRT
Dr. Scarlett — We've seen these new studies that have come out of the National Institutes of Health on hormone-replacement (HRT) therapy. All of us of a certain age are scratching our heads and saying, "OK, now what?"
Dr. Steinberg — About 6 million American women take 0.625 mg of conjugated equine estrogen and 2.5 mg of medroxyprogesterone acetate (Prempro), the most common HRT formulation prescribed in the United States. In July, NIH halted the arm of the Women's Health Initiative (WHI) study evaluating the risks and benefits of the above-mentioned combined estrogen progestin preparation. This arm of the WHI study, a randomized, placebo-controlled trial, assessed the effects of combined HRT use in healthy postmenopausal women with an intact uterus. After review of reported data, the study's Data and Safety Monitoring Board concluded that the risks of combined HRT use in this study population outweighed the benefits.
This study is the first rigorously designed, randomized, controlled trial with a sufficiently large study population to investigate the relationship between HRT and the risk of cardiovascular disease and other vascular events, breast cancer, fractures, and other health outcomes. The study was not intended to measure the effect on vasomotor symptoms. To date, this study is the largest, most statistically valid, and well-analyzed research to evaluate the use of HRT in healthy postmenopausal women. The trial was to have lasted eight-and-a-half years, but it was terminated after a little more than five years to protect the participants from further risk.
Here are the main findings of the study:
- During the five years, women on HRT had slightly more heart attacks, strokes, and blood clots. The increased risk was very small and there were no extra deaths.
- HRT taken for more than four years slightly increased the risk of breast cancer.
- Though HRT helped prevent fractures, the effect was small and would last only as long as you take the hormones.
- Women on HRT had a slightly lower incidence of colon cancer.
The decision about use of HRT requires evaluation of the risk and benefits for each individual woman. For women currently using HRT, it is important to assess their reasons for use and to evaluate potential risks, benefits, and alternatives.
Turning away from HRT, many women are likely to try untested alternative treatments, such as soy supplements, isoflavones, black cohosh, oil of evening primrose, ginkgo biloba, ginseng, dong quai, etc., especially for menopausal symptoms. Remember, far less is known about such supplements than about hormones! If HRT is risky, plant hormones may be risky too. Studies of black cohosh, one of the more popular alternative treatments for menopause, are conflicting as to whether it is beneficial for menopausal symptoms. Remember, none of the herbal remedies is FDA-scrutinized.
Dr. Scarlett — And they might even interact with other medications?
Dr. Steinberg — That's exactly right. Some of these herbs act like the blood thinner coumadin. If we perform an invasive procedure, there could be a bleeding problem. Prior to surgery, herbal treatment should be stopped if there is a chance of bleeding.
Dr. Scarlett — This really highlights the importance of keeping up with changing science. Science gets partial answers slowly, and we now have another partial answer that's taken five years to get. Do you think there will be more studies concerning women-specific issues?
We know that there was a push at the National Institutes of Health to have special studies on women and also women in minorities, which started in the early 1990s and has gradually increased. Now we're starting to see the results of these in long-term studies.
Dr. Steinberg — That's right. There was no specific health research on women prior to that policy change. Everything was extrapolated on what they found in the average male.
Scientific basis on differences between men and women
Dr. Scarlett — We've seen some other instances where researchers have begun to document the scientific basis of the differences between men and women. Can you talk about that?
Dr. Steinberg — We're now seeing more gender-specific research. Take the area of cardiovascular disease. Until the early 1990s, most of the studies about heart disease were conducted on men. We now know that women start developing heart disease 10 years later than men and have myocardial infarctions 10 to 20 years later. Recent research has shown that medications may act differently in women than men. For example, ibuprofen may be less effective in women.
Future research on women's health
Dr. Scarlett — In the next few years, should we expect to see a dramatic increase in reporting of results from the new women's health studies?
Dr. Steinberg — Yes. One of the largest ongoing studies is the other arm of the WHI. That study is looking at women who are taking estrogen unopposed — women who have had hysterectomies and don't need the protective effect of progestin to eliminate the risk of cancer in the endometrium. That part of the Women's Health Initiative has not been curtailed.
In a few years, we're going to get data showing whether women who are on unopposed estrogen have increased risk for other medical problems. I believe that women are built into all other kinds of studies — for example, diabetes and cardiovascular research. In light of gender-specific differences, this is imperative
Dr. Scarlett — Analysis of data by sex is a new area. Researchers are redoing their data analysis to stratify by gender. The National Institute of Drug Abuse came out with a study last month that looks at the differential effects of cocaine among men and women. We've also seen that the pain medication, kappa opiods, has a different impact on women vs. men.
Dr. Steinberg, you have been a leader and a pioneer — not just in the exciting area of women's health, but also in providing care for people with various disabilities and medical conditions. You really are an inspiration!