Murray Brilliant: Our group consisted of basically me [laughs]
--
[laughter]
-- so -- and Dr. Vidya [spelled phonetically], who couldn't be here today.
But we thought that one of the things that we could very well, easily do is to, what
we have is a combined -- a combined dental electronic health record and I'm sorry, combined
electronic health record and a combined electronic dental record.
One of the things that we could do is to work with the pharmacogenetics group in implementing
for example warfarin pharmacogenetics, testing prior to dental procedures because often we
have to let the warfarin levels go down so that, before these kinds of procedures to
prevent excessive bleeding during dental procedures.
So that timing of the warfarin withdrawal prior to dental procedures is quite important
and can be predicted genetically as well as for example, CYP2D6 for pain management.
So that's one type of thing that we'd be like to work with other groups that also have dental
clinics.
And in addition, we thought in terms of the periodontal disease and microbiome type we
would be pleased to work with others, in particular to identify -- and to identify their diabetes
patients, what their requirements for this would be.
Diabetes patients and controls that already have genome-wide association studies and dental
access and basically what we'd like to know is if periodontal disease and or the oral
microbiome can actually stratify some of those genetic signals.
And whether or not you know we could we could be more predictive for type 2 diabetes susceptibility
and outcomes.
So how this might work for example would be to have non-diabetic patients, pre-diabetics
and types 2 diabetics and then compare them in terms of periodontal disease state for
each SNP for example, and similarly, for the oral microbiome.
So and the potential outcomes from this would be to begin a dental pharmacogenetics study,
that's what I talked about first and then better understanding of risks for type 2 diabetes
onset, severity and control.
As well as, as I said, drilling down to better understand the genetics of type 2 diabetes
and the role of the environment in type 2 diabetes.
And this could be expanded to other disorders linked to periodontal disease for example,
coronary artery disease.
So because we were so lonely yesterday, I thought that what we would -- we would do
is to contact those of you at institutions where there are dental schools or dental services
and detail this and see if there is any interest in following any of these up.
So, thank you for your time.
Male Speaker: Questions or comments?
Oh, Marc as usual.
Murray Brilliant: Marc as usual, right.
Male Speaker: Thank you.
So I'll go before Marc.
So did your group [laughs] discuss the role of the dentist in genomic medicine and could
you conceive of some projects that might be sort of implementation projects to get dentists
to capture saliva, relevant biological samples that might be relevant about the microbiome
type of samples, which I'm not sure how you know how you know challenging those are to
ascertain in a meaningful and standardized way, but also samples that could be used for
DNA analysis, at least from my perspective people -- I see my dentist much more frequently
than I see my primary care physician and that's possibly another avenue to implement genomic
medicine.
Murray Brilliant: Yes, so basically this is part of our project
in oral systemic health.
And we will be working with our dentist, the Marshfield clinic dentists, who see the same
patients that we see in the clinic.
And we're training dental hygienists to be able to take these microbiome samples, each
of these participants in this study, we will get DNA, I'm sorry, blood for DNA, plasma
and serum.
They'll be standard clinical tests including hemoglobin A1C, fasting glucose, et cetera
and lipids and then we're also, they'll also be seen periodically, every six months.
So that's kind of the way we're trying to do this.
So, one advantage that we have is that the Marshfield clinic is sort of a conglomerate,
we have our medical clinics, we have our dental clinics, we also run our own healthcare plan,
security health plan and we have our own -- our own electronic health records and electronic
dental records and those are combined.
So the dentists also work for us, we can -- we can work with them and try to combine this
to have pharmacogenetics for dentistry.
It might be actually -- it might be easier to work with the dentists in some way than
the general practitioners, so.
Male Speaker: Just parenthetically, I thought it was interesting
you used the term drill down in your dental --
[laughter]
-- but if we set that aside for a second.
[laughter]
You know one of the things we've talked about peripherally has been how do we engage and
get the attention of decision makers and say, "Hey, this is really important."
And I really like the idea of the pharmacogenomics for warfarin withdrawal for dental procedures.
I can tell you that anecdotally at our place, we hear a lot about cancelled surgical procedures
based on the fact that the patient's INR is not within an acceptable range for surgery
and again, we presume as you have presumed that some of that is due to the different
pharmacogenomic variants.
That's something, cancelled surgeries are you know that's a resource rate waste for
that organization and if we could do something to actually move the needle using the dental
procedures as a pilot and then expanding it to all surgical procedures for patients on
warfarin, and show that we can actually decrease the number of cancelled surgeries as a primary
outcome, that would be something that would really get the attention of administrators
and say, "Hey, maybe there's something to this."
So I think that's a really good project, speaking of someone that's not yet at Geisinger who
is -- has a dental clinic, apparently.
Who knew?
I think we'd be we'd be interested in exploring that.
Murray Brilliant: Excellent, yeah.
Thanks.
Male Speaker: Well, I think there was two [spelled phonetically].
One is coming to some of the comments made yesterday, the end-points that really drive
this in practice are goofy little things like that and so I think that's really important,
that we've done a little bit of work with people implanting devices for cardiac disease
who have the exact same problem.
And that's, except they think they know how to manage warfarin.
At least the dentists freely admit they don't have a clue how to manage warfarin.
[laughter]
But it's the same issue.
You know if you think, you know there's a three day protocol.
They do the three days and aren't ready, they have to cancel, et cetera.
Murray Brilliant: Right.
Male Speaker: I think there's something there.
The other piece is that there are a decent size group of boutique dentistry groups out
there who are doing pharmacogenetics already.
And we've consulted for them a little bit, others have probably in this room as well.
And they've decided that for the pain control, not so much for warfarin, more for pain control
that their patients are special and they want to know about this ahead of time.
And their patients are willing to pay for it, and so they're doing it.
And so there's a, so the company's name, Algynomics [spelled phonetically] I think is the company
that has a whole suite of different tests that they're developing around dental [spelled
phonetically] pain and around dental syndromes.
So there are some early doctors already out there in this space.
But I like your idea of going to the more the generalist dentist and trying to do something
exciting.
Murray Brilliant: And also we're, we also are training some
of these dentists.
We have a whole residency program and eventually we hope to have a dental school, so this could
all be part of their training and practice.
Male Speaker: Okay, thank you very much.
I think what we'll do is since now is the time for break, we'll take a 15 minute break
now and then resume with Geoff.