Spotting Trouble: How to Spot More than Just Oral Issues Your Patients are Facing

Here’s the thing Hygiene Team: now more than ever before, our patients need us. And sadly, our picking and scratching ain’t gonna do the whole trick. Don’t get me wrong, the hand scaling, polishing, and my personal favorite: ultrasonicking are all super important, but the superb plaque and calculus removal simply isn’t enough. We are going to have to dig deeper (poor instrumentation joke pun intended) if we want to make a true impact and help our patients finally get healthy.

For the first time in history more people are dying from chronic rather than communicable diseases worldwide (7 out of 10 deaths). In the United States of America, cardiovascular disease kills 800,000 people every year. This is our cue as health care professionals to refuse to skim over the medical history and assessment portion of the hygiene appointment.¹

In hygiene school we learned how to investigate every positive response on the health history. We learned how to look up medications and understand their purpose, contraindications, and drug interactions. When we exited school, many of us exited this practice as well. My friends, it is time we went back. If we want our patients to move towards health, we must pour a proverbial “cup of tea” and get to know our patients better. The excellent part of this news is that we have more knowledge and expertise to utilize than we did in school. The worst part of this news is our culture promotes chronic inflammation and disease as though they are awesome. Alas, that is a big topic for another day.

Back to the clinic. Let’s start by gathering our patient into our care from the waiting room. Walk right up to Karen and extend a hand and deliver a warm welcome. Ask ourselves silently, “Does Karen look well? How is her coloring? Does she appear to be caring for herself? Is she frazzled? Was she late? Does she seem nervous? How is her energy level?” Our goal here is to get a general feel for her state of being. I am not suggesting reading a book by her cover, I am encouraging us to utilize the incredible amount of information that this initial assessment of Karen provides.

Once seated, pop open the medical history. Explore every positive response as though we are detectives. Please do not ignore any responses that “do not pertain to us” because they all do. If Karen is struggling with her overall health, her response to any pathogenic bacteria will be exacerbated. We also know that when Karen’s immune system is playing whack-a-mole with too many ailments, its ability to a good job in the oral cavity is hindered. When Karen asks why we are being so thorough, we simply respond, “your body and mouth operate together. The more we address you as a whole human, the better our success will be.”

Side note: as our patients present with various diseases, do a little digging. The quest for more information about diseases makes showing up as an RDH more fun and rewarding. This is an excellent way to prevent or recover from burn-out. Did you know that research is showing periodontal disease contributing and even causing fatty liver disease?² It may be fun to blame it on the alcohol, but those gram negative pathogenic oral bacteria are buggers. They are causing major destruction throughout our bodies. I would highly recommend reading the article sited below on the topic. It contains powerful information to equip ourselves and our patients. Discussing the liver’s response to periodontal bacteria that has entered the blood stream is one of my all-time favorite topics with patients. They are surprisingly interested in the liver releasing low-density lipoproteins into the body to contribute to clogged arteries. Who knew?

What about the medications Karen is taking? Is she at risk for dry mouth or periodontium destruction? Is caries prevention going to be the focal point of our efforts today? Perhaps Karen is on medication for prediabetes or diabetes, and we need to discuss blood sugar control in conjunction with periodontal disease. Quizzing Karen about the side effects she experiences with her meds is helpful in our quest to help her address her individual needs.

Does Karen have allergies? If she does, are we making sure that her appointment does not include unnecessary exposure? For example: I was at the dermatologist’s office and marked “latex allergy” on my medical history. I also discussed with the nurse my allergy because I noted both latex and nitrile gloves on the wall. At the risk of being the “annoying patient,” I had to ask the doctor and the nurse if the gloves that they were putting on to numb my skin and biopsy a suspicious lesion were latex… They were. Ugh. They of course changed them immediately, but I was completely disappointed that I had to work so hard to avoid the latex. The take home message was to pay close attention to my own patients so as not to put them in an uncomfortable or unsafe position. Ever.

Last up on the medical history is, “have you had any surgery since we met last Karen?” To our surprise, Karen has had surgery since we last saw her. A minor procedure to place a stent in one of her arteries happened 2 months ago. Hint: anti-inflammatory living and superb gum health will dominate our conversation today.

Following the discussion about positive responses to her medical history, allergies, and surgeries, it is time to discuss the blood pressure reading we acquired today. If Karen has 120/80 mmHg or lower, let’s high five her and move forward with the rest of assessment. Should her blood pressure be higher than that, have a conversation based on the reading. Ask questions such as, “Karen, when is the last time you spoke with your primary care provider about your blood pressure?” And “Do you monitor your blood pressure regularly?” Look back at previous appointments to see what her readings have been. Refer to the current American Dental Association guidelines to ensure that our recommendation matches the reading acquired today.³ It is better to have a candid conversation about the number one killer in America than to avoid the fleeting discomfort and risk a life. Our job is not to diagnose, but rather screen and refer. Many of us blood pressure taking RDHs have a story (or several) about how we helped someone avoid a cardiovascular event. Karen may not be our mom, but her kids would be grateful for our assistance in keeping her around. Let’s all be that hygienist.

Did you know that 7% or 23.5 million Americans have an autoimmune disease?⁴ Many first manifestations occur in the oral cavity and on the face. If diagnosed early, the treatment effectiveness and quality of life improve exponentially. Hello oral cancer screening! Thank you for your information. Let’s discuss a few of the most common diseases we can recognize early in our patients:

Sjögren's syndrome. This disease presents frequently and is noted by extreme tiredness, dry eyes, and dry mouth. The dry mouth is a real issue for us because of the critical contributions it makes to oral function and health. Xerostomia is famous for helping cavities grow, increasing infection susceptibility and severity, and hindering the eating process. While we are performing the oral cancer screening, check to see if the glands are releasing saliva correctly. If not, this is a great time to encourage Karen to seek an appointment with her primary health care provider. Catching Sjögren's early gives Karen the best chance to get rid of or at least lessen the effects. I have seen people commit to anti-inflammatory living and completely eradicate all symptoms of their autoimmune condition.

What are some effective anti-dry mouth modalities you have had good luck with? I am always on the hunt for great suggestions because not everything works for everyone. Please email me any magic tricks you have. My favorite recommendation to share is for the patient to drink milk (of any kind) with meals. The fat in the milk provides lubrication for mastication and swallowing, making eating more enjoyable or at least possible. Based on the commonness of xerostomia, this is a handy bit of info to have ready to pass along.

How about Karen’s butterfly shaped red marks on her cheeks? Does she need to be on the anti-lupus living war path? While not curable, medications such as NSAIDS, corticosteroids, anti-malarial drugs, immunosuppressants and biologics can all manage the autoimmune disease and prolong quality and quantity of life for Karen. Personally, I have seen several people with lupus. Their lifestyle was a direct indicator as to whether they were “struggling” with lupus or “not really noticing” their lupus.

Perhaps Karen has an enlarged thyroid we notice during the palpation of her neck. The thyroid is the major regulator of the body’s systems. It is also the second most common glandular disorder. If there is trouble with the thyroid, Karen can experience several frustrating symptoms. Remember we observed her energy in the waiting room? The thyroid could be the culprit of her lethargy. Let’s say that Karen already knows she has a problem with her thyroid. Both hypothyroidism and taking levothyroxine are associated with the destruction of the periodontium.⁵ Because of oral systemic bidirectional communication, we need to work closely with her endocrinologist to ensure the best outcome possible. In 2013, 2 of my dental professional friends discovered they had thyroid cancer. Both are here today because of early detection. I hope to never find cancer in my own practice. More importantly, I hope to never miss cancer in my own practice.

Geez, Karen is a wreck, isn’t she?! What if we back all the way up and pretend that Karen showed up looking fine with no medical history positive responses. No current medications and no elevated blood pressure. We made it through the oral cancer screening with nothing to note. Then we begin to probe... Karen has good home care with minimal calculus build up, but holy moly she is bleeding like crazy when we probe! There are 2 likely culprits here:

• The virulence of her microbiota make up is excessive or
• Her immune system is on fire.

At this point more questions about her general sense of wellness are prudent. If she appears to feel well and is taking good care of herself, try an oral probiotic and ultrasonic everywhere. An exaggerated response to minimal biofilm indicates dysbiosis and taking a benign probiotic could prove incredibly helpful for both her gums and the rest of her body without the worry of negative side effects. In this situation, invite Karen to return for recare in 3 months to ensure that the homecare regimen is working. When she returns if the gingiva is still overreacting, recommend that she see her primary care provider. Functional blood work can be useful at this point but is way outside of our scope of practice. Nonetheless, if we help Karen tackle a hidden issue, her quality and quantity of life are likely to improve. Karen will love us forever and we will sleep well knowing we made a difference for her.

Isn’t it astounding how much information we have gathered and haven’t even peeked at the radiographs?! This is the last piece to our puzzle that will dictate the dental hygiene care we will provide. Hang on just a minute though. Before examining our favorite interproximal cortical bone, look at the films with an eye for abnormalities. Once we have discerned that Karen’s x-rays are normal, zoom into the interproximal spaces. Keep the perio chart open and compare every bleeding upon probing point to the films. If the periodontal ligament is widened or the crestal bone has lost density, we need to treat this active disease that is causing permanent destruction. Show Karen where the bone is gray and fuzzy rather than a thick white line. She will let us know that she needs to address the disease. We agree and offer her the options for moving forward. Karen is impressed with the exquisite care we provide. She will also leave our operatory with knowledge about her health that allows her to take charge of her own life. This is patient autonomy and health care provider collaboration at its finest.

By now you may be wondering how on earth we have time for all of this. Based on the severity, prevalence of disease, and early death due to non-communicable diseases, my question is: how do we not have time for this?⁶ In health, this entire process happens in a very short amount of time. It is helpful to divide the appointment into 3 segments for healthy patients. Use 20 minutes for assessment. Continue with 25 minutes for implementation. Finish with 15 minutes for exam, scheduling the next appointment, chit chat, and a fabulous hand off to the administrative staff. When Karen shows up and needs more than the above suggested time, we can schedule to meet her needs. The beautiful result of individualized care is an increase in profitability of our clinical work. It turns out that “prophy mills” may get more patients seen in a day but the quality of care and production suffer. In addition, we RDHs in these “prophy mills” often try to provide the care our patients need as fast as possible ultimately compromising our own health and sanity.

At the end of the day, we are the bridge to not only oral but total body health. If we can put the time and effort into utilizing the information each person brings to us, the impact will be profound. We are trusted, educated, and equipped to recognize issues that our patients may be facing. Another benefit to approaching care in this comprehensive format is the way that conversations become deeper. Collaboration becomes effective. Our patients, their smiles, and the health of our population are counting on us to step up and lead the way to a healthier future. This is our chance to be the Thing that makes a difference. Let’s not wait one more minute. Together, you and me, let’s be the Thing. One Karen at a time.

References:

1. Sanz M, Marco Del Castillo A, Jepsen S, et al. Periodontitis and cardiovascular diseases: Consensus report. J Clin Periodontol. 2020;47(3):268-288. doi:10.1111/jcpe.13189

2. Kuraji R, Sekino S, Kapila Y, Numabe Y. Periodontal disease-related nonalcoholic fatty liver disease and nonalcoholic steatohepatitis: An emerging concept of oral-liver axis. Periodontol 2000. 2021;87(1):204-240. doi:10.1111/prd.12387

3. Hypertension (High Blood Pressure). ADA.org. Updated November 1, 2022. Accessed July 28, 2023. https://www.ada.org/en/resources/research/science-and-research-institute/oral-health-topics/hypertension

4. AUTOIMMUNE DISORDERS. Mayo Clinic. Mayo.edu. Accessed July 28, 2023. https://www.mayo.edu/research/centers-programs/mayo-clinic-biobank/projects/auto-immune-disorders

5. Rahangdale SI, Galgali SR. Periodontal status of hypothyroid patients on thyroxine replacement therapy: A comparative cross-sectional study. J Indian Soc Periodontol. 2018;22(6):535-540. doi:10.4103/jisp.jisp_316_18

6. About Global NCD. Centers for Disease Control and Prevention. CDC.gov. Published December 17, 2021. Accessed July 28, 2023. https://www.cdc.gov/globalhealth/healthprotection/ncd/global-ncd-overview.html#:~:text=NCDs%20kill%2041%20million%20people,out%20of%2010%20deaths%20worldwide