Talking About Oral Systemic Health in the Dental Hygiene Room

Research has established a clear association between a patient’s oral disease and other systemic health conditions, referred to as the oral-systemic link. As a prevention specialist, the hygienist seems a natural fit for patient education about this association. We discuss why this education is essential and the hygienist’s role when it comes to teaching patients about mouth-body connections.

The Importance of Patient Education

The Oral-Systemic Link is essential for patients to understand for a number of reasons. Research shows a link between periodontal disease and systemic conditions like heart disease, stroke, diabetes, and others. Research also suggests there is a connection between periodontal disease and adverse pregnancy outcomes. In addition, the American Dental Association (ADA) says that both periodontal disease and systemic conditions have similar risk factors for disease, like smoking or a poor diet.¹

Chris Richardson, DMD, MS, President of the American Academy of Periodontology (AAP), says that the oral-systemic link has been a topic of study for a long time, and the AAP has accumulated, along with academic institutions worldwide, plentfiful data regarding the relationship between the health of the oral cavity and the rest of the body. These connected conditions are serious and worthy of a discussion with patients.

“Some of the diseases that can be affected from an unhealthy oral health perspective are systemic issues like diabetes, rheumatoid arthritis, and cardiovascular disease,” Dr Richardson says.

Dr Richardson refers to a December 2021 study in the British Medical Journal, which suggests that patients with periodontitis or bone loss around teeth,have an increased risk for many systemic conditions. The study encompassed nearly 65,000 adults that had reported a history of periodontal disease who were matched to over 250,000 people without gum disease. The systemic diseases for which the periodontitis group demonstrated anincreased risk included:²

• Cardiovascular disease: 18%
• Type 2 Diabetes: 26%
• Autoimmune Disorders: 33%
• Mental Health issues, including anxiety and depression: 37%

“This is a very large retrospective epidemiological body of evidence that corroborates this oral-systemic relationship,” Dr Richardson says.

Samuel Low, DDS, MS, MEd, Professor Emeritus at University of Florida, College of Dentistry, and the Chief Dental Officer and Vice President of Clinical and Dental Affairs for BIOLASE agrees, adding if it had only been a couple of articles that were not substantiated with other quality studies, the conversation might not be essential. However, numerous publications have found a relationship between inflammatory diseases of the body and periodontitis. Most recently, Dr Low says an October 2021 study in the Journal of Dental Research suggests obese patients with periodontal disease and COVID-19 are more likely to be admitted to the hospital and have higher mortality rates than other patients.³ 

Dental professionals are poised to see indications of systemic conditions first, which can be crucial for early intervention. Hayley Johnson, RDH and Myofunctional Therapist, says that the mouth and nose are the gateways into the body, which means systemic conditions may present early with oral manifestations. Moreover, research shows that what is in the mouth doesn’t stay in the oral cavity.

“It has long been established that bacteria and other microbes associated with the oral cavity are active in other parts of the body and can play a role in bacterial endocarditis and other inflammatory diseases,” Johnson explains. “New studies show that the main pathogen in periodontal disease, P. gingivalis is has been associated with Alzheimer’s disease.”

Speaker and writer Richard Nagelberg, DDS, and Director of Medical Affairs for OraPharma, Inc., says the primary factor at play in the oral-systemic connection is inflammation. Reducing inflammation in the body is essential for patients’ health.

“The goal of dentistry really should be to keep the person as relatively free of inflammation as possible over their lifespan,” Dr Nagelberg says. “It is not to reduce pocket depth, bleeding on probing, swelling and all those things; that’s just a means to an end. By treating those things, you’re going to knock down the inflammation, which addresses their oral and overall health.”

Why Hygienists Are a Natural Fit for This Discussion

With such a strong association with all these serious medical conditions, the discussion about the oral-systemic link seems a natural fit for either a dentist or physician’s office. However, physicians tend to stick to the systemic side and dental professionals to the oral health side of the discussion. Moreover, patients expect it to be like this.

“The dentist’s office and the doctor’s office often have different roles in patients’ perception,”Johnson says. “There is a clear separation of oral considerations from the rest of overall health across much of the medical field and the general population. This separation leads to a perception that oral health is less important to overall well-being and therefore, oral health considerations are not prioritized in healthcare.”

Moreover, patients often separate their oral health from their physical well-being. Tom Viola, RPh, CCP, CDE, CPMP speaker, educator, and author on dental pharmacology, founded Pharmacology Declassified to help dental professionals understand the interplay between medications and diseases of the mouth and body. He says that most patients think of the mouth as distant from the body and don’t associate the oral cavity as an influence on systemic health.

“They feel that their mouths are on an island away from the rest of their body, and they don't see the connection between their teeth and oral health and what the systemic ramifications could be,” Viola says.

This misconception creates challenges for dental professionals who are trying to make the connection for patients. However, Viola says it is essential to keep trying.

“If we can impart the importance of maintaining good oral health earlier in their life, they will have less of a risk for systemic disease,” Viola says.

With 30 years’ private-practice experience as a periodontist and 20 years’ experience as an associate faculty member of the Pankey Institute, Dr Low lectures and teaches dental professionals nationwide. He thinks the problem isn’t knowing the Oral-Systemic link is real and essential to talk about; it’s finding the time to do it. Moreover, with dentistry focused on restorative solutions, educating about gum disease isn’t the priority for many dentists, even though they know it is important.

Absent the dentist leading the conversation, Dr Low believes that hygienists are poised to take the lead in these conversations with patients for a few reasons. First, they have more time with patients than any other healthcare provider. Also, hygienists have access to medical histories and have conversations with patients about them. In addition, he feels hygienists as preventive care specialists are well aware of the oral-systemic link and its implications for patient health.

“If we gave an examination to hygienists about the oral-systemic link, most of them would very successfully pass it because you do see that subject in a lot of their continuing education and hygiene publications,” Dr Low says.
Moreover, Dr Low says hygienists have more of a relationship with patients than the dentist does. For example, hygienists see perio patients every three months for 45 minutes to an hour.

“The hygienist is in a very meaningful, responsible and accountable position in all health care when it comes to the whole systemic link and they’re most attuned to it,” Dr Low explains. “They’re excited about it because many of them are well-body individuals. They have been talking nutrition for 5 decades. It falls on deaf ears, but they been talking about it.”

Lori Hall, CDA, LDH, Director of Hygiene at Heartland Dental, thinks that as a hygienist, having this discussion is a natural fit for their care process. Hygienists see the patients first and are gathering the patient’s medical history, and screening for oral health diseases. Moreover, Hygienists are on the front line with patients, so making that connection between periodontal disease and how that affects the body should be a part of that care, she says. Plus, the hygienist is a great communicator and educator.

“We should also make sure they understand that many times, things show up in their mouth before they show up in their body. We should be comfortable to educate them by saying something like, ‘This is going on in your mouth and we're concerned. We want to make sure that you're not only healthy from an oral perspective, but also not in any danger from a physical perspective, either,’” Hall says.

“As a hygienist and myofunctional therapist, I believe it is the hygienists’ role to bridge the gap between overall systemic health and the health in our patients’ mouths,” Johnson agrees.

Viola says that hygienists may spot more systemic illness than some other healthcare professionals simply because hygienists see the oral effects of systemic illness before patients know they have that illness.

“The other reason,” Viola says, “is that hygienists are likable, affable, and easy to relate to. When hygienists speak, patients listen. Patients know hygienists are approachable and have their best interests at heart.”

Dr Richardson says that the AAP has patient survey results which suggest hygienists are highly trusted caregivers in dental practices and they have the skillset necessary to recognize the impact of periodontal diseases. Dr Richardson, who employs 3 hygienists in his Virginia practice, says he diagnoses patients and as he is leaving, the patient turns to the hygienist and asks, “What do you think about that?” 

“It’s important to have your hygienist understand what you are doing and why you're doing it. Co-therapist is certainly an appropriate term for hygienists as they helptreat disease and maintain health as well as assist the patient in understanding theiradvanced treatment needs,” Dr Richardson says.

Dr Nagelberg also agrees that hygienists have cultivated the patient’s trust. The hygienist can then give patients credible information that is non-threateningand shows concern for what is happening in the mouth.

“The hygienists’ relationship with patients is separate than the dentists’ relationship,” Dr Nagelberg says.“That’s a powerful thing.”

What Hygienists Should Bear in Mind When Undertaking Patient Education on the Oral-Systemic Link

Dr Low says that improving patient education on the oral-systemic link is about changing habits. Dr Low thinks it means making this conversation a priority during their time with patients.

“Hygienists are bombarded with so many things to do in those 45 minutes to an hour they spend with patients. It comes down to contingency management,” Dr Low says.

Furthermore, hygienists should focus on continuing education to gain a comprehensive understanding of why gum disease is an inflammatory reaction. He recommends watching live and recorded webinars and reading hygiene publications like Dimensions of Dental Hygiene and Access Magazine by the American Dental Hygienists’ Association (ADHA).

“I would encourage hygienists to take a 1- to 2-hour webinar-type course, especially when it’s by periodontists,” Dr Low says, adding that they don’t need much more than that. “The information is out there.” 

Dr Richardson agrees continuing education increases hygienists’ comfort level with these conversations. The AAP has symposiums and webinars for hygienists on this topic, which anyone can attend. In addition, reading and other self-education materials are available on the AAP website, perio.org. He also recommends hygienists network with local periodontists in their community.

“Ask a local periodontist for more direction or advice on communicating with patients about the importance of a healthy mouth/healthy body connection,” Dr Richardson says.

Dr Nagelberg thinks patient education should aim to improve the patient’s home care and empower them to be a significant part of the solution. Also, tools like OraPharma’s My PerioHealth App, a free and non-promotional patient education app, can help. For the first time, patients become part of the disease discovery process when they enter clinical data provided by the hygienist into the app on their phone or tablet. In addition, dental teams can use scripted language about what’s going on in the mouth and the impact that could have on the body.

“It can be done in a very non-threatening way without overloading the patient with information or getting too deep into the science,” Dr Nagelberg says.

“The most important thing a hygienist can do is adopt a strategy that does not hit patients over the head with too much information,” Viola agrees. “Speak to patients on their level. Make them aware there is a problem.”

For example, Viola says, if hygienists see evidence of gastroesophageal reflux disease (GERD), they should give the patient basic information about GERD, what they noticed in the mouth, and how untreated reflux affects the mouth. Then, the hygienist should partner with their dentist to make a referral to the medical counterpart, in this case the gastroenterologist.

“Leave the diagnosis to the professional that is best suited for it,” Viola says, adding that dental professional would hope that the opposite would be true, too, if the medical counterpart saw indications of oral disease. “It’s a team approach.”

Moreover, Viola thinks hygienists should speak the language to establish authority on the related systemic conditions and instill patient’s confidence. With indications of GERD, for example, Viola suggests asking patients if they had a screening for Barrett’s esophagus, where cells lining the esophagus change to resemble the lining of the intestine and a common condition for people with GERD.⁴

These kinds of connections are the subject of a new training he is writing and the subject of his Medical History Mysteries, which takes a medical history and breaks it down line by line for what that means and what medications they might take for it. Having this knowledge will help boost the hygienist’s confidence in referring patients for treatment.

“It opens up the dialog by suggesting rather than diagnosing, while it also opens the door for a larger conversation,” Viola says.

Johnson thinks proper management of oral health and periodontal disease requires clinicians to not only address the obvious case of inflammation and disease in the mouth but also to address lifestyle and overall health factors that contribute to oral health.

“This includes having discussions regarding lifestyle choices, diet, exercise, and sleep,” Johnson says. “Being able to screen for breathing disorders such as mouth breathing, tongue ties, and sleep disordered breathing can help explain many causes of periodontal disease.”

“As a hygienist, you want to make sure you're educating your patients about periodontal disease and they understand how important it is to treat it,” Hall agrees. “The bleeding, the decay, the recession, all of those things are key indicators to what's happening in their everyday habits and life.”

Hall says it is also essential that hygienists see themselves taking the lead in this role. It is an essential part of the care a hygienist provides. She would advise other hygienists to also see themselves as healthcare providers with a responsibility to educate patients on this topic.

“We truly are looking out for the patient's overall health. That's why we do things like take blood pressure, and some offices do A1C testing, and those types of things,” Hall says.“It's important that we don't classify ourselves as the ones that just clean the teeth. “ 

“Patients are many times eager and hungry to learn things and those that aren't, we just want to make sure that they've been informed,” Dr Richardson says. “Education and informed consent are honestly 2 of the most important things we do as health care professionals and hygienists certainly play a critical role in that process.”

References

1. Ada.org. 2019. Oral Systemic Health. Accessed 3 January 2022. https://www.ada.org/resources/research/science-and-research-institute/oral-health-topics/oral-systemic-health

2. Medium DT, Chandan JS, Raindi D, et al. Burden of chronic diseases associated with periodontal diseases: a retrospective cohort study using UK primary care data. BMJ Open 2021;11:e048296. do: 10.1136/bmjopen-2020-048296

3. Lanvin H, Wilmott S, Kang J, Aggarwal VR, Pavitt S, Wu J. Additive Effect of Periodontal Disease and Obesity on COVID-19 Outcomes. J Dent Res. 2021;100(11):1228-1235. doi:10.1177/00220345211029638

4. Saling J. Barrett's Esophagus: Symptoms, Causes, and Treatments. WebMD. Published 2021. Accessed January 17, 2022. https://www.webmd.com/heartburn-gerd/guide/barretts-esophagus-symptoms-causes-and-treatments.