Do Patients Understand the Connection?
Last week I had the opportunity to speak with a classroom of nursing students concerning aspects of dental health that impact general health conditions. I was encouraged because the students understood the close relationship between oral health and the rest of the body. As ridiculous as it sounds, until the past several years, oral conditions have not been a focus of general health and wellness. In fact, oral health implications for serious illness have been seriously underappreciated. One may reasonably ask, “How did the mouth become disconnected from the rest of the body?”
In part, the blame may go to the payment division of medical and dental insurance. “Dental” was separated long ago, and has continued to take a much secondary position to payment for other health situations. In addition, many people do not put dental treatment on par with having a heart “condition” or diabetes. But the truth is, home care and professional dental care are indivisibly connected to how a heart condition patient or diabetic is managed.
The nursing students I spoke with were learning about the importance of a complete and thorough health history when evaluating a patient. The format for their evaluation included questions regarding a patient’s dental home care routine, whether the patient received routine “cleanings” at a dental office, whether the patient had any replacements in the mouth, whether the patient had ever been treated for a periodontal condition, and was the patient taking any bisphosphonates. They were conversant in the fact that many inflammatory conditions are impacted by periodontal problems, and understood that bisphosphonate drugs can have a seriously adverse effect on oral healing.
Their focus on bisphosphonates was encouraging. As we know, bisphosphonates are a class of drug used to treat osteoporosis. Unfortunately, they are also closely associated with the development of difficult or impossible to heal ulcers or “craters” in the mouth following an extraction; with such lesions also sometimes arising spontaneously in the absence of any extraction or other trauma. Common brand names include Fosamax and Boniva (and many others), which are typically oral medications used at home.
There are also I.V. medications administered in a clinical setting. Cancer patients with bone lesions often receive the I.V. medications, while persons with less pronounced osteoporosis take the oral meds. In addition to the oral implications, some users of the medications have also suffered from broken femurs.
While it is difficult to understand the relationship between a drug designed to strengthen bones causing a broken femur, the oral situation has an explanation. Boney structures in the mouth are under constant stress due to chewing forces. Osteoblasts create new bone cells as needed, while osteoclasts clear away “old” bone cells. Bisphosphonates inhibit the activity of osteoclasts, reducing cell loss. The problem appears to arise from an overabundance of “old” cells being retained, impacting normal healing. While there are varying opinions regarding taking a “drug holiday” prior to any extractions, many dentists look to root canals instead of extractions for bisphosphonate patients, and are very cautious concerning placement of implants. For the nursing students, the balancing of the benefits and complications with bisphosphonates was important, therefore its inclusion on the health history.
Since heart disease and diabetes are common conditions, the students also wanted to know what dentists and hygienists did to help patients deal with these diseases. Do patients really get the connection between their dental office visit and their general health?
I was happy to let them know that most dental professionals are equipping patients with the knowledge that their dental health is vital to general health and fundamental to the management of diseases such as heart disease and diabetes. I explained the purpose and implementation of a periodontal assessment as performed by a dental hygienist, as well as the types of treatment and maintenance patients can expect. I talked to them about what we want our patients focusing on concerning home care.
While the students knew that tooth brushing is important and “flossing is good”, they did not really know why. We discussed in detail the role of reducing the bacterial load in the mouth on a daily basis as a way of helping the immune system function well throughout the body. If a source of inflammation is never addressed, such as in active periodontal disease, the inflammatory process keeps the immune system ignited for action. When the immune system is working overtime, the organs of the body, including the heart are impacted. Since inflammation affects diabetes, and diabetes affects the operation of so many bodily functions, reducing inflammation is serious.
As dentists and hygienists, we owe it to our patients to continue stressing the connection between oral health and general health. We need to reinforce this message at every recall when we are going over flossing or interdental cleaners again and again. We need to keep the topic of inflammation and the immune system in our discussions at every prophy or perio appointment. While our patients may not appear to be getting the message, good salesmen say it often takes 10 or 12 “contacts” to make an impression on a person. In other words, we can’t give up on helping our patients make the connection. It is gratifying to know that the nursing profession is an ally in this endeavor.
Carol Tekavec RDH is the Director of Hygiene for McKenzie Management. Carol can improve your hygiene department in just one day of training “in your office.” Interested in knowing more about how to improve your hygiene department? Email firstname.lastname@example.org.
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