Where is the fire? Is effort by dental hygiene to control inflammation different from firefighting?
Is dental hygiene's efforts to control inflammation that different from firefighting?
By Kriston Reisnour, RDH, BSDH, CCSH
Firefighters put out fires every time an unwanted blaze surfaces-no matter how big or small. They know a small fire can lead to a bigger one, resulting in a major life-altering event. That is their job. They are life savers. Their goal is to put out the fire and extinguish any hot spots that may reignite, giving the fire fuel to restart and leaving more destruction and devastation in its wake. They know the more a fire is fueled, the harder it is to control. Take away the fuel and the fire will die.
Did you know that you are a life saver too, a firefighter in your own right? In the dental office, we see many individuals who have silent embers simmering in their arterial walls, waiting for the opportunity to cause havoc. The arterial wall becomes inflamed, or "on fire" according to Dr. Amy Doneen, medical director of the Heart Attack and Stroke Prevention Center in Spokane Wash., and Dr. Bradley Bale, medical director of the Heart Health Program in Lubbock, Texas.
When the wall of the artery is inflamed, it is weaker and more permeable, allowing substances including periodontal pathogens to directly invade. The end result is that the body's defense system sends specialized cells that gobble up the invaders. The byproduct is plaque, which builds up over time in the lining of the arterial wall. Inflammation in the body continues to add fuel to the undetected simmering fire, feeding its destructive nature. The arterial wall continues to be assaulted. The wall integrity is compromised to the point that plaque can now rupture out of it. The body wants to fight and protect itself by forming a clot or thrombus. The location of where the plaque breaks through and a clot is formed is what gives the medical diagnosis. If it is in the heart, we call it a heart attack; if it is in the brain, we call it a stroke.1
Locating the fire
How can you determine if there is a fire simmering within your patient? What is the underlying cause? More importantly, how are you going to extinguish it?
Every patient who walks into the dental office has to fill out a medical history. The medical history in the dental office traditionally has been focused on dental-related issues with a few associated medical conditions. The shift to a medical/dental total-health paradigm will change the traditional dental medical histories to be more comprehensive. Medical and dental history forms should be inclusive of medical and dental conditions associated with the demise of our patients' overall health and well-being. Look for the smoke signals on the history forms.
As the medieval poet, Dante Alighieri said, "From a little spark may burst a flame."
There is an associated risk factor for the development of vascular disease with the smoke signals in the list below. For those of you who have had the wonderful opportunity to attend a Bale/Doneen Preceptorship course, they would be called "red flags." It is important that we recognize and familiarize ourselves with the evidence behind each of these so they do not go undetected in our patients, increasing the risk for heart attack, stroke, diabetes, and other health-related issues.1,2
- Periodontal disease: (bleeding gums or receding gums)
- High blood pressure
- Smoking (nicotine in any form)
- Metabolic syndrome
- Abdominal obesity
- Diabetes mellitus
- Elevated blood sugars
- Insulin resistance
- Gestational diabetes
- High birth-weight babies (greater than 9 pounds)
- Polycystic ovarian syndrome (PCOS)
- Post breast cancer
- Migraines with or without aura
- Erectile dysfunction
- Autoimmune disorders such as rheumatoid arthritis, systemic lupus (SLE), and psoriasis
- Gout (uric acid)
- Nonalcoholic fatty liver disease
- Psychosocial issues, including depression, anxiety, PTSD, and work/home stress
- Renal issues
- Sleep apnea, OSA, snoring, sleep-related issues such as restless less syndrome, and CPAP use
- Neck size
- History in men of low testosterone
- Ethnicity: Hispanic or African American descent
- Age: (over 40 for men and over 50 for women)
- Career fields (firefighter)
Family history of any of the aforementioned "red flags" and the following factors should also be considered:1,2
- Heart disease: Stents, bypass surgery, congestive heart failure, or heart attacks (MI)
- Aneurysms, especially abdominal or intracranial
- Stroke (CVA) and mini-strokes (TIA)
- Vascular dementia (or memory changes later in life)
- For men: Sisters with PCOS
- Parents or siblings with dentures or dental implants
- Parents or siblings with a history of gum disease or bleeding gums
If you work in a practice that also provides dental sleep medicine, the following comorbidities may impact your patient and the success of their treatment.3,4
- Cardiovascular: Arrhythmias, nocturnal angina
- Respiratory: Chronic obstructive pulmonary disease (COPD), asthma, restrictive lung disease (kyphoscoliosis)
- Gastrointestinal: Gastro-esophageal reflux disorder (GERD)
- Endocrine: Thyroid (hyper), growth hormone deficiency/excess
- Neurologic: Epilepsy, motor neuron disorders, Parkinson disease, amyotrophic lateral sclerosis (ALS)
What I find compelling is how the medical/dental fields are so interconnected and yet so divided. It is vital that we start to work hand in hand to prevent disease or recidivism in all of our patients. I had the wonderful opportunity to hear the late Dr. Lloyd Rudy, a world-renowned cardiovascular and thoracic surgeon speak, and he stated, "Anywhere you have inflammation, our arteries can take on an assault. Periodontal disease has been known to be an initiator of the inflammatory process in the body, and patients need to be screened for this disease."
If we take a stand and attack the conditions that are causing the inflammation at all angles, the fire will be extinguished. Firefighters work hard at containing a fire prior to putting it out. They know the potential for all-out destruction is imminent if they lose control. Together, health-care providers can contain and put out any lingering fires within the patient and enhance the quality of life for the patient and the generations to follow.
Your patient's medical history, genetics, and patient interview will warn you of any potential fires. Recent heart attack, stroke, surgeries for cardiovascular issues, and diabetes are cause for a five-alarm alert! A five-alarm in the world of a firefighter is when subsequent alarms are calls for additional units, usually because the fire has grown and additional resources are needed to combat it, or that the incident is persisting long enough that firefighters on the scene need to be replaced due to exhaustion.5
These individuals have already had an event, and they cannot afford to have any fires brewing. It is extremely important to eliminate any inflammation you find in the oral cavity. If the patient has not had an event and is asymptomatic, do not come to the conclusion that the patient is in the clear. You want to prevent fire. Don't even let one start.
Remember the smoke signals or the red flags above when you review the history form. If your patient has any of them or a family history of them, the patient is at an increased risk of vascular disease and vascular events. Remember, inflammation is the culprit. Dr. Bale, cofounder of the Bale/Doneen Method adamantly states, "They are considered guilty until proven innocent!"
Educate your patient on the role that inflammation plays in breaking down the integrity of the vascular wall, leading to heart attacks and ischemic strokes. Explain how periodontal disease, bleeding gums, endodontic lesions, OSA, diabetes, and other health issues contribute to that destruction. Encourage your patients to get tested for oral pathogens, blood biomarkers, and genetics to accurately identify the cause of the inflammation.
In educating the patient, we are attempting to get everyone on the same page-the oral health-care provider, medical provider, and the patient. The patient will better understand the reasoning for the recommended treatment, how the treatment will contribute to maintaining overall health, and ultimately enhancing their compliance. We deal in the oral cavity and we can use that expertise to help our patient's total health and well-being. Do not underestimate the importance of the role a dental health-care provider plays in the quality and longevity of a person's life. RDH
Kriston Reisnour, RDH, BSDH, CCSH, is the director of dental hygiene at Advanced Cosmetic & Laser Dentistry in Seattle. A dental hygienist for 26 years, Kriston is passionate about the advancement and education of oral-systemic links and bridging gaps between medical and dental providers. She is a credentialed clinical sleep health educator, as well as certified in sleep medicine by the Academy of Clinical Sleep Disorders Disciplines. She is on the speaker's bureau for the Bale/Doneen Method. Kriston can be contacted at firstname.lastname@example.org.
1. Bale B, Doneen A. Bale/Doneen Method. Las Vegas, Feb. 25-26th, 2011. Preceptorship Course.
2. Bale B, Doneen A, Collier CL. (2014) Beat the Heart Attack Gene. The Revolutionary Plan to Prevent Heart Disease, Stroke, and Diabetes. New York, NY: Turner.
3. Huang QR, Qin Z, Zhand S, Moi C. Clinical Patterns of Obstructive Sleep Apnea and Its Comorbid Conditions: A Data Mining Approach. J Clin Sleep Med.2008 Dec 15: 4(6):543-550.
4. Park JG, Kannan R, Olson EJ. Updates on Definition, Consequences, and Management of Obstructive Sleep Apnea.
5 MacIntyre-Yee T. (January 27, 2015). Demolition of building near MAG to continue Wednesday. Democrat & Chronicle. Retrieved November 11 th 2015.