by Lynne H. Slim RDH, BSDH, MSDH
The stress of surviving Atlanta's traffic on weekday mornings is probably similar to the stress that certain RDHs feel in some profit-driven hygiene departments. Therefore, valet parking at Emory University, School of Medicine, was a welcome relief when I arrived for a two-day adventure with about 30 RNs.
Earlier in 2010, I contacted Dorothy Doughty, MN, RN, CWOCN, FNP, FAAN. She is the program director of a six- to 10-week continuing nursing education course that teaches nurses specialty care for patients with acute and chronic wounds, fecal and urinary incontinence, and standard and continent diversions. (Diversions refer to contemporary surgical techniques that have revolutionized the therapy for persons affected by severe colorectal or urinary bladder conditions such as inflammatory bowel disease and bladder cancer.) By the way, don't ask me what Dorothy's credentials stand for. They remind me of a decorated military officer and I know they mean something extraordinary.
Why, you may ask, would I want to attend a wound care course with a bunch of nurses? Well, besides being a consistent nerd, I'm fascinated by the many articles I've read on chronic wounds and biofilm. I wanted to sit in on the portion of the course that dealt with the nursing management of patients with acute and chronic wounds.
We're a lot like RNs
The program director and classroom of nurses welcomed me with open arms and were eager to make me feel welcome. They were puzzled when I told them I was a dental hygienist, but they could relate when I discussed cariogenic biofilm and subgingival biofilm in periodontal pockets.
RNs are a lot like us in terms of their professional education, but the difference is that they are self-directed and offer their own credentialing in specialized skill sets. One of those skill sets is a group of three separate courses of postgraduate study that are accredited by the Wound Ostomy Continence Nurses Society (WOCN). The RNs I chatted with at Emory felt that certified skill sets enable them to feel more autonomous in their work environment, and none of them are worried about finding work once they receive their specialty certification.
Nursing instructors such as Dorothy Doughty are passionate about evidence-based decision making, which is incorporated into every aspect of the skin and wound modules as "principle-based."
When I initially contacted Dorothy, I told her I was interested in the teaching modules that dealt with nursing implications for wound healing, especially the role of biofilm. Little did I know that I would participate in a wound lab that involved wound debridement of pigs' feet!
The wound healing process for acute wounds is markedly different than for chronic wounds. In a nutshell, acute wounds heal in an orderly cascade of overlapping, predictable events, whereas chronic wounds (such as chronic periodontal pockets) fail to heal normally as the result of some vascular compromise or other pathologic process. Most of what is known about wound healing is based on acute wounds because it's possible to create and manage an acute wound in a laboratory animal.1
What I found particularly interesting in discussing the physiology of the inflammatory phase of an acute wound were the factors affecting the intensity and duration of the inflammatory phase, such as biofilm, tobacco use, diabetes, obesity, and aging. It was a good review for me. For example, nicotine has a vasoconstrictive effect that lasts several hours and interferes with maximal oxygenation. Any state or disease that adversely affects perfusion and/or oxygenation, such as smoking or even obesity, interferes with wound healing.
It's impossible for me to do this course justice in one column, but I want to discuss something that struck a chord with me and I think it will with you, too.
Wound care nurses know the importance of moving any wound through the inflammatory phase quickly so it won't get "stuck." Getting "stuck" in chronic periodontitis constitutes, in part, an ongoing battle between pathogenic subgingival biofilms and a susceptible host. Not only do we need to maximize our biofilm suppression protocols, we also need to pay closer attention to systemic factors because chronic periodontal wounds occur in compromised hosts.
We must not forget risk factors such as perfusion/oxygenation, nutritional status, the presence of diabetes, and persistent injury such as unrelieved pressure. When you perform scaling and root planing on a patient with Type 2 diabetes, for example, do you first determine his or her HbA1C level? Do you realize that a patient with an elevated HbA1C level is going to take a lot longer to heal? I also learned that unrelieved wound pressure and failure to correct the causative factor(s) result in a continuous cycle of injury. Are we perhaps not paying enough attention to the relationship between periodontal disease progression and occlusal factors?
Stay tuned as I continue to explore lessons learned from wound care nurses as they pertain to periodontal diseases in 2011.
Lynne Slim, RDH, BSDH, MSDH, is an award-winning writer who has published extensively in dental/dental hygiene journals. Lynne is the CEO of Perio C Dent, a dental practice management company that specializes in the incorporation of conservative periodontal therapy into the hygiene department of dental practices. Lynne is also the owner and moderator of the periotherapist yahoo group: www.yahoogroups.com/group/periotherapist. Lynne speaks on the topic of conservative periodontal therapy and other dental hygiene-related topics. She can be reached at [email protected] or www.periocdent.com.
1. Emory University WOCNEC. Skin and wound care module. Feb. 2010 (13th Edition).
Past RDH Issues