The 'dental hygiene detective' and the oral-systemic connection
The days of humdrum dental checkups are long gone. As dental professionals, especially dental hygienists, we must be on our toes, aware of everything that could be going on with our patients. As awareness of the oral-systemic connection grows, our profession matters more than ever.
By Chris Bustamante, RDH
The days of humdrum dental checkups are long gone. As dental professionals, especially dental hygienists, we must be on our toes, aware of everything that could be going on with our patients. While some of you might be thinking, “Oh great, more things to watch out for. I have enough to worry about as it is,” there is tremendous gratification in being our patients’ first line of sight. I like to think of us as detectives, because in any routine care setting, we likely spend the most time with our patients, and we might see changes or oddities that others do not. Our six-month checkup is more relevant than ever. Our profession is unique. Our practice matters.
We’ve all heard stories about the astute hygienist who found a suspicious lesion on the lateral border of the tongue, the one that turned out to be oral cancer. Or about the dentist who felt a lump, the one that ended up being a type of salivary gland carcinoma. Though these findings are rare, they are significant and impactful. As dental professionals, we have the opportunity to save lives through the oversight of not only the oral cavity, but also of the head and neck.
But what if there is much more to it than that? In dental hygiene, there has been a gradual shift toward the encouragement of interdisciplinary care and observance of systemic conditions. This is just a fancy way of saying that we’re now more aware of the total body connection and the role our profession plays in it. We must be on the lookout! So, what can we find and what signs do we look for?
Maybe you noticed your patient’s hand tremor when you handed him a pen to sign a form, or perhaps his jaw trembled through his entire cleaning. It could be coincidental. Maybe he had too much coffee that morning. Maybe he suffers from TMD and struggles to keep his jaw open for long periods of time.
But, what if he exhibits those signs and more? When you brought your patient back, did you notice anything unusual about him—something glaring, like a hunched-over appearance or obvious slouch? Did he walk very slowly or clumsily, nearly falling? Did he look mad or depressed, like a statue? When you asked him a question, did he answer in a very low or soft voice? Did he mention trouble sleeping, loss of smell, or recent falls?
These can all be signs of early Parkinson’s disease, though not exclusively. Perhaps the patient is elderly, and aging is starting to take its toll. Maybe he’s lived a hard life and doesn’t like talking to people. People like to see patterns, and our hunches are not always right. But awareness is everything.
If you suspect Parkinson’s, one super detective move is to look at the patient’s handwriting. Perhaps the patient updated his medical history, or maybe you had him sign for his blood pressure. Heck, maybe you asked him to write down his favorite book for you. Is the writing irregularly small? In the patient’s record, is there something that shows his handwriting from years ago that you can compare to? Is there significant change?
If the patient exhibits multiple symptoms, it might be a good idea to recommend a routine medical checkup. Early diagnosis and intervention can make a profound difference, and your patient just might thank you for it.
While our patients may not talk to us about their stomach woes, dime-sized ulcers in the lips or cheeks might be a sign of a condition in a part of the body that’s at the other end of our specialty.
This is just a fancy way of saying that we’re now more aware of the total body connection and the role our profession plays in it. We must be on the lookout!
According to a 2010 study from the Medical University of South Carolina in Charleston, up to 20% of patients with inflammatory bowel disease may develop lesions in their mouth even prior to developing other symptoms such as diarrhea and cramping.1
General ulcers of normal size and shape can be caused from acidic foods or stress. However, mucogingivitis, cobblestoning of the lining inside the cheek, lip swelling with or without fissuring, and indurated taglike lesions are common oral pathologies that present with Crohn’s disease and may be an indication of a bigger problem.
If you see these signs and your patient complains of abdominal symptoms, you might inform the patient that the two may be related and it couldn’t hurt to get it checked.
Elevated or abnormal blood pressure
Many of the offices that I’ve worked at have the fancy little wrist-style blood pressure cuffs. If your office doesn’t, you might ask your dentist to see if it’s in the budget. They’re an inexpensive, useful tool, and your patients might think your office a little swanky for doing it. Can you raise a pinky?
Some patients may ask why you’re checking it. You can simply advise them that you’re concerned for their benefit and would like to monitor it for them. If it is high, we might suggest that they monitor it on their own and always recommend that they see a medical doctor for further evaluation. In my experience, many people are unaware of the dangers of elevated blood pressure, such as the risk of stroke, for instance. If they have higher blood pressure, it may be a signal for us to watch for other chronic conditions as well, such as heart disease, diabetes, or cancer. Education is important, and knowledge is power. If you’ve forgotten what blood pressure readings mean, refresh your memory at the American Heart Association’s website.
Have you been working with a patient for a while now and her gums simply will not come around? She tells you that she’s flossing daily and brushing with the super cool electric brush you recommended, still to no avail. Your records show that every time the patient comes in, her gums bleed on probing, or they appear inflamed or cyanotic.
It could be just a difficult case, ongoing chronic gingivitis, or if pocketing exists, periodontitis. But it could also be diabetes. Perhaps the patient is not healing as fast as she once did; her immune system is compromised, and her body is not forming collagen as it should.
Maybe the patient has given you little clues in your extensive conversations. You know, the ones where your hands are knuckle deep in her mouth, and you ask her every trivia question about her life and family?
Perhaps the patient mentioned going to the bathroom more frequently or that she’s thirsty all the time. Maybe you notice that she’s started losing a little weight (though counterintuitive, it is a sign). She could’ve mentioned a recent fall due to blurry vision or tingling in her extremities, fingers, and toes. The patient tells you she’s more hungry than normal, or that she feels shaky and is tired often.
When we know what to look for, we can piece together these little oddities, and though we cannot diagnose her with a specific disease, we might be her best bet at seeking the help and the treatment that she needs. It happens through the power of suggestion.
Early in our dental education, we were trained to identify enamel erosion. That telltale yellowing and indication of enamel loss on the lingual surfaces of the teeth can sometimes lead to uncomfortable questions about patient history, or conditions such as bulimia. But when in doubt, ask, and start with GERD (gastroesophageal reflux disease).
Even without the obvious indication of enamel erosion, maybe the patient mentioned that he is having trouble staying asleep at night or that his throat hurts in the early morning. Are there erosions or lesions in the back of the throat that meet the profile? The patient might even complain of frequent postnasal drip and bad breath, asking if there is a mouth wash that can help. It could be GERD; it could just be halitosis. A little digging helps.
Many people don’t know that they have GERD. It can present as “silent reflux,” and they might tell you that they never have heartburn. But, unfortunately, this tricky condition can be hard to detect. Things are not always as they seem. You might just be a detective yet.
Aside from the obvious, and by “obvious” I mean bruxism, abfractions, wear facets, or enamel wear, there may be other signs that your patient is suffering from stress, anxiety, or depression-related disorders.
Frequent canker sores, noticeable xerostomia, and ongoing, unresolved gingival inflammation can all be signs. The body’s response to intense stress can present itself in many different ways, often affecting hormonal, vascular, and muscular functions. These changes might present as compromised digestion, reduced salivary flow, and TMJ dysfunction.
In some cases, the stress is so severe that “trench mouth,” or acute necrotizing ulcerative gingivitis (ANUG), perhaps even acute necrotizing ulcerative periodontitis (ANUP), may present itself. The patient may complain of painful gums that bleed with little provocation, and we may notice the characteristic “punched-out” papillae that we learned about in our primary dental education. There may be a fetid odor, or a gray pseudomembrane around the gingival margin, and complaints of fever or malaise by the patient.
Granted, this disease may have many other causes, including a compromised immune system from conditions such as HIV, cancer, or the like, one of the primary causes might be ongoing or high-pressure stress. It’s important to talk to your patient about their stress level and recommend help as needed. Sometimes, you’re the only person they can vent to, and they might be surprised that you caught on. It might open the door that they need to regain control of their life.
You brought your patient back, and he tells you he’s been very tired lately. Your conversation carries on and you ask the usual questions about his work and home life; meanwhile maybe you’re still thinking about his mention of fatigue from earlier on. The dental detective inside is questioning everything and yearning to discover a cause.
You have the patient open up for the initial examination and oral cancer exam. Then, bam! Right there, you notice it! Pale mucosal tissue that makes you wonder if your patient has become a zombie, and glossitis of the tongue that you could play air hockey on. These little nuggets could very well be anemia. Educate the patient—but maybe keep the zombie part to yourself.
There are many other systemic conditions that we can look for as dental detectives, though not nearly as telling, and much more difficult to piece together.
Maybe your patient mentions loss of energy, memory loss, or exhibits signs of forgetfulness during conversation. Did you notice a change in the pitch of her voice while she spoke to you, and something about it didn’t seem quite right? Perhaps she displayed difficulty in the simple task of grasping for a pen during routine paperwork. These could all be signs of something greater—Alzheimer’s, dementia, amyotrophic lateral sclerosis (ALS), or chronic fatigue syndrome. If ever in doubt, suggest a check-up.
The practice of interdisciplinary care is always evolving. Dentistry and dental hygiene are vital in the process as a whole. As the connection between periodontal disease and systemic disease becomes more widely understood, we need to consider our approach to diagnosis as it relates to systemic conditions.
While working for the Colorado Coalition for the Homeless in Denver, Colorado, I got to see firsthand how this type of practice might look in the real world: clinics that offer medical, dental, vision, and pharmacy care all in one place. A unique look into integrative medicine, where a patient comes in for a medical exam and the dental hygienist on staff steps in for an oral evaluation, providing real-time triage assessments and aiding in the overall diagnosis of the patient. In some cases, the patient might be sent down the hall for immediate extraction and infection control.
We’re gaining ground in a wider worldview and awareness of overall health. Patients care that we care. If you see a problem, let them know of your concerns and advise them to get seen by their primary care physician.
I challenge you to be your very best detective, keeping an eye out for clues. You could save a life in the process, and I assure you there is no greater reward!
Chris Bustamante, RDH, is a traditional dental hygienist in Denver. His passion for research and his love for writing have transformed his life both personally and professionally. While working toward completing his first science fiction novel, he writes on his personal blog and for various publications. He can be contacted at Cjbauthor@gmail.com.
1. Chi AC, Neville BW, Krayer JW, Gonsalves WC. Oral manifestations of systemic disease. Am Fam Physician. 2010 Dec 1;82(11):1381-8. https://www.ncbi.nlm.nih.gov/pubmed/21121523?dopt=Abstract
2. Gelman L. Shocking diseases dentists find first. Reader’s Digest website. https://www.rd.com/health/conditions/diseases-dentists-find-first/
3. Gelman L. 10 silent diabetes symptoms you might be missing. Reader’s Digest website. https://www.rd.com/health/conditions/signs-diabetes/1/
4. Lankarani KB, Sivandzadeh GR, Hassanpour S. Oral manifestation in inflammatory bowel disease: A review. World J Gastroenterol. 2013 Dec 14;19(46):8571-9. doi: 10.3748/wjg.v19.i46.8571.
5. 10 Early Warning Signs of Parkinson’s Disease. National Parkinson Foundation website. http://www.parkinson.org/understanding-parkinsons/10-early-warning-signs
6. About ALS - Symptoms and Diagnosis. ALS Association website. http://www.alsa.org/about-als/symptoms.html?referrer=https://www.google.com/
7. Atout RN, Todescan S. Managing patients with necrotizing ulcerative gingivitis. J Can Dent Assoc. 2013;79:d46. http://www.jcda.ca/article/d46
8. 10 Early Signs and Symptoms of Alzheimer’s Disease. Alzheimer’s Association. http://www.alz.org/10-signs-symptoms-alzheimers-dementia.asp
9. Kandagal S, Shenai P, Chatra L, Ronad YAA, Kumar M. Effect of stress on oral mucosa. Biol Biomed Rep. 2012;1(1):13-16.