Putting together the puzzle pieces

Sept. 1, 2004
Attention to detail uncovers non-dental health concerns.

by Kim Nimmons, RDH

Ask your patients when they last saw their family doctor for a physical. You will most likely receive some strange looks as they wonder why you're asking such a question. Most people may not even remember their last trip to the doctor for a checkup. Who goes to the doctor because they feel well, anyway? And what does it have to do with a visit to the dental office?

The problem with this is that many illnesses or dangerous physical conditions can develop slowly or even be present but undetected for many years without making a person feel sick. Despite the proven effectiveness of preventive health-care practices such as regular physical examinations, vaccinations, and screening tests, studies show that many adults do not take the time to see their family doctor on a regular basis, especially if there are few or only minor noticeable symptoms. Furthermore, patients may not always report minor symptoms to physicians.

Now ask your patient about the last time — prior to their current visit — he or she went to their dental office, either for a checkup or to have a procedure completed. My guess is that it was more recently than the last time they saw their physician. Most dental practices see patients between two and four times per year for hygiene or periodontal maintenance procedures, and more often when restorative or other dental procedures are required. These frequent visits allow us many opportunities to monitor not just the oral health, but also the overall health of our patients. As dental professionals, we should be willing to put the puzzle pieces together. From high blood pressure to conflicts in medications, observant dental professionals can positively affect the health of our patients.

If you have developed close relationships with your patients, they will often share how they are feeling with you. In my experience, when given the chance, most people will open up and share details about their lives that they may not reveal to a health-care provider they visit less frequently. Paying attention to these details makes all the difference between simply scratching the surface and uncovering the root of a problem.

Dental hygienists play a special role in patients lives. We can provide for their dental health care while monitoring their overall health.

Finding your roots

While periodontal disease remains a health concern, it can also indicate more serious health problems. Bleeding gums that do not respond to traditional treatments can be an early sign of diabetes. Got gingivitis? It can be linked to hormonal changes such as pregnancy or menopause, or even an imbalance in a prescribed hormone replacement medication. More than a dozen oral symptoms can precede other physical signs of Crohn's disease, an inflammatory bowel disease. And most patients are not aware that gum disease has been identified in many studies as a link to both lung and heart disease. Other studies indicate that people who abuse alcohol have an increased incidence of periodontal disease, caries, and potentially pre-cancerous oral tissue changes.

Keep in mind that not all health concerns are physical, nor are all patients forthcoming with their personal problems. Although bulimia can often be detected by the acidic erosion of teeth, a patient may not want or might be embarrassed to seek help.

I recently read an article about facial rosacea, an obvious and often embarrassing skin problem that appears as extreme facial redness in its early stages. If left untreated, it can result in substantial skin damage. A basic understanding of what to look for can be very advantageous. If you recognize a condition, you can refer patients to an appropriate physician to diagnose and treat the problem. Periostat, a drug currently indicated for the treatment of periodontal disease, is now being prescribed for facial rosacea because both diseases involve collagen breakdown. I mentioned this to a patient who reported on her medical history that she was recently diagnosed with Rosacea. When she returned to her dermatologist, he did indeed prescribe Periostat. Both she and the doctor were impressed that her dental hygienist had made this connection. Fortunately, most people appreciate the intervention and act upon advice, especially if it can improve their health or even save their life.

Breaking ground

It can be awkward to bring up health concerns during a hygiene visit. Again, you may receive some puzzled looks or resistance to your inquiries. You just have to bring it up and plow ahead. Even though it might be difficult at first, it can be very rewarding if you are able to make a difference. You will also develop a strong bond of trust and loyalty with your patients.

Attention to detail can provide a valuable service to patients. Just open your eyes and ears, and you could make a very important discovery. The next time you see a patient you've helped, you can be sure they will not only remember their last trip to the dentist, they will never forget what you've done for them.

On the case:Noting 'unrelated' health concerns

While recently reviewing a patient's medical history (which I recommend be checked at every dental appointment and renewed annually), I noticed she had felt tired for the past three months. Her physician advised her to get more rest and reduce her stress. I made a mental note of this and proceeded with our hygiene appointment. Upon examination, I noted that her gums were unusually pale and white.

After completing the appointment I advised her of my findings and suggested she see her physician immediately. I thought she might just be anemic or very run down. It's a good thing she made her routine visit to the dental office that day. As it turns out, she had internal bleeding due to moderately advanced colon cancer. She had surgery the next day. She was told that she could have died from blood loss overnight, as she had lost nearly two-thirds of her blood volume. I'm happy to say that was five years ago and she is doing well and never misses a hygiene appointment.

I took a panoramic X-ray of a 60-year-old patient. The X-ray itself appeared to be within normal limits, but I noticed one large and several small radiopaque, irregularly shaped clusters near the bottom of the film. I showed my patient and his dentist what I had found. The patient was referred to his physician, who in turn referred him to a vascular surgeon.

A week later I learned that the "mass" was carotid artery plaque buildup for which my patient underwent surgery a week later. Detecting and removing this plaque buildup before it had separated and traveled to his brain probably prevented him from suffering brain damage or a stroke.

A case involving Lyme disease further illustrates the unique position we are in to help our patients. Lyme disease is caused by the bite of a deer tick. Often a person is not even aware of the tick bite. In its early stages, Lyme disease symptoms are vague and intermittent but get progressively worse without treatment. This can eventually end in painful and permanent damage to the central nervous system.

One of my patients reported on her medical history that she was taking antibiotics — a yearlong course of Doxycycline to treat Lyme disease. She explained how she got the disease, its symptoms, and how she was diagnosed. While nothing about this condition affected her oral care, I was able to use the information to help another patient. Several weeks after learning about Lyme disease, one of my long-time patients came in for her hygiene visit. She had not been well for some time so I asked her how she was doing. As she described her health problems, I realized her symptoms were similar to the patient with Lyme disease. I mentioned this to her, and several weeks later she asked her physician to test her for Lyme disease. Her test was positive and she is currently receiving treatment. Unfortunately, as with many cases of Lyme disease, it was undiagnosed for so long that she will probably have some residual permanent nerve damage.

Kimberly J. Nimmons, RDH, is both a certified dental assistant and registered dental hygienist.For the past 19 years, she has worked in both capacities in the group practice of Drs. Ronald Goldstein and David Garber in Atlanta, Ga.Kimberly is an alumnimember of the 3M ESPE Dental Hygiene Advisory Panel.