The dental-medical connection: bridging the interdisciplinary communication gap to broaden patient care.

One patient wasn't healing properly. Another had elevated blood pressure. Yet another was battling anorexia, but didn't share that information during a checkup. Instead, she complains of trouble with acid reflux. An elderly patient in for an early morning visit experienced dizziness, which turned out to be a mild stroke.

These cases seem like a typical day at the physician's office. In actuality, they all started in the dentist's office. On a daily, weekly and monthly basis, medical conditions invade the dental operatory. Who has the experience to handle them? What is the treatment protocol? Who holds the responsibility for the patient's care?

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Professionals in both the dental and medical communities stress that it is a team effort that requires each side to share observations and critical details about treatments, procedures and medication.

For Ann Scarff, RDH, who is in practice with Peter Pang, DDS, FAGD, simple pre-treatment protocol sometimes reveals medical problems. In one such case, Scarff began a typical visit by taking her patient's blood pressure.

"He had a very high blood pressure [that day], and has a history of high blood pressure. He hadn't been taking his medication," Scarff explained. She let him rest for a bit and took the reading again; this time it was higher. She told him to see his physician and rescheduled his dental appointment.

Michael Swick, DDS, and Denise DiNardo, RDH, frequently experience disclosure problems from patients who do not share information vital to treatment protocol.

"It's really interesting," Swick commented. "Some of the people with the worst health problems are the ones who don't want to tell you about them." From patients who have had joint replacements to those taking blood thinners, it presents a mid-procedure challenge when a health problem is suddenly discovered.

"We try to work around [disclosure issues] and tread lightly," said DiNardo, who takes more time with patients who share little about their health condition.

When the clinician is acutely aware like this, said Lori Trost, DMD, detecting medical issues can become a regular occurrence. "The key is to look at more than just teeth," said Karen Kaiser, RDH, who works in practice with Trost.

"The thinking that dental hygienists just clean teeth is quickly going by the wayside," said Trost. To elevate their respect in the office and make that all-important dental-medical connection, dental hygienists need to take a stronger position as oral wellness specialists.

Medical Meets Dental

Trost and Kaiser once treated a 40-something, intellectually challenged patient during a regularly scheduled checkup. He had recently been referred to an oral surgeon for the extraction of a wisdom tooth. Kaiser noticed that the extraction site was not healing, two weeks after the procedure. It was inflamed and had an odd appearance. The patient complained of ear and jaw pain. The dental team used dry socket packing on the area and scheduled another appointment in five days to follow up.

In the meantime, the patient visited an ear, nose and throat specialist for the ear pain and was treated for a standard ear infection. During the follow-up visit to the dental office, the patient was clearly worse, the ear was draining and the extraction site had deteriorated. The dental team had doubts as to whether the extraction and ear pain were separate conditions. Through a process of continual contact with the patient through additional follow-up visits and phone calls, Trost and Kaiser insisted and assisted the patient's care-giving family in getting additional medical attention and blood tests. What emerged was that the patient's lack of healing, inflammation and pain were a result of lymphoma. (1)

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"No one picked up on these symptoms," explained Trost.

The roster of medical conditions passing through DiNardo's operatory includes cancer patients going through chemo or radiation therapy and others living with liver transplants, kidney dialysis, drug abuse, anorexia and bulimia. One of her greater challenges is the patient who takes medications but doesn't know what conditions those prescriptions treat. For Swick, problems stem from an inconsistency in the medical community.

"As we all know, there has been a change in how we treat [patients with heart issues]," he explained. "Some physicians don't go along with that; some do. It's amazing how many of them are unaware that the regimen has changed." He added that the treatment of joint replacement patients, likewise, is not consistent. Some physicians want the patient premedicated before oral health procedures, some don't.

"We always contact the physician. Because we get no consistency from one physician to another, we call every time," Swick said. "The physician doesn't largely understand dental work. It is difficult explaining to them what is going to be done and what the problems might be."

For Pang, challenges arise when physicians fail to advise patients with stabilized medical situations, such as a history of cerebrovascular accident (CVA) or heart attack, and the patient comes in for dental treatment before the prescribed six-month waiting period after such events. The patients don't realize that elective dental work cannot be completed.

Oral cancer is a huge concern for Trost and Kaiser. In a month's time, the practice detected three cases among its patients. They use Oral CDX and Vizilite oral cancer detection systems to test patients, but Trost and Kaiser both have observed an increase in cases that don't fit normal risk categories. Trost noted that changing lifestyles, diets, behaviors and oral home care result in unusual cases that defy traditional at-risk categories. Oral health care providers need to be on the lookout for oral cancer, for example, beyond the adult-male-smoker-over-60 group. Diabetes and heart disease issues have increased, as well, particularly in younger age groups. Xerostomia issues also have increased.

Dry mouth resulting from chemo- or radiation therapy continues to be a challenge for Swick.

"It seems very difficult to control those patients, and a lot of them end up losing teeth even [despite] our best efforts," explained Swick. Saliva substitutes are frequently recommended, but Swick has seen little patient compliance. Another tactic is to steer those patients to sugar-free candies to keep them from using the sugared varieties as palliation.

Being Alert

Trost asserted that the dental hygienist's assessment of a patient's physical condition begins when he or she meets the patient in the reception area and walks them back to the operatory.

"The assessment starts immediately when you shake their hand, hold their arm or assist them--however you are walking with them until the point in time when they sit in the chair and open their mouth," said Trost, who shared that the overall appearance of a regular patient's tongue tipped off health concerns during a recent visit.

"His tongue was totally unhealthy. I asked if he had a history of diabetes in his family," Trost stated, adding that the patient responded that his father had had diabetes.

Kaiser sometimes finds patients with inflamed tissue after scaling and root planing who do not respond to treatment after a couple of follow-up visits. She encourages them to see their medical doctor.

"When ... [the patient] returns, I find they have been an uncontrolled diabetic," Kaiser reported. Once they get treatment, the tissues start to respond and their whole health begins to improve. The dental team completes a health history for each patient and, through that process, detects some potential health situations, according to Kaiser. She admitted there are some issues for dental hygienists in the credibility area with medical doctors, but asserted that hygienists may take control of misconceptions.

"We are keenly aware of what goes on in the mouth. We need to promote ourselves as knowledgeable about the body-mouth connection," Kaiser commented. Many times, patients are surprised that she covers other areas of their health.

Pang and Scarff take a similar approach to making the patient comfortable sharing their whole health background.

"Because we try to emphasize our relationship with the patient, we don't just hand them a form, we also have a conversation about the state of their health," said Pang. Through these discussions, the team learns of critical health problems that the patient might not share when filling out and signing a form.

"Rather than handing them a form, we conduct a new patient interview. We have the form in front of us, we ask them the questions, making it more like a conversation. At the end of the conversation, I have them look over the form to make certain I haven't overlooked something, and have them sign it then," Pang explained.

"I have actually had patients [who] didn't want me to know of [serious health incidents]," noted Scarff. "They didn't think it was our business."

One patient failed to mention that he had a pacemaker. Not particularly a problem, as this is a situation that is not premedicated much anymore. However, this particular type of pacemaker was sensitive to strong magnets. Part of Pang's treatment for TMD is the use of a sensor with a magnet. Pang was thankful he described the procedure and that patient finally shared that he had a pacemaker.

Swick has noticed that patients frequently leave out important details or try to hide elements of their lifestyle. He mentioned that some patients use acid reflux as an excuse to cover up serious disorders such as anorexia nervosa or bulimia. Self-medicating patients, such as those taking massive doses of vitamin E, present their own unique problems. For patients taking prescribed medications, some do not understand the serious side effects that can result.

"I had a situation several months ago where I performed laser surgery on a patient. When I was done, the lady asked me how the procedure went. I told her it went well except that she bled a little more than what I was used to. Usually with laser therapy we don't have any bleeding issues," Swick shared. "The patient asked if she should have mentioned she was taking the blood thinner, Coumadin."

For patients with heart murmurs or joint replacements, or who have been placed on a blood thinner, Swick said, "When we find out at the last minute about these conditions, we have to contact the physician and lose [dental] treatment at that point in time."

"With people on Coumadin, the physician will want to check the patient's clotting time. The other difficulty is planning out the treatment to try to get as much of their work [as possible] done while they are off their blood thinner," Swick stated.

For chemotherapy patients, DiNardo added, "we usually have to go back to the [physician] and get a white blood cell count before we can treat them here."

Trost cautioned that the best way to cope with the new influx of health issues is by being prepared: "You better have a protocol system in place," she advised.

Establishing Protocol

For Swick, a paperless office has become a safeguard for patients with health issues. "Health alerts come up on the computer every time the patient's chart is brought up," he reported. Swick added that he would like to see a centralized medical records facility available, with online, passcode-protected patients' records, complete with indications and contra-indications for different types of dentistry, "without having to call the physician's office."

Dental offices handle each situation differently, noted Pang. "In our office, we will see a situation maybe once every three to four months where their blood pressure is too high, and we think it is unsafe to treat a patient without a medical release," Pang said. "What I usually do is tell them to call their physician and [have the patient] go in for an evaluation because of our concern with their blood pressure. So far, everyone has been very responsive to [this approach]." His offices follow up with the patient a week or two later.

For emergencies that require quicker action, Trost and Kaiser created emergency envelopes. They maintain specific information and helpful medications that cover everything from seizures and fainting to heart attack or stroke. See the sidebar on page 23 for more details on the contents of this system.

"Anyone can step in and be trained. We just had our refresher course two weeks ago," Trost said. Updates go into the system on a regular basis. Part of Trost's protocol is to remain calm and positive, no matter what is discovered while examining the patient.

Trost shared the story of a patient who came to her office with a Class 1 occlusion. The patient mentioned a ringing in her left ear. Over time, she also noticed a popping in her jaw. She, as well as Trost and Kaiser, did not think was right. The team took a panographic X-ray and discovered a globular growth in the patient's left temporomandibular joint (TMJ) region.

Trost called an oral surgeon she knew and sent the digital x-ray to him. He agreed that the patient needed to be seen immediately. In a 10-day period, the patient went from a tingling pain to facial paralysis. A scope of the patient's TMJ in the oral surgeon's office revealed a benign mass that originated from the facial nerve and coursed through the TMJ region.

"When you see something significant that needs treatment, you don't scare the patient; you don't say 'cancer,' " said Trost. "You confidently move them to the referral source and you make the appointment for them before they leave your offices."

Building a Dental-Medical Connection

Trost builds her physician contact list to establish a path before a patient needs to travel it. "You have got to have a good referral source. Say that you identify an oral cancerous lesion. If you do not have a good referral source to whom you can pass the baton and get a biopsy reading, you are not helping yourself or your patient."

She frequently phones physicians in her area and introduces herself, sends letters of introduction or attends career-day and other community events. She also maintains referrals to a mental health intervention team at local crisis hospital.

"We're one of the only offices in our area actively seeking oral health care and opportunities as they relate to medical conditions. Physicians have come to learn that we are on the forefront; we created that leadership position. Now they come to us. They know when they pass a patient to us, that patient will be well taken care of," Trost continues. This groundwork has been laid over the course of many years.

"We personally have very good relationships with most of the referring physicians in [our] area," Trost continued. "We have no problems asking for blood test results or having them run different tests to identify what might be suspicious." Trost viewed the dental hygienist's role as evolving into a direct line of action in medical collaboration.

"As dental hygienists, we really do care about their whole body," Kaiser stated. Dental hygienists should not be afraid to share information they have about the link between oral and overall health. "A lot of [dental hygienists] are afraid to [be] open about it, thinking 'that's not my area.' It is your area. Our area is becoming more than the head and neck."

According to a recent survey thesis project conducted by Kelli Swanson Jaecks, RDH, BSDH, MA (see sidebar, page 24), the dental hygienist rarely talks to medical physicians, and instead interacts with a nurse or front office personnel.

"I think our responsibility is to do the communicating," Jaecks commented. "What happens on the other end is nothing we have control over." Jaecks recommended that dental offices create a communication plan that includes which team member will be the touch point from the dental office responsible for making calls to specialists. The next step, Jaecks said, is to move beyond the fear of communicating with medical professionals.

"They are also concerned about the whole health of the patient. Adding our piece of information to the patient's file is important. We don't have to fill a memo with huge medical terms," Jaecks said, pointing to one of the top barriers identified in the survey. According to the survey, dental hygienists feel they don't know enough about medical conditions. Jaecks asserted that while it is a good idea to be educated about medical conditions, it is not essential in communicating what the dental hygienist observes.

"We do know how to communicate periodontal disease, and that's all we have to communicate," she continued. "It does not have to be medical speak. We can use our dental speak and tell the story." Other communication barriers Jaecks' survey disclosed were a lack of time for all duties the dental hygienist is expected to perform during a dental visit; the need for more professional freedom; and a perceived lack of willingness to collaborate by other professionals.

Pang has experienced this last barrier in some of his work. He described working with patient's physicians as somewhat frustrating. Run-arounds, postponed return calls or varying approaches to antibiotic premedication protocol create delays in treatment.

"What seems to help us quite a bit is a written medical evaluation consult form. We fill out the most essential points and fax it to the medical doctor's office. The legal professionals tell us a faxed document is as strong as a certified letter. At the bottom, we put a direct statement 'If we do not hear from you within 24 hours, we will proceed with treatment per these guidelines.' They usually act quickly because it is in writing," Pang explained. For a sample of Pang's form, see the form above.

Summary

Public awareness tops the list of areas to strengthen the dental-medical link, according to Swick. "Our patients are well educated because we explain situations to them. You still have people who have no clue that they require special treatment," he said.

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Scarff agreed: "I would love it if there was an ad campaign encouraging patients to tell their dentists about these things."

Pang would like to see an effort made to re-educate the medical community about the impact prescription medications have on oral health, from drug interaction due to cancer treatments to bisphosphonate treatment's impact on the jaw bone to the plethora of medications that create devastating dry mouth conditions.

"I think that in the future, dentistry will be in the forefront in helping, maybe not to diagnose, but at least screen more health issues." He also would like to see the public educated, as well.

"As a profession, if we could increase the public's awareness that it is more than teeth--that there is a health issue connecting dentistry to medicine--that would help a lot," Pang concluded.

Kaiser started her own public awareness campaign and encouraged others to take up the cause. "As a grassroots [measure], I had a booth at a local Relay for Life sponsored by the American Cancer Society. They had never had any oral health professionals talking about oral cancer there. I discussed with walkers and passersby about oral cancer and spit tobacco. I provided xerostomia information and samples of mouthwash and xerostomia rinse I got from my local representative. People were surprised. There was a positive response," said Kaiser. She had information stamped with the office logo, address and phone number to connect them to treatment.

"We do make a difference," said Trost. "When you start having patients with these conditions, the world becomes very small and individual. To gain confidence, you have to gain knowledge."

"You have got to step out of your box," Trost said of the dental community. "Do this for your patients. Dental offices practice in isolation. Because of that, they don't realize the knowledge they have and that they are on a peer level with physicians. When you arrive at that point in time, then you can open the doors, gain the respect and pass information."

* Arming the Operatory

Preparing simple instructional envelopes and training the dental team in their use can relieve discomfort or save lives.

Karen Kaiser, RDH, and Lori Trost, DMD, decided to move beyond a first-aid kit into tools that can really help a patient in a medical emergency. Working with a local pharmacist, the pair created envelopes that cover a variety of situations. The envelopes contain instructions, key medications and pharmacy Rx labels for further reference. The outside of the envelope is labeled with the condition the patient may be experiencing. Conditions and contents of the envelopes include:

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Angina

1. Nitroglycerin Tablets 0.4mg

2. Oxygen Mask/Canula

Asthma Attack

1. Albuterol inhaler ($15 from pharmacist)

Allergic Reaction 

1. Diphenhydramine Benadryl Capsules) 50mg ($3)

2. Diphenhydramine Injection 50mg/syringe for IM injection ($24)

3. Epipen Auto injection 0.3mg ($52 from pharmacist

Hypoglycemia 

1. Glucose tablets (10 tabs @ $1.73 from pharmacist

2. Tube of cake decorating icing

Myocardial Infarction 

1. Chewable baby aspirin 81mg

2. Nitroglycerin Tablets 0.4mg

3. Oxygen mask or canula 

Syncope/Unconsciousness

1. Ammonia Ampules ($2 from pharmacist)

2. Available oxygen mask

* Confident Communication

A recent survey measured the dental hygienist's comfort level in connecting with medical personnel.

Most dental hygienists believe that interdisciplinary communication is important and that dental hygienists will have a greater role in the future, according to a recent survey of more than 100 clinicians.

Written and conducted as part of a master's degree thesis by Kelli Swanson Jaecks, RDH, BSDH, MA, the 45-item quantitative survey, "Interdisciplinary Collaboration: The Dental Hygienist's Role," examined dental hygienists' perceptions regarding interdisciplinary collaboration. The survey, featuring sections on the dental hygienist's role, communication barriers, communication skills and demographics, proved to Jaecks that she was not alone in her assessment that dental hygienists were the best candidates for interprofessional communication on the dental team.

"I wanted to find out dental hygienists' perceptions of what their role is and what they think their roles should be in interdisciplinary collaboration," said Jaecks, who queried dental hygienists as to who they thought was the best person from the dental team to collaborate with physicians specifically in regard to diabetes, cardiovascular disease and pregnancy. She also wanted to determine what perceived barriers kept dental hygienists from participating in collaboration, and what communication skills clinicians felt they needed to better participate.

What inspired her to develop the survey were recent discoveries regarding inflammation, periodontal disease and whole health.

"While we know many things that we can't call causal agents, there are certainly many oral-systemic corollary relationships," Jaecks commented. "I think that with the complexity of medical care today and patient expectations, the patient wants a whole-health approach."

The survey revealed that dental hygienists valued a wide range of communication skills and responded that the top three deemed as necessary for interdisciplinary collaboration were speaking, listening and leadership skills.

"Dental hygienists have had some training in communication skills as part of their education, but respondents point to the fact that once you are in practice and need to be communicating with other medical professionals, many dental hygienists find they need and want more training," Jaecks said. "Seventy-seven percent of the respondents feel that their work environment would support this type of training in communication skills."

When questioned about the types of medically involved patients for which the dental hygienist would be the best communicator from the dental team, respondents ranked the diabetic patient (55 percent) and the periodontally involved pregnant patient (68 percent) highest.

"When it came to cardiovascular disease, it was a tie between the dentist and the dental hygienist," Jaecks commented. "Dental hygienists do believe they're the best person to act as the key communicator. They just don't have much experience in it."

"As dental hygienists, we are trained in the collaborative model," Jaecks said of the teamwork already in place between the dentist and the dental hygienist. "We work together as specialists; the dental hygienist in prevention and the dentist in disease treatment," she continued, adding that now is the time to expand the model to include medicine.

"It's not so foreign to us," Jaecks said. "We just need to shift our thinking to include a better whole-health collaborative model for the patient."

For a detailed review of Jaecks' survey, please see the fall 2007 issue of the Journal of Dental Hygiene.

Denise DiNardo, RDH, graduated from the University of Pittsburgh dental hygiene program in 1987. She has practiced dental hygiene in the offices of Michael Swick, DDS, for the past 17 years and has held a dental hygiene position at a pediatric office and another general practice for the past five years. She lives in a suburb outside of Pittsburgh, Penn., with her husband and two children.

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Karen Kaiser, RDH, is a practicing clinician, feature author and monthly columnist for publications in the oral health care field. Her career began as a chairside dental assistant after attending Missouri College is St. Louis, Mo., in 1987. She obtained a dental hygiene degree from Forest Park Community College hygiene program in 1994. In 2002, Kaiser was recognized as an inaugural recipient of the Sunstar Butler Award of Distinction. She has also been the featured hygienist on educational DVDs, is a key influencer to a variety of companies, regularly participates on hygiene advisory panels, is a Clinical Research Associates evaluator, key opinion leader and team member of www.pinktooth.net and a member of the ADHA.

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Peter Pang, DDS, FAGD, holds Advanced and Educator status with the Academy of Laser Dentistry (ALD) and his work has been published in several journals. He provides laser education throughout the U.S. and is a fellow of both the Academy of General Dentistry (AGD) and ALD. Additionally, Pang has been honored to be an official dentist to the Mrs. Globe Pageant, providing smile makeovers for U.S. and international beauty pageant contestants. He holds memberships in several professional organizations. Pang is a graduate of the Las Vegas Institute (LVI) for Advanced Dental Studies and visiting faculty member at LVI Global, and has operated a full-time neuromuscular aesthetic general practice in Sonoma, Calif. for more than 21 years.

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Ann Flynn Scarff, RDH, graduated from the University of Michigan with a BS in dental hygiene and from New York University with a Master of Arts in health education. She has held positions as a teacher, salesperson, clinician and cotherapist in Michigan, New York, New Jersey, New Zealand and California. Scarff achieved Standard Proficient Certification in Diode and Er:YAG wavelengths from the Academy of Laser Dentistry (ALD). Working with Peter Pang, DDS, in Sonoma, Calif., her professional profile includes years of ADHA membership, different therapies, ongoing research and lifelong learning.

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Kelli Swanson Jaecks, RDH, BSDH, MA holds a master's degree from Oregon State University in communication and adult education. She is an active leader in the ADHA, serving at the local, state and national levels. She holds a Limited Access Permit and is currently president-elect of the Oregon Dental Hygienist's Association. Jaecks owns Verbal Impact, LLC, an educational company offering health care courses that include both lecture and interactive formats. She can be reached at her Web site: http:// verbalimpact.org.

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Michael Swick, DDS, is a general dentist and has offices in Allison Park and Conneaut Lake, Penn. He practices micro-dentistry, employing air abrasion and laser, working through a surgical operating microscope. He holds advanced laser proficiency in the 980nm and 2940nm wavelengths and standard proficiency in CO2, Nd:Yag, 810 nm diode, 980nm diode, Er:Cr:YSGG and Er:YAG wavelengths, through the Academy of Laser Dentistry (ALD) and is also an ALD certified educator as well as a recognized course provider whose Standard Proficiency Laser courses are accepted for Standard Proficiency Certification through the ALD. He is currently serving on the board of directors of the ALD as well as several committees. Additionally, he holds certification from St. Luke's Medical Center, in the Pinero Pre-cardiac Surgery Protocol with lasers. Swick is a former fellow in the American Society of Laser Medicine and Surgery, where he has presented clinical papers. He also has lectured, provided training and consulted for several laser companies as well as LED dental on the Velscope and the Institute for Laser Dentistry in Canada for whom he has lectured extensively. Swick has presented more than 300 continuing education and hands-on courses on dental lasers both nationally and internationally. In addition he has presented clinical and scientific papers for numerous organizations.

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Lori Trost, DMD, maintains a private practice in Columbia, Ill., that merges contemporary esthetic dentistry with a minimally invasive approach to patient care. Her writings and vision for dentistry have been widely published. Trost also regularly participates on a variety of key influencer panels. Trost founded pinktooth.net--the online resource for all women in dentistry. This entrepreneurial effort has been recognized by the American Dental Association (ADA) with a Shils Foundation Award for Leadership and Vision. Trost is a member of ADA, the Academy of General Dentistry, and is a fellow in the International Academy of Dental Facial Esthetics.

(1) Lymphoma is a broad term encompassing a variety of cancers of the lymphatic system. The lymphatic system helps filter out bacteria and is important in fighting disease. Every so often, the lymph vessels widen into lymph nodes. Most of us have felt these under our arms or neck when sick with mono or an infection. For more information, visit: www.LymphomaInfo.net/. Copyright 1998-2005 Lymphoma Information Network, Updated November 16, 2005.

from interviews conducted by Christine A. Hovliaras Delozier, RDH, BS, MBA 

Susan Elliott-Smith is a freelance writer in Chicago.