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The dental hygienist as part of an interdisciplinary team: focus on autoimmune diseases.

Dental hygienists frequently hear the following remark from a patient; "Why do you need to know all of the information listed in the medical history form? I am only here to have my teeth cleaned!" Recent scientific studies show strong correlations between oral and systemic disease, creating a crucial need for increased communication between the medical and dental professions. The definition of interdisciplinary care involves professionals from various disciplines working as a team, with each professional contributing an expertise to create a "creative synergy. (1) Through collaboration, the interdisciplinary team increases opportunities for improved health outcomes, including oral health. (2), (3)

We live in an age of an evolving health care system. Health care is often fragmented and/or highly specialized. Communication among health care providers is critical. Dental hygienists must be part of this interdisciplinary communication. Dental hygienists deliver effective oral hygiene care to individuals diagnosed and not yet diagnosed with an autoimmune disease. Access has designated autoimmune diseases as the focus topic for April's issue. The contents of this issue will assist the dental hygienist in identifying and meeting the oral health needs of these individuals as well as understanding the necessity of referral. Autoimmune diseases are difficult to diagnose and require a thorough examination of the patient's history, blood tests and physical examination for a definitive diagnosis.

Autoimmunity is usually harmless and present in everyone to some extent. In addition to genetic factors, environmental triggers (in particular viruses, bacteria and other infectious pathogens) are thought to play a major role in the development of autoimmune diseases. (4) A healthy immune system responds to resist the onslaught of these triggers. Unfortunately, the normal immune response occasionally goes awry and attacks the body instead. Any disease that results from an aberrant immune response is termed an autoimmune disease. Autoimmunity can result in a broad spectrum of human diseases. Examples of autoimmunity diseases include celiac disease, diabetes mellitus type 1, sarcoidosis, systemic lupus erythematosus (SLE), Sj6gren's syndrome, Churg-Strauss syndrome, Hashimoto's thyroiditis, Graves' disease, idiopathic thrombocytopenic purpura, Addison's disease, rheumatoid arthritis (RA), polymyositis (PM), dermatomyositis (DM), pemphigus vulgaris, cicatricial pemphigoid, multiple sclerosis, inflammatory bowel diseases (e.g., ulcerative colitis and Crohn's disease), pernicious anemia, scleroderma, and primary biliary cirrhosis. Although each autoimmune disease is a distinct entity with its own constellation of signs, symptoms and clinical manifestations, many autoimmune diseases share some common characteristics, including the approach to disease management.

Appropriately addressing the treatment needs of each patient is dependent upon a dental hygienist's ability to identify various oral and systemic conditions prior to establishing an individualized dental hygiene care plan. Treatment is based on complete and thorough assessment of all data collected, including risk assessments. Dental hygienists are educated to perform oral health care and risk assessments that include the review and documentation of patients' health history, taking and recording blood pressure, dental and periodontal charting, oral cancer screening and evaluation of oral disease/health. These standards of care provide the foundation for the dental hygienist to assess the patient's risk for disease during the provision of patient care. Refer to boxes 1-3 for examples of autoimmune risk assessment tools including a listing of common symptoms, prevalence and co-occurrence of the autoimmune diseases.

Box 1. Screening Patients for Autoimmune Disease (5)

* Hallmark symptoms are fatigue, dizziness and/ or low grade fever.

* Symptoms have periods of remission and exacerbation.

* Presence of one or more of the following suggests an autoimmune disease: xerostomia, rash, GERD, arthralgia, myalgia, anemia, shortness of breath, lymphadenopathy, arrhythmia, goiter and salivary gland enlargement. (5)

Box 2. Prevalence of Autoimmune Diseases

Gender

* Most autoimmune diseases occur more frequently in females than males.(5), (6), (7), (8)

Genetics

* Autoimmune diseases in general have a high frequency within families. (9)

* Specific autoimmune disease occurs more frequently within first-degree relatives. (9)

Age

* Autoimmune diseases can occur at any age; however, many occur during middle adult years (childbearing years for females)

* Type I diabetes has an onset in childhood and adolescence.

* Rheumatoid arthritis occurs primarily among older adults. (10)

Co-occurrence of Disease

* Individuals diagnosed with autoimmune disease are at high risk for co-occurrence of another autoimmune disease. (11)

* Box 3. Co-occurrence of Autoimmune Diseases

Multiple Sclerosis

* Increased risk of type I diabetes and ulcerative colitis (11), (12)

Genetic factors shared among divergent autoimmune diseases (13)

* Recent studies demonstrate a genome-wide association of rheumatoid arthritis, ankylosing spondylitis, celiac disease, multiple sclerosis, systemic lupus erythematosus, type 1 diabetes and inflammatory bowel disease (Crohn's Disease and ulcerative colitis).

Rheumatoid arthritis, systemic lupus, or multiple sclerosis.

* 60 percent of these individuals also have Sjogren's syndrome (12)

Celiac disease (Celiac sprue or gluten-sensitive enteropathy)

* Associated with Sjogren's syndrome and type I diabetes (14)

A comprehensive patient care plan is formulated following a review of all available data including the signs and symptoms from the patient's medical and dental history and the extra- and intraoral assessments. It is necessary for the dental hygienist to understand the common traits characteristic for most autoimmune diseases as well as those characteristic of a specific autoimmune disease in order to provide the highest standard of care. This comprehensive review requires the utilization of critical thinking skills and excellent communication skills.

The dental hygienist must ask additional screening questions to supplement the completed medical history form to avoid overlooking an autoimmune or other disease. Refer to Box 4 for a list of basic screening questions for the autoimmune diseases.

Box 4. Possible Screening Questions for Autoimmune Diseases

* What changes are there in your medications/dosages?

* How often and when did you first experience symptom/pain/discomfort and under what conditions?

* When was your condition first diagnosed?

* Did you intentionally lose weight?

* Are you currently under a doctor's care for this problem?

* What genetic diseases run in your family? (genetic predisposition)

* What changes have occurred in your medical history since your last appointment?

* Do you smoke? Were you a smoker in the past? (Quantity/how often)?

* Have you experienced chronic physical or emotional stress? (infection, fever, illness or trauma)

* Have you been exposed to any infectious agents or sex hormones (estrogens and androgens)?

* Autoimmune signs: arthralgia, myalgia, xerostomia, rash, GERD, anemia, lymphadenopathy, shortness of breath, arrhythmia, goiter or salivary gland enlargement? (5)

Some autoimmune diseases are life-threatening. Nearly all of these diseases are debilitating and require lifelong medical care. The diseases themselves, as well as their medication management, can adversely affect the oral cavity and significantly impact quality of life. Corticosteroids, commonly prescribed for autoimmune diseases, have significant side effects including adrenal suppression (box 5). The degree of adrenal sup-pression must be evaluated to assess the patient's ability to respond to stress, infection or a potential medical emergency.

Box 5. Adverse Effects of Chronic High Dose Corticosteroid (15), (16), (17)

* Insomnia

* Peptic ulceration

* Osteoporosis

* Cataract formation

* Glaucoma

* Growth suppression

* Delayed wound healing

* Moon face

* Weight gain

* Diabetes

* Osteoporosis

* Increased susceptibility to infection

* Psychosis

* Adrenal suppression

The dental hygienist can make significant contributions as a viable member of an interdisciplinary team. It is up to each of us to continue to strive to provide the highest standard of care for our patients. Lifelong learning, the refinement of critical thinking skills and the continued development of communication skills are necessary components of achieving this goal. Our reward is the gratification knowing our contributions have a positive effect on the health and well-being of our patients.

References

(1.) Casamassimo PS. Pediatric oral health interfaces background paper: Children with special health care needs; patient, professional and systems issues. Washington, DC: American Academy of Pediatric Dentistry, Children's Dental Health Project. Available at: www.astdd.org/docs/13PResLinkInterface-MedicineDentistry.pdf. Accessed June 13, 2012.

(2.) Yeager S: Interdisciplinary collaboration: the heart and soul of health care. Crit Care Nurs Cl in N Am. 2005;17:143-148.

(3.) Swanson Jaecks K: Current perceptions of the role of dental hygienists in interdisciplinary collaboration. 3 Dent Hyg. 2009;83:8491.

(4.) Delogu L, Deidda S, Delitala G., Manetti R: Infectious diseases and autoimmunity. Infect Dev Ctries 2011; 5(10):679-687.

(5.) Gurenlian JR, Spolarich AE. Risk Assessment for Autoimmune Diseases. Dimension Dent Hyg. December, 2012;10(12): 30-33

(6.) Abbas AK, Lichtman AH: Basic immunology: functions and disorders of the immune system, ed. 2. Philadelphia, 2004, Elsevier, Inc.

(7.) Guyton AC, Hall JE: Textbook of medical physiology, ed. 10, Philadelphia, 2000, W.B. Saunders Co.

(8.) Spolarich AE. The Body's Response to Challenge. Chapter 6, in Daniel S, Harfst S and Wilder R, eds., Mosby's Dental Hygiene Concepts, Cases and Competencies, 2nd ed.;St. Louis: Mosby, Inc., pp: 78-104, 2008.

(9.) American Autoimmune Related Diseases Association, Inc. The Common Thread. Available at: http://www.aarda.org/wp-content/uploads/2013/09/common_thread_textalign.indd_.pdf

(10.) Cooper GS, Stroehla BC. The epidemiology of autoimmune diseases. Autoimmun Rev. 2003 May;2(3):119-25.

(11.) Somers EC, Thomas SL, Smeeth L, Hall AJ. Autoimmune Diseases Co-occurring within individuals and within families A Systematic Review. Epidemiology. 2006: 17(2).

(12.) Anaya JM. Corena R, Castiblanco 3, Rojas-Villarraga A, Shoenfeld Y. The kaleidoscope of autoimmunity: multiple autoimmune syndromes and familial autoimmunity. Expert Review of Clinical Immunology. July 2007, Vol. 3, No. 4, Pages 623-635 , DOI 10.1586/1744666X.3.4.623 (doi:10.1586/17 44666X.3.4.623).

(13.) Miceli R, Criswell L. Emerging patterns of genetic overlap across autoimmune disorders Genome Medicine 2012, 4:6 doi:10.1186/ gm305

(14.) Barton SH, Murray JA. Celiac Disease and Autoimmunity in the Gut and Elsewhere. Gas-troenterol Clin North Am. Jun 2008; 37(2): 411-vii. doi:10.1016/j.gtc.2008.02.001

(15.) Little 3W, Falace DA, Miller CS, Rhodus NL. Dental Management of the Medically Compromised Patient. 7th ed. St. Louis: Mosby Elsevier, 2008.

(16.) Pickett FA, Terezhalmy GT. Dental Drug Reference with Clinical Implications. 2nd ed. Baltimore, Lippincott Williams & Wilkins, 2008.

(17.) Wynn RL, MeiIler TF, Crossley HL. Drug Information Handbook in Dentistry. 18th ed. Hudson, Lexi-Comp Inc., 2012.

The dental hygienist can make significant contributions as a viable member of an interdisciplinary team.

By Joanne C. Fletcher, RDH, MS

Joanne C. Fletcher RDH, MS, is the 2010 recipient of the Johnson & Johnson/ADHA Excellence in Dental Hygiene Award and the founding dental hygiene director of Collin College in McKinney, Texas. She is a graduate of the Fones School of Dental Hygiene, University of Bridgeport and was a Fones faculty member for 20 years. She had been a member of the Journal of Dental Hygiene Editorial Review Board for 25 years, member of the Dental Hygiene II National Board Test Construction Committee for five years, a dental hygiene accreditation consultant for the Commission on Dental Accreditation the past 17 years and a past president of the Connecticut Dental Hygienists' Association. She is professor of periodontology, nutrition, radiology, oral medicine and research at Collin College.
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Author:Fletcher, Joanne C.
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Article Type:Guest editorial
Geographic Code:1USA
Date:Apr 1, 2014
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