Most dentists have experienced aggression from patients

NYU study is first to describe rates of physical, verbal, and reputational aggression by patients toward practicing dentists

Roughly half of U.S. dentists experienced verbal or reputational aggression by patients in the past year, and nearly one in four endured physical aggression, according to a new study led by researchers at NYU College of Dentistry.

The study, published in the October issue of the Journal of the American Dental Association, is the first to document aggression toward dentists in the United States.

Workplace aggression toward health care professionals is common, with health care settings second only to law enforcement in the rate of violent incidents. However, there are no studies of aggression toward dentists in the U.S.--a workforce of 200,000--and only four studies have been conducted in other countries.

"Workplace violence toward health care professionals is both widespread and widely overlooked," said Kimberly Rhoades, a research scientist in the Family Translational Research Group at NYU College of Dentistry and the study's lead author. "The purpose of this study was to provide an initial estimate of rates of patient aggression in dental practices in the United States."

Rhoades and her colleagues surveyed 98 dentists practicing in the New York City metropolitan area; the dentists had been working an average of 17 years. Participants completed a confidential online survey assessing whether they had experienced any of 21 specific types of aggressive behaviors from their patients, including types of physical (e.g. being pushed or kicked), verbal (e.g. being insulted or sworn at), and reputational (e.g. threats of lawsuits or posting nasty comments on social media) aggression.

A substantial proportion of dentists reported experiencing aggression from patients in the past year, including physical (22.2%), verbal (55%), and reputational (44.4%) aggression. An even larger proportion of dentists surveyed were subjected to physical (45.5%), verbal (74%), and reputational (68.7%) aggression at some point during their career. These rates of patient aggression toward dentists are high and comparable with those reported in other health care settings.

Rates of aggression did not differ by dentists' sex, race, ethnicity, specialty, age, years practicing, or average number of patients treated per day.

The rates of physical and reputational aggression toward dentists were similar to those from a parallel study by NYU researchers of aggression toward dental students published earlier this year in the Journal of Dental Education. However, practicing dentists experienced less verbal aggression from patients than dental students (55% versus 86%), suggesting that additional experience may reduce the risk of verbal aggression.

"Dentistry is rife with situations that can elicit strong negative emotions, such as fear, pain, distrust, and anger. Many patients also experience high levels of anxiety and vulnerability, which may increase negative responses or aggression," said Rhoades. "Establishing that aggression toward dentists is a problem and how often it occurs can help us develop interventions to prevent aggression in dental practices."

The researchers note that, while a larger, national study is needed to determine the true prevalence of aggression in U.S. dental settings, dental practices should consider implementing training that incorporates strategies for handling workplace violence. Training could address how to prevent patient aggression, and manage or de-escalate aggression when it does occur.

Mechanism linking gum disease to heart disease, other inflammatory conditions discovered

Researchers at the University of Toronto have found first evidence that neutrophil immune cell activity is the missing link connecting periodontal disease with heart disease, cancer, and other inflammatory conditions

UNIVERSITY OF TORONTO - FACULTY OF DENTISTRY

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IMAGE: NEUTROPHIL ACTIVATION IS NOW BELIEVED TO BE AT THE ROOT OF OVERACTIVE INFLAMMATORY RESPONSES, AND LINKS CONDITIONS SUCH AS PERIODONTAL DISEASE AND HEART DISEASE view more 

CREDIT: NOAH FINE

(TORONTO, ON) Oct. 20, 2020 -- The link between periodontal (gum) disease and other inflammatory conditions such as heart disease and diabetes has long been established, but the mechanism behind that association has, until now, remained a mystery. This month, a team of scientists and clinicians led by the University of Toronto's Faculty of Dentistry say they've found the reason why -- and it's related to the body's own hyperactive immune response. The findings were published in October in the Journal of Dental Research.

HYPERACTIVE STATE

Science has already established that state of your oral health is an important indicator of overall health. "There are statistically significant correlations between periodontitis (oral inflammatory disease) and systemic diseases ranging from diabetes to cardiovascular diseases," says Howard Tenenbaum, professor at the University of Toronto's Faculty of Dentistry, and chief dentist at Sinai Health Systems in Toronto, who is one of the authors of the study.

To find what links those conditions, the researchers focused on the behaviours of cells primarily activated by gum disease -- neutrophils, which are cells of the innate immune system. Through in vivo models, the researchers found that the immune system releases an abundance of these neutrophils to tackle the bacterial infections responsible for periodontitis, more commonly known as gum disease.

Activated to fight an oral infection, a systemic effect was noted: once periodontal inflammation was present, an overabundance of neutrophils circulated, 'primed' for attack. The hyper-vigilant immune system then responds with an excess of force to any secondary infection.

"It's almost as if these white blood cells are in second gear when should be in first," says Michael Glogauer, professor at the University of Toronto's Faculty of Dentistry and the study's senior author.

That's when the body becomes susceptible to damage from secondary inflammatory conditions. With the immune system already primed by the neutrophils for attack, a secondary event causes those immune cells to destroy affected tissues and organs.

"The [neutrophils] are much more likely to release cytokines much more quickly, leading to negative outcomes," adds Glogauer, who is also dentist-in-chief at the University Health Network and head of dental oncology at Toronto's Princess Margaret Cancer Centre.

Produced initially in in vivo models, the findings were confirmed through a controlled clinical experiment.

ORAL HEALTH KEY TO OVERALL HEALTH

The study's findings underscore the importance of oral health as a vital indicator of potential complications for other inflammatory conditions, as well as disease model outcomes.

"We believe this is the mechanism by which oral hygiene can impact vulnerability to unrelated secondary health challenges," says lead author Noah Fine, a postdoctoral fellow at the University of Toronto's Faculty of Dentistry. "Neutrophil (immune) priming throughout the body can connect these seemingly distinct conditions," he says.

The study also may have important ramifications for an inflammatory disease at the top of everyone's mind these days: COVID-19.

"There is evidence out there that patients with periodontal disease may be much more likely to have negative outcomes with COVID-19," explains Glogauer. The current study could provide some clues as to why: "Neutrophils are the cells that are at prime risk of causing cytokine storms. That's the exact cell we show is primed with people with periodontal disease," he explains.

Research into the relationship between neutrophils and inflammation is ongoing.

Oral cancer pain predicts likelihood of cancer spreading

Oral cancer is more likely to spread in patients experiencing high levels of pain, according to a team of researchers at New York University (NYU) College of Dentistry that found genetic and cellular clues as to why metastatic oral cancers are so painful.

The findings--which appear in Scientific Reports, a journal published by Nature--may ultimately be used to alleviate oral cancer pain and refine surgical decision making when treating oral cancer.

Oral cancer can cause severe pain during everyday activities, including talking and eating. Previous research by Brian L. Schmidt, DDS, MD, PhD, director of the NYU Oral Cancer Center and one of the study's authors, suggests that patients with metastatic oral cancer--cancer that spreads beyond the mouth--experience more pain than those whose cancer has not spread. The new study helps researchers understand why.

When oral cancer metastasizes, spreading to lymph nodes in the neck, a patient's chance of survival is cut by half. However, it's often unclear through imaging and physical assessment if oral cancer has spread, leaving surgeons struggling with whether to preemptively remove lymph nodes--an invasive procedure termed prophylactic neck dissection--during surgery to remove the oral cancer. While most oral cancer surgeries include a prophylactic neck dissection, research shows that up to 70 percent are unnecessary.

"Clinicians and researchers are keen to define a biomarker that accurately predicts metastasis," said Aditi Bhattacharya, PhD, an assistant professor in the Department of Oral and Maxillofacial Surgery at NYU College of Dentistry, an investigator at NYU Bluestone Center for Clinical Research, and the study's lead author. "Given that patients with metastatic oral cancer experience more pain, we thought that a patient's level of pain might help predict metastasis. A surgeon could then use this knowledge to only remove lymph nodes in patients with cancers that are most likely to metastasize."

In their study in Scientific Reports, the researchers first documented the pain experienced by 72 oral cancer patients before surgery, using an oral cancer pain questionnaire developed by the investigators. While most patients reported some pain, those who suffered with the most pain were more likely to have cancer that spread to lymph nodes in the neck. This observation suggests that patients with less pain are at low risk of metastasis, and will rarely benefit from a neck dissection.

To begin to understand why metastatic cancers are more painful, the investigators looked for differences in gene expression between metastatic cancers from patients with high levels of pain compared to non-metastatic cancers from patients not experiencing pain. Cancer pain is attributed to the release of mediators from cancers that sensitize nerves near the cancer. Forty genes were identified that were more highly expressed in painful metastatic cancers, suggesting that they promote metastasis and mediate cancer pain. Many of these genes are found in exosomes, small vesicles that break away from a cell and can be taken up by other cells--revealing a potential mechanism for how cancers communicate with nerves.

"I have been investigating the underlying cause of oral cancer pain for two decades. This is the first time that we have demonstrated a correlation between a patient's pain and the clinical behavior of the cancer," said Schmidt, who is also the director of the NYU Bluestone Center for Clinical Research and professor in the Department of Oral and Maxillofacial Surgery at NYU College of Dentistry.

Next, the team undertook laboratory experiments to study exosomes found in the extracellular fluid of oral cancer cells grown in the lab. When this extracellular fluid was injected into animal models, it produced pain, but when the cancer-derived exosomes in the fluid were removed, it did not cause pain. This suggests that exosomes from cancer may be responsible for oral cancer pain.

Now, with a deeper understanding of why metastatic oral cancers are painful, the researchers point to several potential clinical applications for their research, including a biomarker for oral cancer metastasis to help with surgical decision making and future testing options.

"While we need to undertake a follow-up study, our current data reveal that a patient's pain intensity score works as well as the current method--depth of invasion, or how deeply a tumor has invaded nearby tissue--as an index to predict metastasis," said Bhattacharya.

"The identified genes are targets for therapy aimed at stopping pain and cancer. In addition, exosomes shed from cancers can be detected in saliva, blood, and urine, offering the potential for an objective molecular test to diagnose risk of metastasis," said Donna Albertson, PhD, professor in the Department of Oral and Maxillofacial Surgery at NYU College of Dentistry, an investigator at NYU Bluestone Center for Clinical Research, and the study's corresponding author.