Floss & Flip-Flops Episode 5: Arthritis

The Sanders Sisters are back, and this month they're talking all about arthritis! Arthritis affects about 1 in 4 adults, meaning it has far-reaching health implications for millions of people. The sisters discuss how healthcare professionals can intervene.

Elizabeth Sanders, DPM 0:01
Hi, I'm Dr. Elizabeth Sanders, a foot and ankle surgeon and assistant professor at Boston University Medical Center.

Katrina Sanders, RDH 0:08
Hi, I'm Katrina Sanders. I'm a registered dental hygienist, consultant, international speaker, and wine lover.

Katrina & Elizabeth Sanders 0:15
And we're sisters.

Elizabeth Sanders, DPM 0:17
I grew up looking up to my big sister Katrina.

Katrina Sanders, RDH 0:20
And now I look up to my lady boss physician sister Elizabeth.

Elizabeth Sanders, DPM 0:23
Together, we are working to unite the dental and medical communities in unique and exciting ways.

Katrina Sanders, RDH 0:29
Welcome to Floss & Flip-Flops with Sanders sisters, our monthly podcast

Elizabeth Sanders, DPM 0:34
where we unpack all things health related from your mouth to your toes.

Katrina Sanders, RDH 0:38
So grab your flossy floss

Elizabeth Sanders, DPM 0:40
and slide on some flippy floppies.

Katrina & Elizabeth Sanders 0:42
And then let's get on with the show!

Katrina Sanders, RDH 0:51
Hello, everyone, and welcome back to an episode of Floss & Flip-Flops with your favorite ginger sisters, the amazing Dr. Elizabeth Sanders, and me your ginger hygenist. Katrina. How are you today, doc? Are you good?

Elizabeth Sanders, DPM 1:10
I'm doing so good. I've had a very productive day. How about you?

Katrina Sanders, RDH 1:13
You've had a productive day? What is a productive day look like in the world of Dr Sanders?

Elizabeth Sanders, DPM 1:19
I mean, today I did just a lot of research and finished an article that I was working on. So I'm pretty happy about that. Yeah.

Katrina Sanders, RDH 1:26
Good. That's so good. Oh, good! I've just been bopping around you know, keeping myself busy and out of trouble. Because you know me, trouble will find me! So, just been keeping busy all day, which is so great.

Elizabeth Sanders, DPM 1:39
I still don't know why you don't have a camera follow you everywhere.

Katrina Sanders, RDH 1:42
Literally, I don't know, either. I know, I always think about that. Like, why why do I not have like some sort of MTV, E! True Hollywood Story about what's happening in my world? Some of the things I'm like, 'Does this happen to anybody else?' You know? So, it just cracks me up. And so before we dive into this episode, do you remember when we were kids? And you know, it was like maybe like the early 90s. And we all had like a favorite boy band? Right?

Elizabeth Sanders, DPM 2:14
Oh, for sure.

Katrina Sanders, RDH 2:15
So who is your favorite boy band?

Elizabeth Sanders, DPM 2:17
Oh, Backstreet Boys.

Katrina Sanders, RDH 2:18
Backstreet Boys, obviously.

Elizabeth Sanders, DPM 2:19
I liked Brian.

Katrina Sanders, RDH 2:20
You did like Brian, I was more of a Howie D. girl myself. But the reason why I bring up boy bands is because one of my favorite songs from a boy band, NSYNC, is it's gonna be May. And what I mean by that is...

Elizabeth Sanders, DPM 2:39
You're too much!

Katrina Sanders, RDH 2:45
May is Arthritis Awareness Month. How exciting is that? I know it's such a great journey for us. So today, today's episode is really going to take a look at the ramifications of arthritis, and what we know about arthritis currently. And of course, more than anything, why it's important for us to talk about how it impacts our dental patients, our podiatric patients and how it affects the community in general. So let's just take a look. Because when we have a dialogue about some of these comorbidities, which you're going to start hearing us kind of trickle-down episode by episode and we talk about these comorbidities, it's really important for us to understand why it's so important for us to even have this dialogue. So arthritis, a few things to know, it is a leading cause of disability. For clinicians, you know, we understand that the prevalence of something like arthritis is ebbing and flowing as we're seeing our patients experiencing more and more comorbidities. So not always, but oftentimes we will see that things like rheumatoid arthritis, which I know we're going to deep dive into a bit that we can oftentimes see a lot of these types of modalities move in tandem with some of these comorbidities. Arthritis affects about 1 in 4 adults. So that's about 58 million United States Americans. And about half of these adults report a limit to their everyday activities because of their arthritis. So these are simple things like holding on to your wine glass. I struggle with not because of how much I love wine. But you know, simple things that, you know, oftentimes we take for granted, like being able to hold on to a grocery bag or getting yourself up out of your own seat walking to a chair, for example. And we also know that arthritis can cause catastrophic issues. Individuals with arthritis are nearly twice as likely to experience an injury associated with a fall. Interestingly enough, adults who live in rural areas have about 3x greater affinity or prevalence of arthritis as compared to those who live in a more urban or industrialized area. I don't know,

Elizabeth Sanders, DPM 5:16
I found that very interesting.

Katrina Sanders, RDH 5:17
It's kind of weird. And I think, you know, part of it, as we start to look at some of the risk factors around arthritis that perhaps—and I know, like, we'll talk about gout being a component of arthritis as well—that, you know, diet, exercise, physical activity, sedentary lifestyle, all of these things can be contributory factors. So maybe that's a component of it.

Elizabeth Sanders, DPM 5:40
Probably the more sedentary lifestyle in the rural environment. Yeah, for sure.

Katrina Sanders, RDH 5:46
You know, the costs associated with the management of arthritis are upwards of about $81 billion, just in direct medical costs. And we also know that arthritis is an inflammatory condition. And because of that, this becomes a comorbidity in which our patients do struggle to manage modalities like cardiovascular disease, diabetes, and even obesity. So, about half of adults with heart disease and half of adults with diabetes, have arthritis. That's an incredible statistic, by the way, like, that's incredible data for us to wrap our minds around, right? Like, because I'm putting myself...I'm putting myself in the shoes of a hygienist. I am a hygienist. So, I'm just going to put my shoes on and wear them. But as a hygienist, you know, we do see a lot of people that sit down in our chairs that have cardiovascular disease, have diabetes, or report that they are pre-diabetic, we get a lot of those pre-diabetic patients that come in, and they'll say, "I'm on Metformin for my pre-diabetes}, and it's like, oh, is it pre? Are you like already starting to swing over into activity of diabetes? And to think about half of those individuals have arthritis? You know, how does arthritis typically bubble up? And you know, we'll talk about it. But, you know, these are patients that are complaining about symptomatic issues, you know, and so this is really where we start to look at, are we in the business of healthcare? Or are we in the business of sick care, when we see patients who do have cardiovascular disease or diabetes, perhaps it's, you know, something to consider dental hygienists, preventive specialists out, there, doctors out there to start asking the patients if they are also experiencing sign stages or symptoms of arthritis. So, you know, we know that it's difficult for individuals who have arthritis to be physically active. So, it's one of those things like physical activity that can stave off or push away the risk of arthritis. But then once arthritis comes into play, there's, you know, pain in the joints. You know, there is a fear that if there are advanced amounts of physical activity, there will be additional pain. And of course, there's also a lack of knowledge around what types of physical activity, low impact physical activity, for example, you know, that are going to be optimal. I'll tell you when we talk about physical activity. And we'll get to that in a minute, it's really important for us to support our patients in exploring physical activity that is low impact, but still can provide them with optimal means of keeping themselves healthy because ¹/₃ of those who are obese also have arthritis, which is just incredible. So I think as we start to look at the importance of awareness around it, and the role that we have, as preventive specialists in helping patients identify earlier stages of arthritis, or, you know, maybe even hearing some of the symptoms that our patients are describing to us, and, you know, encouraging our patients to, you know, go through evaluation for arthritis is really critical. I want to do a way-back playback, if you don't mind, some hardcore history, if you will. Elizabeth, tell us a little bit about some of the history of arthritis, like where did this come from? What do we know? How has it been managed over the years, etc?

Elizabeth Sanders, DPM 9:09
Yeah, it was really interesting. I was doing a little bit of research on arthritis in general. And it's very interesting, what has come to arise to make us diagnose people with different types of arthritis. You really started, I saw some articles on the 19th century where patients, specifically women were diagnosed with or they had basically very swollen hand joints and different deformities to their hands. And back then they didn't really know what it was. And bloodletting was a very interesting way of trying to treat these patients. And it was based on this humoral theory, where people have four key hue morals and basically are liquids throughout our body and basically there's an imbalance of those throughout our body, the four hue morels being blood, black bile, yellow bile, and phlegm.

Katrina Sanders, RDH 10:09
Sounds like a cocktail. This is what I love about the humoral theory, though, because bloodletting for people who don't know, bloodletting is where you would go to some type of a specialist back in like the, you know, the 1800s or whatever. And they would literally, like, open up a major artery, right? And they would just, like, let you they let you bleed out.

Elizabeth Sanders, DPM 10:32
And there are different ways you could either do it through your veins, I guess, or your arteries. Yeah, this is insane.

Katrina Sanders, RDH 10:38
And yes, and by the way, they would, so they would, they would, you would drain your own blood. And then sometimes they would do infusions or transfusions rather with sheep's blood, like, can you imagine like being like half sheep?

Elizabeth Sanders, DPM 10:52
No. I mean, it's almost like a dialysis session. Correct? Like sheep blood. Unbelievable.

Katrina Sanders, RDH 10:58
Very weird. And do you know who actually did bloodletting by the way? Barbers. Barbers were the ones that did bloodletting. So you know, when you see those, like, white and red bars, like bands outside of a barber shop that indicate like, "Oh, this is a barber shop." That's why the so the red band or the swirly circle thing down.

Elizabeth Sanders, DPM 10:59
The same one on in the North Pole?

Katrina Sanders, RDH 11:00
Exactly yeah, the same one that's at the North Pole. But I think that one's supposed to emulate like a candy cane, not blood. But, yes, that red band indicates the blood. And the white band indicates the gauze that they used to stop the bloodletting when they thought that they had led out enough blood.

Elizabeth Sanders, DPM 11:43
It's so weird. But so so interesting that basically are they think that our bodies are not in the correct balance? Because which I mean, it's not all that incorrect to think about. So, you know, that was a very interesting thought process. And they thought that these imbalances of the, of the different humors, were responsible for different physical and even mental ailments. So people Yeah, they would go and say, you know, I'm, I'm ready to get blood let. And then we move on to like 1897 when Bayer first created aspirin, which is basically the first onset, and it's now a very widely used and said to treat arthritic pain, we use it for blood thinners, very widely used, then if we move on to the 1930s. This is when gold injections were highly, highly used.

Katrina Sanders, RDH 12:43
I love this. Wait, so they took gold and they just injected like gold metal into your body? Is that correct?

Elizabeth Sanders, DPM 12:50
Yeah, I guess so.

Katrina Sanders, RDH 12:52
Like, what's happening?

Elizabeth Sanders, DPM 12:54
But of course, it had, you know, pretty severe side effects and eventually, out of favor. I saw this document from 1948, where the doctors in the Mayo Clinic were treating patients with an extract of the adrenal gland called compound E is very interesting. They documented this woman who was given a certain substance, but then she, it sounds like she had a sort of rheumatoid arthritis. But she was just very, very, very sick, they gave her compound E and she got better within maybe one or two days. But then a week later, just felt really, really sick and had some serious side effects. But that's kind of where we start to look at the idea of treating these patients with steroids. And then now we come to nowadays, and fast forward, fast forward. Now, there's this research article by Northwestern University, which confirms that about 10 minutes a day of brisk walking can actually help prevent arthritis, especially in your knee, hips, ankle or your feet. And that was published in April 2019. I found other documents that say that about two and a half hours, week of good exercise is definitely going to help you as well. So if you think about it, that's maybe 25 minutes a day, very doable for people. So I think that's very important that we understand that and that could be the reason why people who live in more rural areas are more affected. Whereas we in the urban areas, we do tend to walk a little bit more. And you mentioned that you said you know some patients, they know that the more they exercise, they're going to start feeling it afterward. And it's kind of discomforting to know that. But it's very important that we do get people moving.

Katrina Sanders, RDH 14:48
I love that. And in fact, I'm actually going to challenge everybody listening to this podcast that if you are in a space where you are able to put some earbuds Then, and walk while you're listening to the rest of this episode, whether it's like taking your dog Darby for a "dubs", or a W-A-L-K, okay. Or, if you're able to just like stroll around the block, pour yourself to go a glass of wine and just like see the sights and breathe in the fresh air and soak up some vitamin D. And I would even encourage you, for future episodes, anytime you listen to us walk around, you know, get those blood vessels moving. Because you are going to, of course, prevent arthritic pain in your knee, hip, ankle, or foot. And you're doing your body such good by being able to do that. So I'm going to challenge you to do that. And when you do, by the way, post a selfie of yourself on social media, don't forget to tag our friends at Dental Products Report, tag them and let them know that you're walking around and listening to our episode, I really want to create that sense of awareness in the dental and the medical communities that we are echoing and emulating what we are preaching to our patients. So get moving everybody. And with that, I want to hear from you, Dr. E, about the different types of arthritis. So, you know, arthritis is a very broad term, right. And it's just kind of an umbrella term that talks about inflammatory conditions of joint areas I'm assuming, but walk us through what are some of the major types of arthritis and what differentiates those different types?

Elizabeth Sanders, DPM 16:36
Sure, of course, there are, of course, many different types of arthritis. But I'll kind of go over the more common ones. Osteoarthritis is the most common form of arthritis. It, in fact, affects about 32 and a half million Americans. And it's essentially known as a degenerative joint disease, which occurs more frequently in the hands, the hips, and the knees. It's essentially the cartilage of your joints actually breaking down causing pain, stiffness, swelling, and decreased range of motion. Rheumatoid arthritis is a little bit different because it's actually an autoimmune response that your body is essentially attacking itself. It's an inflammatory disease, which, in which the immune system attacks the healthy cells in your body by mistake, and it creates a great deal of inflammation. It's a horrible disease. It affects multiple joints most commonly in the hands, the wrists, the knees, the spine, and the feet is other as well as the lungs, the heart, and the eyes. So don't forget about those things. Rheumatoid arthritis typically is genetic, but environmental factors do play a role. For example, patients' age, sex genetics, if they smoke, early life exposure, or obesity. For me, personally, as a podiatrist, I do see it quite often in the feet and the ankles. Usually, I'll try to manage it conservatively, and if not surgery sometimes is an option. Of course, we have to talk about gout. Gout is an inflammatory condition caused by elevated uric acid in the body. Either your body breaks down pure rains too quickly and creates monosodium urate in excess. Or there's another way which is actually it's actually the most common, where you cannot excrete the monosodium urate. And this creates uric acid that builds up in your joints and your fluids and your tissues. So of course, I'll see it from a podiatrist perspective. I'll see someone coming in with this red hot, swollen, great toe joint and they're like, Man, I can't even you know, even the bedsheets bother me. They have a great deal of pain. People say, "Oh, you just have a bunion. Yeah, and it's no big deal." But really, it probably is a gout attack. I usually start people right off the bat with like a steroid, or an anti-inflammatory. But of course, you still want to talk to the patient about things like diet and life modifications, of course avoiding high purine diets like red meat, seafood, limit your alcohol...

Katrina Sanders, RDH 19:17

Every time I go on vacation I'm like, "I'm gonna get gout!" Don't they call it the like cruise ship diet?

Elizabeth Sanders, DPM 19:26
Yeah, absolutely. No, whatever it is. Yeah. As you get meat and seafood, you get your wine, get your beer or your you know, liquor. Yeah, absolutely. A lot of people come back from vacations get it. And of course, like right, like I said, right off the bat. You do want to make sure you're telling the people about their diet, drink more water, you know, exercise, things like that. I will give them steroids or an anti-inflammatory some, in fact, another really big cause of it, well may lead to it is patients who are chronically on diuretics. So that can, of course, lead to it. Sometimes patients do eventually need to go on medications. But if let's say they present you with an acute gouty attack for the first time, there's no indication or really put them on an Allopurinol or Probenecid or anything like that. Usually, they need to have a few attacks before you actually consider a medication like that. And that's when a referral to a rheumatologist might be indicated. Another one we could talk about is lupus. Lupus is a very difficult condition to treat. And that's where definitely a rheumatologist needs to diagnose you with something like that, or a PCP. It's an autoimmune disease that can affect multiple joints, it can affect your skin, kidneys, blood cells, your brain, and your lungs. In fact, I didn't realize this, but I guess more than 200,000 cases are diagnosed in the United States per year. From what I remember, it's almost a diagnosis of exclusion. It's really difficult to diagnose, you know, but some of these patients, they just look so miserable, you feel so bad. A lot of these patients present with chronic fatigue, joint pain, and rash, especially that rash on the face that butterfly rash. They may get fevers, and patients may get flare-ups every once in a while, but then they tend to improve. Unfortunately, there's no cure for it. But the current treatments are mainly focused on improving the quality of life, lifestyle modifications, sun protection, diet, anti-inflammatory steroids, and disease-modifying anti-rheumatic drugs may help. Another big form of arthritis that we'll talk about juvenile idiopathic arthritis or juvenile rheumatoid arthritis. Very difficult in children, because you know, that's the time of your life when you're supposed to be playing and enjoying and having fun. But it is a very difficult condition, it may cause physical, permanent damage to your joints, there really is no cure. But children may achieve permanent remission actually, by modifying their lifestyle. Symptoms do include joint pain, swelling, fever, stiffness, rash, fatigue, loss of appetite, eye inflammation, and difficulty with daily living activities. So as I was doing a lot of research on arthritis in general, of course, my search always comes to and I want to ask you, What is my favorite condition to do surgery on

Katrina Sanders, RDH 22:51
You love Charcot surgery!

Elizabeth Sanders, DPM 22:57
Do you remember when you came to a conference of mine, and they were presenting they're like, "This patient came to the emergency room and was diagnosed with nothing." But what do you see on the x-ray? What did you say?

Unknown Speaker 23:12
To you, I went, "I bet it's Charcot."

Elizabeth Sanders, DPM 23:16
So basically, but it's not a form of arthritis, but it is a form of a terrible deformity. That can affect the foot, the ankle, and the knees. I know it's not necessarily part of this, but it's one of my favorite conditions to treat because it's so there's not much known about it. It's basically an osteoarthropathy Very common in diabetic patients. So on that note, I mean, I know you are a podiatrist. By the way, that was one of the most proud moments I've been at any conference sitting next to you and you diagnosing Charcot that someone else could not diagnose. But they don't know any better. So Katrina, tell me about the oral or the dental implications of arthritis, and what do you see in your dental chair?

Katrina Sanders, RDH 24:15
Yeah, so you know, it's interesting because in hygiene school, particularly, we are not taught a ton about arthritis index. The main thing that we're really taught about arthritis is that if the patient has osteoarthritis, they may struggle to hold on to a toothbrush, or dexterity manual dexterity is going to be an issue. So for a patient that has arthritic issues or joint inflammatory issues, they're not gonna be able to floss very well. So you're going to prescribe some other inner dental aid and tooth brushing either you know, drilling a little hole into a tennis ball and then inserting a toothbrush into that so that you've got a bigger grip or an electric toothbrush is always ideal, right? Like we love those electric toothbrushes because they really do help. So we were really taught that manual dexterity is our biggest challenge with regards to arthritic patients and that's again specific to our osteoarthritic patients. But now we're starting to unpack quite a bit of information about gout and particularly rheumatoid arthritis. In fact, we're starting to see our perio entities looking at rheumatoid arthritis as a major marker for particularly periodontal disease. So we know that periodontal disease and rheumatoid arthritis share many common risk factors like tobacco status, socioeconomic status, obesity, etc. We know that arthritis and periodontitis both cause destruction of hard and soft tissue, they use very similar pathways around those what we call pro-inflammatory cytokines or those, you know, chemical markers that are released from our mast cells in the state of the inflammatory process, of course, and in both situations, these inflammatory cells will result in gingival, collagen or even bone destruction, you know, so that, of course, creates a lot of that kind of multifaceted or multi-layered relationship, particularly rheumatoid arthritis with it being an autoimmune disorder, but arthritic challenges in general, being inflammatory components and periodontal disease have that association with a higher inflammatory burden. So patients that have arthritis will oftentimes demonstrate higher levels of bleeding upon probing, and higher concentrations of inflammatory cytokines, if you were in a practice that measured that. So that would be like interleukin one tumor necrosis factor-alpha, within that gingival crevicular fluid and then higher concentrations, of course of your good old C reactive proteins. Who doesn't love that, right? So, when we take a look at some of those links back and forth between oral disease and periodontal disease, one of the things that we've found in our research, there's still some inconsistency there. But we have found some details that have indicated that if a patient who has arthritis receives non-surgical periodontal therapy, we have been able to trace a reduction in gingival crevicular, fluid levels of interleukin one, and serum levels of tumor necrosis factor-alpha, which is really important for us, of course, to take a look at, you know, in addition, we're starting to see that host modulation therapies. So any type of anti-inflammatory therapies, something that we are doing from a periodontal standpoint, can also provide some simultaneous mitigation of arthritic challenges as well. So I think that's just a really beautiful segue for us to kind of dive into because I know we're talking about, you know, what are some of the things that we can do to treat arthritis. One of those things being yes, periodontal therapy, because we know is going to certainly drain on the systemic burden of inflammation. But, you know, what are some other things that we can do Doctor Sanders to treat arthritic patients?

Elizabeth Sanders, DPM 28:04
We talked about more exercise, and I really liked how you certainly specified the type of exercise as well. So don't be like our brother and go for a marathon. But, but certainly, you know, just walking 25 minutes a day. And getting that moderate exercise in physical therapy can definitely help weight loss to try to take the weight off of your joints, good diet, and I'll kind of talk about a little bit about some things in your diet and supplements that are really helpful for avoiding arthritis. Disease Management. So I saw something too, that disease management education programs can really help patients, although actually only about 10% of adults who are diagnosed with arthritis actually participate in these programs. And actually, adults who are more are more likely to attend if they are recommended by a provider. So that's something that we really can have patients participate in and we can make recommendations. Certainly supportive devices like crutches or a cane, but for example, like me, if I have a patient with ankle arthritis, yeah, I'll give them a brace but they can't be in a brace for the rest of their life. They do still need to get some motion to that ankle. But certainly, those can help you and we talked about different medications that may help as well like anti-inflammatories, although you cannot be on that too long. steroids may be beneficial. But if you're going to be on long-term steroids, I do recommend a referral to rheumatology or endocrinology. And then of course, sometimes surgery is an option and you know, I can certainly talk about the foot and ankle surgery and that's a whole nother topic. And we talked about the different medications and Said's DMARDs or rheumatoid arthritis, lupus, psoriatic arthritis, or any inflammatory diseases, and sometimes biological response modifiers are an option as well.

Katrina Sanders, RDH 30:13
You know, one thing I want to share when you talk about DMARDs, by the way, so that is a Disease-Modifying Anti-Rheumatic Drug (DMARDs) is what that is for our viewers at home. So, I'm going to in the show notes include an article that I wrote alongside the amazing Dr Mia Geissinger, about RA and periodontal disease, because one of the things that we found, and I can't stress it enough, I just had to wrap it up on the medication side is that we're starting to see a demonstration where patients who have chronic periodontitis demonstrated a significantly less improvement in their arthritis when compared with healthy patients. So it is postulated that although we're putting patients on these medications, again, dental professionals are listening to this think through this. So you've got a patient and they are arthritic, and they are on medications for it. So these are the primary things we ask in a medical history, right? What medications are you on? Oh, okay, so it's controlled. And then you evaluate their gum tissues and they have periodontitis. We know or it is readily postulated in research at this time, that if a patient has inflammation due to periodontitis, that inflammation may actually dampen the effects of the medication therapy. So by us performing active curry Donal therapy, we could theoretically be yielding better results with our patients that are on some of these medications to address this disease process.

Elizabeth Sanders, DPM 31:42
Isn't that unbelievably amazing? And that, that alongside you know, any diabetes medications or heart medications are anything that is unbelievable. I just remember reading that article. It was a while ago, and it was a while ago. And by it, I need to read it again. Because it's a great article. I

Katrina Sanders, RDH 32:01
Thank you. But Mia Geissinger really is just the rock star in that article. She is just a boss babe, which I love. So we talked about medications. But you and I both are on a very similar belief mechanism, that food is really the best medicine food can make you sick. But food can also heal you and we've talked about that quite a bit during our nutrition episode. So yes, we talked about that quite a bit there. But what are some foods that are specific to fighting arthritis that we could theoretically counsel our patients on?

Elizabeth Sanders, DPM 32:36
Yeah, I like how you ask that because I really do believe in I know, you do believe we really are what we eat. I think you can manage a lot of things. And it's easy to say, oh, no, I can't afford that. You know, but you can afford your diabetes medications. Sure, for the rest, you know. So it really is important. And we talk last time on our podcast about the anti-inflammatory diet as well. And a lot of these things, the anti-inflammatory foods do also help with fighting arthritis. So we'll just talk about some things. So tart cherries have been known to offer anti-inflammatory and antioxidant benefits. It may also lower your risk of gout flare so that's great. But also other purple fruits like strawberries, raspberries, blueberries, and blackberries. These are all anti-inflammatory superfoods, which are awesome,

Katrina Sanders, RDH 32:28

The darker the berry, the sweeter the juice. And also the more anti-inflammatory it is.

Elizabeth Sanders, DPM 33:32

I like that! I mean, what's our favorite thing to share, Katrina, when we go to The Gladly? Our vegetable plate with colorful vegetables like carrots, red or green peppers, squash, sweet potatoes. These all have abundant Vitamin C which can preserve your bone and bone health and protect your cartilage. Of course, seafood like salmon, tuna, and sardines—these are all great because they have omega-three fatty acids which are essential. And soybeans, tofu, and edamame, you know don't I don't mind that. They contain great three fatty acids as well. They're also low in fat and high in protein and fiber which is great. Different oils like extra virgin olive oil, avocados, and things like that. They help lower your cholesterol. Certainly nuts like walnuts, pine nuts, and almonds. They're high in alpha-linoleic acid, which is a type of anti-inflammatory. They also may help lower your cholesterol and relax your blood vessels and reduce your blood pressure. Garlic. We all know that garlic is great.

Katrina Sanders, RDH 34:51
Great, amazing breath great if you're dating a vampire

Elizabeth Sanders, DPM 34:58
to funny but it really is great for fighting pain, and inflammation. We talk about low-fat dairy products like milk, yogurt, and cheese, these are just packed with calcium and vitamin D which can help with bone strength and assist with calcium absorption. But I like how you mentioned that we do need vitamin D. So make sure you're going outside and getting your sun that can, it can also help with your immune system. If dairy does not really agree with you, like me and Katrina, leafy green veggies like spinach are really gonna help you. Broccoli —love broccoli, it's rich in Vitamins K and C and contains a component called sola 14, which researchers have found that do prevent or slow the progression of osteoarthritis. We know green tea is very good for you because it contains polyphenols and antioxidants to reduce inflammation. Citrus fruits are very helpful because they are rich in vitamin C, which may prevent inflammatory arthritis and maintain healthy joints in arthritis and osteoarthritis. Whole grains like oatmeal, and brown rice, they're excellent sources as well. And then beans like kidney beans, pinto beans, they're great. And they also have excellent sources of protein. They're Richard folic acid, magnesium, iron, zinc, and potassium.

Katrina Sanders, RDH 36:27
I love that, you know, I think it's it's when we take a look at the nutritional component like this right? One thing to remember when you're talking to a patient, and you're you know, and they're explaining to you about their arthritis is that, although I mean, what an arsenal of foods that you just gave us, right, like what an arsenal foods! Yeah, you know, I like the vast majority of these foods like I would eat a lot of these things myself, just because I love these things. So I must eat a low glycemic index or low-inflammatory diet just in general, right? But not all of our patients are going to love all of these things. So the idea being you want to educate your patient and then offer up to them like, what of these sounds feasible? Because I'm sorry, if we're looking at this, and my patient is like, "I hate seafood, right? I hate salmon. I hate tuna." You know, okay, we need you to still get your linolenic fatty acids, right, your omega threes. So that's what we're talking about. Maybe soybeans, tofu, edamame, and then suggesting something like that? Would you be open to maybe infusing something like this into your diet, and really allowing the patient to be able to guide what their diet looks like, is really critical. Now one other thing, too, that I want to ask you about is and I mentioned him earlier, my 15-year-old pug Beagle mix. Darby has arthritis. He's an old man. So now we need to like I have to lift him up onto the bed and things like that. I'm definitely seeing that decline in his joints. But he does take supplements that have been prescribed to him by his veterinarian. So what types of supplements are going to be optimal for our patients? Or for our little furry friends that have arthritis? Yeah, sure. Pay attention, Darby. Pay attention.

Elizabeth Sanders, DPM 38:14
He's there listening, although he can't hear too.

Katrina Sanders, RDH 38:16
Well. That's right. Yeah, he's not hearing very well, unless you open a stringy cheese packet. And then you can hear that no matter where he is in the house. He hears that.

Elizabeth Sanders, DPM 38:24
Selective hearing. Yeah, so I'm always open to trying to suggest to my patients different supplements, especially when they're like, but what about the pain? And it's like, well, I can't just give you narcotics, especially here in Boston, where narcotics is a huge problem, a huge problem. And, you know, I can Yeah, I can give you an anti-inflammatory, but I would really like to try something natural. And some of my patients opt for that. So it's specifically for people with arthritis. I've been suggesting glucosamine and chondroitin. These are actually over the counter. And they actually are components of cartilage. Research on these different supplements has been very mixed, including like why do we mix them and the type of glucosamine that actually should be included. But to be honest with you, most trials are pretty promising. And they even find that the combination of these two supplements together is as effective as an NSAID which is fantastic. We talked about fish, so if you don't like fish, taking fish oil supplements is very helpful. And I tell people it's also very helpful for your nerve health. So my patients with neuropathy, I tell them to take these polyunsaturated omega-three fatty acids found in fish have been found to be anti-inflammatory. And in fact, it's considered to be better in rheumatoid arthritis as opposed to osteoarthritis, probably because of the inflammatory component of rheumatoid arthritis. So this is something that I haven't really had much experience with but something called S-adenosyl-L-methionine (SAMe) is a natural compound in the body that has anti-inflammatory and cartilage protective behaviors as well as pain-relieving effects, which is pretty awesome. It also does have an anti-depressant effect, which I found very interesting. Something I tell all my patients, especially the ones that do not want to take any anti-inflammatory, I tell them to take Tumeric or curcumin, which are the active compounds in the spice of Tumeric. And it's a very powerful anti-inflammatory agent and it blocks the same enzyme actually, as Cox two inhibitors. I swear by it, I should be taking it. But if I take it regularly, I feel like a champion.

Katrina Sanders, RDH 40:52

Wow.

Elizabeth Sanders, DPM 40:53

I don't know if you do, but I swear by it.

Katrina Sanders, RDH 40:54

Oh, maybe I'll start.

Elizabeth Sanders, DPM 40:56

Yeah, just um, over-the-counter tabs.

Katrina Sanders, RDH 40:59
Yeah, it just comes incapsulated, doesn't it?

Elizabeth Sanders, DPM 41:02
Yes, it does. it will stain your hand a little bit. But no worries. If it makes you feel great, do it.

Katrina Sanders, RDH 41:06
Who cares, right?

Elizabeth Sanders, DPM 41:09
And studies have shown that it is as effective as Motrin, without the GI side effects. One side effect is that it is hard for the body to absorb. So make sure you're taking it along with some source of fat, or I guess with some black pepper, how random you know, just a little Tumeric and little pepper, yummy. And then, of course, we know that several vitamins have you know, have been studied for their effects on arthritis, like Vitamins A, C, E, D, and K. No studies really demonstrate that taking these supplements actually improved arthritis symptoms. But of course, eating a diet rich in these nutrients is just great for your health overall. Vitamins D and K, like we talked about are really important for your bone health and your cartilage, so those are some things that you can even recommend to your patients as well as yourself and your friends and your family. So Katrina, what are some other things that we as healthcare providers can be doing for our patients?

Katrina Sanders, RDH 42:13
Yeah, so well, a few things. You know, we talked about it, I hate to be the squeaky wheel here as the hygienist who's like, hello, what about us, but really as a health care provider, knowing that oral inflammation which periodontal disease by the way is the second most frequent modifiable inflammatory condition. So we know that periodontal disease, you know, certainly is an inflammatory component that can contribute to, you know, arthritic bouts. One thing that we're starting to see now is the use of the DAS 28. Score. So DAS is the Disease Activity Score, particularly for our RA patients and dental professionals may be asked moving forward to ask the patient what their DAS 28 score is, it's calculated based on the number of joints that they have, there's a 28 version, which is kind of the original DAS 28 score. Now, we're looking at about 44 different joints, but the DAS 28 score looks at the amount of swollen joints, the amount of tender joints, as well as, you know, blood evaluation to look at C reactive protein markers and erythrocyte sedimentation rate. As you know, as components, we do believe that DAS 28 score could give us a lot of information about the perceived inflammation that our patients have. So we may be screening for that that is a vital signs that we will likely be expected to ask our arthritic patients when we talk about counseling our patients after we know this information, and after we've evaluated their level of oral inflammation, encouraging our patients to be physically active, and you absolutely unpacked that. Take a look at things that are low impact. So like I taught water aerobics, in college, water aerobics, swimming, anything in the water is going to be low impact, which is just absolutely wonderful. I also do this activity called Canggu, where you wear these little moon boot things, the boots have a spring in them, and you're jumping on them. Now the springs absorb all of the shock when you're hitting it when you're moving around. So it's actually a low-impact way to be able to work out. But we know that physical activity is really important because we know that it reduces inflammation, period. We know that it's really great for maintaining a healthy weight and then easing the amount of weight that is getting put on those joints. Darby, did you hear that you're going for a "dubs" in a minute. In addition, also, you know knowing what local educational programs you have available. I do believe that sometimes dietary counseling is an opportunity. You know, looking at educational programs, even around referring the patient to a personal trainer, there are stretch labs that allow for stretching. Anything that you can do to continue to create motility and movement in those joints in a comfortable way, is a physical activity for the patient. And asking them about even anxiety or depression, you know, we forget about that with autoimmune disorders specifically, but anxiety and depression, mental health issues are a big challenge. And I mean, you know, you mentioned earlier with the juvenile rheumatoid arthritis, like a little kiddo who gets sore and can't run and play in the snow forts, and jump in the piles of leaves and all those things that kids just love to do that, you know, there can be some additional ramifications associated with that. So, you know, those are all opportunities to consider, you know, when we counsel our patients on not just arthritis, but really any inflammatory condition, or an autoimmune disorder that requires us to be able to step into our power. Well, one thing I like that you do, I think is important. And you said something earlier, that just really struck me, and that was patients will be a lot more compliant. And it was hard for us to even think about, right, because we all are like, okay, but patients are more inclined to be compliant or to move forward with taking certain supplements or whatever, if they are prescribed by a dental professional, a medical professional, somebody who they respect, who's in a white lab coat with a lot of credentials, and alphabet soup after their name, saying this is important for you. And so I think it's this is our opportunity to, you know, be authorities for our patients in this disease process and helping them understand the why.

Elizabeth Sanders, DPM 46:43
Now, that's really good, because, you know, you think yourself, Oh, I'm a podiatrist, you know, it's I'm one of many appointments that they have, or I'm a dental hygienist, I'm one of the many appointments that they have. But truthfully, you could be one person that they see in a few months, and they're coming to you with a problem. And now this is your opportunity to talk to them about other things. Sure, um, other things that would really help their health overall. And sometimes they do ask you for things that are going to help you because you're absolutely right. They see someone with a white coat in front of them. And I and I just love that you things that you think are just standard, because we talk about it all the time, but they don't really know. And it's so great. So I really loved this topic now. Yeah, it was kind of done. It was kind of a daunting tap topic at first, right? Arthritis, but very interesting. And I think there are a lot of other things we can unpack with this.

Katrina Sanders, RDH 47:34
Oh, 100%. And I know that we've got an awesome arsenal for the rest of this year in some incredible topics. So I'm actually super excited about next month's topic, we got a little surprise for everybody. But you'll have to tune in to find out with that little surprise. So with that, thank you for tuning into another episode of floss and flip flops with the sander sisters, produced by Kristin Hohman and brought to you by our friends at Modern Hygenist. Join us next time as we brush up on more oral-systemic content.

Elizabeth Sanders, DPM 48:08
We promise to keep you on your toes.

Katrina & Elizabeth Sanders 48:13
Thank you for joining us for another monthly episode of Floss & Flip-Flops with the Sanders sisters.

Elizabeth Sanders, DPM 48:19
Thank you for being part of the change we need to see in the medical and dental profession.

Katrina Sanders, RDH 48:25
Join us next month for another sister-to-sister chat about other unique, interesting, and perhaps provocative and disruptive health topics.

Elizabeth Sanders, DPM 48:34
Don't forget to like and subscribe and maybe even leave a fabulous review!

Unknown Speaker 48:38
And we'll catch you next month for another episode of Floss & Flip-Flops with the Sanders sisters!