“Natural ecosystems regulate themselves through diversity.” The biggest little farm, 2018.
This begins a detailed narrative account of first-person, active learning discovery, seeking where necessary alternative and sometimes unorthodox routes to solving unanswered questions within one’s professional life. It is also an empirical journey, combined with traditional sources of research, putting the walk into the talk, using the experience of new knowledge gain, utilising the insight and awareness of it, to add deeper texture, relevance, and meaning into practice. There are unique moments and profound occasions that require such answers and begin your inquiry. This, unwittingly, came knocking on my surgery door in 2017 to hasten this journey. I was working as a self-employed dental hygienist in general practice in Marlborough, New Zealand. A client, younger than myself, with a serious pre-existing health condition, had made a monumental effort to improve their oral health, under my care. They patiently waited for a heart to become available for transplant. The day I saw them for the final review, praise was lavished at vast improvements and evident clinical stability. This should have been the green light to anticipated surgery but was, alas, the last day of their life on earth. It wasn’t enough despite my client’s earnest efforts to prevent a massive heart attack and its fatal consequence. Around the same time, I attended a progressive dental health event in Switzerland. Moments of clarity amongst the events of that international occasion brought greater resonance to a growing sense of unease within the professional me, my wedded ideology, and beliefs. I was drawn away from the threads of the mainstream conference agenda to smaller, just as well attended, but more abstractive presentations that covered holistic and nutritional subject matter. They were freed from convention, and to me, a breath of fresh air.
My locus of intent was switching from reductivism of just teeth and gums to looking at the mouth as a whole, becoming more investigative into the broader context of health related to oral hygiene. I started to read books by journalists and influencers in food science, Michael Pollen, Gary Taubes, and Nina Teicholz. I also began listening to podcasts by endocrinologist Dr. Robert Lustig, pediatrician Dr. Robert Ludwig, and complex problem-solving engineer Ivor Cummings debating systemic health, behaviours and watched documentaries by the likes of Azeem Malhotra, a cardiologist, into nutritional well-being. The ventures into these works drew my attention to profession contention, the gated establishment of food and health politics versus the alternate and burgeoning intelligentsia who challenge contemporary theory. They all believe that the present food environment and culture requires change, for the sake of health, well-being, and economics. They have been profoundly influential, and the push back has been rapid from pharmaceutical, food, and related industries and interests. South African nutritionist and author Dr. Tim Noakes, and Australian senior orthopaedic surgeon Dr. Gary Fettke, have been the subjects of recent high-profile lawsuits. These being brought to bear by their regulatory bodies over contentious claims they have made defying the established thinking.
“It is not the strongest of the species that survives, nor the most intelligent, but the one that responds to change.” Charles Darwin
My headspace has been a flurry of comparative conflict with my established ideology. It has been born of over more than two decades of traditional professional development and a reckoning with my past learning approach. Over the proceeding months, many a long dog walk had me listening to the challenges these individual voices were making to the greater online audience, and the tone and texture of their message began to make more sense by the day. This culminated in a presentation of this learning, in my style, and in a dental health context to professional audiences. Like these great activists, I found walking the walk rather than talking the talk, profoundly influencing. Upon these experiences and knowledge, I realized that other people, many amongst clients, follow a similar path. How would I make the next journey, what would it look like, could it be more experiential and meaningful?
The plan was drawn up on paper, on the dining table, over a few days. The journey would begin in the UK, onward to France and into Scotland, over to the States and back home to New Zealand, learning, feeling, experiencing, reflecting, and enjoying along the way. I thought I had a clear picture of what would be gained and set out on the scroll of cello-taped paper. People contacted, meetings arranged, and all the panoply of its facilitation organised, times and places plotted, and transport to set the project in motion. What was not, at that point, thought out was what would be the outcome of it. I knew that, as many students in the art of warfare acknowledge, is that planning, in reality, doesn’t survive contact with the enemy. I was prepared for it and welcomed it. Tangential flexibility would prove to be the best armour and protection against a rigid and fundamental ideological foe.
“The roots of education are bitter, but the fruit is sweet.” Aristotle
Upon my return to New Zealand in the early spring of the southern hemisphere were harbingers of change, a new home, location, and workplace environment. We started the journey in full knowledge of this, but the reality of the situation saw me embarking on another explorative journey within my place of work. It leans heavily on the symmetry between past practice, recent experiences, and my new professional environment. It also looked at distinct healthcare subject matters like alcohol, fluoride, cannabis, nutrition, and the much-maligned historical figure of Weston A. Price, as well as the evolving and testing my ecological, nutritional and environmental co-existence hypothesis. What follows are accounts of both of these journeys in the context of authentic learning and dramatic world events, founded within my established principles of empiricism, linked to evidence guided practice.
Mark is a registered dental hygienist with over thirty years of varied clinical and learning experience. His practice began in the military, where he witnessed the fall of the Berlin Wall in 1989 and received a royal commendation for his community learning support to service schools. Mark continued his journey in the Highlands of Scotland, the warmth of the Mediterranean, working again in community learning, and an oral maxilla facial department. He also saw clinical service in the turbulent environment of post-communist Moscow as a member of a diplomatic dental team for several years. After his military service, Mark moved onto private, NHS, specialist practice, and affiliations to the trade industry as a key opinion leader and influencer in both the UK and New Zealand. Mark has further highlighted his endless curiosity to engage in learning presently by creating websites and blogs that share his thoughts, demonstrate new knowledge creation processes, and continues to do so today. He is also an active mentor for O’Hehir University, an online tertiary learning hub for postgraduate dental health professionals.
“Nothing has such power to broaden the mind as the ability to investigate systematically and truly all that comes under thy observation in life.”
I can remember the moment that I discovered the beautiful truth of mushrooms. Upon a mound of grassed earth, about 5 metres square was a huge ancient oak tree, perched next to a minor road that led from the railway station to the leafy suburbs of the rich and well-healed. This was a relatively innocent spot when every late-Spring to mid-Autumn when the environmental conditions lend themselves, the fruiting bodies of the Boletus Edulis mushroom appeared. This they do with grateful regularity, along with other less gastronomic varieties, being ignored by all and sundry, ignorant of the identity these fungi fruiting bodies, and the free gift from nature herself. Dear friends of ours, David and Rachel, had the same epiphany, but of the honey bee kind. They have found common purpose, collaboration, well-being, and began to care bees and their production of honey. They had both found peace and greater common interest, teaching and motivating others to the cause. Bees, however, are in crisis and for many reasons.
“Bees do have a smell, you know, and if they don’t they should, for their feet are dusted with spices from a million flowers”. Ray Bradbury
The Woodland Trust, a tree planting, and ancient woodland protecting UK organisation, is acutely aware of the necessity of the bee. They state “bees have been around for millions of years, pollinating our plants and producing the sweet, golden syrup we call honey.” The trees and woods are essential to filter our air but bees are vital for pollinating about a third of our food and 80 percent of the trees and flowers of our wildlife habitat.
New Zealand has 28 native species of bees and 13 introduced species. As the native bees don’t make honey non-native species do the job in their absence collecting pollen from 224 native plant species. Despite this obvious benefit, the native bees are under threat by the honey-producing bees as they take their food sources, possibly threatening indigenous biodiversity.
However, bees are globally declining in numbers due to many threats, and saving them goes hand in hand with saving the trees and ancient woodlands. Habitat loss, caused by urban development, intensive farming methods alongside pesticides are the greatest threats to them. Climate changes, altering seasonal timings affect the flowering calendar, and extremes of weather contribute too, disrupted bee nesting behaviour. Parasites and diseases are another big threat, the Varroa mite clings to the back of the honey bee, passing diseases and viruses to it, thus draining its strength. These and other invasive species cause havoc to native species.
The recently released documentary film Fantastic Fungi, a “time-lapse journey into the mysterious and magical world”, details the power of fungi to heal, sustain and contribute to the regeneration of life on Earth beginning some 1.5 billion years ago. Fungi feature actively in foods as diverse as beer, wine, and cheese. Fungi is neither animal or vegetable, there are over 1.5 million species, 6 times more than plants. They can break down complex organic matter and are responsible for the generation of soil. Fungi extend in vast networks that span hundreds of miles underfoot. They use electrolytes and electric pulses to communicate through mycelial networks, vaster than our own brain neural networks. Trees use these incredibly complex natural communication pathways recognising, protecting, and nurturing their own kind and kin. My hero, Paul Stamets, a mycologist with a mission, has an uncanny knack and passion powered presence regarding all things fungal. Hearing his podcasts with famous talking head Joe Rogan has three dimensionalised my mushroom learning journey. Initially, I was emotionally recruited into being mycophile because of its alternative and historical context. I liked the notion that critical knowledge could surpass that of the power of danger, but Paul’s pervading and persuasive sermons bring cruciality to the messages that a variety of medicines, conventional and alternative, can be created from fungi to ultimately saving the plant and humans by saving the bees.
“A day without a friend is like a pot without a single drop of honey left inside.” Winnie the Pooh
Honey is composed of many things, primary Fructose (38%) then Glucose (31%) followed by water (17%). Other components include minerals, amino acids, proteins, and acids. Sugar composes about 95% of honey dry weight. The acidity and pH of honey are lesser than the balanced level of 7, blossom honey is lower ranging between 3.3 to 4.6. Honeydew honey, due to its higher mineral content, has a higher pH value varying between 4.5 to 6.5. Honey, having a very concentrated sugar solution has a high osmotic pressure which makes it impossible for the growth of any microorganisms.
The oldest civilisation known, the Sumerians, from Mesopotamia, historically renowned for their innovations in language, governance, and architecture were also well acquainted with bee-keeping and honey. They worshipped a honey bee goddess and fashioned pottery, was making special jars for honey. There are biblical references to honey and are mentioned in scrolls from the Talmud and the Koran. The Egyptians and the Romans applied honey to wounds, and English Kings and Queens fermented it into drinkable mead.
Honey has both therapeutic and pharmacological properties, osmolarity, acidity, hydrogen peroxide system (inhibin), phytochemicals, and methylglyoxal. All have healing properties as expectorants, anti-cough, anti-constipation, liver detoxification, and alleviating digestive disorders like peptic ulcers. Honey is also considered both a probiotic and prebiotic and can be classed, as a result as a symbiotic, being contained in one product.
Honey and its associated products have been also researched in the oral health context. Ahuja and Ahuja (2006) examined Apitherapy, specifically looking at the inhibitory effects on bacteria including aerobic and anaerobic gram-positive and gram-negative flora, the significant antimicrobial, antiviral and antifungal properties of flavonoids, and phenolic acids. Honey, having a high fructose and glucose content, would be expected to be very cariogenic, additionally presenting a lower pH too. Various studies (George et al 1978, Shumon et al 1979 and Nizel 1973) have determined it to be equal, or worse (Kong 1967) than sucrose, with one, by Decaix, (1976) surprising finding it less so! The diversity of outcomes demonstrates a degree of confusion, perhaps detailed observations of the differing methodologies, funding, and biases of the research, and researchers might add clarity. It may also be that selected honey having higher antibacterial activity and better-balanced pH, like honeydew, are less harmful to teeth by inhibiting cariogenic bacteria. Further research, if deemed necessary, may reveal more beneficial evidence.
Propolis, a resinous (55-60%), lipophilic material is waxy (30-45%), sticky, yellow-brown to dark brown, with aromatic oil and pollen (5-10%). It is collected from tree buds, sap flows, shrubs, or other botanical sources is used to protect and seal unwanted open spaces in the hive. Propolis is rich in chemicals like flavonoids, phenolics, and aromatic compounds being antioxidant and anti-inflammatory to name but a few. The main benefits come from two propolis products, the first is the Ethanolic Extract of Propolis (EEP). It is a rich source of phenolic acids and flavonoids. EEP and its phenolic compounds have been known for various biological activities including immunopotentiation, chemo preventive, and antitumor effects. It is highly effective against strains of Bacteroides and Pepto streptococcus.
Secondly, Propolis contains Caffeic Acid Phenethyl Ester (CAPE), a versatile therapeutically active polyphenol, and an effective adjuvant of chemotherapy for enhancing therapeutic efficacy and diminishing chemotherapy-induced toxicities. It is acquired from propolis obtained through extraction from honeybee hives. This bioactive compound displays anti-inflammatory and anti-oxidative properties, enhancing the production of cytokines IL4 and IL10 and decreasing the infiltration of monocytes and neutrophils.
Propolis has been shown to inhibit cariogenic microorganisms, slow down the synthesis of insoluble glucans, and inhibit glucosyltransferase enzymes, essential for Streptococcus mutans to become sticky and adherent. Cariostatic effect of propolis is assisted by its fatty acids, slowing down the production of acids by Streptococcus mutans, and decrease the tolerance of microorganisms to acid pH. Also, A study assessed, in vitro, antibacterial effect of Iranian propolis on oral microorganisms concluded that ethanol extract of propolis is effective in the control of oral biofilms and dental caries development.
“Mushrooms were the roses in the garden of that unseen world because the real mushroom plant was underground. The parts you could see – what most people called a mushroom – was just a brief apparition. A cloud flower.” Margaret Atwood, The Year of the Flood
A large variety of mushrooms have been utilised traditionally in many cultures for health purposes, prevention, and treatment of diseases. Over 100 medical functions have been found in mushrooms and fungi. They range from antioxidant, anticancer, antiparasitic, antifungal, detoxification and hepatoprotective. The bioactive properties are found in fruiting bodies, cultured mycelium, and broths which contain polysaccharides (most important in modern medicines), proteins, fats, minerals, phenolics, flavonoids, carotenoids, folates, lectins, and enzymes. Beta-glucan is the next most versatile metabolite from the mushroom kingdom. It has a wide spectrum of biological activity, related to the immune system, especially regarding antitumor benefits.
A critical review on health-promoting benefits of edible mushrooms was undertaken by Jayachandran et al in 2017. They looked into the role of mushrooms as prebiotics in improving the host’s health. They have substances that induce the growth of or the action of microorganisms that contribute to the host’s well-being. Importantly they play a vital role in immune regulating pneumococcal pneumonia and antitumor activities. In particular button mushrooms increase microbial diversity in gut flora. Other mushroom types have been reported to reduce obesity, gut dysbiosis, improve antioxidant status via microbial alterations.
Specific cultivated and wild mushroom species have been researched for their potential application in human health. The Shiitake mushroom, Lentinula edodes, cultivated since the Sung dynasty in 1100 AD, is one of the most popular mushrooms worldwide, prized for their rich, savoury taste. It has a variety of biologically active compounds like erythritol. It is suggested Shiitake possess anti-oxidative and anti-atherosclerotic potential, with regular consumption improving human immunity. A study was undertaken in 2015 (Dai et al) looking at 52 subjects between the ages of 21 – 41 consuming 5g -10g daily. Their blood pictures after 4 weeks revealed reductions in C reactive protein (CRP) and an increase in IgA immune function activity. The cytokine pattern also differed before and after indicating immune improvement also, demonstrating less inflammation than that which existed before. A culinary favourite, the Cep or Penny Bun (Boletus edulis) has a polysaccharide profile, tested in laboratory mice, that demonstrated reduced pro-inflammatory and increased anti-inflammatory responses.
Erythritol is responsible for anti-microbial activity in dental health, being seen to detach cariogenic bacteria from tooth structure, altering the cell surface hydrophobicity, and disrupting signals transmitted in Streptococcus mutans. Studies into Shiitake extract mouthwash was compared to a chlorhexidine rinse in an artificial mouth model. Eight key taxa of the oral health community were investigated over time. The results indicated the Shiitake extract lowered pathogenic bacterial numbers without affecting the taxa associated with health, whereas the commercial rinse affected all.
The symbiotic healing relationship between bees and fungi is becoming more understood. Fungi have an important role as providers of powerful medicine in fighting honey bee viruses. There have been waves of highly infectious viruses contributing to a massive decline in honey bee health. However, it has been recently noted that bees forage on mushroom mycelium. This suggests that they may be deriving medicinal as well as nutritional value from fungi. The wide range of chemicals that mushrooms possess include some that may benefit, antimicrobially, honey bees. They are particularly affected by two viruses, Lake Sinai Virus (LSV) and Deformed Wing Virus (DWV). Research undertaken by Stamets et al (2018), determined that extracts of Omadou and Reishi mushrooms reduced DWV 79 fold and LSV 45,000 fold compared to control colonies and they, understatedly, may gain health benefits from fungi and their antimicrobial contents. Besides the continuing work of Stamets and co-workers beyond fungi, where they are disseminating three-dimensional printing diagrams for the greater public to produce bee feeder platforms. These are simple measures we can all immediately do to meaningful help in real-time. This includes filling your garden with bee-friendly flowers, stopping the use of pesticides, and using 1 tablespoon of water with 2 tablespoons of white granulated sugar to make an energy drink, placing it nearby busy bees.
To conclude I am pleased that a passion project of mine, mycology, can be researched in my clinical field, albeit unorthodox but very relevant in my social context. I am aware that honey, propolis, and fungi will probably never see the mainstream light of day in my practice but will be able to engage, with knowledge, clients who are interested or associated with them. I am more the wiser and sympathetic towards those who have tried through research to bring their benefits to the fore, their work is worthy of examination. Furthermore the future of the human race is aligned with the future of bees and the environment. Greater attention to them and their habitat, be they fungi or bees should be invested in. It is time for man to provide more action and resources to protect them and understand our mutual environmental and sustainable needs.
A critical review of health-promoting benefits of edible mushrooms through gut microbiota Jayachandran et al, 2017. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5618583/
Propolis in Dentistry and Oral Cancer Management. Kumar, 2014. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4083525/
Propolis: A natural biomaterial for dental and oral healthcare. Khurshid et al, 2017. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5768961/
Extracts of polypore mushroom mycelia reduces viruses in honey bees. Stamets et al, 2018. https://www.nature.com/articles/s41598-018-32194-8
In vitro assessment of Shiitake mushroom (Lentinula edodes) Extract for its anti-gingivitis activity. Ciric et al, 2011. https://www.hindawi.com/journals/bmri/2011/507908/
Apitherapy – A sweet approach to dental diseases – Part I : Honey. Ahuja & Ahuja https://static.webshopapp.com/shops/035143/files/056059908/2012-a-sweet-approach-to-dental-diseases-part-i-ho.pdf
Apitherapy – A sweet approach to dental diseases. Part II: Propolis. Ahuja & Ahuja, https://journals.sagepub.com/doi/pdf/10.1177/2229411220110201
Does Propolis Help to Maintain Oral Health? Włodzimierz et al, 2013. https://www.hindawi.com/journals/ecam/2013/351062/
Health from the Hive: Potential Uses of Propolis in General Health. Eshwar, Shruthi, & Suma, 2012. https://www.scirp.org/html/1-2100265_19381.htm
Propolis: A natural biomaterial for dental and oral healthcare. Khurshid et al, 2017.
Effectiveness of Propolis on Oral Health: A Meta-Analysis. Hwu et al, 2014.
Honey for Nutrition and Health: A Review. Bogdanov et al, 2008.
Novel Insights into the Health Importance of Natural Honey. Ajibola, 2015.
Anti-inflammatory effects of Boletus edulis polysaccharide on asthma pathology. Wu et al, 2016. https://www.ncbi.nlm.nih.gov/pubmed/27830033
Edible Mushrooms: Improving Human Health and Promoting Quality Life. Valverde, 2014. https://www.hindawi.com/journals/ijmicro/2015/376387/
Lentinula edodes (shiitake mushroom): An assessment of in vitro anti-atherosclerotic bio-functionality. Rahman et al, 2018.
Consuming Lentinula edodes (Shiitake) Mushrooms Daily Improves Human Immunity: A Randomized Dietary Intervention in Healthy Young Adults. Dai et al, 2014.
Ancient Roman Viaduct and Olive Trees at Nimes, Provence, France, 2019.
Whilst on our 2019 learning odyssey in France we had the privilege to eat whole, real food from local markets and restaurants. It was a contrast to see how the French approached nutrition regionally, from Provence to the Dordogne, the Loire northward to Champagne. One theme ran through the whole adventure, a variety for food staples, solid and liquid, that cropped up time and time again, that of tradition and nature. These products are also grown, produced, and imported into New Zealand. I’m particularly interested in red wine, extra virgin olive oil, green tea, and beer. These featured in my journey then and continue to do so to varying degrees today. It would be of interest to travel through the literature, focusing on their health benefits and recommended intakes to achieve health benefits.
If we sip the wine, we find dreams coming upon us out of the imminent night. D. H. Lawrence.
I have a penchant for red wine, in particular, Pinot Noir orientated red Burgundy. I have tried others with a varying degree of favour, perhaps Syrah and Merlot come close as runner-ups. I’ve been intrigued as to what benefits a glass of red wine might afford, as there seems so much negative health labelling, true or false, about their use, overuse or abuse. Associated with this is the controversy of the French Paradox, where the French statistically demonstrate improved health and longevity despite regular consumption of wine with the additional and confounding controversy regarding saturated fat. My curiosity is not to justify my own behaviour but to know what, if the literature indicates, are the benefits and the safe and most beneficial amounts to consume would be. Would it change my behaviour and attitude if new knowledge was revealed?
The vineyards of Sancerre, Loire Valley, France, 2019.
Moderate wine consumption, in particular red, is a characteristic of the Mediterranean Diet, has been studied intensively for the health benefits it affords to those who have been brought up in its midst traditionally or they that modify their diet and lifestyle towards it. Red Wine is composed of mainly water, carbohydrates, organic acids, minerals, alcohol, polyphenols, and aromatics. Specific substances within wine have significant positive effects on modern non-chronic communicable diseases, with a particular interest in its antioxidant effects for cardiovascular function and disease, endothelial function, lipid regulation, anti-inflammatory potential, some cancers, diabetes and glucose metabolism, and blood pressure reduction in hypertensive patients. Bioactive polyphenolic compounds appear to be the predominant player, in particular resveratrol, anthocyanins, catechins, and tannins. Additional research indicates improvements in cognitive decline, depression, metabolic syndrome, osteoporosis, and gut bacteria.
Antioxidants, such as these, are found in abundance in red and purple berry fruits, the amount dependent on the variety, geographical location, time of harvest, maturity, and health of their growth. The richest red wine grapes are Pinot Noir and St. Laurent red wines. Resveratrol is a sirtuin activator, importantly benefitting and regulating nitric oxide, blood pressure, oxidative stress, and reactive oxygen species. Other antioxidants found in red wine are Flavonoids, rhamnetin, and malvidin, abundant in grape extract which elicits cardio protection.
Moderate red wine consumption appears to positively impact human health compared to abstainers with 5 to 15 grams a day associated with a 26 percent lower risk of cardiovascular disease (CVD) , a 35 percent risk reduction in total mortality, and a 51 percent less risk of CVD mortality, assuming intake was mostly red wine. Healthy intake is cause for much debate still, Sinkiewicz et al indicate that drinking three glasses of red wine every day had the lowest risk of cardiac events and mortality, also decreasing high blood pressure and myocardial infarction in men over the age of 65 significantly. Vilahor and Badimon looked at the Mediterranean Diet and red wine in association with cardio-protectivity suggesting daily red wine consumption of 0.15 litres for women and 0.45 litres for men, aiding reduction in inflammation, lipid metabolism, antioxidation, and endothelial function.
Wine is sunlight, held together by water. Galileo Galilei.
An interesting point for consideration is that is highly likely that red wine alone doesn’t solely contribute to health improvements, many confounding factors need to be considered, in particular with dietary and other lifestyle behaviours that positively and negatively contribute to health. It would be prudent to associate other beneficial foodstuffs like extra virgin olive oil to improved health outcomes. I had the opportunity to taste many gold medal samples in Lambesc, Provence, and was so impressed with the light, flavoursome taste and texture, and despite their price, I bought three sample bottles and stewarded them carefully back to New Zealand. What amount would constitute a health benefit and what are they?
Olives also possess bioactive polyphenolic compounds of various chemical structures, sourced from fruit, vegetables, nuts and seeds, roots, bark, leaves of different plants, herbs, whole grains, dark chocolate ( processed/fermented foods), as well as tea, and coffee. The health-promoting properties in olive oil including the antioxidant, anti-inflammatory, anti-allergenic, anti-atherogenic, anti-thrombotic, and anti-mutagenic properties. They are natural, synthetic, semi-synthetic organic compounds with over 8000 different polyphenolic structures known, several hundred isolated from edible plants. Unlike vitamins and minerals, polyphenols are not essential elements of primary plant metabolism but are the products of secondary plant metabolism that play critical metabolic roles in the human organism. The polyphenols of olive oil, however, are especially interesting for their well-established beneficial effects on human health and metabolism. The oils are obtained through mechanical and chemical extraction, and then are purified for additional refinement. Extra virgin olive oil (EVOO) is a more expensive, low yielding form, having a delicate flavour, aroma, and light colour, with a higher polyphenolic structure. It consists mainly of the fatty acid triacylglycerols (98-99 percent) with monounsaturated oleic acid making up to 83 percent of weight to weight. Other components include palmitic, linoleic, stearic, and palmitoleic acids.
The olive tree is surely the richest gift of heaven, I can scarcely expect bread. Thomas Jefferson.
Consumption of EVOO rich in phenolic acid compounds has been linked to the promotion of antioxidant and anti-inflammatory responses. A minimal dose of 5mg/kg/day, the equivalent of 23gms of EVOO, has been claimed to be protective by the European Food Safety Authority (EFSA), protecting against lipid oxidation. Polyphenolic compounds bind to low-density lipoproteins (LDL) and protect them against oxidation, higher levels of which are considered a strong predictor of CVD, widely associated with metabolic disease, obesity, type 2 diabetes, and metabolic syndrome. Schwingshackl & Hoffman also report from systematic and meta-analysis of cohort studies an overall risk reduction of all-cause mortality of 11 percent, cardiovascular mortality 12 percent, cardiovascular events 9 percent, and stroke 77 percent.
Linked to the Mediterranean Diet, the importance of olive oil consumption impacts blood glucose, triglycerides, increases in high-density lipoproteins (HDL), and the amelioration of the antioxidant and inflammatory status of subjects, with decreases in C-reactive protein (CRP), as well as risk reduction of metabolic syndrome and lower levels of inflammatory markers related to atherosclerosis.
I have always been a big fan of tea, being English it was part of my introduction to hot beverages as a child, slowing sipping it, and when too hot carefully blowing on it to cool it down. Until recently I haven’t been as keen, a major health event has changed how my body reacts to milk, its caffeine sending me on an unpleasant high and a rapid journey to the toilet. Coffee does me a similar disservice. A gentle evolutionary journey into green tea, in particular high-grade Jasmine, has however grown on me, be it hot, tepid, or plain cold it is now welcomed. My body also seems to tolerate it more too.
Green tea is made from the leaf of the plant Camellia sinensis. It is a species of evergreen shrubs or small trees in the flowering plant family Theaceae whose leaves and leaf buds are used to produce the tea. The chemical composition of green tea is a complex of proteins, amino acids, carbohydrates like glucose, fructose, and sucrose with trace elements of calcium, selenium, fluorine, aluminum, and lipids, vitamins, B, C and E with additional sterols, caffeine, and pigmentation. Green tea contains polyphenols, flavanols, flavonoids, and phenolic acids. Beneficial effects come reportedly from 3 cups a day, that being 8 ounces a cup.
A woman is a teabag – you can’t tell how strong she is until you put her in hot water. Eleanor Roosevelt.
It is said to possess anti-cancer, anti-obesity, anti-atherosclerotic, anti-diabetic, anti-bacterial, and anti-viral effects. These are related to the activity of epigallocatechin gallate, a major component of green tea catechins. Its natural caffeine stimulates wakefulness, decreases fatigue, and has diuretic effects. Theanine and y-aminobutyric acid act to lower blood pressure and regulate brain and nerve function. Ongoing research is looking into hepatoprotective and anti-diabetic effects and anti-metastatic and anti-cancer, anti-obesity, and anti-atherosclerotic effects.
Epidemiological evidence demonstrates that populations with a high intake of green tea catechin benefit from regulated and reduced body weight and fat, glucose homeostasis, and cardiovascular health. Human intervention studies have demonstrated improved glucose homeostasis gained from green tea catechins. In particular, in-vitro and in vivo research indicates better endothelial function and increased antioxidant activities and improved pressure control.
Beer is a “tasty beverage”, as a famous Hollywood meme would purport. I have a fondness for hazy beer but in comparison to red wine, olive oil, and green tea the evidence might suggest it to be the poorer cousin in terms of health benefits. The cliched image of the average beer drinker being overweight, and relatively unhealthy is one that needs to be challenged. I will try and advocate for a reappraisal of that perception.
Beer may bring some nutritional and medical health advantages. These include protein, B vitamins, and minerals like selenium and high potassium with low sodium, fibre and have antioxidants values equivalent to that of wine but specifically different in variety. Its antioxidant capacity is also related to its polyphenolic components with the benefit of blocking free radicals, decreasing significantly cholesterol and triglycerides in lager specifically, as well as improved lipid metabolism and increased antioxidant and anticoagulant activity. Further research suggests beer has the potential to aid stress alleviation with the additional effect of the hop derived bittering agent providing sedative and hypnotic benefits.
Beer, if drunk in moderation, softens the temper, cheers the spirit and promotes health. Thomas Jefferson.
Further research by a panel of international experts showed in a large evidence-based review the effects of moderate beer consumption of beer on human health. It indicated non-bingeing behaviour reduces the risk of CVD, that being 1 drink per women and 2 drinks per men, per day, similar to that of wine at comparable alcohols levels. Some observational studies have also demonstrated low to moderate consumption associated with a reduced risk of neurodegenerative diseases. In general, the research alludes to the benefits to human health coming from light to moderate consumption, originating from antioxidant, mineral, vitamin, and fibre components of beer, specifically in low or non-alcohol form.
The benefits of red wine, olive oil, green tea, and beer seem greatly associated with their effect regarding anti-oxidative and anti-inflammatory activities metabolically. Admittedly just looking purely at the health benefits and recommended intake is simplistic. It doesn’t take into consideration the negative health outcomes of alcohol over consumption. However, I do feel it was an appropriate approach to get a comparative snapshot of them all as beneficial fluid ingredients related to health. I would have considered both olive oil and green tea as a given but have learned more about the benefits that red wine and beer afford. It has also made me consider the relative health benefits of them all and amounts required for a health impact. I will continue to enjoy them all to varying degrees, and when in the mood, but am also more aware that they are a small part of a greater whole, in the improvement of our long term systemic and metabolic health.
Contribution of red wine consumption to human health protection. Snopek et at 2018. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6099584/
Alcohol, coronary heart disease and stroke: an examination of the J-shaped curve. Wannamethee & Shaper, 1998. https://www.ncbi.nlm.nih.gov/pubmed/9778595
Network meta-analysis of metabolic effects of olive-oil in humans shows the importance of olive oil consumption with moderate polyphenol levels as part of the Mediterranean Diet. Evangelia Tsartsou et al, 2019. https://www.frontiersin.org/articles/10.3389/fnut.2019.00006/full
Potential Health Benefits of Olive Oil and Plant Polyphenols. Monika Gorzynik-Debicka, 2018. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5877547/
The safety of green tea and green tea extract consumption in adults – Results of a systematic review. Hu et al, 2018. https://www.sciencedirect.com/science/article/pii/S0273230018300928
The Potential Role of Green Tea Catechins in the Prevention of the Metabolic Syndrome – A Review. Thielecke & Boschmann, 2009. https://pubmed.ncbi.nlm.nih.gov/19147161/
Mediterranean diet: The role of long-chain ω-3 fatty acids in fish; polyphenols in fruits, vegetables, cereals, coffee, tea, cacao and wine; probiotics and vitamins in prevention of stroke, age-related cognitive decline, and Alzheimer disease. Roman et al, 2019. https://www.ncbi.nlm.nih.gov/pubmed/31521398
Effects of moderate beer consumption on health and disease: A consensus document. De Gaetano, 2016. https://www.ncbi.nlm.nih.gov/pubmed/27118108
Wine: An Aspiring Agent in Promoting Longevity and Preventing Chronic Diseases. Pavlidou et al, 2018. https://www.ncbi.nlm.nih.gov/pubmed/30096779
Mediterranean Way of Drinking and Longevity. Giacosa et al, 2016. https://www.tandfonline.com/doi/abs/10.1080/10408398.2012.747484?src=recsys&journalCode=bfsn20
Potential Health Benefits of Olive Oil and Plant Polyphenols. Gorzynik-Debicka et al, 2018. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5877547/
Extra Virgin Olive Oil: Lesson from Nutrigenomics. De Santis et al, 2019. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6770023/
Monounsaturated fatty acids, olive oil and health status: a systematic review and meta-analysis of cohort studies. Schwingshackl & Hoffman, 2014. https://www.ncbi.nlm.nih.gov/pubmed/25274026
Olive oil intake and risk of cardiovascular disease and mortality in the PREDIMED Study. Guasch-Ferre et al, 2014. https://bmcmedicine.biomedcentral.com/articles/10.1186/1741-7015-12-78
Health-promoting effects of green tea. Suzuki et al, 2012. https://www.ncbi.nlm.nih.gov/pubmed/22450537
Beneficial effects of green tea: A literature review. Chacko et al, 2010. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2855614/
Health-Related Aspects of Beer: A Review. Sohrabvandi et al, 2009. https://www.tandfonline.com/doi/full/10.1080/10942912.2010.487627
The Fluid Aspect of the Mediterranean Diet in the Prevention and Management of Cardiovascular Disease and Diabetes: The Role of Polyphenol Content in Moderate Consumption of Wine and Olive Oil. Ditano-Vazquez et al, 2019. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6893438/
One can walk down any supermarket aisle and gaze in awe at the array of colourful, cleverly packaged and marketed dental health products. I have spent more years than I care to mention promoting their use to clients, many I now suspect wouldn’t have benefited from my sage advice. Upon consideration I’ve come to the conclusion it may have been smarter to have avoided them all together, in most cases, and trod a more prosaic path. Let me expand more upon reflection. From David Attenborough to Greta Thunberg, we are being actively, perhaps reluctantly, driven into an age of greater environmental awareness, or to be more honest it appears, a lack of it. The increasing urgency in preventing irreparable damage to the ecology of our planet, reducing global warming and protecting innumerable endangered species, us prophetically amongst them, the willing antagonist and unbeknownst victim, has gathered resonance, even amongst our clients and within our workplaces.
“Use the best available evidence resulting from scientific research, or if absent, strong theoretical rationale, suggestive evidence, or the opinion of respected authorities.” Section 20. Professional Standards Framework, New Zealand Dental Council.
There are now three principle aspects of sustainable practice in my clinical world, what I would term the glocal, the clinical and the oral. The glocal is the local and global environment, what we see in the present grass roots pressure groups and political movements championing the cause. Then we have our workplace and clinical environments, the materials and energy we consume and their carbon footprints from source. The oral model is the theoretical recognition that the ecology and habitat in which they dwell require similar ethical consideration, promotion and preservation. Should we continue to advocate a particular method of treatment that locally debrides the microbial habitat within our mouths? Should we learn to be less intense clinically, when in balance, when stable, and more collabotrative and aware of their potential dental and health benefits?
We “seek to provide to patients a holistic dental experience that is aimed at providing the best dental preventative care”. My Practice Strategic Draft Plan.
Picture the scene, of a mutually beneficial ecological balance, serving all who positively participate in its management. Imagine this within your mouth, it being seeded at birth, nurtured through the burgeoning early months and years of life where the landscape gradually grows and evolves. New hyper-mineralised structures erupt, in sequence, bringing with them hard surfaces ripe for colonization. Soft, rough and sleek structures shedding and sluffing, a mixture of gases flowing in and out, regular temperature changes, the ebb and flow of acidity, alkalinity and resident moisture, lubricating and assisting, in its function. Consider what dwells, lives and thrives within that place and its ecological potential for both dental and general health. Could there be a case for a similar, sustainable and environment movement in our mouths? Isn’t this what a dental healthcare professional should be focused upon when considering a holistic approach to care? My journey is to consider this in the context of this learning year, within the bounds of my present practice and professional standards.
Our oral microbiome (OM) is a natural structure and has a symbiotic relationship with us, the host, delivering important health benefits in sustaining a mutually shared ecological co-existence. We as humans form a super organism or “holobiont”, an assemblage of us with many other species living in and around us, forming one ecological unit. Less than half our body, approximately 43%, is human, being made up of 20,000 instructional genes, added to our microbiome of between 2 and 20 million microbial genes. We are home to 500-1000 species of bacteria at any one time, our body’s trillions of microorganisms making up about 1 to 3 percent of the body’s mass, that’s about 2 to 6 pounds per adult.
“What you see is that the most outstanding feature of life’s history is a constant domination by bacteria”. Stephen Jay Gould
Our mouth houses the second most diverse microbial community in the body, harbouring over 700 species of bacteria colonising hard and soft structures of the mouth. The OM is highly regulated, is structurally and functionally organised as a community. The oral habitat constitutes teeth, gingival sulci, a tongue, lips, cheeks, a hard and soft palate and attached gingivae, each offering the right conditions for a variety of distinct bacterial diversity to flourish. However, the modern day excessive consumption of acidic drinks and refined sugar, or cigarette smoking has deeply impacted upon this ecosystem and beyond.
The health of the oral microbiome has been studied to identify the causes of its dysbiosis, one is which the diversity and relative proportions of species or taxa within the microbiota are disturbed, leading to pathological changes. Research into preserved hunter-gatherer dental calculus has seen the shift from beneficial bacterial composition and declines in microbial diversity witnessed in Neolithic man. This has seen to further increase with the introduction of the modern industrial diet supplying greater amounts of more highly processed food and drink. The external environment with widespread and increased use of pesticides, heavy metals, antibiotics and antiseptics contribute significantly too . Consequently, the adaption of species that can develop defences against increased oxidative stress and resistance against acid production has prevailed. This negative change in the numbers and proportions of cariogenic and periodontal pathogenic bacteria has altered the competitiveness and encourages the selection of species best suited to this new environment. The dysbiosis of the OM is also associated with the detriment of general health.
In health the OM is beneficial to the;
An interesting example of how the OM support systemic health is in its supplementation of the hosts Nitric Oxide production. It helps reduce dietary nitrate converting it to nitrite, in turn having the potential to provide important symbiotic functions in human blood pressure physiology. Negative changes in the OM can increase blood pressure. The majority of these beneficial bacteria are found on the surface of the tongue, its cleaning appears to favour the increased metabolism and abundance of nitrate to nitrite production.
The flow of saliva is also a vital function to improving health affording benefits of;
In addition Saliva;
Saliva is a solution composed of 99 percent water, 1 percent electrolytes and proteins from three salivary glands being controlled by the autonomic nervous system. It has a flow rate of 0.4 – 0.5 ml per minute in healthy subjects. Healthy biofilms are associated with pH values of between 6.5 -7.5, this creates homeostatic and nutritional interdependency amongst bacteria. This in turn suppresses and restricts the growth of pathogenic bacteria. When acids are produced, the oral OM compensates by alkaline generation. Critical pH value begins at 5.5 when mineral begins to dissolve and loss occurs, above that value saliva and plaque are super saturated with tooth mineral with repair and remineralisation occurring as a result of bicarbonate buffering.
The stimulation of saliva flow is critical for oral balance in many situations from dry mouth to lower pH values. The use of non-nutritive sugar alcohol sweeteners like sorbitol, xylitol and erythritol can be consumed in a various forms, either in gum or lozenges, added to toothpastes or rinses and used in refined powder form in professional polishing devices clinically. They can also be purchased in granulated forms in health shops. Sorbitol and xylitol treatments have been seen not to affect microbial profiles of saliva and plaque in a 3 week study, with sorbitol increasing the amounts of commensal germs in comparison, effective in particular against Porhyromonas Gingivalis, a periodontal pathogen. However, In combination with erythritol xylitol has been seen to reduce development of cariogenic bacteria such a S. mutan.
Erythritol, a 4 carbon chained sugar alcohol, appears to offer more bacterial support. It is produced from glucose by a fermentation process and research demonstrates better efficacy than sorbitol or xylitol. It can afford;
Prebiotics are compounds found in food that induce growth or activity of beneficial microorganisms. Some species of commensal streptococci generate energy from arginine, an amino acid. The metabolism of arginine can lead to ammonia production that can help increase environmental pH. Ammonia is a compound of hydrogen and nitrogen. Many arginolytic bacteria produce hydrogen peroxide impacting on species associated with periodontal diseases. Probiotics, living microorganisms that deliver health benefits, have yet to have sufficient systematic review evidence to fully support its use dentally. There is little current evidence supporting the reduction dental caries but promising research in certain strains of Streptococcus has been found to express arginine deiminase , thus helping to inhibit the growth and block key functions of S. mutans, raising pH and producing bacteriocins that kill S. mutans. Additionally, small benefits are being seen in the management of gingivitis and periodontitis.
Am I simply a vehicle for numerous bacteria that inhabit my microbiome? Or are they hosting me? Timothy Morton
Simply eradicating all OM sub and supra gingivally, without exception, in pursuit of biological balance allows the onus on dental health promotion as being primarily focused instrumentally. This bellies the benefits of educational an ecological approaches, working in harmony with nature rather than obliterating it where it presents as healthy. Each and every oral health assessment needs to be mindful of the benefits of a balanced OM, not blinded by visual plaque levels but the degree to which it appears dysbiotic. Bleeding on probing on intra-oral examination and observing historical risk needs a blended approach with dietary and other lifestyle behaviour advice and management. This will require greater use of clinical time in communicating this environmental and sustainable dental message. Being more holistic in its nature, it can also embrace the broader general health benefits of the symbiotic relationships between host, saliva and OM.
The “Mouth is the gateway to the total body wellness, thus oral microbiome influences overall health of an individual”. Sharma et al.
I can envisage little resistance from many of my clients who have environmental values like myself. My workplace markets itself as being natural but I do anticipate discourse with colleagues as to my application of my interpretation of holistic and sustainable practice.
If you want to assert a truth, first make sure it is not just an opinion that you desperately want to be true. Neil deGrasse Tyson.
From the German 16th century Martin Luther to the Tolepuddle Martyrs of early 19th century Britain, there have been many human movements demanding change, calling for greater representation, challenging authority and creating opposition to the established norm. Such pressure groups range from the political and cultural to those championing causes from the environment, animal, religious and human rights to global public health. In this of late has a dental dimension, related to the contention of fluoridation of community water supplies. Rather that accepting the status quo and established public health agenda of imposing it on all the population without means of proper address pressure groups and activists have rallied to challenge its scientific validity.
In New Zealand, where I live and practice, 40 percent of 5 year old children have tooth decay, whereas only 27 out of 67 councils fluoridate their water supply and 54 percent of the population have un-fluoridated water. The adoption of water fluoridation nationally, in line with World Health Organisation recommendations, has become a highly contentious public health issue. Alleged negative outcomes of it range from the risk of reactive biological effects of water fluoridation, the dosages of which are up to 200 times higher than is found in mothers breast milk. It is perceived however, in the New Zealand national context to be beneficial due to lower than globally accepted levels of Fluorine, one of a many natural occurring chemical elements, in the native soil. The debate rumbles on beyond our teeth to other parts of the body, and into our professional learning needs as I hope this account demonstrates.
My clinical setting brings this strikingly into focus. I have a broad range of clients with differing opinions on fluoride, more so than I have ever experienced before. The client base is attracted to the “natural” philosophy of the dental practice where I work part-time. Many also show an active scepticism with respect to the myriad of additional products found in many toothpastes, beyond the well-known offenders, Triclosan and Sodium Lauryl Sulphate.
Fluoride is a negatively charged ion of fluorine and is one of the most abundant elements found in nature. Sodium Fluoride is an inorganic salt of fluoride used topically or in community water fluoridation programmes to prevent dental caries. Fluoride appears to bind to calcium ions in the hydroxyapatite of surface tooth enamel, preventing corrosion of tooth enamel by acids. This agent may also inhibit acid production by commensal oral bacteria. However, Sodium Fluoride is an extremely toxic substance, just 200mg of it is enough to kill a young child and 3-5gms, a teaspoon, is enough to kill an adult. The worldwide criticism of systemic fluoride stems from contention with “low margins of safety and lack of control over the amount of individual intake when administered on a community level.”
Who are the opposition? They appear to be well organised and motivated, mainly libertarian and environmental activists, the movement of which began in 1960’s and gained more strength as scientific research began to further support their philosophies. They critically claim that once fluoride is in the water supply it is impossible to control the individual dose and, that fluoride is found in other natural and “added to” products, like tea and mouth rinses, can increase that dosage increasing risk over time. The bigger argument alludes to the moral issues revolve around human rights, mass medication, informed consent necessary to comply ethically for prescriptions of all medication. This is the reason most Western European countries have ruled against its use. The lines are drawn between the “official” evidence, its interpretation and determination as to its veracity within the a given country’s political and social context.
The party line is represented by the scientific community such as the established and renown Centre of Disease Control and Prevention (CDC) in the US. They state that “Fluoridation of the community drinking water is a safe, cost effective and efficient strategy of reducing dental decay among Americans of all ages and from all social strata”. The CDC maintains and attributes a steep decline in tooth decay in the US to fluoride, whereas the lobbyist perspective is that disease rates are globally reducing despite the wide distribution of fluoridated products. They assert that serious research attributes improvement with fluoride as only between 40% – 50%.
The anti-fluoride lobby arguments continue beyond teeth:
The related long term health effects of water-fluoridation is the greater bone of contention with my clients. They are well informed in this matter and their fundamental discord with this element extends in some to the belief that topical fluoride is a problem too.
To add fuel to the smouldering fire The Cochrane Collaboration, a robust, renowned critical scientific organisation looked at 20 studies on the effects of fluoridated water on tooth decay and 135 studies on dental fluorosis. They published the results in 2015. They concluded that “all results are based predominantly on old studies and may not be applicable today. Within the ‘before and after’ studies we did not find any on the benefits of fluoridated water for adults” but there was “insufficient information about the effects of stopping water fluoridation”. They also found “insufficient information to determine whether fluoridation reduces differences in tooth decay levels between children from poorer and more affluent backgrounds”. “Overall, the results of the studies reviewed suggest that, where the fluoride level in water is 0.7 ppm, there is a chance of around 12% of people having dental fluorosis that may cause concern about how their teeth look”.
When reviewing the considered opposition to fluoride I am bewildered by the lack of academic dental advocacy for water fluoridation to counteract them. Those who choose to face educated and fundamental opinion, from well-read academics to informed members of the general public. I also feel, upon reflection, that I have never been fully conversant with all the facts upon consideration. New truths revealed can pose a dilemma to professionals who hold to established doctrine.
How deeply would we go down the rabbit hole of confronting our knowledge gaps? Do we solely rely on the dental industry, who cleverly veil their commercial interests by support professional bodies financially and at the same time promote the benefits of their products, with verifiable education? Are we really serving our client community and their need by paying lip service to what we are promoted to learn? A deeper awareness of their attitudes towards alternative approaches and concepts, alternative oral health products should be engaged with, free of judgement. Some may be persuaded by radiographic or visual evidence of a need to change their oral health habits in the direction of conventional methods like the use of topical fluoride clinically or at home. Conversely, a caries free mouth, demonstrably managed and maintained requires us to think differently in our approach to their support. What have they done to achieve that and what can we learn from it?
Being wedded to our belief system doesn’t make us right, we maybe the product of our initial and ongoing dental education. But by questioning everything, not relying on lazy face value attitudes, reflecting on our own and another’s stand point drives enlightenment and ultimately action upon it. The a result of new knowledge gain is enlightenment, and is ongoing. In the bubble of my clinical culture here in Nelson I would continue to be guided by evident clinical risk and need but also a policy of treating not just what I see but who I see. I would also advocate for associated lifestyle and nutritional behaviour change if indicated. The obvious “big elephant in the room” is the need for high quality oral health education, effective saliva function, beneficial bacteria predominating, fermentable carbohydrate restriction and control.
As the food supply historically evolved it has negatively deviated from ancestrally orientated diets to less nutritional and more simple carbohydrate loaded foods, which in turn play to addictive eating behaviours. The dawn of the modern diet, championed by “experts in the field” of nutrition after the last world war, has led to an increase in chronic communicable diseases, like dental caries. Some even suggested that decay in teeth was a so called” nutritional “side effect” of a healthy diet composed mainly of carbohydrates. Fluoride it seems was the answer to this condition.
Dental health education, in the form of better oral hygiene, nutritional advice and the use, where necessary of topical fluoride is championed loudly by the opposition as an alternative to needless and ineffective water fluoridation. I was pleasantly surprised that they were more supportive of what I champion as a dental healthcare professional. I was deeply disappointed that the proponents of water fluoridation weren’t advocating for these measures in as much magnitude.
We must never forget who benefits from continuing professional development, our clients first and foremost, their safety and health are our primary concern and how we attend the need of updating that knowledge is a sacred truth, where does it come from, who is delivering it, want is their intent, and how do we interpret it? I fall on the side of healthy scepticism regarding water fluoridation, it’s safety and benefits as a result of this inquiry. I will continue to propose the use of topical fluoride in those who have “at risk” lifestyle behaviours and nutritional choices less than optimal for stable oral health. I will give support to those who continue to refuse to use fluoride products with options and advocate behaviour changes that afford a similar outcome to topical fluoride use.
1. Water fluoridation to prevent tooth decay. 2015 https://www.cochrane.org/CD010856/ORAL_water-fluoridation-prevent-tooth-decay
2. Potential fluoride toxicity from oral medicaments: A review
3. The Untold Story of Fluoridation: Revisiting the Changing Perspectives
4. FIRST NZ Fluoride Debate EVER With Dr. Paul Connet
5.The Fluoride Debate: The Pros and Cons of Fluoridation
6.The Case Against Fluoride, Paul Connett in New Zealand 22Feb2013
When I first qualified as a Dental Hygienist in 1988 the thing that gave me to most clinical trepidation was treating Periodontal Disease (PD), despite my training. I can recall my very first case as a green “rookie” hygienist they were young, a heavy smoker with established disease which was active and unstable. I did my best instrumently, following my training, and when I reviewed them, a few weeks later the resolution and repair I witnessed was astonishing. I felt quite proud of my efforts but was crestfallen to learn they had had a prescription for antibiotics for a separate health condition in the meantime. My dentist gently alluded me to the fact that my treatment alone probably wasn’t entirely responsible for the startling outcome. It became very apparent to me that the systemic benefits of medicine had enhanced the patients host response and had significantly aided his dental disease recovery. This systemic “assistance” made me reflect at quite an early stage of my career, in the complexity and ingenuity of the immune system.
Globally, PD is the sixth most prevalent disease affecting over 11% of the world, rising by 57.3% from 1990 to 2010 1. Periodontitis is a major cause of tooth loss in adults, in particular the aging population and vulnerable sections of society 2, 3, 4. The New Zealand population study, undertaken in Dunedin, indicated that untreated adult gum disease in adulthood is associated with negative childhood low economic status 5. PD is classed as a Non-Communicable Disease (NCD) and shares social determinents and risk factors with other NCDs that cause about two-thirds of causes of death such as heart disease, diabetes, cancer, as well as, more topically, respiratory related diseases 5.There is a growing body of evidence that the effects of PD reach beyond the oral cavity with bacteria and associated inflammatory by-products systemically travel from the point of origin to other parts of the body, helping, over time, to initiate various NCDs. The loss of teeth due to the PD process affects mastication, likely changing dietary habits as a consequence to a more sugar and fat based diet and less fruit and vegetables. In turn this has the potential to increase the systemic inflammatory burden further by increasing the degree of PD, tooth decay, and possibly increasing further risk of NCDs 6.
The mouth has often been described as “the window to general health” with oral systemic health, of late, being seen as the connection the oral cavity and health with overall health. The mouth hosts a unique population of microorganisms numbering between 500 -700 7. The quality of individual oral hygiene significantly impacts how they organise themselves culturally and ecologically, with better maintenance allowing beneficial varieties to thrive and dominate. This is balanced by products found in the oral cavity being regularly bathed by a complex of components from saliva and, from between the tooth and gum, crevicular fluid, both playing an important natural role, mediating and balancing the oral environment 8, 9.
Much research has investigated the relationship between PD and cardiovascular disease (CVD) and has proven diverse and varied 10, 11. CVD is amongst the most common medical problems globally, being responsible for the 33% of deaths in New Zealand and 30% in the USA 12, 13. Oral inflammation, from gingivitis, opens the systemic pathway for pathogenic bacteria to travel to blood vessels elsewhere in the body where they can cause inflammation and damage to arterial walls. The remnants of oral bacteria can be found within atherosclerotic blood vessels far from its origin in the mouth. An alternative theory is that the body’s inflammatory immune response sets off a cascade of vascular damage throughout the body, including the heart and brain. They may also be no direct connection between CVD and PD, and the process maybe mediated through other factors like smoking, negative lifestyle choices, genetics and poor nutrition 14. A large cohort study in 2018 observed nearly 1 million people in Korea of a variety of ages from 30. The conclusion demonstrated the relationship between poor oral health and coronary heart disease risk was confounded by smoking, making causation indeterminable 15.
Pulmonary diseases like pneumonia, chronic obstructive pulmonary diseases and chronic bronchitis bring bacteria from the mouth via the oropharynx into the respiratory tract 14. The immune-compromised who are critically ill and intubated are at risk from bacteria seeding of the lower respiratory tract. Multiple intervention studies have shown that improving the oral hygiene of ventilated cases decreased the risk of ventilator associated pneumonia 16, 17. Aligned with this, evidence that poor dental health is causal in such conditions is at present inconclusive, where institutionalised and ventilated patients are at high risk, those with improved oral hygiene has indicated a positive outcome to their systemic health 18. This research requires careful consideration and appropriate action regarding oral health messages given to institutions nursing and treating risk populations during flu outbreaks and the present COVID 19 global epidemic.
Diabetes is a disease of disrupted glycaemic control resulting from a lack of insulin (type 1) or systemic insulin resistance (type 2)19. Their share a bidirectional association with PD. It negatively impacts oral health but also, conversely, glycaemic control and those affected with diabetes can be up to three times a greater risk of PD than those who aren’t. Those who have well controlled diabetes comparatively have no increased risk 20, 21.
Obesity is a chronic disease affecting 42.8% of middle-age adults, is closely related to several other chronic diseases, including heart disease, hypertension, type 2 diabetes, sleep apnea, certain cancers, joint diseases, and more. Obesity is defined as excessive body fat in proportion to lean body mass, to the extent that health is impaired. It is associated with chronic low grade inflammation and both local and system oxidative stress, in which it links to PD in oral health 22. Clinical PD studies reveal significant correlations with body mass indices, insulin and lipid levels and oxidative stress markers 23.
Our systemic health can be measured, in part, by looking more closely and specifically at metabolic risk factors that includes obesity, insulin resistance, hypertension and dyslipidaemia. If these factors are dysfunctional, it is termed as Metabolic Syndrome (MetS) and is often characterized by oxidative stress, a condition in which an imbalance results between the production and activation of reactive oxygen species. MetS is thought to play a major role in the pathogenesis of a variety of human diseases, including atherosclerosis, diabetes, hypertension, aging, Alzheimer’s disease, kidney disease and cancer 24. MetS allows the a pro-oxidative state in periodontal tissue, altering antioxidant defence mechanisms, affecting its response against bacterial plaque attack 25. The components that are most closely related to the risk of periodontitis are dysglycaemia and obesity, but less from atherogenic dyslipidaemia and hypertension, with a risk of increase linked to more MetS components in an individual. However, due to the cross-sectional nature of studies, a direct relationship can’t as yet be established. However evidence suggests that a reduction in serum inflammatory mediators can be achieved through successful periodontal therapy 26. A recent systematic review and meta-analysis reinforces the association between MetS and PD demonstrating a 38% greater likelihood amongst at MetS sufferers to present with PD in relation to those who without 27.
Dental professionals can play a key role in promoting avoiding or reducing the risks to individuals with MetS. Moving from a poor diet of foods with high glycaemic index (GI) towards nutrient rich, high fibre food like fruit and vegetable, as well as maintaining good oral hygiene is fundamental for individuals with MetS. This also has a positive role on affect to improving heart health, reducing tooth loss, which in many alter masticatory function and promotes poor dietary choices 28.
It is important for dental healthcare professionals to understand the oral-systemic links to improving dental health in our patient populations, especially in our present COVID 19 era and oral hygiene recommendations to at-risk groups. I predict we will also soon see an increase in the knowledge base of the significance of the mechanisms of MetS beyond dentistry into the realms of general health. But to understand MetS better we need to take a journey with free thinking fellow healthcare professionals, key influencers, and protagonists involved in the emergence of this key medical field. This will be the theme and feature of part 8b.
So, to conclude, our current knowledge base from the preceding decades of my first clinical journey into PD to the present has and will continue to evolve. This growing body of research has enhanced the awareness of the links between PD and systemic health in general, but more importantly appropriate specific oral health interventions that can improve health outcomes. I feel the moment will soon come when as allied health professionals we will better combined, collaborative and successful approaches to the treatment of the NCDs.
“We can now visualize our universe, its light, gravity and heat, its seasons, tides, and harvest, which prepare a habitation for the universe of vital forms, microscopic and majestic, which fill the oceans and the forests. We have a common denominator for universes within and around each other, our world, our food and our life have potentials so vast that we can only observe directions, not goals. We sense human achievements or ignominious race self-destruction. Every creed today vaguely seeks a utopia; all have visualized a common controlling force or deity as the most potent force in all human affairs. Yes, man’s place is most exalted when he obeys Mother Nature’s laws.”
Weston A. Price.
Have you ever heard of name the Weston A. Price in relation to your dental training or current practice? In all of my 30 plus years in dentistry I must confess, until recently, I hadn’t. My first exposure to him occurred during a visit to a highly recommended Chiropractor. He was fairly alternative, as was Price’s reputation, but respected highly by the person who recommended me to him, my Principal Dentist. Talking to and researching their website brought my attention to Price and the practitioners mistrust of fluoride. The warning bells were ringing loudly but in conversation with him I began to reappraise my position and reconcile the biases and controversy related to his work, and reflection on them. If you claim to be a holistic practitioner you, I hope, would be well versed with Weston A. Price’s work, just as, if you were a nutritionalist, you’d be aware, as well, of the controversial academic and scientific work of Ansel Keyes.
If you carefully delve into the dental literature and research you will find it very difficult, if not almost impossible, to uncover anything related to Price. Ironically, the research and publications he undertook in the early decades of the 20th Century, a revolutionary and controversial book published in 1939 revealing his theories on subjects from root canal treatment, soil health, sacred foods to the development of the face and jaw can be found elsewhere. His work is seen by some as the forefather of the popular Palaeolithic dietary and Low Carb nutritional movements with echoes extending to progressive oral health approaches in the treatment and preventing dental diseases like caries and periodontal diseases. Much, if not all of this work hasn’t been in the curricula of dental schools but now appears to be in the headspace of alternative medical, nutritional and some dental practitioners. Interestingly, the New Zealand Dental Council includes the phrase “holistic” in approaching treatment in its guidance for professionals and encourages collaborative engage with fellow healthcare professionals as part of our practice standards. It appears that the times are changing so let’s dig a little deeper into this subject.
“Life in all its fullness is Mother Nature”. Weston A. Price.
Weston A. Price ( 1870 -1948 ) was born in Ontario, trained and graduated at the University of Michigan as a dentist in 1894. He set up his first practice in the same year but feel ill with Typhoid shortly after. His health was severely affected and a period of convalescence brought him to the realisation of his future higher cause. He decided to direct his attention to the study of the “healthy traditional cultures all over the world”. This was further and tragically enforced by the death of his only son, 9 years of age, from heart related issues, after Price root treated a tooth. This may have also brought the birth pains of the focal theory of infection to his attention. This theory proposed that infected teeth should be treated by dental extraction rather than root canals, to limit the risk of more general illness. He spent 25 years working and researching with endontically treated teeth which lead to the publication in 1925 of Dental Infections and related Degenerative Diseases. Price’s next publication Dental Infections, Oral and Systemic was used as a reference in textbooks and diagnosis guides published in the mid-1930s. Both contributed to the widespread acceptance of the practice of extracting, rather than endodontically treating, infected teeth. By the mid-thirties his work was widely challenged and fell out of favour. Needless dental extractions were seen as too extreme when infected and diseased teeth could be restored and masticatory units maintained. Ironically, as we know now, the foods we eat need molars and other teeth to break down and allow not only passage through the digestive tract but also to gain maximum nutritional value from it. Without teeth, be they unrestored or not, we don’t fully, nutritionally benefit from what we eat. Efficient digestion requires the food be well masticated. His focus soon aligned to the subject of traditional nutrition of communities uninfluenced by modernity by began a global learning journey to ascertain whether the “health of the body is reflected in the health of the teeth.”
“Tooth decay is a symptom, not a disease… it is evidence of faulty nutrition”. Weston A. Price.
In 1939 Price published his now seminal book “Nutrition and Physical Degeneration” and claiming that “eating a nutritional dense diet of whole foods, grown naturally in healthy soil and prepared in a traditional method” producing “nourishing and digestible foods enabling them to build strong and healthy bodies, sustainable over generations.’ His work led him to the conclusion of the power of “sacred foods”, such as “unpasteurised dairy foods, offal, pasture fed animal, seafoods, in particular fish eggs, cod liver oils, fermented foods like sauerkraut, kimchi, kefir and animal fats”. The lack of which, he believed, led to “dental caries and deformed arches, resulting in crowded, crocked teeth was a sign of physical degeneration as a result of suspected nutritional deficiencies”. This was due to his close observation and critical study of isolated communities around the world in that period of time. Price, it is noted, used chemical testing of soil, food quality and the prodigious use of photography in his work. He observed what he described as disease free indigenous populations with “straight teeth”, “stalwart bodies”, “resistance to disease” and “fine” characteristics, associated with their traditional, nutritionally dense diets. Interestingly too, Price also alluded to an unknown but healing component which he defines a “Activator X”, found in butter oil. Price concluded that butter, which was produced from rapidly growing grass in the spring, had higher “Activator X” levels than butter produced during the rest of the year. This “vitamin like activator” was to be better understood, after the Second World War, as Vitamin K1. He also deduced that modern processed foods lacked this and other essential vitamins and minerals due to modern food processing effects.
“For humanity to survive it must eat better – foods must be whole, fresh and unprocessed.” Weston A. Price.
Price’s detractors cite poor observational analysis, a simplistic scientific approach and confirmation bias. They claim, also, that he ignored native people who weren’t healthy, and that those who were in contact with European and modern civilisations were affected by diseases unfamiliar to them historically. They claim, with their own confirmation biases, that modern food is wholesome but native people “overconsumed” and didn’t balance their diets correctly. As a consequence they had higher rates of disease. Sound familiar? Isn’t this the same as what is said of the increasingly obese populations in todays society? This will be discussed in detail in a future post regarding metabolic health, but the burgeoning shoots of its importance begin here.
“The most serious problem confronting the coming generations is the nearly insurmountable handicap of depletion of the quality of the foods because of the depletion of the minerals of the soil”. Weston A. Price.
Let us look further back than Price’s influence on the nutritional debate, but perhaps something he may contend today is as important, that of our very distant ancestors. Fossil records go back nearly 14 million years with Ramapithicus, found in Africa. Our cave dwelling forefathers evolved over time in different habitats, with different foods, and began to migrate north living and eating seasonally, working in communities to hunt and gather foods, designing tools and weapons, working in teams collaboratively to achieve their nutritional necessities. In the mid 20th Century different hypotheses examined the changes in nutritional cultures, meat eating, seed eating and, in particular, the Extensive Tissue Hypothesis which related brain and gut size in human evolution. The control of fire, the preparation of starches and meat led to increases in the energy gained from food in comparison to the raw form. The cooking process increased digestion, higher blood glucose, the energy gained through this process increased it by nearly 30%. 1. Interestingly too, the human microbiome, a mass of trillions of bacteria, is also responsible for 6-10% of daily energy supply, creating short chained fatty acids, hormones than regulate hunger and satiety and vitamins, in particular, B6 and B12, passing via the gut lining into the blood supply. The microbiome has now become a subject of scientific research and its presence into oral cavity cannot be under estimated in its role in digestion and oral health. It is observed that the modern human microbiome in comparison to apes, monkeys and chimpanzees is far less diverse.
“Don’t eat anything your great-great grandmother wouldn’t recognise as food”. Michael Pollan.
What we know, as a consequence of the research of many, including the likes of Weston A. Price, is the importance of nutritional behaviour in the prevention and treatment of dental caries and periodontitis. The optimal function of the body’s host defence system is dependant upon an adequate supply of anti-oxidant micro-nutrients. 2. Micro-nutrient anti-oxidants are important for limiting tissue damage but also decreasing prolonged inflammation. Reducing periodontitis is associated with a reduction in HbA1c, a test measuring your average blood glucose over 2-3 months and gives an indication of your longer-term blood glucose control. Reducing blood sugar is also associated with reductions in death related diabetes and myocardial complications. 3.
“An adequate, well balanced diet combined with regular physical activity”. World Health Organisation, Definition of Nutrition.
Oxidative stress or oxidation is a damaging activity caused by attack from free radicals. Nutrients called antioxidants help the body’s natural defence system combat this process. A variety of anti-oxidants including vitamins, A, C, E as well as minerals like Selenium and Zinc are found in fruits, vegetables, nuts, sees, oily fish and whole grains. Vitamins D2, from food sources and D3, from sunlight are vital, along with calcium, for bone health and repair. It is seen to benefit older age groups, beyond 50 years. 4. Other studies indicate a 20% likelihood of less tooth lose with sufficient Vitamin D blood levels and 14% less likely to lose teeth over 5 years. 5, 6.
“Fermentable carbohydrates are the most relevant common dietary risk factor for caries and periodontal diseases” state Moynihan and Petersen (2004).7. Vitamin C depletion can lead to profuse gingival bleeding, known historically as Scurvy. Periodontal diseases demonstrate lower serum Magnesium and Calcium levels as well as lower antioxidant micronutrient levels. 8, 9. Using Vitamin D supplementation combined with Calcium has been shown to reduce risk in the elderly. 10, 11. The concentration and bioavailability of carbohydrates and starchy foods and the lack of Vitamin D, K and Calcium in the developmental growth of teeth increase the risk of dental caries. 12.
“Let food be thy medicine.” Hypocrates.
Upon reflection of this it is advisable to create a guide for my clients regarding what will benefit healing and repair of dental diseases nutritionally. This I did in the light of an authentic learning project undertaken in 2017 but does it require updating? I would consider a deeper dental orientated nutritional discussion with all clients who have active periodontal disease, including bleeding on probing over 10% with no attachment loss. This would include supplementation of Vitamin D and Calcium with an additional emphasis on an anti-oxidant rich diet and a significant reduction in fermentable carbohydrates. I’d consider, in severe cases, advising them to test for serum Vitamin D levels and advise exposure to a recommended level of sunlight too, depending upon the season. In the case of dental caries in the light of no new knowledge, I would continue with a reduction, cessation where possible, and regulation of fermentable carbohydrates. The onus on oral health improvement measures with both diseases are multifactorial, not just purely nutritional, but it does, however, play a significant role in both.
“Going against the principles of nature does nothing but harm for us, the animals and the environment”. Weston A. Price
Weston A. Price, I believe, was a principled and holistically minded individual worthy of study and attention. The mantle for his ancestrally linked nutritional improvement for better health has been handed over to many others, books written, careers changed, lifestyles altered for the better and his legacy continues. I have learned to put his cannon of work into the context of time and his life experiences. I won’t judge him too harshly on what we know where he was incorrect but will maintain and protect the best intentions and knowledge gained from his work. He attracts and continues to influence those who associate good nutritional behaviour with better environmental practice and those who hold the values of our ancestral nutritional legacy in line with their belief in nature.
From April 2021, to gain recertification as a Dental Hygienist, I am required to create a Professional Developmental Plan (PDP) that lays out my learning and developmental aims and goals for my regulatory board. It, the New Zealand Dental Council (NZDC) has changed the criteria for Dental Healthcare Professionals (DHP) in line with many other regulatory organisations to add depth and quality to continuing professional development (CPD), involve the learner in educational attainment work directed towards their workplace culture and environment. In addition to these a Professional Peer (PP) will be required to act as a mentor, advocate and overseer of this process combined with a personal written reflective practice of Professional Development Activities (PDA). The process of that is demonstrated in figure 1.
Fig 1. GDC UK reflective cycle for PDA’s
In this account I wish to look backward on the previous year, starting April 2019, as the beginning of the new cycle, as the initiation of my PDP. Then account for the learning undertake from then to the present and consider the current situation with COVID 19 disrupting clinical practice for non-essential care. This is also, paradoxically, a great opportunity to consider where you presently are professionally and where you feel you want or need to go in planning you learning journey. Historically I had created a PDP and record on it my PDA when I was studying at The University of Kent several years ago. It is something I lost touch with coming to New Zealand in 2013 but having prior knowledge of it has led me back to my archives to dust off the means of recreating them.
I hope It will indicate where I have been and will go with my learning journey, a part of which is completed, another disrupted and future activities I propose based upon the consequences of world and local events and changes of practice setting and culture.
When choosing goals I look at the NZDC standards framework guidance, feedback from clients and colleagues, appraisals from employers and management. Give consideration to non-clinical aspects of practice too, leadership, communication, research and teaching skills may form ideas for learning objectives. Prioritise, if possible, your goals in order of importance or in a time line (authors note). The various methods of achieving learning objectives include conferences be they regional, national or international, the setting whether online learning or workplace training or shadowing. You could also create your own learning journey, focused on your needs where they can’t be met more formally. Authentic learning and action research, similar to inquiry learning can offer self-directed alternative approaches to new claims to knowledge and more meaningful first personal development in addition to convention education.
Fig 2. PDP log
My practice culture and status over the last year has changed, from a general dental practice setting to a mixed but mainly orthotropic – arch expansion – orthodontic setting with 3 orthodontic auxiliaries, 1 dentist, 3 Dental Assistants, a Manager and Receptionist. The COVID crisis has seen the practice shed a dentist and Dental Assistant. The move from Blenheim to Nelson has seen a role shift into a new dimension of dental hygiene with a greater onus on a strict regime of infection control, being less liberal than the previous practice by some margin. My learning goal became one of catching up. Prior to starting work in my present location, as can been in figure 1, I was engaged in an epic 9 week overseas sabbatical, see “experimental Learning 19” menu and a reflections related to it.
I constructed a way to present it through a website portal. I used WordPress to create a website that could additionally support the goal setting, evidence gathering and writing. Getting the right themes and menus has been a challenge, the intricacies of knowing how to create pages and posts, how to tag and edit, insert pictures and keep up with new ideas and technical challenges has been rewarding and, at times, a little stressful. Potentially It could be a good device for colleagues to adopt if so inclined as a simple way to demonstrate compliance, development and transparency. Below are two links, created by the same person on how to go about creating one.
It was my intention to develop my role in my current practice by travelling to Melbourne to complete a course in Oral Myofacial Function so I could evolve my practice and create my clinical time. This was cancelled due to the COVID 19 crisis and there appears to be little future prospect of undertaking it in the foreseeable future and, in effect, it is on hold. I am presently considering how I move forward with my PDA goals and have come to the conclusion that writing about topics that interest me, that are linked to my workplace and the future recertification process can take precedence for now. My colleagues have advised me on CPD topics related to orthotropics and oral myofacial function but I’ve decided to engage those when the current Alert state reduces and I have the inevitable clinical white space at work. The opportunity to focus on professional writing has been extremely rare, until now. Below are two links to those subjects which will be added to the PDP shortly with a duel reflection and discussion with my professional peer.
During my first few months in Nelson I began to realise, very quickly, that many of my clients were fairly “alternative” and investigative in their approach to subjects like fluoride and nutrition. There were also a cohort of clients interested in environmental issues and sustainability. This made me consider my approach to that as well. In comparison to Blenheim cliental where I continued to work as a locum for two days of the week, this posed a living paradoxical challenge. The contrast between the two client bases was stark both in terms of their dental knowledge and expectations of the nature of my delivery of care which make me reflect. One I was cosy with, having worked there for several years and the other new. I had to move deeper into researching and investigating their positions on it, enquiring as to the nature of their research undertaken which, on many occasions was diametrically opposed to my own indoctrination, experiences and beliefs. I was curious and willing to listen, to understand without judgement and I was careful to recognise and affirm other people’s positions, and offer tailored alternative advice or options, especially regarding topics like nutrition and fluoride.
Moving forward, we still await the proposed changes to recertification to be officially confirmed. The NZDC response to the COVID crisis has allowed the professional to breathe a sigh of relief regarding compliance to the strict verifiable CPD hours. This allows an opportunity for all to reflect on the PDA and future educational goals with the time created by the lockdown. This is exactly what I’m doing, I have a project, begun last year to complete, I can continue on the theme of changing practices and direction within the new one, displayed via a website online for the sake of transparency. It also demonstrates my learning journey for others to view and to comment on and promotes my passion for self-directed, appropriate and authentic learning as a juxta-position to the norm.
“A competent Dental Hygienist understands current biological, physical, cultural, social, and psychological factors involved in dental and oral disease, and in attaining and maintaining oral health.” NZDC, Scope of Practice for Dental Hygienists
Dental Hygienists are called, under a set of professional guiding standards, by the New Zealand Dental Council (NZDC) in their daily clinical and professional practice approach. They include putting our patients interests first, ensuring safe practice, communicating effectively, providing good care and maintaining public trust and confidence in the dental profession.
The NZDC also provides a legal Scope of Practice (SOP) document for Dental Hygienists in New Zealand, that compliments the Standards by guiding the practitioner to the boundaries of clinical activities pertinent to their specific qualifications. This demonstrates what is determined as “Best Practice” by understanding current scientific knowledge and skills, attitudes, communication, judgement and demonstrate a commitment to real health promotion.
“Enable patients to maintain and enhance their individual well-being by increasing their awareness and understanding of “health matters”. NZDC Standards Framework Document section 22.
The Dental Hygienist has a legal commitment to follow the NZDC’s continuing professional development (CPD) 2 year recertification cycle presently by completely and being able to demonstrate compliance through a portfolio of evidence, if required. The Framework Document and Scope of Practice aligns the clinician with what is deemed necessary to do to achieve future recertification, as well as, of course, paying a practice certificate fee. The cost of that to a New Zealand Dental Hygienist is not unsubstantial, in fact far cheaper than that of a UK Hygienist, and very near to want a practising general Dentist has to pay. 1.
The recertification process has recently come under scrutiny by the NZDC when in February of this year a summary of the key features of a final design for their new recertification programme was published and disseminated to the registered body. It has been the subject of focus group attention for several weeks prior to the approval of its principles. We await the final draft details but in the meantime we can posset its incarnation and comparison with the same outcomes that Dental Professionals have adopted in the UK in 2018. I find it interesting that the NZDC derives their inspiration for such change from UK and Europe, once again. Interestingly though it appears they have done things a little differently and, it seems to me, slightly better. Perhaps this alludes to the historic and cultural differences between practice cultures in New Zealand and the UK, as well as the size of the professional populations of both countries.
“Will attending the course change the way you think, or carry out your role in your practice?” Postgraduate Medical and Dental Education for Wales, UK
The key features of the new design include the creation of a Professional Dental Plan (PDP), Professional Dental Activities (PDA’s) replacing the present learning title of CPD , annual online self-declaration to the effect of completion or attendance, a Professional Peer Relationship (PPR) and written reflective practice. These are radical departures from what is presently the norm and the will come into effect, it is reported, from the 1st April 2021. All the above components are found at the General Dental Council (GDC) of the UK with minor nuanced changes from 2018. 2.
The roots of changes in the UK stem from the need to identify and develop personal professional skills, in line with your present skill set and workplace environment. The PDP allows you to track and achieve those goals. A degree of flexibility and review of your learning journey is set into the PDP criteria and is further boosted by the critical and supportive input of a skilled and qualified mentor, in the UK case and, here in New Zealand a Professional Peer (PP). The PP “must be able to provide knowledge and credible feedback relevant to the practitioners professional development”. The New Zealand method is more personal, it can be one on one, via teleconferences or by email. The responsibility of the clinician/professional peer relationship is further emphasised by official confirmation that “before a practitioner applies for an Annual Practising Certificate (APC) each year, the PP will need to provide confirmation online that the practitioner has interacted with them during the year, has a PDP, participated in PDA’s and has reflected in writing”. The PP can also assist in developing and reviewing PDP’s and assist in PDA developmental choices.
“Fail to plan and you plan to fail.” Benjamin Franklin
Primarily though, it allows the clinician learner the ability, responsibility and accountability of self-directing their own knowledge creation. There are a variety of sources to effect meaningful learning. Traditionally we as a professional body have leaned heavily upon the local professional study groups and associated learning events. The annual professional body seminars, Dental Trade Industry (DTI) sponsored events and roadshows are traditionally well trodden sources of knowledge. There is a cost element attached to belonging to associations and paying for events, mollified by the DTI to some extent, more so in the recent years. This brings into focus the issue of PDA’s being overtly linked to commercial interest, in part, where the industry is in direct contact and potentially influencing decision making of professionals. Historically the DTI has been on the fringes of conferences and meetings but now appear to be more directly involved in providing CPD. This is effectively brought to the attention of the discerning clinician by Gillis and McNally (2010) who state “University-industry relationships are becoming increasingly common in academe. While these relationships facilitate curriculum relevance, they also expose students to external market forces”. They continue, “Industry’s presence in academe is a concern. Dental educators (and dental health professionals from 2021 – author’s note), as stewards of the profession, must be nimble in brokering industry’s presence without compromising the integrity of both the educational program and the teaching industry as a whole”. It appears that the NZDC’s move to create a new recertification process has considered this as well. Allowing self-directed study, independent research and authentic learning negates this influence, in part. 3.
“Before you decide to attend a course, or an educational event you need to question the relevance to you of the subject being covered”. Postgraduate Medical and Dental Education for Wales, UK
Additionally, in what I feel is a further bold move, there will be “No mandatory requirement to meet a quota of PDA hours.” There will also be no requirement for PDA’s to be verifiable and will be linked to “Any activity relevant to maintaining and building a practitioners competence in their SOP. PDA activities need to be aligned with “Specific developmental outcomes”. Think about your workplace, your roles within in it, clinically or non-clinically, the nature of the practice and its clients. For example, I work in a general and modern orthodontic practice, I treat both disciplines from a dental hygiene perspective, the parents of the younger orthodontic cases tend to be very involved with their children’s care, they are included too. I work collaboratively with orthodontic auxiliaries, dental assistants, dentists and reception and office staff and managers too, as a team. Planning meaningful and practical PDA may see learning in non-dental related subjects such as leadership, communication or team building.
Writing a PDP begins with a honest appraisal of where you are now professionally, your workspace, where you feel you need to go by identifying your specific career goals and learning needs to ultimately accomplish them. Consider your timeline, the NZDC are preparing a move from it being 2 to 3 years, whereas the GDC, UK have structured 5 into theirs. I’m not sure how I feel about this, the longer would be preferable as learning can be more open ended and reviewing your PDP might lead to more changes as a consequence, as well as workplace changes leading to modifying learning goals. A 3 year cycle might be justified initially as trialling the new regime but alterations to future timelines might require adjustment from feedback and experience. The templates for PDPs will be required too, created individually or by supportive professionally bodies or the DTI.
“You may wish to reflect after every activity, or at intervals during the year, reflect with your employer, or a peer or mentor”. Postgraduate Medical and Dental Education for Wales, UK
Reflection maybe the biggest educational challenge that Dental Professionals face as part of this educational development change process. I had the opportunity to be exposed to reflection during a degree programme at the University of Kent several years ago. Initially the process was very confusing, understanding the methodology, learning to write and express the sentiment of something you do mentally, every day in many clinical and ordinary experiences. Consider cooking a new recipe, you taste it and realise it may need seasoning or more of something and less of the other to enhance it, the next time you repeat it you alter your process again. This reflective critical self-appraisal doesn’t have to be a novel or a work of literal art but just an honest and revealing attempt to describe a situation in your professional environmental. We need to demonstrate learning that as occurred, what we alluded from it, or not, what would we do differently as a consequence of it. Eventually it leads onto planning improved practise and what future developmental directions do you think you need to go.
“Self-reflection is a humbling process. It’s essential to find out why you think, say, and do certain things – then better yourself.” Sonya Teclai
I can remember re registering with the NZDC in 2013, returning to New Zealand from the UK with a portfolio of evidence of learning, with a PDP, PDA log and reflections linked to learning. I was advised that at that time that there were gaps in my portfolio and I needed to catch up with CPD hours to comply. I was horrified to think that what I had learned from a UK university whilst doing a dental education degree wasn’t deemed enough. Ironically now, it seems that the NZDC is adopting those things I presented way back then. I will fall back on what I originally learned and prepare a PDP, construct PDA’s and continue to reflect upon my processes . I will find a PP and form a relationship which will help me evolve my practise further. Also, as part 2 of this piece I will delve further into self-directed learning methods that can help the independently minded critical thinker learner/researcher to move forward in this COVID19, post COVID19 clinical environment “Brave New World”.
Learning and Living with my Contradictions as a Dental Hygienist
I was never really academic at school, much to my fathers consternation. He was an Edwardianist, distant, expecting and stoic. I was very average at most things but enjoyed Art and Sport finding most core subjects totally dull and uninspiring. My school reports pay historic lip service to that. However, where I enjoyed or understood something I began to learn, with a passion and a hunger, as I still do today. I could smell the sweat, carbon and oil in the pictures I drew for Mrs Edwards and she in turn gave me freedom to learn. Teach and preach at me meaninglessly and I will rebel, give me the meaning and method to learn on my own, in my own time and I will thrive and take up the mantle. interestingly I also find this particularly true with languages as when I lived in Germany or holidayed abroad, learning was alive and my very reality, it was all around me. This typifies another learning environment, my workplace.
“Mark appears to spend most of his time on the Eastern Front in the Spring of 1943”.
Mrs Edwards, Marks Art Teacher 4th Year, The Winston Churchill School
Russell, Ackoff and Greenberg (2008) point out in their book, Turning Learning Right Side Up: Putting Education Back on Track , that our education system is seriously flawed focusing on teaching rather than learning. “Why should children or adults be asked to do something computers and related equipment can do much better than they can?” Traditional education focuses on teaching, not learning. It incorrectly assumes that for every ounce of teaching there is an ounce of learning by those who are taught. Most of what is taught in classroom settings is forgotten, and much or what is remembered is irrelevant.
Carl Rogers (1969) famously described in Freedom to Learn learning as “insatiable curiosity.” He divides it significantly into two types, a meaningless “from the neck up” involving no “feelings or personal meanings” with no relevance for the “whole person.” and contrasts this with so-called “experimental learning”, one which brings personal significance and meaning which can proceed rapidly. Such significant learning he defines further as having self initiation and a sense of discovery and being pervasive changing “behaviour, the attitudes, and perhaps even the personality of the learner.” Controversially Rogers continues by conjecting that all teachers and educators would prefer to facilitate such experimental and meaningful learning rather than a nonsensical syllabus.
“Education is an admirable thing, but it is well to remember from time to time that nothing that is worth learning can be taught.” Oscar Wilde
Donald Schon (1963, 1967, 1973) linked the experience of living in a situation of an increasing change with the need for learning. He stated that “we must become adept at learning” and “be able not only to transform our institutions, in response to changing situations and requirements; we must invent and develop institutions which are ‘learning systems’, that is to say, systems capable of bringing about their own continuing transformation.” A learning society culture has now been created as “education systems were no longer able to respond to the demands made upon them” ( Hutchins, 1968). Bring on the concept of lifelong learning.
There are many different ways of learning; teaching is only one of them. We learn a great deal on our own, in independent study or play. We learn a great deal interacting with others informally too, sharing what we are learning with others and vice versa. We learn a great deal by doing, through trial and error. Raj Ratten (2002) states that all dental professionals should pursue “personal and professional growth” and “acquire and refine skills.” He continues with a Criteria for Successful Learning which is “led by the learner”, is “problem centred” and demonstrates “active participation and the use of their own resources.”
Gray et al (2004) indicate, referring to Kolb and Fry’s Learning Cycle (1975), that learning “begins with an experience.” It involves observations and reflections which generate concepts which are then tested in practice. Honey and Mumford (1992) define individual learner styles as either activist, reflector, theorist or pragmatist in nature with experiences followed by reviewing, concluding and planning. It can be seen by both models that learning is reflective in nature too. They continue by attempting to define the meaningfulness of learning by making a distinction between it being deep or surface in nature. Some learners describe learning as “an increase in knowledge, memorisation and increasing ability to apply knowledge.” Others think learning is “an increase in understanding, the seeing of things in different ways or change as a person.” One way of developing a practical, meaningful and deeper understanding of learning in the workplace is the egalitarian and democratic endeavour of action research.
Action research is a value driven, powerful, collaborative and liberating form of enquiry based learning which begins simply with a question. Do I need to improve my practice? If so, how? It is inclusive in nature, there for everyone. McNiff and Whitehead (2011) plan a process that involves observation, reflection, acting, evaluating and modifying before moving on being framed as an action-reflection cycle.
The critical aspect of action research is that of the individual “I” being at the centre of the process, the “first person”. This puts you, your questions and experiences within your workplace into the centre of learning. It brings your thoughts, reflections, theories and actions into a living form. Your theories are not taken just from others, be they your peers or academics but also what is happening to you and is termed “living theory.” Thus we, as Dental Care Professionals can claim to be;
“Practitioner Researchers, First Person Living Theorists”
who “improve their understanding, develop their learning and influence others’ learning.”
McNiff and Whitehead, Action Research (2011, p.26)
My living contradiction – a reflection
There were many times when I felt out of step with the direction of many a practice. I was a professionally conflicted for years, as Whitehead (2006) relates “that you see yourself as a living contradiction, holding educational values whilst at the same time negating them” (http://www.actionresearch.net/writings/china/mllet10908.htm). I aimlessly attended annual symposia never seriously paying attention to or gaining from them. This typified my approach to learning at the time, a dull and meaningless process directed at me. I now have a super system driving and facilitating my desire to learn and earn. I am into my first action research project through the O’Hehir University that introspectively looks to improve my delivery of oral health in my workplace. It is simple in its construction, collaborative with my practices, the dental industry and patients ultimately benefiting the improvement of my practice. The experimental initial project undertaken earlier was supported by a dental supplies company and looked at implementing air polishing to improve my practice (http://mihygienist.wordpress.com/2012/09/17/experimental-learning-within-the-workplace-ems-air-flow-handy/).
I am of the conclusion that traditional education partially qualified and equipped me personally and professionally. I am also still developing in both. I now believe I am a different living contradiction. Not one of clinical negation but more of being opposed to the culture of passive knowledge gain supported by endless corporate opportunists exploiting the crazy regulatory fixation in our professional environment and thus sadly in our workplace too. Attending meetings that don’t reflect our learning needs, mollified by free lunches or so-called “high profile” speakers might tick the boxes but no more than that. Action research is our future and I intend to do as much, if not all, of my future CPD cycle in that method.
Whole Dental Health for a Progressive, Creative and Sustainable New World
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