Reflection – workplace learning – Professional Development Day 9/11/20

The day went very well. My presentation went off without a hitch and we all retired to the bar afterwards to relax and reflect“. Mark

The Days Events

The day started at 08.30am and the whole team arrived in eager anticipation, a degree of anxiety and earnestness. We knew what to expect in terms of the activities of the day, we had been briefed. We did our 2 yearly CPR catch up, about 5 hour’s worth of theory and practical and I presented on protocols in my dental hygiene practice and an investigation into the oral health products we recommend and their application. I could tell there was a tad of tension in the air, there always is when you venture outside of your clinical comfort zone, ironically to learn about events that can happen inside of one’s clinical comfort zone. I think that this is the consequence of a fear, not of the need to learn, but due to the concern that you might have in making an error in front of your colleagues or failing an on the spot exam. I had also asked my team in an earlier meeting as to what they wanted to learn about my proposed presentation but had not had too much feedback so I kind of went into it blind. I hoped it would be interesting, engaging and a learning experience for everyone.

Preparing my presentation was a timely affair. It must have consumed about  30 hours of reading and writing, slide after slide created for power point and quite a few withdrawn because of time restrictions. However, at 10pm the evening before the day I completed it with animations and slide transitions and was satisfied that, without going through it into much detail before the event, I’d be fine. I had a minor concern regarding technical problems with linking it to the flat screen monitor in the conference room, a previous occasion had uncovered glitches and faults and it couldn’t be screened. Fortunately, I’d had the forethought to check it the week before. I was scheduled for the afternoon so I made the conscious effort to forget about it completely and focus on the main event, CPR.

The two instructors were professional emergency department nurses and had an incredible presence. They were both extremely proficient and gauged the mood precisely. The education was practical and visual, just my style, and for once, after all these years and previous CPR training had no concern or fear, like I had before. Maybe I was distracted by the thought of getting my afternoon session right but I really enjoyed the occasion and learnt some really relevant knowledge especially regarding anaphylaxis. We had a simulation in my chair about this exact same emergency. The irony was not lost on me as some of the oral hygiene products in the market place have the potential to create such as extreme physical reaction. It was also enlightening as it is important in my new hobby of bee keeping and the potential for bee stings to do the same. The need for adrenaline, in my case the need to draw up 0.5 mgs and the opportunity to give an additional dose 5 minutes after if required was new knowledge. I was also mindful of the 2:15 breaths to compression for children and 30: 2 for adults. The technology that helps us get a realistic  physical sense of the breathing and compression rates has come a long way since my late teens when I began my professional journey.

The afternoon soon arrived and my turn came to add to the learning day. I had no technicals and the flow was good, I enjoy the moments when the subject can be discussed and was aware that there were some quiet voices in the room but moments arose to bring everyone into the debate. A particular subject, fluoride, demonstrated this perfectly. Some of the team aren’t aligned to the argument there is a problem with it whereas some were interested to question its relevance and validity. This is supported by previous feedback surveys we have undertaken at the practice that had determined that 75% of clients were opposed to it in the water supply and another 50% weren’t happy to use it in toothpaste. It seems to me we need to open to both camps and the many who site in varying positions between the two. Some even need to know the pros and cons with a balance and information to make a self-determined decision. What is important is that we know the noted benefits and the perceived negatives to not only fluoride but additional products, fair and fowl, which cause so much controversy.

Some contemporary oral health products, toothpastes included, have now within them, pre and probiotics. The science in this regard is still in its infancy but is growing exponentially, some are well established like xylitol. The addition to the inventory of products will include these as well as toothpastes that have specific applications to the needs of disease risk reduction in our practice. It was a great moment to explain the appropriate use of these and to whom, in what amount and for how long. It was also important to demonstrate and discuss the contra indications of them too. It was opportune to shed light on calcium phosphate in relation to tooth strengthening, desensitisation, pH balance and elevation as well as our oral biofilm benefiting from its directed use. My mind was changed from recommending no spitting out of fluoridated toothpaste to them clients to deciding for themselves after being given information about it.

What would I do differently and what feedback did I get? I think I’d adjust the presentation slightly, add the slides I edited and extend the length of it from 90 minutes to 2 hours with a break to sample some of the products. The content is sound but I’d like to add a slide or two to add more context. The feedback came back from the receptionist and she was perfectly correct in her request. I was awaiting it as a consequence of self-reflection and will act upon it immediately. I’m going to write a crib sheet for her about the products and their component parts, their benefits, how best to use them and who needs to avoid certain ingredients. I am also going to focus on toothpaste contents and write a briefing sheet for clients, colleagues and myself as they seem to be of great interest to many I see. My learning journey needs to encompass ALL the ingredients of the items we sell. I will also get myself an anaphylaxis syringe, needle and adrenaline vile kit too. All in all, it was a day well spent.

Ongoing Conclusion

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A year to the day 02 September 2020, a reflection on a radical year. September 2019 – August 2020.

March the 23rd, is a day I will never forget. I thought, initially, it would be the last day I practised dental hygiene and strangely, it felt strangely easy on me. After nearly 32 years I was prepared and almost willing to lay down my scalers and hang up my latex free gloves for good. I had been destined to travel to Melbourne, the following week, to do a four day introductory course in myofacial function therapy. This was in jeopardy due to a rapidly unfolding global drama and the spread of COVID 19. This culminated on that Monday, the aforementioned 23rd, when the whole of dentistry, less emergency care, was stood down by the Ministry of Health. That afternoon a final meeting was held at the practice, distances between and masks provided, for each and every one of us, all uncertain of the future and more besides. That very day too, I witnessed something I’d never have considering seeing since my days in East Berlin and Moscow in the heady days of the late 80’s and early 90’s. The beginning of the queue outside food stores had begun. A fit elderly lady on a bike, horrified at the very sight of it, perhaps with memories of her past experiences in leaner times, stopped and hurled abuse at those in the queue. Her ardour was embarrassingly silenced when she fell off her bike, at which point I, observing from a distance, decided enough was enough and cycled home, supplies in hand.

A mere six months before I had returned to New Zealand from a long learning break and started a new adventure in dental health. I have worked in virtually every conceivable dental health scenario except orthodontics. This was about to change with my introduction to orthotropics and orthodontics with Quin Dental in Nelson. My ignorance was blinding, I had hoped to spend a few days observing the practice but the immense jetlag and seasonal adjustment had the better of me as I slowly embarked on the journey of getting to know the intricacies of a new professional landscape, a new uniform, matching clinical footwear and a peculiar personal learning environment to navigate.

The previous weeks had deeply affected me and had shed light upon my less than ideal sustainable approach, and carbon footprint from the previous 9 weeks travel. We decided to stay with one vehicle as we lived near to our places, purchased Ebikes to make future journeys less reliant on the remaining car and began to dig the garden for our vegetable futures. Loaf making, with sourdough yeast from a friend, and continually nurtured by us, became a weekly event. The experiences and experimentation with CBD in the States drew my partner to its legal prescription and use to help her chronic pain.  I had also decided that at some point I would reduce my working week to 4 days, so as to be able to focus on completing this project.

My annoyance and regular triggering by the inconsistent and arrogant responses and attitudes of my governing council to the needs of the profession grew stronger as the COVID days went by. This was enhanced by their unwillingness to recognise the fear and uncertainty that registered professionals felt at that telling moment, the significant reduction in income and the demand to pay registration or be deregistered. This was further inflamed by what I suspected would happen with the professional association being inept and unsupportive to their members. Me not being one (thankfully) but I was witness to the enraged voices and rants of those who were via social media. A pathetically drafted and grammatically piss poor effort of a letter to the regulatory establishment was the last straw and I decided that was it, and my time was officially now “up’ so to speak.

To be honest I can imagine this being the case for many people in a similar state of mind to me. My headspace was somewhat fragile, a consequence of post-traumatic stress disorder, from past events. I had spent many years trying to suppress and manage it without professional help, regular journeys with numbing effects to dull the emotional pain which is thankfully being properly addressed now as I write. My decision making had been somewhat reactive and primed I immediately went about considering my options beyond dentistry. I found a degree nursing course locally and applied, surprisingly being rapidly accepted. This was a relief and allowed me the time to contemplate where the future would go and where it would take me, or I take it. It was put to the back of my head and when the alert levels allowed I returned to clinical practice, unsure of what the PPE requirements were despite advice that seemed logical, for once. Everyone had a different interpretation of it, some wore masks everywhere in the clinic, others only in the surgeries and so on.

I was also uncertain how many clients would attend, still numbed and fearful of the risk of COVID but for 102 days New Zealand registered no community spread despite returning citizens and residents, and Trumps apoplectic rantings about this diminutive country’s record on controlling COVID. I continue to treat clients in a as near as normal environment as before. This has been reassuring but the threat of the looming recession and further community spread is upmost in my rear view mirror. I continue as before clinically and will continue to do so, with an addition of another clinical day elsewhere in Nelson to make the total to 4 days a week.

I have also made a decision to withdraw my interest in general nursing, a decision based upon not wanting to accumulate addition debt from study as well as incur a lack of income through not working. Being 55 years of age, a decade or so way from retirement refocused my priorities and changed my decision. Feeling better mentally and emotionally contributed to this move too.

Possibly the biggest decisions I’ve made within this year has come from two sources. Experiences with bee keeping and study of the benefits of honey and being asked to observe a mentor an online learning portal of friends have reframed my thought processes. The learning hub has made me realise I’m not alone with tough decisions, as over half the course have decided to change their present employment in dentistry and go in different directions, being affected as was I, by the COVID crisis. It also taught me to be more lateral in my future career thinking within dentistry, something that is still ongoing but has got the grey matter stoked. Watch this space with novel and enterprising ideas and action in the months and years to come.  The other has me immediately engaged, and I begin my Certificate in Apiculture tomorrow. It directly links to my other passion, which I’m less engaged with in this country, that of mycology and free food gathering. Apiculture and foraging are great inquiring hobbies which may also lead to income generation, potential teaching and well-being in the future , so I’m very excited.

Finally, professionally where do I go from here? As I have discussed previously I had intended to do a myofacial therapy course abroad. This is impossible now but a virtual learning programme is being constructed soon and at my annual review I will ask to be put on it. Virtual learning is no stranger to me and the thought of using my skills and experience as a dental hygienist align with this perfectly. It also makes me think that perhaps the future of the dental hygienist, long considered redundant with the advent of the multi-disciplined hygiene therapist, isn’t quite an endangered a species as once I thought. The additional knowledge can be used with orthotropics, sleep disorders, mouth breathing issues and perhaps too, myofacial pain. The thought of getting wise counsel and guidance within the workplace from experts is a golden opportunity to be grasped. This may also bear future fruit with consultancy and mentoring too.

The future still appears to be uncertain, once essential international airline pilots, once criss crossing the skies above us are now filling food store shelves. The trick appears to be to make yourself professional self relevant and essential, consider where the opportunities may lie, deal with one’s demons, as in my case, and not consider yourself past it beyond the age of 55. Continue to plan for and be aware and mindful of the opportunities that still may prevail. I wish you all good luck and the best for your clinical and professional futures as I sign off from this year of discovery, thank you all so much for sharing my journey. Stay well and smile.

Professional Development Planning and Reflection

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A New Hope? Re-Registration for Dental Professionals in New Zealand. A Whole Dental Health Perspective, Appraisal and Reflection.

“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 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. In February of this year, a summary of the critical 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 before 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 adopted in the UK in 2018. I find it interesting that the NZDC derives their inspiration for such change from the 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 historical 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 they 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. It 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 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 the 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 negate 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 an 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 necessary 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 may be the most significant 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 has 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 education. 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 while 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 practice 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”.

Sources

Annual renewal and fees, GDC, UK.

https://www.gdc-uk.org/registration/annual-renewal-and-fees

Enhanced CPD guidance, GDC, UK. https://www.gdc-uk.org/docs/default-source/enhanced-cpd-scheme-2018/enhanced-cpd-guidance-for-professionals.pdf?sfvrsn=edbe677f_4

Gillis, MR & McNally ME (2010). The influence of Industry on dental education. https://www.ncbi.nlm.nih.gov/pubmed/20930240

A Personal and Professional Reflective Journey into an unknown and uncertain future. Whole Dental Health, A Brave New World.

Reflection will soon become a requirement of recertification as a Dental Hygienist in New Zealand. I’m not sure how many within the profession have written reflectively but what you find below is a quick example of reflective practice about my recent and ongoing experiences regarding the COVID 19 pandemic as a Dental Hygienist. It is both personal and professional, it could be written in a variety of ways, using different approaches of reflection from Kolb, Gibbs or Schon as examples but I’ve decided to use a What, So What, Now What pathway for its ease of use. For more information and examples, please use the referenced links at the end of the piece. Good luck and remember how beneficial it is they think about what you’ve experienced, how it has affected you and the changes you may consider making as a consequence of them.

“Necessity is the mother of all invention”. Old Proverb

Just three months ago I was looking forward to March, especially the 17th, when I was completing a six-month locum stint in practice in Blenheim, Marlborough. I had work organised in Nelson to replace what I was leaving behind and my professional life, for once, looked peachy. Little did I know that by that date, I had reappraised and adapted my clinical approach to dental hygiene treatment. At the same time, I was feeling underwhelmed by the lack of concern and fragility of fellow professionals being displayed in the clinical environment and in online professional chatline on social media. COVID 19 was a “Clear and present danger” to me and those I respected and cared for both personally and professionally. I had started giving it consideration by about mid-January when the news was slowly filtering from Wuhan via the media that a novel virus was causing lockdowns, infections and, the start of what was to be, many deaths being reported. The concerns of a rising epidemic becoming very real.

After listening to RNZ, I began to think about how I’d respond if it came to New Zealand.  I could potentially be seeing asymptomatic, pre viral or even viral cases not far off in the distance.  Ironically the first thing I did was to pick up a few masks and brought them home, we had a few boxes of gloves in the house from my Wife’s old locum midwifery practice. She had given me the “are you a conspiracy theorist” look initially but found a quiet place for them, just in case. My children and their respective partners had recently been to Europe on holiday, and all but 1 had experienced colds and fevers either during or on their return. I kept my distance from them and as the epidemic continued the realisation of it going pandemic grew. I started to consider how I was going to modify how I worked, my concerns being the safety of my clients and myself. About this time, a rush on not only toilet roll but hand sanitiser saw both items being panic bought and dental supply companies running out of stock rapidly overnight.

We had intended to have a practice meeting, scheduled on the 25th February, and I was going to present on a “Sustainable Approach to Dental Health”. This I withdrew from and advised the Practice Owner and Manager to consider the meeting’s topic changed to what might potentially happen over the next few days and weeks regarding COVID 19 and how protected and safe our clients and ourselves would be. It felt like we were transitioning to a weird kind of war footing (I had experienced this during Gulf War 1 in 1991) and felt some of our colleagues weren’t as aware of all the facts and even concerned as much as they should be. I’m glad we had the meeting as it began the process of mental adjustment for all and adapting to the threat of COVID. We placed information notices on doors, put out hand sanitisers for clients to use and took stock of the supplies we had and began to order more, especially hand gel, masks and gloves. The unknown became very real when on 28th February when” case of COVID 19 in New Zealand was announced.

One of my Wife’s friends is an Emergency Department Nurse who lives in Canada. Her Son, a young, healthy man in his early Thirties was one the first to die of COVID in his country. We heard this sad news about mid-March, Toni was devasted. She and I began to make the growing COVID risk more apparent to all our friends and family. Some found it too extreme, others were still unconcerned, but very soon the reality was setting in that things were not going to stay the same for much longer. The March Fest in Nelson, a Beer Festival, on the 14th, March was the last event I was to attend with my Sons for some time to come. New phrases like “Physical distancing” and “Flattening the curve” began to become accepted norms, similar as our forefathers call to action with phrases such as “Dig for Victory” and “Careless talk costs lives”. Regular visits to the shops to quietly stock up on food and groceries gathered a pace and our cupboards, once empty began to fill to support our “Bubble” isolation for the weeks to come.

The government initiated a COVID 19 strategy of “Going hard and fast” on protecting the population, stepping up testing and self-isolation for those returning to New Zealand after the 25th March. That week, a rapidly created Alert state had been implemented, we were at level 3 by the 23rd and total lockdown, Level 4, by the 25th, March. My routine and regular practice, something very familiar to me in various clinic guises for some 30 years, ceased that Monday and we held a final impromptu “socially distanced “practice meeting. The future and our careers seemed very uncertain, all of a sudden.

Way before the end of March, I started to reduce and then cease all my aerosol producing clinical activity, despite others continuing it. In particular, I hung up my ultrasonic and airflow systems and began making sure that I displayed to my clients super visual hand washing techniques as reassurance. However, I did continue to use slow handpieces continued, which do create a droplet field. My dilemma was genuine that clients were paying and expected to feel that their teeth were effectively cleaned. Aspiration was the best barrier to reducing its potential contamination. Cleaning down after treatment and set up processes for the next client were more deliberate and measured. I work without chairside support. This will need to change.

The New Zealand Dental Council with the Ministry of Health directed all unnecessary treatment cease from the 23rd, March as previously stated. They drew up unambiguous guidance on what is deemed an emergency and what is not. It was crushing to think that everything I did was effectively non-essential and that would remain true until we drop back to Level 2 from 4. The initial 4-week lockdown could be extended, if required, and no suggestion of when Level 2 is on the horizon as yet. However, the Prime Minister is now asking businesses to plan and consider how they restart or reset when that time approaches. What does this mean to me? I’m using the time to catch up on many things, educational I’m writing the blog, and this is fifth so far. I’ve a plan, set out last year and every excuse under the sun has held me back completing it. Not now. Additionally, and perhaps more importantly, I need to familiarise myself with all the recent updates and mentally preparing myself for an alternative, uncertain professional future.

I am also a little uncertain of this new clinical reality, one which will mean the wearing of Personal Protective Equipment beyond my previous norm in the course of routine dental hygiene treatment. One very visual video I saw on YouTube by the Auckland DHB demonstrated how to dress with PPE, hand sanitisation four times for one process of gown, gloves, masks and protective eyewear being put on and taken off. How many would our practice need and wherein these times of shortages of such items would we get them from? How much would they cost and would our clients accept the changes and additional fees is added to the treatment costs? These decisions I, fortunately, don’t have to make but how I approach my clinical practice, beyond the PPE debate, is evident to me.

PPE will need to be updated with visor and if required gowns. A few trial runs getting to know how to put it on, that’ll be interesting.

  • Aerosol creation limited or ceased.
  • Really good evaluation and assessment.
  • Hand instrumentation, even for periodontal cases.
  • Dental Assistant required for helping with aspiration, note-taking and infection control.
  • More time will be required to undertake treatment.

So, as per NZDA guidance, all my cases will be categorised as Low-Risk Care, not positive for COVID 19 or any associated exhibiting symptoms, or in close contact with those who do. The international travel aspect will shortly not apply for sure, for some time. No aerosol-generating equipment, all appropriate PPE equipment required, including gowns and our routine surgery use.

I wonder how many of the profession think everything will return to normal rapidly? Some, like myself, may align to that notion only when vaccination is developed and tested, produced in the numbers required to globally distribute and facilitate it. Essential healthcare and general workers, those at risk, the immunocompromised and the elderly will undoubtedly and rightfully be first in the queue. This will take time, and until then I will subscribe to the immortal words of the great Clint Eastwood, “Improvise, Adapt and Overcome” because “Tomorrow is promised to no one”. However, the lingering thought is this, how much will it ultimately cost the profession, additionally the client and will they return in the numbers they used too?

Sources

1. Ministry of Health, Dental Council and Professional Associations’ joint statement: COVID-19 update*

https://www.dcnz.org.nz/resources-and-publications/updates/update-on-covid-19-novel-coronavirus/

2. What is a Critical Reflection?  Introducing the “What, So What, Now What” Model – Use the Course  environment as your workplace and learning environments

3. Reflecting on a Personal Experience Using the “What, So What, Now What” Model https://youtu.be/_mQ_zDUX9nE

4. Sample Reflection: Reflecting on a Course Activity

Developing my PDA’s and PDP in the light of future changes to recertification. Redesigning from 2019 to 2022. Whole Dental Health – A Brave New World.

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. The New Zealand Dental Council (NZDC) has changed the criteria for Dental Healthcare Professionals (DHP). This is 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 method that is demonstrated in figure 1.

Fig 1. GDC UK reflective cycle for PDA’s

In this account, I wish to look back 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, an excellent opportunity to find where you presently are professionally and where you feel you want or need to go in planning your 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.

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 timeline (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.

https://wholedentalhealth.com/action-research/

https://wholedentalhealth.com/2020/04/08/part-3-learning-and-living-with-my-contradictions-as-a-dental-hygienist-evolving-knowledge-in-the-light-of-change/

https://wholedentalhealth.com/2020/04/06/authentic-learning-environmental-oral-hygiene-part-1-a-sustainable-approach-to-whole-dental-health-introduction-and-intention/

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. Before starting work in my present location, as can be in figure 1, I was engaged in an epic 9-week overseas sabbatical, see “experimental Learning 19” menu and reflections related to it.

https://wholedentalhealth.com/experimental-learning-journey-2019/

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 difficulties has been rewarding and, at times, a little stressful. Potentially It could be a useful 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.

How To Make a WordPress Website – For Beginners https://youtu.be/8AZ8GqW5iak

How To Make a WordPress Website – In 24 Easy Steps https://youtu.be/2cbvZf1jIJM

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 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. Still, 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 scarce 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.

Growing Your Face by Dr Mike Mew

A Speech Therapist’s Approach to Myofunctional Therapy

During my first few months in Nelson, I began to realise, very quickly, that many of my clients were somewhat “alternative” and investigative in their approach to subjects like fluoride and nutrition. There was 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 paradoxical living 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 makes 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. I was curious and willing to listen, to understand without judgement and I was careful to recognise and affirm other people’s opinions, 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 with 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 precisely 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.

Weston A. Price and notable more “modern” others

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Progressive Dental Nutrition? Relating the Lessons of the Past with the Present. Weston A. Price.

“We can now visualise 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 visualised 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 the name the Weston A. Price concerning 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 reasonably 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 their 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 nutritionist, you’d be aware, as well, of the controversial academic and scientific work of one 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.  Interestingly, the New Zealand Dental Council includes the phrase “holistic” in approaching treatment in its guidance for professionals and encourages collaborative engagement 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 “healthy traditional cultures all over the world”. 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 root 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 root 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 to 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 nutritionally 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, seafood, 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, crooked 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. 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 an “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.

“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 essential, 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.  The lived and worked 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 dietary 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 by nearly 30%. 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 the oral cavity cannot be underestimated 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, 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 dependent upon an adequate supply of antioxidant micro-nutrients. Micro-nutrient antioxidants are essential 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.

“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 an attack from free radicals. Nutrients called antioxidants help the body’s natural defence system combat this process. A variety of antioxidants including vitamins, A, C, E as well as minerals like Selenium and Zinc, are found in fruits, vegetables, nuts, seeds, 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. 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.

“Fermentable carbohydrates are the most relevant common dietary risk factor for caries and periodontal diseases” state Moynihan and Petersen (2004). 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. Using Vitamin D supplementation combined with Calcium has been shown to reduce risk in the elderly. 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.

“Let food be thy medicine”. Hippocrates

Upon reflection, 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 antioxidant-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 are 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 dietary legacy in line with their belief in nature.

Sources

Carmody N, Weinstraub G, & Wrangham R. (2011) Nat Academy of Science, USA.Energetic consequences of thermal and nonthermal food processing. Nat Academy of Science, USA.

Schmidt K. (1997) Interaction of antioxidative micronutrients with the host defence mechanisms. A critical review. Int J Vit Nutr Res.

Simpsom T, Needleman I, Wild S, Moles D, & Mills E. (2010) Treatment of periodontal disease for glycaemic control in people with diabetes. Cochrane Database.

Dietrich T, Joshipura K, Dawson-Hughes B, & Bischoff H. (2004) Association between serum concentrations of 25(OH)D3 and periodontal diseases in the US population. Am J Clin Nutr.

Jemenez M, Giovannucci E, Krall Kaye E, Joshipura J, Dietrich T. (2014) Predicted vitamin D status and incidence of tooth loss and periodontitis. Public Health Nutr.

Zahn Y, Samietz S, Holtfreter B et al. (2014) Prospective study of serum 25-hydroxy Vitamin D and tooth loss. J Dent Res.

Moynihan P, & Petersen P. (2004) Diet, nutrition and the prevention of dental diseases. Pub Med.

Leggott P, Robetson P, Rothman D, Murray P, & Jacob R. (1986) The effect of controlled ascorbic acid depletion and supplementation on periodontal health. Journal of Perio.

Van der Velden U, Kuzmanova D, & Chapple I. (2011) Micronutritional approach to periodontal therapy. Journal of Clinical Perio.

Krall E, Wehler C, Garcia R, Harris S, & Dawson-Hughes B. (2001) Calcium and vitamin D supplements reduce bone loss in the elderly. Am Journal of Medicine.

Miley D, et al. (2009) Cross-sectional study of vitamin D and calcium supplementation effects on chronic periodontitis. Journal of Perio.

Chapple et al. (2017) Interaction of lifestyle, behaviour or systemic diseases with dental caries and periodontal diseases. Consensus report EFP/ORCA.

Additional sources

Eat well, keep gums healthy, live longer. Juliette Reeves RDH UK – https://www.nature.com/articles/bdjteam201940

Weston A. Price – Overview – https://youtu.be/OH1HSG9AOS8

CARTA: The Evolution of Human Nutrition – https://youtu.be/jGUsMYXdDDc

Weston A. Price’s appalling legacy-https://sciencebasedmedicine.org/sbm-weston-prices-appalling-legacy/

Weston Price – https://en.wikipedia.org/wiki/Weston_Price

The gang of five. Alternative approaches to dental disease prevention and celebrating the diversity of progressive opinions. Whole dental health and beyond.

When we critically look at scientific research (this assuming we do) our aims are to look at the type of research, the quality of the question, its methodology, their outcomes and results, subsequent conclusions and its relevance to our uniquely individual workplaces. The traditional face value approach featured heavily in the first half of my professional journey as a registered dental hygienist. To pass my certificate in dental hygiene back in 1988 it required of me a straightforward context. To believe everything I was shown or taught, reproduce it in writing and action, to a standard pass. My real learning began on my first day in clinic, post-graduation. My over sharpened and extremely thin sickle scaler fractured at the tip between the lower anterior teeth on my first client. I can remember my overconfidence, not born of experience but of the outcomes I magically and naively envisaged. I was the “master technician”, with all the data inputted, the on switch to go and the power selected for perfection.

I really had no expectation of a need to update on my own, I had been breastfed by the “gated” institutional culture of my learning, latching on at specific points of time and refuel with knowledge relayed from the institutional mothership. No thought of questioning my own practice every crossed my mind initially, to consider enquiring about anomalies observed in my everyday practice or connections between other healthcare practices and my own. The dentist was the one and only direct port of call, but the occasional trade or professional body publication revealed very little edifying additional new knowledge. The annual symposiums were the only real learning hubs available to me, the attending audience obediently and diligently offered applause to every keynote speaker and after each session fled sheeplike to the resident trade stand after which an orgy of sample taking unravelled.

My first experience of open critical thinking began at such an event a dozen or so years into practice, that long. A speaker, talking to a mass of hygienists, brutally and honestly stated that there was no research evidence to demonstrate that flossing was effective at reducing gingivitis, this would be a hot potato, many years later. I was horrified to hear this, I was an advocate to its efficacy and felt affronted by this preposterous charlatan.  It challenged all I was wedded too and that was the point. I immediately put up my hand and challenged him back. He was probably waiting for this moment, well prepared and responsive in a friendly, calm and measured manner. The audience has silent, aware of the relevant context of the exchange. Afterwards, in the trade hall, he tracked me down, laptop and research in hand and explained in further detail, supporting his claim. He was, of course, right. I hadn’t a sound grounding in research, in fact very little at all until that point, thus began my contrarian journey into research, aided and abetted by this and many more fact-finding experiences to come.

I suppose the real rub of the green moment occurred after a year of study at the University of Kent where I studied part-time for a year in the mid-noughties. The first excursion into evidence-based practice learning, critical thinking and reflection were transformative. After that experience, I began blogging on topics close to my heart, getting to grips with new technologies of caries risk assessment and beginning self-directed learning journeys. This culminated in educational trips to New York, Key Opinion Leading and mentoring for Philips Sonicare and presenting to audiences at regional and national meetings. This lifelong learning worm had turned. The final flag-planting assent into learning enlightenment presented itself with O’Hehir University, and action research and reflective practise became active companions in my workplace.

Since then, I’ve taken a somewhat left-field approach to new knowledge creation for creative and curious is what it is to me, without exception. It provides a platform for the unorthodoxy of self-directed or independent person growth. It creates a playing field for new ideas to disseminate, to flow, challenge, and complement the landscape of my personal dental education. The independent researcher, the workplace learner, and reflective practitioner appear to be the future of education in dental health. The educational and regulatory establishments in several countries are now beginning to progressively embrace this new environment and are opening the gates to innovative practices. This also reflected to need to learn what was relevant in the unique workspace, required for the personal and professional development of the clinician.

In this alternative habitat of new learning brought about by modern technologies are a new breed of progressive, professional free thinkers. They are eloquent, motivational and provocative. The first exponent of this “dark dental” movement is Dr. Kim Kutsch. Kim has been active in the field of caries risk management for many years and must qualify, in my mind, as the Godfather of this genera. He is responsible for a significant resurgence into actively treating caries as a disease of imbalance, of pH and specific acidogenic, aciduric bacteria, as well as the more obvious importance of dietary fermentable carbohydrate. He also alludes to the significance of dry mouth, oral hygiene and our DNA. He advocates, as do many other like-minded thinkers the environmental and co-existing balanced approach to dental disease prevention. He has gone commercial one stage further. The creation of www.carifree.com provides a range of research and educational elements alongside a variety of products that can be used to identify at-risk individuals and solutions to pH and bacterial imbalances in caries cases. He has also worked with the research by Professor John Featherstone, a pioneer in caries research, to create caries risk assessment tools. Kim keeps his campaign to reduce disease in teeth up to date and relevant but also engages in active participation in educational topics, fronting presentations both online and in-person across the world and has a large following.

The xylitol prebiotic benefits are at the forefront of Kim’s approach after the destruction of the dysbiotic oral biofilm to help reseed the ecology of the mouth after, over time. This process is further supported by Dr. Mark Cannon, another American dentist and oral environmental activist. Mark is a proponent of the Neuro Arterial Gingival Simplex, positing the implication of a specific bacterial type, Porphyromonas Gingivalis. This alludes to this bacteria’s accountability in gingival diseases, atherosclerosis, and Alzheimer’s disease.

Mark has an intriguing divergent interest, growing amongst alternative and progressive healthcare professionals nowadays, in the evolutionary aspects of dentistry. He has studied and discusses with clarity the nutritional role in the development of the mouth, the evaluation of oral forms in the mouth, frenulum, tonsils and adenoids, the ecology of balanced play, processes that promote it and the benefits of our gateway oral microbiome to the rest of the body. These include, like Kim, the use of xylitol but also a similar sugar alcohol, erythritol. He also advocates the use of calcium phosphate-based toothpaste and Silver Diamine Fluoride in caries risk reduction and remineralisation strategies. You can find out more about the mark at www.drmarklcannon.com.

Dr. Steven Lin, a practising Australian dentist in Sydney in Australia is to me, living in New Zealand, a more local dental health legend. Steve began his journey into enlightening others with his activistic research in 2017. He then published his book, The Dental Diet, gaining a broad international audience. His participation in regional, national and international presentations further added kudos to his moral crusade. He starts by bringing back to the dental world the controversial figure of Weston A. Price, a long forget and conveniently ignored and published dentist with controversial environmental dental health research. The premise of Price with recent advocacy from Lin is not to ignore our ancestral dental past, in particular when compared to current dental issues of the arch under development, crowding of teeth and the nutrition of the body and the mouth with whole food. The importance of micronutrients like vitamins D, A and the recently discovered vitamin K2. He proposed that eating these and other micro and macronutrients are important for dental health. Steve also began the conversation and journey into oral myofacial function and epigenetics. Find out more about this progressive dentist at www.drstevelin.com.

Professor Philip Marsh, based at Leeds University in the UK, and the Health Protection Agency, is an world renown expert in bacterial behaviour in humans. He describes oral health is more than just the absence of disease but also crucial in boosting and promoting general health. He goes onto further propose that pathogenic bacteria grow in the mouth due to changes in the lifestyle of the individual. Beneficial bacteria produce natural benefits, regulating heart health and the immune system and gut health. Our human microbiome has co-evolved with us, living in structurally functionally organised communities communicating with themselves and our human cells. A great YouTube video can be viewed at https://youtu.be/zuxNMVR2nVM.

Last but by no means least is Dr. Bonnie Bassler, a Professor in Microbiology with interest in chemical signalling mechanisms of bacteria. Bonnie has been a keen observer in the growth and development of bacteria, their benefits and negative impacts on the body. She succinctly reveals the importance of bacteria to us, their scale and size comparatively in both cell and gene numbers but more importantly describes the incredible intricacy of their means of quorum sensing or communication. They create hormones to converse, talking and hearing, to neighbouring cells in multiple cellular languages, demonstrating collective behaviours. Her aim is to determine whether this community of communication can be disrupted or modified to produce human health benefits in the future. See more at https://youtu.be/KXWurAmtf78.

The world of dental health education continues to grow, the means to deliver it is evolving too. The age of the book continues with the likes of Dr. Steve Lin, await more publications from him both in paperback and eBook formats. Others will continue with online platforms like websites and video channels as well as podcasts. A special mention must go to Dr. Ryan Nolan for his series of podcasts that includes the likes of Steve, Kim, Mark, and many more besides. You’ll find these at www.thebiofilmfactor.com, ideal for company during a long walk with earphones in or at the gym when working out.

Water fluoridation and alienation

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Understanding the Nature and Intent of the Anti-Water Fluoridation Movement in the Context of My Workplace – A Whole Dental Health Reflection.

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:

  • Fluoride is not an essential nutrient and no disease has ever been linked to a fluoride deficiency.
  • Fluoride is a biologically accumulative poison, active even in low concentrations.
  • 50% of fluoride is excreted from the body via the kidneys, the remainder accumulates in bones, the pineal gland and other tissues.
  • The effect on the pineal gland reduces the production of melatonin and can onset early puberty.
  • Fluoride toxicity can cause renal and chromosome damage in children, interfering with enzymes involved with DNA repair.
  • Dose dependent increased risk in bone cancer in fluoride treated male rats, the follow up to this, done at Harvard University showed a significant link between fluoridation and osteosarcoma in young boys.
  • Fluoride is a neuro toxin affecting the IQs in children, interfering with the function of the brain and body, directly and indirectly. The findings confirmed by further studies indicated that IQ might also be affected with lower exposure to fluoride.

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.

Sources

  1. Water fluoridation to prevent tooth decay. 2015

https://www.cochrane.org/CD010856/ORAL_water-fluoridation-prevent-tooth-decay

  1. Potential fluoride toxicity from oral medicaments: A review

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5651468/#ref25

  1. The Untold Story of Fluoridation: Revisiting the Changing Perspectives

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6309358/

  1. FIRST NZ Fluoride Debate EVER With Dr. Paul Connet

https://youtu.be/qmy3qmBzc7U

5.The Fluoride Debate: The Pros and Cons of Fluoridation

https://www.ncbi.nlm.nih.gov/pubmed/30386744

6.The Case Against Fluoride, Paul Connett in New Zealand 22Feb2013

https://youtu.be/RlBP4WjOIyg

Functional Foods, Pre and Probiotics

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Xylitol:  In the dock and in the surgery

In the Dock

Dental caries can be defined as a carbohydrate modified transmissible local infection with saliva as a critical regulator1 and is a disease with a high prevalence in the European Union (EU) 2. In November 2008 the European Food Safety Authority (EFSA) formed a scientific panel to substantiate a claim made by a sugar free confectionary company who presented evidence that xylitol chewing gum and pastilles can lead to the reduction in the risk of tooth decay in the general population pursuant to Article 14 of Regulation (EC) No 1924/2006. The EFSA is the organization that collaborates closely with national authorities and is tasked with providing independent scientific advice and clear communication on existing and emerging risks in food products and safety 2.

Background

Article 14 of Regulation (EC) No 1924/2006 establishes the rules which govern health claims made by individuals or companies. Health claims are prohibited unless they comply with the general and specific requirements of this regulation. Article 14 is part of the regulation that lays down the provisions for the authorization and subsequent inclusion of reduction of disease risk claims. The Panel on Dietetic products, Nutrition and Allergies evaluated the evidence provided comprising over 31 publications including human intervention and observational studies, systemic reviews and other publications. The evaluation considered the effects of chewing gum sweetened with 100% xylitol and pastilles sweetened with at least 56% xylitol as compared to non-treatment 2.

Results of the Evaluation

The panel concluded that despite some studies demonstrating evidence limitations i.e. not being fully randomized for practical reasons that the higher number of studies, subjects and observation years presented, the consistency of the results and the magnitude of the effect that the cause and effect relationship established between the consumption of 100% xylitol chewing gum lead to the reduction of the risk of tooth decay in children.  The basis of this evidence is related to the consumption of 2-3grams of chewing gum sweetened with 100% xylitol at least 3 times for 5 minutes a day after meals. They also recommended that children under the age of 3years avoid chewing gum due to choking hazards.

However, the panel could not sanction the claim regarding the sweetened pastilles as the cause and effect relationship could not be clearly established conclusively from the evidence provided 2.

What is Xylitol?

Xylitol is not an artificial sweetener but a sweet crystalline carbohydrate that occurs naturally in virtually all vegetables and fruits. It is produced commercially from birch bark, corn husks and stone fruit. The average adult consumes several hundred milligrams of xylitol from fruit and vegetables daily and the body makes between 5 and 10 grams of xylitol every day in addition. Xylitol is significantly different to sorbitol, another well-known polyol, in its chemical make-up. Sugar alcohols like sorbitol have a 6 carbon structure whereas xylitol has 5 carbon atoms. This makes it unique and useful in treating a number of health related conditions including dental caries 3.

The History of Xylitol – Sweet Surrender.

Xylitol has been known to science for over a century after being discovered

by Fischer and Stahel in Germany and Bertram in France prior to the outbreak of the Great War. During the Second World War sugar shortages compelled some countries to produce alternative sweeteners with the Finnish developing a limited xylitol production facility. After the war when shortages diminished xylitol production ceased until its resurrection in the 1960’s and 70’s when scientists started to apply it to dental products. The first xylitol gum was launched in Finland and The United Sates in 1975 3.

Important Related Research

The Turku Sugar Studies (1972-5) undertaken at the University of Turku Dental School in Finland involved 125 volunteer adults who substituted the Sucrose in their diets with Xylitol. Special non sucrose based xylitol sweetened foods were manufactured for the study period of 2 years. The second test group consumed fructose sweetened food using the same protocol and the third group acted as a control with the Sucrose containing diet. During the study period the Xylitol group developed almost no new caries lesions, while more than 7 developed with the sucrose group and 4 among the Fructose group 3, 4.

The Belize Trials in Central America (1989-97), one of several submitted to the EFSA, demonstrated the benefits of xylitol over the other more the extensively used polyol, sorbitol, as a caries preventive agent. One of the trials compared groups of subjects who chewed xylitol sweetened, sorbitol sweetened and a mixed xylitol-sorbitol gum with a “no gum” control group as well as a group who chewed sucrose sweetened gum during a period of 40 months(ethically, this was questioned by some because children were subjected to an unhealthy product during this trial). The results demonstrated the 100% xylitol sweetened gum was the most effective followed by the xylitol-Sorbitol mixture. The trial determined the superiority of xylitol as compared to sorbitol. Children chewing xylitol gum developed 73 percent less tooth decay than those chewing the sorbitol 2, 3, 5.

The Mother-Child Studies (2000-2001) undertaken in Finland demonstrated that the mother or care givers use of xylitol prevented dental caries in their children. The 195 mothers were all determined to have high S. Mutans levels at the start of the study were treated with either Chlorhexidine varnish, fluoride varnish or 100% xylitol gum chewed 2 or 3 times a day for 18 to 21 months. The children of mothers treated with xylitol had the lowest levels of S. Mutans during the intervention period and follow up compared to the children whose mothers received fluoride and Chlorhexidine varnish treatments. Additionally, the children received no preventive treatment and where examined annually for caries until the age of 5. The caries rate for children aged 5 was 70% lower in the xylitol group than the other two 6. A second significant finding was that children whose mothers consumed xylitol had fewer caries incidents over a three year period compared to those who used non xylitol measures. This lead to the conclusion that the mothers and caregivers long term use of xylitol during tooth eruption successfully delays and reduces the transmission of harmful bacteria by reducing the bacteria in their mothers and caregivers mouths 7, 8.

In the Surgery

The benefits of Xylitol

The evidence for xylitol health benefits is very compelling and difficult to dismiss. It cannot be metabolized by disease causing bacteria, it reduces the accumulation of plaque on non-shedding (tooth) surfaces, it enhances remineralisation when chewed in gum by not decreasing the pH and it inhibits the growth of s.mutans in the mouth with suggestions of a permanent reduction in s.mutans levels. Chewing gum also stimulates the flow of saliva, enhancing the beneficial buffering effect in plaque.  It also has two thirds the calorific value of sucrose and has a sweetness ratio similar to ordinary commercial sugar and a low glycaemic index (GI) 3.The body absorbs carbohydrates differently thus raising blood sugars at varying rates. GI is a scientific index that ranks the effects of various carbohydrates on blood sugar levels from a value of 100 and determines the rate at which 50 grams of sugar raises these levels in 2 hours, the higher the number the faster the blood sugars are raised. Xylitol has a value of 7, sucrose is 68.

Promotion of xylitol

Xylitol is still relatively difficult to source commercially in a 100% form. However, new chewing gum ranges are becoming more accessible from the internet and smaller dental and health product companies. Granulated xylitol is also available in some super markets, online and from the dental trade industry.  With time and increased demand it is anticipated that more choice and better availability will result in an enhanced interest from the dental profession and public, cheaper products and better awareness of the benefits thus leading to greater improvements in dental and general health.

The author, as part of a smile campaign at a dental practice, recently demonstrated the dental and health benefits to the public with a xylitol taste challenge. 24 muffins were made at home using the same recipe and were either xylitol or sucrose based being cooked under the same conditions and recipe. The participants who attended the practice open day or were approached on the high street and in local shops were asked to determine the difference between the two in terms of taste, texture and look. They were also challenged about their knowledge of xylitol, its dental and general health benefits. Bespoke handouts were produced and much debate followed. The results demonstrated that nearly all participants couldn’t tell the difference and knew nothing of xylitol and its benefits before being challenged. The participants also felt both looked similar and more considered the texture of the xylitol muffin better.

Xylitol is currently being used by the author and other dental professionals in caries, fresh breath, dry mouth and remineralisation management protocols

Conclusion

Oral health has been described as being “central to our general well-being” and with the rapid changes in the field of oral health there is a “great deal to learn”10. Tickle and Milson in 2008 declared a “need to take prevention serious” and not see it a just “something to which we pay lip service”11. Indeed, In 2005 Cockcroft stated that “Oral health should be considered part of general health, addressed through evidence based interventions focusing on the underlying factors that put people at risk of disease” 12.

Debate

Xylitol has now demonstrated its health benefits internationally. Will we now promote its dental and general health benefits within our clinical environments, local and national dental health promotion strategies to the benefit of our patients and population? As xylitol becomes more accessible within the market place will the dental profession embrace this safe and EFSA endorsed natural product that has demonstrated its efficacy beyond doubt as being able to help reduce the risk of caries, one of greatest chronic diseases in the country and in other dental and health related fields?

References

1. Role of microorganisms in caries aetiology, van Houte, J Dent Res, 73: 672-81, 1994.

2. Xylitol chewing gum/pastilles and reduction of the risk of tooth decay, EFSA Scientific Opinion, The EFSA Journal 852, 1-15, 2008.

3. Xylitol, an amazing discovery for health, Makinen et al, Woodland Publishing, P 9, 2007.

4. The use of sorbitol – and xylitol – sweetened chewing gum in caries control, Burt. B, JADA, Vol. 137, Feb 2006.

5. The rocky road of xylitol to its clinical application, Makinen K, Journal of Dental Research 79 (6): 1352-1355, 2000.

6. Occurrence of dental decay in children after maternal consumption of xylitol chewing gum, a follow-up from 0 to 5 years of age,  Isokangas, P, et al, Journal of Dental Research 79(11): 1885-1889, 2000.

7. Influence of maternal xylitol consumption on mother-child transmission of mutans streptococci: 6 year follow up, Isokangas, P, et al, Caries Res 35:173-7, 2001.

8. Natural and healthy sweeteners, Allen D, Woodland Publishing 9-11, 2009.

9. Influence of xylitol consumption on mutans streptococci by infants, Isokangas, P, et al, J Dent Res 79(3):882-7, 2000.

10. Basic guide to oral health education and promotion, Felton, A et al, Wiley-Blackwell, Preface, 2009.

11. The whole population approach to caries prevention in general dental practice, Tickle, M & Milson, K. BDJ, Vol 205, No. 10 Nov 2008.

12. Choosing better oral health, Department of health Publications, 2005.  Available from: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4123251>  

Internet Bibliography

LEAF International http://www.xylitol.com/eng/index.php?page=7f310aef768c9579689ee8a2c38ce1f

The University of Turku, Finland. http://www.utu.fi/en/research/areas/xylitol_tooth_friendly_sugar.html

The European Food Safety Authority. http://www.efsa.europa.eu/cs/BlobServer/Scientific_Opinion/nda_op_ej852_art14_0158_xylitol_tooth_decay_en.pdf?ssbinary=true

 

Fluid Food for Thought – Health Benefits of Red Wine, Beer, Green Tea, and Extra Virgin Olive Oil and Recommended Dosages. A Whole Dental Health Reflective Perspective.

While 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 debate 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?

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 been found to have significant positive effects on modern non-chronic communicable diseases. There are particular interests 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.  Beneficial amounts vary between 5 to 15 grams a day being associated with a 26 per cent lower risk of cardiovascular disease (CVD).  There is also a 35 per cent risk reduction in total mortality, and a 51 per cent 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. Despite their price, I bought three sample bottles and stewarded them carefully back to New Zealand.

https://www.chateauvirant.com/en/

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, are 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 per cent) with monounsaturated oleic acid making up to 83 per cent 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 per cent, cardiovascular mortality 12 per cent, cardiovascular events 9 per cent, and stroke 77 per cent.

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 significant 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, aluminium, 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 categorically 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 sizeable 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 normal use, 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 significantly 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 adverse health outcomes of alcohol overconsumption. 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 think about 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.

Sources

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 the 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/

Honey, Propolis, Fungi and Mushrooms, Uncommon Allies in Dental Healthcare and Humanity? A Reflective Personal and Professional Journey

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 wealthy, 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 per cent 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 non-native honey 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 protecting 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 significant 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 nor vegetable, there are over 1.5 million species, 6 times more than plants. They can break down complicated 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, more extensive 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. Still, 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 protecting 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 unique 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. It also possesses osmolarity, acidity, hydrogen peroxide system (inhibin), phytochemicals, and methylglyoxal. Expectorants, containing honey, are found in the anti-cough and anti-constipation medications.  Also beneficial in 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 also been researched in the oral health context. 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, chemopreventive, 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, improving the production of cytokines IL4 and IL10 and decreasing the infiltration of monocytes and neutrophils.

Propolis has been shown to inhibit cariogenic microorganisms, as well as slowing down the synthesis of insoluble glucans.  It can hinder 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, the antibacterial effect of Iranian propolis on oral microorganisms concluded that ethanol extract of propolis is useful 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 located 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 broad 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 fungi 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. When tested in laboratory mice, it demonstrated reduced pro-inflammatory and increased anti-inflammatory responses.

Erythritol is responsible for antimicrobial 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 changed all.

The symbiotic healing relationship between bees and fungi is becoming more understood. Mushrooms have an essential 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.

Sources

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 reduce 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.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5768961/

Effectiveness of Propolis on Oral Health: A Meta-Analysis. Hwu et al., 2014.

https://journals.lww.com/jnrtwna/fulltext/2014/12000/Effectiveness_of_Propolis_on_Oral_Health__A.3.aspx

Honey for Nutrition and Health: A Review. Bogdanov et al., 2008.

https://www.tandfonline.com/doi/full/10.1080/07315724.2008.10719745?casa_token=ZYitv9nW1OcAAAAA%3A9gwW1hMAieQCF4W0RyzPZh-ZA7wyql9koKB9op9EvblPoMIEHxOwiz4Qo8yWYjHrHp_5oK6XPg2A7g

Novel Insights into the Health Importance of Natural Honey. Ajibola, 2015.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5295738/

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.

https://www.sciencedirect.com/science/article/pii/S1319562X16000231#!

Consuming Lentinula edodes (Shiitake) Mushrooms Daily Improves Human Immunity: A Randomised Dietary Intervention in Healthy Young Adults. Dai et al., 2014.

https://www.tandfonline.com/doi/full/10.1080/07315724.2014.950391?casa_token=IV08HJ-q8JAAAAAA%3AkI7_6o8u7KKK57edgEtxJo7gsSHLq_ZcPXge3ldFI15tsBV-3X4IcjVM6yv1a1OJFgrkDr4EIbLcig

Azithromycin and Whitening –

azith

Azithromycin – The Final Solution?

I have been of the assumption of late that the once “trending” use of antibiotics as a form of adding a “sledgehammer” to the healing and repair process was defunct. I was also concerned about some of the low dose, long term prescriptive practices where patients were taking pills for up to six months. Consequently I was glad to see that this fashion appeared to be less intense as once it was. My assumption has recently been challenged in New Zealand both by what I have seen anecdotally in practice and the research I have since undertaken.

I was never convinced by the clinical outcomes I saw from other methods in antibiotic or antimicrobial forms. I was shocked, moreover, by their cost in relation to their benefit and the commercial imperative driving them forward. However, Azithromycin appears to have key features that have made me listen to the facts and question them still further. I am inclined to reconsider anything thing which is low dose/exposure/cost and manageable regime with a beneficial outcome when used in combination with effective and appropriately guided non – surgical periodontal treatment.

Azithromycin first came to my attention when discussing periodontal treatment with my New Zealand dentist colleagues who raved about its efficacy. I am always suspicious of quick fixes and over use of antibiotics but the single course of 500 mg daily over 3 days made me reappraise my position and further enquire.

What is Azithromycin?

Azithromycin comes from the Macrolide group of antibiotics being used extensively in medicine for the treatment of a wide range of infections but is also effective against common periodontal pathogens. It has additional immune-modulating/anti -inflammatory effects making it different to the Amoxicillin/Metronidazole combinations which don’t. The later are also used in longer regimes (7 days verses 3) and with 12 times the dose amount.

Azithromycin is; 1

  1. A synthetic derivative of Erythromycin.
  2. 300 times more stable in acid pH then Erythromycin.
  3. Less likely to cause gastro-intestinal upsets and therefore has better patient tolerance.
  4. Able to penetrate in high concentrations into tissue (via fibroblasts and neutrophils) and phagocytic cells allowing 2 targeted routes to infected sites.
  5. Able to be taken once daily for 3 days without regard to meals.

Azithromycin has also be shown to help manage periodontitis by reduce bleeding and increase wound healing in recent studies when used in combination with mechanical debridement 2

Now I am not usually a fan of protocols if you’ve read my previous posts but upon reflection it is important to have regime which reflects the need when to prescribe such combination treatment and for it to be more formalized whilst being refined as new evidence and experiences appear.

Towards an Azithromycin protocol

Protocol for the new patient

As a result of his clinical experience, research and observations Hirsch describes the protocol for the advanced/aggressive/refractory case as: 3, 4, 5

Initial Consult OPG – P/A’

Prescribe Azithromycin 500 mg x 3 – 1 taken daily

Pre Treatment phase

Start prescription 60 minutes (Initial removal of interdental and supra plaque retention factors/biofilm and OH phase – added by MJ and NV)

4-6 weeks

Assessment/ Initial treatment phase 90 minutes

then

Treatment phase

5 monthly appointments at 45 minutes

Review phase @ 6 months OPG P/A’s

Non responding supportive periodontal therapy/maintenance relapse

Hirsch describes the non-responding cases.

Identify/assess as non-responding – OPG P/A’s

Prescribe Azithromycin 500 mg x 3 – 1 taken daily

Pre Treatment phase

Start prescription – 60 minutes (Initial removal of interdental and supra plaque retention factors/biofilm and OH phase – added by NV/MJ)

Then leave 4-6 weeks

Assessment/ Treatment Phase

2 x 90 minute appointments for re assessment and non-surgical periodontal therapy within 24-48 hours (disinfection) – added by NV/MJ

then

5 monthly appointments at 45 minutes

Review phase @ 6 months OPG P/A’s

Non responders refer to Periodontal Specialist 

References

  1. L D Abby & M V Martin (2004) Azithromycin and dentistry – a useful agent? BDJ, 197 ; 141-143.
  2. M Danesh-Mayer (2012) Pockets, pus and periodontitis Non – surgical treatment strategies. Australasian Dental Practice: July/August, p56-57.
  3. Hirsch et al (2012) Azithromycin in periodontal treatment: More than an antibiotic. J Periodontal Res Apr;47(2): 137-48.
  4. Hirsch R (2010) Periodontal healing and bone regeneration in response to Azithromycin. Aust Dent J. Jun;55(2):193-9.
  5. Hirsch R (2011) Azithromycin and periodontal treatment, http;/azithromycinperio.blogspot.co.nz/

Beautiful smile and white teeth of a young woman.

Doing the White Thing – Reviewing and Changing my Practice in the Light of Evidence, Experience and Reflection

Introduction

I must confess I am not really that smitten on whitening and that aesthetic dental hygiene practice is an anathema to me. I put it down to my seniority ( age ) and a stubborn streak in me which maybe change adverse but perhaps more so a reluctance to be seen any more than a dental disease prevention expert. This is not to say I haven’t been on whitening courses, I have worked for Philips UK as a Key Opinion Leader and have been a very, very small party to their early journey after they bought the tooth  whitening company Discuss Dental and also the training that took place subsequently. I have also been very aware of various controversies linked to the whitening industry whilst in the UK and when returning to New Zealand I felt a huge sigh of relief to get aware from it all. I was however very quick to discover it’s less strictly regulated presence in the southern hemisphere.  My challenge was to either avoid it, dabble in it lamely or embrace the health and well-being benefits of it to the patient and, in turn, the professional and financial rewards to me as its clinical deliverer.

Current Situation

The previous and very capable dental hygienist used a combination of tray systems, both night and day. They occasionally used a in chair 35% Carbamide Peroxide (CP) gel for 30 minutes, a 22 % CP for 60 -90 minutes a day and a 16% CP take home  to use at night system. They were very confident about their results. I previously used a 40% in – chair light /heat activated system in Wellington successfully, similar to what I initially used in the UK, back in the days before regulations brought change. I must confess that my preference to the in-house system has changed out of necessity as my current practices aren’t equipped or orientated towards that technique. In a big way I am glad of this because 40% Hydrogen Peroxide (HP) at 2-3 x 10 minute exposures, with the hassle of applying the light, liqui-dam, lip retractors and aspiration plus the risk of gingival chemical burns and sensitivity “zingers” at that strength was ever-present. To add to this the expectation and the price of the procedure to the patient was also at the back of my mind and probably theirs too.  It all seemed a little hit and miss to me as trays and gel were needed to continue the process after anyway so why not just stay with tray systems night or day alone? I am currently contemplating creating a protocol for both day and night systems, considering the products we have and how to employ and deliver them in my current practice now. My dilemma and reflection focuses around my personal experiences, quality research and the “here say” of my current dental colleagues, some who believe that the higher concentration gels, 35% CP,  are bad for the pulp and increase the risk of non-vital teeth, others who believe the night systems are better tolerated than day systems and vice versa. This may lead to contradiction, confusion and perhaps less effective practice. I want to create an evidence based protocol that can be used in both clinics and modified when new research or better materials appear. My protocol decision-making will centre on recent quality research and also the clinical experience of colleagues and myself as well as past feedback from my patients. I use Polawhite products where I practice see http://polawhite.kobecreations.com/en-AU/poladay-polanight

Debate

All my colleagues are agreed on night systems being 16% CP. The debate is whether 22% CP at 60 – 90 minutes or 35% CP at 15 minutes per day is more appropriate. In my experience patients when given the choice prefer day systems to night systems for a variety of reasons. I also prefer 35% CP short exposure based upon length of exposure, bulky trays in my mouth overnight and the risk of not being in control of the process. Patients have fedback to me the need to be in control of the process and I am happy to demonstrate and see them also apply the gel to the tray surfaces to confirm understand of what they need to do. I have decided also persuade them to be with me whilst the trays are in situ in my surgery for 15 minutes if 35% is chosen and a proper brief with printed handout is read and understood, as well as the process itself. I feel confident and comfortable with this process as the client experiences day whitening, the length of time required, has the opportunity to question or ask advice and is undertaken within a controlled clinical environment. Therefore,  the higher percentage of gel requires the patient to be fully informed about the process, empowered to proceed and return within the week to review shade and feedback their experience. This is also done for the other systems too. I feel very comfortable presently this whitening management protocol benefits both operator and recipient.  Will the evidence bear me out?

Research and Evidence

Costa et al (2010) indicated that bleaching with 38% HP for 45 minutes causes irreversible pulp damage in lower incisors but not in premolars .  Also, CP contains HP at a ratio of 1:3. For example, a product with 30% CP has about 10% HP. HP breaks down faster than CP, so it releases most of its whitening power within 30–60 minutes. CP, on the other hand, releases about 50% of its whitening power in the first two hours and can remain active for up to six additional hours. This affirms to me that CP is the better option for a prolonged release and less irritating to the pulp and a less concentrated gel. 1 Goldberg et al (2009) concluded that:

  1. Bleaching causes small defects at the surface and subsurface of enamel. This was a surprise to me initially but is it significant for 15 minutes a day for a week or 2?
  2. The effects on pulp are more controversial and may be inconsistent. Nevertheless, chronic treatment with peroxides may be not safe, and this could be the case when such treatments are carried out in the absence of a sufficient level of control by dental surgeons, hence the training phase is essential in my practice! 2

Meireles et al (2009) states that higher CP concentration does not increase the longevity of the whitening effect of at-home tooth-bleaching agents. One year after bleaching, both treatment groups 16% CP and 10%CP,  had the same median tooth shade, which remained lighter than at baseline.3 Therefore all are similarly effective after a year.

Protocol

I wasn’t aware of the concerns regarding enamel tooth surface change with the higher concentrations but  35% CP is advised for only 15 minutes daily which I feel can be better controlled after appropriate client training prior to use. This and a 1 week follow up and feedback is still an great option for clients who want less exposure and a quicker outcome despite the evidence that indicates a possible similar median shade  comparative to other products after a year and a risk of small enamel defects . My patients are also welcomed to use 22% CP  for longer exposure times and a reduced risk to enamel defects. This appears to be the preferred option considering the evidence. Using 16% CP for several hours at night may also need to be complimented with the option, if available, of a 10% CP product. I’ll look further into this. I will therefore use the 22% CP as the whitening preference. I am hoping that most of my patients won’t mind the time lengths required. If they do find it problematic then the 35% CP  is indicated for those who want a quicker outcome with less exposure but will be advised that there may be a small risk of enamel change if used incorrectly.

Breakdown

Take shade – Tray fit – Training in use of product – Confirm understanding – Read brief whilst product in place – Remove after 15 minutes if 35% CP – Keep in if 22% CP  for 60 -90 minutes  – 16% CP for night use only trays checked and verbal brief – All return after a week for review, feedback and shade check – Review after as required by patient.

References

  1. Costa et al (2010), Human pulp responses to in-officetooth bleaching 2008 : http://www.ncbi.nlm.nih.gov/pubmed/20303048
  2. Goldberg et al (2009), Undesirable and adverse effects of tooth-whitening products:a review http://www.dentalfearcentral.org/media/toothwhitening.pdf
  3. Meireles et al (2009), A double blind randomized controlled clinical trial of 10 percent verses 16 percent carbamide peroxide tooth-bleaching agents: one year follow up: J Am Dent Assoc. 2009 Sep;140(9):1109-17

Environmental and Ecological Oral Health

IMG_4918

Environmental Oral Hygiene – A Sustainable Approach to Whole Dental Health – Introduction and Intention

It is Monday, 6th April here in New Zealand, and the world has changed and is now a different place. The roads are quieter, the streets are empty, less the occasional dog walker and jogger, and the lockdown is solidly in place. A peculiar sense of calm is reinforced by the bird song outside, the environment and habitat seemingly swelling to fill the void of lost modernity. The natural world appears to be benefitting from the lack of human activity too, far fewer cars and planes travelling the streets and airlanes, fewer emissions and, thankfully, less pollution also. The deadly epicentres of the COVID 19 impact, Italy, Spain, Wuhan and New York are experiencing significant improvements of air quality and, strangely too, wild animals, in some places, are seen visiting empty neighbours, once teeming with people.

This novel  COVID 19 experience, from my own particular professional perspective, has created an eerily ideal learning opportunity.  It has presented the opportunity and time to complete a project I began over a year ago finally presents itself. In turn, I will reflect upon it and consider my options and choices regarding whether the economic and financial fallout post-COVID 19 allows me to return to my clinical normality, perhaps.

The project, called Whole Dental Health, began as an idea to implement professional development as part of a nine-week career break between jobs and places. The journey, I called it an odyssey, some might have classed it as a sabbatical, took me to France, the UK and the States. It was a moment in time to test previous learning, undertaken in an action research model of new knowledge creation. It allowed me the space to open up the subject matter, a follow on from the odyssey, where I felt the need to fill knowledge gaps in my present clinical headspace. I had reams of paper, stapled into studies, gathering dust over the months since they were printed, awaiting this moment. I had no excuse and every cause to venture into them. How would I approach the creation of meaning from all of this information? What would be my approach? The action research model would remain, but I also wanted not to feel too restricted by an overtly academic model. I wanted it to feel real, to me, to be an honest and authentic record of the journey.

The choice of a storytelling approach to the project is anathematic of authentic learning and action research. It is particularly indicated with explaining a process or a journey reflectively, where you guide your own learning based upon where you feel you have a need to improve or create new knowledge in particular subjects or matters within your workplace. You become the self-directed learner, you empower your quest for it through a guided process, it being authentic and genuine as it is explicitly applicable to you. Your research, critically appraises, creates and designs ways in which you can test its validity, reflect upon those outcomes, change, implement or reset the parameters or if unsuccessful, try again in a different way. Creating new knowledge, in an open-ended and critical way maybe seem by others in written words, like this, published and disseminated through social media platforms or presented to a professional audience of some kind. Both are a form of peer review and can be, by our colleagues, challenged, adopted or adapted for their own practice to the benefit of their clients.

Ironically, in this time of great global upheaval and change, comes to the New Zealand Dental Healthcare profession change as well. This brave new learning world has the potential to seriously test and challenge the will, intentions and adaptability of all concerned. Traditional continuing professional development (CPD) regulated, via The New Zealand Dental Council (NZDC), in verifiable and non-verifiable formats were expressly set numbers of hours had to be completed, demonstrated through a portfolio of evidence if required by the council as part of an audit. These audits, conducted on about ten per cent of the re-registering dental body every CPD cycle, I feel, made the need to meet the expected numbers higher than achieve appropriate learning, essentially detracting from the real need for authentic, individual education. So I was to my great surprise and delight that several weeks ago the NZDC announced the intention to restructure its current CPD cycle. In will come, as from next March, the new paradigm incorporating the creation of a Professional Learning Plan (PDP), designed Professional Learning Activities (PDA) and a formal personal peer relationship with some you can nominate yourself. The most exciting part of the new direction, however, was the need to undertake written reflection on the learning outcomes from PDA’s you have proposed and made through you PDP, and this in turn, discussed with your peer reviewer and validated as such via an online portal.

The thought that hundreds of dental healthcare professionals undertaking work-related, personally guided and relevant learning with the intent to write it up and it be reviewed may sound quite revolutionary to some, complicated and unnecessary to others. However, it needs to be borne in mind this process is already done by many, especially clinical nurses, midwives and other allied healthcare workers. What this does demonstrate, in my humble opinion, however, is that the New Zealand dental profession is finally catching up with allied healthcare professionals too and that the good old days of mathematical calculations for gaining re-registration has gone. There is no need for the numbers game anymore, just, I hope, the intention to gain quality self-directed education. It is now time for it to be appropriate to one’s workplace and associated practise, to authentically apply it into practice. Additional reflection, a new skill to learn for some, upon its process, perhaps modify or adapt this new knowledge creation, guided with peer support and review. The need for the dental trade industry to get its grubby pores into it will hopefully diminish and, if continued, be more relevant to the clinical spaces of practices and not for cynical influence and gain.

So, finally, over the next few weeks expect posts related to authentic learning and action research, future professional development, oral health, related to systemic and metabolic health, diet and nutrition-related to dental caries and periodontal diseases, the oral microbiome, fluoridation, saliva and pH, alternative antimicrobials ( in particular honey ), sustainability and the creation of a philosophy related to those.

witches

Joellen Coates – University of Wyoming – Honours Thesis – “Got Teeth? How the Oral Microbiome and Diet Affects our Oral Health and the Future of Dentistry.” Aligned with Whole Dental Health? A Reflection.

“The roots of education are bitter, but the fruit is sweet”. Aristotle

When I began the initial research phase for part 2, I pondered the possibility that the subject matter about the aims and goals of Whole Dental Health and the principles I want to pursue professionally here in Nelson had already been published! I came up this nugget of theological gold courtesy of Joellen Coates, a thirty-plus page of her Honours Capstone Project. This is undertaken in the final year of tertiary learning by some educational establishments. It is a unique and very personal and self-directed process by which the individual learner can develop a thesis, develop and establish new knowledge, test it and formulate a learning premise that ultimately goes towards the final grade and graduation. 1, 2 Her thesis looks closely at the human oral microbiome, its constituent parts, it’s history, present and potential future in regards to unlocking its potential to impact the direction of oral health in the future by understanding its very nature better.

She sets the historical context, beginning with hunter-gatherers, then progressing into the Neolithic Period when Palaeolithic man moved from a seasonal and mobile dietary life into an agricultural. This was when the Neolithic people stayed landlocked within the confines of the cereal sown and cattle raised, nearly starting about ten thousand years ago. With this change in dietary lifestyle comes a shift in dietary, behavioural changes. This brings on oral microbial changes leading to dysbiotic changes to oral flora.  This is demonstrated by increasing archaeological evidence of increasing dental diseases, namely caries and periodontitis.

“For the first half of geological time, our ancestors were bacteria”. Richard Dawkins

The several hundred or so bacterial species of our oral microbiome combine with other microorganisms such as fungi, viruses, archaea and protozoa to construct our complex and diverse ecological communities. They have done so from days in memorial. In healthy subjects, they display great diversity and health benefits. It begins before birth with some early pioneering bacterial species culturing the unborn mouth via the umbilical cord, amniotic fluid onward into the developing foetus. During delivery, more significant seeding is initiated by contacting the mother’s vaginal microbiome and contact with their skin, being further reinforced through breastfeeding and so on and so forth throughout life. The development of a functional and balanced oral microbiome has begun. How this community of diverse microorganisms can afford dental and general health benefits is the subject of modern research and, more so, how its disturbance can lead to a host of dental diseases is the subject of my interest.

“The important thing is not to stop questioning. Curiosity has its own reason for existence”. Albert Einstein

Within ancient dental calculus holds the clues and answers within highly preserved bacterial types, their cellular components and DNA. Careful analysis reveals that Neolithic farmers saw a significant increase in the consumption of fermentable carbohydrates as opposed to their cave-dwelling ancestors, in this case, the higher consumption of cereals, such as we do today.  Studies demonstrate that modern microbiomes are “less diverse compared to ancient samples and could be composed of more opportunistic cariogenic bacteria”. Conversely Pre – Neolithic populations were rarely affected by dental diseases. 3

Baumgartner and co-workers in 2009 designed a simple study that took Swiss students from a modern Swiss diet.  For a month, subjects ate a Stone Age type diet to determine the effects of a lack of modern oral hygiene on the oral microbiome and the presence of gingivitis. The results indicated a change and growth in the oral microbiome.  Less pathogenic bacteria were present, and a significant decrease in the signs and symptoms of gingivitis was observed. This simple and less rigorous research brings up many further questions as well as a need for more detail regarding its process. The next paragraph will look a little deeper into it.

The sample size was small, ten subjects, in one group and the study length was just four weeks. Microbiological samples were collected at the mesiobuccal aspects of all teeth and from the dorsum of the tongue. All ten subjects had no periodontitis. The results from samples gathered after four weeks demonstrated mean bleeding on probing decreased from 34.8% to 12.6%, plaque scores increased from 0.68 to 1.47. Periodontal depths also showed changes which decreased at sites of sampling by 0.2mm. All three measured a P-value of <0.001, indicating that the results have less than one in a thousand chance of being wrong. The bacterial profiles had a higher growth count for 24 of 74 species despite the reduction of pathogenicity.

The elimination of refined sugars decreased the risk of gingivitis in the absence of traditional oral hygiene methods, despite the increase in plaque levels. This demonstrates that beneficial and symbiotic bacteria thrived in the oral microbiome in the subjects tested over four weeks without the benefit of oral hygiene or the consumption of a modern style Swiss diet. 4

The oral microbiome is continuously exposed to the elements and pressures of the external environment and needs to treated, in the same way, as a precious ecosystem. The oral microbiome utilises nutrition supplied from the hosts’ diet, their saliva flow, enzymes and minerals. It is ecological disruption, and dysbiosis can stem from reduced saliva flow rates, quantity and quality, illness, stress, poor diets and even genetics.

“Is your diet really nutrient-dense”? Dr Weston A. Price

Importantly, dietary changes since hunter-gatherers have dramatically changed. The simple food staples they once gathered have become processed, starting in Neolithic through to the modern, Industrial Periods. These have fundamentally altered seven crucial nutritional characteristics of our old ancestral dietary habits. These include glycaemic load, fatty acid composition, macronutrient composition and micronutrient density, acid balance, sodium-potassium ratio and fibre content. Glycaemic loading, fatty acids (Omega 3’s), acid balance and macro and micronutrient contents will, in particular, prove crucial regarding the oral-systemic interface of dental health and development. The controversial works and research of Weston A Price will need further examination in a quest for higher knowledge and connection to modern-day alternative lifestyle and medical cultural ideology and practice. 5

The future of dentistry concerning the oral microbiome, let along with everything that appears to be happening in the world right now, is ripe for discovery. The benefits of a balanced, beneficial and healthy oral microbiome and, in turn, how we decide to directly or indirectly affect and influence it to our dental and general health benefit requires our attention. Poor nutritionally based diets, with emphasis on the consumption of processed rich foods, in particular fermentable carbohydrates, promote less diversity and imbalance of our oral ecology. This must become an innate message to our clients who suffer from dental diseases, no matter how mild or severe they present.

“Natural ecosystems regulate themselves through diversity.” Big Little Farm

Finally, what we think, or are led to believe, helps us control and manage oral health issues may actually be more in the way we chose to live and eat and less that comes out of a tube or bottle. The stresses and pressures in our everyday lives, the foods we chose to consume and the ability to manage not only our daily oral hygiene habits effectively but how we sustain and maintain the diversity and symbiosis of our oral microbiome as a whole is vital.

Sources

  1. Coates J, 2017. Got Teeth? How the Oral Microbiome and Diet Affects Our Oral Health and the Future of Dentistry.
  2. Capstone Project. https://youtu.be/CWxwwLP2THU
  3. Alder CJ et al., 2013. Sequencing ancient calcified dental plaque shows changes in oral microbiota with dietary shifts of the Neolithic and Industrial revolutions.
  4. Baumgartner S et al., 2009. The impact of the Stone Age diet on gingival conditions in the absence of oral hygiene. https://www.ncbi.nlm.nih.gov/pubmed/19405829
  5. Cordain, L et al., 2005. Origins and evolution of the Western Diet: health implications for the 21st Century. https://www.ncbi.nlm.nih.gov/pubmed/15699220

The Oral, Systemic and Metabolic links to Whole Dental Health. A Personal Journey and Overview

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 determinants 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 apnoea, 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 recommending 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.

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.

Sources

  1. Tonetti, S. et al (2017). Impact of the global burden of periodontal diseases in health, nutrition and wellbeing of mankind: A call for global action. Journal of Clinical Periodontology.
  2. Jin, L. et al (2016). Global burden of oral diseases: Emerging concepts, management and interplay with systemic health. Oral Diseases.
  3. Chapple, I (2014). Time to take periodontitis seriously. BMJ.
  4. Jepsen, S. et al (2017). Prevention and control of dental caries and periodontal diseases at the individual and populational level: consensus report EFP/ORCA workshop. Journal of Clinical Periodontology.
  5. Poulton, R. et al (2002). Association between children’s experience of socioeconomic disadvantage and adult health: A life-course study. The Lancet.
  6. Watt, R. & Sheilham, A (2012). Integrating the common risk factor approach into a social determinents framework. Community Dent Oral Epidemiology.
  7. Aas, J. et al (2005). Defining the normal bacteria flora of the oral cavity. J. Clin
  8. Amar, S. & Ham, X (2000). The impact of periodontal infection on systemic diseases. Med Sci Monit.
  9. Scamapieco, F (2013). The oral microbiome: Its role in health and in oral and systemic diseases. The Lancet.
  10. Lloyd-Jones, D. et al (1999). Life time risk of developing coronary heart disease. The Lancet.
  11. Blaizot, A. et al (2009). Periodontal diseases and cardiovascular events: Meta-analysis of observational studies: Int Dent J.
  12. World health report (2004). Changing history. World health organization.
  13. Mortality 2016 Data Tables (Provisional) (Ministry of Health, 2018)
  14. Shmerling, R (2018). Gum disease and the connection to heart disease. Harvard Health Publishing.
  15. Batty, D (2018). Oral health and the coronary heart disease: Cohort study of one million people. European Journal of Preventive Cardiology.
  16. Philstrom, B. et al (2005). Periodontal diseases. The Lancet.
  17. Garcia, R. et al (2000). Relationship between periodontal disease and systemic health. Periodontol.
  18. Scamapieco, F (2005). Systemic effects of periodontal diseases. Dent Clin North Am.
  19. Haumschild, M. & Haumschild, R (2009). The importance of oral health in long term care. J. Am Dir Assoc.
  20. Kane, F (2017). The effects of oral health on systemic health. General Dentistry.
  21. Alpert, P (2017). Oral health: the oral-systemic health connection. Home care Manag Pract.
  22. Naito, M. et al (2006). Oral health status and health related quality of life: a systemic review. J.Oral Sci.
  23. Deshpande, N. & Amrutiya, M (2017). Obesity and oral health-is there a link? Pub https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5803880/
  24. Dursun, E. et al (2016). Oxidative stress and periodontal disease in obesity. Pub Med. https://www.ncbi.nlm.nih.gov/pubmed/27015191
  25. Roberts, C. & Sindhu, K (2009). Oxidative stress and metabolic health.https://www.sciencedirect.com/science/article/abs/pii/S0024320509001003
  26. Marchetti, E. et al (2012). Periodontal disease: the influence of metabolic syndrome. BioMed Central.
  27. Lamster, I. et al (2017). Periodontal disease and the metabolic syndrome. https://pubmed.ncbi.nlm.nih.gov/26280008/
  28. Daubt, L, et al (2018) Association between metabolic syndrome and periodontitis: a systematic review and meta-analysis. https://www.ncbi.nlm.nih.gov/pubmed/29846383

IMG_4921

 

Sustaining Host and  Ecological Co-existence within the Habitat of the Mouth. A Whole Dental Health Journey

From David Attenborough to Greta Thunberg, we are actively, perhaps reluctantly, being driven into an age of greater environmental awareness, or to be more honest it appears, a lack of it. There is an increasing urgency in preventing irreparable damage to the ecology of our planet, reducing global warming and protecting innumerable endangered species, we included. This, despite us being willing antagonists and unbeknownst victims, 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 principals 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 burgeoning global pressure groups and political movements championing the cause of protecting the environment. Then we have our workplace and “clinical” settings, the materials and energy we consume and their carbon footprints from the source. The oral model is the 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 collaborative and aware of their potential dental and health benefits?

We “seek to provide patients with a holistic dental experience that is aimed at providing the best dental preventative care”. Quin 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 is 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 colonisation. Soft, rough and sleek surfaces shed and slough material regularly, providing residence for microscopic guests with a mixture of gases flowing in and out. Within it are 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?

Our oral microbiome (OM) is a natural structure and has a symbiotic relationship with us, the host, delivering essential health benefits in sustaining a mutually shared ecological coexistence. We as humans form a superorganism 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 per cent 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 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 in which the diversity and relative proportions of species or taxa within the microbiota are disturbed, potentially 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 more copious amounts of more highly processed food and drink. The external environment with the 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;

  • Digestive tract, stimulating mucus production.
  • Resisting pathogenic colonisation.
  • Regulation of the cardiovascular system.
  • Host defence mechanism.
  • Production of anti-inflammatory properties.
  • Bodies metabolic potential and antioxidant activity.

A curious example of how the OM support systemic health is in its supplementation of the hosts Nitric Oxide production, unknown until recently by myself. It helps reduce dietary nitrate converting it to nitrite, in turn having the potential to provide critical symbiotic functions in human blood pressure physiology. Adverse 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;

  • Lubrication, helping in speech.
  • Dilution of sugars from food and drink intake.
  • Antimicrobial action through proteins and peptides including mucins, lactoferrin, lysozyme, lactoperoxidase, statherin, histatins, and secretory immunoglobulin A.
  • Buffering of acids from low to higher pH.
  • Providing a substrate that supports the growth of beneficial bacteria.
  • Remineralisation and repair with the saturation of calcium and phosphate into saliva and teeth.

Also Saliva;

  • Prepares food before digestion, enhancing chewing and swallowing, then clearance.
  • Aids digestion and food breakdown chemically with enzymes.
  • Enhances tasting.
  • Acts as a delivery system for components of innate and adaptive host defences.

Saliva is a solution composed of 99 per cent water, 1 per cent 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, which 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 supersaturated 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 various forms, either in gum or lozenges, added to toothpaste 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 the development of cariogenic bacteria such as 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;

Reduced plaque weight and counts of S. mutan in saliva and dental biofilm. Erythritol benefits include;

Effective absorption via the small intestine and is not systemically metabolised, being excreted unchanged within the urine.

  • Zero increases in blood sugars or insulin.
  • Non-caloric benefits and higher gastrointestinal tolerance.
  • Possible improved endothelial function in people with Type 2 Diabetes.
  • Less maturation of oral biofilms and may contribute to healthy oral ecosystems.

Prebiotics are compounds found in food that induces 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 their reduction of dental caries, but promising research in certain strains of Streptococcus has been found to express arginine deiminase. This helps to inhibit the growth and block critical 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”.  Mark James RDH NZ

This bellies the benefits of environmental, ecological and sustainable approaches to dental disease prevention. We must consider 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 the 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 the application of my interpretation of holistic and sustainable practice.

Sources

More than half your body is not human. https://www.bbc.com/news/health-43674270

In Sickness and in Health-What Does the Oral Microbiome Mean to Us? An Ecological Perspective. Marsh, 2018. https://www.ncbi.nlm.nih.gov pubmed/29355410 /

Can xylitol used in products like sweets, candy, chewing gum and toothpaste help prevent tooth decay in children and adults? Riley et al., 2015. https://www.cochrane.org/CD010743/ORAL_can-xylitol-used-in-products-like-sweets-candy-chewing-gum-and-toothpaste-help-prevent-tooth-decay-in-children-and-adults

Effect of erythritol on the microbial ecology of in vitro gingivitis biofilms. Janus et al., 2017.

https://www.ncbi.nlm.nih.gov/pubmed/28748040

Exploration of singular and synergistic effect of xylitol and erythritol on causative agents of dental caries. Koljalg et al., 2020. https://www.nature.com/articles/s41598-020-63153-x?proof=trueMay%252F

Erythritol Functional Roles in Oral-Systemic Health. De Cock, 2018. https://journals.sagepub.com/doi/full/10.1177/0022034517736499#

The role of natural salivary defences in maintaining a healthy oral microbiota. Pederson & Belstrom, 2019. https://www.sciencedirect.com/science/article/pii/S030057121830335X

Oral microbiome and health. Sharma et al., 2018. https://www.ncbi.nlm.nih.gov/pubmed/31294203

Erythritol Is More Effective Than Xylitol and Sorbitol in Managing Oral Health Endpoints. De Cock et al., 2016. https://www.hindawi.com/journals/ijd/2016/9868421/

The Effect of Xylitol on the Composition of the Oral Flora: A Pilot Study. Soderling et al., 2011. https://www.thieme-connect.com/products/ejournals/pdf/10.1055/s-0039-1698855.pdf

The effect of xylitol on dental caries and oral flora. Nayak et al., 2014. https://www.ncbi.nlm.nih.gov/pubmed/25422590

Xylitol and sorbitol effects on the microbiome of saliva and plaque. Rafeek et al., 2019. https://www.tandfonline.com/doi/full/10.1080/20002297.2018.1536181

https://www.nature.com/articles/bdjteam2015123 Saliva A review of its role in maintaining oral health and preventing dental disease. Dodds 2015. https://www.nature.com/articles/bdjteam2015123

Oral microbiomes: more and more importance in oral cavity and whole body. Gao et al., 2018. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5960472/

Human Oral Microbial Ecology and Dental Caries and Periodontal Diseases. Liljemark & Bloomquist, 1996. https://journals.sagepub.com/doi/abs/10.1177/10454411960070020601

The oral microbiome – an update for oral healthcare professionals. Kilian et al., 2016. https://journals.sagepub.com/doi/abs/10.1177/10454411960070020601

Oral Dysbiotic Communities and Their Implications in Systemic Diseases. Sudhakara et al., 2018. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6023521/

The oral microbiome: A Lesson in coexistence. Sultan et al., 2018. https://journals.plos.org/plospathogens/article?id=10.1371/journal.ppat.1006719

Frequency of Tongue Cleaning Impacts the Human Tongue Microbiome Composition and Enterosalivary Circulation of Nitrate. Tribble et al., 2019. https://www.frontiersin.org/articles/10.3389/fcimb.2019.00039/full

The role of natural salivary defences in maintaining a healthy oral microbiota. Pedersen & Belstrom, 2018. https://www.sciencedirect.com/science/article/pii/S030057121830335X

 

Action Research, Reflection and Inquiry Learning

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Context – The First Step in this Long Journey of New Knowledge Creation through Action Research 2017

This somewhat alternative looking post is the back story and early learning knowledge creation that lit the touch paper for wholedentalhealth.com. It was presented twice to professional audiences in Nelson and Auckland in 2017. It was the outcome of extensive nutritional research carried out over the previous months when the opportunity arose. This usually occurred during twice-daily dog walks and even during a 5-day cycle through Central Otago, I kid you not. The intention was to fill a vast knowledge gap regarding nutrition and dental health primarily. It, however, soon morphed into a far bigger project as more and more associated health-related material was discovered. What you see before is just a snippet, relevant though, of the presentation delivered on those days. The title really says it all, especially concerning the ongoing nature of learning that followed but also the contrary process of understanding the nutritional relationships between the mouth and the body. It revealed the politics, personalities and clashes between the ideologies of the time, and their effect upon the future of dentistry, and my dental landscape in particular.

The learning aims leant heavily on the available research gleaned from the internet from reliable sites like PubMed and Cochrane, but a lot came from books and news publications.  Some of these appeared in the public domain way before my birth. There seemed to be a massive disconnect between the established science and the voices of some very learned and passionate voices in the medical field. It also became very apparent that current thinking was very slowly unravelling, becoming less convincing and harder to justify within the new age of scepticism and scrutiny. The internet was acting as a courtroom, podcasts and publications contradicting and challenging the present status quo and beliefs. This wasn’t being done in some callous, half-hearted manner but within the bounds of scientific methods and criteria. The most prominent exponents of these were journalists using their talents at spotting a rotten apple and getting their teeth, so to speak, into the meat of the matter, finding obfuscation, contradiction and blatant misleading by the elements of the medical establishment, and the confounding of the public at large. Ego, money, power and persuasion appeared deeply rooted.

Take, for example, the very public journeys of one Ancel Benjamin Keys and a the lesser known, it seemed at the time, John Yudkin. One American, fresh from the nutritional fame of the World War 2 K ration design for US troops and a marked political influencer on one Dwight D. Eisenhower, American President and multiple heart attack sufferer. Key’s diet-heart hypothesis ran contrary to that of John Yudkin, a British scholarly and published Academic. His assertion was that sugar, refined carbohydrates, in particular, was the primary antagonist in the marked decline in modern health, associated with changing lifestyles and behaviours. Both men published books to back up their ideological and theoretical positions.

It was at this time that the scientific method of epidemiology saw its debut. It involved gathering data and assimilating findings into hard data, interpreted with graphs displaying mathematical statistics, revealing answers to scientific questions regarding the particular population being studied. It became a new feature to the public, demonstrating the significance, both colourfully and persuasively, of their research findings and advancing their theories into mainstream policy making. Yudkin, unfortunately, was the loser in this alternative scientific heavyweight contest. His reputation was besmirched by the darling of the medical and political establishment, Ancel Keys, with his subsequent funding for his important future research drying up, and his academic reputation in tatters. The legacy of which is now that of sugar laden processed diets of our modern society, an anathema to our ancestral dietary roots. The demonising of saturated fat continued until recently when investigative journalists sought to demonstrate Yudkin’s assertions and theories would have had a far more positive impact on global health.

The use of visual evidence to demonstrate the correlation of dietary behaviours to disease outcomes was in its infancy. Evidently too, it was also possible to “cherry pick” and select positive data to affirm a position or article of faith, in this case nutritionally. Data gathering on countries with diets that could have confounded the statistical charts was absent or ignored. Evidence was also presented in biased ways, focusing on men, of a specific age, not adjusting for cultural, religious, climatic or physical facts, information that could spoil the effect and positive power of the curve. These charts presented powerful arguments to those in positions of authority and influence. More funding and research would follow, and advice given to the politicians and people of the world, fearful of the negative health implications of fat in their diet, subsequently changed the food industry as we then knew it.

However, recent emerging evidence from critical investigation by determined journalists and medical specialists is challenging the gated medical establishments standpoint. This has been potentiated by the freedom offered by social media, the internet and activistic pressure groups. New research is reversing the belief that saturated fat is bad but is also demonstrating its potential health benefits.

The project made me consider me pre-existing beliefs, one specifically opened up a glaringly obvious omission, that sugar is was only implicated in dental caries. Low and behold the lightbulb moment when the penny dropped on that one. I was stunned, and somewhat crestfallen, some of these studies go back many years. Why wasn’t this part of my training way back  in the mid-eighties?

My critical deep dive into learning also drew my attention to nutritional changes beyond simple sugars. The micro-nutrient components of food, minerals and vitamins essential in the maintenance of good oral health and the development of the mouth, required my attention too. The presentation looked closely at essential fatty and amino acids, as well as, omega 3 and 6 levels, and their role in reducing systemic inflammation. It seemed strange but wholly appropriate to make the association between the mouth and the rest of the body. The paradox that both are separate and neither the twain shall meet now, in itself is plainly inappropriate. What and how we eat, the function of our teeth, their bony support, blood supply and innervation are all connected to the whole well-being and function of our bodies. This also brings into context the holistic approach to practice, more food for future investigation. Further to that it made me consider the endocrine system, chemical messengers, namely hormones, which are intrinsic to the health of our bodies, by regulating hunger or satiety, and chemical communication. But when imbalanced and influenced by poor nutritional choices, may promote addictive habit forming behaviours which can add significantly to the plethora of chronic diseases plaquing dental health like diabetes and obesity.

The experience of this process alerted me to the need to encompass nutrition as part of my workplace practice. It now plays an even larger role in improving oral health, both directly and indirectly. Having a greater general knowledge allows me to better understand client general nutritional behaviour and preferences. The understanding of individual health ideology, for example clients who are vegan, vegetarian or carnivore, allows me greater awareness of how best to adjust or adapt a tailored dental health message.

Future learning will be directed at the nutritional and behavioural role in maintaining and promoting healthy oral flora, our mouths ever present microbiome, part of our bigger, personal bacterial picture. What foods can support or imbalance this important and potentially beneficial ecology in our mouth? Which dietary choices can lower or elevate the mouths critical pH balance? Co-existing with our acquired oral and general bacteria can afford us benefits in health and well-being as much research is now demonstrating. Therefore promoting an environmental and ecological approach to oral health maintenance is the future direction of my personal practice.

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Action Research – At the beginning

I was never really academic at school, much to my father’s consternation. He was Edwardian in his manner, distant, expecting but caring. 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 fact. 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 freedom 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

Learning

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 contrasting 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.

Experimental 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

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 personal 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.”

Action researchers;

  • Identify a research issue
  • Identify research aims
  • Design a research plan
  • Gather data
  • Establish a criteria and standards for judgement
  • Generate evidence
  • Make a claim to knowledge
  • Submit the claim to critique
  • Explain significance of work
  • Disseminate findings
  • Link new and old knowledge

McNiff and Whitehead, Action Research (2011, p.26)

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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. An 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. 

“Continuously review your knowledge, skills and professional performance. Reflect on them, and identify and understand your limits as well as your strengths. “
Professional Standards in Dentistry, GDC, UK

O’Hehir University Project Part 1: A DCP Pilgrims Progress – A Simple Journey into Dental Health Improvement

The term “journey” nowadays seems to be a noun guilty of gross overuse. However, I feel it’s very roots are founded in our great English literary past. John Bunyan, (28 November 1628 – 31 August 1688) an English Christian writer and preacher, wrote in allegorical terms about one such very famous journey. First published in 1678 and written whilst Bunyan was imprisoned in Bedford Jail it follows the journey of an everyman character called Christian. This “burdened” individual sought guidance and deliverance from his sin and guilt and along the way encounters both good and bad people and events including “the Slough of Despond”, a physical swamp of despair, only to be pulled out by Help. He is finally led to the “Place of Deliverance” where the shackles and straps of his many burdens are freed. Christian mirrors my own journey in many respects, one of continuous trials, occasional success, support and the odd moment of deep despair. I am now certain of one reality, I am nearing my proverbial place of deliverance. How do I know that? Professionally I have been, seen and done many things and feel am now completing my professional circle by returning to a simple, deconstructed and stripped back approach to dental health promotion. Perhaps this is where I should always have been (MIHygienist, 2012a).

Observation

People’s minds are changed through observation and not through argument. Will Rogers
I seek a new challenge, one which wants to deliver better simple dental health outcomes to my patients – but why? And more over, what is the best way to achieve it? My Strengths, Weaknesses, Opportunities and Threats (SWOT) assessment indicated to me the need to introspectively look at what I do in practice and affect or influence others to be like-minded. I can easily criticise other clinicians for delivering a poor and less focused dental health message but I need to examine myself too. An appraisal of this determined I was doing a good job but I still I know I can improve my performance further and would like to know how (MIHygienist 2012b &c).

What is Dental Health?

Is the pure message of dental health being diluted by less preventive and more lucrative treasures? Perhaps I am too cynical by half nowadays but worryingly I found no dental health definitions from our Professional major players and had to, instead, go straight to the top to finally discover one. The World Health Organisation (WHO) state the “Oral health is a state of being free from chronic mouth and facial pain, oral and throat cancer, oral sores, birth defects such as cleft lip and palate, periodontal disease, tooth decay and tooth loss, and other diseases and disorders that affect the oral cavity”(WHO, 2013).The Department of Health (DoH) determine that Dental health is a “Standard of health of the oral and related tissues which enables an individual to eat, speak and socialise without active disease, discomfort or embarrassment and which contributes to general well-being. Oral health is integral to general health and should not be considered in isolation (DoH, 2006).
In the UK regulators and professional bodies direct my continuing clinical journey. I am tasked to apply up-to-date knowledge, provide dental hygiene care and skills to a wide range of patients ethically (GDC, 2009). Additionally, clinical governance promotes criteria for successful learning that is founded on what is already familiar to the learner, is owner led and participated, problem-centred, self-resourced, built on previous experiences, and involves relevant and timely feedback and elements of self-assessment (Ratten et al, 2002). This linked to our professional standards which advocate providing a “good standard of care based on available up-to-date evidence and reliable guidance” and “putting patients’ interests before your own or those of any colleague, organisation or business” as well as “maintaining your professional knowledge and competence” (GDC, 2005) sets the legal framework for my project.

Critical Enquiry

Periodontal diseases and caries are both major acute and chronic diseases known to mankind and are of complex multifactorial bacterial, health and lifestyle origin. The 2009 Adult Dental Health Survey indicates that 31 per cent of adults had obvious tooth decay in either the crowns or roots of their teeth but the pattern of decay since 1998 has decreased from 46 per cent to 28 per cent. 45 per cent of adults had periodontal pocketing exceeding 4mm but only 17 per cent of dentate adults had very healthy periodontal tissues and no periodontal disease.

Disturbingly 75 per cent of adults claim to clean their teeth at least twice a day whereas 23 per cent of adults said that they cleaned their teeth once daily. A surprising 78 per cent said that they had been given advice by the dental team on cleaning their teeth and/or gums. 66 per cent of dentate adults had visible plaque on at least one tooth. The survey continues to claim, contradictorily in my opinion, that “Whilst twice-daily brushing is now a fact of life for three quarters of the population, there is still some room for improvements in the effectiveness of that cleaning” (DoH, 2011). I can only surmise that despite the great exposure to “the” dental health message more “smart” and “simple” targeted advice is required in at the “clinical coal face” and elsewhere besides.

“Simplicity is the ultimate sophistication”. Leonardo da Vinci

Action Research – The Vehicle

Action research commits the critically enquiring clinician to improve their individual practice by creating and measuring new knowledge, collaborating with others for social good in a personally accountable and value driven context (McNiff and Whitehead, 2011). Such projects are far removed from traditional methods of enquiry being centred in the individual workplace in a vital, living context, far removed from theory derived outside of the reality of clinical life. The action reflection model follows a logic course unravelling and structuring the activity of the individual. Reason and Bradbury (2008) identify such a project as “First – person research” (me) and is of a kind “that enables the researcher to foster an inquiring approach to his or her life, to act choice fully and with awareness and to assess effects in the outside world while acting.”

I had originally wanted to compare two patients groups in a blinded and controlled manner but after discussion with my mentor I changed from this pretext as it required unnecessary ethically approval with a time delay, complexity and was less driven by the values of action research. I can achieve my learning, discover truths, and by doing so improve and move my practice forward for professional and social benefit in action research.

Into Action

“Fortune Favours the Prepared Mind”. Pasteur

I want the project to focus on simple delivery of a focused dental health message which, I believe will contribute significantly to reducing “active disease” in the gums and teeth by more effectively reducing and deconstructing dental biofilm levels. I also want to demonstrate improving Basic Periodontal Examination (BPE) outcomes but more importantly changes in perception of dental health in my patients. Markman (2012) in his book “Smart Thinking” advocates the role of three in developing high quality knowledge and learning. My action plan will test this theory of a culture of smart by linking existing knowledge, in this case what they currently do as part of their dental hygiene activity, to remembering three things about their interaction with me, namely brushing, interdental cleaning and fluoride advice. (MIHygienist, 2012d) The VAK (aka VARK) learning model postulated by Fleming and Mills (2010) and states four types of learning styles. I am focusing on three listed below as the written (R) will be handed out to the patients in a leaflet.

  1. Visual learners – Preference for learning by seeing
  2. Auditory learners – Preference for Listening and learning
  3. Kinaesthetic learners or tactile learners – Prefer learning by experience

I therefore want to use a role of three model that encapsulates all of the above.

  1. The model – Visually demonstrated
  2. My mouth – Visual and Auditory (and less threatening)
  3. Their mouth – Kinaesthetic, tactile whilst confirming understanding

Protocol
The project form will be given to each patient, over 120 to make the results more meaningful, twice over a project period of 4 months. The design of the form is composed of 2 parts, an initial enquiry into the patient’s current dental health behaviour and a BPE probing and a simple question on how they feel they learn (MIHygienist, 2012e). The appraisal and reflective part concludes the process. I don’t think it will take too much time to complete but the real challenge is determining who to select as some people don’t use a Braun Oral B (most do however) . I have decided to focus on those who use Braun and Manual Brushes as the company have supplied me these products to aid the project. Floss picks I will supply myself. The BPE will measure whether dental health has improved individually and as a whole and the questions will be audited to determine potential behavioural change. I will reflect on those and myself professionally as a consequence of the project.

Conclusion

“Finally, from so little sleeping and so much reading, his brain dried up and he went completely out of his mind.” Don Quixote

I anticipate the need to modify certain aspects of my project upon evaluation will occur. I welcome this and am willingly intent on learning from the outcome and then move on to something else that needs a similar deconstruction job doing to it. I believe that by following action research that I fulfil my commitment to “Continuously review my knowledge, skills and professional performance. Reflect on them, and identify and understand my limits as well as my strengths.”

References

MIHygienist (2012a) O’Hehir in my 2013 Face – Accepting the past, Valuing the present, Embracing the future. Available at http://mihygienist.wordpress.com/2012/11/18/accepting-the-past-valuing-the-presenting-embracing-for-the-future-oherir-in-my-2013-face/ (Accessed 10 January 2013)

MIHygienist (2012b) O’Hehir University SWOT ANALYSIS | SISYLANA TOWS – A Reflection.Available at: http://mihygienist.wordpress.com/2012/12/12/swot-analysis-sisylana-tows-a-reflection/tp (Accessed 10 January 2013)

MIHygienist (2012c) O’Hehir University = Simply Putting Opinions into Action (Learning). Available at: http://mihygienist.wordpress.com/2012/12/29/ohehrir-university-simply-putting-opinions-into-action-learning/ (Accessed 10 January 2013)

World Health Organisation (2013) Definition of Dental Health Available at: http://www.who.int/topics/oral_health/en/(Accessed 10 January 2013)

Department of health (2006) Oral Health, Eastern Regional Public Health Observatory. Availableat:http://www.erpho.org.uk/Download/Public/13920/1/204082%20INPHO%2017.pdf (Accessed 10 January 2013)

Press. General Dental Council. (2009) Standards for Dental Professionals. London, GDC Publications. Available at: http://www.gdc-uk.org/Newsandpublications/Publications/Publications/StandardsforDentalProfessionals%5B1%5D.pdf (Accessed 10 January 2013)

Rattan et al. (2002) Clinical governance in general practice. Oxford, Radcliffe Medical ltd, P49-53.
General Dental Council (2009) Scope of Practice, London, GDC Publications.

Availabkleat:http://www.bristol.ac.uk/dentalpg/dcp/scopeofpractice.pdf (Accessed 10 January 2013)
British Society of Periodontology (2011) Basic Periodontal Examination. Availableat:http://www.bsperio.org.uk/publications/downloads/39_143748_bpe2011.pdf (Accessed 10 January 2013)

Department of Health (2011) 2009 UK Dental Health Survey. Availableat:https://catalogue.ic.nhs.uk/publications/primary-care/dentistry/adul-dent-heal-surv-summ-rep-them-seri-2009/adul-dent-heal-surv-summ-them-exec-2009-rep2.pdf (Accessed 20 January 2013)

McNiff and Whitehead. (2011) All you need to know about action research, SAGE Publications, London.

Reason. and Bradbury. (2008) The SAGE handbook of action research: Participative Inquiry and Practice.

Markman, A (2012) Smart Thinking, Pilatus, UK. p.75-82.

MIHygienist (2012d) Air-Flow A Go-Go – The Role of Three as part of Smart Thinking.Available at: http://mihygienist.wordpress.com/2012/07/12/air-flow-a-go-go-the-rule-of-three-as-part-of-smart-thinking/ (Accessed 10 January 2013)

MIHygienist (2012e) O’Hehir University – My Assessment Tray – A Way Forward For My Practice? Available at: http://mihygienist.wordpress.com/2012/11/25/my-assessment-tray-a-way-forward-for-my-practice/ (Accessed 10 January 2013)

Fleming, N and Mills, C. (2010) “Not another Inventory, Rather a Catalyst or Reflection”, To Improve the Academy, Vol. 11, p.

Recently published in Dental Health I hope this can demonstrate a workplace action research journey that can demonstrate how to develop from research, problem solving, learning and knowledge creation.

Mark James BSc RDH

O’Hehir University Project Part 2: A DCP Pilgrims Progress – A Simple Journey into Dental Health Improvement

“Listen to patients and give them the information they need, in a way they can use, so they can make decisions.”

2.4 Professional Standards in Dentistry, GDC, UK 1

Introduction

I qualified as a Dental Hygienist in 1988 and continue this journey today after nearly a quarter of a century still intent of learning how I can improve my practice, enjoy my work and meaningfully add to society. I currently work between five practices, a personal choice born of economic reality and have found the additional challenge of O’Hehir University at times daunting as a consequence. More daunting however is the reality of dental health in Britain today. It appears to me a World where real truths are hidden with smoke and mirrors to promote a picture of continuing improvements and reductions in dental disease and risk, where smart advertising influences the public in their dental habits and where the reality of true dental health improvement appears to have been diluted in political correctness and dogma. Added to this is a smattering of cynical commercial imperatives for less functional and dental health related care. What had happened to dental health and how could I make a difference in my practice and, if I succeeded, to a bigger dental and general audience? Having learned during mentorship training about learning styles I wondered after so many disappointments at patient reviews and follow ups if I had missed something blindingly obvious, essential and indeed simple? How would I facilitate this investigation and where would it end, if at all? I started where every good narrative in born, at the beginning.

What was my concern?

The Department of Health (DoH) in 2007 published an evidence based preventive toolkit for dental professionals appropriately named “Delivering Better Dental Health.”2 Updated since, it gives a meagre one side of A4 with an understated introduction claiming that the “major dental conditions of caries and periodontal disease can both be reduced by regular toothbrushing and fluoride toothpaste.” The National Health Services (NHS) Dental Epidemiological Programme for England report (2010) stated more resoundingly that “Oral health is an important indicator of a population.” 3 If these are true should we be proud or satisfied of our achievements or crest fallen with despair at the reality? What have we achieved thus far and where are we going? Are we improving dental health and, if so, where is the evidence to prove it?

Why was I concerned?

In 1968 the Adult Dental health Survey (ADHS) began, less the thirty years after the Second World War ended, three years after I was born. The fifth and latest survey, 2009, was published with the additional intention of obtaining “knowledge about and attitudes towards dental care and oral hygiene” and changes over time in dental health, attitudes and behaviour. It demonstrated interesting and sombre reading. 4

In dental health terms;

  • 9 per cent of adults reported current pain.
  • 8 per cent of adults had one or more untreated teeth with unrestorable decay.
  • Untreated and unrestorable decay was present in 23 per cent of those with current dental pain.
  • 66 per cent of dentate adults had visible plaque on at least one tooth averaging nearly 23 percent of all teeth.
  • 68 per cent had calculus in at least one sextant of the mouth.
  • 17 per cent of dentate adults had no evidence of periodontal disease.

The public perception was that;

  • 81 per cent of adults said that their dental health was good or very good.

The ADHS perception was that;

  • The importance of toothbrushing twice a day is a message that appears to have been taken on board by the MAJORITY of dentate adults.
  • Modern dentistry is centred on a “Preventive philosophy.”

If these figures and facts about the nation’s dental health are to be believed and are reflected in our practice environment are we satisfied that Britain’s dental health practice is built upon firm foundations or are there still important questions to be asked? Surely there is a massive discrepancy to what the public believe and their reality as a whole? Moreover, are the academics and politicians who sanction such findings deluded to state that modern dentistry is preventive centred and improving?

A famous British general once reflected upon the dramatic initial events after D-day on the 6th June 1944, where the enemy prevented his advance. He commented that “There is no such thing as an ordinary battle” and that leaders at all levels must “adapt their actions to the particular problems confronting them.” Montgomery clearly was frustrated and aware of the human cost of employing failing tried and tested formulas, predictable and too rigid, which were being defeated by a determined foe. 5

Could a simple dental health strategy, supported now with better direct public access, being affordable and patient centric improve those statistics and more over change attitudes and perceptions of professionals and the public too? I believe we too, are fighting a battle against the causes of dental disease and by approaching the foe with predictable, rigid and unimaginative strategies we too are prevented in making a vital and dramatic breakthrough. Where did I start this process?

“Action research should be seen as not simply about problem solving but also learning and creating knowledge”. McNiff and Whitehead

The vehicle, evidence and data

There are many ways of getting from A to B, of achieving our aims and goals but as a clinical hygienist I had never been trained to think and challenge myself beyond the bounds of my training. This was an attitude that has denied me advancement until I discovered Action Research (AR).

AR is designed to reappraise or affirm old or current knowledge and theory. It is morally and value driven, related to our workplace and is set within a social context (the dental health of our patients and the nation), challenging us to improve our “workplace practice through improving learning”. Its egalitarianism and social context puts the benefit of our learning to the patient first but further more can advocate our newly discovered theory and knowledge gain to a bigger professional audience too. It is first person centred (you and me), living theorist (our workplace learning), collaborative (involving others both public and the profession), and “actively” reflective by improving our practice through experiencing, questioning, researching and finding new knowledge and understanding. 6

Action research aspires the practitioner researcher to be open ended developmentally, allowing them to continue their projects flexibility and within a learning and developmental framework. We never stop learning but through AR we understand that what we do is provisional, not set in concrete, but will grow and change with new knowledge and feedback from our peers and patients alike due to its reflective, unfolding nature.

“Change is the end result of all true learning”. Leo Buscaglia

The evidence

I began the project and started gathering evidence from the beginning of February and intended to complete as many of the second parts of the process as possible. Ideally it would have been more interesting and perhaps convincing to have over a hundred participants in the end but circumstance and poor health only allowed me 21 with 8 completing both parts 1 and 2. As the project began I became aware of a couple of issues that needed addressing, one directly and the other indirectly.

AR allows us the opportunity to change our process reflectively. This happened to me when I began the data gathering. I hadn’t considered stamping an ethical statement on the form initially but upon further reading and research I changed tack and evolved my form (MI Hygienist, 2013a). 7 This I feel was critical in the respect of potential peer validation beyond O’Hehir University and possible future publication to a bigger audience. I also felt that I had intrinsically missed out another important question and asked one that wasn’t so weighted in value. Thus my form evolved further to incorporate a patient value section whilst omitting detailed oral hygiene advice (see forms below). I was more concerned about understanding how the patient thought about their dental status rather than how many times a day they flossed as the later could be addressed through the learning and motivational phase. Knowing where they stood in terms of dental health priority was vital. Did they value their dental health more than function and appearance?

All participating patients, whether they completed part 2 or not, received routine active instrumentation and prophylaxis within the confines of a thirty minute appointment. They were initially asked to answer part of the form and then complete it afterwards in private and give feedback if desired.

Initial Dental Health Improvement Project Form – Mark James RDH

Name                                                         Date                                                    Visit

Do you use a manual or an electric toothbrush or both?        Manual     Electric    Both  
Do you clean between your teeth? Floss/interdental brush     Both      No  
How often do you use them? More than twice, twice or once daily or never? Toothbrush     ________

 

Floss/ Interdental  _________

 
How best do you think you learn?    Seeing  Listening   Doing   Combo
     

 

    

 

 

 

 

 

 

Marking scale is 1 to 5 [5 being the highest]  1     2      3     4      5
How do you rate your mouths present health?          
Do you feel this dental appointment will help you improve your dental health?          
How do you rate your Dental Hygienists performance in delivering your dental health message?          
     
     

 

BPE Examination

 

Additional Comments/Feedback

                           

Adapted Dental Health Improvement Project Form – Mark James RDH

Name                                                         Date                                                    Visit

Do you use a manual or an electric toothbrush or both?    Manual   Electric  Both  
Do you clean between your teeth? Floss/interdental brush   Both   No  
How best do you think you learn?   Seeing  Listening   Doing   Reading
Where would you place these in order of importance to you?        Health      Function  Aesthetics
Marking scale is 1 to 5 [5 being the highest]  1     2      3     4      5
How do you rate your mouths present health?          
Do you feel this dental appointment will help you improve your dental health?          
How do you rate your Dental Hygienists performance in delivering your dental health message?          
     
     

Additional Comments/Feedback                                    BPE

                         

Ethical Statement

I am undertaking action research in how to improve the outcome of dental health through improved communication with and feedback from you. I will give priority to your interests at all times, protect your identity unless you express otherwise. You are free to withdraw from this research at any time and all data will be destroyed. If made public I will check all data related to you.  Mark James RDH  

I hereby give permission to be included in the research.

——————————

The data

The first set of data compiled the evidence gathered in total, divided by the 21 participants. The second combined both parts 1 and 2 of the 8 patients who completed the project.

The 21

Those who allowed me to begin the project were from two of my five practices. The overall impression I got from feedback was a genuine surprise and satisfaction that they felt included, involved and empowered within this process. Most were keen to spend time after the appointment to give feedback and comments. Some feedback proved very useful and most supportive. I learnt the important lessons of time management regarding the questioning and oral hygiene phase. I kept it brief, hence an attraction to a “quick brief” approach which evolved into a motivational interviewing style linked to their preference for learning.

“Came out of today with good solid information on how to progress and improve my oral health, delivered in a professional and friendly manner, many thanks”.

“Expected only a routine clean before fillings, but was advised about other problems. Given information and demonstration about what I need to do moving forwards (very impressive!) and told next steps, which is exactly how I like to be told. He helped me understand instead of being told off as per previous”.

The data told me that;

         Over half, 57 per cent, were using a variety of powered toothbrushes.

         38 per cent didn’t interdentally clean.

         71 per cent viewed themselves primarily as kinaesthetic or “doing” learners.

         73 per cent considered their dental health more important than function or aesthetics.

         57 per cent rated their mouths as average.

         81 per cent felt they’d benefit from and improve their dental health with 85 per cent very satisfied with my performance.

Gathering initial data is great in getting a snap shot of a group with base line records. The most compelling aspect of moving beyond this was to discover whether my concept of delivering a different oral hygiene message would succeed. Would this and the additional benefit of using an oral hygiene product (supplied free) to demonstrate techniques intra orally, based upon their perceived learning style be conducive to behavioural change and improved results and outcomes? Part 2 would be the key phase of the project.

Dental Health Improvement Project – Data Drop Box 1

Do you use a manual or an electric toothbrush or both?    Manual  7 Electric 12 Both 2  
Do you clean between your teeth? Floss/interdental brush 8 Both 5 No 8  
How best do you think you learn? Seeing 2 Listen  1 Doing 15 Reading 3
Where would you place these in order of importance to you? (15 completed )  Health 11  Function 0 Aesthetics 4
Marking scale is 1 to 5 [5 being the highest]     1   2    3     4    5
How do you rate your mouths present health?     4  4   12    1  
Do you feel this dental appointment will help you improve your dental health?  

 

    1

     

 

   3

 

 

  17

How do you rate your Dental Hygienists performance in delivering your dental health message?    

 

    1

     

 

   2

 

 

  18

3.2       

 

(67)

  2.9

 

 (60)

  3.2

 

  (67)

2.9

 

(62)

 2.6 

 

 (55)

  3.1

 

  (65)

 

Average BPE

combined scores in brackets

                         

The 8 of 21

Parts 1 and 2 combined – Dental Health Improvement Project – Data Drop Box 2

The figure before the/is the first appointment, the figure after is the second

Do you use a manual or an electric toothbrush or both? Manual 1/0 Electric 7/8 Both  
Do you clean between your teeth? Floss/interdental brush 4/7 Both        1/1 No  3/0  
How best do you think you learn?  Seeing

 

1/3

Listening  Doing

 

5/4

 Reading

 

2/1

Where would you place these in order of importance to you? 4 out of 8 completed  Health            3/8 Function Aesthetics 1/0
Marking scale is 1 to 5 [5 being the highest]   1   2   3   4    5
How do you rate your mouths present health?    

 

 1/1

 

 

 6/1

  

 

 1/5 

 0/1
Do you feel this dental appointment will help you improve your dental health?        

 

1/0

  

 

  7/8

How do you rate your Dental Hygienists performance in delivering your dental health message?        

 

2/0

 

 

  6/8

3.5 (28) 

 

2.6 (21)

3.3 (26)

 

1.8 (14)

3.5 (28) 

 

2.8 (23)

3.4 (27)

 

2.3 (18)

3.1 (25)

 

1.6 (13)

3.4 (27)

 

2.5 (20)

 

BPE combined in brackets Parts 1 (above) and 2 (below)

Average BPE of Parts 1 and 2 in front of bracketed figure

                         

 

I was initially concerned about the small number who completed part 2 and had hoped to get a bigger snap shot of the group. The time period between the two was between 3 and 4 months but I was content that I would see evidence of behaviour change and dental health improvement. Essentially I wanted to discover whether the VARK learning, intra oral product use and collaborative questioning combined with an evolving motivational interviewing (MI) technique would significantly show progress.

The data told me that;

  • All changed to powered toothbrushes under advisement.
  • All began flossing or interdental cleaning or both.
  • Some of the group reflected upon their learning styles and changed their learning preference to better suit success in the future.
  • All 4 of the group who completed the value section confirmed that their dental health was priority.
  • 75 per cent of the group’s attitude to their mouth had changed and rated positively towards scores of 4 and 5. Previously it had been 25 percent for the same scores and individuals.
  • The entire group now believed they had benefited from the process and rated me also a score of 5.
  •  BPE data analysis indicated an improvement over all of 33.9 percent across the group.

Appraising and evaluating my evidence

Having now completed the data gathering and reflecting upon the evidence I am convinced that my oral hygiene phase of treatment needs to take on greater importance to ensure more effective and beneficial dental health outcomes. I have found that simply “showing, telling and doing” isn’t as effective as developing an action research based strategy that involves determining, understanding and combining;

  1. Patient values and perceptions.

A good starting point is to better understand the patient’s needs by better understanding their present oral hygiene behaviours and values. This has helped me lose the general assumptions and conclusions I draw from the first patient contact or their previous clinical history and further guides the next strategy – that of developing a learning plan, based upon their current status and after BPE (similar to CPITN) is completed.

  1. Tailored patient learning styles

Learning has been a one dimensional process historically in my practice, where I had imposed by beliefs and styles upon the patient. I hadn’t considered that most had developed their own style or a combination of throughout their life, creating barriers to many including mine. Carl Rogers (1969) asserts that people’s ambivalence is deeply routed by their experiences. The learner needs to believe that the information has relevance and purpose to themselves and can be managed in their time. Removing barriers to learning, a reality to those anxious or fearful patients, and creating an environment that allows them freedom to learn is essential as many perceive or expect pain, humiliation and ridicule born of their experiences. Giving the patient responsibility for their learning and self-evaluating their progress through a guided process of facilitation can create an appropriate and effective patient centred learning process. 8

Flemings VARK questionnaire was developed in New Zealand for teachers after its creator noticed “excellent teachers who did not reach some learners and poor teachers who did” and drew me to conclude that perhaps we have taught our patients in our preference rather than theirs. Interestingly too, over half of the participants of the project expressed more than one preference for learning which led me to believe that within our practice of teaching we can adapt different styles to meet their needs or, alternatively, review the styles on follow up and change direction with learning if necessary. I also feel that VAK would be a better format to adopt born of the particular environment we work in. Creating literature that can be taken away by the patient to read negates its usefulness in the clinical environment but still remains a tool to be used for those who see it as a preference after oral hygiene instruction or those requiring additional time to consider change. However I feel that seeing, doing and listening combine well or individually in the workplace. 9

  1. Behavioural Support Intervention

I had never really paid much attention to behavioural change in the preventive dental sense in the past but since the project began I have begun to listen more intently but also critically. Rattan et al (2002) when discussing changing behaviour in terms of clinical governance allude to its use in drug, alcohol and smoking rehabilitation quoting classic examples of its success but where is there similar evidence in improving dental health? 10 Renz and Newton (2009) looked at the express purpose of changing patients’ behaviour with a view to improving periodontal outcomes and explored various psychological models. They could only conclude, however, that despite” several promising targets for interventions” that “critical importance be placed in the field of motivation, volition and self-efficacy. “11 Carr and Ebbert (2012) interestingly put smoking cessation in a dental setting with advice offered by oral health professionals. They concluded that “typically brief” behavioural counselling may reduce tobacco use.  12 Sgan-Cohen (2008) links the dichotomy between the profession and public regarding changing dental health behaviour citing “incorrect assumptions” in dental health promotion. I agree with him. He states that “Dentistry needs to be flexible in accepting new evidence based modalities of oral health promotion.” and continues that “applied prevention is not always easy” requiring the “optimal cooperation and motivation of the public.”13

Frencken et al (2012) in a report from the FDI group linking minimal intervention dentistry (MID) get nearer to a solution by declaring success in dental prevention, in this case caries, be considered not an infectious but instead a “behavioural disease with a bacterial component.”14 Could this be linked to periodontal diseases too? If so, how? In 2013 Brand et al published online a study investigating the impact of single session Motivational Interviewing (MI) in the context of periodontal maintenance therapy. They aligned them to the same principles in smoking, diabetes control and medication adherence to find emerging evidence suggesting the “utility of MI to improve oral health”. The study sampled 56 previously treated periodontal patients in a single blind, randomised control trial. Regardless of their optimism and statistically significant decreases in plaque, pocket depth and bleeding at baseline, 6 and 12 weeks, there were no differences in clinical parameters between the two groups. They surmised that a one- time MI session was insufficient for improving oral hygiene in the study group.15 This runs against the conclusion of Godard et al (2011) who used Leventhal’s theory in improving compliance with plaque control amongst a similar risk group. They determined that the MI group demonstrated greater “satisfaction” scores to those in the control group and deemed MI a promising approach. 16

Leventhal’s self-regulation model defines how an individual goes about identifying they are sick and what they do to get better, involving understanding, acting and appraising their progress. This model relies on the individual’s ability to reflect on their actions and subsequent consequences.

Self-confidence or self-efficacy according to Bandura (1977) is important in an individual’s ability to “perform a particular behaviour regardless of circumstances or contexts linked to expectations of outcome.” Motivation is determined by reasons for action, in this case, dental health improvement. The popular Health Belief Model, developed in the 1950’s in the USA, implies that people are motivated to change by understanding the benefits of them related to their health. 17

Within the short time frame and additional pressures of a hygiene appointment the best method for behavioural support is MI as it is “client centred and collaborative” in exploring and attempting to resolve “ambivalence” (Miller and Rollnick, 2002). It focuses on the process of building motivation for change and strengthening commitment to it. 18 The professionals, us, engage so called “change talk” with the patient focusing on;

  • Reasons for change.
  • Disadvantages of staying as they are.
  • Advantages of change.

Interestingly, in my opinion and born of my experiences too, the professional also needs to ask the patient what they are going to do about it. This can lead to shared goal setting, planning and eventually commitment. I am also aware now that reviewing change, much like we review dental health status, is a key element in this. The belief we can elicit change purely from physically acting in someone’s mouth is now far from the truth and leads me finally to the conclusion that as well as being a “First Person, Living Theorist and Collaborative Practitioner Researcher” I can also claim to be a “Behavioural Support Interventionist” (BSI) in the making too.

Modifying and monitoring my practice

By modifying my practice in the light of my research, evaluation and experience I strongly believe in the effectiveness of a one to one approach which determines;

  1. Their current dental health behaviour and values.
  2. Their preferred learning style(s).
  3. Their commitment to change.
  4. The use of oral hygiene products intra orally to enhance the kinaesthetic or visual benefit of learning.

The support of the dental health industry, in particular Philips Health and Well-Being who supplied me products to facilitate this as well as the purchase of others by myself has also been a critical factor in the success of my project. I will continue to promote their use in this way and hope that the costs incurred by me will be met by a small increase in appointment fees. Additionally, there is an opportunity for me to develop greater in house sales of dental products ethically but also construct an online store that can deliver a similar process as the workplace. This is the theme of my next project through O’Hehir University in New Zealand.

Proposed New Dental Health Improvement Project Form – Mark James RDH

Do you use a manual or an electric toothbrush or both?        Manual     Electric    Both  
Do you clean between your teeth? Floss/interdental brush     Both      No  
How best do you think you learn?    Seeing  Listening   Doing   Reading
Where would you place these in order of importance to you?        Health      Function  Aesthetics
Marking scale is 1 to 5 [5 being the highest]  1     2      3     4      5
How do you rate your present dental health?          
Do you want to improve your dental health?          
Could you change your current behaviour to benefit your dental and general health?          
     
     

Additional Comments/Feedback /Action Plan                                  

 

 

BPE

                         

Conclusion

A good traveller has no fixed plans, and is not intent on arriving.Lao Tzu 

Have I made a contribution to new theory of practice and can I make a claim to knowledge? Action research is opened ended in its final position and for good reason. New knowledge and theory comes from the past and the present and to not learn from it, adapt, review, reflect and subsequently change accordingly would be fallacious.

McNiff and Whitehead (2011) describe a situation familiar to most professionals in practice as being a “living contradiction,” a situation in their workplace where ideologies conflict and where compromise needs to be sought. 19 Ironically I have been supported by both teams and more over by my patients whilst undertaking this project and for this I am very grateful. However, my living contradiction appears to be with the established view of where we are as a society regarding the state of dental health in the UK (MI Hygienist, 2013b). 20 There are steps afoot with truly preventive minds, I believe, intent on improving dental and general health. This gives me hope that on a national level and with greater patient access to dedicated Dental Care Professionals (DCP) the public and society will be better served. My dilemma remains that would we as DCPs continue to develop ourselves professionally not just in the fashionable and lucrative aspects of our scope of practice but to reappraise and seek ways in which we can improve better dental health?

My claim to knowledge, albeit provisionally, is thus – I have developed a simple strategy that combines assessment with a focus not only on traditional scoring but behaviours and values. Also developed is a teaching approach that collaborates with and complements the learning strengths of the individual enhanced with patient centred confidence building, motivational and ongoing support. I will continue to review improvements in my performance and the dental health of my patients and, if other mindful clinicians  develop similar developmental and learning strategies perhaps  our  communities, society and nation alike will benefit too.

References

  1. General Dental Council (2009). Standards for Dental Professionals. London, GDC Publications
  2. Delivering Better Oral Health (2007). An evidence based toolkit for prevention, Department of Health. Part 2.
  3. Rooney (2010). NHS Dental epidemiological Programme for England. http://www.nwph.net/dentalhealth/reports/NHS_Dental_Epidemiology_Programme_for_England_Report_June_2010.pdf
  1. Adult Dental Health Survey (2009).http://www.dhsspsni.gov.uk/adultdentalhealthsurvey_2009_firstrelease.pdf 
  2. Max Hastings (1984). Overlord: D-Day and the Battle for Normandy, Simon & Schuster.  New York
  3. McNiff,J and Whitehead,J. (2011). All you need to know about action research, SAGE Publications, London. 10-39.
  4. MIHygienist(2013a)http://mihygienist.wordpress.com/2013/03/06/ohehir-university-the-shifting-sands-of-action-research-ethics-a-reflection/
  5. Carl Rogers (1969). Freedom to learn. Merrill, Columbus, Ohio, 157-166.
  6. Fleming, N and Mills, C. (1992). Not Another Inventory, Rather a Catalyst for Reflection. To Improve the Academy, 11, 137-155.
  7. Rattan et al. (2002). Clinical governance in general practice. Oxford, Radcliffe Medical ltd, 126-127.
  8. Renz, A and Newton, J. (2009). Changing the behaviour of patients with periodontitis. Periodontology 2000, vol.51,252-268.
  9. Carr, A and Ebbert, J. (2012). Interventions for tobacco cessation in the dental setting. http://www.asat.org.ar/images/comunidad/biblioteca/ib_odontologos_2007.pdf
  10. Sgan-Cohen. H. (2008). Oral hygiene improvement: a pragmatic approach based upon risk and motivation. http://www.biomedcentral.com/1472-6831/8/31
  11. Frencken et al. (2012). Minimal intervention dentistry for managing dental caries-a review: report of a FDI task group, Int Dent J, Oct; 62(5):223-43.
  12. Brand et al. (2012). Impact of single-session motivational interviewing on clinical outcomes following periodontal therapy. International Journal of Dental Hygiene, 11(2): 143-141.
  13. Goddard et al. (2011). Application of self-regulation theory and motivational interview for improving oral hygiene: a randomized controlled trial. Journal of Clinical Periodontology, Dec; 38(12): 1099-105.
  14. The Kings Fund (2008). Motivation and confidence, kicking bad habits. http://www.kingsfund.org.uk/sites/files/kf/field/field_document/motivation-confidence-health-behavious-kicking-bad-habits-supporting-papers-anna-dixon.pdf
  15. Bandura, A. (1977). “Self-efficacy: toward a unifying theory of behavioural change”. Psychological Review, 84(2): 191-215.
  16. Miller, W and Rollnick, S. (2002). Motivational interviewing: preparing people for change. New York: Guilford Press.
  17. McNiff,J and Whitehead,J. (2011). All you need to know about action research, SAGE Publications, London. 57-8.
  18. MIHygienist(2013b) A Reflection.http://mihygienist.wordpress.com/2013/02/09/ohehir-university-learning-and-living-with-my-contraditions-as-a-dental-hygienist/

Unorthodoxy in Learning. Testing a Workplace Concept – Carl R. Rogers –  Supporting Authentic Online Learning at O’Hehir University – A Narrative Account

My whole world, both personal and professional, is in an evolving state of healing as a consequence of the global pandemic. It feels like I’m in a recovering state of COVID decompression akin to a deep-sea diver in a planned act of readjusting to normality after being to the deepest, darkest depths. This imbalance has been emotionally unsettling, for several weeks of lockdown and uncertainty, not knowing whether PPE would be required, the very nature of new practice, and when we were to return to it. It did, however, allow me to drive, undistracted, and determined to complete my self-directed learning project which began the previous June. The reams of printed studies this project generated had been sitting on the bookcase, gathering dust, and tested my resolve to meet its critical challenge. All but one post is now done, so this will be the final piece of the puzzle with just an introduction and ending to conclude it. Let us to it proceed. 

“Educated! We are not even born as far as our feelings are concerned.” D.H. Lawrence

The High-Speed Train (HST) was introduced into service in Britain in the mid-’70s. The idea of this highly modern express train was speed and comfort. I can remember walking into Paddington Station, in West London, in my youth, smelling the scent of diesel, the atmosphere of the Victorian structures surrounding the platforms, and many parked trains. The cacophony of noise, the hustle and bustle of everyday events, door shutting, breaks screeching, and the low drone of the spoken word was omnipresent. The train itself was what is called a “push, and pull” system, state of the art coaches sandwiched between two cutting edge locomotives. The energy created by both pushing and pulling created higher speed. They are still in service today. This analogy reflects the determination required to a more effective learner, the coaches reflect the workplace, where you sit, meet and treat. Still, the locomotives are the intent and motivation of that journey, the drivers of what happens between them.

The addition of that second “pushing” engine creates more energy, more purpose, juxtaposed against having one where you are being pulled towards a destination, unknowingly. The second unit metaphorically pushes you towards a destination of your design, perhaps to answer questions appropriate to the environment in which you operate or those which may determine the way to move your practice forward. Imagine being the driver of that necessity, being in control of the whole process, being accountable for its design, making sense of the research and data, analysing the outcomes, disseminating the results, and evidence of it to others. Consider the strategy and structure that can facilitate that, having confidence in its processes and being able to gather, assimilate, and make sense of the information.

“What thrills me about trains is not their size or their equipment but the fact that they are moving, that they embody a connection between unseen places.” Marianne Wiggins

The two arenas in this story are Quin Dental, Nelson, Tasman, New Zealand, and O’Hehir University, a global action research and self-developmental learning hub created in the USA in 2013. Quin is my place of work, a practice combining general practice, orthotropics, and orthodontics supported by oromyofacial therapy. Quin Dental’s leader details their mission as one of “excellence and innovation in dental health while aiming to make a positive impact on staff and community”. The vision encompasses providing clients with a “holistic dental experience aimed at providing the best dental preventive care” as well as, at all times, “respecting client views” and “providing individualised treatment.” The values of this practice include “dignity, compassion, empathy, warmth, and respect.”

Quin Dental, in the spring of September 2019, become my new professional home. Initially, my focus was to familiarise myself with the nuances and nature of the clinical environment, its people, and clients. The equipment and instruments, infection control procedures, and the history of oral healthcare delivered by previous oral health care professionals all added context to and set the scene of the message spoken and how it was instrumentally delivered. I was aware the wedded ideology lent heavily on EMS piezo and airflow systems and the associated system was available for its delivery. I had an in-depth knowledge of the equipment and the scientific basis of guided biofilm therapy (GBT) having trained with it at the company headquarters at Nyon in Switzerland.

The disruption of dysbiotic biofilms with a variety of powders and processes had featured prominently in my previous practice, for several years. The advantage of GBT has become a phenomenon in dental hygiene circles globally, and its promotion and popularity was increasing until the COVID crisis put the proverbial headlock on it due to aerosol and droplet generation. I, however, began to limit its use almost the moment I arrived at the practice and had an awkward conversation with the practice owner about my devolving view on its clinical application. I explained that based upon my empirical and observational experience, the feedback from clients I treated, and an altering viewpoint as a consequence of directed and self-directed study, I had re-evaluated how I used it. This was linked to a growing environmental and sustainable awareness, born of my odyssey experiences, of the need to sustain altered and more beneficial biofilms. Accordingly, I would be more selective and discriminate in its use. My boss was understanding, cautiously listened to my concerns but stressed its importance and efficacy in superficial stain removal in which we both wholeheartedly agreed. Progress from my perspective had been made.

“Live in each season as it passes, breathe the air, drink the drink, taste the fruit, and resign yourself to the influence of the earth.” Henry David Thoreau

GBT is very much indicated in active cases where the ecological imbalance is negatively sustainable, unstable bleeding on probing is observed, and potential or active loss of periodontal attachment is uncontrollable. In its strictest context, GBT is a local biofilm reset mechanism, especially interproximally and sub gingivally. It is also supremely indicated with gross staining or where a client requests or desires it based upon previous positive experiences. However, the GBT model is one that goes beyond the active phase and has become king in the maintenance realm. My push back relates to an ecological imperative of preserving and allowing balanced biofilm, created as a consequence of careful active clinical and facilitative oral health adaptation to abide and thrive within our oral biofilm. Regular monitoring and reviews are as crucial as COVID isolation is at New Zealand borders at present, the onus of care switching to one of less active intervention, timely reviews maintained self-care and personal oral health sustainability and responsibility.

This leads to the challenge of moving my philosophical change into the Quin oral health arena related to its core mission values. I felt the need to get a perspective from the client base of the practice and created a survey questionnaire that would essentially take a snapshot of their thoughts and feelings. This led to questions regarding expectations of treatment and inquiries about our service. 100 people participated, 93(%) would recommend us to their friends and family, over a third alluded to orthodontics being the primary attraction to the practice and 10% were attracted to its holistic branding. One comment in response to the survey, written with care, stood out to me. “What about your approach is natural?” It was a salient question, and it indicated that although we were marketing ourselves as natural, the practice was growing as a consequence of its reputation of arch expansion and tooth straightening, and not necessarily upon its oral health credentials. I began to feel an additional set of questions requiring answers being centred explicitly around the preventive message of Quin. My curiosity was fuelled by further feedback I felt was relevant when in discourse with clients. The new survey reflected them but also my growing hypothesis born of a notion that my practice was becoming increasingly environmentally and sustainably influenced and orientated.

“Every great idea comes with the minority of one.” Eric Weinstein

Survey two began with my new clinical approach, one of mutual co-existence when stable and in balance and whole intervention when dysbiosis is present. It is born of research undertaken before, during, and since returning from my learning odyssey, published at wholedentalhealth.com;

“Dental diseases are driven by imbalances in oral bacteria and pH (acidity and alkalinity) and saliva function being further mediated by negative dietary and lifestyle choices, our age and health status, and, to a certain extent, our genetics.”

“promoting natural oral health requires sustainable behaviours that reduce the risk of inflammation and disease, promotion of beneficial bacteria, active and functional saliva flow, proper tongue posture, effective breathing, and tooth strengthening strategies tailored to the individual. This, in turn, has the potential to support and promote our general health and well-being.” Mark James RDH NZ

Q1. Do you view your mouth environmentally and/or ecologically? Upon reflection, I think I should have described this less starkly and more in the vein of seeing the bacteria in the mouth environmentally and ecologically. 55% Yes, most upon reflection of the question.

Q2. Do you believe there are links between your general health and your mouth?  100% Yes.

Q3. Do you follow a specific nutritional approach to your health? 95% Yes most whole food or low carb BUT 15% gluten and dairy-free.

Q4. Do you have an opinion regarding fluoridation? I should have said water fluoridation and perhaps differentiated between topical and systemic modalities. 75% Yes – against water fluoridation – 15% of this group said they’d use it in toothpaste.

Surprising responses revolved around questions 1 and 4. Both 2 and 3 were predictable when considering the type of client seen at Quin, being professional, engaged with health and well-being topics, and informed. The age demography between those supporting fluoridation and those not was interesting. The younger the client it seemed, the less supportive of it they were. I’m curious to understand this better, though. Is it due to the nature of modern communication and the omnipresence of social media platforms that support the anti-fluoride pressure groups? Or are more of the younger population less trusting of authority, more critically educated, or concerned about the perceived health impact to fluoride on children? There were forthright and vocal opinions on the effects of fluoride with regards to brain health, and less it seemed to democratic choice and dosage. Question 1 had a curious initial silence before being answered, I got the sense that they had never heard oral bacteria put in the context of environmental, ecological, or sustainable perspectives. After consideration, I felt it required refinement, and I changed the wording to include bacteria in the sentence. Question 3 brought the most variety of responses, but interestingly all were aware of the threat posed dentally by sugar. Less understanding was afforded to pH lowering activities at mealtimes. The erosive potential of health-related options like apple cider vinegar, lemon in water, kombucha, and carbonated water wasn’t considered either.

This survey has helped me dive into client opinions of key issues that present themselves in modern oral health promotion and give credence to a tailored approach to care, looking specifically at individual needs and perceptions, guiding care planning. This process marries well, I feel, with the Quin mission statements that highlight the “holistic dental experience aimed at providing the best dental preventive care”, “respecting client views” and “providing individualised treatment.” Q.E.D, Qoud erat demonstrandum.

“It is in fact nothing short of a miracle that the modern methods of instruction have not yet entirely strangled the holy curiosity of inquiry; for this delicate little plant, aside from stimulation, stands mainly in the need for freedom; without this, it goes to wrack and ruin without fail.” Albert Einstein

Questioning in this format also afforded additional benefits of which I hadn’t foreseen. The opportunity presented itself to enhanced general discourse, encouraging the clients to demonstrate their opinions, allowing active discussion and, I feel, bringing a sense of greater respect for their points of view and mutual trust within the process. I felt it added weight and rigour to the importance of their perception of their mouths being compared to the specific everyday habitats and environments we live in and benefit from. The comparative and similar natures of both explained I hope will bear fruit in oral health outcomes with my co-existing ecological approach to improving oral health outcomes.

Moving forward to early April this year and into the second week of lockdown, I was contacted by a colleague and friend who I’d worked with as a Key Opinion Leader in the UK in the past. I had assisted by being part of a Beta learning group in the infancy of his collaborative online university learning hub, O’Hehir University (OHU). I hadn’t seriously considered involvement with OHU, and, if I’m honest, had avoided it as I couldn’t see a way in which my character and unorthodoxy in practice would lend to it. I didn’t see it being a comfortable fit, and my time up until the lockdown was at a premium. That was soon to change, seeing an end in sight with my wholedentalhealth.com project and deciding upon a change in professional direction brought about a change of heart, the opportunity to observe OHU in motion. I was welcomed to observe and offer support in their online classrooms. I found an engaged, curious and excited community, at first almost shy and timid, perhaps initially fearful, uncertain as to how to proceed in this new environment. Within a matter of a few meetings, the shackles were loosening as the students began to exchange ideas, thoughts, and opinions. It was as if a breakout had occurred, the shell of convention broken and the budding shoots of new discovery and knowledge appearing.

OHU is founded upon action research, an opened ended form of self-reflective first person, inquiry learning, and problem-solving. It is self-directed, workplace-based, and collaborative. The central beating heart is the online classroom with a google classroom suite where students can submit assignments for collective rigour and peer review, the instructors and leaders gently over watching and supporting expressive, creative, and curious learning.

Students at OHU enrol for a six-month odyssey in which professional and personal values are examined, challenged, and potentially altered. They complete a project related to their clinical or professional role and are submitted to scrutiny by their tutors, instructors, and peers. Becoming a small part in the machinery of OHU has become a weekly habit, I’m lubricating my cogs of mentorship, gently participating in the verbal and visual dialogue of the student journey, remembering my pathway through OHU back in 2013. Action research has been a tool that has seen me change, evolve and grow from a face value instrumentalist to a critical, observational, and evidence guided minimal interventionist, with a healthy side order of sustainability and ecologically orientation on the side. Here is an example of a part of the artistic and creative bend of OHU, where the student is asked to reflect on a piece of work which is supported by art, of their choosing, in a way that defines them. This is my example, inspired by them.

“Come forth into the light of things, let nature be your teacher.” William Wordsworth

“The humble tree is emblematic of many things, longevity, wisdom, life, and much more.  Trees are deeply rooted, withstanding the elements, time, and the seasons. They, to me, signify what is right about the environment and, conversely, what might be wrong. They are structures of nurturing, communicating, and protection. Especially for me as a forager, they symbolise community and connectivity, their vast root systems are intertwined by subterranean mycelial networks, huge neurological pathways that support, guide, and nurture the less strong and needy.” Mark James RDH NZ

The inspiration and influencer of OHU is Carl R. Rogers, a humanist psychologist, world-renown author, and keen observer of education, and a proponent of responsible, and participatory student-centred learning. His motivation in the field of education is facilitation rather than pure education, advocating practical and student-centric methods of achieving its effective agency. Rogers sees change in education as creating a real developmental journey, using powerful sentiments, feelings, the risk of sharing ideas, being authentic, and community-driven engagement to drive its purpose. The sense of freedom pervades his written work strengthening the argument that those involved should follow their own goals, be invested in them, and by doing so putting more of themselves, their passion, energies, and efforts into working harder. This, in turn, he opines promotes retention of knowledge and allows more of what they learn to be more meaningful to them, greater than that of established education. The standard of knowledge created has to be tested, just as it is in the conventional system, but the reviewers of it are not only teachers but the peer group of fellow students too. All outcomes and accomplishments are the fruiting bodies of one, very simple question the Rogers clearly defines, “what is the single, most important, unsettled value issue for you right now?”

“There is direction, but there is no destination.” Carl R. Rogers

In effect, my year-long odyssey has reinforced commitment to my social and professional principles. The curious nature of finding evidence that supports or detracts from my journey, allowing new light to be shed upon established values, challenging them to the point of change, or certainty in them, is what endears authentic and genuine learning to me. My future appears now not to lie in clinical dentistry though, as I am beginning now to see the light at the end of the proverbial tunnel. Change is now on the horizon. With no more fruit-bearing branches to climb upon I anticipate, with the supportive help and insight of others, the trunk dividing, one travelling in the direction of my choosing, the other sustaining it, and keeping my experiences and knowledge in dental health alive albeit online and in learning.

Airflow Action Research – Product into practice

An article in the dental press recently caught my eye and made me think more about the direction of my learning journey. It discussed issues regarding our present Continuing Professional Development (CPD) system and the debate around meaningfully improving it. The text raised issues that inferred a need for change from the present “input” based system to a clinically relevant outcome based “output system” where learning evolves by demonstrating its effect on individual professional life and everyday practice.1 This, in my opinion, marries well to our present evidence based practice culture. Many educationalists advocate “learning within the workplace” which is informal, reflective and involves acquiring new knowledge and problem solving. Three important stages in this approach advocated by Gray et al (2004) are technical, interpretive and strategic.

Technical – Acquisition of specific skills or knowledge.

Interpretive – Understanding experiences and making judgements on them.

Strategic – Critical evaluation where technical and interpretive ideas and opinions are discussed and ideas exchanged.

Rattan et al (2003) state that evidence based cultures link science and clinical practice by integrating literature, patient preferences, scientific knowledge, clinical judgement and personal experiences. Our current clinical governance culture promotes adopting proven methods and techniques and replacing those less effective and more costly.3 The four questions he asks are;

Are we doing things the right way?

What is the evidence relating to our practice?

How can we ensure that the necessary changes are implemented into practice?

How do we know that the changes being made are sustainable and, in addition, produce efficacious and cost effective benefits to patients in practice?

So, when introducing new materials and methods clinically we need to measure the extent to which they produce a beneficial result under “ideal conditions”. It also provides an ideal opportunity to begin experimental and developmental learning journey associated with Care Quality Commission regulations as well as the British Dental Association’s advice on clinical governance which advocates communication and consultation with patients that enhance practice relationships and clinical decision making.

My First Step

I wanted to introduce a new polishing system into an established practice that I believe would benefit both patients and practice alike by giving patients more choice and the practice a more effective polishing system. I also hoped to discover more about myself professionally in undertaking this new experimental learning. I have been struck historically by the lack of literature that sets out how an ordinary dental care professional can apply these principles into practice whilst being a busy clinician. How can I implement change within my surgery, demonstrate it to my colleagues and more importantly, deliver it safely, beneficially and effectively to my patients in conjunction with professional standards?

A Critically Reflective Practice Approach to Implementing Air-Flow Handy

Critically reflective practice draws distinction from reflective practice by linking learning within our practice and not just a “pause” for thought. Pure reflection deals with how we feel aspects or events in our professional day to day life went, whether it was good or not so good, and where it could have been improved. Critically reflective practice requires deeper questioning and not taking things at face value, involves self-awareness and turning thought processes into relevant learning. Such a process can be individual or collaborative but leads onto planning and potential change. It links our thinking to doing, thus learning from our experiences and crucially assimilating evidence based practice knowledge and research to make a positive difference in what we do clinically.

The Product

The EMS Air-flow Handy is a portable air polishing unit that uses specially produced bicarbonate of soda powder to remove stain, pellicle and biofilm from tooth surfaces. It has a detachable, autoclavable nozzle that directs the powder and water in a focused spray onto the tooth surface. Care has to be taken to ensure that the root surface is avoided and that patient selection is considered regarding contra indications and their preferences.

Historically I have used Air-Flow units and have heard that some clinicians have found that the nozzle blocks frequently, that some patients found the procedure tastes unpleasant and that the Hendy’s operating procedure and initial and running costs are prohibitive. Having undertaken previous product trials with EMS products through Optident I asked if I could trial this unit free within a practice in which the patient base that have never encountered this product and service before. In undertaking this I asked not to be remunerated which I hope has afforded me better objectivity and critical independence.

Implementation

Having agreed with Optident about the evaluation and article I set about constructing the process. I read the technical aspects of the equipment, research data, how it worked, how to use it, when not to etc. I wanted to focus on the patients experience and preferences as this I feel is under represented in literature. Therefore it involved;

  • Reviewing the research available from EMS and other sources. It was evident from online evidence that most appear dated and refer to the abrasiveness of the bi-carbonate powder on the tooth surface, especially exposed dentine surfaces. The instructions from Air – Flow strongly recommend techniques that avoid this. Current EMS literature discuss the sub gingival benefits of lighter and less abrasive Glycine based powders in Perio-Flow units but these can also be used in Air-Flow Handy units but alas aren’t flavoured yet. Interestingly there is a paucity of literature examining the dental health benefits of conventional polishing. The best research evidence is inconclusive regarding the beneficial and adverse effects of routine (scaling and) polishing for periodontal health.
  • Finding a group of patients who had, within the last 6 to 12 months, been seen by me for conventional polishing treatment. I sought permission of the practice owner and briefed him about the process.
  • Determining the cost benefit analysis by asking my patients to complete a very simple feedback form and the reviewing the cost of the equipment. The sample size is important but I was constrained by only working in the practice 2 to 3 sessions a week and have minimal support.
  • Explaining the benefits of both methods comparatively before using Airflow Handy and seek patient consent. No additional fee would be charged to the patient.
  • Afterwards asking them to complete the form.
  • After two months correlating the data and analysing the results.
  • Evaluating the data.

Airflow Patient Feedback Form

Marking grid: 5=Strongly Agree; 4=Agree; 3=Unsure; 2=Disagree Agree; 1=Strongly Disagree
Airflow Questions 1 2 3 4 5
I was uncertain that airflow would be as effective as conventional polishing          
I felt the procedure was comfortable and beneficial.          
I would be willing to have the Airflow procedure again at future appointments          
My mouth feels fresher and cleaner than I expected with Airflow.          
I would be willing to pay an additional fee for Airflow.          

Process

American Philosopher Henry David Thoreau stated “It takes two to speak the truth – one to speak and one to hear”. Feedback is a peculiar experience and I have been uncomfortable with it historically. It always seemed to me to allude to negative criticism, judgement and poor performance. However, feedback itself is learning and developmental tool, when carefully and simply designed it can objectively focus on delivering improvement. The Collins Dictionary describes its purposes well, stating it as “information in response to an inquiry or experiment.” Interestingly an initial positive from using feedback is the surprise and satisfaction from the patient’s perspective that their experiences and opinions are valued and their input can a make a difference as well as benefitting them in the future too.

I wanted to set out the questions in a statement format as it felt less ambiguous and simpler in addressing Rattan’s four questions. After constructing the form I spent a week getting proficient in operating the Handy as well as ironing out any gremlins likely to cause issues once the feedback process had begun. I discovered that the nozzles need to be purged immediately after use to prevent blockage, how to adjust the water pressure on the dental unit and how, if blocked, to simply remove it effectively. I also needed to make sure that I could use it safely with or without nursing support. This transpired to be not as difficult as anticipated.

Once the survey began I gradually lost any anxiety about asking my patients to participate and feedback to me. I wanted them to be honest and sincere in their responses. This got easier to ask for with experience. Some were very keen to add value to the form by giving measured and mindful comments whereas others were simply keen to tick the boxes and leave. I eventually completed thirty forms and analysed the data.

Air-Flow Patient Feedback

Marking grid: 5=Strongly Agree; 4=Agree; 3=Unsure; 2=Disagree Agree; 1=Strongly Disagree

Air-Flow Question Responses (Data Drop Box) 1 2 3 4 5
I was uncertain that airflow would be as effective as conventional polishing 2 2 15 8 3
I felt the procedure was comfortable and beneficial. 0 0 3 6 21
I would be willing to have the Airflow procedure again at future appointments 0 0 1 3 26
My mouth feels fresher and cleaner than I expected with Airflow. 0 0 1 5 24
I would be willing to pay an additional fee for Airflow. 1 0 12 10 7

The participants voiced many feelings and opinions after the procedure. Comments included;

  • “Much better result than traditional polishing.”
  • “Brilliant and good experience”
  • “A more pleasant experience than before.”
  • Several commented on the taste being “unpleasant” and “initial feeling of cold.”
  • It felt “cold but not uncomfortable” and reminded them of “Sherbet Dabs.”
  • A “towel” rather than tissues would be useful and “warn people that the spray could ruin their make-up.”
  • “My mouth feels really clean” and many commented on the “Fresh” feeling afterwards.

Appraisal and Planning

Most participants preferred the Handy to routine polishing and were surprisingly satisfied with its freshness. I was initially concerned more about patient comfort and determining whether they would pay an additional fee for future its application as part of treatment. It transpired this was less contentious than I thought. When questioned the majority thought that a fee of more than £5 to £10 would be excessive. Only a few considered that it would be inappropriate to charge more than polishing.

Given the opportunity of adding further value to my patients’ polishing preferences with Air-Flow, considering its portability, reliability and clinical benefits I will now begin to use the system in all four of my present practices. This will be made easier through this experience and I will now confidently demonstrate and advocate it to individual practice teams. In future clinical equipment evaluations I will continue to listen, through feedback, to the patient’s perceptions and preferences. I hope that feedback questioning would continue to accurately guide clinical decision making and back up the changes consequently made.

Cost Benefit to the DCP and practice – income and expense

Despite the initial price of the product and ongoing purchasing of powder I can see many pluses to using the Air-Flow Handy from the clinical perspective through to providing additional income. A simplified route map in terms of approximate cost and expenditure is;

Cost of Air-Flow Handy, 1 additional nozzle and 4 boxes (16 bottles) of Air-Flow powder in a year.

£ 2100.00 inc VAT – less if discounts and special offers apply

46 weeks of clinical work using Air-Flow Handy on 8 patients a day @£5 or £10 per patient.

£9,200 @ £5 per patient over a year

£18,400 @£10 per patient over a year

Summing up

Completing this critically reflective experience has to provide answers to the original four questions posed by Rattan;

Are we doing things the right way?

What is the evidence relating to our practice?

How can we ensure that the necessary changes are implemented into practice?

Were changes being made sustainable and, in addition, producing efficacious and cost effective benefits to patients in practice?

By putting the Air-Flow Handy into practice I believe my patients benefit from its stain and biofilm removal efficacy, especially interproximally. Improving my skill with it through experience and feedback has benefitted my personal and professional development.

Gathering evidence from my patients demonstrates approval and positive responses to the Handy. Where it was negative or indifferent opinion was sought to improve future experiences with it.

The changes needed to facilitate Air-Flow have been achieved but will be re-evaluated frequently. The key to its future success is maintaining its serviceability and buying additional Air– Flow powder by charging extra for its use.

The final question is the most critical as Air-Flow needs to be determined by the patient to be beneficial and by the operator to have cost effective benefits. Cost benefit analysis determines all the collated positive factors. These are the benefits. Then it identifies, quantifies, and subtracts all the negatives, the costs. The difference between the two indicates whether the planned action is advisable.

Conclusion

Patient feedback indicates a positive cost benefit result and that an increase in treatment fees would be accepted by most surveyed. Whether to introduce Air-Flow Handy is for the individual clinician to decide but I will continue to promote it a part of my preventive care regimes. Air-Flow Handy can also be used in other treatments, such as preparation for fissure sealants, in fresh breath therapy, periodontal and caries risk management programmes. Furthermore I would recommend all Dental Care Professionals continue their clinical development through evidence based critical reflective practice within their workplace. This allies to our professional duty of care, working in the best interests of patients, but also benefits our practice and ourselves by linking to companies like Optident who can help facilitate this opportunity.

References

Big Conversation on CPD continues. The Probe, May 2012. Available from:http://www.dentalrepublic.co.uk/the-probe/news/detail/big-conversation-on-cpd-continues

Gray, D. Cundell, S Hay, H & O’Neill, J. Learning through the workplace – a guide to work based learning, Nelson Thornes, 2004: pp 1-5. 

Rattan et al. Clinical governance in general practice. Radcliffe Medical Press, Oxford. 2002: P 99-107.

Care Quality Commission. Guidance about Compliance; Essential Standards for Quality and Safety, 2010. :http://www.cqc.org.uk/_db/_documents/Essential_standards_of_quality_and_safety_March_2010_FINAL.pdf

BDA Clinical Governance Kit, version 2.:http://www.bda.org/dentists/advice/practice-mgt/laws/qs/clinical-gov/implementing/clinical-gov-in-practice.aspx&gt;

General Dental Council, Standards for Dental Professionals. London, GDC Publications, 2005.http://www.gdcuk.org/Newsandpublications/Publications/Publications/StandardsforDentalProfessionals%5B1%5D.pdf

Thompson, S & Thompson, N. The critically reflective practitioner. Palgrave MacMillan, Basingstoke, UK. 2008: pp. 26-28.

Cottrell S. Critical thinking skills. Palgrave study guides, Basingstoke, UK, 2008: pp.1-12.

The influence of air polishers on tooth enamel. An in-vitro study. 1998;59(1):1-16.:http://www.ncbi.nlm.nih.gov/pubmed/9505051

Changes in the surface microrelief and the loss of dental enamel after the use of an abrasive spray of sodium bicarbonate,1990;33(2):77-82. :http://www.ncbi.nlm.nih.gov/pubmed/1964618

Routine scale and polish for periodontal health in adults. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004625.pub3/abstract

Pocket Mentor Giving feedback. Harvard Business School Press, Boston, USA. 2006: pp.4-8.

Collins Online Dictionaries :http://www.collinsdictionary.com/dictionary/english/feedback

Mentoring – Guiding the learning journey

Once qualified the DCPs learning journey alters radically to autonomous accountable practitioners working within unknown teams and clinical environments where expectations from employers and patients have to be met in that important first year. 1 Can “novice” hygienists and therapists gain valuable skills and expertise from trained and experienced DCP mentors and is there now a need for an embedded culture of mentoring like our colleague dentists and fellow health care professionals? 2

Standards and Regulations

Professional standards define the DCP as an individual who accepts responsibility for the effective safe care of their patients with underpinning ethical guidance promoting the co-operation with members of the dental team and other health care professionals in the interests of the patient. 3 The Nursing and Midwifery Council (NMC) have established standards that support learning in practice with post graduate professionals being guided within this structure, after training for their first “preceptorship” year and beyond with competencies being validated annually by a supervising “sign off” mentor. 4 Comparable mentoring activities within dental hygiene and therapy have yet to be fully realised by the profession despite greater regulations in place to protect the patient and increased professional standards from authorities like the General Dental Council and the Care Quality Commission 5, 6

Mentoring within our current dental culture

In 2009 a revalidation linked feasibility study undertaken for dentists by Costley identified that many practitioners in the dental sector were not meeting the minimum standards of “operational” competency with a perceived need for face-to-face assessment with all, or a selection, of dentists throughout the UK. 7 Revalidation builds on current standards to protect patients by asking dental professionals to demonstrate their suitability to remain on dental registers. The study made no mention of co-operation, collaboration with or comparison to other health care professionals or mentoring in addressing this serious issue. A rapid response to this was a change to dentist vocational training that extends the course from one to two years and encompasses a new title, Dental Foundation Training (DFT). Participants need to log clinical experiences, assessments, education, continuing professional development (CPD) and personal development with reflective practice required weekly for the first eight weeks then monthly for the duration of training.

The General Dental Council (GDC) currently refers the issue of mentoring activities and training for DCPs to educational and CPD services provided by the Committee of Postgraduate Deans and Directors and have commissioned the Centre for Medical and Dental Education to develop post graduate dental and medical education for dental practitioners. 8The fifteen UK Deaneries are tasked to develop and quality assure opportunities for trainers in Primary and Secondary Care Services and to ensure that sufficient training places are available to meet the future needs of the NHS. Other providers include the Faculty of General Dental Practice, the University of Lancashire and Kings College London. 9, 10, 11 The development of mentoring services from the Deaneries appear very limited varying from a general lack of any training or guidance to a few, like the Northern Deanery, offering training and a mentoring service similar to that of the NMC. Other providers offer level 3 study varying in length and cost which might, to many DCPs, appear prohibitive and distant.

This appears to bode well for struggling or newly graduated dentists but what about the DCP? We too are registered and accountable, regulated by the same body, working within the same standards and guidelines, and are advised, like our dentist colleagues, to evidence base practice whilst viewing our annual retention fees and indemnity costs increasing with incredulity. However, DCPs appear be less served in comparison despite facing increasing risks of negligence claims against us for malpractice or poor performance. Surely there is a need to develop mentorship and guided support, irrespective of costs, which brings parity to dentists and healthcare colleagues, and continues to raise standards, quality of care and safety for patients.

 Mentorship training

 The initial challenge of the team professionally qualifying as mentors was addressed by training at the University of Surrey.13 The tutoring team were very approachable, experienced and flexible providing an established programme over twelve weeks at level three with several mixed professional cohort groups in each academic year. The five day course is divided into two learning sessions with reading and course work set which includes a teaching and assessment session and a fifteen hundred word reflective submission about the teams learning journey in mentoring. Learning with other healthcare workers allows a unique insight into their environment, knowledge and experiences and gave us a good academic foundation helping us to evolve the support programme design with the knowledge and experiences acquired.

The course explored in detail individual learning styles, domains and theories to complement broader mentoring subjects and debate. Knowledge learned was evaluated when we all undertook individual teaching and learning sessions as part of the module. Being able to put our learning into practical use and understanding the underpinning elements of individual learning has better equipped us to structure and deliver the programme more focused upon the individual using their input and feedback to deliver clinical shadowing, online interaction and peer event elements more effectively.

Organised Peer Events and Learning Programme

The programme is designed around three organised peer events throughout the initial pilot year. The events will be heavily influenced by feedback received from several “about to graduate” hygienist and hygiene therapist student cohorts from universities across England. The team ensured that the groups had the opportunity to debate the challenges that the current dental health environment now presents and focused on the opportunities to develop their professional skills and voices. Great weight was given to listening to what they perceived their challenges would be in the coming years and how these may affect or benefit them. Most were concerned about finding appropriate employment after training and losing skills as therapists when only employed as hygienists. With these views considered the course will guide the DCP in designing their aims and goals, to be involved in a reflective process of learning with awards and prizes given for development linked to the promotion of the professional, dental health and their clinical environment. The programme will also use pre and post course feedback to benefit the participant and the team, its future development and quality control.

Shadowing

Skills gained by the mentor during the course can enhance a one to one learning experience with participants potentially benefiting from time with a colleague or co-worker who is further on in their career or has a skill set or experiences the learner values. Being able to observe clinical activities set in different environments, to question the professional directly, absorb the work culture and procedures but also give and receive feedback with that expert provides an opportunity for a unique learning process, from which both can develop. 15, 16

Conclusion

Providing hygienists and hygiene therapists the opportunity to actively participate in a supporting learning culture will benefit the DCP, the professional body and the safety and care provided to the patient. Price (2004) believes mentoring is pivotal in setting goals, socialising learners in the practice culture and understanding their anxieties and needs but goes much further by challenging the mentor to demonstrate and maintain an active interest in learning whilst continuing to create learning opportunities. 17 Other health care environments have and continue to provide opportunities to promote best practice and develop competencies through clinical based mentoring within their professional culture.

Sources

  1. James, M. Ives, T. Dickinson, J and Rawsthorne, P. The Transitional Support Programme for Hygienists and Therapists, A Pilot Study. Dental Health 2011, 50 (3): 20-22.
  2. Benner, P. From novice to expert: Excellence and power in clinical nursing practice. Addison-Wesley,1984.
  3. General Dental Council. Developing the Dental Team, 2004.

http://www.gdc-uk.org/NR/rdonlyres/3029D7DD-81AE-41C6-973A-F39FE7287BF8/15135/developing_dental_team2004.pdf

  1. Nursing and Midwifery Council. Standards to support learning in practice: NMC Publications, 2006.
  2. General Dental Council. Standards for Dental Professionals. London, GDC Publications, 2005.
  3. Care Quality Commission. Guidance about Compliance; Essential Standards for Quality and Safety, 2010.

http://www.cqc.org.uk/_db/_documents/Essential_standards_of_quality_and_safety_March_2010_FINAL.pdf

  1. Costley, N. Revalidation Stage 1 Feasibility Study Final Report, General Dental Council, 2009.
  2. The Committee of Postgraduate Deans and Directors.

http://www.copdend.org.uk/

  1. Faculty of General Dental Practice (UK). Certificate in Mentoring in Dentistry.

:http://www.fgdp.org.uk/professionaldevelopment/dentists/mentoring.ashx

  1. University of Central Lancashire. Mentoring in Dental Practice.

http://www.uclan.ac.uk/schools/dentistry_at_uclan/postgraduate_medical_dental_education/adv_cert_ment_dental_prac.php

  1. Kings College Hospital. Mentoring in the Workplace (online).

http://dnetc.kch.nhs.uk/mentoring-in-the-workplace.html

  1. Philips UK. Dental Professionals, Education and Resources.

http://www.sonicare.com/professional/dp/DP/Default.aspx

  1.  University of Surrey. Health and Social Care, Mentorship. http://www.surrey.ac.uk/healthandsocialcare/study/CPD/mentorship/
  2. Meggison, D & Whitaker, D. Continuing Professional Development. CIPD, 2008;122-123.
  3. Gray, D. Cundell, S. Hay, H & O’Neill, J. Learning through the workplace – a guide to work based learning, Nelson Thornes, 2004;182-183.
  4. Price, R. Mentoring Learners in Practice, Nursing Standard. 2004;18 (52).

Designing hygiene intervention protocols for my practice – whole dental health – part’s 1 and 2

It has been almost a year since I arrived at my new practice in Nelson, time has passed rapidly in an eventful period for us all. Little would I have known that at this very moment I’m typing this nearly a half of my fellow countrymen and women are experiencing a level 3 COVID lockdown. This was the case for us all in New Zealand from the very end of March to the end of May. A few months of near normality followed this to where we are now, awaiting a national reduction to level 1 again. The degree of apprehension and uncertainty has evoked recent memories but the these feel more measured and less existential, for me at least. Despite this the need for normality in the workplace, even progress, has to be engaged, perhaps as a distraction but more so to meet the needs of clients here.

It was during this moment, last week, that my boss, Gerry, approached me to generate a protocol to link hygiene appointments to the treatment planning designed with the orthodontic auxiliaries. It was made clear that there needed to be a differentiation between age groups, youth, youth adult and adult as well as a plan for 12 or 18 month treatment patterns.

I am also mindful of the nature of the practice, it’s desire to be as natural as achievable in its treatment approach and empathetic in its guidance, tolerant by embracing differences of opinion regarding product and lifestyle ideologies. This could originate from objections or concerns regarding contents or perceived toxicity within products that are indicated in controlling and balancing biofilm and pH, strengthening or demineralising tooth substance through to nutritional, habitual or economic realities, even ideologies, that oppose or conflict with mainstream and established approaches to oral health development or management. This can be seen in the debates that rage around fluoride, additional materials found in dentifrices, allergies to components in toothpastes and diets rich in fermentable carbohydrates, acids or dehydrating effects. Consideration required for a dry mouth status emanating from poor tongue posture or arch form, or both is not in my present scope of practice but can be engaged with by our practice oral myo functional therapist and orthotropist.

My aim is to collaboratively design a protocol and consider a linked oral health process complementary to and in symmetry with the treatment planning of orthodontic clients including guided and considerate product recommendation, appropriate linked appointments for team reviews and timely interventions as deemed necessary on reassessment. This I began by designing an provisional flow chart, based upon guidance from the clinical team, aware that it is a prototype and will be changed and challenged. That’s fine by me.

Historic concerns have been raised with specific ortho cases of late, either due to poor oral health compliance, plaque and calculus accumulation linked to an increased risk of poor oral heath outcomes. The demineralisation of young enamel tooth substance, due to caries risk increase has been another subject of growing concern. The management of appropriate and sustainable oral health behaviours, conducive to stabilising and maintaining gingival and tooth integrity is as importance, in my opinion, as the process of arch expansion and tooth realignment. In addition to that, a post treatment phase be  considered, especially where retainers, either fixed and removeable, are utilised.

The instruction in cleaning appliances, currently undertaken by auxiliaries needs to be continued and promoted at fit appointment. Where compliance cannot be demonstrated or achieved during care, despite interventions will be guided back to Gerry for determination.

Screen Shot 2020-08-30 at 3.12.59 PM

                                                                      Option 1

  1. 30 minutes 3 x 12 months

$125 each

Cost for OH phase + review @ 4/52 and 3 x rev follow up and final visit = $640

  1. 30 minutes 5 x 18 months

$125 each

Cost for OH phase + review @ 4/52 and 5 x rev follow up and final visit = $890

 

                                                                            Option 2 ( flat Rate not individual )

 

  1. 30 minutes 3 x 12 months

 

Cost for OH phase + review @ 4/52 and 3 x rev follow up and final visit = $500

  1. 30 minutes 5 x 18 months

 

Cost for OH phase + review @ 4/52 and 5 x rev follow up and final visit = $750

 

OH Phase – 45 minutes

  • Disclose – Pictures – Intra Oral Hygiene Focus
  • Debride calculus – Airflow Plus Biofilm Reset – Polish
  • Nutritional behaviours – pH imbalance, dehydration, carbohydrates, carbonated and acidic foods, fluoride & non-fluoride toothpastes, Calcium Phosphate Based toothpastes, pre and probiotics before and during with at risk cases.

Review Phase – 30 minutes

  • Disclose – Pictures if required – Adjust Oral Hygiene
  • Debride calculus – Airflow Plus Biofilm Reset – Polish

Focus and Strategy

  • Medical status – dry mouth linked to mouth breathing – medication
  • Plaque control – manual or electric – Interstitial cleaning when brackets, bands and wires placed
  • Hydration when dry mouth – regulation of carbohydrates, especially fermentable, to mealtimes – clear with water/milk after and before brushing at night time
  • Nutrition – Regulation, reduction and cessation of fermentable carbohydrates and starches – carbonated and acidic drinks and foods
  • Remineralisation/mineralisation – fluoride where parents accept – with calcium based products or alone if parents not accepting of fluoride intervention – no rinsing after spitting out
  • Antimicrobial intervention with poor compliance or increased risk – pre and probiotics
  • Motivation through visual means and positive affirmation. And demonstrating understanding
  • Intervention – Full debride and polish post treatment/complete or removal of appliances

Products

General ecological balance (pH balance) and hydration/ saliva stimulation

  • Prebiotics – Xylitol and Erythritol – granulated form – 5gms for xylitol diluted in water – or 1 gm per kilo body weight as a maximum – sipped throughout the day or in gum until flavour gone  or lozenges after meals
  • Probiotics – BLIS M18 at night after brushing

Mineral integrity, sensitivity management and ecological balance (pH balance)

  • Fluoride – Stannous Fluoride with Arginine or ACFP – brush spit no rinsing after – hydrate before – determine age for correct amount of fluoride and use of ACP
  • Topical fluoride
  • ACP – non fluoride options – as above

Physical intervention and ecological balance

  • Manual and electric toothbrushes – Interproximal, interdental brushes – WaterPik
  • Fissure sealants

Instruction – Information Sheet

 

Quin Dental Guidance Form

Disclosing/ Plaque

Positive nutrition

Negative nutrition 

Brushing

Tooth strengthening

Oral environment and pH

 Additional

Part 2

I work in two practices in Nelson and am fortunate in one to work with another Hygienist. This hasn’t been the case for a lot of my career so I’m grateful for this and also that they are collaborative and are happy to be part of, contribute to, and help implement change, if sound.

My challenge is that the cost of current treatment is the same whatever the status of dental health. That means that complex care is charged at the same rate as a well-managed and stable mouths. This is irrespective of whether a local anaesthetic is required, additional instrumentation with ultrasonic or airflow polishing and biofilm debriding systems are required. The additional labour, skill level and equipment requirement isn’t reflected by the flat rate being charged. How can we move this situation forward and bring a process that rewards oral health improvement, requiring fewer additional visits but can also demonstrate money well spent, and less costs incurred in the future?

Being employed, but having previously experienced self-employed I can appreciate the disconnect between the two as a dental hygienist. The self-employed hygienist is motivated in the same way as the employed, by their efficacy in line with standards and scope of practice responsibilities but are more likely, from my experience, to be more proactive and inclined to be aware of their efficiency, be it time management or economics. This has its downsides too, with the potential to be time constrained, less client care focused as the employed individual, from my experience. I have found, subjectively, that moving to employed status took a while to adjust to being less time pressured and production focused. The imperative is quality care, delivered safely and effectively, in partnership and with the consent of the client. The quandary being employed is to see a different way, in the relative safety of a system that is established but doesn’t appear fair. If we can marry both ways, the need for sufficient treatment time, bringing the best outcome, delivered ethically, meeting and rewarding the needs of the client and the clinician, then I’m a believer.

The way forward with routine care has been at the forefront of my enquiring mind of late. I have experimented at my previous practice adapting a traffic light system that marries the time and cost required based upon the need demonstrated by assessment prior to treatment commencing. It follows a red green and amber protocol with the fees being set that reflects the need and complexity of care as well as the stage the client’s oral health represents at that moment in time. A code score, linked to recently updated periodontal guidelines, is added as an alternative option. The benefit is with both clinician and client. They now know their status, it has been measured. They can determine the efforts required to either remain where they are if stable or the processes necessary to achieve better oral health and a shorter less costly next visit, determined by the recall recommended by the clinician after.

The original idea was as a consequence of a discussion with a client who challenged the cost of advance care. I indicated the best way to get to routine care would be to achieve oral stability and remission from their periodontal condition. I then considered standard care broken down into three parts to follow this rationale. I separated the advanced care as a different process as it requires more time, use of equipment, materials and skill. I tested it with a colleague and found it to be achievable. This was further approved by the practice owner and with all the team briefed it proceeded successfully into action.

For the purposes of this project we will spend a month doing a trial run, annotating the clinical day sheets with the code/colour and additional costs hypothetically. We will then gather the data, see how many would have been whichever code/colour and additional costs that would have been levied. We will also ascertain whether the idea works or needs modifying. This will guide whether we precede with the action plan. It can also be a useful aid to the practice management team regarding improving our hourly rate or linked to a novel bonus system, so everyone, both clients and the hygiene team benefit from improved dental health.

Dental Centre Hygiene Experimental Guideline Protocol

Routine

Code 0    < 10% BOP  Stable or just Phrophy   30 – 45  minutes     $100/125      GREEN

No risk                                                                      recall 12/12

Code 1    10-30% BOP  Unstable/localised       45 minutes              $110/140       AMBER

Low – Medium risk                                                 recall 6-12/12

Code 2     >30% BOP    Active /generalised      45 – 60 minutes      $120/155       RED

High risk  – possible two visit appointment       recall 3,4-6/12

ALL CODE 3 & 4 CLIENTS NEED CODE 2 Appointment at 45 or 60 minute appointment, dependent on need, for assessment and ORAL HYGIENE PHASE before COMPLEX CARE

 Complex

Clients seen as code 2 before –  5/10 minute review – consider OH review before to determine compliance, reassess need or whether interested in undergoing additional treatment

Code 3    Perio unstable         advanced             60 – 90 minutes      $200 – $300 per appt

per appt                                                                    quadrant or half mouth

Code 4    Perio unstable+       Complex               Combination therapy as above or refer

Or refer                                                                      as above              

Code 2P  Perio stable             Maintenance        45 minutes               $120/155    

Remission                                                                  recall to be determined

Codes 3/4 to be determined by Mark/Kelsey or referred to Periodontist

Based on modified fee structure and 2017 Classification  of Periodontal Diseases to Reach a Diagnosis in Clinical Practice www. Bsperio.ork.uk

 Patient Information Form

Environmental /Ecological – Plaque

pH balance

Caries risk

Perio risk

 Recession and sensitivity

 Products

 Fresh breath/ Tongue cleansing

 Dry mouth

 Erosion/ Wear/ Abrasion

In conclusion, the need to consider costs of care related to need conflicts with the assumption that all treatment should be charged at the same rate and that recall lengths are the alternative. This assumes that the recall will be met, that the clinician isn’t factoring in the additional effort professionally, physically, emotionally and mentally required to facilitate change and an achievable, beneficial outcome. My experiences demonstrate it is at least worth attempting, getting feedback from colleagues and measuring the benefits, quantitively and qualitatively, reflecting on them and making changes if required.

 

The Journey Begins.

“Come forth into the light of things, let nature be your teacher”.

William Wordsworth

“Does a holistic approach to dental hygiene practice, required as part of my professional standards, align with an environmental, nutritional, and ecological approach to dental health? An authentic, first-person, reflective narrative account into personal new knowledge creation and practical application.”

“Natural ecosystems regulate themselves through diversity”. The biggest little farm, 2018

Introduction

“A holistic approach is all-inclusive; it requires you to give consideration to the patient’s overall health, their psychological and social situation, their oral health needs (immediate and long term), and their desired outcomes. Provide patients with oral health advice and treatment options relevant to their situation, and discuss associated benefits, likely outcomes, and potential risks. Carefully balance the patient’s oral health needs with the patient’s wishes and be able to explain your approach to care, which could include declining to treat. Restrict your treatment to the activities permitted by your registered scope of practice. Refer patients who present with issues beyond your area of practice or competence.

https://www.dcnz.org.nz/assets/Uploads/Practice-standards/Standards-Framework-for-oral-health-practitioners.pdf

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 personal 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 very 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 the constraints of convention, and were 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 benefits to improved 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, paediatrician Dr. Robert Ludwig, and complex problem-solving engineer Ivor Cummings debating systemic health, lifestyle behaviours, and watched heart health related documentaries by the likes of Azeem Malhotra, a cardiologist. 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 the contemporary landscape. They believe that the modern food environment and culture require change for broad health, general wellbeing, 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 to me by the day. I designed an academic presentation, delivering it in a local and national venue, with a colleague, to a paying professional audience. I found “walking the walk rather than talking the talk “profoundly influencing, although scary at times. Upon these experiences and knowledge, I realized that other people, many amongst my clients, follow a similar path. How would I make the next developmental  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, 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 booked 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.

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. 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 and observation, linked to evidence guided practice.

The full account is designed loosely around the learning and developmental model of action research. The term action research was coined by social psychologist Kurt Lewin in the United States around 1944,  aimed to promote social action through the democratic decision making and active participation of practitioners in the research process. The project sheds light upon action research throughout the narrative, and I will leave it there for the reader to discover and understand it more thoroughly. I have also decided to use a first-person, narrative style of writing, mainly because it reveals the unique nature of the project and the character of the individual participating. The sources and references reflect the mood and headspace I’m in at the time and the decisions made to demonstrate the association between research and action in a way that appears less formal but allows the reader to refer to them directly online if desired.

The main body is really divided into two parts.  One the physical and secondly, the academic learning journeys. The first part demonstrates learning on the hoof, so to speak, being influenced and motivated by real-time experiences and appetite, sometimes literally, to describe those events as they occur, when and where they happen. The second part of the story reveals an evolving workplace journey, adapting knowledge through an action research context developing into personal clinical behaviour change.  It will culminate in a final piece of work, drawing upon them in the context of action research, but using my own style of referencing.

Finally, the work’s body will be an extensive edit from where the research was deposited during its construction. This was derived from two blog sites, posted to them, designed as a portal for the professional and general public to read and review, but also as a repository for them to be used at a future date. The context of each individual post can be referred to and seen in its unfettered form, with photos and pictures included in the initial post and a rawer, less refined written account.

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”. Marcus Aurelius

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