Toni, Rick and Clare in March at Christchurch Horncastle Arena
We meet him, in Christchurch, the man responsible for one of the greatest Eighties hits, a hand shake, a smile of delight and the presentation to him of a bottle of Pinot Noir. It had been a long journey from my cousin Sally in Somerset to the drive from Nelson to the venue. Along with us that day was Clare, my colleague’s wife. She had no idea of what was to happen, she was only aware that we were meeting up to see him play. The look on her face when we were escorted back stage before the gig was priceless and greatly enhanced when he appeared with his agent. This was the week before lockdown came into force. Rick Astley was the perfect antidote the coming storm at the time as was the MarchFest in Nelson a few days later, the last time I’d see any of my family for several weeks.
It is New Year’s Eve in New Zealand as I write and the weather is surprising mild with cloud cover masking the blue sky and sun. This is unusual for the time of year but was predicted as a consequence of global climate change. It happened several years ago when our close friends from the UK came over the same time of the year in search of clear skies and warmth. Sadly, I listened to the BBC radio this morning to hear the news of yet another leap in the COVID body count, this time 981. The radio presenter was discussing this tragic milestone, the worst daily total since April and the grimly predicted a similar picture in the coming weeks, despite the development and introduction, at astounding speed, of a variety of vaccines. Their uptake has just begun but it appears weeks will be required to build immunity and additional boosters necessary to increase their immunological effect.
Knee jerk signage but not at the time!
Who would have considered the word “lockdown” in 2019 to be so contentious and emotive? It seems to me, so far flung from the present UK epidemic of restrictions and curtailments of normal life hard to comprehend. Those living there I’ve communicated with or have heard off appear to be struggling with the immensity of this. It’s long term effects, of isolation from friends and family, to businesses dependent upon those locked down and the greater economy as a whole will be difficult to calculate. What seems to be remarkable though is that the UK health service continues to manage in the way it does. Surely the message of this pandemic is that for the national economy to thrive, even survive, in unique and unprecedented events demands a robust and resilient health service. This aligned with the leadership of the country carefully listening to and appropriately reacting in accordance with their scientific advisers has been the success story of those, including me, living in New Zealand. This is born out by the resulting repatriation of tens of thousands of Kiwis back to their home land when the borders here were reopened in June. This in itself has created many new and unforeseen problems including the unaffordability of housing increasing on an already struggling marketplace.
“What has socialism ever done for us?”
Despite this the country is prospering, comparatively, to other western nations affected by COVID 19. I still go to work, can plan holidays and weekend breaks, am free to travel within New Zealand unrestricted and see friends and family without restriction. This was not the case back in late March. The tumultuous nature of the government’s decision to do a hard lockdown came as a surprise with many doubters and push back. Several weeks later with alert states returning to relative normality and only a handful of fatalities life began to resemble its pre March picture. Contact tracing and testing continued and the pulse of life led to the occasional local outbreak which was dealt with remarkable effectiveness. This I confess has its own problem, that of complacency, and many not conforming to the ritual of scanning QR codes when entering premises and shops anymore.
This reflection on those heady events will now turn to how we, Toni and myself, have adapted to this new normal which really began in January of this year, 2020. It was then that events became more news worthy. Our daughter and her partner were planning a trip to Europe and the UK and I was becoming increasingly concerned about their welfare and ability to return in the event of this news becoming more serious. It seemed that any cold or flu like symptom was an indicator of a COVID infection. An old school friend of Toni’s, living in Canada lost her young Son to COVID in March, or so we thought. The anxiety of this and the rapid onset of measures to combat and control this, its immediacy and the somewhat draconian response was breathtaking. A workplace presentation on sustainability in dental practice was soon changed to become the forum to discuss what we do if or when the inevitable decision to lock down occurred. Toni, as a core midwife at Nelson Hospital, had no choice but to continue regardless of the pandemic but we soon both adopting the strip off at the back door to go directly into the shower, unceremoniously throwing our work clothes into the washing machine. This became the norm until lockdown and continued for Toni through the early weeks of the crisis. I became head chef and gardener and was kept very busy on various projects that were in the long grass. It wasn’t long, however, before New Zealand returned to work and in particular for me stood some obstacles before my headspace and mental health accepted this new reality. I had made this decision based upon the notion the dental hygiene profession would suffer as a fear of COVID, this was reinforced by the fact that we as clinicians deal with all manner of oral flora and our mechanical processes, our instrumentation of biofilms can create bacterial fields potentially harmful to us and others. This concern was reiterated by the governing and regulatory bodies decision to ban the use of ultrasonic and sonic scaling equipment in higher alert levels. I’ll return to this shortly.
Banksy at his best extolling the virtues of essential workers during COVID
At this point I must allude to the role that social and main stream media played during this time. I was glued, like many others at the time I suspect, to the only real form of immediate communication, the internet. I must have spent many hours listening to podcasts and media broadcasts to either understand the nature and response to COVID nationally and globally but also as a distraction. My mother, at the tender age of 81 years, and myself began a Zoom thread that continues weekly to this day. Respect to her, adapting to the new technology scene and adopting this a form of real communication with us. At one point I was organising meetings from here between her, her sister and nephew, all in the UK! Strange times indeed. The media I believe will take some responsibility for its reporting of events during COVID when all the facts are known and lessons learned from it. Social media in particular will be more cautiously approached by those of a more discerning persuasion. Feverish and hungry consumption of any news be it verified or wholly misleading will change I hope after infections and vaccines bring an effective degree of heard immunity and normality return.
A menacing dark cloud taken from our balcony summing up the moment of lockdown
In May, whilst stationed in my home I decided to apply for a new profession, the fear that dental hygiene as I knew it would cease or irreparably change drove my application to train as a nurse at Nelson College. I was surprised that my application was immediately accepted and my headspace began to accept the inevitable move from dentistry, after 38 years. I kept this quiet from my colleagues initially and uncertainty with this decision began to appear when I considered the income I’d lose and debt I’d incur after 3 years of training. I was also perturbed by the fears and anxiety shown by my daughter-in-law who was into her final year of training locally. The idea that you were in a lottery after graduation as to where you ended up working appeared totally Dickensian to me. This affected me and a few counselling sessions and medication helped me traverse the stormy seas of my emotions. Life felt tough to me and affected my workspace as well as my headspace.
Herman our German Toyota Mini Campervan
I am very thankful that we did our odyssey back in 2019. We learned much from it especially the decision to make it our last for quite some time. We decided to buy a tent and all the finery that goes with the camping scene, a tow bar for the Volvo and a decent bike rack to transport the Ebikes around this country. The purpose of this was to save the expense of long haul travel, it’s environmental footprint and impact as well as the time in transit, jet lag and organising headaches. We were also fortunate to meet Cedric in August. He was a traveller from Northern Germany, like many thousands of young folk making a pilgrimage to these shores, supporting the economy with their presence and being witnesses and ambassadors to future tourists wanting to travel to our country. Annoyingly to me they get a bad press in this country, free campers for which Cedric was one, have been bad mouthed for poor toilet behaviour. A few have been responsible for this feverish media assassination but most are abiding and responsible, furthermore they add to the economy in multiple ways and buying Cedric’s converted Toyota Estima was acknowledgement of that and support of him. Herman, the aforesaid Toyota is now a firm family favourite and we thank Cedric for his attention to detail in converting this MPV to a mini mobile home. This is an addition to the travel inventory and Oli, our Spaniel, can now be part of our journey too.
Social Distancing during vintage at Neudorf Winery – Germans and French playing their part
Another positive from 2020, from a completely unforeseen angle was the provision of free training for primary industries. Apiculture being one of these. Now bees have been off my radar of interest until the last few years. Dear friends of ours have been drawn to the beauty and necessity of beekeeping and have inspired me to consider it as a hobby, if not a job in the future. I wasn’t really aware of this opportunity provided as a COVID response to aiding the economy but thanks to Facebook and the Nelson Beekeeping page I fortuitously stumbled upon it. The class of 18 features more females than males, they are really passionate about their learning and contribute much to this journey. I’ve now 2 hives, in the 2 corners of the garden, have endured many ups and downs with Queen bee dramas that many an expert hasn’t had to endure, several stings and a curious obsession with watching them landing on the hive laden with pollen. Anyone who thinks that a foray into keeping bees is an easy ride be warned it is far from that. There is a need for regular inspections, checking for a variety of infestations and diseases and a need to conform to a responsible yearly management plan to protect the bee colonies of New Zealand and their welfare throughout the year.
Bees in a brood box and feeder with bracken as a gym
To sum up 2020 has been a rough ride, an emotional and physical rollercoaster to me and I would reliably assume many others. I’m not in the super COVID risk age group unlike my mum and the in – laws. I have learned much about myself, faced a few demons and changes along the way. I am lucky, as part of the team of 5 million New Zealanders, that we had decisive leadership who took the right advice from the right advisers and the right time. The damage was minimal and the social consequences I hope less than predicted. I will continue as a dentalcare professional, as a gardener, a writer, and now as a budding hobbyist beekeeper. Where this coming year will take me I’m not certain, Toni will hopefully get her new hip and our friends from the States, returning to Aotearoa will find a place and settle back into this great country. I wish all who read this and friends and family the very best, health, happiness and a greater degree of certainty for your future. Kia Ora.
An eternal memory where nature felt more powerful than manned flight – Air New Zealand paralysed and on the deck
If you’d have asked me when I embarked on my learning odyssey back in 2019 (boy that seems such a long time ago now) whether I’d be on a Level 3 Certificate Course in Apiculture, having two hives ready to host colonies of bees and a growing concern and understanding of the nature of bees, their protection and importance to humans I’d have chortled, very loudly. It shouldn’t have been any surprise to me really, given my tendency to explore and deep dive into many non mainstream subjects ranging from craft beer brewing to foraging for nuts, fruit, mushrooms and plants to allotmenteering for exchange and barter or pure home food production. These less than mainstream pursuits meet my innate requirement to tax and satiate my curiosity and left field nature, and, moreover, engage my visual and kinaesthetic learning styles.
Before COVID announced its menacing presence back in March I had spent the previous months being focused on sustainable professional and personal practise development. In my workplace I had undertaken prolonged research into its significance, meaning and application towards my dental health practice and was on the point of presentation and action, hopefully persuading my colleagues. My intention was to make changes along the lines of improving the perception and belief to our cliental that we were taking the looming climate and environment crisis very seriously and were changing our behaviours to meet this existential threat.
https://www.nature.com/articles/s41598-018-32194-8 Extracts of Polypore Mushroom Mycelia Reduces Viruses in Honey Bees. Paul E. Stamets et al. 2018
My dealings with mushrooms and research related to offthplot.wordpress.com and wholedentalhealth.com had brought me to greater awareness of the association between birch polypore mushrooms and the bee population that use them to aid the natural disease prevention of bee deformed wing virus. Discovering this fact and the work undertaken by Prof. Paul Stamets, an global expert in Mycology, including his energy behind the creation of 3D bee feeders for the promotion of bee colonies in back gardens, inspired me to take the next few steps towards a greater journey. This was additionally aided and abetted by dear friends Dave and Rachel Annette at honeybehappy.co.uk, in Alresford, Hampshire, whilst staying with them in the UK last year. They have both undertaken a fundamental lifestyle and value changing venture into keeping bees, educating the public about their benefits and training those inclined to go beyond knowledge into practical application in apicultural practice. I owe Dave and Rachel both directly and Paul, very indirectly, a debt of gratitude in providing not only a substitute for the COVID postponed clinical sustainability project but also to a meaningfully related cause for bee sustainability, aligned to my social values and personal intent.
Enter the real world. How and where to do and achieve this? New Zealand is an agricultural country, especially in the north of the south island where a healthy bee population is essential in pollenating the vast areas of cultivated fruit and plant food production. Native Manuka honey is also a huge export industry, it’s Unique Manuka Factor (UMF) being sited by ongoing research as very beneficial for health. I’m in the right place to be for certain. However, apiculture courses are expensive, running into several thousand dollars NZ, or more, and such course providers not marketing them especially well, perhaps for that very reason. Enter COVID once again and the New Zealand Governments immediate investment in primary industry training programmes, some of which are being fully funded. Also, interestingly, enter stage door left social media, and in my case, FaceBook. The Regional Bee Keepers Association in Nelson had a thread on their page casually promoting this very thing. I immediately latched on and asked the question, where do I sign up? To my amazement it was as simple as that, two great instructors and experts in the industry, Scott and Jezebel Williamson, began the course in Brightwater, Nelson in August through Land Based Training, a commercial organisation promoting primary industry education. Fifteen very rookie and novice students of all ages and sizes turned up for the first day of term not fully knowing quite what to expect.
So, I’m now three months into a nine month course. I’ve two hives, one provided free as part of the training, this we had to construct, treat and paint. It sits on my deck at home presently awaiting a journey to Brightwater this weekend and its temporary future home for its first colony to reside in it. The other was donated to me by my former Marlborough dental boss Ed Durrheim, also a hobbyist beekeeper, which has also been treated, painted and set up for a home based hive here in Nelson. A big thank you to Ed. The neighbours have given consent and I’m priming a spot for its location, sheltered, north facing and exposed to plenty of sunlight. It awaits a Queen nucleus and will be my home learning hive, a fortnight behind the course hive. I’ve two suits and all the equipment required at present, including Adrenaline for bee sting hypersensitivity. Fortunately I’ve recently undertaken a work based first aid course where this was practiced. It appears all my ducks are stars are aligned and the active part of the beekeeping learning journey, post three month theory, begins in earnest this coming Sunday.
There is still so much more to learn, to experience and achieve but my goal is to focus on the health and well-being of bees in my charge, to be fully cognisant of the ways to achieve this, not to be concerned about asking questions, no matter how daft they may seem and to encourage all those I know to be mindful of the importance of the role that bees play in our everyday lives. The honey will be a bonus but not essential if needed by the bees themselves.
In the next thrilling episode of “Too Bee or Not too Bee” I will be more reflective and explicit about managing a hive on two sites, the routines, disease and pest risks and the highs and lows of this adventure. I will, no doubt, have many new experiences to reveal and new knowledge of lessons learned.
“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 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.
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.
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”.
Annual renewal and fees, GDC, UK.
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.
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?
1. Ministry of Health, Dental Council and Professional Associations’ joint statement: COVID-19 update*
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.
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.
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.
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.
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.
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.
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:
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.
5.The Fluoride Debate: The Pros and Cons of Fluoridation
6.The Case Against Fluoride, Paul Connett in New Zealand 22Feb2013
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.
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
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.
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?
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>
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;
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.
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.
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.
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.
Effectiveness of Propolis on Oral Health: A Meta-Analysis. Hwu et al., 2014.
Honey for Nutrition and Health: A Review. Bogdanov et al., 2008.
Novel Insights into the Health Importance of Natural Honey. Ajibola, 2015.
Anti-inflammatory effects of Boletus edulis polysaccharide on asthma pathology. Wu et al., 2016. https://www.ncbi.nlm.nih.gov/pubmed/27830033
Edible Mushrooms: Improving Human Health and Promoting Quality Life. Valverde, 2014. https://www.hindawi.com/journals/ijmicro/2015/376387/
Lentinula edodes (shiitake mushroom): An assessment of in vitro anti-atherosclerotic bio-functionality. Rahman et al., 2018.
Consuming Lentinula edodes (Shiitake) Mushrooms Daily Improves Human Immunity: A Randomised Dietary Intervention in Healthy Young Adults. Dai et al., 2014.
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
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)
Assessment/ Initial treatment phase 90 minutes
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
5 monthly appointments at 45 minutes
Review phase @ 6 months OPG P/A’s
Non responders refer to Periodontal Specialist
Doing the White Thing – Reviewing and Changing my Practice in the Light of Evidence, Experience and Reflection
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.
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
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:
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.
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.
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.
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.
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.
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.
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;
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;
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.
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.
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.
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
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
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