My whole world, both personal and professional is in an evolving state of healing as a consequence of the global pandemic. It feels like I’m in a recovering state of COVID decompression akin to a deep-sea diver in a planned act of readjusting to normality after being to the deepest, darkest depths. This imbalance has been emotionally unsettling, for several weeks of lockdown and uncertainty, not knowing whether PPE would be required, the very nature of new practice, and when we were to return to it. It did, however, allow me to drive, undistracted, and determined to complete my self-directed learning project which began the previous June. The reams of printed studies this project generated had been sitting on the bookcase, gathering dust, and tested my resolve to meet its critical challenge. All but one post is now done, so this will be the final piece of the puzzle with just an introduction and ending to conclude it. Let us to it proceed.
“Educated! We are not even born as far as our feelings are concerned.” D.H. Lawrence
The High-Speed Train (HST) was introduced into service in Britain in the mid-’70s. The idea of this highly modern express train was speed and comfort. I can remember walking into Paddington Station, in West London, in my youth, smelling the scent of diesel, the atmosphere of the Victorian structures surrounding the platforms, and many parked trains. The cacophony of noise, the hustle and bustle of everyday events, door shutting, breaks screeching, and the low drone of the spoken word was omnipresent. The train itself was what is called a “push and pull” system, state of the art coaches sandwiched between two cutting edge locomotives. The energy created by both pushing and pulling created greater speed. They are still in service today. This analogy reflects the determination required to a more effective learner, the coaches reflect the workplace, where you sit, meet and treat but the locomotives are the intent and motivation of that journey, the drivers of what happens between them.
The addition of that second “pushing” engine creates more energy, more purpose, juxtaposed against having one where you are being pulled towards a destination, unknowingly. The second unit metaphorically pushes you towards a destination of your design, perhaps to answer questions appropriate to the environment in which you operate or those which may determine the way to move your practice forward. Imagine being the driver of that necessity, being in control of the whole process, being accountable for its design, making sense of the research and data, analysing the outcomes, disseminating the outcomes, and evidence of it to others. Consider the strategy and structure that can facilitate that, having confidence in its processes and being able to gather, assimilate, and make sense of the information.
“What thrills me about trains is not their size or their equipment but the fact that they are moving, that they embody a connection between unseen places.” Marianne Wiggins
The two arenas in this story are Quin Dental, Nelson, Tasman, New Zealand, and O’Hehir University, a global action research and self-developmental learning hub created in the USA in 2013. Quin is my place of work, a practice combining general practice, orthotropics, and orthodontics supported by oromyofacial therapy. Quin Dental’s leader details their mission as one of “excellence and innovation in dental health whilst aiming to make a positive impact on staff and community”. The vision encompasses providing clients with a “holistic dental experience aimed at providing the best dental preventive care” as well as, at all times, “respecting client views” and “providing individualised treatment.” The values of this practice include “dignity, compassion, empathy, warmth, and respect.”
Quin Dental, in the spring of September 2019, become my new professional home. Initially, my focus was to familiarise myself with the nuances and nature of the clinical environment, its people, and clients. The equipment and instruments, infection control procedures, and the history of oral healthcare delivered by previous oral health care professionals all added context to and set the scene of the message spoken and how it was instrumentally delivered. I was aware the wedded ideology lent heavily on EMS piezo and airflow systems and the associated system was available for its delivery. I had a deep knowledge of the equipment and the scientific basis of guided biofilm therapy (GBT) having trained with it at the company headquarters at Nyon in Switzerland.
The disruption of dysbiotic biofilms with a variety of powders and processes had featured prominently in my previous practice, for several years. The advantage of GBT has become a phenomenon in dental hygiene circles globally and its promotion and popularity was increasing until the COVID crisis put the proverbial headlock on it due to aerosol and droplet generation. I, however, began to limit its use almost the moment I arrived at the practice and had a difficult conversation with the practice owner about my devolving view on its clinical application. I explained that based upon my empirical and observational experience, the feedback from clients I treated, and an altering viewpoint as a consequence of directed and self-directed study I had re-evaluated how I used it. This was linked to a growing environmental and sustainable awareness, born of my odyssey experiences, of the need to sustain altered and more beneficial biofilms. Accordingly, I would be more selective and discriminate in its use. My boss was understanding, cautiously listened to my concerns but stressed its importance and efficacy in superficial stain removal in which we both wholeheartedly agreed. Progress from my perspective had been made.
“Live in each season as it passes, breathe the air, drink the drink, taste the fruit, and resign yourself to the influence of the earth.” Henry David Thoreau
GBT is very much indicated in active cases where the ecological imbalance is negatively sustainable, unstable bleeding on probing is observed, and potential or active loss of periodontal attachment is uncontrollable. In its strictest context, GBT is a local biofilm reset mechanism, especially interproximally and subgingivally. It is also supremely indicated with gross staining or where a client requests or desires it based upon previous positive experiences. However, the GBT model is one that goes beyond the active phase and has become king in the maintenance realm. My push back relates to an ecological imperative of preserving and allowing balanced biofilm, created as a consequence of careful active clinical and facilitative oral health adaptation to abide and thrive within our oral biofilm. Regular monitoring and reviews are as important as COVID isolation is at New Zealand borders at present, the onus of care switching to one of less active intervention, timely reviews, maintained self-care and personal oral health sustainability and responsibility.
This leads to the challenge of moving my philosophical change into the Quin oral health arena related to its core mission values. I felt the need to get a perspective from the client base of the practice and created a survey questionnaire that would essentially take a snapshot of their thoughts and feelings. This led to questions regarding expectations of treatment and inquiries about our service. 100 people participated, 93(%) would recommend us to their friends and family, over a third alluded to orthodontics being the primary attraction to the practice and 10% were attracted to its holistic branding. One comment in response to the survey, written with care, stood out to me. “What about your approach is natural?” It was a salient question and it indicated that although we were marketing ourselves as natural the practice was growing as a consequence of its reputation of arch expansion and tooth straightening, and not necessarily upon its oral health credentials. I began to feel an additional set of questions requiring answers being specifically centred around the preventive message of Quin. My curiosity was fuelled by further feedback I felt was relevant when in discourse with clients. The new survey reflected them but also my growing hypothesis born of a notion that my practice was becoming increasingly environmentally and sustainably influenced and orientated.
“Every great idea comes with the minority of one.” Eric Weinstein
Survey two began with my new clinical approach, one of mutual co-existence when stable and in balance and whole intervention when dysbiosis is present. It is born of research undertaken before, during, and since returning from my learning odyssey, published at wholedentalhealth.com;
“Dental diseases are driven by imbalances in oral bacteria and pH (acidity and alkalinity) and saliva function being further mediated by negative dietary and lifestyle choices, our age and health status, and, to a certain extent, our genetics.”
“promoting natural oral health requires sustainable behaviours that reduce the risk of inflammation and disease, promotion of beneficial bacteria, active and functional saliva flow, proper tongue posture, effective breathing, and tooth strengthening strategies tailored to the individual. This in turn has the potential to support and promote our general health and well-being.” Mark James RDH NZ
Q1. Do you view your mouth environmentally and/or ecologically? Upon reflection, I think I should have described this less starkly and more in the vein of seeing the bacteria in the mouth environmentally and ecologically. 55% Yes, most upon reflection of the question.
Q2. Do you believe there are links between your general health and your mouth? 100% Yes.
Q3. Do you follow a specific nutritional approach to your health? 95% Yes most whole food or low carb BUT 15% gluten and dairy-free.
Q4. Do you have an opinion regarding fluoridation? I should have said water fluoridation and perhaps differentiated between topical and systemic modalities. 75% Yes – against water fluoridation – 15% of this group said they’d use it in toothpaste.
Surprising responses revolved around questions 1 and 4. Both 2 and 3 were predictable when considering the type of client seen at Quin, being professional, engaged with health and well-being topics, and informed. The age demography between those supporting fluoridation and those not was interesting. The younger the client it seemed the less supportive of it they were. I’m curious to understand this better though. Is it due to the nature of modern communication and the omnipresence of social media platforms that support the anti-fluoride pressure groups? Or are more of the younger population less trusting of authority, more critically educated, or concerned about the perceived health impact to fluoride on children? There were forthright and vocal opinions on the effects of fluoride with regards to brain health and less it seemed to democratic choice and dosage. Question 1 had a curious initial silence before being answered, I got the sense that they had never heard oral bacteria put in the context of environmental, ecological, or sustainable perspectives. After consideration, I felt it required refinement and I changed the wording to include bacteria in the sentence. Question 3 brought the most variety of responses but interestingly all were aware of the threat posed dentally by sugar. Less understanding was afforded to pH lowering activities at mealtimes. The erosive potential of health-related options like apple cider vinegar, lemon in water, kombucha, and carbonated water wasn’t considered either.
This survey has helped me dive into client opinions of key issues that present themselves in modern oral health promotion and give credence to a tailored approach to care, looking specifically at individual needs and perceptions, guiding care planning. This process marries well, I feel, with the Quin mission statements that highlight the “holistic dental experience aimed at providing the best dental preventive care”, “respecting client views” and “providing individualised treatment.” Q.E.D, Qoud erat demonstrandum.
“It is in fact nothing short of a miracle that the modern methods of instruction have not yet entirely strangled the holy curiosity of inquiry; for this delicate little plant, aside from stimulation, stands mainly in the need for freedom; without this, it goes to wrack and ruin without fail.” Albert Einstein
Questioning in this format also afforded additional benefits of which I hadn’t foreseen. The opportunity presented itself to enhanced general discourse, encouraging the clients to demonstrate their opinions, allowing active discussion and, I feel, bringing a sense of greater respect for their points of view and mutual trust within the process. I felt it added weight and rigour to the importance of their perception of their mouths being compared to the specific everyday habitats and environments we live in and benefit from. The comparative and similar natures of both explained I hope will bear fruit in oral health outcomes with my co-existing ecological approach to improving oral health outcomes.
Moving forward to early April this year and into the second week of lockdown I was contacted by a colleague and friend who I’d worked with as a Key Opinion Leader in the UK in the past and had assisted by being part of a Beta learning group in the infancy of his collaborative online university learning hub, O’Hehir University (OHU). I hadn’t seriously considered involvement with OHU, and, if I’m honest, had avoided it as I couldn’t see a way in which my character and unorthodoxy in practice would lend to it. I didn’t see it being an easy fit and my time up until the lockdown was at a premium. That was soon to change, seeing an end in sight with my wholedentalhealth.com project and deciding upon a change in professional direction brought about a change of heart, the opportunity to observe OHU in motion. I was welcomed to observe and offer support in their online classrooms and found an engaged, curious and excited community, at first almost shy and timid, perhaps initially fearful, uncertain as to how to proceed in this new environment. Within a matter of a few meetings the shackles were loosening as the students began to exchange ideas, thoughts, and opinions. It was as if a breakout had occurred, the shell of convention broken and the budding shoots of new discovery and knowledge appearing.
OHU is founded upon action research, an opened ended form of self-reflective first person, inquiry learning, and problem-solving. It is self-directed, workplace-based, and collaborative. The central beating heart is the online classroom with a google classroom suite where students can submit assignments for collective rigour and peer review, the instructors and leaders gently over watching and supporting expressive, creative, and curious learning.
Students at OHU enrol for a six-month odyssey in which professional and personal values are examined, challenged, and potentially altered. They complete a project related to their clinical or professional role and are submitted to scrutiny by their tutors, instructors, and peers. Becoming a small part in the machinery of OHU has become a weekly habit, I’m lubricating my cogs of mentorship, gently participating in the verbal and visual dialogue of the student journey, remembering my pathway through OHU back in 2013. Action research has been a tool that has seen me change, evolve and grow from a face value instrumentalist to a critical, observational, and evidence guided minimal interventionist, with a healthy side order of sustainability and ecologically orientation on the side. Here is an example of a part of the artistic and creative bend of OHU, where the student is asked to reflect on a piece of work which is supported by art, of their choosing, in a way that defines them. This is my example, inspired by them.
“Come forth into the light of things, let nature be your teacher.” William Wordsworth
“The humble tree is emblematic of many things, longevity, wisdom, life, and much more. Trees are deeply rooted, withstanding the elements, time, and the seasons. They, to me, signify what is right about the environment and, conversely, what might be wrong. They are structures of nurturing, communicating, and protection. Especially for me as a forager, they symbolise community and connectivity, their vast root systems are intertwined by subterranean mycelial networks, huge neurological pathways that support, guide, and nurture the less strong and needy.” Mark James RDH NZ
The inspiration and influencer of OHU is Carl R. Rogers, a humanist psychologist, world-renown author, and keen observer of education, and a proponent of responsible, and participatory student centred learning. His motivation in the field of education is facilitation rather than pure education, advocating practical and student-centric methods of achieving its effective agency. Rogers sees change in education as creating a real developmental journey, using powerful sentiments, feelings, the risk of sharing ideas, being authentic, and community-driven engagement to drive its purpose. The sense of freedom pervades his written work strengthening the argument that those involved should follow their own goals, be invested in them, and by doing so putting more of themselves, their passion, energies, and efforts into working harder. This, in turn, he opines promotes retention of knowledge and allows more of what they learn to be more meaningful to them, greater than that of established education. The standard of knowledge created has to be tested, just as it is in the conventional system but the reviewers of it are not only teachers but the peer group of fellow students too. All outcomes and accomplishments are the fruiting bodies of one, very simple question the Rogers clearly defines, “what is the single, most important, unsettled value issue for you right now?”
“There is direction but there is no destination.” Carl R. Rogers
In effect, my year-long odyssey has reinforced commitment to my social and professional principles. The curious nature of finding evidence that supports or detracts from my journey, allowing new light to be shed upon established values, challenging them to the point of change, or certainty in them, is what endears authentic and true learning to me. My future appears now not to lie in clinical dentistry though, as I am beginning now to see the light at the end of the proverbial tunnel. Change is now on the horizon. With no more fruit-bearing branches to climb upon I anticipate, with the supportive help and insight of others, the trunk dividing, one traveling in a direction of my choosing, the other sustaining it, and keeping my experiences and knowledge in dental health alive albeit online and in learning.
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