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
Context – The First Step in this Long Journey of New Knowledge Creation through Action Research 2017
This somewhat alternative looking post is the back story and early learning knowledge creation that lit the touch paper for wholedentalhealth.com. It was presented twice to professional audiences in Nelson and Auckland in 2017. It was the outcome of extensive nutritional research carried out over the previous months when the opportunity arose. This usually occurred during twice-daily dog walks and even during a 5-day cycle through Central Otago, I kid you not. The intention was to fill a vast knowledge gap regarding nutrition and dental health primarily. It, however, soon morphed into a far bigger project as more and more associated health-related material was discovered. What you see before is just a snippet, relevant though, of the presentation delivered on those days. The title really says it all, especially concerning the ongoing nature of learning that followed but also the contrary process of understanding the nutritional relationships between the mouth and the body. It revealed the politics, personalities and clashes between the ideologies of the time, and their effect upon the future of dentistry, and my dental landscape in particular.
The learning aims leant heavily on the available research gleaned from the internet from reliable sites like PubMed and Cochrane, but a lot came from books and news publications. Some of these appeared in the public domain way before my birth. There seemed to be a massive disconnect between the established science and the voices of some very learned and passionate voices in the medical field. It also became very apparent that current thinking was very slowly unravelling, becoming less convincing and harder to justify within the new age of scepticism and scrutiny. The internet was acting as a courtroom, podcasts and publications contradicting and challenging the present status quo and beliefs. This wasn’t being done in some callous, half-hearted manner but within the bounds of scientific methods and criteria. The most prominent exponents of these were journalists using their talents at spotting a rotten apple and getting their teeth, so to speak, into the meat of the matter, finding obfuscation, contradiction and blatant misleading by the elements of the medical establishment, and the confounding of the public at large. Ego, money, power and persuasion appeared deeply rooted.
Take, for example, the very public journeys of one Ancel Benjamin Keys and a the lesser known, it seemed at the time, John Yudkin. One American, fresh from the nutritional fame of the World War 2 K ration design for US troops and a marked political influencer on one Dwight D. Eisenhower, American President and multiple heart attack sufferer. Key’s diet-heart hypothesis ran contrary to that of John Yudkin, a British scholarly and published Academic. His assertion was that sugar, refined carbohydrates, in particular, was the primary antagonist in the marked decline in modern health, associated with changing lifestyles and behaviours. Both men published books to back up their ideological and theoretical positions.
It was at this time that the scientific method of epidemiology saw its debut. It involved gathering data and assimilating findings into hard data, interpreted with graphs displaying mathematical statistics, revealing answers to scientific questions regarding the particular population being studied. It became a new feature to the public, demonstrating the significance, both colourfully and persuasively, of their research findings and advancing their theories into mainstream policy making. Yudkin, unfortunately, was the loser in this alternative scientific heavyweight contest. His reputation was besmirched by the darling of the medical and political establishment, Ancel Keys, with his subsequent funding for his important future research drying up, and his academic reputation in tatters. The legacy of which is now that of sugar laden processed diets of our modern society, an anathema to our ancestral dietary roots. The demonising of saturated fat continued until recently when investigative journalists sought to demonstrate Yudkin’s assertions and theories would have had a far more positive impact on global health.
The use of visual evidence to demonstrate the correlation of dietary behaviours to disease outcomes was in its infancy. Evidently too, it was also possible to “cherry pick” and select positive data to affirm a position or article of faith, in this case nutritionally. Data gathering on countries with diets that could have confounded the statistical charts was absent or ignored. Evidence was also presented in biased ways, focusing on men, of a specific age, not adjusting for cultural, religious, climatic or physical facts, information that could spoil the effect and positive power of the curve. These charts presented powerful arguments to those in positions of authority and influence. More funding and research would follow, and advice given to the politicians and people of the world, fearful of the negative health implications of fat in their diet, subsequently changed the food industry as we then knew it.
However, recent emerging evidence from critical investigation by determined journalists and medical specialists is challenging the gated medical establishments standpoint. This has been potentiated by the freedom offered by social media, the internet and activistic pressure groups. New research is reversing the belief that saturated fat is bad but is also demonstrating its potential health benefits.
The project made me consider me pre-existing beliefs, one specifically opened up a glaringly obvious omission, that sugar is was only implicated in dental caries. Low and behold the lightbulb moment when the penny dropped on that one. I was stunned, and somewhat crestfallen, some of these studies go back many years. Why wasn’t this part of my training way back in the mid-eighties?
My critical deep dive into learning also drew my attention to nutritional changes beyond simple sugars. The micro-nutrient components of food, minerals and vitamins essential in the maintenance of good oral health and the development of the mouth, required my attention too. The presentation looked closely at essential fatty and amino acids, as well as, omega 3 and 6 levels, and their role in reducing systemic inflammation. It seemed strange but wholly appropriate to make the association between the mouth and the rest of the body. The paradox that both are separate and neither the twain shall meet now, in itself is plainly inappropriate. What and how we eat, the function of our teeth, their bony support, blood supply and innervation are all connected to the whole well-being and function of our bodies. This also brings into context the holistic approach to practice, more food for future investigation. Further to that it made me consider the endocrine system, chemical messengers, namely hormones, which are intrinsic to the health of our bodies, by regulating hunger or satiety, and chemical communication. But when imbalanced and influenced by poor nutritional choices, may promote addictive habit forming behaviours which can add significantly to the plethora of chronic diseases plaquing dental health like diabetes and obesity.
The experience of this process alerted me to the need to encompass nutrition as part of my workplace practice. It now plays an even larger role in improving oral health, both directly and indirectly. Having a greater general knowledge allows me to better understand client general nutritional behaviour and preferences. The understanding of individual health ideology, for example clients who are vegan, vegetarian or carnivore, allows me greater awareness of how best to adjust or adapt a tailored dental health message.
Future learning will be directed at the nutritional and behavioural role in maintaining and promoting healthy oral flora, our mouths ever present microbiome, part of our bigger, personal bacterial picture. What foods can support or imbalance this important and potentially beneficial ecology in our mouth? Which dietary choices can lower or elevate the mouths critical pH balance? Co-existing with our acquired oral and general bacteria can afford us benefits in health and well-being as much research is now demonstrating. Therefore promoting an environmental and ecological approach to oral health maintenance is the future direction of my personal practice.
Action Research – At the beginning
I was never really academic at school, much to my father’s consternation. He was Edwardian in his manner, distant, expecting but caring. I was very average at most things but enjoyed Art and Sport finding most core subjects totally dull and uninspiring. My school reports pay historic lip service to that fact. However, where I enjoyed or understood something I began to learn, with a passion and a hunger, as I still do today. I could smell the sweat, carbon and oil in the pictures I drew for Mrs Edwards and she in turn gave me freedom to learn. Teach and preach at me meaninglessly and I will rebel, give me the freedom and method to learn on my own, in my own time and I will thrive and take up the mantle. interestingly I also find this particularly true with languages as when I lived in Germany or holidayed abroad, learning was alive and my very reality, it was all around me. This typifies another learning environment, my workplace.
“Mark appears to spend most of his time on the Eastern Front in the Spring of 1943”.
Mrs Edwards, Marks Art Teacher 4th Year, The Winston Churchill School
Russell, Ackoff and Greenberg (2008) point out in their book, Turning Learning Right Side Up: Putting Education Back on Track , that our education system is seriously flawed focusing on teaching rather than learning. “Why should children or adults be asked to do something computers and related equipment can do much better than they can?” Traditional education focuses on teaching, not learning. It incorrectly assumes that for every ounce of teaching there is an ounce of learning by those who are taught. Most of what is taught in classroom settings is forgotten, and much or what is remembered is irrelevant.
Carl Rogers (1969) famously described in Freedom to Learn learning as “insatiable curiosity.” He divides it significantly into two types, a meaningless “from the neck up” involving no “feelings or personal meanings” with no relevance for the “whole person.” and contrasting this with so-called “experimental learning”, one which brings personal significance and meaning which can proceed rapidly. Such significant learning he defines further as having self-initiation and a sense of discovery and being pervasive changing “behaviour, the attitudes, and perhaps even the personality of the learner.” Controversially Rogers continues by conjecting that all teachers and educators would prefer to facilitate such experimental and meaningful learning rather than a nonsensical syllabus.
“Education is an admirable thing, but it is well to remember from time to time that nothing that is worth learning can be taught.” Oscar Wilde
Donald Schon (1963, 1967, 1973) linked the experience of living in a situation of an increasing change with the need for learning. He stated that “we must become adept at learning” and “be able not only to transform our institutions, in response to changing situations and requirements; we must invent and develop institutions which are ‘learning systems’, that is to say, systems capable of bringing about their own continuing transformation.” A learning society culture has now been created as “education systems were no longer able to respond to the demands made upon them” ( Hutchins, 1968). Bring on the concept of lifelong learning.
There are many different ways of learning; teaching is only one of them. We learn a great deal on our own, in independent study or play. We learn a great deal interacting with others informally too, sharing what we are learning with others and vice versa. We learn a great deal by doing, through trial and error. Raj Ratten (2002) states that all dental professionals should pursue “personal and professional growth” and “acquire and refine skills.” He continues with a criteria for successful learning which is “led by the learner”, is “problem centred” and demonstrates “active participation and the use of their own resources.”
Gray et al (2004) indicate, referring to Kolb and Fry’s Learning Cycle (1975), that learning “begins with an experience.” It involves observations and reflections which generate concepts which are then tested in practice. Honey and Mumford (1992) define individual learner styles as either activist, reflector, theorist or pragmatist in nature with experiences followed by reviewing, concluding and planning. It can be seen by both models that learning is reflective in nature too. They continue by attempting to define the meaningfulness of learning by making a distinction between it being deep or surface in nature. Some learners describe learning as “an increase in knowledge, memorisation and increasing ability to apply knowledge.” Others think learning is “an increase in understanding, the seeing of things in different ways or change as a person.” One way of developing a practical, meaningful and deeper understanding of learning in the workplace is the egalitarian and democratic endeavour of action research.
Action research is a value driven, powerful, collaborative and liberating form of enquiry based learning which begins simply with a question. Do I need to improve my practice? If so, how? It is inclusive in nature, there for everyone. McNiff and Whitehead (2011) plan a process that involves observation, reflection, acting, evaluating and modifying before moving on being framed as an action-reflection cycle.
The critical aspect of action research is that of the individual “I” being at the centre of the process, the “first person”. This puts you, your questions and experiences within your workplace into the centre of learning. It brings your thoughts, reflections, theories and actions into a personal living form. Your theories are not taken just from others, be they your peers or academics but also what is happening to you and is termed “living theory.” Thus we, as Dental Care Professionals can claim to be;
“Practitioner Researchers, First Person Living Theorists”
who “improve their understanding, develop their learning and influence others’ learning.”
McNiff and Whitehead, Action Research (2011, p.26)
My living contradiction – a reflection
There were many times when I felt out of step with the direction of many a practice. I was a professionally conflicted for years, as Whitehead (2006) relates “that you see yourself as a living contradiction, holding educational values whilst at the same time negating them” (http://www.actionresearch.net/writings/china/mllet10908.htm). I aimlessly attended annual symposia never seriously paying attention to or gaining from them. This typified my approach to learning at the time, a dull and meaningless process directed at me. I now have a super system driving and facilitating my desire to learn and earn. I am into my first action research project through the O’Hehir University that introspectively looks to improve my delivery of oral health in my workplace. It is simple in its construction, collaborative with my practices, the dental industry and patients ultimately benefiting the improvement of my practice. An experimental initial project undertaken earlier was supported by a dental supplies company and looked at implementing air polishing to improve my practice (http://mihygienist.wordpress.com/2012/09/17/experimental-learning-within-the-workplace-ems-air-flow-handy/).
I am of the conclusion that traditional education partially qualified and equipped me personally and professionally. I am also still developing in both. I now believe I am a different living contradiction. Not one of clinical negation but more of being opposed to the culture of passive knowledge gain supported by endless corporate opportunists exploiting the crazy regulatory fixation in our professional environment and thus sadly in our workplace too. Attending meetings that don’t reflect our learning needs, mollified by free lunches or so-called “high profile” speakers might tick the boxes but no more than that. Action research is our future and I intend to do as much, if not all, of my future CPD cycle in that method.
“Continuously review your knowledge, skills and professional performance. Reflect on them, and identify and understand your limits as well as your strengths. “
Professional Standards in Dentistry, GDC, UK
O’Hehir University Project Part 1: A DCP Pilgrims Progress – A Simple Journey into Dental Health Improvement
The term “journey” nowadays seems to be a noun guilty of gross overuse. However, I feel it’s very roots are founded in our great English literary past. John Bunyan, (28 November 1628 – 31 August 1688) an English Christian writer and preacher, wrote in allegorical terms about one such very famous journey. First published in 1678 and written whilst Bunyan was imprisoned in Bedford Jail it follows the journey of an everyman character called Christian. This “burdened” individual sought guidance and deliverance from his sin and guilt and along the way encounters both good and bad people and events including “the Slough of Despond”, a physical swamp of despair, only to be pulled out by Help. He is finally led to the “Place of Deliverance” where the shackles and straps of his many burdens are freed. Christian mirrors my own journey in many respects, one of continuous trials, occasional success, support and the odd moment of deep despair. I am now certain of one reality, I am nearing my proverbial place of deliverance. How do I know that? Professionally I have been, seen and done many things and feel am now completing my professional circle by returning to a simple, deconstructed and stripped back approach to dental health promotion. Perhaps this is where I should always have been (MIHygienist, 2012a).
People’s minds are changed through observation and not through argument. Will Rogers
I seek a new challenge, one which wants to deliver better simple dental health outcomes to my patients – but why? And more over, what is the best way to achieve it? My Strengths, Weaknesses, Opportunities and Threats (SWOT) assessment indicated to me the need to introspectively look at what I do in practice and affect or influence others to be like-minded. I can easily criticise other clinicians for delivering a poor and less focused dental health message but I need to examine myself too. An appraisal of this determined I was doing a good job but I still I know I can improve my performance further and would like to know how (MIHygienist 2012b &c).
What is Dental Health?
Is the pure message of dental health being diluted by less preventive and more lucrative treasures? Perhaps I am too cynical by half nowadays but worryingly I found no dental health definitions from our Professional major players and had to, instead, go straight to the top to finally discover one. The World Health Organisation (WHO) state the “Oral health is a state of being free from chronic mouth and facial pain, oral and throat cancer, oral sores, birth defects such as cleft lip and palate, periodontal disease, tooth decay and tooth loss, and other diseases and disorders that affect the oral cavity”(WHO, 2013).The Department of Health (DoH) determine that Dental health is a “Standard of health of the oral and related tissues which enables an individual to eat, speak and socialise without active disease, discomfort or embarrassment and which contributes to general well-being. Oral health is integral to general health and should not be considered in isolation (DoH, 2006).
In the UK regulators and professional bodies direct my continuing clinical journey. I am tasked to apply up-to-date knowledge, provide dental hygiene care and skills to a wide range of patients ethically (GDC, 2009). Additionally, clinical governance promotes criteria for successful learning that is founded on what is already familiar to the learner, is owner led and participated, problem-centred, self-resourced, built on previous experiences, and involves relevant and timely feedback and elements of self-assessment (Ratten et al, 2002). This linked to our professional standards which advocate providing a “good standard of care based on available up-to-date evidence and reliable guidance” and “putting patients’ interests before your own or those of any colleague, organisation or business” as well as “maintaining your professional knowledge and competence” (GDC, 2005) sets the legal framework for my project.
Periodontal diseases and caries are both major acute and chronic diseases known to mankind and are of complex multifactorial bacterial, health and lifestyle origin. The 2009 Adult Dental Health Survey indicates that 31 per cent of adults had obvious tooth decay in either the crowns or roots of their teeth but the pattern of decay since 1998 has decreased from 46 per cent to 28 per cent. 45 per cent of adults had periodontal pocketing exceeding 4mm but only 17 per cent of dentate adults had very healthy periodontal tissues and no periodontal disease.
Disturbingly 75 per cent of adults claim to clean their teeth at least twice a day whereas 23 per cent of adults said that they cleaned their teeth once daily. A surprising 78 per cent said that they had been given advice by the dental team on cleaning their teeth and/or gums. 66 per cent of dentate adults had visible plaque on at least one tooth. The survey continues to claim, contradictorily in my opinion, that “Whilst twice-daily brushing is now a fact of life for three quarters of the population, there is still some room for improvements in the effectiveness of that cleaning” (DoH, 2011). I can only surmise that despite the great exposure to “the” dental health message more “smart” and “simple” targeted advice is required in at the “clinical coal face” and elsewhere besides.
“Simplicity is the ultimate sophistication”. Leonardo da Vinci
Action Research – The Vehicle
Action research commits the critically enquiring clinician to improve their individual practice by creating and measuring new knowledge, collaborating with others for social good in a personally accountable and value driven context (McNiff and Whitehead, 2011). Such projects are far removed from traditional methods of enquiry being centred in the individual workplace in a vital, living context, far removed from theory derived outside of the reality of clinical life. The action reflection model follows a logic course unravelling and structuring the activity of the individual. Reason and Bradbury (2008) identify such a project as “First – person research” (me) and is of a kind “that enables the researcher to foster an inquiring approach to his or her life, to act choice fully and with awareness and to assess effects in the outside world while acting.”
I had originally wanted to compare two patients groups in a blinded and controlled manner but after discussion with my mentor I changed from this pretext as it required unnecessary ethically approval with a time delay, complexity and was less driven by the values of action research. I can achieve my learning, discover truths, and by doing so improve and move my practice forward for professional and social benefit in action research.
“Fortune Favours the Prepared Mind”. Pasteur
I want the project to focus on simple delivery of a focused dental health message which, I believe will contribute significantly to reducing “active disease” in the gums and teeth by more effectively reducing and deconstructing dental biofilm levels. I also want to demonstrate improving Basic Periodontal Examination (BPE) outcomes but more importantly changes in perception of dental health in my patients. Markman (2012) in his book “Smart Thinking” advocates the role of three in developing high quality knowledge and learning. My action plan will test this theory of a culture of smart by linking existing knowledge, in this case what they currently do as part of their dental hygiene activity, to remembering three things about their interaction with me, namely brushing, interdental cleaning and fluoride advice. (MIHygienist, 2012d) The VAK (aka VARK) learning model postulated by Fleming and Mills (2010) and states four types of learning styles. I am focusing on three listed below as the written (R) will be handed out to the patients in a leaflet.
I therefore want to use a role of three model that encapsulates all of the above.
The project form will be given to each patient, over 120 to make the results more meaningful, twice over a project period of 4 months. The design of the form is composed of 2 parts, an initial enquiry into the patient’s current dental health behaviour and a BPE probing and a simple question on how they feel they learn (MIHygienist, 2012e). The appraisal and reflective part concludes the process. I don’t think it will take too much time to complete but the real challenge is determining who to select as some people don’t use a Braun Oral B (most do however) . I have decided to focus on those who use Braun and Manual Brushes as the company have supplied me these products to aid the project. Floss picks I will supply myself. The BPE will measure whether dental health has improved individually and as a whole and the questions will be audited to determine potential behavioural change. I will reflect on those and myself professionally as a consequence of the project.
“Finally, from so little sleeping and so much reading, his brain dried up and he went completely out of his mind.” Don Quixote
I anticipate the need to modify certain aspects of my project upon evaluation will occur. I welcome this and am willingly intent on learning from the outcome and then move on to something else that needs a similar deconstruction job doing to it. I believe that by following action research that I fulfil my commitment to “Continuously review my knowledge, skills and professional performance. Reflect on them, and identify and understand my limits as well as my strengths.”
MIHygienist (2012a) O’Hehir in my 2013 Face – Accepting the past, Valuing the present, Embracing the future. Available at http://mihygienist.wordpress.com/2012/11/18/accepting-the-past-valuing-the-presenting-embracing-for-the-future-oherir-in-my-2013-face/ (Accessed 10 January 2013)
MIHygienist (2012b) O’Hehir University SWOT ANALYSIS | SISYLANA TOWS – A Reflection.Available at: http://mihygienist.wordpress.com/2012/12/12/swot-analysis-sisylana-tows-a-reflection/tp (Accessed 10 January 2013)
MIHygienist (2012c) O’Hehir University = Simply Putting Opinions into Action (Learning). Available at: http://mihygienist.wordpress.com/2012/12/29/ohehrir-university-simply-putting-opinions-into-action-learning/ (Accessed 10 January 2013)
World Health Organisation (2013) Definition of Dental Health Available at: http://www.who.int/topics/oral_health/en/(Accessed 10 January 2013)
Department of health (2006) Oral Health, Eastern Regional Public Health Observatory. Availableat:http://www.erpho.org.uk/Download/Public/13920/1/204082%20INPHO%2017.pdf (Accessed 10 January 2013)
Press. General Dental Council. (2009) Standards for Dental Professionals. London, GDC Publications. Available at: http://www.gdc-uk.org/Newsandpublications/Publications/Publications/StandardsforDentalProfessionals%5B1%5D.pdf (Accessed 10 January 2013)
Rattan et al. (2002) Clinical governance in general practice. Oxford, Radcliffe Medical ltd, P49-53.
General Dental Council (2009) Scope of Practice, London, GDC Publications.
Availabkleat:http://www.bristol.ac.uk/dentalpg/dcp/scopeofpractice.pdf (Accessed 10 January 2013)
British Society of Periodontology (2011) Basic Periodontal Examination. Availableat:http://www.bsperio.org.uk/publications/downloads/39_143748_bpe2011.pdf (Accessed 10 January 2013)
Department of Health (2011) 2009 UK Dental Health Survey. Availableat:https://catalogue.ic.nhs.uk/publications/primary-care/dentistry/adul-dent-heal-surv-summ-rep-them-seri-2009/adul-dent-heal-surv-summ-them-exec-2009-rep2.pdf (Accessed 20 January 2013)
McNiff and Whitehead. (2011) All you need to know about action research, SAGE Publications, London.
Reason. and Bradbury. (2008) The SAGE handbook of action research: Participative Inquiry and Practice.
Markman, A (2012) Smart Thinking, Pilatus, UK. p.75-82.
MIHygienist (2012d) Air-Flow A Go-Go – The Role of Three as part of Smart Thinking.Available at: http://mihygienist.wordpress.com/2012/07/12/air-flow-a-go-go-the-rule-of-three-as-part-of-smart-thinking/ (Accessed 10 January 2013)
MIHygienist (2012e) O’Hehir University – My Assessment Tray – A Way Forward For My Practice? Available at: http://mihygienist.wordpress.com/2012/11/25/my-assessment-tray-a-way-forward-for-my-practice/ (Accessed 10 January 2013)
Fleming, N and Mills, C. (2010) “Not another Inventory, Rather a Catalyst or Reflection”, To Improve the Academy, Vol. 11, p.
Recently published in Dental Health I hope this can demonstrate a workplace action research journey that can demonstrate how to develop from research, problem solving, learning and knowledge creation.
Mark James BSc RDH
O’Hehir University Project Part 2: A DCP Pilgrims Progress – A Simple Journey into Dental Health Improvement
“Listen to patients and give them the information they need, in a way they can use, so they can make decisions.”
2.4 Professional Standards in Dentistry, GDC, UK 1
I qualified as a Dental Hygienist in 1988 and continue this journey today after nearly a quarter of a century still intent of learning how I can improve my practice, enjoy my work and meaningfully add to society. I currently work between five practices, a personal choice born of economic reality and have found the additional challenge of O’Hehir University at times daunting as a consequence. More daunting however is the reality of dental health in Britain today. It appears to me a World where real truths are hidden with smoke and mirrors to promote a picture of continuing improvements and reductions in dental disease and risk, where smart advertising influences the public in their dental habits and where the reality of true dental health improvement appears to have been diluted in political correctness and dogma. Added to this is a smattering of cynical commercial imperatives for less functional and dental health related care. What had happened to dental health and how could I make a difference in my practice and, if I succeeded, to a bigger dental and general audience? Having learned during mentorship training about learning styles I wondered after so many disappointments at patient reviews and follow ups if I had missed something blindingly obvious, essential and indeed simple? How would I facilitate this investigation and where would it end, if at all? I started where every good narrative in born, at the beginning.
What was my concern?
The Department of Health (DoH) in 2007 published an evidence based preventive toolkit for dental professionals appropriately named “Delivering Better Dental Health.”2 Updated since, it gives a meagre one side of A4 with an understated introduction claiming that the “major dental conditions of caries and periodontal disease can both be reduced by regular toothbrushing and fluoride toothpaste.” The National Health Services (NHS) Dental Epidemiological Programme for England report (2010) stated more resoundingly that “Oral health is an important indicator of a population.” 3 If these are true should we be proud or satisfied of our achievements or crest fallen with despair at the reality? What have we achieved thus far and where are we going? Are we improving dental health and, if so, where is the evidence to prove it?
Why was I concerned?
In 1968 the Adult Dental health Survey (ADHS) began, less the thirty years after the Second World War ended, three years after I was born. The fifth and latest survey, 2009, was published with the additional intention of obtaining “knowledge about and attitudes towards dental care and oral hygiene” and changes over time in dental health, attitudes and behaviour. It demonstrated interesting and sombre reading. 4
In dental health terms;
The public perception was that;
The ADHS perception was that;
If these figures and facts about the nation’s dental health are to be believed and are reflected in our practice environment are we satisfied that Britain’s dental health practice is built upon firm foundations or are there still important questions to be asked? Surely there is a massive discrepancy to what the public believe and their reality as a whole? Moreover, are the academics and politicians who sanction such findings deluded to state that modern dentistry is preventive centred and improving?
A famous British general once reflected upon the dramatic initial events after D-day on the 6th June 1944, where the enemy prevented his advance. He commented that “There is no such thing as an ordinary battle” and that leaders at all levels must “adapt their actions to the particular problems confronting them.” Montgomery clearly was frustrated and aware of the human cost of employing failing tried and tested formulas, predictable and too rigid, which were being defeated by a determined foe. 5
Could a simple dental health strategy, supported now with better direct public access, being affordable and patient centric improve those statistics and more over change attitudes and perceptions of professionals and the public too? I believe we too, are fighting a battle against the causes of dental disease and by approaching the foe with predictable, rigid and unimaginative strategies we too are prevented in making a vital and dramatic breakthrough. Where did I start this process?
“Action research should be seen as not simply about problem solving but also learning and creating knowledge”. McNiff and Whitehead
The vehicle, evidence and data
There are many ways of getting from A to B, of achieving our aims and goals but as a clinical hygienist I had never been trained to think and challenge myself beyond the bounds of my training. This was an attitude that has denied me advancement until I discovered Action Research (AR).
AR is designed to reappraise or affirm old or current knowledge and theory. It is morally and value driven, related to our workplace and is set within a social context (the dental health of our patients and the nation), challenging us to improve our “workplace practice through improving learning”. Its egalitarianism and social context puts the benefit of our learning to the patient first but further more can advocate our newly discovered theory and knowledge gain to a bigger professional audience too. It is first person centred (you and me), living theorist (our workplace learning), collaborative (involving others both public and the profession), and “actively” reflective by improving our practice through experiencing, questioning, researching and finding new knowledge and understanding. 6
Action research aspires the practitioner researcher to be open ended developmentally, allowing them to continue their projects flexibility and within a learning and developmental framework. We never stop learning but through AR we understand that what we do is provisional, not set in concrete, but will grow and change with new knowledge and feedback from our peers and patients alike due to its reflective, unfolding nature.
“Change is the end result of all true learning”. Leo Buscaglia
I began the project and started gathering evidence from the beginning of February and intended to complete as many of the second parts of the process as possible. Ideally it would have been more interesting and perhaps convincing to have over a hundred participants in the end but circumstance and poor health only allowed me 21 with 8 completing both parts 1 and 2. As the project began I became aware of a couple of issues that needed addressing, one directly and the other indirectly.
AR allows us the opportunity to change our process reflectively. This happened to me when I began the data gathering. I hadn’t considered stamping an ethical statement on the form initially but upon further reading and research I changed tack and evolved my form (MI Hygienist, 2013a). 7 This I feel was critical in the respect of potential peer validation beyond O’Hehir University and possible future publication to a bigger audience. I also felt that I had intrinsically missed out another important question and asked one that wasn’t so weighted in value. Thus my form evolved further to incorporate a patient value section whilst omitting detailed oral hygiene advice (see forms below). I was more concerned about understanding how the patient thought about their dental status rather than how many times a day they flossed as the later could be addressed through the learning and motivational phase. Knowing where they stood in terms of dental health priority was vital. Did they value their dental health more than function and appearance?
All participating patients, whether they completed part 2 or not, received routine active instrumentation and prophylaxis within the confines of a thirty minute appointment. They were initially asked to answer part of the form and then complete it afterwards in private and give feedback if desired.
Initial Dental Health Improvement Project Form – Mark James RDH
Name Date Visit
|Do you use a manual or an electric toothbrush or both?||Manual||Electric||Both|
|Do you clean between your teeth?||Floss/interdental brush||Both||No|
|How often do you use them? More than twice, twice or once daily or never?||Toothbrush ________
Floss/ Interdental _________
|How best do you think you learn?||Seeing||Listening||Doing||Combo|
|Marking scale is 1 to 5 [5 being the highest]||1||2||3||4||5|
|How do you rate your mouths present health?|
|Do you feel this dental appointment will help you improve your dental health?|
|How do you rate your Dental Hygienists performance in delivering your dental health message?|
Adapted Dental Health Improvement Project Form – Mark James RDH
Name Date Visit
|Do you use a manual or an electric toothbrush or both?||Manual||Electric||Both|
|Do you clean between your teeth?||Floss/interdental brush||Both||No|
|How best do you think you learn?||Seeing||Listening||Doing||Reading|
|Where would you place these in order of importance to you?||Health||Function||Aesthetics|
|Marking scale is 1 to 5 [5 being the highest]||1||2||3||4||5|
|How do you rate your mouths present health?|
|Do you feel this dental appointment will help you improve your dental health?|
|How do you rate your Dental Hygienists performance in delivering your dental health message?|
Additional Comments/Feedback BPE
I am undertaking action research in how to improve the outcome of dental health through improved communication with and feedback from you. I will give priority to your interests at all times, protect your identity unless you express otherwise. You are free to withdraw from this research at any time and all data will be destroyed. If made public I will check all data related to you. Mark James RDH
I hereby give permission to be included in the research.
The first set of data compiled the evidence gathered in total, divided by the 21 participants. The second combined both parts 1 and 2 of the 8 patients who completed the project.
Those who allowed me to begin the project were from two of my five practices. The overall impression I got from feedback was a genuine surprise and satisfaction that they felt included, involved and empowered within this process. Most were keen to spend time after the appointment to give feedback and comments. Some feedback proved very useful and most supportive. I learnt the important lessons of time management regarding the questioning and oral hygiene phase. I kept it brief, hence an attraction to a “quick brief” approach which evolved into a motivational interviewing style linked to their preference for learning.
“Came out of today with good solid information on how to progress and improve my oral health, delivered in a professional and friendly manner, many thanks”.
“Expected only a routine clean before fillings, but was advised about other problems. Given information and demonstration about what I need to do moving forwards (very impressive!) and told next steps, which is exactly how I like to be told. He helped me understand instead of being told off as per previous”.
The data told me that;
Over half, 57 per cent, were using a variety of powered toothbrushes.
38 per cent didn’t interdentally clean.
71 per cent viewed themselves primarily as kinaesthetic or “doing” learners.
73 per cent considered their dental health more important than function or aesthetics.
57 per cent rated their mouths as average.
81 per cent felt they’d benefit from and improve their dental health with 85 per cent very satisfied with my performance.
Gathering initial data is great in getting a snap shot of a group with base line records. The most compelling aspect of moving beyond this was to discover whether my concept of delivering a different oral hygiene message would succeed. Would this and the additional benefit of using an oral hygiene product (supplied free) to demonstrate techniques intra orally, based upon their perceived learning style be conducive to behavioural change and improved results and outcomes? Part 2 would be the key phase of the project.
Dental Health Improvement Project – Data Drop Box 1
|Do you use a manual or an electric toothbrush or both?||Manual 7||Electric 12||Both 2|
|Do you clean between your teeth?||Floss/interdental brush 8||Both 5||No 8|
|How best do you think you learn?||Seeing 2||Listen 1||Doing 15||Reading 3|
|Where would you place these in order of importance to you? (15 completed )||Health 11||Function 0||Aesthetics 4|
|Marking scale is 1 to 5 [5 being the highest]||1||2||3||4||5|
|How do you rate your mouths present health?||4||4||12||1|
|Do you feel this dental appointment will help you improve your dental health?||
|How do you rate your Dental Hygienists performance in delivering your dental health message?||
combined scores in brackets
The 8 of 21
Parts 1 and 2 combined – Dental Health Improvement Project – Data Drop Box 2
The figure before the/is the first appointment, the figure after is the second
|Do you use a manual or an electric toothbrush or both?||Manual 1/0||Electric 7/8||Both|
|Do you clean between your teeth?||Floss/interdental brush 4/7||Both 1/1||No 3/0|
|How best do you think you learn?|| Seeing
|Where would you place these in order of importance to you? 4 out of 8 completed||Health 3/8||Function||Aesthetics 1/0|
|Marking scale is 1 to 5 [5 being the highest]||1||2||3||4||5|
|How do you rate your mouths present health?||
|Do you feel this dental appointment will help you improve your dental health?||
|How do you rate your Dental Hygienists performance in delivering your dental health message?||
BPE combined in brackets Parts 1 (above) and 2 (below)
Average BPE of Parts 1 and 2 in front of bracketed figure
I was initially concerned about the small number who completed part 2 and had hoped to get a bigger snap shot of the group. The time period between the two was between 3 and 4 months but I was content that I would see evidence of behaviour change and dental health improvement. Essentially I wanted to discover whether the VARK learning, intra oral product use and collaborative questioning combined with an evolving motivational interviewing (MI) technique would significantly show progress.
The data told me that;
Appraising and evaluating my evidence
Having now completed the data gathering and reflecting upon the evidence I am convinced that my oral hygiene phase of treatment needs to take on greater importance to ensure more effective and beneficial dental health outcomes. I have found that simply “showing, telling and doing” isn’t as effective as developing an action research based strategy that involves determining, understanding and combining;
A good starting point is to better understand the patient’s needs by better understanding their present oral hygiene behaviours and values. This has helped me lose the general assumptions and conclusions I draw from the first patient contact or their previous clinical history and further guides the next strategy – that of developing a learning plan, based upon their current status and after BPE (similar to CPITN) is completed.
Learning has been a one dimensional process historically in my practice, where I had imposed by beliefs and styles upon the patient. I hadn’t considered that most had developed their own style or a combination of throughout their life, creating barriers to many including mine. Carl Rogers (1969) asserts that people’s ambivalence is deeply routed by their experiences. The learner needs to believe that the information has relevance and purpose to themselves and can be managed in their time. Removing barriers to learning, a reality to those anxious or fearful patients, and creating an environment that allows them freedom to learn is essential as many perceive or expect pain, humiliation and ridicule born of their experiences. Giving the patient responsibility for their learning and self-evaluating their progress through a guided process of facilitation can create an appropriate and effective patient centred learning process. 8
Flemings VARK questionnaire was developed in New Zealand for teachers after its creator noticed “excellent teachers who did not reach some learners and poor teachers who did” and drew me to conclude that perhaps we have taught our patients in our preference rather than theirs. Interestingly too, over half of the participants of the project expressed more than one preference for learning which led me to believe that within our practice of teaching we can adapt different styles to meet their needs or, alternatively, review the styles on follow up and change direction with learning if necessary. I also feel that VAK would be a better format to adopt born of the particular environment we work in. Creating literature that can be taken away by the patient to read negates its usefulness in the clinical environment but still remains a tool to be used for those who see it as a preference after oral hygiene instruction or those requiring additional time to consider change. However I feel that seeing, doing and listening combine well or individually in the workplace. 9
I had never really paid much attention to behavioural change in the preventive dental sense in the past but since the project began I have begun to listen more intently but also critically. Rattan et al (2002) when discussing changing behaviour in terms of clinical governance allude to its use in drug, alcohol and smoking rehabilitation quoting classic examples of its success but where is there similar evidence in improving dental health? 10 Renz and Newton (2009) looked at the express purpose of changing patients’ behaviour with a view to improving periodontal outcomes and explored various psychological models. They could only conclude, however, that despite” several promising targets for interventions” that “critical importance be placed in the field of motivation, volition and self-efficacy. “11 Carr and Ebbert (2012) interestingly put smoking cessation in a dental setting with advice offered by oral health professionals. They concluded that “typically brief” behavioural counselling may reduce tobacco use. 12 Sgan-Cohen (2008) links the dichotomy between the profession and public regarding changing dental health behaviour citing “incorrect assumptions” in dental health promotion. I agree with him. He states that “Dentistry needs to be flexible in accepting new evidence based modalities of oral health promotion.” and continues that “applied prevention is not always easy” requiring the “optimal cooperation and motivation of the public.”13
Frencken et al (2012) in a report from the FDI group linking minimal intervention dentistry (MID) get nearer to a solution by declaring success in dental prevention, in this case caries, be considered not an infectious but instead a “behavioural disease with a bacterial component.”14 Could this be linked to periodontal diseases too? If so, how? In 2013 Brand et al published online a study investigating the impact of single session Motivational Interviewing (MI) in the context of periodontal maintenance therapy. They aligned them to the same principles in smoking, diabetes control and medication adherence to find emerging evidence suggesting the “utility of MI to improve oral health”. The study sampled 56 previously treated periodontal patients in a single blind, randomised control trial. Regardless of their optimism and statistically significant decreases in plaque, pocket depth and bleeding at baseline, 6 and 12 weeks, there were no differences in clinical parameters between the two groups. They surmised that a one- time MI session was insufficient for improving oral hygiene in the study group.15 This runs against the conclusion of Godard et al (2011) who used Leventhal’s theory in improving compliance with plaque control amongst a similar risk group. They determined that the MI group demonstrated greater “satisfaction” scores to those in the control group and deemed MI a promising approach. 16
Leventhal’s self-regulation model defines how an individual goes about identifying they are sick and what they do to get better, involving understanding, acting and appraising their progress. This model relies on the individual’s ability to reflect on their actions and subsequent consequences.
Self-confidence or self-efficacy according to Bandura (1977) is important in an individual’s ability to “perform a particular behaviour regardless of circumstances or contexts linked to expectations of outcome.” Motivation is determined by reasons for action, in this case, dental health improvement. The popular Health Belief Model, developed in the 1950’s in the USA, implies that people are motivated to change by understanding the benefits of them related to their health. 17
Within the short time frame and additional pressures of a hygiene appointment the best method for behavioural support is MI as it is “client centred and collaborative” in exploring and attempting to resolve “ambivalence” (Miller and Rollnick, 2002). It focuses on the process of building motivation for change and strengthening commitment to it. 18 The professionals, us, engage so called “change talk” with the patient focusing on;
Interestingly, in my opinion and born of my experiences too, the professional also needs to ask the patient what they are going to do about it. This can lead to shared goal setting, planning and eventually commitment. I am also aware now that reviewing change, much like we review dental health status, is a key element in this. The belief we can elicit change purely from physically acting in someone’s mouth is now far from the truth and leads me finally to the conclusion that as well as being a “First Person, Living Theorist and Collaborative Practitioner Researcher” I can also claim to be a “Behavioural Support Interventionist” (BSI) in the making too.
Modifying and monitoring my practice
By modifying my practice in the light of my research, evaluation and experience I strongly believe in the effectiveness of a one to one approach which determines;
The support of the dental health industry, in particular Philips Health and Well-Being who supplied me products to facilitate this as well as the purchase of others by myself has also been a critical factor in the success of my project. I will continue to promote their use in this way and hope that the costs incurred by me will be met by a small increase in appointment fees. Additionally, there is an opportunity for me to develop greater in house sales of dental products ethically but also construct an online store that can deliver a similar process as the workplace. This is the theme of my next project through O’Hehir University in New Zealand.
Proposed New Dental Health Improvement Project Form – Mark James RDH
|Do you use a manual or an electric toothbrush or both?||Manual||Electric||Both|
|Do you clean between your teeth?||Floss/interdental brush||Both||No|
|How best do you think you learn?||Seeing||Listening||Doing||Reading|
|Where would you place these in order of importance to you?||Health||Function||Aesthetics|
|Marking scale is 1 to 5 [5 being the highest]||1||2||3||4||5|
|How do you rate your present dental health?|
|Do you want to improve your dental health?|
|Could you change your current behaviour to benefit your dental and general health?|
Additional Comments/Feedback /Action Plan
Have I made a contribution to new theory of practice and can I make a claim to knowledge? Action research is opened ended in its final position and for good reason. New knowledge and theory comes from the past and the present and to not learn from it, adapt, review, reflect and subsequently change accordingly would be fallacious.
McNiff and Whitehead (2011) describe a situation familiar to most professionals in practice as being a “living contradiction,” a situation in their workplace where ideologies conflict and where compromise needs to be sought. 19 Ironically I have been supported by both teams and more over by my patients whilst undertaking this project and for this I am very grateful. However, my living contradiction appears to be with the established view of where we are as a society regarding the state of dental health in the UK (MI Hygienist, 2013b). 20 There are steps afoot with truly preventive minds, I believe, intent on improving dental and general health. This gives me hope that on a national level and with greater patient access to dedicated Dental Care Professionals (DCP) the public and society will be better served. My dilemma remains that would we as DCPs continue to develop ourselves professionally not just in the fashionable and lucrative aspects of our scope of practice but to reappraise and seek ways in which we can improve better dental health?
My claim to knowledge, albeit provisionally, is thus – I have developed a simple strategy that combines assessment with a focus not only on traditional scoring but behaviours and values. Also developed is a teaching approach that collaborates with and complements the learning strengths of the individual enhanced with patient centred confidence building, motivational and ongoing support. I will continue to review improvements in my performance and the dental health of my patients and, if other mindful clinicians develop similar developmental and learning strategies perhaps our communities, society and nation alike will benefit too.
Unorthodoxy in Learning. Testing a Workplace Concept – Carl R. Rogers – Supporting Authentic Online Learning at O’Hehir University – A Narrative Account
My whole world, both personal and professional, is in an evolving state of healing as a consequence of the global pandemic. It feels like I’m in a recovering state of COVID decompression akin to a deep-sea diver in a planned act of readjusting to normality after being to the deepest, darkest depths. This imbalance has been emotionally unsettling, for several weeks of lockdown and uncertainty, not knowing whether PPE would be required, the very nature of new practice, and when we were to return to it. It did, however, allow me to drive, undistracted, and determined to complete my self-directed learning project which began the previous June. The reams of printed studies this project generated had been sitting on the bookcase, gathering dust, and tested my resolve to meet its critical challenge. All but one post is now done, so this will be the final piece of the puzzle with just an introduction and ending to conclude it. Let us to it proceed.
“Educated! We are not even born as far as our feelings are concerned.” D.H. Lawrence
The High-Speed Train (HST) was introduced into service in Britain in the mid-’70s. The idea of this highly modern express train was speed and comfort. I can remember walking into Paddington Station, in West London, in my youth, smelling the scent of diesel, the atmosphere of the Victorian structures surrounding the platforms, and many parked trains. The cacophony of noise, the hustle and bustle of everyday events, door shutting, breaks screeching, and the low drone of the spoken word was omnipresent. The train itself was what is called a “push, and pull” system, state of the art coaches sandwiched between two cutting edge locomotives. The energy created by both pushing and pulling created higher speed. They are still in service today. This analogy reflects the determination required to a more effective learner, the coaches reflect the workplace, where you sit, meet and treat. Still, the locomotives are the intent and motivation of that journey, the drivers of what happens between them.
The addition of that second “pushing” engine creates more energy, more purpose, juxtaposed against having one where you are being pulled towards a destination, unknowingly. The second unit metaphorically pushes you towards a destination of your design, perhaps to answer questions appropriate to the environment in which you operate or those which may determine the way to move your practice forward. Imagine being the driver of that necessity, being in control of the whole process, being accountable for its design, making sense of the research and data, analysing the outcomes, disseminating the results, and evidence of it to others. Consider the strategy and structure that can facilitate that, having confidence in its processes and being able to gather, assimilate, and make sense of the information.
“What thrills me about trains is not their size or their equipment but the fact that they are moving, that they embody a connection between unseen places.” Marianne Wiggins
The two arenas in this story are Quin Dental, Nelson, Tasman, New Zealand, and O’Hehir University, a global action research and self-developmental learning hub created in the USA in 2013. Quin is my place of work, a practice combining general practice, orthotropics, and orthodontics supported by oromyofacial therapy. Quin Dental’s leader details their mission as one of “excellence and innovation in dental health while aiming to make a positive impact on staff and community”. The vision encompasses providing clients with a “holistic dental experience aimed at providing the best dental preventive care” as well as, at all times, “respecting client views” and “providing individualised treatment.” The values of this practice include “dignity, compassion, empathy, warmth, and respect.”
Quin Dental, in the spring of September 2019, become my new professional home. Initially, my focus was to familiarise myself with the nuances and nature of the clinical environment, its people, and clients. The equipment and instruments, infection control procedures, and the history of oral healthcare delivered by previous oral health care professionals all added context to and set the scene of the message spoken and how it was instrumentally delivered. I was aware the wedded ideology lent heavily on EMS piezo and airflow systems and the associated system was available for its delivery. I had an in-depth knowledge of the equipment and the scientific basis of guided biofilm therapy (GBT) having trained with it at the company headquarters at Nyon in Switzerland.
The disruption of dysbiotic biofilms with a variety of powders and processes had featured prominently in my previous practice, for several years. The advantage of GBT has become a phenomenon in dental hygiene circles globally, and its promotion and popularity was increasing until the COVID crisis put the proverbial headlock on it due to aerosol and droplet generation. I, however, began to limit its use almost the moment I arrived at the practice and had an awkward conversation with the practice owner about my devolving view on its clinical application. I explained that based upon my empirical and observational experience, the feedback from clients I treated, and an altering viewpoint as a consequence of directed and self-directed study, I had re-evaluated how I used it. This was linked to a growing environmental and sustainable awareness, born of my odyssey experiences, of the need to sustain altered and more beneficial biofilms. Accordingly, I would be more selective and discriminate in its use. My boss was understanding, cautiously listened to my concerns but stressed its importance and efficacy in superficial stain removal in which we both wholeheartedly agreed. Progress from my perspective had been made.
“Live in each season as it passes, breathe the air, drink the drink, taste the fruit, and resign yourself to the influence of the earth.” Henry David Thoreau
GBT is very much indicated in active cases where the ecological imbalance is negatively sustainable, unstable bleeding on probing is observed, and potential or active loss of periodontal attachment is uncontrollable. In its strictest context, GBT is a local biofilm reset mechanism, especially interproximally and sub gingivally. It is also supremely indicated with gross staining or where a client requests or desires it based upon previous positive experiences. However, the GBT model is one that goes beyond the active phase and has become king in the maintenance realm. My push back relates to an ecological imperative of preserving and allowing balanced biofilm, created as a consequence of careful active clinical and facilitative oral health adaptation to abide and thrive within our oral biofilm. Regular monitoring and reviews are as crucial as COVID isolation is at New Zealand borders at present, the onus of care switching to one of less active intervention, timely reviews maintained self-care and personal oral health sustainability and responsibility.
This leads to the challenge of moving my philosophical change into the Quin oral health arena related to its core mission values. I felt the need to get a perspective from the client base of the practice and created a survey questionnaire that would essentially take a snapshot of their thoughts and feelings. This led to questions regarding expectations of treatment and inquiries about our service. 100 people participated, 93(%) would recommend us to their friends and family, over a third alluded to orthodontics being the primary attraction to the practice and 10% were attracted to its holistic branding. One comment in response to the survey, written with care, stood out to me. “What about your approach is natural?” It was a salient question, and it indicated that although we were marketing ourselves as natural, the practice was growing as a consequence of its reputation of arch expansion and tooth straightening, and not necessarily upon its oral health credentials. I began to feel an additional set of questions requiring answers being centred explicitly around the preventive message of Quin. My curiosity was fuelled by further feedback I felt was relevant when in discourse with clients. The new survey reflected them but also my growing hypothesis born of a notion that my practice was becoming increasingly environmentally and sustainably influenced and orientated.
“Every great idea comes with the minority of one.” Eric Weinstein
Survey two began with my new clinical approach, one of mutual co-existence when stable and in balance and whole intervention when dysbiosis is present. It is born of research undertaken before, during, and since returning from my learning odyssey, published at wholedentalhealth.com;
“Dental diseases are driven by imbalances in oral bacteria and pH (acidity and alkalinity) and saliva function being further mediated by negative dietary and lifestyle choices, our age and health status, and, to a certain extent, our genetics.”
“promoting natural oral health requires sustainable behaviours that reduce the risk of inflammation and disease, promotion of beneficial bacteria, active and functional saliva flow, proper tongue posture, effective breathing, and tooth strengthening strategies tailored to the individual. This, in turn, has the potential to support and promote our general health and well-being.” Mark James RDH NZ
Q1. Do you view your mouth environmentally and/or ecologically? Upon reflection, I think I should have described this less starkly and more in the vein of seeing the bacteria in the mouth environmentally and ecologically. 55% Yes, most upon reflection of the question.
Q2. Do you believe there are links between your general health and your mouth? 100% Yes.
Q3. Do you follow a specific nutritional approach to your health? 95% Yes most whole food or low carb BUT 15% gluten and dairy-free.
Q4. Do you have an opinion regarding fluoridation? I should have said water fluoridation and perhaps differentiated between topical and systemic modalities. 75% Yes – against water fluoridation – 15% of this group said they’d use it in toothpaste.
Surprising responses revolved around questions 1 and 4. Both 2 and 3 were predictable when considering the type of client seen at Quin, being professional, engaged with health and well-being topics, and informed. The age demography between those supporting fluoridation and those not was interesting. The younger the client it seemed, the less supportive of it they were. I’m curious to understand this better, though. Is it due to the nature of modern communication and the omnipresence of social media platforms that support the anti-fluoride pressure groups? Or are more of the younger population less trusting of authority, more critically educated, or concerned about the perceived health impact to fluoride on children? There were forthright and vocal opinions on the effects of fluoride with regards to brain health, and less it seemed to democratic choice and dosage. Question 1 had a curious initial silence before being answered, I got the sense that they had never heard oral bacteria put in the context of environmental, ecological, or sustainable perspectives. After consideration, I felt it required refinement, and I changed the wording to include bacteria in the sentence. Question 3 brought the most variety of responses, but interestingly all were aware of the threat posed dentally by sugar. Less understanding was afforded to pH lowering activities at mealtimes. The erosive potential of health-related options like apple cider vinegar, lemon in water, kombucha, and carbonated water wasn’t considered either.
This survey has helped me dive into client opinions of key issues that present themselves in modern oral health promotion and give credence to a tailored approach to care, looking specifically at individual needs and perceptions, guiding care planning. This process marries well, I feel, with the Quin mission statements that highlight the “holistic dental experience aimed at providing the best dental preventive care”, “respecting client views” and “providing individualised treatment.” Q.E.D, Qoud erat demonstrandum.
“It is in fact nothing short of a miracle that the modern methods of instruction have not yet entirely strangled the holy curiosity of inquiry; for this delicate little plant, aside from stimulation, stands mainly in the need for freedom; without this, it goes to wrack and ruin without fail.” Albert Einstein
Questioning in this format also afforded additional benefits of which I hadn’t foreseen. The opportunity presented itself to enhanced general discourse, encouraging the clients to demonstrate their opinions, allowing active discussion and, I feel, bringing a sense of greater respect for their points of view and mutual trust within the process. I felt it added weight and rigour to the importance of their perception of their mouths being compared to the specific everyday habitats and environments we live in and benefit from. The comparative and similar natures of both explained I hope will bear fruit in oral health outcomes with my co-existing ecological approach to improving oral health outcomes.
Moving forward to early April this year and into the second week of lockdown, I was contacted by a colleague and friend who I’d worked with as a Key Opinion Leader in the UK in the past. I had assisted by being part of a Beta learning group in the infancy of his collaborative online university learning hub, O’Hehir University (OHU). I hadn’t seriously considered involvement with OHU, and, if I’m honest, had avoided it as I couldn’t see a way in which my character and unorthodoxy in practice would lend to it. I didn’t see it being a comfortable fit, and my time up until the lockdown was at a premium. That was soon to change, seeing an end in sight with my wholedentalhealth.com project and deciding upon a change in professional direction brought about a change of heart, the opportunity to observe OHU in motion. I was welcomed to observe and offer support in their online classrooms. I found an engaged, curious and excited community, at first almost shy and timid, perhaps initially fearful, uncertain as to how to proceed in this new environment. Within a matter of a few meetings, the shackles were loosening as the students began to exchange ideas, thoughts, and opinions. It was as if a breakout had occurred, the shell of convention broken and the budding shoots of new discovery and knowledge appearing.
OHU is founded upon action research, an opened ended form of self-reflective first person, inquiry learning, and problem-solving. It is self-directed, workplace-based, and collaborative. The central beating heart is the online classroom with a google classroom suite where students can submit assignments for collective rigour and peer review, the instructors and leaders gently over watching and supporting expressive, creative, and curious learning.
Students at OHU enrol for a six-month odyssey in which professional and personal values are examined, challenged, and potentially altered. They complete a project related to their clinical or professional role and are submitted to scrutiny by their tutors, instructors, and peers. Becoming a small part in the machinery of OHU has become a weekly habit, I’m lubricating my cogs of mentorship, gently participating in the verbal and visual dialogue of the student journey, remembering my pathway through OHU back in 2013. Action research has been a tool that has seen me change, evolve and grow from a face value instrumentalist to a critical, observational, and evidence guided minimal interventionist, with a healthy side order of sustainability and ecologically orientation on the side. Here is an example of a part of the artistic and creative bend of OHU, where the student is asked to reflect on a piece of work which is supported by art, of their choosing, in a way that defines them. This is my example, inspired by them.
“Come forth into the light of things, let nature be your teacher.” William Wordsworth
“The humble tree is emblematic of many things, longevity, wisdom, life, and much more. Trees are deeply rooted, withstanding the elements, time, and the seasons. They, to me, signify what is right about the environment and, conversely, what might be wrong. They are structures of nurturing, communicating, and protection. Especially for me as a forager, they symbolise community and connectivity, their vast root systems are intertwined by subterranean mycelial networks, huge neurological pathways that support, guide, and nurture the less strong and needy.” Mark James RDH NZ
The inspiration and influencer of OHU is Carl R. Rogers, a humanist psychologist, world-renown author, and keen observer of education, and a proponent of responsible, and participatory student-centred learning. His motivation in the field of education is facilitation rather than pure education, advocating practical and student-centric methods of achieving its effective agency. Rogers sees change in education as creating a real developmental journey, using powerful sentiments, feelings, the risk of sharing ideas, being authentic, and community-driven engagement to drive its purpose. The sense of freedom pervades his written work strengthening the argument that those involved should follow their own goals, be invested in them, and by doing so putting more of themselves, their passion, energies, and efforts into working harder. This, in turn, he opines promotes retention of knowledge and allows more of what they learn to be more meaningful to them, greater than that of established education. The standard of knowledge created has to be tested, just as it is in the conventional system, but the reviewers of it are not only teachers but the peer group of fellow students too. All outcomes and accomplishments are the fruiting bodies of one, very simple question the Rogers clearly defines, “what is the single, most important, unsettled value issue for you right now?”
“There is direction, but there is no destination.” Carl R. Rogers
In effect, my year-long odyssey has reinforced commitment to my social and professional principles. The curious nature of finding evidence that supports or detracts from my journey, allowing new light to be shed upon established values, challenging them to the point of change, or certainty in them, is what endears authentic and genuine learning to me. My future appears now not to lie in clinical dentistry though, as I am beginning now to see the light at the end of the proverbial tunnel. Change is now on the horizon. With no more fruit-bearing branches to climb upon I anticipate, with the supportive help and insight of others, the trunk dividing, one travelling in the direction of my choosing, the other sustaining it, and keeping my experiences and knowledge in dental health alive albeit online and in learning.
Airflow Action Research – Product into practice
An article in the dental press recently caught my eye and made me think more about the direction of my learning journey. It discussed issues regarding our present Continuing Professional Development (CPD) system and the debate around meaningfully improving it. The text raised issues that inferred a need for change from the present “input” based system to a clinically relevant outcome based “output system” where learning evolves by demonstrating its effect on individual professional life and everyday practice.1 This, in my opinion, marries well to our present evidence based practice culture. Many educationalists advocate “learning within the workplace” which is informal, reflective and involves acquiring new knowledge and problem solving. Three important stages in this approach advocated by Gray et al (2004) are technical, interpretive and strategic.
Technical – Acquisition of specific skills or knowledge.
Interpretive – Understanding experiences and making judgements on them.
Strategic – Critical evaluation where technical and interpretive ideas and opinions are discussed and ideas exchanged.
Rattan et al (2003) state that evidence based cultures link science and clinical practice by integrating literature, patient preferences, scientific knowledge, clinical judgement and personal experiences. Our current clinical governance culture promotes adopting proven methods and techniques and replacing those less effective and more costly.3 The four questions he asks are;
Are we doing things the right way?
What is the evidence relating to our practice?
How can we ensure that the necessary changes are implemented into practice?
How do we know that the changes being made are sustainable and, in addition, produce efficacious and cost effective benefits to patients in practice?
So, when introducing new materials and methods clinically we need to measure the extent to which they produce a beneficial result under “ideal conditions”. It also provides an ideal opportunity to begin experimental and developmental learning journey associated with Care Quality Commission regulations as well as the British Dental Association’s advice on clinical governance which advocates communication and consultation with patients that enhance practice relationships and clinical decision making.
My First Step
I wanted to introduce a new polishing system into an established practice that I believe would benefit both patients and practice alike by giving patients more choice and the practice a more effective polishing system. I also hoped to discover more about myself professionally in undertaking this new experimental learning. I have been struck historically by the lack of literature that sets out how an ordinary dental care professional can apply these principles into practice whilst being a busy clinician. How can I implement change within my surgery, demonstrate it to my colleagues and more importantly, deliver it safely, beneficially and effectively to my patients in conjunction with professional standards?
A Critically Reflective Practice Approach to Implementing Air-Flow Handy
Critically reflective practice draws distinction from reflective practice by linking learning within our practice and not just a “pause” for thought. Pure reflection deals with how we feel aspects or events in our professional day to day life went, whether it was good or not so good, and where it could have been improved. Critically reflective practice requires deeper questioning and not taking things at face value, involves self-awareness and turning thought processes into relevant learning. Such a process can be individual or collaborative but leads onto planning and potential change. It links our thinking to doing, thus learning from our experiences and crucially assimilating evidence based practice knowledge and research to make a positive difference in what we do clinically.
The EMS Air-flow Handy is a portable air polishing unit that uses specially produced bicarbonate of soda powder to remove stain, pellicle and biofilm from tooth surfaces. It has a detachable, autoclavable nozzle that directs the powder and water in a focused spray onto the tooth surface. Care has to be taken to ensure that the root surface is avoided and that patient selection is considered regarding contra indications and their preferences.
Historically I have used Air-Flow units and have heard that some clinicians have found that the nozzle blocks frequently, that some patients found the procedure tastes unpleasant and that the Hendy’s operating procedure and initial and running costs are prohibitive. Having undertaken previous product trials with EMS products through Optident I asked if I could trial this unit free within a practice in which the patient base that have never encountered this product and service before. In undertaking this I asked not to be remunerated which I hope has afforded me better objectivity and critical independence.
Having agreed with Optident about the evaluation and article I set about constructing the process. I read the technical aspects of the equipment, research data, how it worked, how to use it, when not to etc. I wanted to focus on the patients experience and preferences as this I feel is under represented in literature. Therefore it involved;
Airflow Patient Feedback Form
|Marking grid: 5=Strongly Agree; 4=Agree; 3=Unsure; 2=Disagree Agree; 1=Strongly Disagree|
|I was uncertain that airflow would be as effective as conventional polishing|
|I felt the procedure was comfortable and beneficial.|
|I would be willing to have the Airflow procedure again at future appointments|
|My mouth feels fresher and cleaner than I expected with Airflow.|
|I would be willing to pay an additional fee for Airflow.|
American Philosopher Henry David Thoreau stated “It takes two to speak the truth – one to speak and one to hear”. Feedback is a peculiar experience and I have been uncomfortable with it historically. It always seemed to me to allude to negative criticism, judgement and poor performance. However, feedback itself is learning and developmental tool, when carefully and simply designed it can objectively focus on delivering improvement. The Collins Dictionary describes its purposes well, stating it as “information in response to an inquiry or experiment.” Interestingly an initial positive from using feedback is the surprise and satisfaction from the patient’s perspective that their experiences and opinions are valued and their input can a make a difference as well as benefitting them in the future too.
I wanted to set out the questions in a statement format as it felt less ambiguous and simpler in addressing Rattan’s four questions. After constructing the form I spent a week getting proficient in operating the Handy as well as ironing out any gremlins likely to cause issues once the feedback process had begun. I discovered that the nozzles need to be purged immediately after use to prevent blockage, how to adjust the water pressure on the dental unit and how, if blocked, to simply remove it effectively. I also needed to make sure that I could use it safely with or without nursing support. This transpired to be not as difficult as anticipated.
Once the survey began I gradually lost any anxiety about asking my patients to participate and feedback to me. I wanted them to be honest and sincere in their responses. This got easier to ask for with experience. Some were very keen to add value to the form by giving measured and mindful comments whereas others were simply keen to tick the boxes and leave. I eventually completed thirty forms and analysed the data.
Air-Flow Patient Feedback
Marking grid: 5=Strongly Agree; 4=Agree; 3=Unsure; 2=Disagree Agree; 1=Strongly Disagree
|Air-Flow Question Responses (Data Drop Box)||1||2||3||4||5|
|I was uncertain that airflow would be as effective as conventional polishing||2||2||15||8||3|
|I felt the procedure was comfortable and beneficial.||0||0||3||6||21|
|I would be willing to have the Airflow procedure again at future appointments||0||0||1||3||26|
|My mouth feels fresher and cleaner than I expected with Airflow.||0||0||1||5||24|
|I would be willing to pay an additional fee for Airflow.||1||0||12||10||7|
The participants voiced many feelings and opinions after the procedure. Comments included;
Appraisal and Planning
Most participants preferred the Handy to routine polishing and were surprisingly satisfied with its freshness. I was initially concerned more about patient comfort and determining whether they would pay an additional fee for future its application as part of treatment. It transpired this was less contentious than I thought. When questioned the majority thought that a fee of more than £5 to £10 would be excessive. Only a few considered that it would be inappropriate to charge more than polishing.
Given the opportunity of adding further value to my patients’ polishing preferences with Air-Flow, considering its portability, reliability and clinical benefits I will now begin to use the system in all four of my present practices. This will be made easier through this experience and I will now confidently demonstrate and advocate it to individual practice teams. In future clinical equipment evaluations I will continue to listen, through feedback, to the patient’s perceptions and preferences. I hope that feedback questioning would continue to accurately guide clinical decision making and back up the changes consequently made.
Cost Benefit to the DCP and practice – income and expense
Despite the initial price of the product and ongoing purchasing of powder I can see many pluses to using the Air-Flow Handy from the clinical perspective through to providing additional income. A simplified route map in terms of approximate cost and expenditure is;
Cost of Air-Flow Handy, 1 additional nozzle and 4 boxes (16 bottles) of Air-Flow powder in a year.
£ 2100.00 inc VAT – less if discounts and special offers apply
46 weeks of clinical work using Air-Flow Handy on 8 patients a day @£5 or £10 per patient.
£9,200 @ £5 per patient over a year
£18,400 @£10 per patient over a year
Completing this critically reflective experience has to provide answers to the original four questions posed by Rattan;
Are we doing things the right way?
What is the evidence relating to our practice?
How can we ensure that the necessary changes are implemented into practice?
Were changes being made sustainable and, in addition, producing efficacious and cost effective benefits to patients in practice?
By putting the Air-Flow Handy into practice I believe my patients benefit from its stain and biofilm removal efficacy, especially interproximally. Improving my skill with it through experience and feedback has benefitted my personal and professional development.
Gathering evidence from my patients demonstrates approval and positive responses to the Handy. Where it was negative or indifferent opinion was sought to improve future experiences with it.
The changes needed to facilitate Air-Flow have been achieved but will be re-evaluated frequently. The key to its future success is maintaining its serviceability and buying additional Air– Flow powder by charging extra for its use.
The final question is the most critical as Air-Flow needs to be determined by the patient to be beneficial and by the operator to have cost effective benefits. Cost benefit analysis determines all the collated positive factors. These are the benefits. Then it identifies, quantifies, and subtracts all the negatives, the costs. The difference between the two indicates whether the planned action is advisable.
Patient feedback indicates a positive cost benefit result and that an increase in treatment fees would be accepted by most surveyed. Whether to introduce Air-Flow Handy is for the individual clinician to decide but I will continue to promote it a part of my preventive care regimes. Air-Flow Handy can also be used in other treatments, such as preparation for fissure sealants, in fresh breath therapy, periodontal and caries risk management programmes. Furthermore I would recommend all Dental Care Professionals continue their clinical development through evidence based critical reflective practice within their workplace. This allies to our professional duty of care, working in the best interests of patients, but also benefits our practice and ourselves by linking to companies like Optident who can help facilitate this opportunity.
Big Conversation on CPD continues. The Probe, May 2012. Available from:http://www.dentalrepublic.co.uk/the-probe/news/detail/big-conversation-on-cpd-continues
Gray, D. Cundell, S Hay, H & O’Neill, J. Learning through the workplace – a guide to work based learning, Nelson Thornes, 2004: pp 1-5.
Rattan et al. Clinical governance in general practice. Radcliffe Medical Press, Oxford. 2002: P 99-107.
Care Quality Commission. Guidance about Compliance; Essential Standards for Quality and Safety, 2010. :http://www.cqc.org.uk/_db/_documents/Essential_standards_of_quality_and_safety_March_2010_FINAL.pdf
BDA Clinical Governance Kit, version 2.:http://www.bda.org/dentists/advice/practice-mgt/laws/qs/clinical-gov/implementing/clinical-gov-in-practice.aspx>
General Dental Council, Standards for Dental Professionals. London, GDC Publications, 2005.http://www.gdcuk.org/Newsandpublications/Publications/Publications/StandardsforDentalProfessionals%5B1%5D.pdf
Thompson, S & Thompson, N. The critically reflective practitioner. Palgrave MacMillan, Basingstoke, UK. 2008: pp. 26-28.
Cottrell S. Critical thinking skills. Palgrave study guides, Basingstoke, UK, 2008: pp.1-12.
The influence of air polishers on tooth enamel. An in-vitro study. 1998;59(1):1-16.:http://www.ncbi.nlm.nih.gov/pubmed/9505051
Changes in the surface microrelief and the loss of dental enamel after the use of an abrasive spray of sodium bicarbonate,1990;33(2):77-82. :http://www.ncbi.nlm.nih.gov/pubmed/1964618
Routine scale and polish for periodontal health in adults. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004625.pub3/abstract
Pocket Mentor Giving feedback. Harvard Business School Press, Boston, USA. 2006: pp.4-8.
Collins Online Dictionaries :http://www.collinsdictionary.com/dictionary/english/feedback
Mentoring – Guiding the learning journey
Once qualified the DCPs learning journey alters radically to autonomous accountable practitioners working within unknown teams and clinical environments where expectations from employers and patients have to be met in that important first year. 1 Can “novice” hygienists and therapists gain valuable skills and expertise from trained and experienced DCP mentors and is there now a need for an embedded culture of mentoring like our colleague dentists and fellow health care professionals? 2
Standards and Regulations
Professional standards define the DCP as an individual who accepts responsibility for the effective safe care of their patients with underpinning ethical guidance promoting the co-operation with members of the dental team and other health care professionals in the interests of the patient. 3 The Nursing and Midwifery Council (NMC) have established standards that support learning in practice with post graduate professionals being guided within this structure, after training for their first “preceptorship” year and beyond with competencies being validated annually by a supervising “sign off” mentor. 4 Comparable mentoring activities within dental hygiene and therapy have yet to be fully realised by the profession despite greater regulations in place to protect the patient and increased professional standards from authorities like the General Dental Council and the Care Quality Commission 5, 6
Mentoring within our current dental culture
In 2009 a revalidation linked feasibility study undertaken for dentists by Costley identified that many practitioners in the dental sector were not meeting the minimum standards of “operational” competency with a perceived need for face-to-face assessment with all, or a selection, of dentists throughout the UK. 7 Revalidation builds on current standards to protect patients by asking dental professionals to demonstrate their suitability to remain on dental registers. The study made no mention of co-operation, collaboration with or comparison to other health care professionals or mentoring in addressing this serious issue. A rapid response to this was a change to dentist vocational training that extends the course from one to two years and encompasses a new title, Dental Foundation Training (DFT). Participants need to log clinical experiences, assessments, education, continuing professional development (CPD) and personal development with reflective practice required weekly for the first eight weeks then monthly for the duration of training.
The General Dental Council (GDC) currently refers the issue of mentoring activities and training for DCPs to educational and CPD services provided by the Committee of Postgraduate Deans and Directors and have commissioned the Centre for Medical and Dental Education to develop post graduate dental and medical education for dental practitioners. 8The fifteen UK Deaneries are tasked to develop and quality assure opportunities for trainers in Primary and Secondary Care Services and to ensure that sufficient training places are available to meet the future needs of the NHS. Other providers include the Faculty of General Dental Practice, the University of Lancashire and Kings College London. 9, 10, 11 The development of mentoring services from the Deaneries appear very limited varying from a general lack of any training or guidance to a few, like the Northern Deanery, offering training and a mentoring service similar to that of the NMC. Other providers offer level 3 study varying in length and cost which might, to many DCPs, appear prohibitive and distant.
This appears to bode well for struggling or newly graduated dentists but what about the DCP? We too are registered and accountable, regulated by the same body, working within the same standards and guidelines, and are advised, like our dentist colleagues, to evidence base practice whilst viewing our annual retention fees and indemnity costs increasing with incredulity. However, DCPs appear be less served in comparison despite facing increasing risks of negligence claims against us for malpractice or poor performance. Surely there is a need to develop mentorship and guided support, irrespective of costs, which brings parity to dentists and healthcare colleagues, and continues to raise standards, quality of care and safety for patients.
The initial challenge of the team professionally qualifying as mentors was addressed by training at the University of Surrey.13 The tutoring team were very approachable, experienced and flexible providing an established programme over twelve weeks at level three with several mixed professional cohort groups in each academic year. The five day course is divided into two learning sessions with reading and course work set which includes a teaching and assessment session and a fifteen hundred word reflective submission about the teams learning journey in mentoring. Learning with other healthcare workers allows a unique insight into their environment, knowledge and experiences and gave us a good academic foundation helping us to evolve the support programme design with the knowledge and experiences acquired.
The course explored in detail individual learning styles, domains and theories to complement broader mentoring subjects and debate. Knowledge learned was evaluated when we all undertook individual teaching and learning sessions as part of the module. Being able to put our learning into practical use and understanding the underpinning elements of individual learning has better equipped us to structure and deliver the programme more focused upon the individual using their input and feedback to deliver clinical shadowing, online interaction and peer event elements more effectively.
Organised Peer Events and Learning Programme
The programme is designed around three organised peer events throughout the initial pilot year. The events will be heavily influenced by feedback received from several “about to graduate” hygienist and hygiene therapist student cohorts from universities across England. The team ensured that the groups had the opportunity to debate the challenges that the current dental health environment now presents and focused on the opportunities to develop their professional skills and voices. Great weight was given to listening to what they perceived their challenges would be in the coming years and how these may affect or benefit them. Most were concerned about finding appropriate employment after training and losing skills as therapists when only employed as hygienists. With these views considered the course will guide the DCP in designing their aims and goals, to be involved in a reflective process of learning with awards and prizes given for development linked to the promotion of the professional, dental health and their clinical environment. The programme will also use pre and post course feedback to benefit the participant and the team, its future development and quality control.
Skills gained by the mentor during the course can enhance a one to one learning experience with participants potentially benefiting from time with a colleague or co-worker who is further on in their career or has a skill set or experiences the learner values. Being able to observe clinical activities set in different environments, to question the professional directly, absorb the work culture and procedures but also give and receive feedback with that expert provides an opportunity for a unique learning process, from which both can develop. 15, 16
Providing hygienists and hygiene therapists the opportunity to actively participate in a supporting learning culture will benefit the DCP, the professional body and the safety and care provided to the patient. Price (2004) believes mentoring is pivotal in setting goals, socialising learners in the practice culture and understanding their anxieties and needs but goes much further by challenging the mentor to demonstrate and maintain an active interest in learning whilst continuing to create learning opportunities. 17 Other health care environments have and continue to provide opportunities to promote best practice and develop competencies through clinical based mentoring within their professional culture.
Designing hygiene intervention protocols for my practice – whole dental health – part’s 1 and 2
It has been almost a year since I arrived at my new practice in Nelson, time has passed rapidly in an eventful period for us all. Little would I have known that at this very moment I’m typing this nearly a half of my fellow countrymen and women are experiencing a level 3 COVID lockdown. This was the case for us all in New Zealand from the very end of March to the end of May. A few months of near normality followed this to where we are now, awaiting a national reduction to level 1 again. The degree of apprehension and uncertainty has evoked recent memories but the these feel more measured and less existential, for me at least. Despite this the need for normality in the workplace, even progress, has to be engaged, perhaps as a distraction but more so to meet the needs of clients here.
It was during this moment, last week, that my boss, Gerry, approached me to generate a protocol to link hygiene appointments to the treatment planning designed with the orthodontic auxiliaries. It was made clear that there needed to be a differentiation between age groups, youth, youth adult and adult as well as a plan for 12 or 18 month treatment patterns.
I am also mindful of the nature of the practice, it’s desire to be as natural as achievable in its treatment approach and empathetic in its guidance, tolerant by embracing differences of opinion regarding product and lifestyle ideologies. This could originate from objections or concerns regarding contents or perceived toxicity within products that are indicated in controlling and balancing biofilm and pH, strengthening or demineralising tooth substance through to nutritional, habitual or economic realities, even ideologies, that oppose or conflict with mainstream and established approaches to oral health development or management. This can be seen in the debates that rage around fluoride, additional materials found in dentifrices, allergies to components in toothpastes and diets rich in fermentable carbohydrates, acids or dehydrating effects. Consideration required for a dry mouth status emanating from poor tongue posture or arch form, or both is not in my present scope of practice but can be engaged with by our practice oral myo functional therapist and orthotropist.
My aim is to collaboratively design a protocol and consider a linked oral health process complementary to and in symmetry with the treatment planning of orthodontic clients including guided and considerate product recommendation, appropriate linked appointments for team reviews and timely interventions as deemed necessary on reassessment. This I began by designing an provisional flow chart, based upon guidance from the clinical team, aware that it is a prototype and will be changed and challenged. That’s fine by me.
Historic concerns have been raised with specific ortho cases of late, either due to poor oral health compliance, plaque and calculus accumulation linked to an increased risk of poor oral heath outcomes. The demineralisation of young enamel tooth substance, due to caries risk increase has been another subject of growing concern. The management of appropriate and sustainable oral health behaviours, conducive to stabilising and maintaining gingival and tooth integrity is as importance, in my opinion, as the process of arch expansion and tooth realignment. In addition to that, a post treatment phase be considered, especially where retainers, either fixed and removeable, are utilised.
The instruction in cleaning appliances, currently undertaken by auxiliaries needs to be continued and promoted at fit appointment. Where compliance cannot be demonstrated or achieved during care, despite interventions will be guided back to Gerry for determination.
Cost for OH phase + review @ 4/52 and 3 x rev follow up and final visit = $640
Cost for OH phase + review @ 4/52 and 5 x rev follow up and final visit = $890
Option 2 ( flat Rate not individual )
Cost for OH phase + review @ 4/52 and 3 x rev follow up and final visit = $500
Cost for OH phase + review @ 4/52 and 5 x rev follow up and final visit = $750
OH Phase – 45 minutes
Review Phase – 30 minutes
Focus and Strategy
General ecological balance (pH balance) and hydration/ saliva stimulation
Mineral integrity, sensitivity management and ecological balance (pH balance)
Physical intervention and ecological balance
Instruction – Information Sheet
Quin Dental Guidance Form
Oral environment and pH
I work in two practices in Nelson and am fortunate in one to work with another Hygienist. This hasn’t been the case for a lot of my career so I’m grateful for this and also that they are collaborative and are happy to be part of, contribute to, and help implement change, if sound.
My challenge is that the cost of current treatment is the same whatever the status of dental health. That means that complex care is charged at the same rate as a well-managed and stable mouths. This is irrespective of whether a local anaesthetic is required, additional instrumentation with ultrasonic or airflow polishing and biofilm debriding systems are required. The additional labour, skill level and equipment requirement isn’t reflected by the flat rate being charged. How can we move this situation forward and bring a process that rewards oral health improvement, requiring fewer additional visits but can also demonstrate money well spent, and less costs incurred in the future?
Being employed, but having previously experienced self-employed I can appreciate the disconnect between the two as a dental hygienist. The self-employed hygienist is motivated in the same way as the employed, by their efficacy in line with standards and scope of practice responsibilities but are more likely, from my experience, to be more proactive and inclined to be aware of their efficiency, be it time management or economics. This has its downsides too, with the potential to be time constrained, less client care focused as the employed individual, from my experience. I have found, subjectively, that moving to employed status took a while to adjust to being less time pressured and production focused. The imperative is quality care, delivered safely and effectively, in partnership and with the consent of the client. The quandary being employed is to see a different way, in the relative safety of a system that is established but doesn’t appear fair. If we can marry both ways, the need for sufficient treatment time, bringing the best outcome, delivered ethically, meeting and rewarding the needs of the client and the clinician, then I’m a believer.
The way forward with routine care has been at the forefront of my enquiring mind of late. I have experimented at my previous practice adapting a traffic light system that marries the time and cost required based upon the need demonstrated by assessment prior to treatment commencing. It follows a red green and amber protocol with the fees being set that reflects the need and complexity of care as well as the stage the client’s oral health represents at that moment in time. A code score, linked to recently updated periodontal guidelines, is added as an alternative option. The benefit is with both clinician and client. They now know their status, it has been measured. They can determine the efforts required to either remain where they are if stable or the processes necessary to achieve better oral health and a shorter less costly next visit, determined by the recall recommended by the clinician after.
The original idea was as a consequence of a discussion with a client who challenged the cost of advance care. I indicated the best way to get to routine care would be to achieve oral stability and remission from their periodontal condition. I then considered standard care broken down into three parts to follow this rationale. I separated the advanced care as a different process as it requires more time, use of equipment, materials and skill. I tested it with a colleague and found it to be achievable. This was further approved by the practice owner and with all the team briefed it proceeded successfully into action.
For the purposes of this project we will spend a month doing a trial run, annotating the clinical day sheets with the code/colour and additional costs hypothetically. We will then gather the data, see how many would have been whichever code/colour and additional costs that would have been levied. We will also ascertain whether the idea works or needs modifying. This will guide whether we precede with the action plan. It can also be a useful aid to the practice management team regarding improving our hourly rate or linked to a novel bonus system, so everyone, both clients and the hygiene team benefit from improved dental health.
Dental Centre Hygiene Experimental Guideline Protocol
Code 0 < 10% BOP Stable or just Phrophy 30 – 45 minutes $100/125 GREEN
No risk recall 12/12
Code 1 10-30% BOP Unstable/localised 45 minutes $110/140 AMBER
Low – Medium risk recall 6-12/12
Code 2 >30% BOP Active /generalised 45 – 60 minutes $120/155 RED
High risk – possible two visit appointment recall 3,4-6/12
ALL CODE 3 & 4 CLIENTS NEED CODE 2 Appointment at 45 or 60 minute appointment, dependent on need, for assessment and ORAL HYGIENE PHASE before COMPLEX CARE
Clients seen as code 2 before – 5/10 minute review – consider OH review before to determine compliance, reassess need or whether interested in undergoing additional treatment
Code 3 Perio unstable advanced 60 – 90 minutes $200 – $300 per appt
per appt quadrant or half mouth
Code 4 Perio unstable+ Complex Combination therapy as above or refer
Or refer as above
Code 2P Perio stable Maintenance 45 minutes $120/155
Remission recall to be determined
Codes 3/4 to be determined by Mark/Kelsey or referred to Periodontist
Based on modified fee structure and 2017 Classification of Periodontal Diseases to Reach a Diagnosis in Clinical Practice www. Bsperio.ork.uk
Patient Information Form
Environmental /Ecological – Plaque
Recession and sensitivity
Fresh breath/ Tongue cleansing
Erosion/ Wear/ Abrasion
In conclusion, the need to consider costs of care related to need conflicts with the assumption that all treatment should be charged at the same rate and that recall lengths are the alternative. This assumes that the recall will be met, that the clinician isn’t factoring in the additional effort professionally, physically, emotionally and mentally required to facilitate change and an achievable, beneficial outcome. My experiences demonstrate it is at least worth attempting, getting feedback from colleagues and measuring the benefits, quantitively and qualitatively, reflecting on them and making changes if required.
“Come forth into the light of things, let nature be your teacher”.
“Does a holistic approach to dental hygiene practice, required as part of my professional standards, align with an environmental, nutritional, and ecological approach to dental health? An authentic, first-person, reflective narrative account into personal new knowledge creation and practical application.”
“Natural ecosystems regulate themselves through diversity”. The biggest little farm, 2018
“A holistic approach is all-inclusive; it requires you to give consideration to the patient’s overall health, their psychological and social situation, their oral health needs (immediate and long term), and their desired outcomes. Provide patients with oral health advice and treatment options relevant to their situation, and discuss associated benefits, likely outcomes, and potential risks. Carefully balance the patient’s oral health needs with the patient’s wishes and be able to explain your approach to care, which could include declining to treat. Restrict your treatment to the activities permitted by your registered scope of practice. Refer patients who present with issues beyond your area of practice or competence.
This begins a detailed narrative account of first-person, active learning discovery, seeking where necessary alternative and sometimes unorthodox routes to solving unanswered questions within one’s professional life. It is also an empirical journey, combined with traditional sources of research, putting the walk into the talk, using the experience of new knowledge gain, utilising the insight and awareness of it, to add deeper texture, relevance, and meaning into personal practice. There are unique moments and profound occasions that require such answers and begin your inquiry. This, unwittingly, came knocking on my surgery door in 2017 to hasten this journey. I was working as a self-employed dental hygienist in general practice in Marlborough, New Zealand. A client, younger than myself, with a serious pre-existing health condition, had made a monumental effort to improve their oral health, under my care. They patiently waited for a heart to become available for transplant. The day I saw them for the final review, praise was lavished at vast improvements and very evident clinical stability. This should have been the green light to anticipated surgery but was, alas, the last day of their life on earth. It wasn’t enough despite my client’s earnest efforts to prevent a massive heart attack and its fatal consequence. Around the same time, I attended a progressive dental health event in Switzerland. Moments of clarity amongst the events of that international occasion brought greater resonance to a growing sense of unease within the professional me, my wedded ideology, and beliefs. I was drawn away from the threads of the mainstream conference agenda to smaller, just as well attended, but more abstractive presentations that covered holistic and nutritional subject matter. They were freed from the constraints of convention, and were to me, a breath of fresh air.
My locus of intent was switching from reductivism of just teeth and gums to looking at the mouth as a whole, becoming more investigative into the broader context of health-related benefits to improved oral hygiene. I started to read books by journalists and influencers in food science, Michael Pollen, Gary Taubes, and Nina Teicholz. I also began listening to podcasts by endocrinologist Dr. Robert Lustig, paediatrician Dr. Robert Ludwig, and complex problem-solving engineer Ivor Cummings debating systemic health, lifestyle behaviours, and watched heart health related documentaries by the likes of Azeem Malhotra, a cardiologist. The ventures into these works drew my attention to profession contention, the gated establishment of food and health politics versus the alternate and burgeoning intelligentsia who challenge the contemporary landscape. They believe that the modern food environment and culture require change for broad health, general wellbeing, and economics. They have been profoundly influential, and the push back has been rapid from pharmaceutical, food, and related industries and interests. South African nutritionist and author Dr. Tim Noakes, and Australian senior orthopaedic surgeon Dr. Gary Fettke, have been the subjects of recent high-profile lawsuits. These being brought to bear by their regulatory bodies over contentious claims they have made defying the established thinking.
“It is not the strongest of the species that survives, nor the most intelligent, but the one that responds to change”. Charles Darwin
My headspace has been a flurry of comparative conflict with my established ideology. It has been born of over more than two decades of traditional professional development and a reckoning with my past learning approach. Over the proceeding months, many a long dog walk had me listening to the challenges these individual voices were making to the greater online audience, and the tone and texture of their message began to make more sense to me by the day. I designed an academic presentation, delivering it in a local and national venue, with a colleague, to a paying professional audience. I found “walking the walk rather than talking the talk “profoundly influencing, although scary at times. Upon these experiences and knowledge, I realized that other people, many amongst my clients, follow a similar path. How would I make the next developmental journey, what would it look like, could it be more experiential and meaningful?
The plan was drawn up on paper, on the dining table, over a few days. The journey would begin in the UK, onward to France and into Scotland, to the States and back home to New Zealand, learning, feeling, experiencing, reflecting, and enjoying along the way. I thought I had a clear picture of what would be gained and set out on the scroll of cello-taped paper. People contacted, meetings arranged, and all the panoply of its facilitation organised, times and places plotted, and transport booked to set the project in motion. What was not, at that point, thought out was what would be the outcome of it. I knew that, as many students in the art of warfare acknowledge, is that planning, in reality, doesn’t survive contact with the enemy. I was prepared for it and welcomed it. Tangential flexibility would prove to be the best armour and protection against a rigid and fundamental ideological foe.
Upon my return to New Zealand in the early spring of the southern hemisphere were harbingers of change, a new home, location, and workplace environment. We started the journey in full knowledge of this, but the reality of the situation saw me embarking on another explorative journey. It leans heavily on the symmetry between past practice, recent experiences, and my new professional environment. It also looked at distinct healthcare subject matters like alcohol, fluoride, cannabis, nutrition, and the much-maligned historical figure of Weston A. Price, as well as the evolving and testing my ecological, nutritional and environmental co-existence hypothesis. What follows are accounts of both of these journeys in the context of authentic learning, and dramatic world events, founded within my established principles of empiricism and observation, linked to evidence guided practice.
The full account is designed loosely around the learning and developmental model of action research. The term action research was coined by social psychologist Kurt Lewin in the United States around 1944, aimed to promote social action through the democratic decision making and active participation of practitioners in the research process. The project sheds light upon action research throughout the narrative, and I will leave it there for the reader to discover and understand it more thoroughly. I have also decided to use a first-person, narrative style of writing, mainly because it reveals the unique nature of the project and the character of the individual participating. The sources and references reflect the mood and headspace I’m in at the time and the decisions made to demonstrate the association between research and action in a way that appears less formal but allows the reader to refer to them directly online if desired.
The main body is really divided into two parts. One the physical and secondly, the academic learning journeys. The first part demonstrates learning on the hoof, so to speak, being influenced and motivated by real-time experiences and appetite, sometimes literally, to describe those events as they occur, when and where they happen. The second part of the story reveals an evolving workplace journey, adapting knowledge through an action research context developing into personal clinical behaviour change. It will culminate in a final piece of work, drawing upon them in the context of action research, but using my own style of referencing.
Finally, the work’s body will be an extensive edit from where the research was deposited during its construction. This was derived from two blog sites, posted to them, designed as a portal for the professional and general public to read and review, but also as a repository for them to be used at a future date. The context of each individual post can be referred to and seen in its unfettered form, with photos and pictures included in the initial post and a rawer, less refined written account.
Mark is a registered dental hygienist with over thirty years of varied clinical and learning experience. His practice began in the military, where he witnessed the fall of the Berlin Wall in 1989 and received a royal commendation for his community learning support to service schools. Mark continued his journey in the Highlands of Scotland, the warmth of the Mediterranean, working again in community learning, and an oral maxilla facial department. He also saw clinical service in the turbulent environment of post-communist Moscow as a member of a diplomatic dental team for several years. After his military service, Mark moved onto private, NHS, specialist practice, and affiliations to the trade industry as a key opinion leader and influencer in both the UK and New Zealand. Mark has further highlighted his endless curiosity to engage in learning presently by creating websites and blogs that share his thoughts, demonstrate new knowledge creation processes, and continues to do so today. He is also an active mentor for O’Hehir University, an online tertiary learning hub for postgraduate dental health professionals.
“Nothing has such power to broaden the mind as the ability to investigate systematically and truly all that comes under thy observation in life”. Marcus Aurelius
Mark and Toni’s 2019 Odyssey. New Zealand to Provence via London
As we sit on the 07.15 Eurostar train in carriage 4, seats 21 and 22, we listen intently to the ambient pulsing noise of the electric motors, stationary at present but soon to leave London St. Pancreas at high-speed journey south to Avignon, Provence, France. The gentle hum blends with passengers’ accents and languages, just like us awaiting the beginning of a trip, our odyssey. The procession through passport control and customs to the train platform had been mercifully swift and virtually stress-free, in stark contrast to LAX. Those who have trodden that path know precisely my sentiment. Finally, a nudge, the long-awaited jolt hails its departure, and ours.
How was our first week, the week that was the anticipated jet lag reset? A bit of context seems appropriate at this point. Toni and I have just left the blanket of vines that is Marlborough, our friends and colleagues, to live and work ( in the order we hope ) in Nelson, Tasman, New Zealand. Many reasons have facilitated this change of scenery. The prospect of new employment opportunities, kinder shift patterns, more aligned to our social and professional intent of functional and holistic practice, and lifestyle await our return. Our family, less our middle lad Dale and daughter Naomi, are there, as are our adopted family of Isa, Pat and Ruby. We stored our possessions and hauled over the Whangamoa Ranges. Contracts are agreed, and hands shook, our optimism topped up.
Many months in preparation, we decided to begin in Wellington, our cultural hub. It has sustained us during our time in Blenheim, a beacon of hope and culture we understand and enjoy. Then the long flight to London, car hire and cabin booked in the North Downs for 3 nights, and a short stay with friends in Cheriton, Hampshire. Beyond lies a French experience in Provence, The Dordogne, and The Loire Valley in France. Designed to head north from the Mediterranean through a variety of traditional food regions and cultures, we intend to embrace and be part of the scene. We then return to the UK and onward to Portland, Oregon, and Boulder, Colorado, USA. Returning via San Fransisco to New Zealand at the journey’s end.
We are trialling a fasting programme, a modified 16/8 method. It began with a test run in Wellington the previous Sunday. It is adapted for the benefit of our work routine with an 8 – to 10-hour eating window and a 14 – 16-hour fasting window prior. We hope for some weight loss, better mitochondrial function, and reduction in HBa1C/ blood glucose. Intended for every day of the week, we, however, will try to stick to 5 days as a weekly minimum
The food journey involves what we believe is a whole/real food concept, complex carbohydrates with an onus on quality, seasonality, locally sourced, functional (affording an additional general health benefit), and foraged. Quality fat and protein combined with green vegetables cooked with healthy oils, and salads, of course. No waste and smaller portion sizes are also on the menu. Eating out is at a premium as we are on a tight budget, but on a few occasions we must, for empirical research, of course.
We set off from London Airport and headed to Puttenham, a little village lost in time in the North Down’s of Surrey. En route, we stopped to eat a small Kebab, we were tired and jet-lagged and hadn’t had much sleep. The opportunity to eat something tasty and “fast” overruled everything else. We took the smallest menu, and we drove the Kebab to a quiet, gentle spot in a nearby churchyard. It wasn’t so much a religious experience or perhaps nutritional either, but it was essential.
We set out to find locally sourced, seasonal, and optimally nutritional food, low human interference, avoiding processed and ultra-processed food and drink. It was interesting to see how food is presented in the Supermarkets, sadly covered or encased in plastic for obvious reasons but not for, it seems, our health. The burgeoning problem of microplastics and food miles adds to the conundrum of how to safely and ethically keep food fresh on the shelves, avoid waste, and sustain shelf life. A paradoxical demonstration of this was Tesco’s and Secrett’s at Milford, Surrey. Secrett’s is a small food, and grocery concern had most items as nature intended, the smell rich, and the colours vibrant. Costly, yes, to an extent. Much of the produce grow literally on-site or very nearby. The cheeses and cream are stored very much like Tesco, in a chiller. The big commercial stores were brash and alluring to the bargain hunter, 2 for 3, half price and this or that percent off, ease of parking with additional alluring benefits like cheaper petrol. I’m not sure what to expect in France, but from previous experiences, we’ll stick to the local markets where at all possible and find places, we hope, like Secrett’s in Surrey, on our journey.
The week involved a lot of emotional sentiment, I lived as a young boy in Surrey and as a family for several years, up until 2013. We had moved here in 2006 to heal following a huge medical drama. We both walked a lot, along the Wey Navigation back and forth to Guildford. We had a dog and an allotment, it kept us sane in that dark time, www.offtheplot.wordpress.com charts our journey of that period of our lives. This time, however, born of that, decided to forage for our first dinner, and a container of both Chanterelles and Ceps were soon in hand. With Sourdough Toast, local Broccoli, market place Black Pudding, we were suitably satiated.
Walking in the woods, or “nature bathing” is an essential component of well-being and mental health and physical health improvement. Learning we are part and not separate from nature is vital, whether just to be or abide with it or harvest is fruits, be they mushrooms, berries, leaves or nuts is a decision for the individual, but for me, it makes the me come to life and feel whole, as one with nature. Importantly when picking free food, it takes your experience and knowledge to the next level. When it comes to sourcing wild food you have to put your health literally in your hands of your research and judgment of nature, just like our forefathers and ancestors did before. Their knowledge was passed on through the generations until modern times when much appears lost. The mystery and majesty of seeing the trends and time tables of their fruiting, the conditions in which the prevail, the association of them to other species of trees or plants, and their locations memorised for the next season.
Wednesday took us to RHS Wisley Gardens, a moment to research fruit and vegetable gardens and community allotments. The gentle English passion for flower gardening eludes me. If grown, it either has to be used in the kitchen, eaten raw or sensual, and healing, like for example Lavender or garlic. I found Wisley interesting as it gave us both a commitment to return to allotment growing in Nelson.
Thursday took us to Winchester, the Anglo – Saxon capital of Britain before the untimely intervention of William of Normandy in 1066. The Cathedral itself dates back to 1079. It’s a suitable place to think about our health status and the fragility of life, but also the purpose of deep spirituality, traditional in this context. In the west wing of the building lies famed and lauded Author Jane Austen, a true literal heroine, observer of social status, etiquette, and early female emancipation. Her untimely death at such a young age should be a testament to all of us to be mindful of our health and wellbeing but also not to wait exploring and cherishing our innate potential for creativity and legacy. Spiritually the strictest sense this toweringly built and exceptionally crafted Cathedral does nothing for me, but as a monument to man’s ability to engineer and construct vast structures, it is awe-inspiring. Surely the nature of man in science, in art, and spirit are a testament to a higher, more creative, and unifying purpose, perhaps more so than established religions?
Also, as a footnote, and very much like the example of gardening, it appears as a place where people come to gather, to abide and commune, for protection, support, in faith and belief in a higher cause, connection to the seasons and nature, more significant than themselves, acting and behaving in the interests of others as a collective. My “church” has a similar philosophy but less of a traditional, human construct but a reverence of the power and majesty of the natural order. I respect their belief systems, but wonder if they’d appreciate mine as kindly? There is a deep impish side to me, brought about perhaps by too many Sunday school moments in my early years.
In Bighton, a little north west of Alresford lies a scarce natural feature, chalk and flint streams, clear as day, gently pulsing through the Hampshire countryside. The water itself has become the source of a potent raw natural superfood, namely Watercress. Ironically, we’d brought some the few days previously thinking it was locally to discover it had been imported from Spain! How crazy is this? The growers are a company called, ironically, The Watercress Company, and their website http://www.thewatercresscompany.com is an amazingly successful attempt at promoting the health benefits with referenced and sourced information set out in a clean, logical way. I recommend you read it. Superfood it is.
Back to the here and now, in carriage 4, seats 21 and 22 on the high-speed journey of a lifetime, 240 Plus KM/H awaiting arrival in Avignon at 14.15 pm. I’m eating Sourdough Baguettes with soft, “walking” Coulston Bassett Blue Cheese and Iberico Ham and Avocado. Our hopes for Provence? More of the same, well – being, peace, and adventure. We’re in southern French nutrition heaven, and it sure feels good. We wish you all Bonjour and Sante.
Mark and Toni’s 2019 Learning Odyssey: En Provence, France.
We are sitting on the deck of our cabin/caravan, I’m listening to the second semi-final of the World Cup 1 Day International Cricket between England and Australia. The winners meet New Zealand this Sunday! How exciting, who to support if England beat the Aussies today?
A thought on last week’s experiences was to perhaps look at some of the research I’ve done of late regarding Southern Europe’s nutritional research to add some sense to my ramblings. I have also got into the habit of looking at the various foods we consume detailing their nutritional and health benefits. I must confess being very surprised by the revelations and will post on this some. Veal liver looks amazing regarding Vitamin A!
So as Toni and I watch a film called “Paris can wait” with Diane Lane, a road trip film heavy on French food, culture, and national character from an American visitors perspective. Many studies have looked at these, but the one detailed below shows a little higher end quality and, in the case of PREDIMED, how important precise science can be found to be less than accurate, and that detail is everything.
PREDIMED controversy @ https://www.medscape.com/viewarticle/898110#vp_3
Apologies for the lack of entries since I arrived in France, but I have been so involved with experiencing my environment that writing has taken a back seat. The first significant distraction is food (naturally). I have finally eaten salad every day in addition to veal liver, pork chop, cheese (goat/chevre, Comte), and saucisson/cured meat. I’m in tomato heaven, too. Provençale vegetables are packed with flavour and NOT wrapped in plastic. Even Supermarkets here seem more ” Market.” Where possible, Mark and I are buying totally local, and we can honestly say we have produced zero food waste. We have managed to forage herbs just outside the campsite: thyme and rosemary dried by nature in the hot Provencal sun.
A visit to a local goat farm has supplied us with a variety of cheeses from frais (just three days old) to demi-sec (two weeks old). There were 33 goats, all named beginning with the letter N. I hugged and thanked the goats (my favourites were Naf Naf and Nounou. Mark liked Nebulues).
The wine, Rose, yummy….. difficult not to overindulge. On the plus side, the 16-hour fasting continues, but not today because we went to market in Aix-en-Provence.
The weather has been hot, eased by the occasional thunderstorm and gentle breeze. With the sunshine and fresh local tasty food, I really do feel healthier. A bit more sleep would be a bonus, but at least now the mosquitoes are leaving me alone (many thanks to all my Facebook friends for their mosquito repellent tips). Toni
The road was straight and to the point. The endpoint is the market at Pellisane. It was Sunday, but no church bells could be heard. The mass of people moved slowly, like waves, to their centre of concentration, whichever stall caught their eye or the scribbled words on their hastily written shopping list. At first glance, from the eyes of an amateur in these affairs, the market looked a small affair, one long street zoned off with tightly packed stalls of every shape, size, and variety. All seemed disorganised and jumbled, but I’m sure all stallholders knew their patch and were accustomed to the area they flew their commercial flag having done so for many, many moons. Dogs, children, babies in prams, or in the arms of their guardians swelled in the midst of human traffic. It was indeed a sensory event. The market grew as we saw over the heads of people around us alternative avenues of trade going left and right, east and west. We would remember and return to them, as was the difficulty in diverting and losing each other in the melee.
The human sounds blended with the intensity of the constant insect hum. Supermarket music could not compete. This was no supermarket, Artisans and stallholder spoke out to the crowd like a demanding Priest to a silent, sleepy congregation. Please, thank you, good day or good-bye was heard frequently at every turn, the slow momentum held us up every so often as a conversation became elaborate, no one moaned or complained, patience it seemed was in abundance. Food smells were met with occasional tasting to add, additionally, flavour and meaning to the sights before our eyes, to tempt us to purchase, not to gaze, but to part with real money. Only out of the corner of one’s eye, if you cared to carefully look, emblazoned up a wall nearby was a predictable sign of McDonald’s and a direction to its operation in a nearby street. Modernity had to lure the blessed to the fiery hell of the ultra-processed, commercial, and ultra-predictable.
Fruit drinks and sugar-sweetened beverages were the only semblance of that huge processed beast being consumed that hot Sunday. Far less by volume than what we saw a few days previously in Borough Market, London mercifully. We’ve avoided these things on purpose. Why the need for that when nature and seasonality were so barely naked amidst us? Soft berry fruits, super coloured, gnarled and misshapen peppers and tomatoes were present and incorrect but just as tasty, forgotten by the big food chains as imperfect. Even artisan bread weighed and sliced to order, joined the throng of the nutritionally possible and plausible. Comte fromage, in huge wheels and chunks, was cut to preference by its maker, cigarette in a steady hand. The price was discussed after it was chopped, sealed, and weighed. It was pure theatre.
Lambesc is a great place to stay. Quality extra virgin olive oil, rose wine, local markets, lavender, sunflowers, honey, foraged herbs, and the pulsing hum of insects everywhere. There is a passion for the land here, for community and provenance. History is within reach, the Cathars, Templars, Pilgrims, and Romans. Would we come back again? Qui! Mark.
Mark and Toni’s 2019 Learning Odyssey 2019. Food for Thought , Duck Fat, Cave men and the Dordogne
When you step into this vast area of central France, you are wrapped around, like a big warm cloth, rich in history, food, nature, and much more besides. We had made the long trip north via Longuedoc and Lot Valley to Salignac, Dordogne. The countryside was flourishing with numerous shades of green, trees, mainly of European Oak, Hazelnut, Walnut, and Chestnut lined the rural roads, either neatly organised in well-manicured orchards or randomly arranged. This was probably the first indication of the food culture we had come to witness. The Dordogne is also the historic centre of the European hunter-gatherer with caves displaying the art of our ancestral past, food, especially animals being centre stage. These are protected world heritage sites and are physical evidence of the dietary behaviours of our ancestors.
The little village of Salignac was a short 30-minute walk from the campsite. We took very little time, in our best pigeon French, to ask the local natives directions to it. Through the wildwood, across ancient paths, passing by homesteads and their allotments and animals, we traversed and found it’s beating centre in no time. It is really a Bourg, not a village, something a little bigger. There are the cafes of course, the supermarket was on the fringes of the town, modernity and convenience relegated to the fringes. However, the pride of place was the Grower’s market Shop, a treasure trove of locally produced and seasonal goods the region offers open every day. The town’s centre, a small but very significant affair, is the venue to these twice-weekly markets, on Saturday mornings and Thursday evenings. The later is also a time for locals and tourists to commune, abide, and take food cooked from the market, eating together in covered venues.
We decided not to travel too far from our rural base, we found the right places to shop for food in the local produce market in Sarlat – la – Caneda and the Grower’s Shop in Salignac. They displayed locally grown foods like nuts, nut oils, foie gras, pate, duck, and truffles. The additional staples like bread, vegetables, and salad were also in seasonal abundance.
However, cooking ourselves was one thing and a total delight, but getting a real food experience led us down the proverbial and literal country path. We went to two places, one a Relais (or Inn) and a Ferme Auberge, a farm guesthouse restaurant. The later was the pick of the bunch, I’ll get back to that later. A more significant quest lurks in the shadows and one that has spawned controversy and still does to this day. In the Dordogne the history surrounding fat, especially saturated fat, is everywhere, but also other kinds of fat too, mono and polyunsaturated fats from locally caught fish and nuts pressed into oils or just plain raw. Saturated fats are an enigma, it seems, a paradox even to some. Why are the French supposedly statistically healthier? As are the Swiss? The French go about their lives with a reverence for (quality) saturated fats, it’s in their blood both culturally and physically. There is talk about a paradox, fat making them healthier in combination with wine, especially red, and living longer. This is challenged by British academics reading research data.
Replacing saturated fat with polyunsaturated oils for preventing heart disease has been a source of continued argument and discourse, but current Evidence (RCT’s, systematic reviews, etc.) doesn’t clearly support this. However, consumption of fructose-sweetened, high fructose corn syrup or sucrose sweetened beverages (and pure fruit juices) is more strongly associated with poor heart health and now cancer risk. More research, it always seems, is required, particularly in this case, regarding whole grains (starches) and complex carbohydrates, as well as the quality of saturated fats. Added sugar, especially early in life, is associated with obesity and diabetes.
The gut microbiome (our second brain) alters with highly processed fat and sugar diets, as seen in mouse studies. Our oral microbiome, as we have additionally discovered, alters less beneficially too. The consumption of foods rich in Omega 3’s and 6’s, especially in balance (The Paleo Ratio), results in lower heart disease risk than saturated fats and sugars. However, differences can exist between individuals. Foods like dairy, yogurt, cheeses are associated with reduced risk, but again, more research is required for clarification among specific sat fat and sat fat-containing foodstuff.
A few studies might reveal answers to this ongoing contentious debate. Cordain et al.(2002) reviewed the evidence of hunter-gatherer diets, meat-based yet non-atherogenic, and found from 13 known quantitative dietary studies that animal food provided the dominant energy source (65%) while gathered plant foods comprised the remaining 35%. The paradoxical nature of this in terms of a modern Western diet associated with increased risk for cardiovascular disease (CVD) mortality is evident when it is not so present in hunter-gatherer communities. Fat energy intake from the diet equated to 28-58% of energy, more than from protein or carbohydrates, is similar to or higher than that found in Western foods. Hunter-gatherer diets also have greater mono and polyunsaturated fatty acids and a lower omega 6 to 3 ratio. This would serve to reduce the development of CVD. Additionally, foods rich in fibre, antioxidants, vitamins, and phytochemicals with low salt intake may operate synergistically with lifestyle behaviours. No smoking or alcohol, less stress, and more exercise further deter heart disease.
Further to this, Cordain et al.(2005) discuss the origins and evolution of the Western diet and its health implications for the 21st Century. They propose that changes in the food and lifestyle environment began with agricultural and animal husbandry approximately 10,000 years ago. The so-called diseases of modern civilisation started with the discordance of our ancient, genetically determined biology with the nutritional, cultural, and activity patterns of contemporary Western populations. Crucially 7 nutritional characteristics have changed from ancestral hominin diets; 1. Glycaemic load, 2. Fatty acid composition, 3. Macronutrient composition, 4. Micronutrient density, 5. Acid-based balance, 6. Sodium-potassium ratio, and, 7. Fibre content.
A study undertaken in Switzerland with dental students in 2009 (Baumgartner S et al.) tried to ascertain the impact of the stone age diet on gingival (gum) conditions in the absence of oral hygiene on the oral microbiome. This small-sized study saw 10 subjects living in an environment replicating stone age living for 4 weeks. Baseline assessment included bleeding on probing, gingival and plaque indices, and probing depth. The outcomes demonstrated after 4 weeks decrease in bleeding (34.8% – 12.6%), gingival scoring up from 0.38 to 0.43% (not significant), mean plaque scores increased from 0.68 to 1.47 and probing depths decreasing significantly. Bacterial counts at week 4 were also higher for 24 of 74 species. Overall a positive outcome with less bleeding and probing depths despite plaque growth was observed. The absence of refined sugars demonstrated gum health benefits despite the lack of oral hygiene. However, diseased teeth, or decay, maybe not be so straight forward.
The transition between hunter-gathers and Neolithic farmers regarding diseased teeth is contentious. Research done with modern Hadza tribes of Tanzania indicates decay is similar to modern societies, especially in women and young boys. Evidence from skulls excavated in Morocco, from several thousand years before the Neolithic lifestyle changes, found decay in half the remaining teeth. Only 3 of the 52 skulls showed no disease at all with evidence at the cave sites showing pine and acorn nuts being processed into a porridge-like state. Interestingly, it appears that they ate diets high in plants and not animals.
Stone age dentistry is in evidence too. Hunter-gatherer’s teeth found recently in the north of Italy dating over 10,000 years show signs of cavity preparation and filling with bitumen, an ancient tar-like substance used primarily for attaching axe heads and spear tips to shafts with woven material and wood. A pointed stone tool had been used in this process too. This precedes the Neolithic period and again challenges the perception that hunter-gatherers had less decay.
The subject of saturated fats versus carbohydrate-rich diets poses a dilemma for us all professionally. Evidently, quality saturated fat food appears to be better than carbohydrate-rich diets in dental health. Refined, processed, and ultra-processed sugars are implicated in both gum and tooth disease. Remarkably, saturated fats don’t elevate oral pH, alter the oral microbiome pathologically, even in the absence of oral hygiene methods. Hunter-gatherers suffered from poor dental health regarding their teeth only in certain areas and attempted to heal their ailing teeth with “pre-dentistry”.
Toni and Mark’s 2019 Odyssey. Food and Drink for Thought. Keeping the pH balance in Sancerre, Bats, Pinot Noir Barrels, and Kayaking through ancient Roman ruins.
Week four of our learning journey continues as we head north from The Dordogne, crossing the pilgrimage paths of Limoges and Perigueux. We pass wandering Pellegrino’s near the Cathedral city of Bourges, having sadly not, ourselves, being able to get to the pilgrimage centres and staging posts of Avalon and Valencay. We arrive at our destination, a small campsite next to the River Loire in the sweltering heat, and find a moment to get over yet another long drive. The Monday was set to be 38 degrees, and we had made the unwittingly odd decision to kayak 25 kilometres downstream from La Charitie-sur-Loire, to the east to St.Satur (Saturday related I’m sure) along the River Loire. The recent heatwaves in France had put pay to kayaking journeys we’ve undertaken before, the shorter route from Pouilly-sur-Loire on the left bank of the river halfway between our current course. For those of you, not hardcore wine buffs, this is the area of France where the Sauvignon Blanc wine varietal made its mark. The Kiwi’s, Aussie’s, South African’s, American’s, both north and south, have made substantial commercial enterprises from bringing this humble grape to the forefront of our vinous appetites. This is where the legend of the Sauvignon Blanc wine grape was born and continues to set the traditional standard of sunlight and water capturing the essence of the “terroir” and create a thing of liquid beauty.
The outward bound adventure team conveniently positioned just outside the campsite, took us with kayak in hand to the start point. We were advised to move very carefully from the get-go. We thought the river, being very low, would be an issue, and memories of grounding on previous trips made us initially cautious. Still, to our surprise and astonishment, the guide pointed out several black stumps pointing out of the river. These were the wooden supports of a Roman bridge long disused and usually hidden by the water level. This was the first of three to traverse on our epic 4-hour journey. Arriving back at St. Satur, we paddled through the third ancient bridge and then under the current bridge, a vastly more modern one, through the rapids and back to base. The 4-hour journey had been testing, Toni behind me navigating the shallows and rapids and the sun beating down. Thirsty doesn’t even come close, but we made it and ticked it off the bucket list.
The theme of week 4 determined itself. We started our wine journey in New Zealand, not when we lived there but after a bottle of pioneering, gooseberry cum blackcurrant leaf note driven Savvie in the UK in the mid-’90s. We visited Martinborough, to the east of Wellington and Hawkes Bay, but never Blenheim. Ironically we ended up living there for 5 years for professional reasons and ever since our wine knowledge has grown but also our opinions and behaviours towards it. Much of what we feel about it now stems from the environmental and ecological debates that rage regarding the use of herbicides and pesticides locally and their toxicity not only to humans but also to the good earth. Consideration also needs to be given to the prodigious consumption of water resources in the area too. Its sustainability seems in question when talking with exponents and detractors of modern winemaking. Will, the Marlborough plains of the Awatere, Wairau, and Whaihope be destined to be a dry, toxic wasteland long-term? It’s a concern that has partially influenced our decision to move westward to Nelson.
Back to France and the heat the first night in St. Satur. We decided to call our local friends Lynne and Philippe, resident 12 kilometres from our sweltering riverside cabin. We were welcomed with the wide-open loving arms of the Raimbault’s of Sury-en-Vaux. The village name literally translates to the “Sound of the Moo”. Generations of Philippe’s family have tended the land and vines, his father, born in September 1940, was celebrated not only by his family but the occupying local German Army. During the same war, their cave in Sancerre was a safe haven for downed allied aircrew and special operation executive members. The rich vein of cultural winemaking heritage runs deeply in many families and communities of the region. Sancerre sits south of the River Loire and covers approximately 3,000 hectares of vines with around 300 winemakers following the rigid Appellation Origine Controlle (AOC) guidelines that strictly determine the growing and production methods and processes of France at that quality level. Any deviation from that creed is closely scrutinized, and even the smallest of misdemeanours can be severely punished. To that extent, the art and craft of winemaking and vine growing have been culturally significant for many generations.
Philippe and Lynne are a unique, kind, and affable couple. Lynne is a “hard case,” and a “legend,” to us (and many more besides), a kind and compassionate London lady who meet Philippe in a bar in Sancerre many moon’s ago, and the rest, as they say, is history. Their vineyard is set in a little village on the fringes of Sancerre in a traditional small town. Philippe’s vineyard spans the region from Sancerre to Pouilly sur Loire, with small parcels of vines scattered throughout the area. We meet them some years ago when we stayed in Sancerre and keep in touch and meet up again from time to time.
This time I took the opportunity, despite the hot weather, to follow Philippe on a workplace journey at his cave just for an afternoon. Philippe and I just about understand each other in his version of my language and vice versa. We both drove off from their house several kilometres away to Domaine Philippe Raimbault, the Cave, the beating heart of his business and passion. Once there, I got the guided tour, from the destemming and de pipping machines of the harvest to the huge hectolitre chrome wine tanks and the cool cave where Burgundian barrels are stored for the fermentation and maturation of his red Pinot Noir. A lot of care goes into all of his winemaking processes. This day, the red wine seemed to require more attention as sulphur tablets were added to each barrel after samples were sent to the local laboratory for analysis. I questioned Philippe regarding this “addition.” His answer drew focus to the need to get to optimal levels of tannins and balance before bottling. The chemical also gives and antioxidant and antibacterial benefit to the wine and, ultimately, the wine lover.
Red wine, more so than white wine (the skins are kept on during fermentation), has been proven to be beneficial to health in moderation. The flavonoids, of which there are 4 groups, catechins, flavanols, anthocyanins, and tannins are the benefactors. Red wine also has 3 times the Riboflavin of white wine. Among the many benefits attributed to flavonoids are reduced risk of cancer, heart disease, dementia, and stroke. More than 100 studies have shown that moderate alcohol consumption is linked to a 25-40% reduction in the risk of heart disease. They work by corralling cell-damaging free radicals and metallic ions. Resveratrol, another antioxidant found in the grape skins, is linked to fighting inflammation and blood clotting and reducing heart disease and cancer.
We continued the day and traveled to Les Godons, the nearest vines to the centre of operation. He is a man of quiet passion, aware and alert to the health of his maturing wines and bottling production line, you’ll find his white Sancerre, Apud in Waitrose food stores, in England. A keen observer of the holistic and near organic approach to his art, Philippe, with friends, has designed and built wooden dwellings for the local bat population. Bats, far from being a menace, have many useful functions, looking at their droppings allows science to demonstrate the health of individual bat and colonies, as well as their insect food sources. They are positioned in a variety of areas, against trees that abut the vines and nearby buildings. He also has a bat radar that measures the type, number, and time they’re active. They play an essential role in reducing insect numbers, especially those which affect the grapes themselves. Also in use are insect pheromones at the end of each vine’s row, and a smelly organic odour spray is being tested soon too. This is part of an adaptation by Philippe in light of the changes to the climate which he is all too aware of. The pest challenges are a growing concern as the weather changes, the vines aren’t allowed to be watered, in accordance with the regulations, and the need to preserve the precious fruit crop dominates proceedings. The future appears uncertain but tradition must go on.
The whole theme continues with Philippe’s association with Terra Vitis, a growing environmental and social organisation dedicated to promoting a whole approach to winemaking. Not only is the health of the vine paramount but also the soil and, remarkably, the welfare of the staff too. Paperwork and compliance are other duties of the winemaker these days. Extra attention is also given to the choice of wooden barrels, not only the capacity, Bordeaux barrels store less the Burgundian, 225 litres to 228, but also the quality of the Oak. Philippe mindfully chooses them from specific areas of France where the porosity and permeability of the wood is less, allowing the wine to mature to its determined design and taste. This is used more so in red but also in white where the oaky, vanilla notes are desired. The traditional cork is still in use today too.
We both discussed each other’s work as we motored around the wine region, touching on the amount of sugar per litre of wine required for fermentation and achieving an ideal level of alcohol. Of the 200 grams per litre most, if not all, is consumed by the yeasts and left only is a residual amount of between 10 to 12 grams. From a dental perspective, attention needs to be focused not only on the remaining mainly fructose monosaccharides but also, and perhaps more importantly, regarding wine, its pH. Having worked for several years in the Marlborough region of New Zealand I’ve noticed the effects of a poor, modern industrial diet on many a client regarding caries but specifically with the wine industry regarding acid erosion and tooth surface loss, whether through abrasion, attrition or abfraction. Tooth enamel demineralises in pH values below 5.75 and far less with exposed weaker root structure of dentine. Over time with increased regular exposure, tooth structure can disease and be lost as well. Lower pH values intraorally also allow destructive bacteria to flourish and remove tooth mineral as well as reduce the numbers of beneficial germs that thrive in diversity in higher pH scenarios.
In New Zealand, the most prominent winemaking operation, Peter Yealands, recently approached me to create a protocol for their winemakers. The research was untaken, guidance produced, and products purchased ranging from electric toothbrushes to calcium phosphate-based toothpaste and sugar-free gum for each individual. Whitening trays were also created to allow the remineralisation of teeth to be more effective as the product stayed longer. I discuss this with Philippe, as he chomped merrily on sugar-free gum. The dental benefits of stimulated saliva flow with an increase in pH balance, an influx of minerals and ions from the saliva, and the promotion in balanced or higher pH of beneficial calcium “building” bacteria to remineralise the affected tooth structure. The sugar alcohol debate regarding Xylitol wasn’t broached this time. Touched on, however, was the use of calcium phosphate toothpaste with stannous and other fluoride types in adding their bioavailability to the teeth for further protection, desensitising and strengthening.
Both dental health professionals and winemakers have similar aims and goals, creating an end product that needs to be managed and maintained. We deal with bacteria, teeth, gums, bone and behaviours, the vigneron with weather, soil, fruit, yeasts, bacteria, and the seasons. Both deal with environmental pressures and ecology. Philippe’s work environment is the weather, the soil, and the vine married to the patient process of picking, gentle crushing of perfectly ripe grapes and fermenting wine, allowing nature, bacteria, yeasts, and time to capture the essence of Sancerre. Ironically too, The Romans had to deal with the land and the water. They carefully selected the right materials to support the bridges that allowed access to the wide French rivers they faced to control the environment, the natives, and their vast Empire. Those ancient wooden bridge supports remain as a testimony to the pressures of weather, water, sediment, and the river’s microbiome, over nearly 2,000 years, preserving them. Will Philippe’s progeny have to continue to contend with adverse climatic in the coming years? Will wine still be a feature of the Loire Valley landscape or will time make permanent changes to the industry like time and tide changed those ancient bridges over that mighty river?
Mark and Toni’s Learning Odyssey 2019. Champagne and onward to Wells, More Food for Thought, Family, Friends, Dental Updates, Cathedrals, and Cathedral Thinking.
It was a hard drive in intense heat to Champagne after finals with Lynne and Philippe. Early in the week, we decided not to attempt the long trek north early in the morning to get to Charles De Gaulle International and risk missing the onward flight. Our attention turned to Champagne’s staying with an old acquaintance in Mailly Champagne, a little village in the Grand Cru Blanc de Noir region south of the capital Reims. We’d visited it occasionally way back when and returning was a chance again, like in Sancerre, to catch up. One of the previous “flying” visits saw Toni and I drive south from Weybridge, UK to Mailly over a Friday afternoon in March 2009, on her birthday. We had booked into a local restaurant, Relais du Sillery, near to where we were staying. I had called ahead of time to Anni France Mailisart, the owner of the nearby bed and breakfast, to ask her to confirm with the restaurant the time and, more importantly, that it was Toni’s birthday.
Not only was the evening special, but Anni France hauled us rapidly into her 2cv6 van and raced us to the destination after we arrived, just in the nick of time. The meal and wine, a Mailly Champagne Grand Cru, was outstanding, but the total surprise came at dessert when unbeknownst to Toni, out came a birthday cake with fireworks exploding out of it. The whole restaurant stood up and burst into song. Happy birthday was sung with gusto in the way only the French can do. We felt touched and very welcomed and honoured.
Anni France Mallisart is a generous and hard-working individual, looking after a brand new Chambres D’Hotes that sits on her champagne cellar and press. We found her new place eventually, parked up, and welcomed renewed friendships. We had booked, once again, into Relais de Sillery and prepared for an evening out. We had looked at the online menu and decided, mainly due to cost but also out of nutritional intrigue, to select the Fricassée de Ris et Rognons de Veau aux Champignons. Pancreas, we think, and Kidneys, Wild Mushrooms and New Potatoes in an amazing rich and tasty jus.
Sweetbreads are in the offal group, and so are meats coming from organs rather than muscle tissue. Sweetbreads come from two organs, the thymus (sometimes called the throat sweetbread), an organ from the immune system, and the pancreas (sometimes called the stomach sweetbread), an organ from the digestive system. Usually, sweetbreads come from veal or lamb or occasionally young pigs, but veal sweetbreads are the most popular, due to their mild flavour and their creamy, velvety texture.
However, a bigger question, And one posed by our good friends Ralph and Hanna back at week 1, is not how it’s cooked and how much it costs but whether offal or organ meat is nutritious? In the past, organ meat considered more valuable than today. Hunter-gatherer and native Peoples valued it above muscle tissue, which was left to feed their animals. They also ate intestines, brains, and testicles. Vitamins A and B12, folate, iron, and protein are abundant in offal, aa well as anti-inflammatory Omega 3’s. The liver is particularly nutritious. Vitamin A comprises a group of organic compounds, including retinol, retinal, retinoic acid, and beta carotene. It plays a crucial role in eyesight, teeth and bone development, reproduction, and the immune system. Plants and microorganisms make their own Vitamin A, but we have to get it from our diet, animal food sources of the active form than plants. Cod liver oil is a particularly good source and has Vitamin D and various beneficial fatty acids too.
After recent discussions with aging parents and in-laws about their first food memories, during and after the War, a standard tread was being ritually forced, at school, to consume fresh full fat milk, apples, and, interestingly, cod or haddock liver oil. In my day, in the early ’70s, we were given just milk and apples, until Margaret Thatcher, health minister under Edward Heath withdrew it. She was nicknamed the Margaret “Milk Snatcher” by the press at the time.
A 3.5-ounce (100-gram) portion of cooked beef liver provides; RDI (Recommended Daily Intake)
Protein: 27 grams
Vitamin B12: 1,386% of the RDI
Copper: 730% of the RDI
Vitamin A: 522% of the RDI
Riboflavin: 201% of the RDI
Niacin: 87% of the RDI
Vitamin B6: 51% of the RDI
Selenium: 47% of the RDI
Zinc: 35% of the RDI
Iron: 34% of the RDI
Eating organ meats has several benefits: Excellent sources of iron: Meat contains heme iron, which is highly bioavailable, so the body better absorbs it than non-heme iron from plant foods. Keeps you fuller for longer: Many studies have shown that high-protein diets can reduce appetite and increase feelings of fullness. They may also promote weight loss by boosting your metabolic rate. Organ meats are a source of high-quality protein, which is essential for building and retaining muscle mass. Organ meats are among the World’s best sources of choline, a necessary nutrient for brain, muscle, and liver health. Cheaper cuts and reduced waste: Organ meats are not a popular cut of meat, so you can often get them at a more affordable price. Eating these parts of the animal also reduces food waste.
The drawbacks of overeating offal are minimal, but high levels of Vitamin A are not for pregnant women, and those suffering from gout don’t benefit from Purin, a dietary form of Uric Acid.
From a dental health perspective, Vitamins A, B6, and B12 have essential roles in preventing dental diseases. Deficiencies can result in enamel hypoplasia, xerostomia, gingivitis, gum disease. In children, a lack of B12 increases caries and gum disease risk. Again, vitamin B6 is associated with gum disease risk and anaemia related to sore tongue and burning sensations in the mouth. It may be appropriate from a dental health perspective to encourage moderate consumption of offal rich in A and B vitamins. Vitamin A may be particularly important in early facial development too. Vitamins A with vitamin D necessarily tell our cells to produce specific proteins – osteocalcin and MGP – Matrix Gla protein, a member of a family of vitamin-K2 – that help build and repair teeth and bones by taking calcium where it needs to go, among other things. But for the body to use these proteins, it has to call on vitamin K2 to activate them.
Back to the UK, after an eventful three weeks in France and onward to Burgess Hill, Sussex. Brighton was the venue for a Periocourses dental update I’d booked several months prior back in New Zealand. The course leader is a former RAF Dental periodontist of my personal acquaintance. We’d passed each other going from and to Saxa Vord, a radar outpost in the very north of the British Isles in the mid to late ’80s. Phil Ower is a dental legend, gentle, softly spoken, and very engaging. Recent changes to the classification of gum disease and a mindful reinterpretation of it by him and his colleagues that makes more practical sense to the coalface clinician, like myself.
The statistics for poor dental gum health are staggering. 98% of the UK have gingivitis, 10-15% of gum disease to the extent of losing their teeth. The primary culprit is the oral bacteria out of balance, which causes inflammation and alters the host response. In the oral microbiome, the collection of microorganisms in the mouth is sophisticated. They communicate chemically and electrically, are symbiotic, constructive, protective of themselves, and collaborative. Factors that affect host response include;
Type 2 Diabetes
Lifestyle behaviours – sleep, sedentary behaviour, depression and loneliness
80% of hard tissue damage (bone loss) is caused by how the body responds to the pathogenic oral flora. Learning outcomes to the course indicate a developing nutritional and lifestyle bend to diagnosis and treatment. These include the need to test periodontal cases for prediabetes and diabetes, and an HBA1C glycated haemoglobin blood test is required. A 3-day diet sheet might be appropriate, but I disagree with Phil regarding saturated fat, especially quality saturated fat. In my eyes, the culprits are both refined sugar and ultra and processed foods, being less nutritionally but more energy-dense and glycating inflammatory foods. Something to chew over on another occasion me thinks.
Two journeys and two days later, we arrived in Shepton Mallet, Somerset. We went via good friends Sue and Chris in Fareham and Dave and Rachel in Hampshire once again. The later will feature on a future post, their journey and influence on ours are immense. Shepton Mallet was our staging post for an extraordinary occasion. My Step – Mother Audrey, now living in Wells, Somerset, was celebrating her 80th birthday. She had recently moved from her home established with my late father to a retirement lodge. I’ve not always been on her wavelength, but recent years have seen me, in particular, change my position. I’m only human and had issues that needed correcting. I’m a better man for it, I feel. We discussed many things together, and I was particularly interested in learning about her early nutritional life journey. In the early stages of the Second World War, she was a young girl, evacuated with her twin sister Shirley to Dorset. It brought on many changes, dietary too. After the War and after the post rationing period, Audrey became the secretary to the head of Coca Cola Europe. Her stories regarding that and a stint as a rep for Birdseye span the nutritional changes that shape our current, unhealthy food environment. Little did we know or were allowed to know in those days. We enjoyed her fellowship and were delighted to see and be with her for her birthday and more besides.
Recently attended church sermons had taught lessons of atonement and redemption and the benefits of being forgiven, forgiveness, and behaviour change. Not being religious but believing in our spiritual connection with nature, I find organised religion an ongoing challenge. Things that bring us together should be greater than that which divides us. My philosophy, if it is one, is to treat all the way I want to be treated, compassion before reaction, forgiveness before judgment, and loving-kindness that dispels fear and promotes a fellowship of peace and harmony. That’s not to say the church doesn’t do good, it certainly does, but the physical building is a just like Mother Nature from the canopy of the ancient elder forests. We aren’t separate, and we all together in fellowship with each other and everything around us. When we do things wrong, we need the courage to accept it, make changes to ensure it doesn’t happen again and offer our apologies before moving on.
Wells Cathedral is immense, but at the same time, simple. The Yew Tree in the centre of the land acts as a natural nucleus apart from its pagan origins. The imposing building houses one the oldest clocks in the World, a stripped-back interior compared to the less austere Winchester Cathedral. Outside in the nearby market square is a twice-weekly market. Nothing compared to Provence and The Dordogne for sure, it seems that Britain doesn’t embrace its deep food history sadly. Despite its paucity, Wells Market, the unlikely scenery for the “Hot Fuzz“ movie, presented some treasures. The Bagnell Farm stall had rare breed meat from their Ruby Red cattle, Jacob sheep, and Iron age pigs. Others had local cheeses, colourful vegetables and a variety of pies and pasties. It’s comparison to the ethereal markets of the Dordogne, Provence and the Loire is unfair and unintended, my Step -Mother swears by it and that, as they say, is good enough for me.
On a completely different spiritual level and something that ultimately affects us all, young or old, even rich or poor, is climate change. The deniers, the rich and powerful, those with scientific and critical minds or those blissfully unaware of the catastrophe that is predicted to befall us need to wake up. Let’s not deny, obfuscate, or ignore any longer that which will soon be upon us and generations to come. We have a climate crisis. Its torch has recently been taken up from the most obscure and determined individuals and is virally spreading through global culture through real activism. Thunberg, a young Danish “agent provocateur”, said of the disaster that recently befell Paris, that “Notre Dame will be rebuilt, I hope its foundations are strong, I hope that our foundations are even stronger, but I fear they are not.” She points the finger at World leaders “If our house were falling apart, our leaders wouldn’t go on like the way they do today (in tackling climate change). You would change everything you do.” She listed how humans were causing “climate economic breakdown,” such as deforestation, air pollution, the extinction of animals, and the ocean’s acidification. Accusing world leaders of being too relaxed in tackling climate change, she said that she wants leaders to panic, evoking an image of a house on fire, comparing the Notre Dame event to the climate emergency. Spiritual change may be considered optional, but environmentally, sustainably, and climatically the situation is far from a lottery. That may be the biggest challenge to us on our return to New Zealand. Extinct Rebellion might become the activism we find occurring in our everyday home and workplace environments.
On a less sombre note and one that I’m proud to say I have a certain degree of genetic association with is The Litton, a destination pub, a place people travel to and stay and use as a base for visiting local sites and attractions. The likes of certain 80’s pop heroes and International artists going to play at Glastonbury nearby are regular visitors. It was once a ruin until a certain Sally Billington, my cousin, had a moment of madness and decided on a whim to act. It is a passion project like no other. Sally’s eye for originality and retaining its former glory is voiced by her mission statement, “Traditionally Untraditional.” She has an indoor and outdoor restaurant, a bar selling local craft beers and a whiskey bar dating back pre-Sally times and some. Renovation and resurrection leach out of every seam. Attention to tradition morphs into the food philosophy too, locally sourced and seasonal dishes are available to those wanting something homely and comforting. Audrey, Toni, and I opted for Sunday Roasts, mine, and Roast Beef was very hearty and generous. It filled me but not quite enough for a Sticky Toffee Pudding to top off the occasion. Sally afforded precious moments to catch up with many years of lost opportunities to be as we once were back in the early to mid-seventies. A guided tour followed, and parting was, as the immortal bard would have it as “such sweet sorrow.”
Sally taught me a few things that day at her Litton. It has taken her years of dedicated effort, frustration, and delight, moments of despair, but also of great joy and meaning. She manages dozens of staff, pays them well, has programmes that support their welfare and development, and like Philippe in Sancerre, and has a hands-on and very present approach at work. She is frank and sincere and is aware of the need to continue improving through feedback from customers and is super proactive and direct when need be. She’s modest too, not displaying her awards and gongs too obviously. I’d, for one, would love to work for her. Please call Toni and me whenever you want Sally, we’d be straight over.
Mark and Toni’s Learning Odyssey 2019: Highland Flings, Foraging, Family, Healthy Walking, and Organic Small Holding.
Our next destination, Scotland, awaits. We drop by Sainsbury’s, Woking, in the hope of surprising my sister Melanie, we were in luck, and the surprise was complete. It was great to see her. Ironically in the same aisle was Carol, a friend of our daughter, Naomi, from her college days in Woking, spooky? She grabbed us and ask to pass her best onto Naomi.
The arrival in Balmoral, at Toni’s parents, was dramatic. Police guarded the entrance to their road, The Queen was in residence in a nearby cottage, and security looked tight. We stayed with Mike and Pauline, Toni’s parents, they were very generous and accommodating.
The weather in and around Balmoral is a microclimate, we’re told to ignore the national weather forecast as those rules don’t apply. They were right, the promised daily rain for a week never appeared until the last day.
“As dew upon the tender herb
diffusing fragrance round;
as showers that usher in the spring
that cheer the thirsty ground.”
Let us come to the Lord our God, John Morison 1749-98
The tiny church at the Parish of Braemar and Crathie near Ballater is the venue for the Sunday morning service for Toni’s parents. The hymns came thick and fast. The sermon focused on forgiveness, community, and wisdom. The best moment for me was the above verse of a hymn sung by the small congregation. It’s author, John Morison, was born in Aberdeenshire in 1749 and became a Parish Minister in Caithness. His hymn spoke volumes to me about our visit to Scotland, it’s wild nature and beauty. The words describe a connection between the seen world, it’s mystery, seasonality, climate, and the importance of the earth.
Walking along the now disused Deeside Railway, the hidden basket of nature reveals itself to those who are tuned into and aware of its seasonal secrets. The line once ran from Aberdeen to Banchory and then was extended further to Aboyne. Further extensions took the line onward to Ballater by 1866. 99 years later, the last train left Ballater with the Queen in attendance. Time and technology wait for no-one. Mother nature reclaimed the unattended tracks, and, in time, a cycle and walking route was created and is beautifully maintained. Along the trail we walked, we find a plethora of nutritious wild foods from nuts, berries, and mushrooms. I’m not suggesting that this gig is for everyone. We all live busy lives and time to connect with each other in the hue and cry of everyday life is as absent as our awareness of what physically sustains us.
A recent report by the Ramblers and McMillian Cancer Support details the health benefits of the humble walk stating it could also lead to nearly 300,000 fewer cases of type 2 diabetes. In some cases, walking can be more effective than running. Scientists at the Lawrence Berkeley National Laboratory in California found that brisk walking reduces the risk of heart disease more effectively than running. They observed participants aged between 18 and 80 over six years and found that walking reduced the risk of heart disease by 9.3% while running reduced it by just 4.5%. Additionally, 30 minutes of brisk walking over five days could help you sleep easy, according to research by Oregon State University. A study by the university showed that walking helped participants sleep better and feel more alert during the day.
The first rule of exercise always engages your core muscles. This is particularly important in walking because you are upright the whole time and supporting your entire body weight. So tighten your stomach muscles. The best way to do this is to make sure you are not slouching when you walk. Spinal alignment is part of this core strength. You should stand up straight, trying not to lean too far forward or backward with your chin parallel to the ground.
Once you’ve mastered the 30 minutes of exercise per day, changing your walking route is a great way to keep motivated. Walk up hills for a great glute workout. Or if you are exercising in a gym, increase the incline for a similar effect. Walking uphill uses more energy than walking along flat surfaces.
Walking is also a great way to connect with nature. Such green exercise, research by the Essex University observed the benefits of walking in green space, finding that it reduces stress levels, improves mood, enhances psychological wellbeing, and improves attention and concentration. Walking also helps the planet. By parking the car up and walking instead, you help to reduce air pollution. This is particularly important for short journeys. Taking the car for short trips uses almost twice the CO2 per mile. So leaving the car keys at home helps you and the environment. Recently the Woodland Trust suggested that forest bathing, which doesn’t, despite its name, involves getting in the water but should be among a range of non-medical therapies and activities recommended by GPs’ surgeries to boost patients’ well – being.
“Forest bathing is an opportunity for people to take time out, slow down, and connect with nature. We think it could be part of the mix of activities for social prescription,” Stuart Dainton of the Woodland Trust states. “Evidence about its benefits is building. So-called “Social prescribing” is a growing movement in the NHS, which can include volunteering, gardening, sports activities, cookery, and befriending. Gary Evans, who set up the Forest Bathing Institute in the UK last year, said, “People initially think they’ve been doing this all their lives, going for a walk in the woods. But it might be a brisk walk, or you might be worrying about where the dog has got to!
One UK study, carried out by King’s College London and published in January 2018, found that exposure to trees, the sky, and birdsong in cities improved mental wellbeing. The benefits were still evident several hours after the exposure. “Even just 20 minutes can help, though 10 hours a month is even better,” said Dainton. “If you live in a city, you may not be able to get to a forest easily, but taking off your shoes in the park and feeling the grass will help you de-stress.” Healthcare professionals, politicians, and charities alike should encourage these physical behaviour changes.
Foraging for me, incorporates meaningful movement, attention to and focus on the seasons, the weather, and the mental acuity and awareness in observing and identifying wild food. Mushrooms are fungi, biologically distinct from plant and animal-derived foods, and the nutrients they provide have a unique profile. Edible mushrooms, when exposed to UV light, creates within itself vitamin D2. These fungi, informally known as “white vegetables,” are being researched for their immune function and anticancer effects. Still, more research is being done to understand their additional unique nutritional properties currently unknown.
The Chanterelle is found singularly or scattered in groups or clusters in woods. They are loaded with iron, copper, vitamins D, B3, and 5. Raspberries, bilberries, strawberries, blueberry, and red berries are packed with antioxidants, high in soluble fibre, nutrient-dense, rich in vitamin C, and K1, copper, manganese, and folate. Many more benefits abide with berry fruit, but furthermore involved with foraging is the exercise, exposure to sunshine and fresh air, a sense of purpose and connection to the seasons and nature. It is obvious to state that when gathering wild foods, have an expert along for the ride or identify them yourself from written or online guides. Identification is essential, if in doubt leave it out.
The annual gathering of the Aboyne Highland Games immediately grabbed our attention. We turned up with no idea of what to expect, aside from the traditional highland game themes of hammer and caber tossing to highland dancing, pipes and drums, and a lot of tartan. I was particularly interested in the pipes and drums as a friend back in Blenheim recently asked me to join her pipe and drum outfit as a drummer. I was at first surprised by her offer, I might take her up on it. I was thrilled to hear the Aboyne and district associations’ massed bands and a few days later at Balmoral, the Pipes and Drums of the Royal Highland Regiment. Amazing experiences both. The Highlands’ rich culture goes back to the Clans, the tribal nature of governance way back when. The historic tartan clan colours, the heritage of individual Clans, pride and passion, the importance of competition, and community were very apparent. Community is something Toni and I are aware we lack. It is our own fault, I suppose, we’ve not afforded enough time to its importance. We need to address this to find our community, like-minded and gentle, kind, and nurturing people and purposes. It’s a work in progress on our return.
We journeyed north to Forres, through Whiskey territory, to catch up on our past. We once lived in Elgin, on the Moray Firth, back in my RAF days, just two boys, Arran and Dale, and us as young and intrepid parents. In fact, our current journey, living in New Zealand, began in 1993 when we first traveled to Australasia. This time we stayed just outside of Elgin, at Wester Lawrenceton, on an organic farm, come smallholding, for one night. Extreme weather, a massive deluge of rain, unheard of for decades, had nearly washed away the gravel drive away at the farm stay. The hosts, Pam and Nick, were seasoned veterans of the smallholding and cheese makers originally from Devon, now in the Highlands of Scotland as sustainable, organic, and local food scene suppliers. Their smallholding farms 5 acres, 300 chickens, 2 polytunnels, a small greenhouse, an orchard, and goats.
Pam revealed a lesser-known, but a historically significant organisation called the McCarrison Society. Their slogan, “health through nutrition, a birthright,” demonstrates their stated aspirations of assembling scientific knowledge on nutrition and health. They aim to educate and foster discussion through blogs and chat forums, and create a free access library, education, and videos for schools. They also want to encourage dialogue between the food industry, the medical profession, and government, especially in terms of bringing attention to the issues of food and the broader impact of things such as soil, human waste, and ocean acidification. Many thanks to both Nick and Pam, two very connected people, trying their best to respect and utilise the soil sustainably and holistically.
Mark and Ton’s Learning Odyssey 2019. High as a kite in High Wycombe, Buckinghamshire, Weed and feed in Portland, Oregon and Social Agriculture in Boulder, Colorado. The lost last post.
This is a replacement post, the original was last in a past edit, after it was originally published. I had thought it unnecessary to replace, but upon reflection the experience, of nearly a fortnight, was too good to ignore. I have decided to write a updated version, looking back upon it a year later in order to better understand it’s true meaning in the light of recent events and the next month or so in New Zealand. This mysterious and cryptic first paragraph will hopefully set the scene for a revealing reflection.
High Wycombe is a busy place. The air is filled with planes approaching London and birds of prey, in this case Kites, huge birds of prey slowly circling high above homes looking for fresh food, as if they too were waiting for clearance to land. We caught the bus from Heathrow, after flying from Aberdeen south. The motorways were jammed packed with traffic and the sense of the nature we’d experienced in the Highlands felt very distant. We were met by Mark, our friend from our Cyprus days and were soon in the heart of our extended family. Rose, Mark’s partner is a great source of professional knowledge regarding infection control but had recently been seconded to the department of the UK Nursing Council responsible for sustainability. She was very insistent about what the future held for civilisation if we weren’t able to sustain change in healthcare practice, let alone the world. She had spent many years concerned about pandemic responses, having been involved with the UK involvement in the Ebola outbreak in Africa and promoting awareness of MRSA and antibiotic resistance historically. Rose was emphatic about the need to consider even the smallest of behaviour changes in our clinical settings, in particular the journey of the surgical glove in terms of production, transportation and its carbon footprint.
“I don’t want your hope, I don’t want you to be hopeful, I want you to panic, and act as if your house is on fire”. Greta Thunberg
This and many other things gave me more food for thought. I hadn’t expected the degree of concern she felt and this was a broadside across my bow making me reflect upon my future practice at Quin on my imminent return to New Zealand. In fact it made me immediately more aware of the glove use in general, on airplanes by cabin crew and at border control and customs points at airports. I was stunned and surprised to see how much they were used. This was just the tip of the iceberg as COVID 19 came rolling into town a few months later. All the effort I had gone through to address this concern in my practice paled into insignificance as we tried to make sense of this threat, adapt personal and clinical hygiene methods to meet it and prevent its community spread. The amount of additional clinical waste we are generating is frightening, the gowns, masks and gloves being consumed in vast quantities but also the degree to which the public are now using masks and gloves as well is phenomenal. It’s as if we’ve conveniently forgotten about the planet and are ignoring the consequences. I hope I’m wrong but I can remember my headspace, at the beginning of March shifting from preparing a sustainability presentation at work to urging my boss to change the subject matter to preparing for COVID clinically. Many things were expediently ignored.
We landed in Portland after a long journey via a less than desirable LAX arrival and overnight stay. After collecting our luggage we headed into the city and to our booked residence. We immediately felt the gears drop, the sense that the pace of life and even its intent had changed. The train from the airport to town on the MAX light railway was fun and cheap. Nothing like any airport we’d experienced on the trip to date. Portland was the venue for an occasion to explore an urban farm, or so we thought. It is also a city famed for craft beer, café culture and a liberal nature which allows, legally, the consumption of cannabis in a variety of forms. We set out to explore this experience as the next election in New Zealand will have a vote on it. Both legalisation of euthanasia and recreational cannabis is being engaged in a national referendum as part of the general election in September 2020. Canada, Uruguay, Portugal, Holland, and other countries have seen a benefit to creating greater regulation of weed, for safety and cultural reasons. Opposition to it is strong but before one can judge its merits or disadvantages one should choose to experience it in a controlled and measured way, before casting a vote or expressing an opinion.
Our arrival at “Oasis of Change” was late, as we’d misjudged the time required to walk the several miles across town. We arrived greeted with open arms and with bowls to go pick our lunch from the produce growing on their urban farm. It is literally in derelict space next door to an “under construction” purpose built holistic medical practice. We had caught it in its infancy and the place was pretty chaotic but the purpose of it appealed to my view of seeing the body as a whole. The intent of this urban farm was to demonstrate community, nutrition and engaging with growing food in urban spaces. The menu was mainly vegetarian, mushroom and leaves, including marijuana, but other dishes had protien too. It was an experience we hadn’t anticipated but had a great time and learned a lot about an alternative approach to eating and healing.
“Let food by thy medicine and medicine by thy food.” Hippocrates
Visiting a bud store is something else. The one we found was situated next to a Lutheran church. The whole place looked professional, clean and well presented. The bud tenders, for that is their professional title, are very knowledgeable and not at all “pushy”. They seem to be very aware, also, of the responsibility of the health and safety aspects of their products but also the need to be certain of the legal ages and credentials of those who turn up intending to buy. We had to show ID. This bodes well for any changes to the law in New Zealand if they adopt a similar approach to cannabis reform. Interestingly we met many older people buying their products for whatever they intended to use them for. This is a freedom we presently hide secretively from each other and indulge in illicitly here. We tried a variety of products and weren’t in the slightest bit concerned about a negative influence, especially compared to alcohol, even sugar. There must be regulation and control however, especially with strong emphasis on drug driving education and prevention.
From Portland we flew to Denver, driving onward to Boulder and Estes Park in the Rocky Mountains. We landed on a Saturday and slept over en route to Boulder. The Sunday market there was in full swing. The onus was definitely orientated towards health and well -being. Alternative therapeutics and physical therapies prevailed along the path that snaked through the park in the centre of town. Boulder had recently decriminalised the use of magic mushrooms AKA Psilocybin, a possible topic for future inclusion. None, however, were present here today. Despite this an array of CBD oils, tinctures and balm were available to trial or buy. Not having much knowledge of cannabidiol it presented an opportunity to find out more about it. It can be used in the treatment of anxiety, pain, movement disorders and cognition and can be up taken in the body by smoke, vapour, aerosol spray or by mouth. CDB one of 113 compounds in cannabis and can be used with tetrahydrocannabinol (THC) or terpenes or alone after being extracted. These are the psychoactive compounds that are so contentious. CDB has a non – toxic effect on the body and is the subject of much research having been successfully used in epilepsy treatment. Toni, who suffers from chronic hip pain whilst awaiting approval to have a replacement operation in New Zealand compared the medical grade CDB allowed for medicinal use in New Zealand once we returned. It proved to be less potent, especially without the THC to help boost its effects, than the products she trialled in the States during our brief stay. We both hope the referendum allows the combination of both CDB and THC to be used in a measured doses and be regulated to offer the public both a quality product and the best advice in its use. I’m certain there will be strong opposite to its introduction by lobbyists and pressure groups who fear the whole country will become stoners or their businesses will suffer as a consequence. This is not the impression we got from our empirical journey, rather the opposite in fact.
The Cannabis Legalisation and Control Bill will be voted on by the population of New Zealand on the 19th September, now a month later due to COVID. Its aim is to reduce harm, legalise the age of purchase and regulate the amount accessible per day. Products will have health warnings on them, just like cigarettes and alcohol, descriptions of dosage and potency. Advertising and marketing will be controlled strictly or denied as will its use in open public spaces. Growing it at home will be limited to 2 plants per person at any time and a maximum of 4 per household. A regulatory authority will enforce strict rules for licenses and tax revenue taken from sales.
“Herb is the healing of a nation, alcohol its destruction.” Bob Marley
We were also attracted to the concept, completely new to us, of community supported agriculture. This form of food supply appeals to the inner Frenchman in me. Essentially a collaborative and cooperative effort born of an organic and sustainable, regenerative too, approaches and practice to growing food. We travelled out of Boulder to the flat countryside to meet up with such operations. They survive by supplying markets both in towns for the population but also have boxes of foods going out to the community through online sales. Those in receipt sign up for membership and get discounts and a certain amount delivered according to what they choose to sign up to. Prospective purchases can also be made onsite as can exchanges of vegetables from their own garden for other foods. On our return we met other like – minded people from the States who have brought the same ideas to Motueka, just north of where we live in Nelson. It also inspired us to place more value on our own vegetable growing efforts and where we have surplus exchange for other things or gift to those who haven’t what we have.
We left Colorado for San Fransisco and the long journey home. We enjoyed our times in High Wycombe, Portland and Boulder, satisfied that what we had experienced was food for thought and had been a very nourishing adventure. The last 12 months, since our return has enforced the lessons and experiences gained from that time. COVID has highlighted the need to adapt and think outside the box when growing food, the use of CBD and THC products will, we hope, be legalised to allow those in chronic pain the ability to manage their own analgesia with support and advice from skilled staff at shops or outlets. The big elephant in the room however is the vast amounts of waste created through tackling COVID, this I’m uncertain will be addressed in the immediate future but awareness that fighting COVID has come at not just a human cost but its environmental price too should not be forgotten too.
Mark and Toni’s 2019 Learning Odyssey. A Final Reflection, Future Planning, and a Greater Purpose.
The best-laid plans of mice and men often go awry. No matter how carefully a project is planned, something may still go wrong with it Robert Burns, To a mouse.
This quote from Robbie Burns clearly sums up the lessons learned while on our odyssey. Expect the unexpected also rings an accord. The plan was hatched nearly a year ago. Its embryonic nature began with just a single flight back to the UK, possibly working again in the UK in mind. The thought of re-registration and working in a Brexit uncertain UK rapidly made us think twice as to the wisdom of such a venture. We extended the trip and decided to build it into multiple weeks of learning. The home and job move from Blenheim to Nelson made the opportunity even more logical, and the hiatus between them was ideal.
We traveled from Nelson via LA to the UK, from there onward to the Mediterranean, Central France, and Champagne. The UK leg saw us visit Brighton, Fareham, Shepton Mallet, Wells, Scotland, and High Wycombe. The US leg saw us in Portland, Colorado, and San Francisco. Along the way, we drove, flew, trained, and bused to varying locations that marked our discovery and learning path. We were very fortunate to have the assistance and collaborative support of so many amazing friends along the way. Our gratitude and thanks go to Deb, Pat and Isa, Hanna and Ralph, Dave and Rachel, Lynne and Philippe, Anni-France, Andy, Sue and Chris, Audrey, Sally, Tracey and Neil, Mike and Pauline, Mark and Rose, Dan and Carola and Jack and Peggy. Their kindness and time afforded to us made it all possible.
The trip went as planned, not much to this point has gone wrong. The most reliable, most lasting impression I have of the venture is of the environment, climate change, and sustainability. Ironic and a tad dark of me considering the carbon footprint that trails behind us. “That Humbleman” Ollie Langridge we found in the early days of his 100-day climate change protest outside the Bee Hive Parliament Building as we made our way from Wellington to Auckland. His message through social media has been following us along the way. His determination to persist and engage with the public and politicians for a cause greater than himself is inspiring. His demonstration and advocacy continues.
The link to the environment, sustainability, food waste, climate change is becoming more apparent to many around the World. Talking to beekeepers, winemakers, healthcare professionals, and farmers on this trip has made me consider my own position. It may not affect me in my life significantly, but for my children and their children, too, I am deeply concerned. Can we affect change in our professional lives to undo, halt, and prevent further environmental catastrophe? Our plan is to join the Green Party of New Zealand and become more active within it, look intently at our work and home place behaviours, and encourage change. We have downsized to one car, walking and cycling will very much continue to be part of our life.
With environmental considerations comes the question of what nutritional behaviours we adopt. In the 8 weeks of this trip has come to the news that we allegedly need to eat less red meat, the Brazilian Rain forests are being destroyed by fire to clear land for grazing and pasture to feed animals as our global dietary change. Do we need to eat less? Do we need to eat to need rather than eat to greed? Do we need to eat less meat and more plant-based foods? What evidence is there for such dietary changes? Is saturated fat bad? The best way forward I feel is to gain more knowledge on these matters.
We both had the intention to be more sociable. We have spent many years really just getting on with our lives without association to a more significant cause or community. The search for community, for more meaningful use of our time, we hope has been joined with the need to support the worlds struggling bee colonies and those supporting food education and growing food. I’m hoping it will keep us rooted in the land, make us think more than once or twice about going away frequently to find purpose away from where we live.
Clinically things are about to change for both of us, more so for me, I suspect. Working for Gerry at Quinn Dental, Nelson will be a professional journey into a higher professional purpose. The need to determine how I fit into this dynamic and progression clinical scene will be a challenge. My initial thoughts were to follow the oral myofacial therapy and Buteyko breathing study route. The practice, however, already has clinicians working in these fields, so I feel a working knowledge is essential only presently. I’m more inclined to think a greater understanding of lifestyle and nutritional change regarding dental and metabolic health improvement are crucial. My learning journey begins there.
From April 2021, to gain recertification as a Dental Hygienist, I am required to create a Professional Developmental Plan (PDP) that lays out my learning and developmental aims and goals for my regulatory board. It, the New Zealand Dental Council (NZDC) has changed the criteria for Dental Healthcare Professionals (DHP) in line with many other regulatory organisations to add depth and quality to continuing professional development (CPD), involve the learner in educational attainment work directed towards their workplace culture and environment. In addition to these a Professional Peer (PP) will be required to act as a mentor, advocate and overseer of this process combined with a personal written reflective practice of Professional Development Activities (PDA). The process of that is demonstrated in figure 1.
Fig 1. GDC UK reflective cycle for PDA’s
In this account I wish to look backward on the previous year, starting April 2019, as the beginning of the new cycle, as the initiation of my PDP. Then account for the learning undertake from then to the present and consider the current situation with COVID 19 disrupting clinical practice for non-essential care. This is also, paradoxically, a great opportunity to consider where you presently are professionally and where you feel you want or need to go in planning you learning journey. Historically I had created a PDP and record on it my PDA when I was studying at The University of Kent several years ago. It is something I lost touch with coming to New Zealand in 2013 but having prior knowledge of it has led me back to my archives to dust off the means of recreating them.
I hope It will indicate where I have been and will go with my learning journey, a part of which is completed, another disrupted and future activities I propose based upon the consequences of world and local events and changes of practice setting and culture.
When choosing goals I look at the NZDC standards framework guidance, feedback from clients and colleagues, appraisals from employers and management. Give consideration to non-clinical aspects of practice too, leadership, communication, research and teaching skills may form ideas for learning objectives. Prioritise, if possible, your goals in order of importance or in a time line (authors note). The various methods of achieving learning objectives include conferences be they regional, national or international, the setting whether online learning or workplace training or shadowing. You could also create your own learning journey, focused on your needs where they can’t be met more formally. Authentic learning and action research, similar to inquiry learning can offer self-directed alternative approaches to new claims to knowledge and more meaningful first personal development in addition to convention education.
Fig 2. PDP log
My practice culture and status over the last year has changed, from a general dental practice setting to a mixed but mainly orthotropic – arch expansion – orthodontic setting with 3 orthodontic auxiliaries, 1 dentist, 3 Dental Assistants, a Manager and Receptionist. The COVID crisis has seen the practice shed a dentist and Dental Assistant. The move from Blenheim to Nelson has seen a role shift into a new dimension of dental hygiene with a greater onus on a strict regime of infection control, being less liberal than the previous practice by some margin. My learning goal became one of catching up. Prior to starting work in my present location, as can been in figure 1, I was engaged in an epic 9 week overseas sabbatical, see “experimental Learning 19” menu and a reflections related to it.
I constructed a way to present it through a website portal. I used WordPress to create a website that could additionally support the goal setting, evidence gathering and writing. Getting the right themes and menus has been a challenge, the intricacies of knowing how to create pages and posts, how to tag and edit, insert pictures and keep up with new ideas and technical challenges has been rewarding and, at times, a little stressful. Potentially It could be a good device for colleagues to adopt if so inclined as a simple way to demonstrate compliance, development and transparency. Below are two links, created by the same person on how to go about creating one.
It was my intention to develop my role in my current practice by travelling to Melbourne to complete a course in Oral Myofacial Function so I could evolve my practice and create my clinical time. This was cancelled due to the COVID 19 crisis and there appears to be little future prospect of undertaking it in the foreseeable future and, in effect, it is on hold. I am presently considering how I move forward with my PDA goals and have come to the conclusion that writing about topics that interest me, that are linked to my workplace and the future recertification process can take precedence for now. My colleagues have advised me on CPD topics related to orthotropics and oral myofacial function but I’ve decided to engage those when the current Alert state reduces and I have the inevitable clinical white space at work. The opportunity to focus on professional writing has been extremely rare, until now. Below are two links to those subjects which will be added to the PDP shortly with a duel reflection and discussion with my professional peer.
During my first few months in Nelson I began to realise, very quickly, that many of my clients were fairly “alternative” and investigative in their approach to subjects like fluoride and nutrition. There were also a cohort of clients interested in environmental issues and sustainability. This made me consider my approach to that as well. In comparison to Blenheim cliental where I continued to work as a locum for two days of the week, this posed a living paradoxical challenge. The contrast between the two client bases was stark both in terms of their dental knowledge and expectations of the nature of my delivery of care which make me reflect. One I was cosy with, having worked there for several years and the other new. I had to move deeper into researching and investigating their positions on it, enquiring as to the nature of their research undertaken which, on many occasions was diametrically opposed to my own indoctrination, experiences and beliefs. I was curious and willing to listen, to understand without judgement and I was careful to recognise and affirm other people’s positions, and offer tailored alternative advice or options, especially regarding topics like nutrition and fluoride.
Moving forward, we still await the proposed changes to recertification to be officially confirmed. The NZDC response to the COVID crisis has allowed the professional to breathe a sigh of relief regarding compliance to the strict verifiable CPD hours. This allows an opportunity for all to reflect on the PDA and future educational goals with the time created by the lockdown. This is exactly what I’m doing, I have a project, begun last year to complete, I can continue on the theme of changing practices and direction within the new one, displayed via a website online for the sake of transparency. It also demonstrates my learning journey for others to view and to comment on and promotes my passion for self-directed, appropriate and authentic learning as a juxta-position to the norm.
“Come forth into the light of things, let nature be your teacher”.
William Wordsworth (7 April 1770 – 23 April 1850) was a major English Romantic poet who, with Samuel Taylor Coleridge, helped to launch the Romantic Age in English literature with the 1798 joint publication Lyrical Ballads.
Yes, Bears do. (Can't speak for the Pope though.)
Navigating the evolving and shifting learning landscape of professional and personal development aligned to my dental health journey
Brewing techniques, beer and the ins and outs of running a small brewery in Northland NZ.
Pinot in all its glory, cool Kiwi craft beer plus shitz and giggles of course.
In the beginner’s mind there are many possibilities, but in the experts there are few – Shunryu Suzuki
Understanding how to be the best you can be. Professor Grant Schofield.
a wine blog
Conversations to take learning forward
History never really says "goodbye", it instead says "see you later".
The Land, It's People and their Wine
Abiding in a life rich in experiences from the leafy down lands of Surrey to the warmer climbs of Nelson