"Nutrition For All Ages"
A Personal Perspective
The following articles were first published in the University of Toronto Dental Journal Volume 11, Numbers 1 & 2 in December 1998. They are a reflection on the more than 30 years that have passed since I was a first year dental student at the Faculty of Dentistry in the Class of 7T2. They reflect my personal views and opinions on why I think dentistry has the potential to be the prime “health” care profession of the new millennium.
DENTAL PRACTICE IN THE EARLY 1970s
||JOURNEY TO THE EAST|
||DIET AND ORAL HEALTH|
||ORAL HEALTH EVALUATION||
||NUTRITION IN DENTISTRY||
||DISEASE AND HEALTH||
DENTISTRY AND ITS REMARKABLE SUCCESS
1 EARLY MEMORIES:
My father was my dentist, so there was no escape. Back in the 1950s, just about everyone I grew up with had cavities that needed filling. My earliest memories of his dental office involve the antiseptic smell of eugenol (oil of cloves), the use of a slow belt-driven handpiece with a large #2 round burr, with no anaesthetic or freezing for fillings. It made quite a painful impression on me at a very early age. With that experience, came the desire to learn how to stay our of his dental office for anything other than healthy checkups. I admired my father’s dedication to his patients, and the high level of respect he received for it in the community. When I followed his footsteps into dental school, I brought with me a deep-seated interest in preventive dentistry.
When my father graduated from dental school in the Class of 2T7, dental disease was rampant. Disfigurement and death from an abscessed maxillary first molar was not at all uncommon before the discovery of penicillin. So many people required extractions and dentures, that loss of teeth was actually considered a natural part of the aging process.
From a 1920's perspective, organized dentistry was born out of necessity. It was the result of the need for safe medical intervention in a potentially life threatening disease process that was not clearly understood at that time. The central focus was on the diagnosis of dental caries (tooth decay) and related infections. The most predictable treatment was exodontia (tooth extraction). If you are unable to eliminate the cause of a problem, then you eliminate the things involved in the problem. The philosophy was based on the fact, that a hook is better than a badly infected hand, and dentures are better than a badly infected mouth. It was true in 1927, and it is still true today.
Times have changed. Dental caries is not longer a major life threatening problem. The focus has shifted to periodontal disease. When it comes to information on dental research and technology, the dentists of today have a tremendous advantage over the dentists of my father’s era. Not only are there a far more extensive dental faculty libraries, there is the capability of Medline searches and Internet access to dental faculties everywhere. There is a profusion of journal articles, case histories, dissertations, and evidence-based studies, on every aspect of dental practice, from AAC (Actinobacillus Actinomycetems Comitans - type of bacteria) and its role in periodontal disease to ZZZs and the prevention of snoring.
And yet we are still tightly focused on teeth and their supporting structures. There is a risk to a myopic (near sighted) view that makes it difficult to see the forest for the trees (or rather the patient for their teeth). Sometimes we tend to forget that the mouth is connected to the rest of the human body, and that there are important diagnostic links between dental health, and general or systemic health. Obviously, if you do not have dental health, you are not healthy, but, if dental health plays a role in the definition of overall health, then general health also must play a role in the definition of dental health.
Vitamin deficiency and toxicity syndromes have clinically apparent oral manifestations, as do the immunocompetency (ability to resist infection) problems related to A.I.D.S., diabetes, hepatitis, and allergic or autoimmune response. Conversely, common oral bacteria have been implicated in geriatric pneumonia, and bi-products of anaerobic (without oxygen) periodontal pathogens (exotoxins) have been implicated in coronary artery disease and bacterial endocarditis.
This is why, of all the subjects in the dental school curriculum, oral diagnosis is the most challenging and has the greatest potential. In my opinion, a comprehensive diagnosis is by far the most valuable service offered by a health professional to a patient. It is the cornerstone of consultation, patient education, treatment planning, prevention and cure of disease. In dentistry, it involves the mouth, which is the gateway to the human body, and the most easily accessible diagnostic window on internal health. Oral diagnosis also became my favourite subject in dental school and I received the Hugh Alexander Hoskin Award for the Highest Standing in Oral Diagnosis from the University of Toronto in 1972.
2 ORAL DIAGNOSIS:
The most fascinating thing about oral diagnosis, is that it can be like solving a Sherlock Holmes detective mystery. The evidence of disease is obvious, but the clues to the actual causes are so subtle, that they may be easily overlooked. Patient X presents, suffering from gross dental caries (tooth decay). Poor oral hygiene and sugar in the coffee points to a cariogenic bacteria known as Streptococus Mutans. Patient Y, is suffering from recurrent episodes of periodontal disease. Poor oral hygiene is observed, and the family history reveals a possible susceptibility to periodontal problems. A local anaerobic pathogen, ACC (Actinobacillus Actinomycetems Comitans) is the prime suspect. In both cases, the medical histories appear unremarkable, and the evidence seems quite straight forward. Yet before you leap to conclusions, every variable; every last bit of evidence should be considered. The underlying cause may be other than it seems. Are you totally convinced that bacteria are the primary underlying cause, or are they merely symptoms of a lack of the appropriate or impaired systemic immune response? As one of my bacteriology professors at the Faculty used to say, “Woe betide the bacteria that tries to take on a healthy human being!”
If you can help both of the above patients solve the riddle of their disease, successfully eliminate their problem, and keep their teeth healthy for a lifetime, then what other service does dentistry offer that is more valuable? Unfortunately, many people do not value their health until they have almost completely lost it. “The fool ends up doing in the end, what the wise do in the beginning” - WKH
3 DENTAL PRACTICE IN THE EARLY 1970s:
When I graduated in 1972, I began general practice as an associate in a brand-new office in Thunder Bay that eventually grew to include five other associates. Because of my father’s excellent reputation, from the first day I began practice, I was booked six months ahead, with no turn around time. There was a call waiting list for any cancellations. I especially enjoyed restorative and prosthetics because it brought out the latent artist in me.
It took me almost four years of general practice to learn the truth in my father’s old saying, “There is nothing any dentist can do, that will make up for what the patient will not do!”
Even excellent restorations can fail, if they’re not maintained, and inferior ones can last an unbelievably long time, if they are. The prime variable was not the quality of the restorations, as much as it was the dentist’s ability to motivate or convince patients to alter the causative factors that damaged the teeth in the first place. Patient compliance to dietary suggestions and oral hygiene instructions is the most significant variable in sustaining oral health over a lifetime. As Dr. Bob Barkley, one of the pioneers in preventive dentistry in the late 1960's used to say, “When the house is on fire, you don’t call the carpenter; he just can’t drive the nails fast enough!” and, “There’s no point in building a mansion in a swamp.” If you treat the effects of dental disease without affecting the cause , it can become an expensive lesson in chasing without catching. I would rather be known by how healthy my patients become with my help, than how wealthy I’ve become doing recurrent repair in unhealthy mouths.
I began to devote more and more time to patient education. I soon found that it was much easier to assign a monetary value to a surgical extraction or a four surface restoration than it was to place a value on patient counseling. It is extremely difficult to prove what your efforts have prevented. There is no easy answer; idealism is one thing, but one still has to pay the rent.
To further complicate matters, in dental school, I was taught that oral hygiene and dental health were always directly related. Good oral hygiene = good dental health. Yet, one of the first things I discovered in private practice, was that some patients with excellent oral hygiene and regular dental care still suffered from recurrent periodontal disease. Others with poor oral hygiene still had very healthy smiles. If it was not oral hygiene, what was the primary variable?
4 JOURNEY TO THE EAST:
In 1976, to counteract my frustration and impending burnout, I embarked on an extensive nine month journey to India and Sri Lanka. There is nothing like traveling in a third world country to reinforce just how fortunate we are to live in Canada. I ended up visiting a number of dental schools and clinics. I saw everything, from treadle-driven slow handpieces in rural areas, to state of the art air rotors in downtown Bombay. One clinic had such long lineups of patients, that they encamped on the steps over night, just to get an appointment. The dentists did all the periodontal scaling by hand, and would have given anything for a cavitron (electronic scaling instrument).
As fate would have it, I also met some people with exceptionally healthy smiles, extolling the principles of ayurveda or nutrition-based medicine, and the benefits of traditional diet patterns and oral hygiene practises. I became acquainted with the ancient yoga principles of “danta dhauti” or the daily care and feeding of the teeth.
5 LIMITED PRACTICE:
When I returned to Canada, I decided to change the direction or
focus of my practice. Just as a dentist, who limits his/her practice
to crown & bridge, can become exceedingly proficient in that discipline,
I hoped to do the same, by limiting my practice to primary prevention and
nutrition. Since then, with the help of members of the Thunder Bay
Dental Association, more than 2,600 private patients and 235 full families
have been referred to the YTFL Clinic offices for consultation, diagnosis,
diet pattern analysis and patient education. As I begin my 26th year
of this discipline, it is my privilege to share some of my opinions and
insights gained in this endeavour.
“I don’t expect you to believe anything I tell you, just because I tell it to you. It has got to make common sense, or you won’t change you practice style. I don’t make the rules, the Creator, or Mother Nature does. If you break them, you don’t have to answer to me, you have to answer to reality. Health is a prove-it-yourself experience in which actions speaks better than words. An ounce of prevention is worth more than a pound of dental fillings.”
It can be difficult to see the picture, when your are inside the frame. If your training as a dental student becomes too focused on disease and its treatment, then the subtle dynamics of health can become almost transparent. Health is reduced to just a symptomless state, of little diagnostic interest. When you focus totally on disease, it becomes exceedingly easy to look on only the lack of health, as being diagnostically significant. Even though dental school provided me with a well developed medical treatment model of disease, I had little real understanding of the essential requirements for sustained health. The fact is, that the medical treatment model rarely involves healthy people. If you limit your view of diagnosis, to dental disease and dysfunction, your are observing that which has happened after the fact. How can you see the big picture of human health and wellness, if your view of diagnosis is framed by a focus centred on patients with a lack of it. You can end up studying the almost limitless manifestations of disease that occur when the body is missing what it needs to be healthy, without every learning what is missing.
“Study health, and disease and you will learn what you need to be and stay healthy. Study only disease, and what you need to be healthy will always be missing, because everyone you see does not have it.” -WKHFor example, if a certain diet pattern contains all the essential micronutrients necessary for strong host resistance to the bacteria that cause periodontal disease, how are you going to find that pattern, if you see only patients who require treatment, because their diets are missing it? You end up looking for answers to health in all the wrong places. A comparative study of both health and disease is the most logical approach to finding the answers.
When you expand your view of dental diagnosis to also include the identification and quantification of optimal oral health, you are observing that which happens before the fact. This is the pre-disease state, in which the body is functioning with a measurable degree of health and wellness. The missing variable, the clue to why some people with excellent oral hygiene still suffer from recurrent periodontal disease, and who others with poor oral hygiene don not, must be there. “Res ipse locquator” (Things speak for themselves).
6 THE SEARCH:
If we are searching for the missing primary variable, we must not only recognize the basic biological requirements needed to generate and sustain optimal health, we must first be able to define and recognize health and figure out how to accurately measure or quantify it.
What are the clinical symptoms of optimal dental health? Highly stippled, light coral pink gingiva (gums), tightly attached with sulcus (gum crevice) depth less than 1mm, no red halos, no bleeding on probing, no radiographic evidence of a lack of cortication of the interproximal alveolar ridge, no bone loss or pocket formation, no significant plaque or calculus buildup, no active caries et cetera. It is important that when a patient presents with the symptoms of optimal health, we use the same diagnostic zeal to uncover the underlying causes, as we would in our diagnosis of oral disease.
Health and disease are not really opposites. You can have health (ease) without disease, but you cannot have disease without some degree of health. In many aboriginal traditions disease is considered the Creator’s or Mother Nature’s way of telling you that you are doing something wrong. My years of clinical experience in primary prevention and nutrition have taught me that health is not just a symptomless state. It has depth and strength to it.
My role as a doctor is to be a teacher of health; to help my patients understand where their level of health is, and how to improve it. Ultimately, the goal is to help them put as much distance between themselves and the possibility of disease as possible. I show them before and after slides of the signs on the road to health and the signs on the road to disease, so that they can travel where they like. Even the best motivation only last a few weeks; a good education lasts a lifetime.
7 MEASURING HEALTH:
If you want to measure the depth and strength of health, then measure the degree of resistance to disease. The mouth is the ideal diagnostic window or health barometer for this purpose. At any given time, gingival tissue vascular response to the bacteria in common dental plaque is a reflection of the body’s defensive resistance to chronic bacterial irritation or infection.
There is no question in my mind, that the vast majority of dental health problems are directly related to inadequate oral hygiene (brushing and flossing) . If common dental plaque accumulations are left undisturbed for more than 24 to 36 hours, muco-polysaccharide dextran-walled colonies, adhere to the sulcular tooth surface, become saliva-proof and eventually, support pathogenic (disease causing) anaerobic (without oxygen) bacteria. This is why there is such a strong emphasis on plaque control in the treatment and prevention of periodontal disease.
However, the degree of gingival tissue response (erythema) varies from individual to individual. I began to notice that the cases that responded poorly to excellent oral hygiene, often showed an exaggerated tissue response to minimal plaque accumulation. I think this observation has been largely overlooked by the profession, because plaque is clear and transparent and almost totally invisible to the naked eye. When plaque accumulation was first linked to dental caries, a red disclosing dye (2% erythrosine) was originally chosen as the disclosing agent. Although effective in highlighting dental plaque, it also masks the degree of gingival erythema (redness) in response to plaque. It was not until I switched to a sodium fluorescein (FD&C #8 Yellow) and blue filtered light (SFFL) disclosing system, that the true extent of the gingival redness and vascular response became obvious.
8 DIET AND ORAL HEALTH:
If diet patterns can potentially affect oral health, then should not some form of nutritional assessment play a diagnostic role in everyday practice? It has been reasoned that certain positive benefits may be seen through the local effects of food. For example, firm fibrous foods provide additional chewing which tends to increase salivary flow, strengthen periodontal ligaments, promote inter-proximal circulation in the inter-dental papillae, and increase alveolar bone density through increased physiologic function. Also, these foods do not tend to promote dental plaque formation because they are non retentive.
In addition to the local effects, it has been demonstrated that poor nutrition decreases host resistance to the disease process and can modify the progress of existing lesions. This has certainly been proven true for gross deficiencies of specific micronutrients. For example, the lack of Vitamin C (ascorbic acid) in Scurvy, the lack of Vitamin B1 (thiamine) in Beriberi, and the lack of Vitamin B3 (niacin) in Pellagra et cetera.
When faced with the effects of more subtle, or borderline deficiencies, the problem becomes more difficult. “Sub-clinical” deficiencies may not produce consistent or easily identifiable “medical deficiency disease” symptoms, and the relationship to possible weakness at the systemic level (that could affect host resistance to periodontal problems), is extremely difficult to evaluate and define.
This is where a balanced approach to dental diagnostics comes in. Where can you learn this? With so much emphasis placed on the value of mandatory professional education courses, we tend to forget that one of our greatest potential continuing education resources is each and every patient. People form all walks of life, sit in our chairs for a variety of reasons. We examine, observe, chart, and evaluate their hard and soft tissue relationships every 6 months for years. If we are observant and include a broad field of variables, we may learn about the conditions that promote or impair patient health over time. We see what happens when patients follow our advice, and what happens when they do not. If you include diet and nutrition in your field of variables, then you may also become convinced that nutrition plays a far more important role in dental health than generally acknowledged.
9 ORAL HEALTH EVALUATION:
The parts of the puzzle finally started to come together, when I began to comparatively index oral hygiene and gingival health, and to target specific patients for diet pattern analysis. I eliminated those in which oral hygiene appeared to be the prime variable, or cause of the patient’s dental health problem. I then focused on contrasting the diet patterns of patients having excellent oral hygiene and poor gingival health, with those having poor oral hygiene and excellent gingival health. By developing a computer assisted Oral Health Evaluation System (OHES), I was able to easily cross-index patients’ oral hygiene and gingival health and graph their progress over time. In approximately, 78% of the patients I evaluated, there was a direct relationship between oral hygiene and gingival health (local factors ie. plaque accumulation patterns, were primarily implicated). 20% of the patients presented with excellent oral hygiene and very poor gingival health and 2% of patients presented with poor oral hygiene and excellent gingival health.
When the diet patterns from the 22% of patients, in which systemic
factors were implicated, (ie. local factors could not clearly explain why
there was exceptionally high or low resistance to periodontal disease)
were cross-referenced and compared, those diet patterns which obey a basic
biological concentration perspective and contain few anti-bacterial preservatives
appeared to be the most beneficial and potentially health generative.
By evaluation the degree of gingival vascular or inflammatory response
(erythema) to common dental plaque over time, and by observing the diet
patterns that enhance or impair their response, we can learn to what extent
diet and nutrition play a role in generating health and preventing disease.
This has dramatic implications for both dentistry and medicine.
10 NUTRITION IN DENTISTRY:
I was very fortunate to have had two and a half years of diet analysis and nutrition in dental school. Somehow, I became convinced of its importance enough to make it an essential part of my dental practice (special thanks to Drs. Maret Truuvert and Nina Burgess). After completing my first 200 diet studies in general practice, I became convinced that diet was definitely and important variable worth monitoring. After more than 2,600 diet studies, I am convinced that it is, in fact the prime variable, and that primary prevention is nutrition based.
Oral hygiene in the end, will be proved to be a secondary form of prevention, in that it enables the patient to make up for a diet pattern that promotes rapid plaque accumulation and the high levels of bacterial activity, that result in the acid and proteolytic enzyme production, associated with most dental disease. My experience in India taught me that simple traditional diets of whole grains, legumes, mixed vegetables, fruit and dairy products require very simple oral hygiene practices to sustain excellent health. On the other hand, highly refined civilized diets in the West tend to require highly refined oral hygiene techniques which may or may not prove to be enough to sustain health.
Fluoride, in 1 ppm (part per million) concentrations, is a form of tertiary prevention. It makes the teeth resistant to a poor diet and lack of proper oral hygiene.
Although genetics is one of the variables, it is not considered easily controllable. A patient may have certain genetic predispositions to disease, although it is extremely difficult, without DNA analysis, to determine whether the effects are truly hereditary or dietary environmental. (Many diet patterns and lifestyles are passed down from generation to generation.) It is possible to have a good diet and poor nutrition. There may be genetic factors that predispose and inability to absorb certain nutrients form the diet and result in a lower resistance to disease, but you cannot choose your parents or easily alter your genetic code. However, your diet, your oral hygiene and use of fluorides are controllable variables. You can be dealt a poor hand and play it well, or be dealt a good hand and play it poorly.
11 DISEASE AND HEALTH:
Disease is not a totally negative phenomenon. If health or “ease’ is what we are striving to help our patients achieve, then the pain of disease can be seen as the body’s way of drawing our attention to the fact that we are doing something wrong. We are not meeting the body’s minimum requirements for sustainable health. When you view a symptom of a disease as an answer in itself that simply requires treatment, you run the risk of overlooking or even masking sub-clinical diagnostic evidence. Restorative dentistry may repair the damage done by disease, but it does not in any way affect the cause.
The key is in seeing health as biological balance. By discovering those diet patterns, healthy oral hygiene skills and habits that increase or enhance the degree of balance, we can learn how to help our patients gain health and remain healthy. Once oral health has been attained, then it forms a sound foundation for quality restorative or cosmetic dentistry. Prognosis is remarkably improved, if the symptoms are treated in a way that eliminates the underlying cause.
12 DENTISTRY AND ITS REMARKABLE SUCCESS:
Dentistry was the first of the traditional health professions to make prevention its hallmark.* Of all the regulated health professions, it has had the greatest success and impact in promoting better health through prevention. In Ontario, more than 80% of the general public visit a dental office regularly. More people regularly visit their dentist, than their family physician. Why? Because the benefits of regular checkups, dental health and prevention speak for themselves.
To me, the prime indicator of our success as a health profession, is measured in the growing number of healthy smiles we see in our practices every day. We have dramatically reduced the incidence of dental disease, through patient education in the benefits of regular preventive dental care. While placing patient health first, even when it could potentially reduce financial gain is commendable, it poses problems to those practitioners that may view the reduction in the incidence of disease as a threat to their future livelihood. This is the conundrum that we must unravel, if dentistry is to remain viable in the 21st Century.
The first step in finding a solution, is a matter of adjusting our perception of where dentistry is headed. Is our success in the reduction of dental disease a stumbling block to the profession, or a stepping stone to greater opportunities? Our future livelihood will always depend on our ability to adapt to change, both at the office and in the marketplace. We have a choice. We can resist the impact of change by clinging to the cherished old ways of doing things, or we learn to anticipate change, and turn it to our advantage.
Dentistry has a wealth of scientific knowledge based on years of clinical experience and dental faculty research. It has a long history and honoured tradition of ethical practice and professionalism. It enjoys a wonderful legacy of dedicated men and women that have spent their lives doing the best to alleviate pain, and prevent the suffering of dental disease.
Dentistry also has the mouth as its diagnostic window on health and disease. Because the mouth is the gateway to the human body, it has tremendous diagnostic potential. Viewed and monitored form the proper perspective, it is not only possible for us to tell how well a patient is aging by their teeth, it is also possible to shed light on how certain diet patterns and lifestyles support health and resistance to disease.
Whether we are able to fully realize this untapped potential, depends on our ability to expand our clinical horizons, beyond the diagnosis and treatment of dental disease. The clinical evaluation and practical generation of health will require both invention and innovation, and the ability to transcend the shortsightedness that separates dental health from overall or total systemic health.
Although my personal clinical experience has led me to believe that the mouth can be used a s a non-invasive diagnostic window or ‘barometer’ on the relationship between systemic health and nutrition, I need the assistance of others to help validate this innovative concept. I hope that today’s dental students, who represent the next generation of dentists will except this challenge “to make it so”.
May I also take this opportunity to wish all the students at my alma mater, the University of Toronto, Faculty of Dentistry, every success in their promising careers as future dentists.
“Health and happiness are very closely related. When you help people increase their health, You are bound to increase their happiness, And happiness is a wondrous commodity, the more you give, the more you have.” -WKH
If you made it this far, and are interested in more information about the diet patterns that support resistance to disease, please feel free to e-mail me at firstname.lastname@example.org
Yours in Healthy Smiles,
William Hettenhausen DDS