That's how the light gets in

Aug. 6, 2013
While flipping through the book, "Mouth Matters: How your mouth ages your body and what you can do about it," a recent patient commented, "I thought everything in dentistry was settled!"

An interview with author Carol Vander Stoep explores how dentistry can improve care by changing traditional approaches

by Cathleen Terhune Alty, RDH

Forget your perfect offering. There is a crack in everything. That's how the light gets in. Leonard Cohen – Anthem

While flipping through the book, "Mouth Matters: How your mouth ages your body and what you can do about it," a recent patient commented, "I thought everything in dentistry was settled!" He had just purchased the book, which had raised numerous questions about dentistry.

Carol Vander Stoep, RDH

How comfortable it would be to live in a static world where nothing changes. But that is not the world in which we live.

"Cracks in our knowledge base turn into chasms. What we knew yesterday is debunked, or understood at deeper levels than yesterday," says Carol Vander Stoep, RDH, BSDH, OMT, and author of "Mouth Matters," which is a book outlining oral/systemic medicine and inflammatory disease solutions that address root causes.

"The faster research clarifies how our bodies function within our changing environment, the further away we all operate from a scientific basis. The more we learn, the easier to reconcile contradictions. Yet research also raises more questions. Staying open to change is key to success for all of us. This truth was constantly reinforced as I wrote and revised Mouth Matters.

"The real shocker is how strongly my work resonates with an expanding segment of a general public who have grown weary and distrustful of static care. I sense a slow but steady awakening to what is swamping us. I knew distrust was a factor in why people do not seek dental care. I had no idea of the degree until I began receiving a deluge of relieved and appreciative feedback."


Other articles by Cathy Alty


Statistically, the U.S. health-care system strains the financial strength of the country. Carol is dedicated to helping hygienists become an important part of the solution. After all, she notes hygienists have more patient face time than do any other health workers, and the more chronic inflammation a person suffers, the more it is reflected orally, and the more time a knowledgeable hygienist has to influence lifestyle. If nothing else, we ensure personal job stability by becoming indispensable partners with our clients.

Carol operates on this principle when possible: "Superior professionals prevent disease; mediocre professionals treat before disease is evidenced; and inferior professionals treat full-blown disease."

In uncertain economic times, Carol envisions a need for at least triple the current number of dental hygienists. Employed in novel ways, she knows hygienists can eventually change the health-care landscape in the United States and far beyond its borders.

Carol attended the University of Texas from 1974 to 1978, studying several disciplines, and then entered Baylor's dental school, chosen because it was the only Texas school that offered a bachelor's in dental hygiene within a dental school setting.

She worked in a number of traditional dental practices, but essentially "grew" out of them as her independent studies in health and prevention as related to dentistry expanded. Her philosophies and optimistic beliefs in what is possible continue to evolve. Currently, she manages her own orofacial myofunctional therapy practice and also works as a clinical hygienist for two "biological" dentists. (Biological is an expansive term indicating these dentists understand profound oral-systemic links. They share general, broad understandings such as heavy metal and fluoride pollution in the body and biocompatibility of dental materials. To paraphrase the International Academy of Oral Medicine and Toxicology's mission: They seek the safest, least toxic way to accomplish dental treatment while treading as softly as possible on the patient's biological terrain.)

Individual biological dentists embrace a world of other interests from nutrition and homeopathy to energy medicine, encompassing the use of electromagnetics, sound, and light. Some understand that small tolerances involved in dental work can have profound effects on neural pathways connected via the temporomanibular joint, and which can be involved in dyskinesias such as Tourette's and Parkinson's at the far end of the range.

Will you share your past experiences as a dental hygienist in terms of frustrations, or concerns or things that made you start thinking all was not right with dentistry as it was being practiced?

Vander Stoep: "A trigger occurred concurrently with a summer task I had set for myself. I had been so successful with prevention in a particular dental practice that the doctor's schedule was rarely full while mine was packed. I was asked to stop teaching prevention, and the intraoral camera and hygiene aids disappeared from my room.

Hundreds of hours clearing cedar during an intense Texas summer allowed deep contemplation. While I believe my trigger belied an uncommon attitude, it was the first time I considered the deep problems we face within our capitalist system. It is daily more evident what results from what has evolved over the last half century: the U.S. industrialized food complex, the pharmaceutical industry, the insurance industry, what is taught in medical and dental schools, and other mechanics of health-care delivery. America's health suffers as a direct result of these concentrations of money and power. Health care costs will bankrupt the United States if we don't turn this barge around. The one check/balance we have is to educate consumers so they make wise choices as they vote with their dollars. "Mouth Matters" was my response.

I don't believe any thoughtful hygienist with years of experience can miss observing the obvious oral-systemic links. I remember a time when eating in restaurants was a rare treat; meals were home-cooked vs. processed, and foods were predominantly locally and sustainably grown. Sodas were an occasional treat -- and eight ounces instead of 64 ounces and made of cane sugar instead of high fructose corn syrup or other sugar substitutes.

Observing health changes in populations coupled with parental responsibilities helped alert me to political pressures that mold ideas in this country. I knew my children deserved my best efforts to give their bodies and minds the right building blocks to maximize their genetic potential. So I started an organic garden and orchard, began making my own breads, grinding up whole grains, and offered the best I could with what I knew at the time. Like all moms, I missed some key points. We are all so busy it is hard to know all we should and to stay on top of the politics that guide the media and our belief systems.

Having had a diabetic partner who passed his sugar addiction epigenetically to both daughters, I was particularly interested in Dr. Brian Mealy's work. Dr. Mealy is now well known for drawing the connections between diabetes and gum disease. His work was exceptional, and, as I said, I was making observations of my own. Yet, often I was asked not to discuss oral-systemic medicine with clients, even the obvious diabetes connection. All is not right when prevention takes a back seat to fear of profit loss.

The studies on oral/systemic medicine confirm what we see daily. As I say in my presentations, "Professionally, hygienists live in the sulcus. We live in the most visible and accessible end organ that gives us incredible information if we will just read the body's story as we work." For those who do, we have extended appointment times during which we can explain inflammatory processes and discuss lifestyle strategies.

Where did you seek answers/information to these issues?

Vander Stoep: The usual suspects -- decades of borrowed journals, the Internet, and hundreds of hours of CEUs a year. I would never have finished writing "Mouth Matters" if I had annotated every source I consulted, but 25 pages of source notes would give any interested reader plenty of rabbit trails to follow. The Japanese are credited with a mindset called kaizen, a philosophy that focuses on constant improvement.

What was the defining moment that changed your dental paradigm? How did this change how you personally practiced?

Vander Stoep: I change how I practice as I learn and as I am allowed. Of course, this is continuous. I believe no one could radically change her practicing paradigm overnight. First, one must realize through years of observation and active analyzing that traditional ways do not solve all problems. In my case, a decade of studying has led me to conclude that organized, traditional dentistry solves few problems. As with all medicine, dentistry largely applies bandages to the end stages of disease, while barely addressing root causes. While necessary, we must think far beyond what we are now doing.

This has been an agonizing solo journey, but it didn't have to be. What I discovered is that I was reinventing the wheel. There are many dental practitioners who incorporate wide practice models. Though parts of "Mouth Matters" will be radical to some, it is a basic, if extensive primer. Some dental professionals are successfully practicing way beyond this foundational work.

I slowly realized I was a terrific salesperson. Almost everyone in my practice flossed, and I could sell the idea of fluoride to almost everyone! How often had clients looked to me to answer their concerns about amalgam fillings? Though I had discussed the mercury issue with my then partner, a brilliant chemist, before I started at Baylor, I learned what to think and say during my formal training and never looked back -- until I realized I was writing a book on oral/systemic links and I couldn't dodge the hard questions. While each person has to come to his own conclusions after thoroughly evaluating the available evidence, I made a U-turn on what I had been taught.

A pivotal moment in my journey was reading Weston Price's, then George Meinig's books about root canals. At that point, and after a great deal of soul searching as I tried to unlearn what I knew, I realized infected teeth, root canals, and cavitations can wreak worse silent havoc on a person's health than gum disease.

It is difficult enough for a doctor running an independent practice and who thus has more control over how she practices to make changes as she learns more. Hygienists are in a more precarious position because of the institutional pecking order and state dental practice acts unfavorable to hygienists and, thus, prevention.

Two things. Many influential people within dentistry privately express to me they think fluoride should not be added to water supplies. Many dentists suggest to me they agree hygienists should be allowed to perform some basic dentistry. Fear and politics operate on a much higher level in the United States than I think they should. What if we all opened our minds and hearts? I believe everyone would benefit. As I say in "Mouth Matters," there is room for all.

How has the response been to the book?

Vander Stoep: The response has been tremendously gratifying. I hear from relieved dentists, some dental professors, and hygienists often -- not just from within the United States but also other countries. Most seem to have extensive experience under their belts and know much is amiss in our dental world, not unlike problems in many other fields. This seems like a great time of awakening.

It was a challenge to write for the general public. I knew I had to incorporate extensive detail to obtain legitimacy and to keep naysayers at bay, so much is in footnotes and appendices. Still, I seem to have bridged the gap. "Mouth Matters" is well accepted by the dental professionals I know and there has been an outpouring of appreciation from the general public from many countries.

Where do you want to see this go? How do you see dental hygiene being a leader in "true" prevention? What do you think it will take to get us there?

Vander Stoep: The dental industry is as mired in the miasma of distrust as that engulfing the financial industry, the pharmaceutical industry, the industrialized food industry, and loss of faith in our political leaders. We were taught that half our population doesn't visit dentists due to fear or finances. My experiences tell me distrust plays a huge role.

Statistics show the general public trusts nurses above all other health-care providers. I believe educated hygienists, allowed to grow into their full potential can gain a similar respect. Honestly, while there are hard-working hygienists working for some minor independence, we need to have a bigger vision -- and likely less fear. I used to enjoy my golden handcuffs and lack of homework. Hygiene was a cool gig, even though looking back, I can see I always chafed. But now, I hands-down love my life! The secret really is about giving freely.

I worry our schools make most students not enjoy learning. Somewhere, many of us have lost our sense of wonder. I am not certain how we rekindle that flame once lost, but perhaps some independence, some self-determination, some good old competition built into the system could go a long way. My goal was to educate the public as to what they might want to ask for. I hope they ask for more from all of us in all the wonderful social media ways that are evolving as well as with their dollars. And I envision hygienists using these techniques to help back up primary prevention as they see their stake involves not just their profession, but indeed the health of their families and themselves as we all try to keep special interests in check. RDH

Cathleen Terhune Alty, RDH, is a frequent contributor who is based in King George, Va.

Carol Vander Stoep shares with us several areas in which she sees the necessity of dental hygienists playing a greater role in patient care.

Sealants -- Current technology allows clinicians appropriately trained in air abrasion/minimally invasive dental techniques to (up to 75%) more accurately diagnose fissure decay at the early end of the spectrum compared to the methods used in most traditional offices via X-rays and the poke-and-hope method. Long-term restorative success, general health, and cost savings depend on it.

How do hygienists fit in? We can stop applying sealants on teeth that have not been accurately diagnosed, as I discuss in "Mouth Matters." We can ozonate and/or place "super" sealants on clear fissures, using glass ionomers so teeth can continue their four-year enamel maturation cycle after eruption. While I know glass ionomers do not contain BPAs as do most sealant materials, I also know they contain fluoride. If we were able to implement a large program, it would be easy to ask manufacturers to produce some without, so parents can be informed of the risks/benefits and make informed decisions.

Performing sealants places hygienists solidly in the world of adhesive dentistry. It is imperative we place sealants with integrity. We must also insist on clean water and clean air; that is, the air must be exceptionally dry (biofilm free) and filtered of contaminants such as lubricating oil for exceptional bond strength.

The Pew Center wants to see vastly expanded programs of hygienists applying sealants. Depending on how we proceed, this could eliminate perhaps more than 50 percent of drill-and-fill dentistry in future generations. Or it could be an unmitigated disaster that keeps many future dentists from exploring the more interesting and technical aspects of dentistry as they stay busy amputating and replacing tooth structure as they have always done. It is time we stop feeling so blasé about cavities.

Ozone -- Ozone is one of the most exciting, versatile tools in the dental toolbox. If its benefits were confined to periodontal disease, it would be enough; however, ozone gas can also profoundly desensitize roots, treat herpes outbreaks, successfully treat osteonecrosis while alleviating pain, correct pH imbalances within teeth and pockets, and change structural and optical properties of decalcified and tetracycline stained teeth. Ozone gas is also the most predictable way to remineralize teeth.

Properly trained hygienists can perform many of these techniques. Ozone's broad medical uses are even more astounding. Many modalities are applicable to dentistry as fundamentals of oral/systemic, functional medicine become integrated within practices.

Ozone works on several levels. It supercharges the immune system while destroying microbes almost on contact. In the process, it creates a hospitable environment for beneficial microbes. Does that not sound like a medical dream?

Conversely, antibiotics take acute infections and turn them chronic. Biofilms by definition are resistant to antibiotics and a partial bacterial kill leaves a niche that can then fill with fungi, viruses, and other microbes as well as nonbeneficial bacteria. This ecological shift is not localized to the mouth. We all know antibiotics destroy gut bacteria, yet a healthy gut microbiome is a critical part of our immune systems.

To focus for a moment on what is primarily expected of us, localized symptom-driven therapy, I will not manipulate tissues without coating my probe or curette in ozonated oil. This kills microbes on contact and thus cannot create a bacterial shower into the bloodstream. My patients are happy because ozone slows nerve transduction. They are comfortable without anesthetic. Anecdotally, it also softens calculus and its bonds to tooth structure. What hygienist would not appreciate an easier job with improved success?

My favorite proven benefits about ozone beyond dissolving plaques are:

  • Ozone painlessly sloughs infected tissues without the pain and difficulty of a curettage
  • Ozone oxygenates and raises the pH of the sulcus. Periodontally involved tissues have a sluggish blood supply and sulcular pH is low/acidic. This creates the optimum environment for healing and repopulation by beneficial bacteria
  • Ozone vastly increases fibroblast production, important to tissue rebuilding and reconnection
  • It causes the release of growth factors that stimulate regeneration within damaged joints and degenerative discs.

Ozone gas has more penetrating power than ozonated oils and so has many more uses. When a bony framework is present, however minimal, ozone applications can increase bone density.

There is a shortage of literature regarding ozone in dentistry in the United States, but there are over 184 articles on ozone in medicine and soon the University of Detroit will run a European search engine so that we have broader exposure to international peer-reviewed research literature.

There is some misunderstanding about ozone use in the United States. Ozone's medical/dental uses are grandfathered. The medical community determines standards of care for ozone, its purity, and its uses. A key point of approved protocol is that ozone generators meet standards to assure the public the ozone product is pure/medical grade.

Sleep apnea -- Sleep apnea is underdiagnosed; hygienists can play a tremendous role in screening for it. It is everywhere once you know what to look for. Poor oral posture is so rampant; conceivably each dental practice could supply enough patients to keep a myofunctional therapy practice busy full time.

The screening process should begin in the reception area, as patients answer questions to the Epworth Sleepiness Scale. This can open necessary dialogue.One can also estimate or ask for a person's BMI (>25), measure neck circumference (>16 inches for females, >17 inches for males), check for a recessive jaw or an open gonial angle, look for dark circles under the eyes, check for tooth misalignment, bruxing/abfractions, and a flaccid and/or scalloped tongue. Bruxing is now considered a sleep disorder. A practiced eye can determine almost all these signs in seconds. All negatively impact the airway.

Myofunctional therapy -- I came to myofunctional therapy from studying the sleep apnea question, never realizing both of my children and I needed it, as do many in my RDH practice. Few even want to get tested for apnea because they don't want to use the gold standard, the various C-pap machines available.

Many dentists fit patients with jaw forward positioners. These help because they move a patient's mandible, thus their tongues off their airways. Keep in mind these positioners for snoring or OSA position the mandible forward by hooking the mandible to the maxilla, essentially exerting a headgear effect on the maxilla. Over time, maxillary anterior teeth are brought back and the bite changes in the front. A normal bite can end up in an end-to-end incisor relationship and/or an anterior open-bite. These clients usually need a C-pap eventually, but they have had a 15 year or so hiatus. The Full Breath Solution is the only device so far as I know that does not change tooth position over time.

Myofunctional therapy can assist everyone to increase the airway space, but it is especially helpful for those with mild to moderate sleep apnea.

I strongly urge hygienists to screen for/refer to orofacial myofunctional therapists, children with poor oral posture. These therapists help children maximize their genetic potential -- for developing maximal airway space.

Minimally, we should check for mouth breathing (not maintaining a lip seal), and where a child's tongue rests while not talking or eating. It should be plastered to the roof of their mouth.

Hygienists should also check for a dysfunctional swallow. During this active swallow, the tongue moves forward to touch the front teeth, the lips close to create the negative pressure necessary to help "slingshot" saliva or food down, the head bobs forward, the jaw drops down and back to compress the TMJ, and many facial muscles are activated. To check, I hold the lips apart with two fingers in each mouth corner so I can observe the swallow. Quite often, a reverse swallower will look at me with huge, startled eyes, wondering why they suddenly cannot swallow – something they have always accomplished without thinking. I let go of their lips and they shift from panic mode.

Incidentally, these are quite often the people who panic behind a rubber dam – they can't swallow well with their lips apart and can't identify what is wrong. It is a relief to them to understand why this occurs.

Fluoride Questions

This issue seems clear, once one researches it. I don't mind discussing fluoride with anyone who has open-mindedly looked at all the issues and read as extensively as I have.

As with the mercury issue, we can't just hold unsupported opinions. Innumerable dental professionals tell me they haven't looked into certain issues such as fluoride, but they still believe in the company line.

Does fluoride remineralize teeth? Yes, as do more benign materials. Can teeth reform their crystalline structure again, once lost? No, not unless one uses hydroxyapatite crystals in the 20nm range. Is surface remineralization important? I am uncertain even about that deeply held dental tenet. Could surface remineralization actually delay diagnosis? I begin to think so. X-rays seem to pass through fluoridated teeth differently. I believe diagnosis is often delayed. I'd like to see some research on this, if we can even find people who never ingested fluoridated water, never ingested foods sprayed with the crop fumigants cryolite or sulfuryl fluoride, took any of the numerous pharmaceuticals containing fluoride, drinks tea, etc.

I agree with Hardy Limeback, head of preventive dentistry at the University of Toronto and one of many former advocates of water fluoridation who have reversed their position on fluoride safety and efficacy. With him stands Kathleen Thiessen, another NRC fluoride toxicology review panel member. She believes water fluoridation is a reckless policy on many counts. Our task is to first "do no harm." Alternatives are available. I hold that air abrasion, ozone, and a reasonable diet together are the only predictable ways to remineralize enamel or dentin.

Neither fluoride nor any other drug should be medicinally and universally added to water without regard to dosage. People can try to make a personal choice about intake based on their own health needs. Communities across the nation are reconsidering the issue, but how many hygienists are as aware as their patients?

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