"I want the alternative please Doctor"

With the growing trend of complementary therapies in dentistry What can we learn to to provide effective modern dental care?

By Dr Christine May BDS(Hons) USyd BHSc(TCM) UTS - integrative dentist

WHO DOESN’T LOVE some DIY? The DIY industry is huge in Australia: builders, cooks, makers, innovators, hackers. Really is there anything more satisfying than solving an issue yourself and giving the bird to pricey professionals regardless of the industry? It’s lauded and promoted across our screens: the stuff of reality TV shows, glossy magazines, influencers, bloggers and sharers. So is it any surprise that people would extend this DIY mindset to health?

Yet conventional health is largely a highly regulated industry, as are many of the tools - therapies, medicines, and, most contentiously in my opinion, knowledge. Until now the only way to get expert dental help is to physically visit a dental clinic and spend at least $150 or much more - not always practical or desirable for patients. Recent studies show that 50 thousand people in Australia visit a community pharmacy every week to get help for dental issues (1,2). The rise of Dr Google is evidence of people sourcing health information and solutions in the most convenient way possible for them, despite often having low health literacy (3).

Complementary therapies are more easily accessed by the non-qualified for use as they see fit, whether that be indicated or not via supermarkets, pharmacy or online. It’s an unfortunate bi-product of the conventional health industry that can be rather dismissive of the value of complementary therapies. As they say, a little knowledge can be dangerous!

LESSON #1A Many people like to be self-empowered, in control of their destiny, enjoy the sense of accomplishment and to save a buck.

LESSON #1B Less studied therapies are less regulated and therefore more accessible to the general public for unguided self use.

Self and complementary management of oral and systemic health conditions by patients is on the rise. The challenge of accessing highly regulated conventional health services is contrasted with the easy access of less or unregulated health products, services and information, regardless of a patient’s health literacy level.

The situation is fueled by a general lack of understanding of the mechanisms of complementary therapy applications by regulated health practitioners like dentists. Developing a deeper awareness and understanding of the relative strengths and weaknesses of complementary therapies relative to conventional therapies in overall health and wellness management is key. By doing so, dentists can better manage patients, provide informed opinions based on evidence and experience and offer more tools in the treatment box to provide effective personalised care.

What is a complementary or alternative therapy and how does it differ to conventional therapies?

Much confusion exists around what complementary therapies are, and are not. Misleading marketing strategies have people believing complementary therapies are more natural or organic, less invasive, better or safer, more holistic, more effective, or cheaper than conventional therapies. In some cases this is true, in others it is not. It depends on all the same factors to be assessed as for using conventional therapies.

Scientific evaluation as a differentiator Complementary therapies by definition refer to therapies that are used alongside conventional treatment, in an adjunctive way. Alternative therapies are used instead of conventional therapies (4). There may or may not be quality scientific evidence to support their use, which is actually the main distinguishing feature between them and conventional therapies that must be supported be scientific rigour. Many complementary or alternative therapies have a long traditional history of use in various world cultures.

Languages of health After studying and practising western medical science, dentistry, naturopathy, chinese medicine, integrative nutrition and some yoga (ayurveda), I’ve come to understand the various paradigms of health to be like the different languages of the world: each has their own structure, syntax and nuances. Fluency in each model is key to understandable, effective communication and appropriate use of each.

Superimposing the framework of one language/health paradigm onto another will lead to misinterpretation or incorrect translation - like someone speaking English using the sentence structure or grammar of their native language. This is exactly where problems are arising currently between the use of different health ‘languages’. Patients and practitioners are using a conventional approach to the use of complementary>>

therapies, which is often not how they’ve been intended to be used. This is particularly true of single use or isolation of key active substances. It’s also why getting quality scientific evidence for traditional therapies in particular can be so difficult - like trying to fit a round peg in a square hole - more on that later!

LESSON #2A Conventional therapies are based on scientific rigour, complementary or alternative therapies are traditionally less so, but are used alongside or instead of conventional therapies.

LESSON #2B Like languages, paradigms of health have evolved from various cultural roots and have different ways of explaining and approaching health. Understanding this is key to successful integration of different models of care.

What do complementary therapies offer? A qualitative matrix vs a quantitative linear approach After much struggle, over many years of study, I’ve come to explain complementary therapies as the ‘qualitative analysis’ of health, while conventional therapies bring the ‘quantitative analysis’. In my experience, conventional medicine approaches are generally quite linear and reductionist, looking for a simple or singular cause to explain phenomenon in a segmental way, or solution to remedy the problem. Not necessarily joining the dots between parallels of disease expression in different systems or parts of the body, or synergistic effects of multiple therapeutic tools. Old concepts become obsolete as new information emerges in conventional therapies, often brought about by new measurement technologies.

Contrastingly, complementary health principles can be visualised more like a matrix, instead of a linear path. There is intersection and crossover throughout the matrix that represents the whole body ecosystem. Contradiction is accounted for: it’s accepted that either/or can occur at different points in time or with a different subset of conditions through dynamism, unlike conventional assessments that tend to be more rigid.

Patterns vs discrete points Complementary therapies, through longitudinal observation by large numbers of people over many years, have developed defined patterns of symptoms that tend to occur together throughout the body in various types of ailments. These are not necessarily quantified in the way we are used to in conventional science. Symptom presence in greater or lesser amounts ie relative terms is of more interest than solely mere presence or absence. This helps account for variability between people, ascertaining the root cause of a symptom, and guides how treatment of illness is approached. Conventional therapy studies and applications rarely account for individual variability to this level. This contributes to the range of side effects with many conventional medicines.

There’s a famous saying in Chinese Medicine (TCM): “Same disease, different treatment. Different treatment same disease” (5). This means five people who would all be diagnosed with asthma in conventional medicine and given the same medication would be treated differently in TCM. It means five people who’d be given different diagnoses in conventional medicine and treated differently because of it, would be treated the same in TCM because their overall symptom profile is very similar.

This approach makes therapies like TCM notoriously difficult to study under accepted scientific methodologies. Standardisation of applied therapies for a given conventional diagnosis is more important than reaching the same outcome - which can often be quite variable between subjects. TCM works the opposite way around: the techniques applied may be variable (by conventional approaches), but the outcome achieved will be standardised in terms of clearly defined observational signs of a return to health: pulse, tongue appearance and 10 other key signs. Treatment success in TCM is based on a defined outcome, less on a range of improvement or amelioration that conventional medicine accepts.

LESSON #3 Complementary therapies promote selfmanaged, lifestyle-based wellness, conventional medicine fights disease but traditionally offers little guidance on how to stay well (dentistry being the notable exception to this!)

Living well vs treating disease Complementary therapies when followed fully and correctly are great at providing guidelines for living well and preventing disease in everyday life. They offer protocols on sleep patterns, eating for the seasons and constitutional body type, doing exercise to support wellbeing, connecting with self and others, the importance of effective breathing and digestion, relevance of emotions to health and more (6,7). These aspects till very recently generally haven’t formed part of conventional science, but more recently are being recognised as being important and increasingly included into conventional therapy delivery.

Conventional therapies excel at managing acute and physical conditions - infections, trauma, growths, surgery, things that can be seen, measured and labelled. Conventional therapies can numb pain and help suffering be better tolerated, but this approach doesn’t necessarily resolve the underlying causative issue that can be rooted in lifestyle habits. Complementary therapies have strengths in managing chronic conditions, including ailments that are considered to have vague symptomatology, unable to be labelled conventionally.

Conventional therapy works by ‘attacking’, ‘fighting’ or ‘removing’ illness and pathogens, focusing on the manifesting problem foremost. Whereas complementary therapies tend to work to ‘restore balance’ to all parts of the body’s ecosystem that supports wellness. This subtle difference to approach to healthcare is hugely significant.

How do dental practitioners work with complementary therapies and patients wanting to use them in their care?

The beauty of dentistry as a conventional modality, in my experience, is we have a very evolved understanding of prevention, lifestyle factors contributing to, and therapy for dental disease, along with how oral health impacts on total body health and vice versa. Perhaps more so than any other conventional modality. So the dental approach to oral health is naturally holistic - even if the patient or other type of health practitioner doesn’t always appreciate it!

This mindset makes it easier to incorporate complementary therapies into dental care in an integrative way. Science is strengthening for the use of many complementary therapies in general body and also dental applications that suits our conventional mindset tendencies. Awareness of herb-drug interactions is also important (8). Some highlights being incorporated into dentistry are listed below:

• Dry needling/laser/acupuncture for chronic facial pain management and TMD treatment (9,10)

• Herbs, vitamins and minerals in the management of soft tissue pathology and bruxism (11)

• Tongue signs like scalloping and deviation to the side as indicators for underlying oral-systemic health issues (12,13)

• Facial signs like pooling under eyes, elongated face shape and fuller lower lip in dental sleep airway issues (14)

• Posture assessment - ascending or descending musculoskeletal syndromes in forward head posture (15)

• There are plenty more and Dr May will be discussing them in more depth at the upcoming DHAA CPD event in Bali in late November 2019.

There’s many more tools we could integrate into oralsystemic care given we’re presented with them so frequently :

• Tongue diagnosis

• Expanded facial diagnosis n Selected supplements, herbs and diet management to better help rebalance the oral microbiome instead of using antibacterials that contribute to sustained mouth and gut dysbiosis

• Home care management strategies for patients to take more control of their own health journeys

LESSON #4 Applying the simplest, least invasive, most preventive focused, least costly, least harmful approach to health is a good modus operandus to follow. Complementary therapies provide more tools in a practitioner’s therapy box to help this be achievable for more patients with adequate knowledge.

I believe the artistry of great care comes by applying just the right mix of a range of different tools at just the right time, conscientiously tailored to the person’s presenting situation. The more tools in your box, the options available. But I appreciate this can be hard to implement without an in depth knowledge of more than one health paradigm.

As practitioners we have a professional obligation to continue to learn and evolve in our clinical practice. Be open minded: as the science emerges, or undeniable clinical experiences present themselves, we have the ability to wager the risk/benefit ratio for new or different therapies. If it makes achieving our oral healthcare goals simpler, faster, better and the patient happier, why not investigate it and get on board?

About the author

Dr CHRISTINE MAY has degrees in dental surgery and traditional Chinese medicine, along with advanced studies in naturopathy, integrative nutrition, physical therapies and yoga. This expanded scope of understanding of health and wellness provides a unique perspective towards assessment, diagnosis and management of oral-systemic conditions in general dental practice.

References 1. ‘The public rely on me a lot’: Rural pharmacists’ perspectives on their roles in oral health care. https:// onlinelibrary.wiley.com/doi/full/10.1111/ajr.12460. Accessed 28/9/19. 2. Describing the role of Australian community pharmacists in oral healthcare. https://onlinelibrary. wiley.com/doi/full/10.1111/ijpp.12241. Accessed 28/9/19. 3. Consumer Use of “Dr Google”: A Survey on Health Information-Seeking Behaviors and Navigational Needs. https://www.jmir.org/2015/12/e288/. Accessed 3/10/19 4.Complementary therapies - an overview. https:// www.healthdirect.gov.au/complementary-therapiesoverview. Accessed 3/10/19. 5. The Web That Has No Weaver: Understanding Chinese Medicine. Kaptchuk, T. Book, Contemporary, May, 2000. 6.Diagnosis in Chinese Medicine: A Comprehensive Guide, 2nd Ed.. Maciocia, G. Book, Elselvier, March, 2018. 7. The Yoga-Sutra of Patanjali: A New Translation with Commentary. Hartranft, C. Book, Random House, 2003. 8.Complementary and alternative medicine: impact on dentistry. https://www.ncbi.nlm.nih.gov/ pubmed/15316539. Accessed 3/10/19. 9.Acupuncture in Dentistry: Its Possible Role and Application. Wong, L, B. https://journals.sagepub. com/doi/abs/10.1177/201010581202100108. Accessed 3/10/19. 10. Laser therapy on points of acupuncture: Are there benefits in dentistry? Ferriera de Oliveira, R., et. al. https://www.sciencedirect.com/science/article/pii/ S1011134415002274. Accessed 3/10/19. 11. Herbs in dentistry. Taheri, JB., et. al. https:// onlinelibrary.wiley.com/doi/full/10.1111/j.1875- 595X.2011.00064.x. Accessed 3/10/19. 12. The association of tongue scalloping with obstructive sleep apnea and related sleep pathology. https://www. ncbi.nlm.nih.gov/pubmed/16360522. Accessed 3/10/19. 13. Analysis of using the tongue deviation angle as a warning sign of a stroke. https://www.ncbi.nlm.nih.gov/ pubmed/22908956. Accessed 3/10/19. 14. Screening patients for risk of sleep apnea using facial photographs. https://www.ncbi.nlm.nih.gov/ pubmed/29060289. Accessed 3/10/19 15. The many faces of forward head posture: the importance of differential diagnosis. https://www. tandfonline.com/doi/full/10.1080/08869634.2019.1594 003. Accessed 3/10/19.