Professor Gus Heyden
Not long ago, when I was
professor of Oral Pathology at Gothenburg University, Sweden, I carried out
research that can be characterized by the idea ‘the mouth as the mirror
of health.’ For 26 years I studied how heredity and environment can contribute
to explaining why the older people get, the more their oral health depends on
their general health. Not the opposite – how one’s general health
can be influenced by oral health.
In terms of strict anatomy the mouth is a picturesque little entranceway to
the gastro-intestinal tract. In that dark cavity, between lips and throat, there
dwell biological phenomena — unique to every human being. Hence dental
workers can say to their patients, “Open wide and I’ll tell you
who you are!”
But the custodians of that little territory aren’t always especially popular.
Unkind MDs in Sweden have called them ‘rats in the back alleys of medicine’.
And, unfortunately, sometimes even society’s decision makers would rather
regard dentistry as a lucrative commercial activity than an asset to the general
health care system.
To defend its threatened hegemony, odontology maintains, with varying degrees
of success, that good oral health is a precondition for good general health.
Just as is implied in the title of this talk. Still, the evidence for this has
not, at least yet, been convincing enough. Hence, in Sweden, dentistry has not
been considered an integral part of the medical system by non practitioners.
And so mainstream health care has one, taxpayer-subsidized, system of payment,
while dental care has its own, more or less market-based, set of fees. Cynical
Swedes can tell you that it nowadays costs more per minute to go to the dentist,
for example, than to fly from Gothenburg to Miami. Yet you can get an advanced
eye operation done at the hospital for a few hundred Swedish crowns.
How can this be? Is it possible that dentistry itself is to blame? It is, after
all, a well known fact that many of the mouth’s original tissues still
belong, in 2002 AD, to nature’s closely guarded secrets. Basic biological
research has not made any spectacular advances in the last decades. Technical
research, on the other hand, has exploded. Since neither teeth nor salivary
glands regenerate, when damaged it becomes a case of ‘the spare parts
human being’. It’s quicker and easier to repair or replace defective
oral components than to wait for basic research to catch up. And so the development
gets caught in an inhibiting cycle, and dentists come ultimately to be regarded
more as experts in oral refurbishment than ‘healers’.
It’s a certain fact that good oral health can improve a person’s
overall well being. Of that there is not the slightest doubt. And illnesses
of the mouth certainly do sometimes spread to the rest of the body and aggravate
previously existing pathological conditions. But a fully fit person usually
has high biological thresholds of resistance to such risks — even if the
champions of focal infection theory sometimes wish to deny it. Inheriting the
right genes is still the best protection against all of these sorts of health
risks. But if you happen to be stuck with the wrong genes, even the slightest
threat can lead to catastrophe. That’s why it’s important to choose
your parents carefully if you plan to live dangerously.
On the basis of many years’ experience I am of the position that the importance
of oral status is rather negligible for the physical health of the rest of the
body. On the other hand I can agree that there is a strong connection between
oral health and a person’s psychological well-being, especially if the
goal of dentistry is that a fully fit person should have a flashy grin –
with at least 32 shiny white teeth and an occlusion that sounds like a Mercedes
door clicking shut! But thank goodness such aesthetic ideals aren’t shared
by everyone here on Earth. As a newly appointed professor of Oral Pathology
in the 1970s, I was still a parent of young children. A few years later, one
of my offspring had reached school age. His teacher, noticing my impressive
academic position, wanted to take the opportunity to spread public health information
to the children in her class. She was, like so many in those days, inspired
by a sort of dawning passion for social justice, cheered on by the experts at
the desks of the Swedish Board of Health and Welfare. For this took place back
when Swedish odontology was still trying to gain new market shares by constantly
warning that caries and loosening of the teeth were “national health concerns”.
That made it a basic human right to suffer from them — and also to be
treated for them, whatever the cost!
Thanks to a successful marketing campaign, and a relatively strong national
economy, the odontological establishment grew to unthinkable proportions. Soon
there was more than one tenured professor for every tooth in the mouth, even
if you count the baby teeth. New research centers sprouted up like mushrooms,
and the diverse flora of specialists fostered thousands of new offshoots. It
was getting more and more crowded in that little oral cavity. They studied everything
imaginable and unimaginable — if not for the sake of humanity then at
least to further their own careers. Patients were submitted to being referred
back and forth like ping pong balls among the growing corps of odontological
experts.. The time of the generalists was over.
In any case, I was recruited to provide my son’s teacher and her little
novices with a free lesson on teeth and their care. Being a tenured professor,
and fancying myself proficient in the subject, I accepted the assignment gladly.
But my little son neither ate nor drank for several days. He was that nervous.
Suppose his father was to stand up in front of the class and totally bomb. Think
how much scorn and derision he’d have to face!
D-day had arrived and I entered the classroom to find the children bright as
little suns. They were well prepared for my arrival and were loaded with questions
which they thought a dentist professor could answer.
I’d hardly come through the door before little Kalle, who sat at the very
front, jumped up eagerly from his bench and shouted:
“Umm… Perfessor, Perfessor! Why do we have teeth…?”
It was as if my academic status and supposed wisdom had suddenly vanished. That
was a question I definitely wasn’t ready for. While I was trying to put
some order into my thoughts, the little rascal got in his final killing blow:
“…only in our mouths?”
Curtain.
I haven’t often felt as dry in the mouth as right then. My son was cowering
terrified in his bench. For a few second there was complete silence in the classroom.
But I was suddenly saved by another alert little whippersnapper who answered:
“You’re so stupid, Kalle! Everyone knows why we have to have teeth.
What else would we have dentists for?”
Kalle had popped my odontological bubble. What was I actually trying to do,
as a researcher and part time dentist? Was I really competent enough for my
job? Or was I just a simple messenger, delivering sheet music for a heavenly
choir chanting the high mass of odontology?
I’ve gleaned some answers to these questions through dialogue with a wise
and clear sighted fishing population on Sweden’s westernmost inhabited
islands, the Koster Islands. These people too have often made me feel like a
scientific dunce. But they’ve also given me new insights into the importance
of environmental factors and lifestyle for their well-being – regardless
of whether or not they have teeth. During the 16 years which the project has
so far been underway, I’ve namely learned more from the people of Koster
than from all the scientific classes, articles and congresses combined. A bit
of common sense can be very healthy – even for a weather beaten professor.
In the project on Koster, each islander functions as his or her own experimental
“control” along the axis of time. The participating subjects’
biological, physiological, social, cultural and economic requirements for good
quality of life vary from person to person and year to year. For this reason
the islanders aren’t compared with each other.
In the individual follow-ups each person is surveyed as to which strategies
and lifestyles he or she chooses to secure personal ‘survival’,
while maintaining good quality of life, in a rapidly changing environment. It
takes many years of follow ups to show with any degree of certainty which environmental
factors above all affect a particular subject and his or her pattern of response.
Hence this sort of science is not very attractive to researchers who don’t
yet have their careers safely behind them.
In the photographic archives of the Koster Health Project there are now 45,000
clinical dental images which show that oral health can be the mirror of general
health – but also that good teeth are becoming less and less important
for people’s quality of life as life becomes tougher. In times of short
resources and other misfortunes, dental care isn’t always prioritized
as highly as dentists and dental hygienists nowadays expect. For islanders,
living far from modern society’s service and care, the concept of ‘health’
is synonymous with “appetite for life – despite eventual illness
or handicap.” There, a toothless grin warms the heart at least as much
as a shiny white smile.
During my years as a UNESCO monitor of the situation of refugee children in
the Balkans, I got a chance to find out how little oral health matters to people
when the thumb-screws of life are tightened. Those poor little beings were interned,
together with their surviving grandparents, on the Island Hvar, far out in the
Adriatic Sea. The older relatives generally had wretched dental status –
at least by Swedish standards. Most of them were entirely or partly without
teeth. But they smiled happily in front of our cameras. With every other tooth!
When the pictures were later shown on Swedish TV, the citizens of the Welfare
State sat in their leather sofas and were revolted by what they saw: “Ugh,
such awful teeth! If your mouth looks like that you better make sure not to
laugh.”
But those poor people hadn’t smiled at our cameras to irritate the Swedes.
They smiled because they’d managed to survive a miserable war. They were
alive. Perhaps one day, even the Swedish know-it-alls would find a reason to
smile.
Even in today’s Sweden the level of oral health is not always all it should
be, even if the authorities try to make things look otherwise. Worry, anxiety,
burn-out and depression are on the rise among a general public increasingly
exposed to stressful milieus and growing environmental threats. In conditions
like this, dryness of the mouth runs rampant. Just look at the situation of
bullied immigrant children. It’s hardly surprising that their oral health
can collapse due to inadequate salivary protection. Or think of the man who
unexpectedly is placed at the hostess’ table at a large dinner. He has
to hold a thank-you speech for a meal that tasted like gravel.What lessons can
we gather from our well-tried experience? Well, that a human being can live
up to 120 years without a single tooth. We’ve also seen that a healthy
gastro-intestinal tract doesn’t always require one to be able to chew
one’s food. This has been confirmed in Swedish gerontological studies
which still haven’t been allowed to be published because the results conflict
with current opinions. Talk about scientific censorship! Modern human beings
are encouraged to be very careful with their teeth as long as they live. But
teeth are actually among the most indestructible tissues in the body. The little
biters are often all that’s left in ancient graves and after catastrophic
fires. It’s only trauma, various microorganisms and dentists that can
destroy the enamel coated original parts.
The first dental filling is said to be the ‘market maker’ for dentistry.
And when the art of prevention has decayed to the point that there are no longer
any teeth to repair, we carry on by screwing in monuments to the failure of
preventative treatment. By means of procedures like this an aesthetically fixated
odontology can earn good money – at least as long as the osteoporosis
and the question of survival don’t take their toll. And this time I happen
to know what I’m talking about. One of my sons is namely a successful
“screwdriver” in Norway.
But perhaps the riddle of why we have teeth – only in the mouth –
remains unsolved by odontology. This despite the fact that we’re presently
up to two professorships in Sweden for every tooth!
It seems that human beings in the 21st century mainly have teeth to smile with
and fit into modern society with. These chewing tools are no longer needed for
the physical survival of the individual. Daily nutritional requirements can
be met with pills and decoctions. But of course it’s more pleasant to
sink one’s teeth into a chateaubriand or an apple than to have the delicacies
served in pureed form!
Science, unfortunately, seldom keeps up with reality. While researchers busy
their minds with other things, environmental threats in the world are presently
lowering our biological thresholds of resistance to contaminants that we’ve
previously been able to handle. We are being exposed, for instance, to increasing
amounts of metal in our drinking water. Now this harmful development has gone
to such lengths that dentists in the west are no longer advised to use amalgam
fillings to repair teeth. A few decades ago it was working just fine. For more
than one hundred years! But not now any more. And that´s fine. Because
mixing mercury with various heavy metals and pressing it into an open surgical
wound can hardly be a good idea in the long run – neither for the patient,
nor for the environment in which our children and grandchildren will have to
live.
The laws of thermodynamics and human ecology demonstrate that nothing in this
incubator we call Earth ever disappears. It’s all still here! And everything
has to be paid for one way or another – either with illness or with money.
There’s no such thing as a free lunch. Not even the alternative filling
materials of modern dentistry, or its sophisticated chemicals, are safe for
the environment of our descendents. Even the much lauded fluoride is an enzyme
toxin which sooner or later ends up in the sewage sludge and returns to the
fields, eventually causing problems in biological cycles. Who knows? The long-term
effects of this are still obscure.
Most of society’s so called hygienic limits are actually nonsense parameters
for an ever more compromised human body with reduced biological thresholds of
resistance. And dentistry’s handling of toxins seems to be unlimited.
To achieve a sustainable future a more holistic view of the human situation,
than what the dental care system has today, may be required.
Personally I would find it fitting if the odontological establishment was a
bit more self-critical. Dentistry has admittedly – at least historically
– placed many laurels at the altar of philanthropy and found decent cures
for toothaches, bruxism, loosening of the teeth and “inappropriate”
appearance. But it has also paid its tribute to mammon.
I would have liked to see odontology work for improved integration with other
branches of science, and actively contribute to the UN’s plan of action
for a sustainable society and good quality of life for our children and grandchildren,
Agenda 21 (UNCED; Rio, 1992), while there’s still time. After all, dental
care workers have the advantage of regularly meeting the same people year in
and year out, and cultivating trust. Few occupations, excepting perhaps the
hairdressers, are endowed with such a benefit?
An old Swedish saying goes “while the grass grows the cow dies.”
The magnitude of illness is constantly growing in the world in spite of all
research and millions of scientific articles. In the time it takes to find a
cure for one single disease, several new ones make their debut. The pathological
processes are growing all the time, in both number and medical complexity. Soon
there won’t be any completely healthy children, not even in pre-school.
The demands placed on society’s medical resources are already enormous
and are constantly increasing.
Can you really grasp the fact that there are more human beings alive today than
have died during the whole history of the planet? I can hardly grasp it. And
when our grandchildren have grown up there will be twice as many – in
a world which has nothing more to offer by way of land, water or food. Studying
the effects of shrinking resources on human beings and their behavior is one
of the purposes of the project Koster Health. A vacation island is namely a
good model for such a survey. In wintertime there are 350 people on Koster –
in the summer 3,500! You can perhaps imagine how people behave when the resources
don’t suffice. Living of tourism has its cost.
Drawing on current research in Human Ecology, I can say in this connection that
when the thumbscrews are pulled tight in a world with limited resources, even
well educated and normally sensible people are going to be fighting for their
survival. Then democracy, solidarity and peaceful coexistence will all be put
to a difficult test. And dental care will risk falling even lower on the list
of priorities.
If odontology has any fore-sight, it ought then to look after its own best interest
while there’s still time. Now that oral health has been adapted to fit
each individual’s tiniest conceivable needs, the dental care system ought
to be granted enough surplus time and resources to actively participate also
in the monitoring of the general health of its fellow human beings and the ongoing
changes in their neighbouring environment. Well, this is a strict personal view
which I hope to share with, at least, some of you.
Guy Heyden
UNESCO/Cousteau Ecotechnie Chairholder
Author
First Published in Dentistry On-line, January 1st 2003.