My friend, Dr. Clive Friedman, forwarded this article and I feel compelled to share it with all of you as there is an important message in these lines. Please read what Jessica Gold & Anna Urbano wrote about their experience in rural Honduras.
For a week this past March we were fortunate to participate in an outreach mission to Honduras. The mission was lead by pediatrician Dr. F. Gorodzinsky and pediatric dentist Dr. C. Friedman, and included pediatric residents, registered nurses and pediatric dentists; this was the first time in fifteen years that dental students participated. This has been the most eye-opening experience of our careers as dental students thus far.
Before embarking on our daily brigades where we provided urgent dental care, we had the opportunity to meet with the public health dental team in Gracias to develop a risk management program intended to improve oral health in school-aged children. The day began by engaging the local team in a dialogue in order to assess the needs of the community, the current state of oral health, and perceived barriers to care. The Honduran dentists identified the relationship between oral health and general health with an emphasis on oral infection and general infection being a common theme. The main barriers to care: access and resources. Once these were identified, together we prioritized the issues and set specific goals that are measurable, attainable, realistic and timely for this community (“SMART”).
Together with the local oral health team, we created a pilot program whereby supervised tooth brushing will be implemented in primary schools. The “PUFA” oral health evaluative system, which identifies infection, was introduced to the public health team and was accepted with enthusiasm to help determine baseline and outcome impacts of any intervention.
This system is best used in countries where decay rates are extremely high (90-99%). In such situations, assigning DMFT values alone would not be appropriate and a more advanced description of the stage of infection is needed. DMFT in this population would be in the region of 20/20 teeth for 90% of the population.
Research shows that supervised toothbrushing programs are one of the most effective ways to reduce caries rates. In high risk areas, such as rural Honduras, resources are scarce and a toothbrushing program can be a cost-effective way to reduce infection. For this reason, we decided, with the local dentists, to initiate a study in hopes of demonstrating how supervised toothbrushing can help reduce the prevalence of infection.
Following this initial meeting, we worked with the local dental team to hone their evaluation skills using the PUFA system. We visited a school in the district of Guanteque where each dentist scored the same children to ensure inter-rater reliability for the study. After these baseline PUFA scores were collected, we reviewed tooth brushing techniques with the school teacher to ensure that the toothbrushing program would be properly supervised. For some of these children, access to toothbrushes and toothpaste is scarce. It was very rewarding to see such excitement in these children as they showed off their brushing skills!
This pilot program will involve seven members of the public dental team who will be working in different communities. Each will be responsible for collecting data for the schools in their district to give a representative sample of rural Honduras. We have committed to supply the materials needed to drive this program for two years. The mayor of Gracias, who is also a dentist, was an enthusiastic supporter of developing this pilot project and promoting Gracias as a model for affecting cost effective sustainable interventions to improve overall health. In two years time, PUFA scores will be taken again and compared to the baseline scores. This will provide an information base to facilitate the design of prevention programs.
With the seeds of the study planted, the remainder of our trip was spent on daily pediatric brigades to under-serviced communities. News of our brigades quickly spread to surrounding villages, and there were people who walked for miles to visit the dentist. Every day we transformed a classroom into a mobile dental clinic. Children flooded into the room where they were first triaged and then directed to the proper area for care. Treatment included fluoride varnish, disinfection with iodine and silver nitrate, atraumatic restorative treatment (ART) and multiple extractions. All the children received toothbrushes, toothpaste, and instructions on proper toothbrushing technique. It was heartbreaking to see such an extent of infection and the impact it has on the children’s quality of life. Most children were malnourished and showed signs of failure to thrive, due in large part to their chronic dental pain. The question for us was not “are you in pain?”, but rather “which tooth hurts the most?” Although we were able to provide some pain relief, there is still much more work to be done.
This experience was enlightening in that it reinforced the idea that we as dentists should not be merely filling a hole or extracting a tooth, but rather managing a dynamic disease process. We are fortunate to have witnessed this at such an early stage in our dental careers. This has triggered a shift in us from focusing primarily on restorative care to prevention and health promotion, and taught us to see not only the tooth in question but more broadly the individual as a whole.
by Jessica Gold & Anna Urbano
Pressed with permission for the authors
INDEPENDENT CLINICAL STUDY FINDS THE CANARY SYSTEM TO BE SUPERIOR TO BITEWING RADIOGRAPHY
Toronto, Canada – New clinical research findings were announced last week in Boston at the International Association of Dental (IADR) Research General Session. Dr. Ben Amaechi from the University of Texas Health Science Center in San Antonio, who led an independent clinical study, found The Canary System® to exhibit superior performance compared to bitewing radiography for the detection of proximal caries.
Thirty subjects from a mixed population of caries risk patients were involved in the study. The authors of the study found the sensitivity/specificity of The Canary System to be 0.92/0.78 versus 0.67/0.54 for bitewing radiography. The authors of the study concluded that The Canary System is more accurate than bitewing radiography for proximal caries diagnosis.
“Bitewing radiographs and visual examination have been considered the gold standard for caries detection but this study along with others demonstrate that The Canary System should become the next gold standard for the detection and monitoring of tooth decay”, said Dr. Stephen Abrams, President of Quantum Dental Technologies Inc, the manufacturer of The Canary System.
Other research presented at IADR included a study showing the effectiveness of The Canary System for detecting smooth surface caries compared to radiography, DIAGNOdent, and Spectra; a study showing excellent intra- and inter-examiner reproducibility of The Canary System for scanning smooth and occlusal surfaces with natural decay; and a report demonstrating the power of combining cloud computing and The Canary System to provide epidemiological data and trends on caries prevalence among populations, age groups, geographies, and tooth type and surface.
The Canary System, with its unique crystal structure diagnostics, allows oral health professionals to detect, image, track and monitor tooth decay on all tooth surfaces, beneath opaque sealants, around the margins of restorations and detect cracks in teeth. The accompanying Canary Cloud (www.thecanarycloud.com) enables dentists to view and manage this data in an online environment, track Canary usage in the office, and keep up-to-date on Canary products and clinical news. With The Canary System, caries detection is not simply shining a light on a tooth surface but it’s about gathering accurate information on the status of the tooth’s crystal structure and then storing it to allow ongoing analysis and monitoring.
In October, I attended the University of Maryland’s Innovations in the Prevention and Treatment of Early Childhood Caries Conference: an intensive and very interesting update on the status of caries, the disease, and its various treatments.
A few things became quite clear: measuring oral health is difficult. Treating dental disease is challenging, labor intensive and extremely expensive. The currently accepted surgical approach to caries fails often and regularly and has a questionable return on investment: for example, the relapse rate of 52 to 79% after 24 months for children treated in the OR. Sobering statistics.
At one point during the conference, my notes morphed into a mind map. I placed CARIES at the center and filled the bubbles to the left of CARIES with the inherent qualities of teeth and the disease that destroys them. On the right side of the map I focused on the embarrassing statistics related to this PREVENTABLE disease.
What are we missing?
For one thing, the prevention we do in our clinics is based on a teach and tell model that fails to honor the ability of our patients to manage themselves. At the conference I learned about promising research projects focusing on filling that gap with Motivational Interviewing to help people change, video games to help teens change their health behaviors, saliva tests being developed in Japan to identify pathogens, the promises of xylitol.
What remains is: our current approach with caries prevents us from seeing the bigger picture: an oral microbiome out of balance from a 21st century diet loaded with sugars and fermentable carbohydrates, (malnutrition?) and compounded by the lack of oral hygiene facilities everywhere.
What is a dentist’s work?
It is hard to be a dentist. It is physically demanding and the work seemingly never ending. But there is more to the stress of being a dentist. In my search for authenticity and integrity, I have struggled with reconciling my construct of a successful dentist with the statistics relating to caries. It seems to me that I worked very hard to make very little difference. I would imagine that you, like me, also struggle with this dilemma, especially if you have a decade or 2 of practice behind your belt. This tension ate away at me, especially when I heard remarks on the cost of care or comments on how financially rewarding it must be to be a dentist. Somehow, I was never completely satisfied with my replies to these comments highlighting the fact that dentists are highly qualified health professionals.
What can we do to fill those gray areas on the diagram?
On September 12, 2014, FDI World Dental Federation launched its Data Hub for Global Oral Health a first of its kind online database collating oral health data from various international sources – including World Health Organization (WHO), Niigata University, Malmö University, World Bank and Globocan
The FDI Data Hub is an easy-to-use, one-stop-shop for global oral health data. It provides FDI members and policy makers with the tools to support and promote advocacy for the dental profession. As recognized by the United Nations, oral diseases pose a major health burden for many countries, share common risk factors and can benefit from common responses to non-communicable diseases (NCDs). Therefore, the FDI Data Hub includes the use of NCD risk factors together with oral health indicators. Click Data Hub for Global Oral Health to learn more.
A new book on the oral-systemic connection has just been published: “The Oral-Systemic Health Connection: a guide to patient care” – edited by Michael Glick, DMD.
It is a collection of 13 chapters on different topics ranging from “Causation, Association, and Oral Health-Systemic Disease Connections” to “Oral Manifestations of Systemic Diseases” and “The Traveling Oral Microbiome”. These chapters were written (some co-authored) by 19 different university professors in fields ranging from Periodontics to Oral Medicine.
I was pleasantly surprised by how easy the book was to read. While it had copious references and detailed scientific descriptions, it is written in a way that wet gloved dental professionals can easily understand. This is because of the many conclusions, summary boxes, color pictures, Figures, and other pages like “Clinical Considerations- What you can take back to your practice” interspersed throughout the book.
Upon completion of the book, I felt like I had been updated on the different facets of the science behind the O-S connection.
Here are a few outtakes from the book:
- “The notion that infections in the oral cavity may influence oral health is not a novel idea. More than 2,000 years ago, Hippocrates was credited with curing arthritis by extracting presumably infected teeth.” (Glick, preface)
- “Moving forward, oral health care providers should have a role in preventing and treating non communicable and communicable disease in an effort to reduce their associated morbidity and mortality,” (Greenberg, Chapter 1)
- “This concept is supported by the fact that currently there is no scientific evidence that identifies any particular bacteria as a cause of periodontitis.” (Borgnakke, Chapter 4)
- Oral conditions can significantly influence or be influenced by events locally and systemically.”(Freire and Van Dyke, Chapter 5)
- The target of periodontal therapy, whether it be control of the biofilm, and/or control of the local inflammation, should be to control systemic inflammation associated with chronic systemic diseases.”(Freire and Van Dyke, Chapter 5)
As you can see by my above quotes, I found the first 5 chapters to be the most interesting. The remaining chapters were on the O-S connection in diabetes, the cardiovascular system, obesity, pneumonia, pregnancy, immunocompromised patients, osteoporosis, and the oral manifestations of systemic diseases. The last 8 chapters addressed the clinical considerations of these maladies and how you can address them in your dental practice.
The negatives of the book for me were the price ($118.00) and no mention of how important it is to understand the dynamics of how people change their health behaviors and how dental professionals can learn how to facilitate this.
This book review was first published in www.SpiritOfCaring.com and is reprinted here with Lynn Carlisle’s permission.
To read more about the book visit Amazon Books The Oral-Systemic Health Connection: a Guide to Patient Care