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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
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?
Our surroundings influence how we come together and how we come together in turn influences how we speak with one another. Knowing these fundamental facts, Dr. Ian McConnachie, Dr. Clive S. Friedman, Dr. Stephan Abrams and myself, Dr. Marielle Pariseau, launched a workshop this morning to facilitate a different kind of working conversation at the heart of ASM14, the Ontario Dental Association’s Annual Spring Meeting.
This workshop embodies a different way of learning that has the capacity to engage and empower our membership in dealing with the many concerns that have been identified with regards to the present and future of dentistry. It models an agile style of leadership that sees a leader in every chair in the room and it uses conversation as a core process around questions that invite all participants to make choices today to positively influence the future of dentistry.
We put a lot of thought in creating a space for this workshop that would give participants a new perspective, a sense of belonging, of connection with their inner wisdom and that of others around them. A space to inspire participants to move from knowing deep inside what to do, to talking about it, and to actually doing it.
The vision at the core of this process is
EMPOWERING ALL DENTISTS TO BE
LEADERS IN HEALTH
A spark was ignited this morning as a result of this workshop. As a participant, we invite you to keep the spark alive with your comments. The rules are the same as the ones we presented during the workshop:* Be mindful * Be willing to be influenced * Set aside your preconceived conclusions, your judgement * Comment from your heart * Engage your right brain: your left brain may be very smart, but without your right brain you can not see the whole picture
If you were not a participant this morning, May 9 2014, we welcome your comments too. However, if you find it difficult to express your inner wisdom in writing, we understand. This is normal. We learn to speak before we learn to write and this is WHY we created this workshop, to give dentists a chance to speak first. You may want to contact us to explore the possibilities of hosting a Shaping the Future of Dentistry workshop at the heart of your dental community.
“Fed Up” was a hot topic during the Sundance Film Festival this year. The movie exposes how the food industry replaced the fat content in “light” and “low fat” food items with sugar. Medical experts and powerful newsmakers also expose the relationship between the food industry and the US government.
One of the facts that caught my attention is the time frame during which the shift from fat to sugar began: in the late 70’s. In the early 80’s the benefits of water fluoridation reached a plateau. Dentists assumed at the time that the plateau indicated the limitations of water fluoridation. But knowing that the frequency of carbohydrates consumption leads to an increase in numbers of acidogenic bacteria, I am now thinking that the fluoride added to community water supplies was no longer able to cope with the new challenge. Today, while many parents consider cereals a healthy way to start the day, most breakfast cereals contain so much sugar, they should be labelled as dessert.
Another fact that shocked me was that the World Health Organization’s recommendation from 2002, that sugars should make up less than 10% of total energy intake per day was not only silenced by the food industry, but increased to 25%.
The film follows the lives of a group of obese children over the course of two years as they diet and exercise in an effort to become healthier. Some scenes are heart breaking. Interestingly though, there is not a single mention of the caries or early childhood caries epidemic. Nothing new here. Oral health is seldom included in total health. But what if dentists could reverse this state of things? Are dentists Fed Up enough of being left out of the health equation to do something about it? Are we ready to take a stand against sugar to finally connect the mouth to the rest of the body?
Fed Up opens in theatres across United States on May the 9th. An eye opener on what is making America so sick, caries not included. Dentists, see the movie, support the WHO’s recommendations regarding maximum daily sugar intake and embrace the FDI’s vision of oral health as the foundation to overall health.
What if dentists approached findings that indicate an imbalance in the mouth as a far more serious warning sign, like canaries dying in yesteryears’ mines?
An article titled Added Sugar Intake and Cardiovascular Diseases Mortality Among US Adults earlier this week in JAMA Internal Medicine created a flood of headlines in news papers across the country.
In Chicago • Could too much sugar be deadly? The biggest study of its kind suggests the answer is yes, at least when it comes to fatal heart problems.
In a nutshell, researchers conducting this large study found a significant relationship between added sugar consumption and increased risk for cardio-vascular disease mortality.
It doesn’t take all that much extra sugar, hidden in many processed foods, to substantially raise the risk, the researchers found, and most Americans eat more than the safest amount.
How does dentistry and teeth fit in this story? It’s been known for a long time that the frequent consumption of sugar, hidden or not, causes havoc in the mouth. It promotes the growth of acidogenic / aciduric bacteria, which leads to an imbalance in the demineralization / remineralization cycles, and this in turn eventually results in tooth decay.
Dentists regularly see signs of this kind of imbalance in their patients’ mouth and address such findings with therapeutic recommendations and / or interventions directly applied to the teeth. What if dentists could offer more than fillings and pretty smiles as their contribution to health care?
WHAT IF DENTISTS APPROACHED FINDINGS THAT INDICATE AN IMBALANCE IN THE MOUTH AS A FAR MORE SERIOUS WARNING SIGN, LIKE CANARIES DYING IN YESTERYEARS’ MINES?
COULD DENTISTS THEN CHANGE THE COURSE OF HEALTH AND HEALTH CARE?
It is becoming increasingly evident that excessive sugar consumption causes damage at the cellular level which eventually leads to organs and systems damage. Most organs and systems in the human body are not easily accessible, enabling many diseases to morph into silent killers. The mouth, on the other hand, is very easily accessible, yielding itself to examination quite nicely, with up to 32 canaries offering clues as to what is happening lower down in the mine. Think about this!