HUMANITARIAN DENTAL ELECTIVES
Supervising national Dentists:
Page Title Page number
Section I: Planning our elective 5
A: Why we chose this elective 5
B: What we hoped to achieve ........... 5
C: How we planned our elective 6
Section II: Implementing our elective 8
A: First clinic – Miramar 8
B: Second clinic – Alto Trujillo ............ 11
C: Third clinic – Palmeras 14
D: Pregnant Mothers’ Dental Project 16
Section III: Work carried out in addition to our elective 20
Section IV: Conclusion to our elective 23
I: Email contact with Bruce Peru 26
II: Email contact with GC International ............. 30
III: Awards letters 32
IV: Country information about Peru 34
V: Useful Spanish phrases 36
VI: Risk assessment 37
VII: Travel tickets to Lima 39
VIII: Phrases from our translator 40
IX: Pregnant Mothers’ Dental Project information sheet 41
X: English exam 42
XI: Spanish lessons worksheet ............ 45
This is a descriptive account of a humanitarian elective carried out in Trujillo, Peru in July 2007. It consists of two parts: a description of our planning and execution of the project, and an appendix comprising our evidence of the work we carried out and further information.
SECTION 1: PLANNING OUR ELECTIVE
Why we chose this elective
As a group, we wished to carry out a humanitarian elective and each shared a common interest in Peru. There was a series of past elective projects in Lima, but we each felt it would be more of a challenge for us to establish our own individual project while providing treatment for a community away from the capital. While searching the internet for a charity in South America which would allow us to carry out dental work, we came across Bruce Peru which is part of the charity Agenda SOS. We were particularly interested in working with children through our experiences in Glasgow Dental School, and Bruce Peru’s operations were able to cater to us in this regard.
What we hoped to achieve
Firstly, we hoped to gain dental experience in a different environment from Glasgow Dental School whilst also being exposed to a foreign culture. Secondly, we hoped to have a small but positive effect on the dental health of the community we would be treating.
How we planned our elective
After discovering Bruce Peru, we established contact via email (appendix I) and found that they were open to the idea of us joining them for a period in the summer to carry out a dental project with their assistance. We were charged a fee of £180 each which would cover our food and accommodation for the 2 weeks we would be with them. Following consultation with our Glasgow supervisor, we were told we would require a dental supervisor for our project, and Bruce Peru were able to arrange this by allowing us access to local clinics and dentists. They were also able to provide us with a translator for the duration of our clinical time.
Bruce Peru provided us with a list of much-needed equipment, and we set about contacting dentists in each of our home regions, as well as dental suppliers for donations. As we knew we would be carrying out mainly atraumatic restorative treatment (ART), we contacted GC International, the manufacturers of Fuji IX, the recommended restorative material for this type of treatment (appendix II). We also applied for bursaries and awards relevant to the work we would be carrying out, and were awarded money by the Royal College of Surgeons and Physicians (Glasgow), the British Medical and Dental Students Trust and the Paediatrics Department of Glasgow Dental Hospital and School (appendix III). With the money we received, we purchased a large number of toothbrushes and toothpaste, and also our own personal protective equipment, such as our own tunics.
We enquired with British Airways about the possibility of transporting an additional piece of luggage to hold all our equipment, but they were unable to accommodate us. This meant we had to be selective in what personal items we took as all equipment had to be transported in our own bags.
In preparation for our stay, we researched Peru and in particular the area around Trujillo (appendix IV). This provided information about the local currency, customs, weather and transport which we believed we should be familiar with. We were also advised by previous elective students who were based in Peru as to essential Spanish phrases that they found to be particularly valuable both in the dental clinic and on a more general basis (appendix V)
In addition to researching the area, we also carried out a risk assessment (appendix VI) which included general safety advice, advice specific to traveling and to the area, and highlighted the need for certain vaccinations such as rabies, yellow fever, typhoid and hepatitis A. The money we were awarded helped greatly in financing this.
Bruce Peru assisted us in planning our transport to Trujillo. We were instructed to fly into Lima Airport (appendix VII) where we were to be collected by a Bruce Peru representative called Leonardo Moya. From there we would be taken to our hostel in Lima where we decided we wished to spend the first two nights. From Lima, we would purchase bus tickets to Trujillo with the view to reaching Bruce Peru by the weekend, ready to start work on the Monday morning.
SECTION 2: IMPLEMENTING OUR ELECTIVE
First clinic: Miramar
Our first visit was to Miramar, a barrio (shanty town) set in the outskirts of Trujillo. The clinic was set in purpose build breezeblock construction which also housed the local health centre for the area. The dental clinic was operated by a full time dentist, Jose Lopez, who acted as our supervisor for the 2 days we spent there. The patients we treated were the children from the local school established by Bruce Peru, their mothers, and the women involved in the economic project also run by Bruce Peru. All treatment provided by ourselves was free, and this held true for all treatment provided at subsequent clinics.
The room we operated in consisted of only one dental unit, a bench and a white plastic chair, and we were required to use the instruments, materials and personal protective equipment we had brought with us. The dental unit had no water spray so irrigation was required when using the high-speed. A slow-speed drill was not available. We had not brought any forceps with us, but we were able to borrow Dr Lopez’s only set – these were upper universals which was not ideal when deciduous teeth were to be extracted. Dr Lopez was responsible for taking the instruments to be sterlised to an autoclave outside the dental surgery, in the medical section of the health centre All restorations were provided using Fuji IX, which we had brought with us, as there were no filling materials available for us in the clinic.
At first, we organised the patients as follows: each patient was seen initially in the white plastic chair for an examination, on a first-come-first-served basis. If there was obvious decay which would require a high-speed instrumentation, they were moved to the dental unit. If the decay could be treated with ART, this was carried out with the patient sitting on the bench, and extractions were also carried out here. If only scaling or tooth-brushing instruction was required, this was carried out on the white chair. This set up was not ideal, either for the patients or for ourselves as the operators, but the objective we set out to achieve was to treat as many patients as possible in the short time we had, as effectively as possible.
After evaluating our first day at Dr Lopez’s surgery, we concluded it would be more efficient to have one nurse assisting for two dentists. In order for everyone to experience an equal share of dental work, the nursing role would be alternated at a regular basis. This practice was carried out on the second day in Miramar. We found this rearrangement to have a positive outcome as it not only allowed the dentists to concentrate fully on the delivery of treatment but also reduced the time taken to mix Fuji IX and obtain instruments.
We occasionally observed that a lower standard of dental care had been provided for some of the patients. An example of this was a 12 year old boy whose lower right six had been restored with a composite material which was dislodged with the application of the three-in-one. Due to time constraints we could only restore the cavity with Fuji IX although we felt amalgam would have been a better option. Further examples of treatment included scalings, restoring deciduous teeth using the ART method and extractions of unrestorable teeth. Each patient who attended this and all subsequent clinics was given TBI and provided with a toothbrush and a small tube of toothpaste.
Second clinic: Alto Trujillo
The first group of patients we saw consisted of children from the Alto Trujillo school who required a mixture of restorations and oral hygiene instruction. Treatment examples included: an occlusal restoration on a lower right six of a 13 year old patient – done with some difficulty due to the patient’s unwillingness to cooperate with treatment and the lack of water spray on the highspeed meant repeated pauses in treatment to allow the patient to rinse; the restoration of a carious fissure pattern on the upper left six of a 10 year old patient – the lack of small burs for the highspeed made for an unavoidable yet unnecessarily large preparation; and an 8 year old boy with severe gingivitis, who received toothbrushing instructions. Later on in the morning, we also treated a group of the pregnant women. Treatments included the extraction of retained roots and some restorations.
With only one of the chairs having a functioning highspeed, we treated the patients as we had done in the first clinic: assessment, ART and extractions in the chair with no highspeed, and reserved the other chair for restorations requiring the drill. As in Miramar, there would be two operators and one nurse working at all times.
The second morning started with treating patients who we had assessed the previous day, but had been unable to treat due to time constraints. The first of these patients was a lady in her twenties in need of restorations in each of her four present lower molars. Due to time constraints and the queue of patients outside, it was decided that she would receive one filling, but was told she would need to return when the regular clinics began again to have the others treated. Attaining anaesthesia proved difficult, something we had grown accustomed to because of the short needles the clinics stocked. The patient however was content to let the treatment progress however, as she found the IDB more concerning than the drilling.
More children from the charity’s school arrived for assessment, including one girl with a labially displaced, horizontally positioned lower left C. The treatment plan was to extract the tooth, but the girl refused treatment. Other patients seen that morning included ladies from the business enterprise project who had been told of our arrival, treatment examples including class III restorations on upper centrals and toothbrushing instruction for a pregnant lady with a clear case of pregnancy gingivitis.
Photograph of the labially displaced, horizontally positioned lower left C
The most interesting patient seen however was also our youngest. An 18 month old baby was presented for assessment and Sheylla demonstrated the knee to knee arrangement of mother and dentist that allowed for assessment of the child’s mouth with the child lying across both laps. One of us was allowed to follow her lead and assess the child ourself. The baby’s compunction to cry at the top of its voice made for a rather straightforward assessment of its teeth, which were in an excellent condition.
The third and final day at the Alto Trujillo clinic was completed quickly and consisted of a list of 6 patients only. We learned that there was currently a strike by public health workers and by treating patients the day before we had essentially crossed a picket line and unsurprisingly there were some annoyed people within the clinic and we really shouldn’t have been allowed to treat anyone at all that day. We were very thankful to Sheylla for agreeing to supervise us and let us continue with our elective.
The group of patients consisted of women from the business enterprise group, and one girl who was actively pursuing a career in nursing and was volunteering at the clinic. She had assisted with dental procedures and allegedly enjoyed them very much. We were unable to treat her however as our Fuji material would not provide a good shade match with her teeth and the proposed restoration would have ruined her lovely smile. Treatments which were carried out included upper anterior class IIIs, the extraction of an upper right 8 and the restoration of a lower left 6.
Third clinic: Palmeras
We visited this clinic in the afternoon rather than the mornings as usual. This was more dangerous, as we had been told only to go into the barrios before afternoon as in the past some volunteers associated with Bruce Peru had experienced trouble at the hands of gangs in the area. However, we were taxied directly to the clinic, and the taxi waited at the door to take us straight back once we were finished.
The clinic was set in the local health centre and was the best equipped of the three. There was one working dental unit with high speed, a light and extra instruments that we could borrow, including different forceps. There were also 2 supervising dentists who were attending to their own patients at the same time.
We again used a system whereby one person assessed the patient on a plastic chair, and if they required treatment in the dental unit they were transferred to that chair. If disease could be managed with ART, this was carried out in the plastic chair, as were scalings, oral hygiene instruction and toothbrushing instruction. Our translator assisted us in this by holding a hand-held torch as lighting was poor.
The patients treated here were, again, the children from the local Bruce Peru school and their mothers. As in previous clinics we carried out predominantly extractions and ART, with OHI and TBI provided for all patients.
View of the barrio from outside the Palmeras clinic
The Pregnant Mothers’ Dental Project
Due to the strike in Peru there were no dentists available for our last day working with Bruce Peru. We were therefore unable to run the dental clinics which then led us to the idea for the Pregnant Mothers’ Dental Project.
Bruce Peru was managing a project called “The Pregnant Mothers’ Project” which was designed to give support to young pregnant women from the shanty towns. A group of young pregnant women would meet a helper from Bruce Peru who would support the mothers to reassure them and build up their confidence. This included activities such and group knitting and yoga classes.
We decided to organise a similar project to “Childsmile” which is in place here in Scotland, which we hoped would teach the pregnant mothers the importance of caring for their childrens’ teeth and equip them with the knowledge of how to do so.
We hoped to achieve the following:
We researched the “Childsmile” website and chose the key points regarding oral hygiene and dietary advice. We then decided on a format for an information sheet which we would provide along with a childrens’ toothbrush and appropriate toothpaste to each mother. It was decided to make the information sheet A5 size and laminated, with one side informing the mothers about plaque and the problems it can cause, and the other side providing oral hygiene and dietary advice (appendix IX). A draft version was typed in English which was then translated into Spanish by a Spanish speaking Bruce Peru volunteer. Some illustrations were then added from the internet and the information sheet was printed in colour and laminated. The information sheet was placed in a small bag with three tubes of fluoride toothpaste, a children’s toothbrush and a pair of child’s socks for each mother.
The kits we made up for the Pregnant Mothers’ Dental Project
The Pregnant Mothers Visit
On our last day working with Bruce Peru we were taken to the pregnant mothers group in Alto Trujillo with our translator, Franco. The group was held in a children’s classroom so there was a whiteboard and several tables and stools. It was explained to the pregnant mothers why we were visiting them, and each mother was given a bag with all its contents.
We started by explaining to the pregnant mothers about plaque. This involved explaining what it was and how it builds up on the teeth, as well as the damage it can cause to the teeth and the gingivae if not removed properly.
A plan of a child’s dentition was drawn on the whiteboard to show the order in which the teeth normally erupt. It was explained to the pregnant mothers that they must brush their child’s teeth from the point when the first teeth are erupting, and the mothers were then told what age they should expect to see their child teeth erupting at.
We then explained to the mothers how good oral hygiene could be achieved by providing them with tooth brushing instructions and dietary advice for when their child’s teeth had erupted. This was done using a combination of diagrams on the whiteboard to show the areas in the mouth and the surfaces of each tooth that must be brushed, and by referring to the information sheet so they could see how to hold their baby whilst brushing his or her teeth. With dietary advice, it was recommended that only milk and water should be given to the children, and to replace sugary snacks such as sweets and chocolate with savoury snacks and fruit and vegetables where possible. It was also explained why they should reduce snacking between meal times and the mothers were told to avoid giving their child a bottle of milk or juice at bedtime.
The packs and the information both appeared to be well received by the mothers, and Bruce Peru were supportive of continuing the project after we left as we made up several extra packs to be given out to new mothers joining the programme.
The women involved in the Pregnant Mothers’ Project
SECTION 3: WORK CARRIED OUT IN ADDITION TO OUR ELECTIVE
Bruce Peru is an organisation which predominantly aims to educate street children and help to eradicate poverty in South America. In the centre we joined in Trujillo, there were many projects running concurrently which were able to observe and help out in, as well as carrying out our own dental project. Bruce himself wanted us to have an overview of the organisation as a whole, so we could understand his own aims and objectives for the charity. This would mean we would have an understanding of how we fit into the charity as a whole, rather than only being aware of our own project and impact. The other projects we observed and volunteered in were:
Teaching children in the barrios
This is one of the major projects Bruce Peru has established. It involves at least one Peruvian volunteer and one foreign volunteer visiting one of the schools in the barrios from 9am until 1pm. Work would involve helping the children who attend to improve their Spanish literacy so that they can enter mainstream schools, which requires an entrance exam to be passed before a child can enrol. The children are also each provided with a sandwich (made by the volunteers in the morning on a rota basis) and a drink after classes finish. We each attended a different school on our first morning and helped with reading, writing, drawing and sports.
This is an economic project designed to help South American women to help themselves, rather than relying on handouts from Bruce Peru. The women are given help to design a business plan from volunteers from Bruce Peru and also by business students at the local college, and the organisation essentially acts as their business partner. They meet every Tuesday for follow-up sessions and training where, depending how well they are doing in improving their home lives and how well they are caring for their children, they are helped to progress, part of which involves giving more money to the business they have established. We observed one of these sessions and had the opportunity to speak to the women in the project who set up, for example, jewellery making, bakery, vulcanising tyres, cafes and many other businesses. The women were also given the opportunity for free dental treatment from us in the clinic nearest to them, which was Miramar.
Adult English classes
These were held in the main Bruce Peru centre, where all the foreign volunteers lived together. There were 3 classrooms, and classes were held at 6pm, 7pm and 8pm. All volunteers were required to donate some of their time to take one of these classes each day, ourselves being no exception. We taught an intermediate class grammar and conversational English and were required to set an exam to be taken by the adult pupils before they could progress to the next class (appendix X).
Volunteer Spanish classes
These were available twice a week to all volunteers to improve any Spanish they may already have been able to speak and to build on this (appendix XI). It was taken by one of the Peruvian volunteers and was valuable for communication not only in the clinic with patients and supervisors, but in the city as well, where English speakers are very rare.
SECTION 4: CONCLUSIONS FROM OUR ELECTIVE
On the whole the experience was positive. Some aspects were not as we had envisaged when planning the elective, for example we only worked half days, i.e. 9-1pm when we had anticipated that we would be able to work whole days. We had expected there to be some equipment we would be able to borrow but we only had access to the instruments we had brought with us. We had hoped to have a working dental unit each with nursing support, but this was not experienced in any of the clinics. We expected dental units to be similar to those in the dental school, for example with aspiration and water spray, but this was not the case. Cross infection control was more lax than that which we experience in the dental school, for example in some cases only one bur was available and this was wiped down with alcohol between patients.
Oral health and hygiene in Peru was comparable to what we experience treating patients from the west of Scotland. This was probably due to the fact that toothbrushes were not viewed as essential items, and sweets and fizzy juice (particularly Inca Kola) were readily available. Oral health education was not emphasised by schools or primary care physicians, which is something we tried to address while we were there.
What we gained from the experience
In general, we thoroughly enjoyed both the dental work and the experience of living and working with a charity. Each of us now feels much more confident in caries diagnosis and efficient treatment and assessment of patients to form a basic treatment plan. This was due to the fact that we were relied on to examine and treat patients independently, with the supervisor acting essentially in an advisory capacity, and in case of emergencies. We developed our communication skills as we had to work in accordance with our translator who had no dental experience.
We enhanced our time management skills and our ability to organise patients in an efficient manner. This was due to a relatively slow pace of work on our first day as we realised our setup was ineffective. We devised amongst ourselves a nursing rota which relied on our teamwork skills and allowed us to observe and advise each other, providing a second opinion where necessary. This helped to give us confidence in the decisions that we made.
In addition to the dental work, we felt confident enough to develop the Pregnant Mothers’ Dental Project, something which we had not planned or even contemplated before arriving in Peru. The experience of developing and implementing a project which was entirely our own was particularly satisfying. We also feel it has the potential to be sustained by Bruce Peru for the foreseeable future.
After delivering treatment, we were also personally thanked by some patients for coming to Peru to provide this service, which gave a feeling of great satisfaction. We feel privileged to have gained this insight and to experience dentistry in a developing country which does not have the same health care support as we benefit from, and it helped us to realise how fortunate we are to live and work in Britain.
Outside the Palmeras clinic with our translator, Franco