Approaches to clinical care

Let’s start with this scenario: a dental clinician travels to work in a remote community.  He/she has spent most of their 20 year career working in an inner city private practice.  On day one in the community clinic they see more dental decay than they would usually see in one month in their city practice.

This scenario could be found in Australia or overseas.  Where do they start?  They are way out of their comfort zone of implants, fixed prostheses, tooth whitening and bleaching.

Firstly, we hope they don’t lecture people about how negligent they’ve been in looking after their teeth.  Chances are the person will never come back and most likely won’t take notice of any advice.

We can’t tell dental personnel how to practise their dentistry, but we can offer some experiences of others, combined with what the evidence tells us is effective.

KIDS

The basic dental “toolbox” ie program “tools”:

  • regular dental screening, risk identification, early detection of problems
  • pit and fissure sealing permanent teeth molars particularly
  • fissure protection with GIC
  • regular fluoride applications (fluoride varnish)
  • caries management in the primary teeth – see below in “Treating kids atraumatically”
  • judicious use of the various forms of GIC for caries management, fissure protection, restorations.

If the local school cooperates to supervise daily school based toothbrushing, then this is even better.

Documentation is critical – caries rates, kids at risk, services provided.  Immediate access to necessary dental treatment is also critical – “No survey without service”, Dr Fred Hollows 1993 ie don’t screen, record, have fun with showing kids how to clean teeth, and then leave town.

Treating kids atraumatically

Kids from remote communities don’t have to end up in hospitals for general dental treatment under general anaesthesia.  Yes there might be a lot of dental caries, poor diet, no brushing, but let’s look at some options.

Think wholistically and not on a tooth by tooth basis. Caries management is vital.  Technique notes for atraumatic procedures for child patients in outreach dental programmes is a very informative manual and guideline written by Drs Graham Craig and Keith Powell, based on years of treatments and observations in remote communities.

For kids, trying to fill every decayed primary tooth is not always necessary.  Caries control, caries arrestment with Silver Fluoride, opening out lesions to avoid food impaction in primary teeth and opening them up to the beneficial effects of saliva, minimal intervention dentistry, fluoride applications, safeguarding the future of permanent molars.

Preservation of erupted/partly erupted permanent teeth is paramount, and should be attended to (ie application of sealants whether GIC or composite resin types), fluoride, protection, whatever is appropriate) as a very high priority in treatment.  Glass ionomer cements in their various forms can be used for caries control, fissure protection, fissure sealing, as well as general tooth restoration.

Silver fluoride (AgF) is very effective in arresting and controlling dental caries.  See Resources for further information.

ADULTS

In the areas TT is likely to visit, adults tend to come for relief of pain, or for a “clean” ie removal of long term calculus.

It can be tempting to just remove the painful tooth. However experienced remote area dentists discuss the issues with the person seeking care, and can attempt some caries control in other non-painful decayed teeth, removing gross caries, cleaning margins, and placing GIC in the same visit. AgF could also be considered in some cases for open lesion caries arrestment eg root surfaces.

Some dentists will go further and – if appropriate and the person is happy and time and resources permit – will do a one-stage root canal treatment.

Calculus removal – consider carefully.  Sometimes we see “structural calculus” which, if removed, would lead to tooth loss of mobile teeth.  Discussions with periodontists indicate a once-only complete scaling of long term and widespread calculus is pretty ineffective if the program is such that the person won’t be seen again eg single and occasional outreach visits. It could also cause some acute problems: small fragments of calculus can lodge into the base of the gingival/periodontal pocket, get trapped as the margins heal, and infections occur.