Maximizing care through dental assistant expanded functions in a humanitarian mission. (The Army Goes Rolling Along ...).

ABSTRACT

Objective: Dental Readiness Training Exercises (DENRETEs) are the military form of dental humanitarian missions. Most dental humanitarian missions focus on extractions and the provision of oral hygiene instructions. This paper describes a dental humanitarian mission, sponsored by the US Army Dental Command (DENCOM), to Honduras in 2003 and how expanded function dental assistants can increase the provision of dental care.

Materials & Methods: The US Army Southern Command requested a DENRETE for fiscal year 2003. A site visit revealed the absence of water fluoridation, high levels of dental disease, and a desire to have an American dental team perform the mission at the Escuela Lempira, a low-income elementary school in the Honduran capital city of Tegucigalpa.

Results: DENCOM in conjunction with dental personnel performing a 6-month rotation with Joint Task Force Bravo performed a Pediatric Humanitarian mission in Tegucigalpa from 1 to 9 April 2003. During 6.5 treatment days, there were 416 patient encounters totaling 1490 treatment procedures. Over $90,000 in dental services were provided.

Conclusions: The 2003 Honduran DENRETE represented a changing paradigm from extraction-based dental missions toward providing comprehensive care aided by maximizing the use of dental assistants trained in expanded functions. With this philosophical shift in focused care, dental humanitarian missions have the ability to enhance the oral health of more children.

INTRODUCTION

Dental Readiness Training Exercises (DENRETEs) are the military version of humanitarian and civic assistance projects. DENRETEs provide military members with realistic training, facilitate access to healthcare for traditionally underserved populations, and provide an opportunity for professional exchange. This fostering of international cooperation between the U.S. Government and those countries being served promotes a favorable view of the United States. These missions also give military members an opportunity to use their professional skills in a deployed environment to help those less fortunate.

Military humanitarian projects have been widely used in Honduras, performing missions in remote areas where residents have little opportunity to benefit from medical care. Typical teams for general humanitarian missions include physicians, dentists, veterinarians, nurses, and pharmacists. (1) Dental services in general missions are traditionally limited to extractions, but some have recently been expanded to include dental sealants. Military humanitarian missions within Honduras are supported by Joint Task Force Bravo's (JTF-Bravo) Medical Element, located at Soto Cano Air Base. The Medical Element is the working liaison between the Honduran Ministry of Health and the United States Military Group in Tegucigalpa and is charged with coordinating each mission. JTF-Bravo also provides broad-spectrum logistical support to deploying teams; to include everything from vehicles and medical equipment to liaison personnel, translators, and communications.

The 2003 DENRETE is the second such mission to serve Honduras. The first mission was in 2002 and focused on providing comprehensive care and initiating a prevention program in the Escuela Lempira.

Many dental missions have been conducted in the past, but have been a part of general missions, which focus on primary care with only a small number of dental professionals on the team. The dental focus of these missions has been on extractions and the provisions of oral hygiene based on the staffing and focus of the mission. This DENRETE involved all of the steps required to deploy a dental unit from the U.S. to an austere environment and be able to provide a broad range of dental care. The major difference from a deployment was that the beneficiaries were indigenous patients from the host nation, but the ultimate training benefit was for those involved in the planning, deployment and execution, since they went through all of the steps similar to a deployment.

An exodontia-focused mission is relatively easy to support, as it requires minimal materials and equipment and can be predictably performed in a variety of environments. But it addresses only the lower spectrum of needs and provides only minimal postoperative follow-up for infection or complications such as bleeding or delayed healing. Even though there is instant payoff with the removal of teeth, this episodic type of care does not have a long-term impact upon the health of the population. As Weisser asserted in 1993, "If missions are evaluated with parameters other than emotion, there is found to be little durable effect and virtually no improvement in the health status of the host nation." (2)

To address the need for lasting changes, Weisser called for a change in missions to become more preventive in nature. Prevention oriented missions have the admirable goal of increasing the population well being through health education. This constitutes a much more difficult objective, one often compromised due to insufficient cultural knowledge, continuing poverty which makes long term compliance difficult or impossible, and inappropriate targeting of those to receive the health education.

To leverage the treatment capability and still keep the mission prevention oriented, the 2003 mission made a major change in the way patients were treated. Instead of using field dental equipment, we utilized the existing dental treatment facilities at the Catholic University Dental School in Tegucigalpa. This provided the opportunity for the two pediatric dentists to use six dental chairs, which created efficiency in patient treatment.

The second major change was that experienced dental assistants trained as preventive dentistry specialists were included in the team. These assistants all had prior training and experience in working in expanded functions in placing restorations. Four assistants were assigned to the two pediatric dentists in an effort to increase patient access and therefore patient treatment.

Previous research has shown that dental assistants can perform a wide range of duties when properly trained, including placing restorations, which also directly increases the productivity of dentists. (3-6)

The purpose of this paper is to describe the fundamental tenets of a comprehensive-based dental humanitarian mission to Honduras in 2003 aided by use of expanded function dental assistants and to contrast that to the traditional tooth-extraction based mission.

MATERIALS AND METHODS

The US Army Southern Command requested a DENRETE for fiscal year 2003. The US Army Dental Command (DENCOM) accepted the mission, with all coordination made through the JTF-Bravo Medical Element. The stated objective for this mission was to provide dental health treatment to an underserved inner-city pediatric population, and to initiate a dental public health prevention program.

The target population was the elementary school students of the Escuela Lempira, which has approximately 800 children in grades K through 6, divided between morning and afternoon sessions. Most children work in the nearby markets when not in school.

The First Lady of Honduras is heavily involved with the Healthy School Program, a Honduran charitable organization whose aim is to better the lives of children through community improvements in education, health, agriculture, and economic development. The Healthy School Program chose the Escuela Lempira to be the recipient of the dental care, as the school had been a participant in other Association programs. The students predominately came from economically disadvantaged families having limited or no access to dental care. One morning session of treatment was provided to 15 village children from Pailiguin, a remote village that the Catholic University supports.

Tegucigalpa is the capital of Honduras and has a population of more than one million residents. Over 50% of the country's populace are children under the age of 18 and more than one-half of the city's residents subsist below the Honduran poverty line for annual income. The pre-mission assessment revealed the absence of a community water fluoridation program. An alternate method of fluoridation utilizing fluoride-enriched table salt has not been instituted in the city or country similar to other Central American countries. Initial cursory examinations confirmed reports by Honduran officials that indeed the general oral health of the children is remarkably poor, and that the greatest impact for the long-term would come from a combination of a treatment and prevention oriented mission. Children from the Escuela Lempira seemed to have poor nutrition habits and we observed that they were constantly eating varying forms of candy as seen in Photo 1. Although the Escuela Lempira had a staff dentist, she had limited access to basic dental materials and was routinely limited to providing extractions. The presence of even this rudimentary dental clinic within the school provided a great opportunity to centralize preventive services, dental materials, and education for the staff dentist, so that the benefits offered these children during the mission would continue long after the team had departed.

In addition to the school site, the Catholic University Dental School was chosen to be the location for providing definitive dental care. This location met the mission needs for space availability, physical security, relative proximity to the Escuela Lempira and adequate chair space for the mission. The Dean of the Catholic University Dental School welcomed the opportunity to not only treat the underserved pediatric population, but also for their students and staff to participate in professional exchange. The Surgeon General of the Honduran Forces graciously proffered armed guards and transportation for the equipment and materials.

The composition of the team was important to reflect the nature of the mission. The 12 members included four military dentists, one local national dentist, one registered dental hygienist, four dental prevention specialists, and two military personnel who we trained as assistants. Photo 2 shows the four assistants who served as expanded function dental assistants. The public health dentist and one assistant were tasked with providing examinations, dental cleanings, pit & fissure sealants, and simple limited emergency care in the school dental clinic. The two pediatric dentists directed the remaining team members at the Catholic University location. The treatment team provided a broad spectrum of pediatric dental services, such as preventive care, simple and complex restorations, pulpal therapy, stainless steel crowns, and exodontia.

RESULTS

Mission personnel of the US Army Dental Command performed a dental humanitarian mission in Tegucigalpa, Honduras from 1 to 9 April 2003. During the 6.5 treatment days, there were 416 patient encounters totaling 1490 treatment procedures. In keeping with the comprehensive focus of the mission, 415 dental pit and fissure sealants, 242 restorations, and 55 stainless steel crowns were provided, as compared to only 251 extractions. There was a significant demand for definitive dental care. Given the volume of dental needs within the treatment population, several modifiers were in place to maintain the focus on preventive dental care. Extractions were performed only when active infection or pain existed and the definitive diagnosis warranted an extraction. Providers did not focus attention on non-restorable primary teeth that would exfoliate within 12 months. Prevention of future caries in the permanent dentition by placement of pit & fissure sealants, especially in the permanent first molars of younger patients was the primary objective.

Sealants, basic prophylaxis treatment and oral hygiene instructions composed a large portion of the workload of the dental assistants. Photo 3 shows one of the assistants giving tooth-brushing instruction. The dental assistants also placed basic amalgam and composite restorations, which freed up the dentists to treat additional patients.

The 2002 mission was composed of four military dentists and one local national dentist. It produced $76,412 worth of dentistry over nine treatment days. Field dental chairs were used which did not support multiple chair and expanded function dentistry. The 2003 mission had the same number of dentists as 2002, except that there were two pediatric dentists as compared to only one in 2002. The 2003 mission produced $91,077 worth of dentistry in only 6.5 treatment days and can be largely attributed to the ability to work with multiple chairs and the use of expanded function dental assistants. Figure 1 provides a summary of all dental procedures performed in 2002 and 2003, and also displays the dollar value of the direct dental services provided the children, based on the 75th percentile of US national fees for 1999.

Education in oral hygiene was stressed to all children and educators within the school. Children were given toothbrushes and toothpaste and the oral hygiene instruction for their proper use. Siblings were also supplied with toothbrushes as well, since many children commented that they did not have a toothbrush at home. Education and training of the school dentist and staff at the Catholic Dental School also played a vital part in preventing future disease.

DISCUSSION

It was evident that the children treated had an overall lack of access to dental care both from the private and public sector. Emergency care was available through the school dental program. Poor nutrition and numerous exposures to sugar are major drivers in the development of dental caries. Deficiencies in the diet and the lack of access to dental care results in poor oral health. It was a challenge for dental providers to look past active caries on some children, so that the maximum number of children could benefit from the mission. The public health perspective is to maximize the preventive effort, which dictates that not all disease can be addressed.

It is interesting to note that the military played a large role in the creation of expanded function dental auxiliaries in the U.S. During World War II there was a severe shortage of civilian dentists as thousands had entered military service. For the first time, on a large scale, U.S. dentists began delegating additional responsibilities to ancillaries to make up for the shortage. (7) There was a renewed fervor for expanded function assistants in the 1960's when there was a perceived critical shortage of U.S. dentists, and the federal government subsidized dental schools to operate Dental Auxiliary Utilization programs. The interest in expanded functions waned as the shortage of dentists was corrected. The overall objective of using dental assistants for expanded function is to increase the productivity of dentists. The use of expanded functions personnel allows us to address the oral health disparities of the children treated during the mission. The use of expanded functions during a treatment-based humanitarian mission proved to be extremely successful.

CONCLUSIONS

The 2003 Honduran Dental mission represented an effective paradigm shift from extraction-based dental missions to comprehensive care aided by expanded function dental assistants. By preventing future caries this pediatric population may enjoy increased oral health throughout their lives. Prevention practices offered to the children included dental sealants, professional topical fluoride applications, oral hygiene instruction, oral health literature, and the school fluoride mouthrinse program. It will be beneficial to evaluate the effectiveness of this school program during future DENRETEs to Honduras.

Figure 1. Procedures provided during the 2002 and 2003 Pediatric
DENRETE and the civilian Comparable Cost

Treatment Type        ADA     Dental       Number     Value of Services
                      Code   Weighted    Performed       (in dollars)
                              Value     2002   2003     2002      2003

Periodic Oral Eval   D0120     0.3       337    167   $10,110    $5,010
Limited Oral Eval    D0140     0.4         0    122         0    $4,880
Periapical
  Film--1st film     D0220     0.16       17      2      $272       $32

Periapical--each
  additional         D0230     0.12        2      0       $24         0
Periodontal
  Scaling            D4341     0.7         4      0      $280         0
Child Prophy         D1120     0.43        0     45         0    $1,935

Child Prophy with
  fluoride           D1201     0.60      130    129    $7,800    $7,740
Fluoride
  Treatments         D1203     0.25      120      0    $3,000         0
Oral Hygiene
  Instruction        D1330     0.34      123      0    $4,182         0

Group Oral Hygiene
 Instruction         D1331     0.55        4     37      $220    $2,035
Sealants             D1351     0.32      514    415   $16,448   $13,280
1 surface Amalgam
  (primary)          D2110     0.65       13      4      $845      $260

2 surface Amalgam
  (primary)          D2120     0.8         6      1      $480       $80
1 surface Amalgam
  (permanent)        D2140     0.75       29     51    $2,175    $3,825
2 surface Amalgam
  (permanent)        D2150     0.93        6     13      $558    $1,209

3 surface Amalgam
  (permanent)        D2160     1.11        1      3      $111      $333
1 surface
  composite,
  anterior           D2330     0.9        11     27      $990    $2,430
2 surface
  composite,
  anterior           D2331     1.15       23     18    $2,645    $2,070

3 surface
  composite,
  anterior           D2332     1.75        2      5      $350      $875
4 surface
  composite,
  anterior           D2335     1.75        0      2         0      $350
1 surface
  composite
  posterior,
  primary            D2380     0.87       10     34      $870    $2,958

1 surface
  composite
  posterior,
  permanent          D2385     1          60     72    $6,000    $7,200
2 surface
  composite
  posterior,
  primary            D2381     1.13        7      7      $791      $791
2 surface
  composite
  posterior,
  permanent          D2386     1.39        2      4      $278      $556

3 surface
  composite
  posterior,
  primary            D2382     1.44        2      0      $288         0
Prefabricated
  Stainless Steel
  Crown, primary     D2930     1.59       28     55    $4,452    $8,745
Sedative
  Restoration        D2940     0.65        0      2         0      $130

Pulp Cap, direct     D3110     0.5         2      0      $100         0
Pulp Cap,
  indirect           D3120     0.5         3      1      $150       $50
Therapeutic
  Pulpotomy          D3220     1.04       28     10    $2,912    $1,040

Anterior 1 canal
  endodontic
  therapy            D3310     4.15        1      0      $415         0
Scaling & Root
  planing            D4341     1.55       10      0    $1,550         0
Simple Extraction    D7110     0.9        82    160    $7,380   $14,400

Each additional
  extraction         D7120     0.85        3     88      $255    $7,480
Root removal         D7130     1.08        1      3      $108      $324
Surgical
  Extraction         D7210     1.75        4      0      $700         0

Biopsy Soft Tissue   D7286     2.89        0      1         0      $289
Sutures              D7910     1.33        1      0      $133         0
Behavior
  Management         D9920       --        0     10         0      $570

Odontoplasty         D9971     1.0         0      2         0      $200
Space Maintainer     D1510     2.5         7      0    $1,750         0

TOTALS                                  1593   1490   $76,412   $91,077

References

(1.) Wittich AC. The medical care system and medical readiness training exercises (MEDRETEs) in Honduras. Mil Med 1989; 154:19-22.

(2.) Weisser RJ, The maturing of MEDRETEs. Mil Med 1993;158:573-5.

(3.) Bergner M, Milgrom P, Chapko MK, et al. The Washington state dental auxiliary project: Quality of care in private practice. J Am Dent Assoc 1983;107:781-6.

(4.) Soricelli DA. Implementation of the delivery of dental services by auxiliaries: The Philadelphia experience. Am J Public Health 1972;62:1077-87.

(5.) Milgrom P, Bergner M, Chapko MK, et al. The Washington state dental auxiliary project: Delegating expanded functions in general practice. J Am Dent Assoc 1983:107;776-80.

(6.) Pelton WJ, Overstreet GA, Embry OH, Dilworth JB. Economic implications of adding one therapist to a practice. J Am Dent Assoc 1973;86:1301-9.

(7.) Burt BA, Eklund S. Dentistry, Dental Practice and the Community, 5th ed. WB Saunders Co, Philadelphia Pennsylvania, 1999.

Disclaimer: The views expressed in this article are those of the authors and do not reflect the official policy of the U.S. Department of Defense or other departments of the U.S. Government.

The authors are with the Dental Corps, US Army Dental Command: MAJ Jeffrey Chaffin, DDS, MPH is Public Health Dental Officer; SGM Stephen Spadaro is Dental Command Sergeant Major; and SFC Tina Pirofsky is Dental Prevention Specialist. All serve at Fort Sam Houston, TX.