A Mobile Dental System in Southern Africa - Wiley Online Library

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ity, limited financial resources, and a maldistribution of ... unique, purpose-built, mobile dental unit (MDU). From a ... Assessment of the MDU indicates that it is.
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Vol. 52, No. 2, Winter 1992

A Mobile Dental System in Southern Africa Michael J. Rudolph, MPH, MSc Usuf M. E. Chikte, M Dent Helen A. Lewis, Cert. of Proficiency in Dental Hygiene Department of Community Dentistry University of the Witwatersrand Private Bag X15 Braamfontein 2017, South Africa

Abstract Recent studies indicate a great need for dental treatment and preventive services in dentally underserved communitiesin southernAfrica. Geographic inaccessibility, limited financial resources, and a maldistribution of dental personnel are the main barriers to oral health care. This project describes the evolution and utilization of a unique, purpose-built, mobile dental unit (MDU). From a compact 2 x 2.5 meter box trailer, an enclosed area of 8 x 9 meters is formed by deploying a cover system housed on top of the trailer. Once deployed, the unit becomes four fully equipped dental operatories and a combined waiting and educational area, with all-weatherprotection. Comprehensive care is provided by dental auxiliaries. The underlying philosophy of the service is based on the primary oral health care approach. To date, the MDU has visited a wide variety of rural and urban communities where several thousand patients have been examined and treated. Assessment of the MDU indicates that it is an effective and viable alternative oral health delivery system. Key Words: mobile dental unit, auxiliary personnel, primary oral health care, student training.

South Africa and its people have a unique and complex socioeconomic, cultural, and political makeup. The consequencesof these factors include where and how people live, the education they receive, jobs, health care, and the type of political representation they are permitted, all of which affect health, including oral health. According to the last official census (1985), the total population in South Africa was 33,272,100. The black racial group made up by far the majority of the population (73%)'were the least urbanized, and had a typical Third-World population structure, with a large proportion being children under 15 years of age (43%)(1).They were the least healthy, with an unacceptably low life Send correspondence and reprint requests to Prof. Rudolph. Manuscript received: 11/2/90; returned to authors for revision: 11/29/90; accepted for publication: 3/25/91.

J Public Health Dent 1992;52(2):59-63

expectancy, poor nutritional status, and high infant mortality rate. The whites were more urbanized, had a typical First-World aging population, and were healthier, judged by WHO indicators.The colored and Indian populations fell between these two extremes, with Indians being closer to whites and coloreds closer to blacks (2).

...alternative methods of oral health care delivey were required t o meet the overwhelming needs of the underserved rural and urban populations." 'I

Health services in South Africa are deficient, and available care does not meet the needs of many communities. Public health services are fragmented; at present, the private health sector is dominant, resulting in disparities in accessibility,availability, and affordability of services. Epidemiologic Trends. Research in South and southem Africa has shown a wide range of patterns of oral disease. In rural black communities a very low prevalence of dental canes among 12- and 15-year-old children has been demonstrated (3). Due to the lack of dental services in these areas, there is an enormous backlog of dental treatment. Adults in the rural areas have been shown to have many untreated lesions, with large numbers of teeth lost as a result of caries and moderate levels of periodontal disease (4). The prevalence of caries in urban black and Indian schoolchildren has been described as increasing (5),and similarly with rural groups where dental services are limited and the number of untreated lesions is high (6). Moderate to high canes prevalence in colored groups has been reported by S t e p et al. (7). A high prevalence of bleeding and calculus was found in urban black children (8) and moderate pocketing and periodontal disease in the urban and rural black adult communities (9). Oral Health Personnel. Most dentists and oral hygienists (80%)work in the private sector (10). Dental therapists have been trained in South Africa for the past 15 years expressly to provide essential primary oral care to underserved communities. By law, all dental therapists

Journal of Public Health Dentistry

60 FIGURE 1 The Mobile Dental Unit

Storage rack %

Work Statlon (dupllcate of opposite side)

are employed by the state in public health services and are required to function under the direct supervision of dentists. Barriers to Oral Care. The geographic spread of the black rural population over vast and often isolated areas makes access to dental care difficult. In urban areas the critical shortage of oral health personnel in public services and inadequate facilities are insufficient to cope with increasing levels of oral disease and demand for treatment. Strongcultural bamers, as a result of people’s knowledge, beliefs, and attitudes regarding oral care, further affect utilization of services (11). The complete picture must be seen against the present background of rapidly escalating costs in dental care delivery, a drastic cutback in government spending, and the low priority that oral health occupies in many communities, particularly in the midst of recent dramatic sociopolitical changes. It was clear from the information outlined above that alternative methods of oral health care delivery were required to meet the overwhelming needs of the un-

derserved rural and urban populations. Thus, the Department of Community Dentistry, University of Witwatersrand, Johannesburg, undertook to investigate the feasibility of a mobile dental unit using the primary health care approach as outlined at Alma Ata (12). This paper describesthe evolution, development, and utilization of a purpose-built mobile dental unit during the period 1988-90. Mobile Clinics The introduction of mobile clinics into dentistry dates back to 1924. They have been successfully used to provide dental treatment to schools, disabled patients, rural communities,industries, and the armed forces of various countries (13). Different combinations of oral health personnel have been employed to staff mobile clinics, including dental and dental auxiliary students, qualified dentists, dental therapists, and oral hygienists (14,15). Types of mobile facilities reported in the literature are portable dental equipment transported by air or road, specially modified

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Vol. 52, No. 2, Winter 1992 TABLE 1 Distribution of Services Rendered during 1988 Treatment Urban Treatment Exams Scaling and polishing OH1

Fissure sealants Amalgams Composites Temporary fillings Extractions Fluoride treatments Total

Rural

Number

Number

%

911 381 387 642 96 28 224 434 18 3,121

%

1,216 301

29 12 12 21 3 1 7 14 1

Number

%

2,127 682 387 657 305 60 224 1,723 19 6,184

34 11 7 11 5 1 4 28 0 100

39 10 0

0 15 209 32

1

7 1

0

0 42 0 100

1,289 1 3,063

100

Total

TABLE 2 Treatment from 1988 to May 1990 1988

Treatment Exams Scaling and polishing OH1

Fissure sealants Amalgams Composites Temporary fillings Extractions Total patients

1990 (May)

1989

Urban

Rural

Urban

Rural

Urban

911 381 387 642

1,216 301

2,098 626 427 207

269 267 267

96 28 224 434 3,121

209 32

146 76 79 845 2,286

-

2,061 292 317 171 358 83 575 1,053 2,773

-

15

1,289 3,063

trucks, dental caravans, and pantechnicons (13). These mobile units have facilitated a range of treatment and services to communities (16,17). In some projects the maintenance of mobile clinics and portable dental equipment has been reported as problematic, mainly due to the use of highly specialized equipment and limited access to technical and mechanical backup (18). Evolution and Description of the Mobile Dental Unit. The special requirements of the large, dentally underserved southern African community and the rugged, often difficult, terrain required a sturdy multidelivery unit with easy maneuverability. The design of the unit is unique, and evolved through consultation with the Council for Scientific and Industrial Research, who specialized in innovative mechanical design. In addition, dental suppliers and their technical support staff were consulted for their specialist knowledge of dental equipment. The united comprises a 2 x 2.5 meter box trailer that can be towed by a four-wheel drive vehicle over any type

-

-

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of terrain and deployed in almost any weather conditions. By deploying a weather-proof canvas cover, housed on the roof of the trailer, the compact box trailer is transformed into four fully equipped dental operatories with a combined educationaland waiting area (Figure 1). This deployment is achieved by operating a remote control device that activatesa series of electricallydriven arms. Once deployed, the cover is anchored by means of guy ropes. Each of the two sides of the unit is equipped with dental consoles that are stored on overhead delivery rails. When drawn out of their housing, the consoles facilitate four patients being treated simultaneously. The design of each work station allows for fourhanded or solo operating mode. The third module of the unit, which is housed in the rear, functions as a health education and reception area. It is equipped with a television monitor, video cassette recorder, slide projector, and a selection of slide programs. In addition, the unit carries a wide range of health education posters and pamphlets in all languages.

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The unit is further equipped with a generator and compressor, a central suction system, four specially designed patient couches, eight operator and assistant chairs, and ten folding chairs (used in the reception/health education area). Work surfaces and cabinets are provided for instruments, materials, and medicaments and patient-record cards. All the necessary equipment and support items required for four fully equipped dental surgeries are provided and stored on the unit. It can be deployed in 45 minutes, from arrival on site to treating the first patients; once deployed, it remains on site until all treatment is completed. An alarm system is fitted to provide extra security. The staffing complement during the period of utilization comprised two oral hygienists, two dental therapists, a chairside assistant, and a project coordinator. Activities during 1988-90. From previous experience in dentally underserved areas, the demand for treatment was expected to be far higher than the staff could reasonably be expected to cope with. Therefore, in both rural and urban areas, target groups were identified and selected for the provision of comprehensive care. Other patients requesting treatment were provided with emergency care. In rural areas, nurses, teachers, and schoolchildren were chosen as target groups and the unit was sited at different hospitals. In urban areas schoolchildren and teachers were selected as target groups from specific schools, mainly as a result of previous involvement thak had indicated an enormous need for curative and preventive services. All treatment was provided free of charge, which included examinations, scalings and polishings, group health education, individual oral hygiene instruction, fluoride treatments, fissure sealants, amalgam and composite restorations, extractions, and minor oral surgery. In addition to providing a much-needed service, the unit was used as a springboard for a number of research projects and student training. The project offers students the opportunity for acquiring clinical skillsand facilitates the application of the principles of community service. It also exposes students to communities and the specific health needs of people different from that with which they are familiar. It orients students toward a value system based on service to others and reflects the stated attitudes and policy of the University of the Witwatersrand. Results and Discussion Evaluation of treatment services was based on collection and analysis of some quantitative, but primarily qualitative,data. Apart from initial technical difficulties, the unit functioned adequately in many different environmental and climatic conditions. Careful organization enabled the provision of preventive and curative care to many patients, as well as group health education deliv-

ered in the reception/education area. During 1988 the mobile dental unit delivered curative and preventive servicesto 6,184 patients, with 46 percent of treatment oriented toward prevention (Table 1). A number of investigations were conducted using the unit during 1988, including an assessment of the suitability of schoolteachersand nurses as oral health educators, and the effectiveness of an anticalculus toothpaste. Less time was spent in the rural areas during 1989 and, overall, fewer patients were seen; however, there was an increase in the number of scaling, polishing, and restorative procedures done. The first few months of 1990 demonstrated a productive working period as a result of minimum technical interruption (Table 2). An encouraging amount of preventive treatment was provided in urban areas. Most of the extractions carried out in the urban areas were of primary teeth and, in the rural areas, permanent teeth. The care provided by the oral health auxiliary personnel was of high quality, effective, and appropriate, which confirmed reports of other studies (19). Team effort was an important factor when working with large groups and resulted in satisfactory productivity and efficiency of care. Although effective in treatment delivery, there were factors limiting the efficiency of the service. In the urban areas clinical work at schools was often reduced to only three hours a day because of lengthy traveling time and the relatively short school day. Initially, several working days were lost due to technical and mechanical problems, confirmingthe reported experiencesof other mobile dental unit programs. Nevertheless, the overall results have been positive and experience with the unit demonstrated that it was a viable means of providing a dental service. It has made a high standard of primary oral care available to rural childrenand adults, underserved schoolchildren, and mentally and physically disabled patients, and has used teams of oral health auxiliary personnel effectively. Acknowledgments The authors wish to acknowledge Colgate-Palmolive (SA) for their generous financial support and ongoing interest in this project.

References 1. Policies for a new urban future: population trends. Johannesburg, South Africa: Urban Foundation, 19W12. 2. Rationale for a National Health Service in South Africa. University of Witwatersrand: Centre for Health Policy, 1990. 3. Chlkte UME, Rudolph MI, Smith A. Dental caries of 12- and 15year-old children in Gazankulu. Community Dent Oral Epidemiol 1991;19:237-8. 4. Rudolph MJ, Brand AA. Oral health status of patients seeing emergency dental care in the Transkei. J Dent Assoc SA 1989;44:105-8. 5. Cleaton-JonesPE, Richardson BD, Setzer S, Williams SDL. Primary dentition trends, 1976-81, in four South African populations. Community Dent Oral Epidemiol1983;11:312-16. 6. Cleaton-JonesPE, Hargreaves JA, Roberts G ,WilliamsSDL, Leidal TI. The dmfs and dmft of young South African children. Community Dent Oral Epidemiol1989;173840. 7. Steyn NP, Albertse EC, van Wyk Kotze TJ,van Wyk CW,van Eck M. Sucrose consumption and dental caries in 12-year-old children

Vol. 52, No. 2, Winter 1992 of all ethnic groups residing in Cape Town. J Dent Assoc SA 1987;42:43-9. 8. Chikte UME, Gugushe TS, Rudolph MJ, Reinach SG. Dental caries prevalence and CPITNof 12-year-oldrural schoolchildren in Trans kei. J Dent AssocSA 1990;45:245-9. 9. Chikte UME, Kekana D, Brand AA, Rudolph MI. Oral health status and treatment needsof teachersin Gazankulu [Abstract].J Dent Res 1991;69:1088. 10. Smith M, CleatomJones PE. Dentists in the RSA, 1972 and 1982. A study of geographicspreadand dentist to population ratios. J Dent Assoc SA 1985;40:467-72. 11. Blackie DC. Cultural barriers to preventive dentistry. Aust Dent J 1979;24398-401. 12. Sheiham A, Barmes DE. The goals and strategies of community dentistry in developing countries. In: Granath L, McHugh WD. Systematized prevention of oral disease, theory and practice. B o a Raton, FL:CRC Press, 1986:21519. 13. Jeboda SO. Mobile dental dinics-their place in dental public

63 health. Odontostomatol Trop 1981;1:53-8. 14. Gordon M, Ronen E, Kusner W. A new type of mobile dental clinic developed following the Lebanon war, 1982. Israel J Med scl 198420366-8. 15. Ellis RL, Ingham F. A mobile dental clinic program as part of the dental curriculum.Can Dent Assoc J 1985;2:125-9. 16. Collins WJ. Experience with a mobile fissure sealing unit in the greater Glasgow area: results after three years. Community Dent Health 1985;2:195-202. 17. Robinson E, Bagramian RA. The community practice program at the University of Michigan, Ann Arbor, USA. Community Dent Oral Epidemiol1974;2:269-72. 18. Titley KC. TheSiouxLookoutdentalcareproject: a progressreport. Can Dent Assoc J 197339:793-6. 19. Report of Working Group of Fcideration Dentaire Internationale and World Health Organisation. C h a n p g patterns of oral health and implications for oral health manpower: part 1. Int Dent J 198535235-51.