Hammond, Trevor Hodge, Gavin Caves, Shirley Scola and Dr Richard Pilley â together with Dr Chern Chern. Ling, a Malaysian national, established the ...
focus on cambodia
Foundations for excellence The team, from left to right, are Veasna, Sythan Yin, Chern Chern Ling, Tola Khoun, Valine Sann and Kim Huy
to achieve this it was decided a number of Cambodians should be trained to a level of specialist expertise enabling them to also teach future postgraduates and to run a department where a complete range of patients could be treated. Finally, in 2004 a team of five UK nationals – Dr Hammond, Trevor Hodge, Gavin Caves, Shirley Scola and Dr Richard Pilley – together with Dr Chern Chern Ling, a Malaysian national, established the Cambodian Orthodontic Training Programme. The College’s exams system provides a unique method of benchmarking the standards of individuals from around the globe; an important factor in helping to put together the initial and subsequent teams in this project because it ensures a common core knowledge and approach to the management of clinical problems. After successful application and interview, four Khmer dentists who spoke English and worked part of their time for the government (with the intention that they remain
“The process of training appropriate clinicians is a gradual one and requires commitment and dedication, with a long-term vision” The clinicians involved in Cambodia’s first orthodontic cleft progamme reveal the years of work leading to the service’s launch in 2012
C
ambodia is one of the world’s poorest countries (listed in the low-income category by the World Bank), where the average life expectancy myanmar is 65 years and at least a quarter of the population aged over 15 years old is illiterate. Agriculture makes up the bulk of the economy and, increasingly, garment production and tourism provide a significant amount of income. Cambodia is still recovering from the time of the Khmer Rouge regime (1975–79) in which more than 2 million Khmer people were killed. During this period the dental profession was almost annihilated and the
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dental school in Phnom Penh stripped bare. The training of dentists resumed in the late-1980s, although with little specialist education occurring in the years after and, to date, there is still no comprehensive multidisciplinary team carrying out cleft vietnam lip and palate work in the country. LAOS Establishing a cleft lip and palate service in the ‘developing’ world can often be a challenge because of a lack of resources Thailand and infrastructure. To develop a sustainable service where there is a lack of trained personnel locally cambodia it is important to create training programmes to match the oral health needs and the infrastructure of the
country. The process of training appropriate clinicians is a gradual one and requires commitment and dedication, combined with a long-term vision to achieve the goal of a multidisciplinary team for patients with cleft lip and palate.
Establishing an orthodontic programme After a number of visits to Cambodia in the years leading up to 2003, Dr Jon Hammond (Consultant Orthodontist, Edinburgh Dental Institute) and the late Dr Paul Smith (Specialist Orthodontist, London) set about establishing an orthodontic programme. The location of the sole training institute for dentists in Cambodia dictated where the programme would be set up – the Faculty of OdontoStomatology, University of Health Sciences, Phnom Penh. The intention of the project was to lay a foundation of theoretical knowledge and clinical skill in orthodontics, which in time could be developed into a clinical specialty capable of matching that in any ‘developed’ nation. In order
in government employment at the end of the period of training) were enrolled on a three-year postgraduate diploma course in orthodontics starting in the autumn of 2004. In line with good practice, all the training was undertaken by registered specialists currently working in the field of orthodontics. Supervision of training and patient management was made possible locally by Dr Ling and the team of visiting specialists from the UK attending the faculty on an individual basis approximately once a year, supervising cases, and delivering lectures and tutorials. As well as the teaching of case diagnosis and patient care at the clinic, secure electronic transmission of case records allowed for continued input by members of the UK team on their return home. The students who were appointed – Sythan Yin, Thin Ly, Sovannrithy Mom and Phoung Mey – made the project a success through hard work and determination. At the time of completion of their clinical training in 2012 this cohort of students became part of the first Cambodian www.rcsed.ac.uk | 21
focus on cambodia
Profile:
Dr Chern Chern Ling MOrth RCSEd is the only member of the College based in Cambodia Where did you train and in which specialty? I did my undergraduate training in Malaysia and specialty orthodontic training and MOrth RCSEd in Singapore. How did you become involved with OMF International in Cambodia? Since Cambodia opened up in the early 1990s, OMF International has had a presence there to help rebuild the country. I joined OMF International in 1996 to contribute to the development of dental training at the University of Health Sciences in Phnom Penh. What’s the most enjoyable aspect of your work? Transferring values, knowledge and skills to locals. And secondly, parents of cleft babies keeping their babies instead of ‘throwing them away’ when they know that the cleft clinic has services to treat and support them. What have been the project’s main achievements over the past decade? Seeing locals empowered to teach orthodontics and provide quality treatment to patients. A family learns about oral hygiene at the cleft clinic
postgraduate dental course to have run through to its conclusion, and with no students having dropped out. In 2013, all four students also successfully defended their MSc theses. Alongside clinical training, other skills necessary for continued success of the programme were also taught, including research skills training, managing budgets, material purchasing, patient charging and – importantly – a need to train further cohorts of orthodontists was also identified. With this in mind a second group of students was appointed in 2009 – Trak Sam Ouen, Kak Tola, Seng Sochenda and Sann Valine. Now, with the assistance of the first cohort and the continued support of Dr Ling, Dr Hammond and Trevor Hodge this group is also near to the completion of its MSc training.
Early progress As would happen in the UK before embarking on cleft orthodontic care, the students needed to be trained on more routine orthodontic cases. Cases were identified and taken on using the Index of Orthodontic Treatment Need (IOTN) and training requirements to give the students exposure to a wide range of appliance types and malocclusion. In addition, the number of cases taken on for treatment among the first cohort was dictated by material resource (e.g., orthodontic brackets, arch wire availability, etc.) and the fact the students were part-time. This was the result of supervisor availability and the fact that the students themselves worked in private
“The first cohort scored very highly on quality of treatment” 22 | Surgeons’ News Global | March 2014
What’s the most challenging aspect? Lack of funding and infrastructure.
clinics as dentists to provide an income for themselves and their families. Of the cases taken on for treatment, 30% had a class-I malocclusion, 27% a class-II division-1 malocclusion, 2% a class-II division-2 malocclusion, and 41% a class-III malocclusion. While this does not entirely represent the breakdown of malocclusion because it occurs in the general Khmer population, it is clear that there is a far greater proportion of class-III malocclusions in this ethnic group than compared with a Caucasian population. Using the well-regarded Peer Assessment Rating (PAR) index to assign a score to each occlusal trait that makes up a malocclusion we reviewed the difference between the pre- and post-treatment PAR scores for all class-II division-1 and class-III cases (right) to look at the degree of orthodontic improvement as a result of orthodontic intervention. A mean percentage reduction in weighted PAR is considered high when there is a greater than 70% reduction. From these scores it can be seen that the students scored very highly on the quality of their treatment outcomes.
Where are we now? In 2011, the team was joined by Dr Peter Fowler – a cleft orthodontist in Christchurch, New Zealand – who, along with Dr Hammond and Dr Ling, was able to concentrate on the next stage of developing the cleft service. From this came the organisation Friends of Clefts in Cambodia, the aims of which are to: lH elp individuals born with a cleft to achieve their innate potential, enabling them to both integrate and contribute to the society in which they live. This may require not
Outcome of Class-II division-1 treatments
25.2
Average PAR score reduction
86 % Percentage
PAR reduction
14.4%
S.D.
Outcome of Class-III treatments
32.6
Average PAR score reduction
89.22 % Percentage PAR reduction
6.62%
S.D.
only medical but educational and psychological support lU se international and local expertise working in collaboration to establish and support interdisciplinary teams for the treatment of cleft lip, palate and craniofacial anomalies lC oncentrate on the provision of non-surgical cleft care, including speech and hearing, dental and orthodontic treatment, to support all surgical providers within Cambodia regardless of race, religion and gender, or of which organisation provided the primary surgery. This recognises that primary surgical treatment alone for patients with orofacial clefts does not complete the journey to full recovery and integration within their communities and families lU ndertake training and support for local Khmer personnel and those long-term foreign allied health professionals involved in cleft care in Cambodia lP romote core values of efficiency, quality, respect, mutuality, empowerment and sustainability The specialist orthodontic clinic at the National Pediatric Hospital in Phnom Penh was opened in July 2012. Sythan Yin, a graduate from the first cohort of students, was appointed orthodontic clinical lead. Following her initial training she had spent a year as a visiting fellow sponsored by the Noordhoff Foundation at its craniofacial unit in Taiwan learning about orthodontic cleft management. She is supported in the provision of orthodontic care by Dr Ling, who has undertaken additional cleft training in Singapore, and Dr Fowler and Dr Hammond, both members of cleft teams in their own countries. Links have been established with local speech and language therapists, while paediatric dentists Dr Sokpheakny and Tola Khoun are working alongside the team at the National Pediatric
Clockwise from left: Seng Sochenda, Sythan Yin, Trevor Hodge and Sovannrithy Mom, who are training future examiners
Hospital. Technical and nursing support is provided by Kim Huy. Orthodontic referrals are being taken from several surgical teams and, in addition, the targeted use of presurgical orthopaedics – e.g., nasoalveolar moulding (NAM) to facilitate primary surgery is being offered by the team. Advice and feeding support is being given in an environment where parents of newborn cleft patients can see they are not alone and opportunities are provided for parents to speak to others who have children born with clefts. All patients are being entered on to the Crux Cleft Database by Veasna, a team member who classifies the presentation of the cleft patient according to the criteria outlined by Harkins et al., and records are being collected to monitor the results of treatment in the long term. The recruitment of babies to the unit is also exciting, and it is particularly good to see interventions undertaken at the optimal earliest stage and much-needed preventative advice being given at the outset, especially with respect to diet and dental caries. In the near future it is hoped that other team members will be recruited to undertake some of the general nursing duties, while establishing a Cleft Lip and Palate Association (CLAPA) support group will be helpful in supporting those affected and in fund-raising for the service.
Trevor Hodge Consultant Orthodontist, Leeds Dental Hospital, UK Chern Chern Ling Specialist Orthodontist, National Pediatric Hospital and Faculty of Odonto-Stomatology, University of Health Sciences, Phnom Penh
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