Case Notes:
Grant and Vishal
(Dental outreach, Ghana )

 

On the 9 July 2007, in Ghana, West Africa, we embarked upon a Dental Outreach project. Together with three students from University of Newcastle Dental School, a team of four from University of Ghana Dental School (UGDS) and Work the World, we set up a free clinic in an area with no access to dental care.

Using the UGDS mobile unit and our temporary extraction clinic, we provided 942 courses of treatment to 820 patients over a three week period. In addition, 4000 patients were screened from 15 schools and 680 were found to be in need of treatment.

The aim of our elective was to provide free dental treatment to as many people as possible who normally have no access to a dentist. In doing so we hoped to build on our previous clinical experience and become more confident, particularly at extracting teeth, whilst gaining an insight into dentistry in a developing country.

The decision to undertake a humanitarian elective was an easy one. Finding somewhere suitable to carry out such a project with our specific aims was to prove more difficult. The starting point for our elective was the internet. We also spent much time speaking to senior colleagues (SHOs and final year students) who had carried out similar projects in the past. Everyone we spoke to had found their project enjoyable and fulfilling, but most had wished they could have spent more time actually providing dental treatment.

We researched countless organisations and projects in various countries including: Cambodia; Cuba; Ecuador; India; Jamaica; Mexico; Peru and Tanzania. For all of these countries we found sites for different charities and religious groups who operate some form of humanitarian dental relief. After careful consideration and scrutiny of both the country in question and the organisation, we narrowed our choices down to Cambodia, Tanzania and Ghana.

We got in touch with Work the World (WTW), who specialise in organising medical based electives in third world countries. Much information was gained from talking to their experienced staff, particularly about the African countries. WTW have operated in Ghana for four years and have formed many close partnerships with hospitals in order to provide electives for medical students. Having never before been involved in dental outreach projects, WTW were to pilot a three week programme during July and we were keen to be involved in this new venture. We were attracted to the 24hour emergency support WTW could offer us while in Ghana, and the ground work they were prepared to do to make this elective successful.

WTW were responsible for organising the logistics of our elective. This role involved on the ground research in Ghana in collaboration with UGDS prior to our arrival to arrange a suitable area for our project and obtain the necessary permission. A Ghanaian dental team (one dentist, 2 nurses and 1 technician) were employed on our behalf, and accommodation, food and transport were all secured. WTW’s Ghanaian co-ordinator stayed with the team for most of the project to ensure its smooth running.

UGDS is the only dental training facility in the country and is situated within Korle-Bu, a large medical and teaching hospital campus on the western outskirts of the capital city Accra. Ten dentists graduate each year, and this number is set to increase in the future with the proposed opening of a second training facility in Kumasi, the country’s second largest city. Many of the academic staff at UGDS have carried out part of their training in the UK. The dental course content appears very similar to that taught here, covering all aspects of modern dental care and laboratory work.

The first day of our project was spent in UGDS, where we were given a tour and the freedom to roam and assist in clinics. Supplies were organised and the mobile dental unit prepared for transit.

Our project base was located in the eastern region of Ghana (2hours north-west of Accra) in the town of Akwatia, which is known mainly for its diamond mines. Our base was at St Dominic’s Hospital, a very well maintained establishment run by missionaries. For our clinic, we had the use of a large room with its adjacent outdoor waiting area. Beside this there was space to park the mobile unit.

Screening clinics

Each morning, we operated a screening clinic between 20km and 30km from our clinic. These were usually held at randomly selected primary schools, and often one or two other schools would arrive for check-ups whilst we were there. The screening clinic team consisted of two UK team members, our driver/translator, and either the DCO or WTW co-ordinator.

Upon our arrival, teachers from the school would be taught oral hygiene instructions and given the ‘oversized model mouth’ so as they could then teach small groups of children whilst we proceeded with the screening.

A table with gloves, alcohol gel and wooden spatulas would be set up in an area of good light, and each clinician would sit at either end of the table with a teacher. Every child and teacher would then have a dental inspection.

Any tooth requiring restoration or extraction was noted along with age and sex, and the patient was given a slip of paper outlining the required treatment and stating where our clinic was. Children with heavy calculus deposits were also referred. Toothpaste and toothbrushes were issued to those with the worst oral health, and painkillers and antibiotics were in our kit bag should they be required.

Screening would normally be finished by late morning and the screening team would be back in time for our afternoon clinic at St Dominic’s.

Treatment area

We set up the room as our inspection and extraction clinic. Teeth requiring restoration were referred to the unit, although the atraumatic restorative technique (ART) was also carried out in the room depending on waiting time for the mobile unit.

In the mornings two project members would run the extraction clinic under the supervision of the Ghanaian dentist. In the afternoons there would be up to four extraction chairs in operation. One project member would work in the mobile unit with the assistance of a nurse, and the other nurse would be responsible for decontamination. Our technician would maintain the unit and help with translation, note taking and post-operative instructions. The role of the dentist was to give practical advice, assist whenever difficulties arose, make decisions regarding referrals and issue painkillers and antibiotics as appropriate.

The mobile dental unit

The UGDS mobile dental unit was parked outside our extraction room beside our waiting area for the duration of the project, and was reserved mainly for restorations. This fully equipped, air-conditioned unit with autoclave was gifted to UGDS 3 years ago, but is rarely used due to lack of funds.

Treatments offered

Treatment was always underway by 9am and would finish at about 5.30pm. The treatments we offered were extractions, restorations and limited scaling. Extractions were carried out under local anaesthetic. Extraction sockets were packed with gauze until haemostatis attained, and post-operative instructions were given in Twi, the local language. Sutures were placed as required. Painkillers were issued to all extraction patients. Antibiotics were issued if required.

Glass ionomer was the main restorative material used. Amalgam was available in our second week although it had a long set time (and suspected high mercury content). Composite was used in the final week when we had obtained a curing light.

Dietary sugar advice and oral hygiene instruction were given to patients on an individual basis and we offered limited scaling. Our scaling instruments were fairly blunt making removing calculus a slow process. In view of this, we felt our time was better spent treating patients in pain, and patients requiring scaling were referred to UGDS. Patients with impacted lower third molars and tumours were also referred for treatment at UGDS.

Treatment allocation

Treatment was allocated on a first-come-first-serve basis. Each morning there would be 20-30 patients awaiting our arrival, some of whom had spent the night in the waiting area. Keeping track of who was next was impossible as many hospital staff took the liberty of joining the queue at the front. Numbered tickets were issued to the patients to reduce this problem and we aimed to treat any child with a screening clinic ticket as soon as possible, as it was known they had travelled far. There was only one day where we treated all the patients in the waiting area. Every other day, patients were turned away or ‘sacked’. This was perhaps the most difficult part of our elective.

Cross infection control

Masks and protective glasses were worn at all times. Hands were washed between each patient and new gloves worn. Alcohol hand gel was also used and surfaces were cleaned with alcohol wipes regularly. Instrument trays were covered with a plastic bag before each patient to prevent the tray from becoming soiled. After each patient, the covering was removed and turned inside-out such that any clinical waste would now be contained in the bag, ready for disposal. All instruments were first disinfected in Hypochlorite solution for ten minutes before being scrubbed and visually inspected for residue. They were then transferred to a different bucket of the same solution for a further 20min before being rendered fit for use. Several buckets were set up to cope with high instrument turnover, with each bucket having a time sheet to eliminate confusion. All instruments were autoclaved twice a day: once at lunchtime; and again at the end of the day. The decontamination corner was set out in a contemporary manner with a continuous flow from dirty through to clean. All sharps were disposed of in a proper sharps bin.

Accommodation, transport and food

Our accommodation was in the neighbouring town of Kade approximately 8-10km from St Dominic’s. All ten team members lived together in a basic but comfortable guest house. We ate both breakfast and lunch in the hospital canteen. Each morning we would all be picked up in the 4x4 at 7.30am and our breakfast would be ready by the time we reached St Dominic’s. Lunch was taken whenever suited, but tended to be quite late. Each night we went straight from work to have dinner at Birim Court, an eatery situated beside the river Birim, between Kade and Akwatia.

WTW’s Ghanaian co-ordinator worked very hard to ensure that we never had to worry about accommodation, transport and food, allowing us to concentrate on the task in hand.

Project visitors

Over the duration of our project we had some visitors who were not seeking dental treatment. German missionaries on an HIV awareness programme looked in to wish us well. Four African television crews invaded our clinic to run a story on our project, having been invited by the local District Chief Executive.

Dr Sackeyfio, Professor of Dental Public Health at UGDS came up for a day to show her support despite having been recently bereaved.

Dr. Francis Ababio, President of Ghana Medical Association was most interested in our programme and dropped in for two days offering his assistance, advice and encouragement.

Conclusion

We gained so much valuable experience from working in Ghana. Our confidence and skills for a wide range of dental procedures has improved vast amounts. We became competent at various extraction techniques and learnt how to place sutures. Treating so many patients allowed us get an idea of the dental health of the population and their degree of dental awareness. Due to the lack of dental care, many conditions we observed had progressed to an extent that would not be seen in the UK.

Living and working with Ghanaians allowed us to form friendships and gain a better understanding of the cultures and language surrounding us. Teamwork was central to the success of this elective, which brought together so many people from different organisations.

Spending time in UGDS afforded us an insight into how dental treatment is usually provided in Ghana, and how dentistry is taught. We became aware of the pressures and rewards of running a dental clinic, and at times found the project both physically demanding and emotionally challenging.

For us, this elective helped to put many things into perspective, not just with regards to dentistry, but also with the world as a whole.