Pitts NB, Evans DJ, Nugent ZJ. The dental caries experience of 12-year-old children in the United Kingdom. Surveys coordinated by the British Association for the Study of Community Dentistry in 1996/1997. Community Dent Hlth. 1998; 15:(1)49-54
The Vine Trust's Amazon Hope Project is a medical and dental programme providing healthcare to communities along the Amazon River in Peru. Volunteers from the UK and other countries work alongside Peruvian staff employed by their partner organization, Union Biblica del Peru, to provide a health service from a boat which serves communities on several tributaries who otherwise would have no other access to care. The dental programme involves a basic restorative and extraction service, with scope to develop a preventive programme.
Clinical Relevance: Dentists' and DCPs' skills are transferable globally: this article illustrates how one volunteer dental project is working to provide relevant and sustainable dental health care in the Amazon jungle.
Article
The Peruvian Amazon basin is an area covering over 140,000 square miles in the north of the country. In the region of Loreto lies Iquitos, the capital of the Peruvian jungle. It has a population of about 600,000 and is only accessible by air or river (Figure 1). Iquitos is a huge river port on the Amazon connecting Peru with the Atlantic Ocean nearly 3000 km away. Many tributaries flow into the river system in this area, and it is along some of these tributaries that a pair of small refurbished UK naval tenders sail, providing medical and dental care to a remote population of around 100,000 people.
Figure 1. A map of Peru, showing the relationship of the city of Iquitos to the Amazon River and the area the Amazon Hope boats are serving.
The boats were donated to a Scottish charity called ‘The Vine Trust’ (SC017386, www.vinetrust.org), a charity which seeks to enable volunteers to make a real and significant difference to some of the poorest communities in the world, building the capacity of local partners to meet local needs in the areas of children, enterprise and healthcare.
The Vine Trust was established in 1985 and became involved with Peru in the early 90s. From work with street children followed micro-enterprises which enabled projects to become sustainable. The first boat was donated from the UK in 2001 to be a ferry project, supporting work with street children, but a series of events led it to being converted into a medical boat. In October 2004, the first UK medical volunteer team went out to work on the Amazon. The healthcare project was, and continues to be, developed alongside and with the full co-operation of local government and healthcare authorities. There are now two boats serving in this area (Figure 2) carrying a full, employed Peruvian medical team and crew, including three doctors, one of whom is now the medical director of the project, and a full-time dentist. A boat is out serving one of the river populations for 10–14 days, 22 times a year (Table 1). Each trip affords the opportunity for a volunteer team from the UK or other country to work alongside the Peruvian team. A volunteer team consists of up to eight people, which may include 2–3 doctors, 1–2 dentists, dental hygienists or therapists, nurses, dental nurses, physiotherapists, even opticians. The scheduling of the visits to the river systems ensures that we reach the same people every three months, providing a reliable healthcare service.
Figure 2. The Amazon Hope 1.
Month
Number
Date
River
Boat
January
1
16.1 to 1.2
Amazonas
AH1
February
2
3.2 to 10.2
Manati
AH1
3
13.2 to 26.2
Ucayali
AH2
March
4
27.2 to 8.3
Puinahua
AH2
5
13.3 to 25.3
Tigre
AH1
April
6
3.4 to 15.4
Marañón
AH1
7
17.4 to 29.4
Amazonas
AH2
May
8
1.5 to 10.5
Manati
AH2
9
22.5 to 4.6
Ucayali
AH1
June
10
5.6 to 14.6
Puinahua
AH1
11
19.6 to 1.7
Tigre
AH2
July
12
3.7 to 15.7
Marañón
AH2
13
17.7 to 29.7
Amazonas
AH2
August
14
31.7 to 12.8
Ucayali
AH1
15
14.8 to 26.8
Puinahua
AH1
September
16
4.9 to 13.9
Tigre
AH2
17
18.9 to 30.9
Marañón
AH1
October
18
9.10 to 21.10
Amazonas
AH1
19
2.10 to 4.11
Manati
AH2
November
20
6.11 to 19.11
Ucayali
AH1
21
20.11 to 29.11
Puinahua
AH2
December
22
27.11 to 2.12
Ophthalmic campaign
AH1
The value of dental volunteering
In recent times, there has been much discussion and deliberate consideration of the value of volunteer dental projects in developing countries.1,2 Reservations have included the inability to make a lasting impact, the danger of undermining a local health service and raising expectations of care provision which cannot be sustained. At the BDA Conference in May 2011, a seminar was held and a paper subsequently published3 on issues to be considered when looking at how we can use our valuable dental skills to aid peoples and countries with limited resources. From this meeting, the lead of a steering group composed of a variety of representatives of dental volunteer programmes, Ian Wilson of Bridge2Aid, has proposed the following draft resolution (email communication):
Dental Charities can make a significant contribution to global oral health.
A paradigm shift in approach is required to ensure capacity building and strengthening of the primary health system in developing nations. It is suggested that emphasis on prevention and pain relief take priority as representative of the basic package of oral care [see later]. Partnerships are essential between dental charities, private sector, governments and individuals to ensure effective delivery of programmes.
The careful development of the Amazon Hope project means that this service already fulfils the objectives of such a resolution.
Working conditions and treatment provision
The original boat, the Amazon Hope 1 has been refurbished twice and now boasts a comfortable and well-equipped dental surgery (Figure 3). All materials and equipment were sourced locally, therefore helping the local economy and ensuring maintenance systems are available. The surgery on Amazon Hope 2 was installed and equipped in the UK by BAe Systems in 2005 prior to the boat sailing from the UK to Iquitos. The boats are fully air-conditioned.
Figure 3. The dental surgery on Amazon Hope 1.
To ensure that the communities visited receive the same care provision, a set of guidelines for dental treatment has been developed in collaboration with the Peruvian dentist on the project (available on request).
The treatment provided on the boat is basic but consistent – simple conservation or extractions. Data collected from the author's three most recent trips show that 672 dental patients were treated over 28 working days, ranging in age from 5–77 (Figure 4). This reflects the population profile (Figure 5) as reported by the Pan American Health Organization (PAHO) in September 2004.4 For restorations, there is composite for anterior teeth and amalgam for posteriors, glass ionomer and temporary materials are also available. The majority of our materials are now provided through a partnership agreement with the Vine Trust with International Health Partners (www.ihpuk.org) who are currently working with Henry Schein® to develop free packs of dental materials and consumables for this and other dental projects.
Figure 4. The age range and frequency of the 672 dental patients attended to over three trips (February 2010, June 2010, January 2011).Figure 5. Population structure by age and sex, Peru. PAHO, 2004.4
Treatment needs can vary from village to village and river to river as poverty levels and village organizational systems vary. Some of the larger villages have government run medical posts but these are often poorly staffed. There is officially one doctor to serve a population of 100,000. There are no dentists. On a recent trip we found a dental chair inside a hut which had a sign outside saying ‘teeth extracted here’ (Figure 6). The story was that the chair had been brought from Canada in the 50s and that the father of the man who spoke to us used to carry out an extraction service.
Figure 6. The dental chair found inside the hut which had a sign outside saying ‘teeth extracted here’.
Caries rates are high among the young (Figures 7, 8 and 9). While there is very little disposable income (the average monthly income is about £5), the local shops do stock sweets and coca cola and the ubiquitous Inca Cola alongside the machetes, pots and pans. The indigenous diet consists of rice, chicken, fish, yucca (a versatile root vegetable) and fruit. Sugar cane is widely available and enjoyed. The elderly generally suffer from toothwear and periodontal disease (Figure 10). Figures provided by the PAHO4 report a DMFT index of 5.6 in 12-year-olds in 2000, with a prevalence of dental caries of 84%. This compares with a UK DMFT index of 1.13 and caries prevalence of 44%.5 As part of the ongoing development of the programme, audits of oral health are carried out when time permits, in order to ascertain current needs and monitor the effectiveness of the project.
Figure 7. A typical example of the oral health state. Note the pulpal polyp in the LR7 and the completely carious roots of the LR6.Figure 8. Another typical presentation. Note the crowding issue too.Figure 9. Rampant caries presenting in a five-year-old. The apex of the root of URA can be seen towards the sulcus. Extraction under LA was uneventful.Figure 10. An elderly patient presenting with complete bone loss around the lower central incisors, without exfoliation.
Table 2 and Figure 11 show a breakdown of the treatment provision over three recent trips (February 2010, June 2010 and January 2011). Of items of treatment, 58% were extractions, almost 30% of which were deciduous extractions. Of the 422 permanent teeth extracted, 59 were first permanent molars in children aged 16 or less (14%). Very few children presented with deciduous teeth which were still restorable, so deciduous restorations accounted for only 1% of treatment provided. In the permanent dentition, 48% of restorations were composites in anterior teeth and 51% were amalgam in posterior teeth.
River Trip
Tigre Feb-10
Tigre Jun-10
Amazon Jan-11
Total
Total patients
205
167
300
672
Total male
75
88
125
288
Total female
130
79
175
384
Teeth restored
130
89
157
376
Permanent teeth restored
124
82
156
362
Deciduous teeth restored
6
7
1
14
Deciduous amalgam
0
4
0
4
Permanent amalgam
75
49
60
184
Deciduous composite
0
0
1
1
Permanent composite
45
32
96
173
Deciduous GI
6
3
0
9
Permanent GI
4
1
0
5
Total XLA
132
130
331
593
Deciduous XLA
39
40
92
171
Permanent XLA
93
90
239
422
6s extracted in under 17s
12
10
37
59
Other treatments
29
17
14
60
Figure 11.
(a) Pie chart showing the breakdown of treatments provided over three trips. The number of treatments was 1029 and the number of patients was 672. (b) Pie chart showing the proportion of types of restorative materials used in permanent teeth: 362 restorations.
Being in the middle of the Amazon jungle does have its impact on treatment planning. While the programme provides a regular service, visiting the villages every three months, each dentist has to consider the complete lack of access to dental care between visits as we plan treatment. Thus, caries in close proximity to pulp or any indication of irreversible pulpitis must be treated with extraction – temporization and review is not an option. Crowding with an aesthetic impact routinely presents and careful consideration of extractions is necessary in the knowledge that no orthodontic treatment with appliances is available. Supernumary teeth are a not infrequent finding (Figure 12), at least two every trip. ‘Gold’ basket crowns on the anterior teeth are common in the older patients, probably provided on a visit to Iquitos as a young adult. These crowns (Figure 13) are placed around one or more upper incisors, the soft gold-coloured metal wrapping the visible borders of the labial surface and covering the palatal surface. These crowns can also serve as abutments for bridges. Sometimes healthy labial enamel is seen in the open face of the crown, other times the labial face is some form of acrylic. Frequently patients present with caries under the crowns, which is not surprising when most are ill-fitting with poor margins. Invariably the patient is desperate to keep his/her crown or bridge, no matter how poor the prognosis of the tooth (Figure 14). Respect for the culture and living circumstances of the locals must come into play when treatment planning, alongside clinical judgement.
Figure 12.
(a) An example of the presentation of a supernumerary tooth. (b) Another example of the presentation of a supernumerary in a young patient. Alignment of these teeth with appliances is not an option for these patients.Figure 13. An example of the open faced ‘gold’ basket crowns which are commonly seen in this area.Figure 14.
(a) A failing bridge – UR3 and UL1 are the abutments. Note the decayed abutment tooth UL1. The pontics are UR1 and UR2 and UL2 and UL3. (b) The removed bridge. (c) The abutment teeth with caries removed.
Changing patterns of need
The pattern of work has changed over the years; anecdotal feedback from dentists who worked on the earlier trips indicates that nearly all the work was extractions. This is not surprising considering that, prior to the Amazon Hope boats arriving, people may have suffered pain for months or years. The next phase is to educate the people into presenting on the boat for treatment, even when they have no symptoms, something of which the younger adults are now more aware.
Long term change
Dental health education and prevention of disease needs to be provided on a more regular basis. The new medical director in Peru plans to train local healthcare workers in an effort to improve basic health. This will include dental health. While there is only one Peruvian dentist working on the boat, he is busy dealing with the treatment needs which present. He has undertaken some work to assess more fully the needs of the population in an effort to target more specifically the work provided. There is funding within the project for another dentist, and a prevention and education programme needs to be developed. It is well documented6 that the regular, professional application of fluoride significantly reduces caries levels. Once we have secured a regular provision of fluoride varnish, a simple programme of visiting each school every three months, applying fluoride varnish professionally, could have a significant effect on the caries levels of the next generations.
Basic Package of Oral Care (BPOC)
The BPOC is a WHO recommended approach to dental care provision in developing countries where the need is high and the local provision low.7 The three categories of treatment are Atraumatic Restorative Treatment (ART), Oral Urgent Treatment (OUT) and Affordable Fluoride Toothpaste (AFT). The care which is provided with the facilities available on the Amazon Hope boats is beyond ART and OUT, thanks to the hard work and careful planning of the developers of the project. The provision of affordable fluoride toothpaste is an issue at state level.
Teams and elective programme
The first UK Vine Trust volunteer medical and dental team on the Amazon Hope was in 2004. The following year five teams volunteered. Since 2004, up to and including June 2011, 92 teams have taken part in this project; over 530 volunteers, including over 60 dentists, and 26 dental students. The development of a dental elective programme started in 2007, when I took two students with me. The students gained a wealth of practical experience, had their vision of dentistry expanded, coped with working in difficult circumstances and, to quote one of them ‘…it reinforced the reason that I am doing dentistry in the first place’. In the summer of 2011, 14 students took part in the programme, 6 from Dundee Dental School, 2 from Sheffield and 6 from Peninsula Dental Schools.
Medical aspect of project
This is not a solely dental project. Three Peruvian doctors are employed on the project, working in rotation, and each visiting team has up to three doctors. The most common presenting conditions are respiratory ailments, dehydration and/or malnutrition, gastrointestinal problems, especially diarrhoea in children, and skin infections/conditions. Malaria, yellow fever and dengue fever may present. The occasional machete injury or snake bite keeps everyone on their toes. The key to the current and future success of this project is the collaboration with the sparse healthcare system which does exist in this jungle river area. The Vine Trust/Union Biblica del Peru partnership works alongside local midwives, nurses, and other healthcare workers providing pre- and post-natal care and vaccination programmes; they expand the amount of care which can be provided on the boat, and their mobility and access to better equipment is improved, a mutually beneficial arrangement.
Eye surgery
During routine trips, names are gathered of people who need surgery to remove cataracts or pterygium (a growth over the cornea which is caused by extreme sunlight and light reflection on the river). Once or twice a year special trips (Table 1, December) are made when this surgery is undertaken in an operating theatre onboard. This was initiated by an ophthalmic surgeon, Iain Whyte, from Inverness who is the Chairman of the Vine Trust Medical Committee. He has made links with ophthalmic surgeons in the Peruvian capital, Lima, and they will be carrying on this work in an effort to make this locally sustainable.
Conclusion
There are many motives for being involved in global volunteer dentistry – faith based ones, humanitarian ones, or a desire to see a different world and be part of it for a while. We dentists and DCPs have skills which are transferable globally; we are practical people who see a need and want to respond to it. Yes, in developing countries ultimately it would be better if the care was provided by their own government organizations and healthcare systems, but until these systems are developed adequately, a careful and well thought out helping hand is welcome. August 2011 marks my eighth trip with the Vine Trust on the Amazon since 2006. This project is one which is executed well, taking care not to undermine the meagre local healthcare system, encouraging its development and helping it achieve its goals. The ultimate goal is to be able to hand it completely over to the Peruvians as their economic and social care systems improve.
If you would like more information about the work of the Vine Trust or would like to volunteer, please visit the website www.vinetrust.org, or email shona.mason@nhs.net
