When sharing our passion for short-term missions, we are often asked how we do it. The process of putting together a mission team, along with coordinating and organizing the endless details, continues to be a work in progress. We have learned many lessons over the last fifteen years and thirty trips. Each mission is different. We’ve done a one-chair clinic with the two of us, to a maximum of a six-chair clinic with up to twenty-six Americans. We’ve held dental clinics in orphanages, street youth centers, transition houses, summer camps, schools, seminaries, hospitals, churches, outreach centers, medical clinics, military posts, gers, houses, and under tents.
Dentistry affords us a unique opportunity to use our gifts to heal others physically, which opens doors for us to contribute to the unity within the Church of Jesus Christ. We begin each day with prayer as instructed in Philippians 4:6-7: “Do not be anxious about anything, but in everything, by prayer and petition, with thanksgiving, present your request to God. And the peace of God, which transcends all understanding, will guard your hearts and your minds in Christ Jesus.” These are some frequently asked questions:
How do you pick which groups to go with? The world is a large, daunting place with many needs and opportunities. We believe that God can use anyone with a desire to serve on a short-term, overseas mission trip. Initially, we recommend that people go with someone who has traveled before. Hopeful participants can join up with local churches or denominations, as we did on our first mission. Numerous, well-established, Christian organizations beg for dental help, which can be found on the Internet under such topics as “dental missions” or “medical dental missions”. The Christian Dental Society is also a great resource for dental mission assignments and for help in planning and equipping missions. The large Global Missions Health Conference, held in Louisville, Kentucky each November, is an excellent place to network. Contacts with family members, relatives, friends, missionaries, and Christian organizations have all provided us with opportunities to go on dental missions. As a CEO of a large multinational Christian outreach organization said to us, “Everywhere we go they are desperate for dentistry and will welcome it at any time. I do not even have to ask, it is a given.”
How do you gather a group for a mission and develop group dynamics? It is amazing to see how individuals get called to step out of their comfort zones and commit to an overseas mission. People from all walks of life and in different stages of maturity—both physically and spiritually—volunteer and we must meld them together. Bob learned in the Army’s Command and General Staff College about Bruce Tuckman’s group dynamics model of Forming-Storming-Norming-Performing. This parallels with the phases of coping with cultural shock, the psychological disorientation that stems from unfamiliar and unmet expectations in a new culture. With diversity among individuals and the preconceived ideas and expectations each one carries, it is important to communicate as we pass through these stages/phases. We seek to ensure maximum harmony and efficiency of purpose as rapidly as possible. Several group meetings are highly recommended, not just to disseminate mission trip information, but to build the team, define roles, and align expectations within the group and cross-culturally.
The “forming” stage is driven by a desire to be accepted and to avoid controversy and serious issues. People are on their best behavior and gather information and impressions. They learn about the opportunities of the mission, the challenges involved, agree on goals, and begin to tackle tasks. It is a comfortable stage where the leaders can be quite directive concerning the details of the trip and the motivation and purposes of the mission. This goes along with the cross-cultural “romantic/tourist” phase where everything is quaint and the euphoria of new experiences blurs cultural differences.
The “storming” stage is inevitable and although conflict may be more or less suppressed, it will be present and is necessary for growth. People deal with issues and differences, and often are establishing a pecking order. We stress tolerance, patience, open communications, and conflict resolution, as this stage can be destructive. Our goal is to help everyone feel safe in sharing input without negative judgment from others. This relates to the “lost that loving feeling” phase in becoming cross-cultural. Curiosity gives way to frustration as feelings of irritation, anger, and helplessness join with fatigue. Each member receives “three freebies” to be used for mistakes, omissions, or wrong actions. Described as extensions of grace, the “freebies” become a gentle reminder that everyone is forgiven and tolerated, since it is a new group with members who are out of their normal routines and practices.
In the “norming” stage, the “rules of engagement” for the group become established and responsibilities are clear and agreed upon. Individuals listen to each other, appreciate and support each other, and prepare to change preconceived views. The team agrees on goals and has a mutual plan. Some do have to compromise in their expectations and wishes. This relates to the “recovery” phase of becoming cross-cultural where local ideas and practices do not seem strange any longer. Self-confidence returns.
The fourth stage is “performing”, characterized by a state of interdependence and flexibility. The team knows each other well enough to work together and trusts everyone enough to allow independent activity. The high degree of comfort allows the energy of the group to be directed towards the task with maximum efficiency. Cross-cultural “acceptance” phase has been reached as differences are understood and expected. Humor returns and all relax.
Forming-Storming-Norming-Performing in cross-cultural settings for short-term mission work is dynamic to say the least. Maintaining group cohesion is every bit as hard as the dentistry and is just as important.
How do you explain why you have come? We are often asked to share our story of why we are there. 1 Peter 3:15 says, “Always be prepared to give an answer to everyone who asks you to give a reason for the hope that you have.” We instruct and encourage everyone to be ready with a testimony as a good “door opener”, but not to expect it to convince anyone to change. We try to attend church services with our country hosts and patients and are regularly asked to speak and even bring a message during their services. This is a great opportunity to share why we are there, and to encourage the locals, many of whom have never seen an American. We share the living hope we have in Christ, and encourage the team to be prepared to speak.
What time of year do you go? We plan our trips to coincide with the best environmental conditions to maximize effectiveness and enjoyment. On our first trip we went to Nicaragua in the middle of summer and it was oppressively hot, humid, and buggy. It caught us once, but not again. Since the need for dentistry is so great throughout most of the world, we can plan to go when the conditions are the most favorable for the team and the patients.
What is your connection to the local leadership? We go overseas with good support from local nationals within the country. The sponsoring leaders know the political, spiritual, and safety considerations and strive to use the team to the maximum benefit possible. We are usually protected and provided for from the time we arrive at the airport until we are dropped off to return home. Although we supply the funds for our stay, the sponsoring organization plans our budget, helps us with airfares, immunization requirements, airport fees, visas, transportation, food, water, lodging, travelers insurance, tourism, and administrative details. They introduce the team to the organization’s mission and we symbiotically encourage and strengthen each other. Although our presence and attitude of service is a witness to Christ’s love, we still consider ourselves a special tool to be used by the local pastors and religious organizations to further God’s kingdom. The spiritual welfare of our patients and the outreach to the communities are the responsibility of our hosts. We are there for them and they are orchestrating the priorities on whom we see and where we go as well as the follow-up after we leave. Our country hosts, along with the trip leader, plan for a balanced experience with work, outreach, rest, relaxation, and some shopping and tourism. Everyone understands that if the team is too tired or sick, they will be ineffective. The local nationals have always taken great care of us to ensure our health, safety, and general comfort within the restraints of the setting.
What do you tell the nationals about your dental capability? How many patients can you serve? The sponsoring organization, and especially the in-country support, have most likely never hosted a dental team and do not know how to use us. The team leader is responsible to communicate what the dental team can do. The following is an excerpt which we generally share with the sponsoring organization and country host to give them an idea of dental capabilities and limitations:
Concerning dental care, we attempt to do the greatest good for the greatest number and try most diligently not to make promises we cannot keep. Your role in explaining carefully our capabilities is critical, so we do not disappoint patients and have negative feelings from those who might have expected treatment and did not get it.
We are comfortable doing extractions and fillings which are generally needed by most patients. We sterilize all our instruments and patients need not worry about transmission of any diseases.
We try to teach dental hygiene to groups as prevention is important. We can do cleanings, but that is very time-consuming and takes away from others who are often in pain. We can generally treat the patient’s chief complaint in about half an hour, which means removing a bad tooth or two or doing a filling or two. We frequently find patients present with many dental problems and everyone needs and wants a cleaning, but that is just not possible if we are trying to do the most good for the greatest number. Whoever is responsible for patient flow, has the hardest job because a dentist can only treat about fifteen patients a day and someone has to decide who we see without upsetting all the others who would like to be seen. Also we must make it clear we are only treating one problem area and not the whole mouth, unless it is determined that we spend hours on a few patients treating all their dental needs, which we could do, if that is what the organization wants.
For these reasons, we strongly suggest a tight control on whom we are to see. We can do much good for many people and share God’s love. However, our good will and Christian outreach is decreased if feelings are hurt because someone felt they were going to get dental care, and it did not happen. Pain and swelling are definite priorities and, if possible, they should be seen first. We have often used sign up lists with a patient scheduled every half hour, or cards with numbers for those we can see. These can be given to those in charge to hand out.
Also dentistry is very hard on the workers backs and we will probably need a day of rest from dentistry in the middle of the week to stay effective. We sleep anywhere and we come to serve. To operate, we need an electric plug in, several tables, three or four chairs per dentist, and water. We will bring the dental patient chair, light, dental operating unit, sterilizer, instruments, and all supplies to do dental care. It takes about an hour to set up the clinic and about the same to pack it up again.
Of critical importance to our dental mission is a dedicated interpreter for every dentist and hygienist. Dentistry can be frightening for the patients, and we need to communicate well to treat them efficiently and effectively. The interpreter must learn dental terms, quickly translate the diagnosis of the problem, and put the patient at ease while the dentist gives anesthesia, removes a tooth or does a filling. It is important for the interpreter to give clear post-operative instructions. It often takes a day of working with a dentist for the interpreter to understand the terms needed and how to best reassure and instruct patients. We always pray earnestly for a good interpreter.
What immunizations and safety measures do you take? In developing countries additional immunizations/preventative measures are often recommended by the Centers for Disease Control. We routinely require Hepatitis A and B immunization, tetanus/diphtheria boosters every ten years, and a flu shot. We do not take chances with our health and try to be prudent about getting the necessary vaccinations, malaria pills, and insect spray. We attempt to wash properly, watch what we eat, and drink and brush our teeth with bottled water. The local hosts are quite proficient at knowing what we can and cannot safely eat or drink.
Travel abroad can be an enlightening experience, but what would happens if someone becomes ill or injured while away from home? Most people assume they will be covered by their standard medical plan, but most domestic medical coverage does not cover Americans overseas. Travelers insurance is well worth a few extra dollars a day and is usually provided for by the sponsoring organization.
What equipment do you need to provide portable dental care? We can diagnosis, extract many teeth, and provide oral hygiene instruction without equipment, but everything is easier if you have a few portable items.
A portable dental chair enables the operator to favorably position the patient. The proper chair efficiently allows the dentist/hygienist to work longer without back strains or injury. We use a plasticized, durable, light-weight chair available through the Christian Dental Society for under $400. Two chairs fit in one airline carry-on bag which only weighs 42 pounds.
For restorative dentistry, surgical extractions, endodontics, or prosthetics, we use a dental operating unit with a high speed and low speed hand-piece, suction capability, and an air/water syringe. We currently use Aseptico’s 33 pound, self-contained Task Force Deluxe dental unit which is easily transportable as checked baggage on the plane, costing about $2200 with the 20% missionary discount. We further protect the unit by placing it into a rolling Sears tool box for ease of transporting.
A dental light is essential for the dentist/hygienist to see adequately in the dark corners of the patient’s mouth. Mini LED lights with rechargeable batteries, mounted on magnifying or protective eye-ware are the best source of light and it is what Bob uses in his private practice. Spelunker head lights mounted on head bands also work, although not as well.
Dental curing lights for restorative dentistry are needed to set the bonding agents, resin restorations, and basing agents. Rechargeable LED curing lights are the lightest and easiest to use.
An amalgamator is needed to mix dental amalgam as well as certain cements and other Glass-Ionomer restorative materials. Amalgam is still the least expensive, strongest, longest lasting, most easily used restorative material available for posterior restoration and considered safe by both the FDA and the ADA. Therefore, we believe amalgam is the restoration of choice for posterior large fillings, especially on the mission field where patients will most likely never have routine dental care.
Sterilization is a must as we do not want to receive or pass diseases such as HIV, Hepatitis, Bacterial infections and TB. We use a four-quart Presto Stainless Pressure Cooker which can be bought in a hardware store for about $60. We use a 1000-watt, small, single-burner, heating element which can be purchased in either 110 volts or 220 volts for around $50. Sterilization will be discussed in detail later.
Dental x-rays can be portable with hand-held units using computer generated films, but they are usually not necessary for what we do. For the basic dental care we provide, we have found x-rays to be too cumbersome, time consuming, and expensive to be worthwhile. X-ray capability is nice to have, but we are dealing with the major dental problem areas which consist of oral hygiene instruction, extractions of hurting teeth, and restorations of the most critical teeth in a portable—often austere—setting.
How do you deal with electrical requirements? In developing countries, electrical power is a major consideration to run the equipment. It is important to know the difference between 110 voltage (used in the United States) and 220 voltage (used in many countries). They do not work the same. When touching a bare wire of 110 volts, it will definitely bite. 220 volts is much more powerful, causing an immediate muscle spasm that keeps one’s hand from releasing the bare wire—and has the power to kill. When faced with 220 volt power, an adequate step-down transformer must be used for 110 volt equipment. Fortunately, the dental operating unit we use accepts either 110 or 220 volts, as do many of the newer curing lights, amalgamators, and head lights. A small converter charges cell phones, cameras, and works on high watt/low amperage heating elements for a short time only. The amalgamator requires a larger converter as it uses more amps—as does anything with a motor.
In a foreign country it is important to find the right power plug adapter to fit our American plug into their electrical outlets. International power plugs can be looked up on the Internet, or ask the sponsoring organization to purchase the appropriate adapters. We use power strips with circuit breakers to help protect the equipment against power surges. Another consideration is the size of extension cords in use. Small 16-18 gauge extension cords do not allow enough current through to run the dental operating units. When coming off a 5 KW generator, a 12-14 gauge extension cord is needed to carry power without the risk of burning out the units.
Calculating how much power in watts (KW) needed to run a one chair clinic to a six chair clinic follows this formula: power in watts = voltage (110 or 220) times the current in amps. Our Aseptico dental operating unit requires 110 volts X 6 amps or about 800 watts to run, which is not that much considering what it accomplishes. Because the motor requires more power to overcome the inertia to turn the motor over, it requires about 1400 watts of start-up power. Most developing countries, when they have electricity, generally have enough electrical power to turn the lights on and run a fan, but not enough juice to meet the electrical demands of even a simple dental clinic. I generally need a 3 KW generator to run a one chair dental clinic if the electrical current is not reasonable or dependable. For larger clinics of up to five chairs, we can function with a 5 KW generator, as all units are rarely on at the same time. To decrease the load on the generator, I can often use the local power source to run one unit or the sterilization heating element. We depend upon the in-country sponsor to obtain a generator, which we sometimes have to rent. We make sure it has enough kilowatts to meet our needs, with enough gasoline purchased to keep in running. Someone on the team must know this information as the power considerations are essential.
If electricity is not available or the need to do restorative dentistry is not a priority, then extractions can become the only expectation for the mission. I would still recommend taking a battery operated hand-piece to help with the removal of the more difficult teeth. Bell International has an excellent battery operated hand-piece. Whenever possible, we take the equipment to perform restorative dentistry.
What dental instruments do you take? We hope to do extractions, fillings, an occasional root canal, and have the capability to make a partial to replace missing front teeth. The rubber dam is helpful in many restorative situations and we include it with our instruments. Every dentist/hygienist has their own method of treatment and the array of instrumentation can be broad, but basic surgical, restorative, and hygiene procedures can be accomplished with standard instrumentation which we provide. I always encourage our dentists/hygienists to bring along any special instruments they are comfortable using which we do not have in our basic kits.
How many instruments do you need? This depends upon how many providers we have and how fast we can sterilize the instruments to get them back in use. With the pressure pot, the turn-around is about thirty minutes, which includes wash, rinse, bringing the pot to pressure for ten minutes, and a five minute cool down time. With a mixture of restorative and surgical procedures, we need about three sets of instruments per provider, since we treat two patients at a time. All instruments and most supplies are stored in plastic fishing tackle containers, which have dividers to separate the instruments. Various sizes and configurations can be found wherever fishing supplies are sold. Instruments are easily transported, organized, and accessed in these containers.
How do you handle the patient flow for dental treatment in the developing country? We emphasize that we want to do the greatest good for the greatest number of patients. Every patient is important and a child of God. We desire to keep the mood light and calm, without hurry or deadlines. We encourage patience and flexibility. We give this list of instructions as a guideline for our teams:
- Focus on the patient’s chief complaint. “How may we help you?” “Do you have any pain?” “What is your primary dental concern?”
- Try to limit treatment to about thirty minutes per patient, which means generally only treating the chief complaint. If possible, patients can come back another day for other concerns.
- As dentists, we are focused on surgical and restorative procedures. Unless we have extra time, we don’t encourage cleanings, although most patients could use it.
- On children, we try to avoid filling primary teeth. We take only the teeth out which are infected, hurting, or interfering with the eruption of permanent teeth. There is no follow-up care, so even if the tooth is decayed, it is holding space for the permanent tooth.
- On children, we focus on the restoration of permanent first molars (usually with amalgam, as it will last much longer) and restoration of decayed permanent anterior teeth.
- On all patients, if the tooth is hurting, we take it out. We stay away from large fillings which can compromise the nerve as there is no follow-up. We warn patients that if the decay is into the nerve, it will be extracted. Sometimes it is better to leave the tooth if it’s not hurting, even if the decay is into the nerve. A root canal can be done on a critical, immediately restorable, front tooth, but this has to be the exception.
- Permanent anterior teeth with cavities are a priority. Restoring a smile and saving anterior teeth is especially appreciated by patients. Often we have to ignore broken-down, posterior teeth to fix interproximal decay on the incisors to satisfy the chief complaint.
- We do not attempt to take out third molars unless it represents a true emergency.
Treatment works well following this protocol:
- The interpreter seats the patient, positioning their heads to the top of the chair. The interpreter asks about the patients chief dental concern is and if they have pain or not. If there is a parent or guardian for a child, it is helpful to involve them in the exam.
- The dentist will have a tray with a mirror, explorer, and anesthesia syringe to do a quick exam focusing on the chief complaint. We don’t use a patient bib at this point.
- If the patient does not need anesthesia, we apply the bib and do the work or consult with the patient immediately.
- If the patient needs work and anesthesia, explain the situation to the patient and numb the area. The dentist picks the needle and places it on the syringe. Topical is recommended prior to anesthesia.
After anesthesia, the interpreter follows with this procedure:
- The interpreter has the patient get up and wait for anesthesia to take.
- The interpreter explains that the patient will take a Motrin or Tylenol pre-op if doing an extraction (the pill is usually given by the assistant).
- The interpreter seats the second patient and finds out the chief complaint.
- While the patients are being exchanged, the dentist takes the tray and gets the instruments needed for the procedure planned, and sets the tray aside.
- The dentist uses another tray with a mirror, explorer, and syringe to diagnose and anesthetize the second patient. After the second patient is numbed, the patients are exchanged.
- The interpreter exchanges the first patient with the second patient and ensures that pain pills have been given if an extraction is to be performed.
- The dentist takes the second tray, gets the instruments needed for the second patient and sets it aside. The first tray is retrieved, which has the instruments ready to treat the first patient.
- The assistant places a patient bib and protective eyewear on the patient, provides the patient with a stuffed animal to hold with the help of the interpreter, and makes sure the unit is ready with a proper suction tip. Post-operative instructions are given, if necessary, and a few extra pain pills and guaze are dispensed in a paper cup as the patient is dismissed.
- After the first patient is treated, the interpreter exchanges the first patient with the second patient that is now numb.
- The assistant cleans the unit, removing the burs and wiping down the hand-pieces, air water syringe, and suction tube. If the hand-pieces are very contaminated, they can be sterilized. When the second patient is seated, the assistant again places a bib, protective eyewear, stuffed animal, and suction tip.
- The dentist always removes the needle and anesthetic carpule from the syringe and places them in an empty water bottle, which is the sharps container. For everyone’s safety, it is best to have the needle taken off by the dentist to avoid needle sticks. If a suture needle or surgical blade is used, the dentist also removes it and places in the sharps container before taking the dirty instrument tray to sterilization. The dentist obtains the tray which has been prepared for the second patient.
- After the second patient is treated and the unit is cleaned, we start the process over with the next two patients.
What other related dental items do you take? Amalgam is our first choice for restoring large posterior fillings. For everything else we use resins. The variety of bonding agents and composites are endless. We generally give each dentist a plastic fishing tackle box with dividers, and have them bring the composite restorative materials they use. It is faster and easier for dentists to work with materials they are familiar with. We also recommend each dentist bring along their own rubber dam set-up.
Dental burs are also very dental-operator specific as some like carbide burs and others prefer diamonds. There are high-speed and slow-speed burs and the variation of sizes is numerous. We recommend dentists bring several bur blocks containing their favorite burs, and we carry a plastic box full of extra basic burs.
For the occasional root canal, we have a basic endodontic kit in one plastic, divided box. We also keep a small tackle box with everything needed to fabricate an interim partial to replace missing front teeth. Both of these procedures are more time-consuming, but on occasion it’s worth having this capability. When used judiciously, this procedure pays great dividends in satisfaction to special patients.
The medications we bring include Ibuprofen and Tylenol for pain relief for our patients. Narcotics are generally not given. For more severe infections, we have Penicillin and Clindamycin, but find we rarely need it, since local infections resolve quickly with the removal of the teeth. There can be a few cases where a patient with systemic signs or a spreading infection needs antibiotics. It is helpful, especially when working with kids to leave extra pain pills and post-surgical instructions with a responsible person. For the team we take along a basic first aid kit with medications for colds, cuts, insect bites, etc. We also have Ciprofloxacin for traveler’s diarrhea, although we rarely use it as our hosts protect us. Individual team members also bring along any medications they might be on or feel they might need. As far as emergency drugs we bring along an Epi-pen for anaphylaxis reactions, a medi-haler for asthmatic conditions. Fortunately we have never had to use any of these emergency drugs—Praise the Lord.
We take a blood pressure cuff and stethoscope for selected individuals and have deferred treatment and sent patients to a physician if the blood pressure is too high.
We always carry a repair and maintenance kit which fits in a plastic, divided box, which is easy to access and see. It includes a Leatherman multipurpose tool, heavy duty scissors, duct tape, assorted zip ties, plug adaptors, extra fuses, batteries, repair parts, lubrication for hand-pieces, etc. We also take extra parts for essential items that can break or get lost like the pressure pot seal, suction tip holder, air-water syringe tips, etc.
A dual voltage travel iron for wrinkled clothing is nice in some settings, and a battery-operated alarm clock comes in handy with jet lag. We carry our passports and money in a travel pack which we keep under our clothes for safety. Sunscreen and insect repellent are helpful. Antiseptic hand cleanser helps as there are not always places to wash. We want our team members to carry an extra copy of their passport in case of loss. Small bills for tips are handy. Ambien, or a sleeping pill, can be useful for the first several nights, especially when traveling across multiple times zones. Pen and paper help with journaling.
How many supplies and disposable items do you take? We figure out how many patients we are expecting to treat by counting the days of work and multiplying by the hours we will work times the number of operators times two patients per hour. We add a 25% fudge factor. For two dentists working five days for nine hours treating two patients/hour = 180 patients rounding up to between 200-220 patients. If we plan on doing primarily surgical procedures, they take less time than restorative and we increase the numbers to three patients per hour. We match the size of the gloves to the providers and assistants and we’d need six boxes for the dentist and five for the assistant. For anesthesia, we figure two carpules per patient, which comes to eight boxes of fifty. For needles we’d need 250 of the size the dentist/assistant/hygienist uses. Gauze comes in 2 X 2 sizes with two hundred per package. We figure ten to fifteen per patient so would need ten to fifteen packages. We cut bibs in half for the tray and for children. We figure 1.5 bibs per patient, so would need three hundred. We take one bottle of topical per dentist with 250 cotton tip applicators. Toothbrushes are 1.25/patient because there are always a few extra people who need them, so we’d figure 260. We take one container of disinfection wipes per provider. This gives a reasonable approximation on the supplies needed and we have never run out.
What items do you have the providers bring? The dentists or hygienists bring their own dental loops and protective eyewear for themselves and their assistant. They are responsible for their own head light, and we carry several spare headlights if needed. Dentists bring two slow speed and two high speed hand-pieces with two bur blocks of their favorite burs. Hygienists provide their ultrasonic cavitron and a hand-piece for polishing. Dentists include their own composite materials and rubber dam set up. We ask the dentist to provide their own gloves and the gloves for their assistant, as they have to be sized correctly and some work with different types of gloves. We let the dentist/hygienist bring their own face masks to match what they are comfortable and familiar with. Dentists are encouraged to supplement the basic operative and surgical instruments with any special instruments they like to use. We work in surgical smocks/scrubs as they are easy to clean, comfortable, and convey a professional appearance—we ask each team member to bring along two or three sets for themselves.
Where do you get supplies, instruments, and equipment? This has been an ongoing process and we add to our capabilities each year as we continue to purchase needed items. There is another dentist in town involved in overseas dental work and we have shared equipment and instruments when we put together larger teams. The dental school instruments and hand-pieces, which we purchased in dental school, acted as my starter stash of instruments. World Dental Relief provides us with many supplies and some equipment at a greatly reduced cost. The Christian Dental Society rents out equipment and instruments and we used them to equip our early trips until we obtained our own. Other organizations which have helped us (primarily to set up clinics in other countries) include Project Cure, Aseptio, GC America, Henry Schein, Septodont, Ultradent, our local church, religious sponsor organizations, and the World Health Organization. This is our ministry and we do not ask for contributions. We have been able to finance the complete cost of all our trips and to build a reasonable base of equipment and instruments to support the dental missions over the years.
How do you transport everything? When we take a six-chair clinic overseas, there are about 26,000 dental items, costing around $100,000. Everything is packed in fifty pound bags/boxes/containers suitable for transport as checked luggage on the plane. We have never lost anything and everything has made it into the country and back home. Purchasing travelers insurance for all this expensive equipment would be costly and a hassle to obtain, so we lean on prayer. Airlines allow two, fifty-pound bags per person. Each couple is allowed a fifty- pound bag and their carry-on bags for personnel luggage. The other three bags are filled with dental items. When we go alone as a couple, we can carry a complete clinic in four checked bags and place our personal items in our carry-on bags. We like all the containers to have wheels and we weigh the bags with a small digital luggage scale to within a pound of fifty pounds to maximize what we can take. If there is extra room or weight, the developing countries always need clothes, shoes, and various items.
How do you get through security checks? Security is increasing their restrictions to the point that we have to pack our duct tape and zip ties in our luggage or they will confiscate them as items which can be used to restrain airline staff. Some allow fingernail clippers and water bottles and other do not. Trying to outguess airport security is like trying to hit a moving target. Customs usually goes very well, but is always a stress point for us. One country had restrictions on used medical equipment and another restricts new equipment. Others may want a bribe and some are just curious, wanting us to open every container to be inspected. Most countries are happy that we are helping their people and let us through with no hassle. All the equipment, supplies, and instruments travel fine as checked bags, and somehow we always manage to get our items through.
How do you set up the dental clinic? This can be done rapidly and efficiently when everyone knows their area of responsibility. This comes from team meetings, good communication, and organization. It helps when others are experienced and responsibilities can be delegated on the larger teams. Ideally we want to set the clinic up the afternoon before we treat patients, but we often travel to a site where patients are already waiting and we desire to begin patient treatment as soon as possible. As the team is unloading the supplies and setting up the chairs, the team leader quickly works out the power grid to determine where the chairs, sterilization, and instruments go, and how patient flow will work. The setting can be anything from a tent in a field powered with a generator to a large open facility with ample room and power. Houses, churches, schools, conference centers and from one chair to six chairs make flexibility and adaptation key. We try to find out as much as possible about the clinic setting beforehand, and attempt to work out some of the logistics. The host team leader communicates with the people in charge of the area where we will be providing care so that chairs, tables, interpreters, a suitable generator when needed, and a reasonable space to work are available when we arrive.
We communicate our capabilities for treatment as adamantly as possible, so the correct expectations are understood on what we can do. We hope to have the appropriate number of patients selected for us to treat. The team leader assigns the location for each provider to set up their operatory, and shows sterilization where to set up the sterilization table and instrument table. When coming into a setting with patients already waiting, we assign someone to teach our patients oral hygiene and what to expect during their treatment time. We use an interpreter and a chart full of pictures. Someone else is gathering and briefing the interpreters and explaining how patients will flow. The instruments are already organized in the plastic see-through, tackle boxes and only require being set on a table. We need about thirty minutes to set up or take down a single operatory, as we have done it many times and know our routines. In Kenya with six dentists, we traveled several hours down a rough dirt road to a large tent. We stepped off the bus, greeted everyone, set up a fully functional six-chair clinic, briefed responsibilities, educated our clients, and had six patients in the chairs in less than an hour. With an experienced team bonded together through organizational meetings, everyone knew their roles and functioned in harmony from the first hour.
How do you educate the patients? We briefly educate our patients (especially children) about why we have come, what to expect in the dental chair, and the basics of oral hygiene. We believe this invaluable step is as important as the dental care we provide in many instances. Because language and understanding is often a barrier, we have put together a flip chart with large pictures to help convey our message. Without effective interpreters patient education as well as treatment is very difficult and often impossible.
How do you calm the fears of the patients? Most patients, even kids, are very stoic in the dental chair. They are generally thankful for a shot and sit well for extractions and restorative treatment. On occasion there are patients who are so terrified of dental treatment that we cannot console them and must defer treatment. When treating children, we like to start with the older ones who are hurting and very willing to get a painful tooth pulled. When they are treated, without pain, the word quickly spreads that we are acceptable. If we start with a small, anxious child, who appears upset, we begin with a bad impression and it is difficult to reverse. When a child is too apprehensive for dental treatment, we often let them watch with the help of a trusted caregiver to develop a rapport and to show the child what we do before attempting treatment. Parents and empathetic caregivers are often a great help for a child through their comforting demeanors. We try to maintain a loving, caring atmosphere. When an occasional child refuses to be treated, often when a parent is trying to force a child into the chair, we do not get upset or take it personally, but move on to the next patient as there are always so many needs.
How should the dentists treat the other helpers on the team? We have become more cognizant of how easily family relationships can be thrown out of harmony in a unfamiliar, often stressful setting. Although the dentist is in a familiar setting doing dentistry, the spouse, family member, or friend is trying to assist in a situation where they have little or no knowledge of their role and how to assist, sterilize, comfort a patient, etc. Dentists must adjust their mentality to not be driven to the efficiency and productive levels they may be used to in their home offices. It is helpful if the dentist offers praise and reassurances to all those helping. It is quite different using family members and friends as the dental staff as they are thrown into an altered, subservient role. The dentist must appreciate and adjust to the reality that friends and family are voluntarily doing their best and are not a hired employee as the dentist’s staff is at home. With so many needs on the mission field, it is often hard to slow down and be kind and patient in this very foreign environment. Everyone’s makeup is different, and the understanding of personality types helps us deal with the variations in people. It is all part of the Forming-Storming-Norming-Performing stages of group development, but is especially relevant for family members working together.
How do you insure infection control? This is extremely important with the prevalence of AIDS, Hepatitis, Herpes, Tuberculosis, and infectious diseases from bacteria, viruses, fungal, insects, worms, and other maladies. We want to protect not only ourselves, but prevent any transmission of disease from one patient to another. On numerous occasions we have seen dentists in developing countries not adequately protecting themselves or their patients from transmission of disease. “Standards of Care” for treatment and for infection control are almost non-existent in many parts of the world.
We had an Egyptian Physician, who ran a Family Practice Residency Program in a missionary hospital visit us. When we asked him how his teeth were, he replied that he had a toothache. When we asked him why he did not have it fixed, as he had money and influence, he answered, “I would rather have a toothache and lose a tooth than get AIDS or Hepatitis from a dentist who does not sterilize instruments.” This is not an isolated incident as we have seen it repeated in most places within the developing world. The “Oral Health Atlas”, published by the World Dental Federation estimates that 90% of the people in the world do not have access to reasonable dental care, which includes infection control.
“Universal Precautions” using “Personnel Protective Measures” are employed to prevent the spread of disease. We always wear gloves when in contact with bodily fluids, including blood, saliva, and infected tissue. When operating in an environment where there is likely to be splatter of fluids, we wear a protective mask and protective eyeglasses. We often have patients wear protective glasses when we might splatter something into their eyes when doing dental procedures.
How do you sterilize the instruments and equipment? We strive to sterilize, defined as removing or destroying all forms of microbial life for all instruments and burs which come into contact with a patient’s mouth. Where this is not possible or practical, we use chemical disinfectant wipes, which destroy most pathogens to a level that it is not generally harmful to health. Wipes are generally used on inanimate objects like hoses, trays, knobs, protective eye glasses, etc. Antiseptics use chemicals to kill microorganisms on skin or living tissue.
Our sterilization method is a simple, inexpensive steam autoclave consisting of a four-quart, stainless steel, Presto pressure pot and a heating source. Heat and pressure efficiently kill all micro-organisms. The pressure pot comes with a pressure regulator which fits on the lid and the steam vents at sixteen pounds per square inch (psi). Fifteen minutes at sixteen psi ensures sterilization. By adding an additional weight to the pressure regulator (which can be purchased through the Christian Dental Society), the psi is raised to twenty-four pounds of pressure. This enables sterilization to occur in ten minutes. The process is simple:
- The dirty instruments come onto the un-clean side of the sterilization table from the dental chair on a tray. The anesthetic needle, glass cartridge, surgical blades, and surgical needles are removed at the chair by the dentist to avoid needle stick injury and placed in a plastic bottle which works well as a sharps container. Heavy duty gloves are worn to decrease the chance of injury from the sharp instruments used in dental treatment.
- Blood and debris are removed using a tub of soapy water and brushes to clean everything well. The tubs are plastic food storage containers just large enough to hold and clean the instruments.
- The instruments are then rinsed in a tub of clean water before being placed in the pressure pot. Small items like dental burs and rubber dam clamps can be placed in a tea strainer for ease of containment.
- Place one half to one cup of water in the pressure pot and secure the lid, making sure the handles click to seal. Place the pressure regulator on the top and put the pot on a heat source. We use an electric single element heat source, but a gas or propane stove works well and in a pinch you can place the pot over a fire.
- Once the steam begins to vent around the pressure regulator, start the timer, which takes ten minutes at 24 psi.
- After the ten minute cycle, remove the pot from the heat source, remove the pressure regulator which allows the steam to quickly vent, and open the lid.
- Using the lid to hold the instruments in the pressure pot, drain off any excess water into the clean water tub. Use cooking hot pads to avoiding burns.
- Dump the instruments onto a clean tray. The hot instruments immediately dry and are cool enough to use in about five minutes. Chemicals or moisture are avoided as they rust the instruments.
How do you dispose of other infected items? All disposable items such as gloves, patient bibs, and gauze are placed in plastic bags which we collect from grocery stores. In developing countries there is always a place to burn and we want to destroy all the infected items to avoid the spread of any disease. We place the plastic bottle sharps container on top of the plastic bags where the heat from the flaming plastic burns very hot. The fire melts the needles and pulverizes the glass so there is no chance for contamination. The suction container of liquid spit and blood is dumped into the latrine.
How do you schedule rest and relaxation times? Dentistry is hard, demanding work and we want to build into our trips time to rest, relax, and enjoy the people and culture. We find it best to work no more than two or three days in a row before taking a break to transition between work sites and experience some local activities like shopping and tourism. We want to be flexible, patient, and resilient, but also want to have fun and experience the blessings of serving.