BPOC Chapter5

Basic Package of Oral Care

Jo E. Frencken

Christopher J. Holmgren

Wim H. van Palenstein Helderman

WHO Collaborating Centre for Oral Health Care Planning and Future Scenarios

Chapter 5 - Personnel and equipment for OUT and ART

The training and job description of oral health personnel will differ from country to country and are regulated by the country's legislative system. This chapter provides information about the various types of oral health personnel suitable to provide OUT and ART services at the lower level of the PHC pyramid. Affordable fluoride toothpaste is considered an element of health pro-

motion and no attempt is made to discuss the types of personnel required to be involved in this promotion. Furthermore, an attempt is made to list the basic requirements in terms of equipment and instruments to perform OUT and ART.

Personnel requirements for OUT

The precise type of personnel required for OUT services largely depends on local conditions, national health personnel infrastructure, and health strategies. The differences in types of health care personnel for OUT are shown in the three examples presented here. In Cambodia, primary health care nurses implement the Basic Package of Oral Care (BPOC). These nurses undergo a five-month dental training program. They are considered proficient in the skills required to render all services included in the BPOC. The requirements for enrolling in the dental upgrading course include the following: one year of basic health training; at least one year employed as a primary health care nurse at a district referral or health center; and a signed agreement to return to the district referral or health center after the dental training has been completed.

Tanzania is the next example. There, rural medical aids provide pain relief through tooth extraction supported by drug therapy at rural health centers or dispensaries. The basic training for rural medical aids lasts three years. The dental upgrading training is accomplished through a short in-service training course. The rural medical aid is then considered proficient in the skills required to render OUT services. Both patient satisfaction with the pain relief service and job satisfaction among rural medical aids were reported to be high.

In Nepal, health assistants with extended duties that include oral health education, tooth extraction and first aid for maxillo-facial trauma, have been trained in a couple of months. In other countries, such as Kenya, Malawi, Vietnam and Zimbabwe, OUT services may be provided by dentally trained personnel such as dental therapists.

Personnel requirements for ART

Different types of dental personnel have participated in ART studies. They vary from final year dental therapy students to dentists. Data analyses have shown the following findings.

• There was a statistically significant difference in survival of ART restorations between dentists (Pakistan, Syria) and between senior dentists and junior dental therapists, with the former performing better (Zimbabwe), but not between senior dentists and senior dental therapists (Thailand).

• The survival of ART restorations placed by dental therapists (China and Tanzania) was comparable to those placed by dentists (Pakistan and Syria).

• The survival of ART restorations placed by final year dental therapy students was below average (Cambodia).

Restoring decayed teeth through ART requires knowledge and skills about the maintenance and functioning of the dentition in total. Therefore, short training courses, as have been conducted for OUT personnel in Nepal and Tanzania, are inappropriate. It seems that the dental therapist is a suitable type of dental personnel to carry out the ART approach. However, local circumstances may lead to specific training courses on ART that exclude elements that make up the dental therapy training. Such a training course would then be shorter than the usual three years needed for the dental therapy training. It is up to each government to decide what is best under the prevailing circumstances.

Conclusion

While auxiliary medical and dental personnel will provide most of the OUT services at the lower level of the PHC pyramid, dentists play an important role in the overall structure. Dentists interested in community dentistry may be useful as teachers and instructors in the competency-based training of providing OUT and ART personnel. Furthermore, dentists in government service, preferably with some training in public health, are required to supervise and monitor the oral health services in regions or districts. These government dental officers are also responsible for the training and upgrading/refresher courses for dental and medical auxiliaries.

Equipment, instruments and materials required for OUT

The equipment may include the following:

• A chair or bed/couch with head support;

• A stool for the dental health worker and assistant;

• A table for instruments and medicines;

• A light source, which ideally does not rely totally on electricity supply;

• A wash basin;

• A system of water storage if running water is not available;

• A pressure cooker and heat source for sterilizing the instruments.

A basic set of dental instruments and materials should be compiled. This should be considered the minimum required for the provision of OUT services. There are numerous types of extraction forceps and they are expensive. Decisions must be made regarding the number and type of forceps required. A limited set of two to four different types of forceps and one or two dental elevators will suffice for the extraction of all types of teeth. The expected number of patients per day and the time needed for sterilizing the instruments determine the number of sets of instruments required. This will differ from country to country and from community to community.

Equipment, instruments and materials required for ART

The equipment and material requirements for ART have been reduced to a minimum. This lowers initial set up and maintenance costs and allows treatment to be provided in virtually any environment. All that is required are appropriate supports for the patient and operator, dental hand instruments, an adhesive restorative material, relevant consumable materials and a source of lighting.

The hand instruments used in the ART approach have been carefully selected and are based on the steps involved in placing an ART restoration. Only those instruments that are essential are included. Almost all the instruments used are those commonly found in dental clinics and are readily available from dental instrument suppliers. The instruments used are mouth mirror, explorer or probe, tweezers, excavators, dental hatchet and an applier/carver. A new instrument for opening tooth cavities has been developed recently (Figure 5.1).

The consumable materials required include cotton wool rolls, cotton wool pellets, petroleum jelly, tumbler/cup, wooden wedges, matrix band and plastic strip. Until now glass ionomers have been used as the restorative material. However, if ART is to be undertaken in a well-equipped dental clinic, either in a district or provincial hospital or privately, then resin-based composite materials might be considered.

Conclusion

The type of dental personnel needed to perform OUT requires a shorter training period than those performing ART. The national health and legal structures will have to be followed when introducing the BPOC. The equipment, materials and instruments required to do OUT and ART are not electricity-dependent, much cheaper to purchase and to maintain than that required for traditional western dental treatment and, therefore, permit the BPOC to be undertaken almost anywhere.