Oral Health Care In Camps For Refugees
© World Health Organization, 2000
This document is not a formal publication of the World Health Organization (WHO) and all rights are reserved by the Organization. The document may, however, be freely reviewed, abstracted, reproduced or translated, in part or in whole, but not for sale or for use in conjunction with commercial purposes.
The views expressed in documents by named authors are solely the responsibility of those authors.
List of Contents
Assessment
Decisions on oral care objectives
Manpower requirements
Referral network and procurement of instruments and materials
Treatment
Reporting
Transition
Programme preparation
Training refugees as community oral health workers
Self-management of community oral health workers
Reintegration of community oral health workers
Phase-down of oral health services
Documentation and termination of programme
Top of page
Introduction This document is written for organizations involved in the administration and management of camps for refugees and displaced persons, including the health authorities of the host country, the United Nations High Commissioner for Refugees (UNHCR), nongovernmental organizations (NGOs), and other relief agencies. Its intended audience is principally those individuals with responsibility for implementing oral health care programmes in refugee camps.
The authors have based their recommendations on personal experience. While acknowledging that most refugee situations are unique, the authors fee] that there is enough common ground for these recommendations to be widely applicable.
For practical reasons, the oral health programme is described under three headings - Emergency, Stability, and Repatriation - although it is probable that there will be significant overlap between them. Although most care in the emergency phase is likely to be provided by non-refugees, the emphasis throughout programme planning is on self-care. lndeed, dental caries and gum infection, which are the two most common oral health problems, can be managed to a very large extent by self-care and through the use of low-cost instruments and materials. There is therefore little need for sophisticated dental equipment in refugee camps.
The authors also stress the advisability of oral health care and health promotion being integral elements of the overall health programme.
Additional publications on ART and how to implement a community scheme are availabie from WHO/Oral Health Programme.
Top of page
Phase 1 - EmergencyAssessment:
dental morbidity and case-load registerDecision on oral care objectives for:
pain relief preventive self-care ART approach patient referralCalculation of manpower requirements
Set-up of a referral network;
procurement of instruments and materialsPatient treatment
Reporting:
activity reports inventoryAssessment
In emergency situations, the first step in oral health care activities must be an assessment of dental problems and treatment needs. This should be based on morbidity and can be undertaken by field staff in the course of their routine work
Decisions on oral care objectives
Oral health care objectives wil] not be the same in every refugee situation and will be dictated by the needs assessment. Appropriate dental personnel will need to be recruited to achieve these objectives. At this stage, it is likely that the principal needs wil] be for pain relief, preventive and curative care, improved self-care, and referral, which may be summarized as follows:
• Pain relief .
- tooth extraction
- medication.
• Preventive care and self-care
- individual oral hygiene instructions
- use of fluoridate toothpaste.
• Curative care
- atraumatic restorative treatment (ART).
• Referral
Depending on the circumstances, application of an ART sealant may be the appropriate method of preventing tooth decay. It is widely accepted that dental caries and gum infection can be largely prevented by use of a fluoridated toothpaste for brushing teeth and gums, and this appears to be true also of the refugee situation. However, once a cavity has developed in a tooth, the most appropriate approach to its management is ART. This involves removal of the soft, decayed tissue with hand instruments. The cleaned tooth cavity is then filled with a material that bonds to the remaining healthy tooth tissue.
In 1994, WHO adopted ART as a promising low-cost approach to the treatment of dental caries in situations where there is no electricity. Longevity studies have since shown that the survival of ART restorations after three years to be as good as that of conventional (amalgam) restorations, which require teeth to be drilled.
Manpower requirements
The organization responsible for overall health care in a refugee or displaced-person camp will probably determine the manpower needs for oral care activities. Initially, short-term personnel should be externally recruited, but every effort should be made to find individuals who can communicate in the language of the refugees.
Referral network and procurement of instruments and materials
The oral health care team should establish a referral network within the host country. They should also make use of any existing procurement system for the purchase of materials and instruments, although many supplies may be donated. The equipment and materials needed for most oral health activities during this phase (tooth extraction and ART) are listed in the Annex; it should be stressed again that expensive and sophisticated equipment is not necessary. During treatment, patients can be placed on a padded table or similar surface, or on a locally made bed.
Treatment
Depending on the resources available, oral health activities among refugees and displaced persons may include the following:
• In the camp
tooth extraction, ART
oral medication
preventive treatment, oral health promotion
screening and referral.
• Outside the camp
diagnosis, using outpatient laboratory and X-ray facilities
oral surgery, hospitalization.
Reporting
The report should be sent regularly to the responsible authorities on oral health activities and usage of resources.
Top of page
Phase 2 - StabilityTransition:
from emergency to stable phaseProgramme preparation
Training of refugees as community oral health workers
Management of oral health services by community oral health workers (COHW)
Outcomes:
dental treatment oral health promotion community assessmentTransition
The responsible authorities will be able to identify the point at which the refugee situation stabilizes. Oral health care in the stable phase will build upon the programme put in place during the emergency phase.
Programme preparation
Once conditions of stability are achieved, it is probable that externally recruited oral health personnel wijl no jonger be available. Where that is the case, individuals selected from among the refugee population wijl need to be recruited to take their place. The emphasis of the oral health programme wijl therefore shift to the training of "community oral health workers" COHW. A typical sequence of steps in the preparation of an appropriate oral health care programme for a stable refugee situation is illustrated below.
Steps in preparation of an oral health care programme under conditions of stability
SITUATIONAL ANALYSIS
DEFINITION OF OBJECTIVES IN ORAL CARE
CALCULATION OF REQUIRED COHW MANPOWER
SETUP OF TRAINING FACILITIES
COLLABORATION WITH: REFUGEES
AND HEALTH AUTHORITIES OF HOST COUNTRY
Training refugees as community oral health workers
Following a joint decision by all relevant parties, a selected group of refugees will be trained as community oral health workers. Training should make use of recognized training modules and should be in accordance with any legal requirements of the host country.
Successful trainees should receive appropriate certificates as evidence of their achievements and should be provided with detailed job descriptions. Typically, a job description might outline the oral health worker's responsibilities as follows:
1. Manage and maintain dental equipment, instruments, and supplies.
2. Carry out all procedures relating to hygiene, disinfection, and sterilization.
3. Take patient histories.
4. Examine the oral cavity. Identify healthy structures, diagnose the common oral diseases,
and make appropriate treatment plans. When necessary, refer patients to a higher
level of care.
5. Maintain a registration file and fill out patient record cards. Use these for evaluation
procedures and for reports to your supervisor.
6. Provide pain relief and treatment for common oral diseases:
• perform uncomplicated extractions
• prescribe appropriate medication
• perform first aid procedures when necessary, e.g. management of dislocated jaw.
7. Provide preventive and curative care for dental caries, using the ART approách.
8. Provide preventive care for periodontal diseases, through health education and instruction
in oral hygiene and by removal of dental calculus, where necessary, using hand
instruments.
9. Organize and participate in diagnostic surveys of community oral health; analyse data with
a view to planning féasible oral health interventions.
10. Promote and organize realistic programmes for prevention of oral health problems based
on, for example:
• home visits
• school visits
• community visits.
11. Collaborate with your supervisor in planning orai health care objectives, using measurable
criteria to evaluate your progress.
12. In all your work, be aware of the need to provide a positive role model. Respect for
patients and a positive attitude to preventive oral health care are essential.
In summary, community oral health workers are responsible for assessing oral health status and dental treatment needs in the refugee community; maintaining oral health clinics within the refugee camp; promoting oral health during visits to families and to schools, by organizing oral health awareness weeks, running workshops for parents and teachers, and encouraging the use of fluoridated toothpaste to maintain oral hygiene. Their clinical responsibilities extend to examination of the oral cavity, ART and application of sealants, extractions, and referral of patients with problems requiring more sophisticated treatment.
Self-management of community oral health workers
The community oral health workers will be responsible for the management of their own work programmes, although programmes should be regularly monitored and evaluated. Their work should be fully integrated into the genera] health services within the refugee camp -there is no reason to separate the two.
Training refugees for placement as oral health workers in their own encampments has been successfully demonstrated, and UN agencies and health authorities have endorsed the community oral health worker programmes for Cambodian (1978-1993), Laotian (1993-1994), and Liberian (1997, continuing) refugees:
"....UNHCR/WHO endorses and supports the Oral Health Pilot
Project for Liberian refugees in Buduburam Refugee Camp, Ghana.»
UNHCR, Ghana, 9 December 1996
WHO fully supports the approach being proposed and the use of the set of training manuals for community oral health workers .... [WHO wilij provide further input .... for both the training course and for the community care services being developed for the refugees...."
WHO, 17 March 1997
"A team of ten Liberian refugees resident at Buduburam Camp near Accra in Ghana were trained .... to promote oral health among inhabitants in and around the camp .... The zeal and enthusiasm that the group has exhibited in promoting oral health at the camp is highly commendable. Their activities have no doubt had tremendous impact on the creation of oral health awareness among the inhabitants at the camp and Ghanaians living nearby."
Ministry of Health, Ghana, 9 September 1998
.... we are convinced that the proposed curriculum is relevant to our situation in Liberia. The training of auxiliary staff would help in meeting the needs of oral health care in Liberia."
(interim) Ministry of Health, Liberia, 24 June, 1997
I can only support the introduction of ART in any primary oral health programme aimed at improving oral health of refugee populations."
Ministry of Health, Zimbabwe, 15 April 1997
Top of page
Phase 3 - RepatriationIn home country:
reintegration of community oral health workers
In refugee camp:
service phase-down
Termination of programme/documentation
Reintegration of community oral health workers
The desirable outcome of any refugee situation is repatriation of the refugees, to their country of origin or to a third country. Refugee oral health programmes, developed in the emergency phase and operated throughout the stable phase, provide the refugee community with its own primary oral health care service. The empowerment of community oral health workers through their training has also produced a valuable manpower resource for the repatriated community. As a matter of policy, reintegration of these workers should be undertaken in parallel with the reintegration of al] repatriated health personnel. Experience gained from the repatriation of refugee community oral health workers to Cambodia showed that:
• without such a policy, reintegration of refugee community oral health workers is a
lengthy process;
• circumstances permitting, repatriated oral health workers are likely to remain within
the oral health care profession;
• the most likely employers of repatriated oral health workers are ministries of health,
nongovernmental organizations, and private dental practitioners.
Phase-down of oral health care services
As the population of the refugee camp decreases, oral health care services can be systematically phased-down. The rate at which this happens can be calculated by the community oral health workers and the operational partners from data on the oral care needs of the remaining camp population. Where a programme of oral health maintenance is well established, continuing needs for basic care can be met by the volunteer oral health workers; otherwise, it may be necessary to seek help from outside the camp.
Documentation and termination of programme
All data collected during the oral care programme should be collated and analysed by the oral health workers and the camp's operational partners. A self-evaluation report and a program~audit should be produced. Additionally, each oral health care provider should deliver an inventory report to the authorities.
Self-evaluation report - Programme audit - Inventory report
Top of page
AnnexList of essential instruments and materials
Examination and diagnosis
Mirror and handle
Periodontal probe
Explorer
Tweezers
Prevention
Hand scaler
Fluoride toothpaste
Toothbrushes
Extractions
Straight elevator
Pair of universal forceps
Cartridge syringe
Miscellaneous items
Water syringe
Suture scissors
Glass mixing slab
Mixing spatula
Latex gloves
Eye protector
Other support items
Stainless steel tray
Pressure cooker
Instrument forceps
Plastic water buckets
Head lights
Torch
Plastic sheet
Plastic bags for prescriptions
Gas tank and burner
Large lockable chest for all items
Foam headrest
Consumables
Needles, disposable
Zinc oxide/Eugenol
Glass ionomer cement
Cotton wool rolls
Cotton pellets
Gauze
Mouth mask, disposable
Examination gloves
Local anaesthetic
Disinfectant
Paper towels
Soap
Antiseptic
Petroleum jelly
Matrix bands
Wedges
Articulating paper
Plastic refuse bags
Torch batteries
Analgesic
Antibiotic
Haemofibrin
Portable water
Chlorhexidine mouthwash
Autoclave paper packs
Oral health record cards
Inventory card
Requisition/order form
Printed oral health messages
Top of page
Recommended further readingSITUATIONAL ANALYSIS
Oral Health Surveys Basic Methods, 0 edition, 1996. World Health Organization. Source: World Health Organization, Oral Health Programme, Management of Noncommunicable Diseases, 1211 Geneva 27, Switzerland. Fax: +41 22 7913111.
PREVENTION/PROMOTION
The Berlin Declaration 1992 on oral health and oral health services in deprived communities - The oral health alliance, promoting oral health in deprived communities. Mautsch, Sheiham, Berlin, 1995. Source: Dr W. Mautsch, Klinik f.Zahnaerztiiche Prothetik, University Aachen, Pauwelstr. 30, D-52057 Aachen, Germany. Fax: +49 24188 88 410.
PAIN RELIEF AND CURATIVE CARE
Atraumatic Restorative Treatment (ART) for dental caries, Frencken, (textbook), 1999. Source: Dr J. Frencken, College of Dental Science, Department of Preventive Dentistry, Radboud Universiteit Nijmegen, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands. email: j.frenken@dent.umcn.nl
COMMUNITY ORAL HEALTH WORKERS (COHW) TRAINING
Case study on oral health care provision in refugee and displaced persons encampments along the Thai-Cambodian border 1978-1993. Frencken, Htoon, Pilot, December 1993. Source: Professor T. Pilot, Woerdakkers 5, 9461 EB Gieten, The Netherlands. Fax: +31 592 264 158.
Development of a model for primary oral health care in refugee and displaced persons encampments, Pilot, December 1995. Source: Professor T. Pilot,Woerdakkers; 5, 9461 EB Gieten, The Netherlands. Fax: +31 592 264 158.
La formación de refugiados liberianos en Ghana como asistentes de cuidado dental (Oral health worker training for Liberian Refugees in Ghana) Mickenautsch. Anales de Odontoestomatologia, 1998 5(1): 37-39 Source: Dr S. Mickenautsch, Division of Community Dentistry, University of the Witwatersrand, Johannesburg (Medical School), 7 York Road, Parktown, 2193 South Africa. email: neem@altavista.net
(COHW) Selection of students and project sustainability
(COHW) Subject Areas
(COHW) Course Timetable
(COHW) Student Assessment, Formal Examination
Walker, Australia/Ghana, 1997 Source: Dr D. Walker, 275 Elizabeth Bay Road, Lake Munmorah, 2259 Australia. email: d.wal@hunterlink.net.au
Oral health among Liberian refugees in Ghana, Mickenautsch, Rudolph, Ogunbodede, Chikte. East African Medical Journal, Vol.76, No.4 April 1999, pp206-21 1. Source: Dr S. Mickenautsch, Division of Community Dentistry, University of the Witwatersrand, Johannesburg (Medical School), 7 York Road, Parktowri, 2193 South Africa. email: neem@altavista.net
Guidelines on how to run an ART Training Course, Frencken, Holmgren, 1999 Source: Dr J.E. Frencken, College of Dental Science, Department of Preventive Dentistry, Radboud Universiteit Nijmegen, P.O. Box 9101 6500 HB Nijmegen, The Netherlands. email: j.frencken@dent.kun.ni or World Health Organization, Oral Health Programme, Management of Noncommunicable Diseases, 1211 Geneva 27, Switzerland. Fax: +4122 7913111.
SELF MANAGEMENT
Oral health care for displaced persons on the Thai-Cambodian border. Htoon, Promoting oral health in deprived communities, Berlin, 1995. Source: Dr H.M. Htoon, 6 Charles Bullock Av., Beivedere, Harare, Zimbabwe. emaii: htoon@africaonline.co.zw
EVALUATION
Monitoring and evaluation of oral health. Technical Report Series No. 782., World Health Organization, Geneva, 1989. Source: World Health Organization, Oral Heaith Programme, Management of Noncommunicable Disease~, 1211 Geneva 27, Switzerland. Fax: +4122 1913111.
REPATRIATION / REINTEGRATION
Preliminary survey of basic dental assistants after repatriation. Htoon, Chew, Klaipo, Menh Khin, 1999 Source: Dr H.M. Htoon, 6 Charles Bullock Av., Belvedere, Harare, Zimbabwe. email: htoon@africaonline.co.zw
Top of page
Back to literature