The Third (2005) Caribbean Dental Program (CDP) was hosted once again at the all-inclusive Jolly Beach Resort in Antigua. CDP’s goal continues to be the provision of CE, primarily for our Caribbean dental professionals, in an effort to improve and update the clinical and academic skills of all members of the profession. On this occasion the first two days were dedicated to an HIV/AIDS workshop being hosted in conjunction with the Pan American Health Organisation (PAHO). The remaining five days were dedicated to “Restorative Dentistry”, “Aesthetic Dentistry”, “Treatment of the Tempero-Mandibular Joint Dysfunction”, “Periodontics”; “Endodontics”; “Implants”; Hands-On practical for Dental Surgery Assistants and “Ozone therapy”. Everyone benefited from the interaction and exchange of ideas but more so from knowledge shared.
Drs. Victor Eastmond and Soumi SenGupta, the Co-Chairmen of Caribbean Dental Program Ltd., which had responsibility for the hosting of the workshop in conjunction with the running of a Dental Continuing Education Programme at the Jolly Beach Resort in Antigua, arranged this workshop. The workshop was conceptualised by Professor S.R. Prabhu, Associate Dean of the University of the West Indies Dental School. Assistance was solicited from the Pan American Health Organisation (PAHO) through its oral health director, Dr. Saskia Estupinan Day, and the Caribbean HIV/AIDS Regional Training (CHART) through its director, Professor Brendan Bain.
Dr. Eastmond was the Organising Chairman. Siixty-four delegates, of whom two were UWI final year dental students, attended the meeting. They came from the following sixteen countries: Antigua and Barbuda, Barbados, British Virgin Islands, Canada, Commonwealth of Dominica, Grenada, Guyana, Ireland, Jamaica, Mexico, Montserrat, Puerto Rico, St. Lucia, Trinidad and Tobago, United Kingdom, and the USA.
The objectives of the workshop were to:
- Empower professional oral health care providers with guidelines on aetiology, pathogenesis, and clinical, physical and oral manifestations of HIV/AIDS.
- Empower attendees on methods of controlling the disease within the dental and public environment.
- Empower dental health care providers with skills to deliver HIV testing and counselling services, clinical ma
- Discuss feasibility to put forward proposals for HIV/AIDS to international agencies.
4) The Workshop.
A) On Monday, 11th April 2005, Dr. Eastmond gave a brief overview of the workshop’s goals and objectives (see above). He then introduced Professor Prabhu, Associate Dean for Special Initiatives at the University of the West Indies (UWI) School of Dentistry, as the Chairman for the workshop. Dr. Eastmond then invited Dr. Saskia Estupinan-Day, Oral Health Director of PAHO, to welcome delegates to the workshop. She proceeded to give a PowerPoint presentation and informed them of the current and past work done by PAHO whose aim is the promotion of health and protection of life while focusing on its Millennium goals to combat extreme poverty and hunger in an effort to achieve universal primary education and promote gender equality. PAHO is building foundations for better health by strengthening health care services in needy countries especially in oral health. She stressed that education of both public and private sectors in the early detection of HIV is necessary and complemented the initiative for this workshop. She advised delegates not to focus on “reinventing the wheel” but review work that was already done by organisations in this field. Dr. Estupinan-Day highlighted Brazil, which has preventative measures in place including universal access to Antiretroviral Treatments (ART) and condoms.
She reminded delegates that the most common epidemiological problem in oral health is still caries (tooth decay) before concluded by informing delegates of PAHO’s achievements in this area. One of these included preventative work using the most cost effective mechanism of fluoridated salt. She was impressed with the decline in the DMFT rate in Jamaica through that mechanism. It is hoped that by 2010, 99% of children would access fluoride treatment while six year olds would have their first molars fissure sealed. This preventative mechanism is estimated to cost $4,000.000.00 US, which would be less than continued treatment modalities for caries.
B) Professor Bain, the Director of the Regional Coordinating Unit for the Caribbean HIV/AIDS Regional Training (CHART), spoke about the pathogenesis and epidemiology of the HIV infection. There are approximately 40,000,000 people living with HIV/AIDS of which 2.1 million are from the Caribbean and Latin America. 14,000 new cases occur each year with 95% coming from the low and middle-income countries. Of this latter group, 2,000 are children under 15 years while 12,000 are between 15 – 49 age group. This is likely to produce a critical situation as the Caribbean loses its youth while in the prime of their working life. A high percentage of this group are female and the disease is confirmed in more than 1% of pregnant women. Persons at risk include those who have multiple partners, men having sex with men, sex workers, drug-abusers and pregnant AIDS positive mothers who pass on the virus to their babies through breast-feeding. Some Caribbean countries have reported a plateau of the disease but in most of the CARICOM countries, it is still on the increase while in the Americas, it appears to be on the decline.
C) The lectures by Drs. Mario Alves and Jeff Hill, who are both practicing dentists within their respective HIV/AIDS clinics in the USA, were most revealing in demonstrating through their PowerPoint presentations, the different signs and symptoms that would be manifested by the disease. These manifestations were magnified in these individuals due to their reduced immune response. Zerostomia and Candidiasis, two commonly related illness from which the patients suffer, can lead to dysphasia, pain and tenderness on swallowing thereby worsening their already immuno-compromised problems. Most of these problems can be treated and dentists must be encouraged to play a bigger role in providing the necessary treatments. Treatments and recommendations for this illness were discusses at great length with the involvement of all dental personnel as related to its cross infection control and treatment. Suggestions, with the use of many practical examples such as artificial saliva, were made and highlighted. Avoidance of smoking, alcohol and salt was recommended. This lack of saliva will also lead to an increase caries rate. Other lesions include parotid enlargement, periodontitis, acute necrotising gingivitis and/or ulcers which can be single, multiple or recurrent on the palate, tongue, buccal mucosa, or tonsils. In children candidiasis is one of the more frequent signs but similar symptoms may persist as for the adult. Both lecturers work within HIV/AIDS clinics and stressed the stigma associated with the treatment of such patients. Although oral problems are very common in this pandemic, they are not as extensive today with the inclusion of antiretroviral treatment (ART), but patients still manifest them with associated pain and tenderness when eating. This can lead to lack of nourishment to the already weakened immune system of such patients. Thanks were directed at companies which developed and marketed the ART for this illness. Initially this type of treatment was very expensive but governments and NGO’s, especially on the African and Asian continents have been instrumental in lobbying and attaining a reduction in cost on humanitarian grounds. Dental personnel were warned to be vigilant since it is not always possible to certify the patients’ HIV/AIDS status in spite of taking a comprehensive medical history. Because some patients are totally unaware of his/her status, it is imperative that each patient be treated as though he/she is HIV positive. It is now possible for saliva tests to be done which can render a diagnosis. This test has been proven to be very reliable.
D) Dr. Prince Ramsay, an Antiguan medical practitioner who is responsible for dealing with the “Aids Programme” in Antigua, gave the first presentation on Tuesday, 12th April 2005, entitled “STI’s and AIDS in Women”. He provided statistics which demonstrated that pregnant women with the disease who access ART, will most likely have a healthy baby whereas those that did not have access will pass the virus onto their offspring(s). Those that were most vulnerable were the indigent, prostitutes and homosexuals who were very liberal by having multiple partners. His lecture was accompanied by PowerPoint slide presentation of Caribbean persons. His message of caution, and abstention was well received.
E) Dr. A. Enrique Acosta-Gío is a PAHO consultant and director of the Organization for Safety & Asepsis Procedures (OSAP), spoke extensively on the reasons and methods of cross infection control and care that is necessary for post exposure injury. His lecture was most interesting and maintained a high level of alertness from the audience who were most interactive. He reiterated that all patients (not just HIV/AIDS patients) must be treated with the highest standard of control and provided the delegates with many visual cine and PowerPoint demonstrations.
F) The final lecture of the workshop was by Dr. J. Hill who addressed the stigma factor as it relates to the profession’s ethical and moral obligation. He stressed that it is not a disease for which practitioners must be frightened as the virus is weak but once cross infection controls are in place, as stressed by the previous lecturer, there is no need to worry. If a patient discloses that he/she is HIV positive, it is important that he/she be not made to feel more uncomfortable than he/she already is. He was concerned about the liability that could occur with disclosure of information and stressed the need for confidentiality. The saliva test can be a useful adjunct but the practitioner should be trained in its use and most importantly, he/she must be trained in counseling techniques. He suggested that practitioners participating in this methodology will need further training and resources must be found for such. It is imperative that members of the dental profession do continuing education courses to keep updated in order to educate themselves and their patients. In most cases, dentists will need to refer patients to the appropriate specialists for continuing treatment care and thereafter work in partnership with the appropriate agencies. His presentation was done with PowerPoint.
5) Group Discussion
Delegates were divided into three groups.
The Groups Work – Caribbean Dental Programme Conference April 12, 2005
Coordinated by Group 1: Dr. Victor Eastmond
Group 1- Education: Dr. Victor Eastmond whose scribe was Dr. Mario Alves;
Be it resolved that:
- Be provided to Healthcare providers, HIV/AIDS patients and the general population who feel they do not have the virus.
- Dentists should be trained to counsel patients.
- Make dental care accessible to a large number of populations
- Establish a network of dentists and medical practitioners.
- Both private and public health care practitioners should be involved in this common goal and objective.
- Work with Governments to provide funds and include dentistry in primary care.
- Develop a strategic plan within the profession (CARDA and others agencies)
- Data should be kept for monitoring purposes.
- Appropriate dental personnel should be assigned to hospitals to help patients who present with oral problems.
- Governments and NGO must source international funds.
- Members of the dental profession should not discriminate against HIV/AIDS patients
- Publish education through the media.
- That the issues of confidentiality be addressed conscientiously.
- Dentist should follow international guidelines for infection control.
- Patients be safe guarded by having adequate quotas of instruments, handpieces etc)
Group 2 – Continuing Education Dr. Saskia Estupinan-Day whose scribe was Dr. Soumi SenGupta;
Problem Statement: Given the pandemic, which faces our people especially when HIV/AIDS has invaded our community, we must do something to improve the situation. In the interest of maintaining the integrity of our people/community, we must utilise our education (medical and dental) to reduce, and stabilize the spread of this disease.
Being committed to oral health care, our training places us on the forefront of early identification, diagnosis, and treatment of this disease.
- Public – Reducing and eventually eliminating the stigma associated with HIV/AIDS, through education of the general population. This can be done through using print and audio-visual media, talks and programs in schools and community groups e.g. using posters, billboards, cartoons in newspapers, on television, radio, the Internet etc.
- Profession The ultimate goal should be to provide continuing education on a regular basis to all dental health providers. This ought to be mandatory. Certification should be provided to each practitioner/dental office, to instill confidence in patients that they are ready to provide full and confidential medical histories, and be treated by properly trained professionals. It ought to be a requirement of registration for practitioners to be licensed with a certain minimum continuing education hours is undertaken of which a 10% or 20% should be in cross infection control, and HIV/STD management.
- Work to establish a network with other health care providers, such as physicians, nurses and public service providers to more effectively manage HIV+ patients through a multidisciplinary approach.
All oral health providers become an integral part of HIV detection and management.
Group 3 – Way Forward Dr. Acosta Gio and Professor Ram Prabhu whose scribe was Dr. Maria Agard
Facilitators: (2) Prof Ram Prabhu and Dr. A. Enrique Acosta-Gio
Group Members: (9) Danielle Eastmond – Barbados
Idaline John – Dominica
Sherry Ephraim – St. Lucia
Nadera Khelawan – Guyana
Jonnel Mortley – Guyana
Maria Agard – Barbados
Barry Thomas – Antigua
Shameer Ali – Guyana
Charmaine Gouveia – Antigua
Brain Storm Session regarding the Way forward.
- Infection Control Policy for the Caribbean with special emphasis on control of Blood Borne pathogens and TB.
- Introduction of Oral and General Manifestations of HIV to include detection, management, control and referral. Include in the undergraduate programmes. Utilise expertise from CAREC – pretest Counseling, PEP
- Identify leaders and facilitate networking within the Caribbean.
- Develop methods of attracting post-graduate dental practitioners into post grad courses, cc TOT in Mexico. (OASP’s work in Infection Control that is done in collaboration with CDC). Identify experts who will form the faculty team. Look at the need for making these courses certified e.g., Diploma
- Dentists/ OHCP needs training in the psychosocial management of the HIV infection. Look at need for Pretest counseling. Establish a protocol within the Dental School to address this area.
- Establish a Time-Line by which these activities need to happen.
- Questions – How many dentists work in the public and the private sectors
- Trinidad -close to 400 in total and? 70 in MOH/public sector.
- Guyana – about 26 in total and 16 in the public sector (Dental Surgeons). They serve about 80-100, 000 persons all together.
- Will the authorities provide an incentive for dental surgeons /OHCP who want to work with PLWAs?
- OHCP need the help of Policy Makers to change # 7
- Contact the MOHs and MOEs to develop policies re medical requirement for practice. This could be done at time of registration and certification of these persons.
- Can Dentists provide the Quick Test – Saliva Method? Should this be done as a Screening Method? Convince the government/policy makers to involve OHCP in issues of requesting the test
- Greater collaboration between the OHCP and Medical team.
- What is the attitude of the OHCP team towards dealing with PLWA? – Not necessarily good partly due to high level of stigma and discrimination. Training needed. Issue of confidentiality has to be addressed. May need to include file management and confidentiality guide in the training courses.
- PEP guidelines may differ according to country (Acosta). CAREC guidelines must be disseminated to the member countries. Why not to every practicing dentist? Do through the Dental Councils (legal bodies).
- Prof Prabhu is in the process of publishing a book that will be distributed free of cost to Dentists in the region. Will be ready by December. Can this be put on a Website for persons to access easily?
- CARDA (Caribbean Regional Dental Association) is hosting a conference in association with DATT (Dental Association of Trinidad and Tobago) in June. HIV/AIDS should be included
- Can policies be introduced to make dentists compliant – regarding training and protection of staff?
- Should Dental practices be inspected regularly (yearly)? If yes, whose responsibility will it be?
- Lobby for Dental Insurance for all persons on the OHCP team to cover against every blood borne pathogens. It was pointed out that if persons are practicing Universal Precautions this should not be an issue.
- WHO/PAHO recognise the UWI’s School of Dentistry as the body for all collaborating activities such as research, training etc. There is no data available to provide information to OHCP.
After much discussion, It was resolved that the ideas from the brain storming sessions (all 3 groups) be put together and called the Antigua Summit Resolution – April 2005. It was resolved that this précis will be done by Professor Ram Prabhu and Dr. Saskia Estupinan-Day for presentation to delegates on Thursday morning for their ratification.
Delegates attended this function at which dignitaries were present. These included the Mr. John Maginley, Honourable Minister of Health of Antigua and Barbuda; Dr. Prince Ramsay HIV/AIDS co-ordinator for Antigua and Barbuda; and Professor Pitt-Miller Dean of the University of The west Indies Mount Hope Campus.
Dr. Eastmond acted as Master of Ceremonies. Professor Pitt-miller spoke on the Dental School and the need for its accreditation to be acknowledged especially in light of the return of many of its graduates who are now lecturing within the programme and the recent success achieved in a UK based external exam.
Dr. Saskia Estupinan-Day was then invited to give the keynote address. She used PowerPoint to assist. She stated that 38,000 persons died in the Caribbean from this condition and that is an optimistic figure which can be reduced by 2006 if oral health care providers play a major role, especially since they are usually the first persons to see the clinical signs and symptoms within the oral cavity. She felt that their additional manpower resources would greatly assist in reducing the stigma of the disease and provide another avenue for its management by getting the dental profession more involved with educating, screening, testing and counseling patients. PAHO is trying to improve the inadequate services in oral health care while improving low efficiency, productivity and public health expenditure. Dr. Estupinan-Day highlighted Brazil, which has preventative measures in place with universal access to Antiretroviral Treatments (ART) and condoms. This has reduced the epidemic there in spite of the vulnerability of the poverty-stricken population and its high level of prostitution. In 2001, Brazil was the major country in the region that participated in the programme where 170,000 persons had access to the ART. This number had since increased. PAHO provides technical assistance for those countries where the political will and population assistance will provide adequate health services at affordable cost. She briefly spoke about the 3 by 5 initiative where people living with AIDS must have universal access to treatment as a part of their human rights. She thought the dental profession could have an impact on the disease as the use of dental personnel will increase the available manpower in reaching the people and assist in attaining this objective. She advised that there are funds available to reach the required goals and hoped that this workshop will provide the necessary mandate and avenue to open the door for the release of funds to provide necessary training for dental personnel who will participate in the HIV/AIDS fight. The advantages of such a proposal would be its sustainability but coordination will be needed plus there must be acceptance of change at medical and governmental level to accept the participation of dental manpower and thereby utilise the Caribbean’s total manpower resources with greater efficiency.
She advised that once accepted, the proposal to have dental personnel involved with the HIV/AIDS programme would require funding and continual training. She suggested that there is much funding available that can be accessed once a funding proposal is made to the appropriate agency. She promised to assist the region in achieving this goal, as PAHO and the people of the region will be the beneficiaries.
Dr. Estupinan-Day summarised the meeting as “The Antigua Summit Resolution April 2005”.
THE ANTIGUA RESOLUTION
Caribbean Dental Program
HIV/AIDS Workshop 11 – 12 April 2005.
Participants from 17 countries took note of the following document essential to improved oral health in the Caribbean
WE THE PARTICIPANTS AT THE Caribbean Dental Program in Antigua RECOGNIZE THAT Health is a pre-requisite for good governance, social stability, and sustainable development.
The burden of disease from poor oral health remains high in certain populations due to inequity of care, changing pattern of oral disease, and insufficient data on overall oral health status.
Oral health is an integral part of general health and requires full integration into primary care delivery services in order to advance national health development and foster social protection between and within countries.
Major oral health advancements made in our Region must be maintained and protected via strong partnerships, sustainable infrastructure and effective public policies.
ENCOURAGE AND SUPPORT
- Training of Oral health providers to respond to HIV/AIDS initiatives such as:
- Reduction of stigma associated with the illness.
- Continued education on a regular basis on HIV/AIDS
- Develop more effective case management and referral systems
- Through integration of providers and activists
- Multidisciplinary approaches and service settings.
- Emphasise evaluation and evidence based approaches to programme management, resource allocation and decision-making.
- The expected result is to:
- Diminish/lessen the stigma of HIV/AIDS
- Empowerment of oral health care providers through the strengthening of the HIV?AIDS skill base and self confidence.
- Oral health care providers are actively involved in national multidisciplinary HIV/AIDS networks.
- Programmes and resources reflect evidence of oral health care providers’ impact on HIV/AIDS case detection.