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SIX-YEAR MOLAR PROJECT, ZAMBIA

Zambia The school, a first of its kind in the world, opened in March of 2003 and graduated the first class of five young men, six months later as "Community Oral Health Educator and Atraumatic Restorative Treatment (ART) Technologist" (COHE). The second intake of five young ladies and one young man, graduated in June 2004. The school in a large four bed room house in Chipata, provides tuition, room and board. Dr. Pashane Mtolo, DDS MPH, Chief Dental Office of Zambia, consulted on the curriculum, government alliances and many more essential areas. Diadactics, practical and non-dental consist of the program.

The Six-Year Molar Focus School Presented The New Delivery System for Oral Health. September 1, 2004, a team of 15; eight COHE and seven dental assistants, chosen from applicants for the next intake, will teach and treat, in the next 11 to 12 months, some 40,000 children in 198 mostly rural schools and villages. With a rented truck for transporting the team and its 8 wooden benches, assistants tables and stools, food and supplies - our overnight trips add to our circus coming-to-town look.

THE SCHOOL GAVE BIRTH TO THE NEW DELIVERY SYSTEM FOR ORAL HEALTH

"We think this is The Worlds Largest Movable Dental Office"
Dr. Jack Rudd D.D.S. F.A.G.D. Director
Community Oral Health Educator and Atraumatic Restorative Treatment (ART) Technologist

These four graduates rotate as teaching assistance at the Zambia Six-Year Molar Focus School and supervised teams teaching and treating in the 139 government and 59 community schools in Chipata District. Volunteers needed, both Dental and NON-Dental, in our fieldwork where we focus on vulnerable children in the villages where many do not go to school. Donated used children's books are utilized by connecting an older child in the village with some reading ability and the "Vulnerable Girl Child". In the villages and in the 59 community schools we have visited there where few if any books of any kind. Community Schools are started by and run by parents, guardians and other children-lovers to fill the void left by the government schools. One government school had 350 students, 7 classes and two teachers.

RESULTS OF THE SIX-YEAR MOLAR PROJECT, ZAMBIA

Zambia

Oral Health Survey: ART sealants and restorations placed three years ago, September 2005, were evaluated September 2008 by three of Teethsavers evaluators trained by Dr. Jo Frencken, MSc, DDS, PhD, 2008 at Chipata, Zambia. The 12 schools and children were randomly selected. Each survey school had 10% of the children in the survey checked for 85 to 95% agreement of evaluators. Teethsavers records of each child in the survey were transferred to computer adapted records and taken to Dr. Frencken office at Nijmegen Dental School, the Netherlands where they were analyzed by computer by Dr. Frencken and his staff February 2009.

Results of a 3 year evaluation of ART sealants and restorations by 6 different graduates:
By Jo Frencken , MSc, DDS, PhD, Nijmegen, the Netherlands (2005 – 2008)

Evaluation

The training and calibration exercises on the use of the ART sealants and ART restoration criteria took place in July 2008 under guidance of Dr. J. Frencken. For a period of 4 days, 3 senior operators and dental ancillaries were trained and calibrated in the use of the evaluation criteria (Table 1). Previous examination calibration trials of five days each, had been lead by Dr. Ramon Baez, associated with the World Health Organization (WHO), May and September of 2007.

A proper treatment recording system had been in place from mid 2004 onwards. This allowed the evaluation of ART sealants and restorations to cover the period September 2005 to September 2008. A convenient random sample of 12 primary schools in and around Chipata were selected.

The dependent variables under study were retention of ART sealants, percentage of caries free pits and fissures and success percentage of ART restorations after 3 years. The independent variables were age, gender, tooth type and operators. The statistical analyses were carried out by a statistician of the College of Dental Sciences in Nijmegen, The Netherlands.

Quality of the Data

ZambiaThe intra- and inter-observer consistency of ART sealants and ART restorations combined, and that of diagnosing dentine carious lesions, expressed in kappa coefficient and 95% confidence interval, is presented in Table 2. About 6 percent of the sample was reevaluated. Using the kappa coefficient interpretation scale

Disposition of subjects

A total of 496 children, 53% boys and 47% girls, were evaluated. The mean age of these children was 11 years. The drop-out of the included children was 23. Almost 90% of the evaluated sealants and restorations had been placed in molar teeth of the lower jaw by 6 operators. The occlusal surface was treated in 99% of the cases. The distribution of procedures evaluated by the 3 evaluators was 30, 33 and 37%.

Survival Outcomes

ART Sealants
A total of 332 sealants in 273 children were evaluated. After 3 years the percentage of sealants fully retained, partially retained and complete lost were 5.7%, 13.9% and 80.4%, respectively. Dentine carious lesion developed in 5.1% of the surfaces previously sealed. There was no age, gender, tooth type or operator effect observed for ART sealants.
 
ART Restorations
A total of 437 single-surface ART restorations in 283 children were evaluated. The success rate after 3 years was 89.2%, divided over 60.4% for score=0 and 28.8% for score=1. Failures were related to marginal defect of more than 0.5 mm (5.5%) and complete absence of the restoration (5.3%). Dentine carious lesions were observed in 5.7% of the restorations evaluated and were always combined with one of the other failure characteristics. There was no age, gender, tooth type or operator effect observed for single-surface ART restorations.

Discussion

According to the classification of Landis and Koch (1977), the kappa coefficient values show a near to perfect quality of the data obtained. This indicates that the final outcomes of this study can be considered a true reflection of the clinical state of the ART sealants and ART restorations. Based upon the results of the meta-analysis of ART sealants (Van t Hof et al, 2006), the proportion of ART sealant completely gone after 3 years is rather high, 28% versus 80.4%. Also the prevalence of dentine carious lesion development in pits and fissures previously sealed after 3 years is with 5.1% somewhat higher than the mean prevalence of 3% after 3 years reported in the meta-analysis.

The fact that the sealants did not stay too long may be the main reason for the somewhat higher dentine carious lesion development in the present study compared to those included in the meta-analysis. The success of single-surface ART restorations in permanent teeth obtained in the present study is in line with the mean survival percentage reported in the meta-analysis after 3 years; 89.2% versus 92%.

Considering the fact that the ART procedures have been carried out by people who have not undergone formal dental training but have obtained their clinical from on-the-spot training in the field, the outcomes should be regarded as very good. The ART approach in the hands of these young dental operators and their assistants have alleviated toothache, prevented dentine carious lesion development and restored cavitated teeth in children in rural Chipata at an adequate level.

Maiden, 23rd May 2009,
Dr. J. Frencken, Msc, DDS, PhD

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