The Fill In The Fill In January / February 2009
January / February, 2009
FIRST VISIT
Cover Photo: Marc Mootoo Editors: Cindy Beckles, Devin Jaggernauth, Denelle Furlonge, Carlen Chandler, Lois Applewhite, Ryszardo Jennings Photography: Marc Mootoo, Annalese Percy
Here we are, well into 2009: a new year, a new semester and a new issue of The Fill In. This is the semester when the workload doubles. The Year Ones will be introduced to their first Phase exams, the Year twos have officially become full‐time dental students, now separated from their medical colleagues, the Year threes have embarked upon their clinical programme, the fourth years are focussing on projects and presentations while the final year students are tirelessly preparing for final examinations. With such a hectic schedule now on the plates of every student in the school, we all welcome a little “de‐stresser”; and The Fill In offers just that!
UWI Dental Students Association School of Dentistry, Faculty of Medical Sciences UWI St Augustine Eric Williams Medical Sciences Complex Uriah Butler Highway Trinidad, West Indies Email: uwidsa@yahoo.com Website: http://www.uwidsa.org
UWI DSA Executive: Devin Jaggernauth - President Arif Saqui – Vice President Sarah Ramsaroop – Treasurer Allana Tang Choon - Secretary
You probably will hear, or have already heard, the word “Scot” thrown around a lot this Semester. Who is this Scot Character? We’ve got the answer for you, right here. This is the semester of the Dental Outreach Programs. We will tell you exactly what these entail, and give you the rundown on one such recent program, which was held at the Laventille Church Health Fair. Also in this issue, we offer you the scoop on one of our favourite lecturers, Dr. Larry Coldero in 24 Questions with Dr. Coldero. Many of our very own lecturers are hard at work on various research papers, with a fair bit already published. In this issue, we present the first in a series of articles, highlighting the work Drs Naidu, Juman, Rafeek, Singh and Maharaj. We do hope that you enjoy all that this issue has to offer, and as always we welcome your ideas and suggestions. TFI
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The Scene If the clinic seems busier than usual, it’s because the 3rd year students have officially begun seeing patients! The environment may seem totally different, but this is when the action really starts! The editors wish to recognize the tremendous effort and hard work of Sarika Sarpavarapu (Class of 2010) that went into the DSA's Introduction to Clinic lecture. In order to help make up for time lost, final year students have been granted Thursday afternoons for work on exam case patients for the months of January and February. Dr. Kevin Moze has now taken up the position of Lecturer in Oral Radiology. We welcome you and look forward to your knowledge and experience in the field! Dent Team faced Vet Team in the finals of the Intra‐Faculty Football League. Supporters came out in full strength to witness an exciting match. It was a close nail biting 90 minutes but Christian landed a penalty in the last minute to seal the deal for the Dent Team. Congratulations to the Team. You've made us proud.
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Who is this Scot Character? Devin Jaggernauth As the time draws nearer to final exams, continuous assessments take a turn in a different direction. Examiners’ interest is not as focused on how much theory you can write; now they want to test your ability to provide treatment for a patient (yes, a real patient!). Enter: the Department of Restorative Dentistry’s Structured Clinical Objective Tests (SCOT’s). In addition to the Clinical Assessment in Periodontology (CAP), these exams in Conservative Dentistry, Endodontics, Crown and Bridge, and Prosthodontics comprise the clinical continuous assessments. SCOT exams are usually distributed between December and January; however, this year, all except CAP were crammed into one month, making it as daunting as it sounds! (Something to do with students protesting for better conditions on clinic) So what’s it about? Here’s the typical breakdown: 1. SCOT 1 (Conservative): Restoration of a Class 2 lesion (with opposing and adjacent contacts) or Class 3 lesion. 2. SCOT 2 (Endodontics): Initiation of root canal treatment of an incisor to trial GP fit or a multi‐rooted tooth (preferably a premolar) to corrected working length determination. 3. SCOT 3 (Crown and bridge): Previously a crown prep on a patient, but now entails a preparation on the phantom head jaw with a written paper (technically speaking, not exactly a SCOT) 4. Prosthodontics: Mouth preps and secondary impressions. All these exams require some level of clinical competency, and a thorough knowledge of the procedure. Basically, you need to know (and will be asked about) what you’re doing, why you’re doing it and how you’re doing it. You’ll need to be familiar with the procedure inside and out, as well as every single instrument and material to be used. This includes everything from choice of restorative material to material composition and even constituents of local anaesthetic being used! Think of it like this: anything forming part of your armamentarium for the procedure poses a possible question! In addition to the theory behind it, instructors want to see that you can actually perform the procedure. They will want to check your progress at various stages and may question you at each stage. It will be undoubtedly beneficial to have actually done the procedure several times before; for your own sake, don’t let your SCOT exam be the first time! As with any procedure (especially Endodontics), assistance will be invaluable. You should request the help of a Dental Surgery Assistant, as fellow students will not be permitted in the cubicle. Do remember to fill out your instrument request forms from the day before, and also check to ensure no instruments are missing. This will simplify the process by saving you the hassle of having to run to the dispensary ever so often. The exam normally spans the usual 3 hour session, so there’s no time to waste, especially as examiners have to check several other students. Case selection obviously forms an important part of the exam; therefore the search for an appropriate patient should begin several weeks before. If you’re fortunate to have a patient with the required lesion, you may want 3
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to consider delaying treatment of the tooth for the exam (although this may not necessary constitute ideal treatment). The Emergency Clinic is a tremendous aid in locating patients (particularly for SCOT 2), so attending the clinic and communicating with interns will be of great value. Additionally, if you’re still unable to find one, you can see a colleague’s patient just for the exam. (The author actually went trolling, checking through multiple patients’ bitewing radiographs before locating a case). Remember to familiarize yourself with the patient and recheck the histories as well as charting, should this route be chosen. Inform the patient of the importance of the visit: treatment is being provided, but it’s still an exam for you! It is also helpful to take note of the patient’s contact number and give a reminder the day before. You don’t want a “did not attend” on the day of your SCOT. Take no chances! Prosthodontic cases will require completion of all pre‐prosthetic work. Primary impressions for study models and custom tray fabrication will also need to be done before the exam. Furthermore, your models will need to be surveyed and your dentures designed so you know exactly what preparations are to be done. As challenging as they were at times, the SCOT’s were among some of the more interesting examinations. You will be required to pass them all before being able to write your DDS finals, so don’t take them lightly. As with any exam, preparation is key; so prepare thyself, go forth and restore! Good luck!
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Dental Outreach Program at Laventille Church’s Health Fair Ryszardo Jennings
Dental Outreach Programs were established to provide dental services to areas that were identified as isolated and under serviced. The Dental Outreach Program (DOP) is one strategy implemented to assist with monitoring, sustaining and restoring the dental health of under serviced communities. Once a community has been defined as underserviced, there are several ways of how services may be provided. The community is assessed as to which strategy is the most appropriate way to deliver services. Dental Outreach Programs allow for the charitable aspect of the dental profession to be implemented. These programs are usually operated by volunteers giving freely of their time and knowledge, with absolutely no payment or reward being requested. Its impact is often greatest felt by those who otherwise may not be able to afford/experience such an intervention. With the aforementioned in mind, please permit me to give my (biased) account of what was a wonderful Dental Outreach held by the UWI School of Dentistry, Child Dental Health Unit (CDHU) in November, 2008 hosted by the Laventille Open Bible Church. The church contacted Dr. Naidu (Senior Lecturer CDHU) through their PRO Collen Holder and requested that a booth be set up to provide dental screening to the attendees at their Health Fair. Without any hesitation the wheels of the CDHU were put into gear and the necessary arrangements made. Anyone attending the Health Fair would not have expected what they would find at the dental booth. Dr. Naidu along with seven (7) UWI Dental Interns gathered early that Saturday morning and boarded the maxi taxi to Laventille. Upon arriving the team quickly set up their screening clinic and went above expectations by also setting up an Oral Hygiene booth. Every patient who presented to be screened received a thorough examination and then was ushered to be educated on correct oral hygiene techniques appropriate to their age, with gifts given to participants thanks to the Colgate® brand. The team examined approximately fifty (50) individuals ranging from the very young to the elderly, even some beautiful special needs individuals were in attendance. After being screened some left, only to return with their families or friends for them to have the benefit of the screening and even oral hygiene education. Both teams were kept very busy by the very inquisitive and open minded crowd that developed as the day went by. It is without reservation that I write that the Dental booth was the most popular at the health fair, even with the Cancer Society Of T&T’s mobile unit being present, and most certainly it was very well 5
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received. The team worked until the very last of their disposable mirrors (used for the screening examination) was finished, at which time there was no more they could do. The team then sat and enjoyed a wonderful lunch, which was supplied by their host. Immediately following a group photograph was taken and then they departed. It was certainly, in my opinion, time well spent with a group of appreciative people. I would like to encourage all readers to become active in similar chartable missions, no matter what stage of your personal or professional life you may find yourself. Now is the best time, forget waiting till the next time and go now, everything else can wait! Please visit the UWI CDHU to view the poster showing photographs of the Dental Outreach.
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Meet the Staff Lois Applewhite
Dr. Coldero Most, if not all of us, have heard the popular saying, even if part thereof; “Who can find a virtuous woman? for her price is far above rubies.” Moreover, we are most definitely familiar with the quotation- “Patience is a virtue”. Now if we could just combine these two lines, and somehow revise the initial quote to presume reference to a man, it would capture the essence of our featured lecturer for this issue. Dr. Larry Coldero is one of the most patient and down-to-earth persons here at our fine institution. His calmness and level-headedness is evident during a single lab session with a class full of students, which he usually single-handedly mans, always smiling and with an encouraging word to lend. His gentle and modest disposition may sometimes be mistaken for coyness, but do not be fooled! ‘Larry’, as he is affectionately known throughout the student body, is known for his spontaneous sarcasm; but this only lends to the enjoyable educational environment he brings to what is usually thought of as a tedious specialty. It is apparent that this sphere of dentistry, Endodontics, is where Dr. Coldero’s passion lies. According to one of his colleagues, friends and a previous interviewee of ‘24 Questions’, Dr. William Smith, “Dr. Coldero will perform a root canal on just about anything….” Dr. Coldero’s journey thus far began back in November 1995, upon his graduation with the Doctor of Dental Surgery degree (D.D.S.) from our very own School of Dentistry, University of the West Indies, St. Augustine Campus. After completing a one-year internship, he worked as an Associate to Dr. 8 www.uwidsa.org thefillin@gmail.com
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Derrick Marshall in Antigua for a year. It was during this year that his interest in the field of Endodontics was developed, and subsequently, in November 1998, Dr. Coldero embarked upon graduate studies in the UK. He later obtained the degree of Master of Science in Endodontics from the University of Glasgow in December 2000. Since then, Dr. Coldero has practiced privately as a parttime associate from December 2000 to January 2005. He has also been lecturing in Endodontics at U.W.I School of Dentistry since October 2000 while running a part-time private practice limited to Endodontics, in Port-of-Spain. We are most privileged to take a peek into the life of this virtuous man, whose price is definitely far above rubies here at our school, and we thank him for so graciously participating in ‘24 Questions with Dr. Larry Coldero’.
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24 Questions with Dr. Coldero 1. Biggest pet peeve? Arrogance
2. Favourite movie? Star Wars
3. What do you do to unwind? Watch a good movie
4. What's your favourite food? Macaroni pie, callaloo and stew chicken
5. Favourite drinks? (alcoholic/non alcoholic) Stag / Passion Fruit Juice
6. What is your greatest joy? A job well done
7. What is your secret fear? Going blind
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8. What is the best advice you have ever received, and from whom? Nothing happens before its time and everything happens for a reason from my mother
9. Most embarrassing moment? Making a rude joke about a neighbour and my parents hearing about it. I was about ten and no need to say what happened after
10. What is the happiest moment you can remember? Too many, can’t choose one
11. What do you consider your greatest achievement? Top student award at O-Levels
12. What is something people don't know about you? I’m an open book…no secrets
13. What influenced your decision to enter the field of dentistry? Career guidance seminar while in Secondary school (A-Levels)
14. You were one of the pioneering students of the Dental school. How have things changed from your days as a student to now? Is there anything you dislike? Most significant change is that we now have permanent academic staff and not just visiting ones
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15. What is the funniest thing that has ever happened to you in your days as a student, especially on the clinic? It was actually during an exam and I remembered an examiner laughing (trying to hide too) at the rubbish answer I gave to a question another examiner asked…..I still passed
16. What is the worst thing that has ever happened to you in your days as a student, especially on the clinic? Trying to cover up a mistake I made while on the clinic, my patient realised and was pleasant about it but never came back. It really wasn’t a serious mistake but one I regretted.
17. As a lecturer, what is the one thing you hate to see a student doing? Getting other people to do your work on clinic and trying to pass it off as your own
18. Any interests/hobbies other than dentistry? Dentistry is not a hobby :-). My interests include anything that’s nature (scenery and wild-life).
19. If you could do something other than dentistry, what would it be? Engineering
20. People you admire and why? My parents….the sacrifices they made for their children
21. Where is the one place you would like to visit? Africa and any of its wild life safaris 12
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22. If you win the lottery tomorrow, what would you do with the money? I really don’t know
23. What is the one thing in your life you would like to accomplish in the future? Still thinking about that one
24. Is there anything in your life you would like to do over, if you could? Yes…fixing the answer to question 16
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International Dental Journal (2008) 58, 00-00
Oral and dental conditions presenting to medical practitioners in Trinidad and Tobago R S Naidu, S Juman, R N Rafeek, R Singh and K Maharaj Trinidad and Tobago
Objectives: To describe the type and frequency of oral and dental conditions presenting to medical practitioners in Trinidad and Tobago, type of management, and interest in continuing education in oral diseases. Method: Cross sectional survey of registered medical practitioners in Trinidad. 20-item self-reported questionnaire. Results: 103 medical practitioners participated in the study (response rate 69%). Mean age 33 years. Mean years since qualifying was 8 years and 72% worked mainly in hospital service or private practice (19%); 67% had seen patients with a dental problems, with 69% of those at least as frequently as once a month. Most frequently seen problems were dental abscess (72.5%) and toothache (59.4%). In the case of dental abscess and oral mucosal infection 31.9% and 63.8% respectively, diagnosed and treated before referring. 84% cent expressed interest in receiving continuing education in oral diseases. Conclusions: In the context of access to oral care in Trinidad and Tobago, medical practitioners appear to be important providers and may benefit from further training in the diagnosis and management of oral diseases. Key words: Oral health, oral diseases, medical practitioner, West Indies
The impact of oral and dental problems is significant both for the individual in terms of pain and discomfort as well as for whole communities. For example a national study in the USA has shown that in one year 4.9 million acute dental conditions were reported and caused 17 million days of restricted activity along with 7 million days of work loss and had a comparatively greater impact at the community level compared to common medical problems such gastrointestinal disorders, ear infections and skin and eye problems1. Due to problems of access to dental care, patients may turn to other primary health care providers for their oral health needs, sometimes resulting in medical practitioners encountering patients presenting with oral and dental problems2-4. Physician encounters with patients complaining of dental problems may take place both in private offices and hospitals emergency rooms2. Knowledge of oral diseases by medical practitioners maybe somewhat lacking5. For instance, 80% of doctors in one study misdiagnosed early oral squamous cell carcinoma in elderly patients and 56% did not feel confident about examining the oral cavity6. This is most © 2008 FDI/World Dental Press 0020-6539/08/00000-05
likely to be due to the fact that oral and dental problems and their management is not a significant part of most medical undergraduate training programmes5,7,8. This suggests that physicians may require some additional training to aid in the appropriate management and referral of patients with oral and dental problems. In developing countries, access to primary dental care is frequently an issue of concern due to geographic, socioeconomic barriers and availability of dental services9. Patient’s use of physicians for dental care may therefore be common. For instance 74% of physicians in Kwara State Nigeria reported dealing with dental problems10. Trinidad and Tobago is a twin-island nation in the English-speaking Caribbean located about 11km off the north of the coast of Venezuela. It has a total area of 5,128km2 of which Trinidad accounts for 4,828km2. The country has a population of 1.3 million, one quarter of which live in rural areas11. There is no data on the oral health of adults in Trinidad and Tobago but recent studies on school children have reported high levels of untreated dental caries (tooth decay) in primary schoolchildren12,13. doi:10.1922/IDJ_1849Naidu05
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Presently there are approximately 300 registered dentists in the country giving a dentist population ratio of 1:4,333 which is much lower than that in the UK of 1:2,18014, the physician to population ratio in Trinidad and Tobago is around 1:1,20011. Most dentists work in private practice in urban centres. Free dental care is available in the government sector for children and adults but mainly in terms of emergency care and extractions, delivered in the health centres throughout the country. Only twenty dentists work in the government sector supported by 46 dental nurses (the equivalent of dental therapists in the UK) who provide care for children under 12 years old). The use of alternative providers of dental care in Trinidad and Tobago has been reported15 and highlights the problem of access to dental care in the country. Anecdotal evidence also suggests that due to greater availability of medical practitioners, they may on occasion be dealing with patients who present with oral and dental conditions, however the extent of this or its implications for dental care and the training of doctors has not been investigated. The aim was therefore to investigate medical practitioners experience of managing oral and dental conditions in Trinidad and Tobago and the objectives to describe: • The type and frequency of oral and dental conditions presenting to medical practitioners in Trinidad and Tobago • The type of management of these conditions by medical practitioners • Describe medical practitioners’ knowledge of oral diseases and use of dental services • Medical practitioners’ interest in continuing education in oral diseases. Methods
A survey using a self reported questionnaire was administered to sample of doctors registered with the Medical Board of Trinidad and Tobago. A convenience sample of doctors in primary care was accessed through contact with general practices, A&E departments in the general hospitals and government health centres. The survey instrument included questions on frequency of patients seen with oral and dental problems, type of management and referral, knowledge of oral diseases, own use of dental services and views on dental services in Trinidad and Tobago. Information was also collected on age, years in practice, main area of practice, specialist training and interest in continuing education courses in oral disease. The questionnaire was piloted on a group of hospital doctors (not included in the final analysis) to test appropriateness of questions and response choices.
International Dental Journal (2008) Vol. 58/No.0
Results Participants
Out of 150 medical practitioners invited to participate, 103 doctors agreed to complete the questionnaire giving a response rate of 69%. Their ages ranged from of 23 to 70 years with a mean of 33 years. Number of years since qualifying ranged from 1 to 39 years with a mean of 8 years and 72% had been in practice less then 10 years. Twenty-three per cent had specialist qualifications and the majority (72%), worked mainly in the hospital service or private practice (19%), with health centre and other work being the main employment for 9%. Dental and oral problems and their management
Sixty-nine participants (67%) had at some time seen a patient with a dental problem. Sixty-nine per cent of these doctors see patients with dental problems at least as frequently as once a month and 16.9% see such cases more than once a week. The types of dental problems seen, are described in Table 1,infection and toothache being the most common problems. With respect to three oral conditions (dental abscess, trauma and oral mucosal lesions), participants were asked to report on their types of management. In the case of dental abscess and oral mucosal infection 31.9% and 63.8% respectively, diagnosed and treated before referring, whereas for dental trauma only 14.5 % attempted treatment (Table 2). Knowledge of oral diseases
One hundred and three participants responded to the questions regarding knowledge of oral diseases. For the main causes of dental caries, 56.3% chose amount of sugar, 71.8% frequency of sugar intake, 80.6% plaque and 33% lack of vitamin D and calcium. For periodontal disease most chose 87.4% plaque, 59.2% sugary food, 63.1% vitamin deficiency and 81.6% poor general health. Responses to questions on oral cancer risk factors and lesion associated with HIV/ AIDS are given in Tables 3 and 4. No association was found between knowledge of oral diseases and postgraduate educational experience. Own use of dental services
Regarding their own use of dental services, 25% reported visiting a dentist within six months and 37% within the last two years with cleaning (62%) and fillings (33%) being the most common treatment at their last visit.
3 Table 1 Main types of presenting dental / oral problems (N=69) Presenting problem
n
%
Oral infection / abscess Toothache Dental trauma Oral mucosal lesion Bleeding gums Dental consultation or other advice
50 41 21 28 24 12
72.5 59.4 30.4 40.1 34.8 17.4
Table 2 Type of management of dental problems (N=69)*. Type of management
Oral infection/ abscess
Refer to a dentist Provisional diagnose and refer to a dentist Call a dentist for advice and treat Provisionally diagnose, treat and refer to a dentist Provide medication Other
Dental trauma
Oral mucosal lesion
n
%
n
%
n
%
12 14 5 22 14 6
17.4 20.3 7.2 31.9 20.3 8.7
48 14 2 10 4 1
69.6 20.3 2.9 14.5 5.8 1.4
14 15 4 44 14 3
20.3 21.7 5.8 63.8 20.3 4.3
*More than one response could be selected so per centages may total more then 100
Table 3 Participants’ knowledge of risk factors for oral cancer (N=103) Risk factor Smoking Age Alcohol Tobacco chewing UV light White patches in the oral mucosa Red patches in the oral mucosa
n
%
100 49 42 95 8 65 18
97.1 47.8 40.8 92.2 7.8 63.1 17.5
Table 4 Participants’ knowledge of oral conditions associated with HIV / AIDS (N=103) Condition Oral candida Lymphoma Bi-lateral parotitis Kaposis Sarcoma Acute periodontal disease Hairy Leukoplakia
Continuing education and interest in oral diseases
Seventy-five per cent of participants undertake continuing medical education. Eighty-four per cent stated that they would be interested in receiving continuing education in oral diseases if made available with the majority (61%) choosing self study modules as compared to workshops (45%) and lectures (38%).
n
%
100 49 43 65 41 53
97.1 47.6 41.7 63.1 39.8 51.5
Discussion
As a small convenience sample was used for this study the findings may not be representative of all doctors in the country. This type of data is difficult to obtain due to the many clinical and administrative demands upon medical practitioners. The information gained however does provide hitherto unknown insight into their experiences and views on the management of patients with dental problems in Trinidad and Tobago. Naidu et al.: Medical practitioners in Trinidad and Tobago
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The sample was relatively young with a mean age of less then 35 and most with less than 10 years in practice. Over two thirds saw patients with a dental problem at least monthly. This is almost as high as in one study from Nigeria where 71% of physicians regularly encountered dental problems10. Although some doctors reported having specialist qualifications they were working in primary care at the time of data collection for the study. Similarly to Nigeria, oral infection / abscess and toothache were the most common reason for attendance. This suggests that people with acute dental problems may find it easier to access care in a medical as opposed to a dental setting indicating that access to primary dental care in Trinidad and Tobago is an issue of concern. Almost third of the practitioners in this study provisionally diagnosed and treated oral infections before referring to a dentist, with a fifth prescribing medication (probably antibiotics and or pain killers). This would seem an appropriate course of action and allow some symptomatic relief prior to the patient seeing a dentist for definitive treatment. Similarly, most participants felt able to manage oral mucosal lesions, with almost two thirds providing some treatment before referring. Interestingly a UK based study16 reported that the general public were more likely to seek the opinion of a medical practitioner with regards to mouth ulcers which highlights the importance of oral medicine in primary care. Few participants felt able to manage dental trauma and the great majority referred to a dentist without attempting treatment. Knowledge of oral diseases was generally good and most participants knew the main causes of dental decay were amount / frequency of sugar intake and presence of dental plaque. A third chose vitamin D or calcium deficiency, however there is no conclusive evidence as to diet influencing susceptibility to dental decay other than fluoride intake17. Encouragingly participants’ knowledge that plaque was a main cause of periodontal disease was very high and interestingly most also chose poor general health. Links between periodontal disease and systemic health have been established18,19. Knowledge of smoking and tobacco chewing as risk factors for oral cancer was good but there was low awareness of alcohol being a risk factor. There is strong evidence for the synergistic role of alcohol and smoking in the aetiology of oral sqaumous cell carcinoma (SCC)20. Knowledge was also low that exposure to UV light is a risk factor for SCC but people with prolonged exposure to sunlight e.g. outdoor workers, do have a higher incidence of lip cancer21. Almost two thirds of participants correctly selected white patches in the mouth (leukoplakia) as risk factors for SCC but worryingly, very few chose red patches. Red patches (erythroplakia) are usually early markers of oral SCC as they have a rate of malignant change far in excess of white patches22. These findings are consistent International Dental Journal (2008) Vol. 58/No.0
with those for general medical practitioners in the UK6,23 where knowledge of oral cancer risk factors was lower compared to dentists. Knowledge that Kaposi’s sarcoma and oral candidosis are signs of HIV/ AIDS was generally good. But, similarly to USA medical clinicians, there was low awareness of the other HIV associated oral conditions i.e. hairy leukoplakia, lymphoma, parotitis and acute periodontal disease24. The adult HIV/ AIDS prevalence rate in the Caribbean (1.6%) is second only to Sub-Saharan Africa25. The general perception among the medical practitioners in this study was that dental services in Trinidad and Tobago were inadequate particularly with respect to serving people from lower socioeconmic groups and those in rural areas and is likely to be a reflection of the low dentist to population ratio and limited public sector dental service. Improving dental services in Trinidad and Tobago will require significant investment in infrastructure and human resources, Compulsory service in the public service by nationals for one to two years following qualification from the UWI dental school has been proposed as a means to improve manpower. Increased patient education through the media to highlight where dental services can be accessed may also lessen the burden for medical practitioners. Attendance at continuing medical education was high among this sample of doctors suggesting that most are keen to keep up to date. Most encouragingly almost all were interested in learning more about oral diseases. It may therefore be incumbent on the dental schools or dental associations to engage with medical associations and other groups that regularly host continuing medical education e.g. pharmaceutical companies, to develop short courses in oral diseases for physicians. For example the training of doctors in Uganda (by dental students), in the diagnosis of oral manifestations of HIV was found to be effective26. A study on the teaching of oral pathology/ oral medicine in UK medical schools concluded that doctors and medical students are inadequately educated about oral diseases27. Therefore, another avenue for increasing awareness and confidence in the management of oral problems could be to incorporate some training in oral disease into the medical undergraduate curriculum e.g. in the ENT or GI rotation. This however may prove challenging as most medical undergraduate curricula are already very busy allowing little room for more teaching. An alternative approach could be exposure during the intern / residency training. For example inclusion of oral health knowledge and management of common oral conditions improved the oral health care of residents in a US paediatric residency28 and interestingly 95% of directors of family medicine residency programmes in the USA felt that oral health should be a component of residency training29.
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Further research in this area should include a larger sample of medical practitioners and an investigation of general dental practitioners’ medical knowledge to inform the development of continuing education courses. Conclusion
Medical practitioners in Trinidad and Tobago frequently encounter patients with oral and dental problems. Most feel able to manage the immediate/ emergency treatment of oral infections, toothache and oral mucosal lesions. General knowledge of the aetiology of dental caries and periodontal disease was fairly good but not so for risk factors for oral cancer and orofacial disease associated with HIV/ AIDS. In view of their level of contact with patients with oral problems, providing doctors in Trinidad and Tobago with continuing education in oral diseases may be of benefit, as in the context of access to primary dental care, medical practitioners appear to be important providers in Trinidad and Tobago. Acknowledgements
Drs. Visha Ramroop and Elizabeth Preyman (assistance with piloting the questionnaire), Drs. Bishnu Balbirsingh, Lesley Anne Brunton, Candice Gransaull, (assistance with data collection) and Miss Anisa Baksh (data entry). The medical practitioners who took part in the survey. This study was funded by a grant from the Campus Research and Publication Fund of the University of the West Indies, St Augustine, Trinidad and Tobago.
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Correspondence to: Dr Rahul Naidu, School of Dentistry, Faculty of Medical Sciences, The University of the West Indies, Mount Hope, Trinidad, West Indies. Email: rahul@trinidad.net Naidu et al.: Medical practitioners in Trinidad and Tobago
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