Challenges and Successes POPULATION AND PUBLIC HEALTH DENTAL CLINIC
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Challenges and Successes
POPULATION AND PUBLIC HEALTH DENTAL CLINIC
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LEANNE Hello, Happy Monday everyone! My name is Leanne Ziolkoski and this is Gwen Sawicki . We are both Senior Dental Therapists employed by the Saskatoon Health Region. We work at the Population and Public Health Dental Clinic at the West Winds Primary Health Center. I am married and have 2 girls, ages 3 and 5 years. I am a registered dental assistant, and have been a dental therapist for the past 6 years. I have been employed with the health region at the clinic for close to 2 years. GWEN I am married and have 1 daughter who is 24 . She is a registered nurse and works at Royal University Hospital. I have been a dental therapist for 29 years and employed with the health region for 3 years.
History
Began as Pilot project 1995
Became a Program in 1998
5 High Risk schools identified Program expanded to include all high risk schools A permanent clinic was needed and the PPH
Dental clinic was born!
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We wanted to get started with a bit of history on how our program came to be It started as a pilot project in 1995 and In 1998 it was accepted as a program. The staff included 1 DA, 1 DT and a contract dentist. The 4 DHE that were employed by SRH identified the 5 highest risk schools, periphery to the inner city schools, through the provincial dental screening process. The program was funded for 10 months of the year and every 2 months they would move into a new school Eventually, it became too confusing for the families to locate where the clinic was operating from. A permanent clinic was needed and The PPH Dental Clinic was born!
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In April 2006 the Population and Public Health Dental Clinic opened it’s doors. At that time all children under 16 who resided in the Saskatoon Health Region, that were in need, were eligible to access the Dental clinic. The office operates 5 days a week all year long. Currently we are going through some staff changes. Myself, Leah Abrook and a casual dental therapist are the current staff. Leslie Topola is our Manager and Dr. Uswak is our consulting Dentist.
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This is our waiting area. As you can see we have very advanced technology with the dual TV and VHS!
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The Entrance to the clinic and we are very fortunate to have windows for extra sunlight. The dental clinic policy is posted just outside the door.
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Our education and coloring display bulletin board
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We try to keep our themes current the seasons. This is our Halloween theme.
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Our Client care area
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Office admin area
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Sterilization area
Dental Clinic Policy
The Population and Public Health Dental Clinic only sees children who are experiencing poor oral health, and who have limited or no dental coverage. Paying for dental treatment must be a hardship for the family. The Population and Public Health Dental Clinic has a long waiting list. In order to see as many children as possible and restore their oral health, Population and Public Health has a policy that allows children to have a one-time full treatment plan completed. This may be 5 – 8 appointments. We will teach your family about good oral health care and nutrition, so that your child’s teeth stay healthy and future dental disease is prevented. When your child’s full treatment is complete, your child will be discharged from the clinic. Our staff will help you to link with a dentist/dental services in the community. It will be your responsibility to connect with a new dental provider.
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We wanted to touch on our policy We see children , who are under 18 years of age who are in need of dental treatment. This treatment is done at no charge to the families, although if they do have insurance we will try to cost recover We will only see children referred by a professional source. These sources can be dental professionals, nurses, social workers etc. Children are seen for a One-time treatment plan . This includes examination, xrays, prevention and treatment services. Once treatment is completed, if they don’t have a family dentist, we help them find a dental home Something new we are piloting is seeing pregnant and new moms from some of the programs run out of the West Winds Primary Health Center
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The children are eligible to return to see us if they have issues with treatment we provided. This is a certificate the children receive once they have had all of their work completed.
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You just never know what you’re going to hear in an office where you only see children!
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Gwen: Why do we do what we do? These beautiful smiles are the reason we come to work every day. This picture was taken in Jamaica. This is my neices, daughter and some local children.
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3 little sisters. They were so cute and kept asking… Can we see the picture, can we see the picture!
Our Challenges Language barriers
Behavior Management
Nutritional Education
Severity of treatment
Follow up care of our treatment recommendations
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Now we’ll jump into some of the challenges we face at the clinic. These are just a few of the many
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Always smile at little children. To ignore them is to destroy their belief that the world is good. Sometimes our body language says a lot to other people and greeting our families and children with big smiles and enthusiasm is so important.
Our Challenges •Language Barriers
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The biggest challenge that we face at the clinic is language barrier. The majority of our clientelle are new Canadians who speak little to no English. We do have access to Language Services through the telephone and we work with some organizations such as Global Gathering and Open Door Society who will arrange for interpreters to come with the families, some families know how to use translation services through apps on their cell phones and we will use it if they offer but most of the time, it is a lively game of charades! A couple of stories about language barriers: A family came to the clinic. Mom and 8 year old son spoke fairly good english, dad not as much english. Mom filled out the history forms and I started to review them before calling in the 8 year old boy. On our forms we have a question about breastfeeding. It states “ Is your child breastfed now?” and “If so … when?” Mom had marked down “Yes” and 10:00am (child was 8 years old) Kerrie Krieg was working with me at the time and I asked her to look at it. We could see maybe making a mistake on marking the question yes to breastfeeding, but she had put 10:00 as the time. We pondered the situation. We often see families from other countries breastfeeding long past infancy and we will sometimes have a discussion about that. Breastfeeding at 8 years old seemed excessive , many questions came to mind…. does she go at recess to school to feed? Where would she feed him at school? At any rate , it was going to be a “delicate “ discussion. We called mom in separately to discuss this. Kerrie read the question out loud. Mom, the questions states “ Is your child breastfed now?” You have marked yes to this. MOM GASPED!! I THOUGHT THAT SAID BREAKFAST! NO, NO BREASTFEEDING. Mom laughed and we laughed. Language Barriers are always a challenge. The second story I will share about language barrier is a mom who stopped at the clinic with her son. She was also hearing impaired. The little boy spoke some english. She showed me his mouth. He had clearly lost a SSC off of a tooth. First of all I needed to know if this child was a previous patient or were they here thinking that they were making an appointment. Asked mom to write child’s name down. Gave her pen and paper. I looked this child up in computer. Yes he was a previous patient, but had all of his treatment done under General Anaesthetic. (from 3 years ago) Read further into his notes in chart and I learned that mom and dad are hearing impaired and only read arabic. At this point I started asking the 5 year son some questions. He could not hold still long enough to carry a conversation. He tried asking mom but she was frustrated with him and he would just shrug at me and leave the room. He was really only concerned if I was giving him “The Shot” today and “Where was the shot?” I finally got them to have a seat in waiting room . I called and had to leave a message at the office that saw him for General Anaesthetic to see if they would see him again for retreatment. I tried explaining this to mom . She did not understand. Asked 5 year old to explain to mom, he did not understand. Tried writing it down, she cannot read english. Then mom brought in her phone and just kept pointing to it. I finally realized she was trying to tell me that she had no signal, I think she may have had translate app. But without signal, this would not work. I looked up the contact information in our computer and showed mom the names and numbers, we had. She just shrugged her shoulders. Asked the little boy if he recognized the names of the contact people, he didn’t know the names. Again, got mom to have seat in waiting room. I really was at a loss. I could not communicate with mom and she was not leaving. Numerous times she would bring him back in to clinic show me his tooth and push him in room. I decided the best thing for us to do was make an appointment and have them back. I would try to find someone who could help us by the next appointment. I wrote down on a card the date and time and tried to explain to mom and child they needed to come back. Mom could not understand and would not leave. I am literally using charades at this point. Mom gives me her phone again and show me a man’s name and it has a phone number. I take the number and name down. I find a calender to show her dates and she then shows me her calender in her phone. I finally get across to her by showing her the date in her phone, that she will come back on that day. The light bulb comes on, she gets up, blows me kisses and leaves! This process with one family at our door took ¾ of an hour. Confusing… Yes…. Frustrating, yes ….for both of us. But this is very common at our clinic doors. I went through my notes and counted 12 different phone calls over the course of a couple of days, to finally set up to have someone bring the family and have a sign language interpreter come for the appointment. A very time consuming process. But in the end , it is a little boy who needs treatment and we have a responsibliblty to make sure we can help him to the best of our ability.
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The kids who need the most love will ask for it in the most unloving ways. We have experienced children hitting or kicking their parents in front of us. I have had a boy throw his toy at me and run out of the clinic. On his way he stopped stared at me and took his lip and squeezed it as hard as he could. (Of course that is something we stress to children to NOT do as their lip is numb now, but they will feel it later. ) His mom was angry with him and made him come back and apologize. I thanked him for apologizing to me. We had a little heart to heart talk in front of mom about respect and his behavior. There is often a reason why they are acting out and somedays it takes incredible patience and understanding. Mom was so grateful that we were patient with him and she had tears telling me how frustrating he is to handle. I sympathized with her and told her we all do the best we can with our children and that some days being a parent is not easy!
Our Challenges •Behavior Management
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This is Always a challenge when we are dealing with young children. There are an incredible number factors here to consider: Are they tired, scared , hungry, present with a special need, attention span—Do They Have One! , personality (shy, outgoing, very talkative) is there a language barrier? What past dental experience (if any) have they had? For example : Are they scared because dad got child to watch a u-tube video of an injection before appt.? The list is endless, but we try to understand where the behavior is coming from and address it accordingly. Sometimes the ones that we have the most doubt about can be the most surprising! It is amazing when they come back and prove us wrong! I will share one of these stories: An 11 year old female from Pakistan came to the clinic with her mom. The appointment was going well until it came time to talk about the treatment needed. When the child found out she had to come back, she started crying uncontrollably. She had treatment done in Pakistan and it had not gone well. Her mom tried to calm her. We tried to explain that her treatment would be different here. She could not be consoled and cried so loudly that we had to close our door. We made some appointments but the child left still crying. This would be a challenge and Kerrie(who was the dental assisitant at the time) and I both thought that it was unlikely that we not would not be able to complete treatment , but we would try. At the first appointment, I explained to mom that we were going to start out with simple treatment, such as sealants to get her comfortable in the office and gain some trust. At this appointment we learned that her and her mom had just come back from vacation in Pakistan. 2 of her uncles had gotten married. We started to ask her questions about how the weddings in Pakistan and Canada were different. She finally started to talk to us. She went on to tell us that she had a cousin that she loved and missed very much in Pakistan .She told us they had planned their future. She told her cousin to come to Canada for her University education and then they were both going back to Pakistan to be actresses. She did very well for this appointment. Before she left, I explained to her that she could pick a picture to have drawn on her tooth at the next appt. In our office, I wear loupes (the magnification glasses. I call them my magic glasses. Because I can see very tiny things, I ask the children to pick something that they want drawn on their tooth. I can’t remember whose suggestion it was but it was decided that I would draw a picture of her cousin on her tooth when she came back. She was so excited for her next appointment. She would now have her cousin with her wherever she went. She brought in her dad’s cell phone with the picture on it. She did amazing for the whole appointment! Not a tear was shed. The biggest problem we had is that Dad’s cell phone rang as I was carving the picture. The child was not impressed at all that dad had to take this call. Luckily, I told her that I had a photographic memory and I could finish the picture without the phone. Some days we have to think very quickly on our feet! After this appointment, she looked forward to coming. At her last appointment, she brought us cake her mom had baked and gave us each a big hug and thanked us for helping her. We told her how proud she should be of herself for overcoming her fear. If she can overcome that fear, she could do anything she puts her mind to… including being an actress! There were high fives that day when the family left!!
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Some tactics we use to help when we have children who are very nervous, we ask them to wiggle their toes and not just all their toes but JUST their baby toe on their left foot or thumb on their right hand and just to see if they are paying attention.… their big toe on their left hand. It brings a smile every time. Any kind of distraction to help keep their mind off of what we are doing, say an injection. We talked about this in an earlier story, but because I wearthe loupes for magnification, I call them my magic glasses and if they would like to have a picture drawn on their silver filling, they can. I then will let them pick what ever picture they would like. What started out as hearts and stars has now turned into pixies, princesses, (of course Elsa and Anna from Frozen are popular) monster trucks, motorbikes and has had requests for moms and cousins drawn on teeth. Most recently, I had a little boy and I had asked him to think about what he wanted drawn on his tooth at the next appointment and he said” I already know”. I asked “What” and he looked at me and said “ I want you!” . Sometimes after anaesthetic it is difficult to calm the children. I will sit them up and bring up pictures on the computer and they can pick the exact picture they want . Children love it and it gives them a sense of having input and control in their appointment.
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LEANNE This little girl is a Syrian refugee who arrived in Saskatoon about 3 months ago with her family. She was seen in another dental office for an exam and they referred her to our clinic because she was extremely shy, scared and apprehensive about treatment. She wouldn’t even let them get a good look in her mouth. We spent the first appointment working on gaining her trust and helping her get comfortable with the clinic and with us. It took a lot of time but it paid off. Even after all the time we spent with her, when she left her exam we had our doubts. She showed up for her first treatment appointment she really surprised us, she did amazingly well and even gave a big hug! The second appointment also went great but the last appointment she came back very nervous again. We ended up using a few temporary fillings but were able to complete her. We were so proud of her and she left with a huge smile on her face!
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Children are like wet cement, whatever falls on them makes an impression. Sometimes a dental experience, good or bad, can be something that a child will remember for a lifetime. We really try to make our experiences at the clinic as positive as possible!
Our Challenges •Nutritional Education
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When the children come for their initial appointment, we spend time on OHI but a lot of time is also spent on nutrition counselling. On our client history we ask a few questions about their diet and from there we have a good starting point to open the discussion on healthy eating. (are they snacking on sweet things too often? Are they drinking a lot of sugary drinks?) The most common complaint we hear from parents is “but they will cry until they get what they want” The parents are giving in easily to the child’s demands for junk food. It often feels like we are giving parenting advice. Reminding them that they are the parent and its ok to say no when you have to. Some ways we do this is by encouraging them not to have junk food in the house or having it in a hidden place. Including the children in the grocery shopping and letting them to be a part of the choices in healthy eating. Suggesting a “treat night” instead of sweets every day We really try helping the child develop a positive attitude towards healthy eating by making it fun Gwen We had a 7 year old new Canadian female come to the clinic for a new patient exam. What we noticed about her was that she was very thin, quiet and sullen. (Her physical appearance did not indicate male or female to us). Both her parents sat in on the appointment. We started with talking about oral health and then went on to nutrition. This is when her parents told me that she would only eat fruit. No other foods. They had been to their family Doctor and he told them that she is underweight and that they were her parents and MUST make her eat. The parents went on to explain that they have tried everything to get her to eat. Her father is a chef and has tried many different ways of preparing foods for her. She has told them that she would call the police if they made her eat anything but the fruit. Her parents were very frustrated! The child sat quietly and would not talk, while the parents explained their frustrations to me. The first question I had for the child was: What do you think the police would say if she called them? She would not answer me. I told her that they would say: Listen to your parents! We went on to talk at great length about the problem. We explained to the child that her parents loved her and were only trying to take good care of her. On our display board were many ideas of different foods and food groups to try. We explained why she should try other foods … not only for her teeth but for her whole body to be healthy. I encouraged mom and dad to use positive reinforcement and to use fruit as the reward if she would try other foods. It would not be easy, but they had to be firm with her and to start out with small changes. We made a deal with the client that she had to try 2 new foods before she came to her next appointment. All we asked was that she try and told her she may not like what she tries but the important thing was to make an effort. We also suggested that seeing a nutritionist may help as they may be able to suggest different methods of approaching the situation. Appointments were made for the dental treatment required. Finding someone for the family to talk to within our health region about her nutrition was difficult, as she did not meet the criteria. We finally spoke with a nutritionist in Population and Public Health who would make an “exception “and see her. The whole family attended the next appointment. I went out to get her and the dad immediately stood up and approached me. He said “I cannot thank you enough for what you said to my daughter last time.” He said she has completely changed. She will sit at the kitchen table and now tell them what foods are healthy at their meal. I asked if they saw the nutritionist and dad stated that she had phoned, but their daughter was already eating and trying new foods. They did not need the appointment. Dad stated that everything had changed at home. She was a different little girl. We brought her in and told her how proud we were of her! She had the biggest smile, she was dressed in pretty clothes and had her hair done up in a braid. She truly was a happy and confident little girl! This is why we do our work in public health! You never know when or if the things you say will make a difference. That day, we made a difference and that is truly rewarding!
Our Challenges
•Severity of Treatment
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LEANNE Unfortunately this is normal for us to see on a daily basis. This is what makes our clinic so unique is that this is our normal. If we see minor MO’s or small occlusals/simple fillings that is out of the ordinary for us.
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These are just a few of the mouths we see
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Some times we are seeing children who have broken anterior teeth that have been that way for many years. Trying to find room for anterior buildups is difficult .
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Carious lesion
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Multiple teeth in a quadrant to repair is routine
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The next three slides are a child we saw who had a cleft palate
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This is a very typical BW x-ray of a mouth we commonly see. Multiple abscesses, broken shards of teeth remaining and space loss.
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Often parents and children do not realize that the shards of baby teeth remaining is not normal after permanent teeth erupt.
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Retained primary teeth are seen quite.
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Gwen This child came to his appointment and I was prepared to remove this tooth on palate at that appt. I looked in his mouth, looked at x-ray, looked in his mouth, looked up his picture in chart. I thought I had the wrong child as this tooth was gone. I asked him if he had this tooth removed at a dental office since we saw him last… he said no I took it out myself!! How he did this remains a mystery to me!
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We do many pulpotomies (nerve treatments), stainless steel crowns, extractions and space maintainers
COMPLETED TREATMENT
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Leanne: Here are a few pictures of some of the work that has been completed in our clinic
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As you can see from some of the slides, that not only do they have a lot of restorative treatment but also gingivitis or swollen gums is a very common problem from lack of oral hygiene.
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A child’s life is a piece of paper on which every person leaves a mark. Our goal at the clinic is to have the children leave with a positive experience. One bad experience as a child , can cause fear and anxiety at dental appointments for a lifetime.
Our Challenges •Follow up care of our treatment recommendations
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Leanne An issue that comes up frequently in our clinic is dealing with parents or guardians who refuse to follow through with our referrals for general anesthetic. When we see a child and are unable to do treatment due to patient management the next step is to refer them to have their treatment completed under general anesthetic. We give a detailed explanation to the families about what the next steps are, Forms are filled out, the referral is sent and we tell the families that they will be contacted for an appointment by another office One of the biggest problems with this is that when referral for GA is needed, this appointment is at cost to the families, which can be quite an expense especially if they have no type of insurance, and especially if there is a lot of work to be completed. They will simply refuse to go. We must explain to them that this is considered child neglect and it is not an option, these appointments MUST be kept. A difficult conversation to have. Another issue we deal with often is children/parents who do not enforce the OHI and nutrition education that we have offered them. We regularly see clients who have come back to their 2nd and 3rd appointments with heavy plaque, and quite often we are seeing their younger siblings after a year or two, who present with the same dental problems, even after we have stressed the importance of this with the whole family A lot of the parents and guardians do not understand the importance of dental health, they brush it off as if it is not a big deal and a saying we often hear is “they're just baby teeth, they’ll fall out anyways”. Their child will have a sore tooth, but often this pain comes and goes, and when it’s gone, parents think that because there is no pain, there is no problem. It is discouraging that this is such a huge challenge since we spend so much of our time educating these families on the importance of OHI and healthy eating habits. We try to help them understand that this is preventable!
Our Successes
Our Stories
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Many of the families who come to us, have had difficulties in their lives. They have dealt with unexpected deaths of a family member, poverty, come from war torn countries, the list goes on There are many days that we have to close the door, shed a few tears and decompress by talking to one another. Gwen and I feel that although this is one of the toughest jobs we have ever had, it is definitely the most rewarding. It is an amazing feeling to help them over come their fears of dental treatment. It is wonderful to be a part of their journey. Although we are not always successful, we really do have a lot of amazing wonderful outcomes Gwen: Client Story We had a 17 year old female come to the clinic. Her mom came to sign the forms but after that we had to send a taxi for her or she caught rides. She was incredibly nervous and scared. Her medical history included medication for depression. She had numerous carious teeth , 1 permanent tooth that needed root canal treatment or extraction, and she had chipped her 2 upper centrals many years ago( causing her to hide her smile and she stated she was teased about her teeth) She had been to an office and had an estimate for treatment . She had 1 permanent tooth extracted there because it was abscessed, but could not afford any other treatment. We set up a time that Dr. Uswak could come to do the extraction. She came early to the appointment. She said she didn’t know if she could do it. She was shaking and sweating profusely . I sat in the waiting room with her and we started talking. She said she was so scared. She had many “what if” questions. She then proceded to tell me her experience at the private practice office. She said (with teary eyes) that the office made her feel really bad about herself. They said to her “ How could you let your mouth get like this?”. She told them numerous times during her extraction that it was hurting, but they would not listen to her. She said” I cried through the whole thing”. I told her how sorry I was that she had gone through that . I told her that I was sorry she had been “judged” and unheard. I reassured her that her experience here would be different. I promised that we would take very good care of her. I had charting to finish before Dr. Uswak arrived, but every time I got up she had another question for me. We sat and talked for 30 min. She just needed someone to listen to her. The extraction with Dr. Uswak went well. She had lots of questions for him and she needed a hand to hold but she got through it. I told her I would keep my cell phone on and that she could text me if she needed to that evening (and she did) She just needed reassurance. We repaired her anterior teeth before school started this fall. She was ecstatic when she saw them! She said” They look so cute” Her family told her that they couldn’t believe what a difference it made and she now smiled without a hand over her face. She still needs a hand to hold but has made incredible progress in her confidence . She has really opened up to us and talks about her future plans for school now. At one of her last appointments , she started to tell us how her marks had improved, she talked about going to school to be a Teacher Aid and she said how her friends comment on her teeth now that they look so good. Her self-confidence had completely changed! We saw her from April to Dec with multiple appointments. At her last appointment, I asked her if she remembered her first appointment and how scared she was. She said” I can’t believe I did it” I told her she could do anything she wanted to do, wished her well and told her how proud we were of her!
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LEANNE We saw a family who had just recently arrived in Saskatoon from the Philippines. We had just finished the NP exam and they were on their way home when Laureen (who was the dental assistant at the time) noticed that it was raining, windy and cold, it was just miserable outside. They had mentioned that they took the bus here and it was their first attempt at using the public transit system. We stopped them and offered them a taxi, our clinic will provide transportation to families who have need for it. We also offered them some buss passes for the next appointment. They graciously accepted and dad was so thankful that he started telling us about how kind and welcoming their time in Canada had been so far. He got very emotional and just kept thanking us over and over again. It was just so impactful to be able to be a part of their great experience!
Appreciation
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Gwen: Many families are so grateful for the support they receive at the clinic. They often bring gifts of appreciation. Sometimes its cakes, pizza, coffee, hair accessories and sometimes it is a hug which is really the best gift of all. I worked in private practice for 26 years. In that time I only received one hug from a mentally challenged young man who asked me to marry him. I told him I was already married but that I was flattered and asked if he would settle for a hug.
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This is one of the recent thank-yous that Leanne and Leah received along with a set of cappacino mugs!
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Thank you everyone for your time and attention, this just gives a little glimpse into our successes and challenges at the Population and Public Health Dental Clinic. Any questions?
