Remote dentistry
Treating patients in Edinburgh … in the south Atlantic Ocean, more than 6,400 miles from Scotland and the most remote inhabited community on earth1
“I was looking for a job that was a little more family friendly,” said Penny Granger, laughing.
After completing her vocational training, Penny took time out to travel and volunteer in India. Next stop was Malaysia and then, cycling most of the way, Christchurch in New Zealand. She worked as a ‘flying dentist’ – her bike still with her as she was flown to the remote Aboriginal communities in Cape York, Northern Queensland.
“Nothing in dental school quite prepared me for the first, humbling, experience of being dropped off on the runway at Pormpuraaw – with a degree, a smidgen of experience, a pile of equipment and a remit to ‘treat as many patients as you can’. It was the start of my ‘remote and rural’ career.” But Penny knew she could always rely on her alma mater, Dundee University’s School of Dentistry, to “answer random faxes and emails from various far-flung parts of the world”.
She worked with the British Antarctic Survey, treating patients on British Antarctic bases near the South Pole, studied for an MSc in Community Dental Health, completed a “very fun” diploma in Mountain Medicine and lived and worked in northern Sweden “where my daughter spent the first six years of her life, amongst the snow and the aurora borealis”.
Then, in 2012, looking for a more “family friendly” post, Penny heard that Tristan da Cunha, a UK overseas territory, needed a visiting dentist. Edinburgh of the Seven Seas was founded by Sergeant William Glass, from Kelso, in 1816 after the UK annexed the island. It is named after Prince Alfred, Duke of Edinburgh, the second son of Queen Victoria, in honour of his visit there in 1867. Penny has been there eight times now. “Our first trip was aboard the South African Polar Research Vessel, The Agulhas. Tristan da Cunha is essentially a 6,760 ft volcano rising out of the South Atlantic and six days’ sail from Cape Town.
“Getting from ship to shore involves a helicopter ride, or a heart-in-mouth shimmy down a ladder onto a waiting rigid inflatable boat and transfer to the island’s harbour. Most of our trips to the island have been on a fishing boat and, as we are heading into the prevailing wind and seas, the crossing can be long and a bit rough at times.”
Penny does, of course, have a family friendly job; she works as a clinical supervisor for undergraduate students in Dundee, in the restorative department. She is also involved with pre-departure dental screening for those about to deploy to the Antarctic alongside ‘remote dental support’ for the British Antarctic Medical Unit (BASMU).
Since starting to visit Tristan da Cunha, Penny has worked closely with Dundee’s Professor Pete Mossey, using study models and interceptive orthodontics where applicable. Alongside locally trained staff, they have piloted a fixed orthodontic case with good results. Penny, Professor Mossey and Dundee’s Dr Clem Seaballuck have also conducted the island’s first live orthodontic consultation via NearMe.
An island dental health survey has been carried out, supported by Susan Carson, Consultant in Dental Public Health, Derek Richards, Senior Lecturer, and Zainab Kidwai, Research Associate at York University.
Professor Graham Ogden, former Head of Oral & Maxillofacial Clinical Sciences, and Dr Simon Shepherd, Clinical Lecturer and Honorary Consultant in Oral Surgery, have helped with diagnosis and management of oral cancer. Stan Riley, Senior Dental Technician, has also visited the island twice.
On the island, Penny always stays with Barbara and Herbert Glass who have become surrogate grandparents to Elika “as well as extending friendship and insight into island life,” said Penny. Island life is set against the backdrop of the sea and ever-changing weather. The island’s main industry revolves around Jasus tristani, a species of rock lobster. Thanks to the work of the local community, the RSPB and partners, the seas around the archipelago have been established as a Marine Protection Zone, safeguarding one of the world’s most pristine marine environments.
The islanders grow a lot of their own food – potatoes, vegetables, with hens and ducks for eggs, beef and mutton; all are free-range. They build their own houses, with family and friends often helping. Ships visit every six-to-eight weeks, bringing fuel and supplies for the local shop. There is a nursery, a school and a hospital with a resident doctor.
“My first visit was really about delivering a ‘dental service’, offering simple but high-quality dentistry – with examinations, x-rays, extractions, amalgam and resin restorations, acrylic dentures, periodontal treatment, endodontics and a basic orthodontic service for the children,” said Penny.
“It was also about fact-finding and meeting and working with local staff, finding out what the surgery was like, what equipment we had, what was the Island’s dental health like, what foodstuffs are available, were there any preventive schemes in place, how do you examine and treat 270 people in 3.5 weeks. The first visit involved long, long days, six days a week.
“But after that, I was hooked not just on the physical place and the islanders but also on how the dental service could move forward, both in terms of treatment and preventive strategies – local staff training alongside new dental surgeries within a new replacement hospital.
“The newly-constructed Camogli Hospital has two dental surgeries, a dental lab and an LDU fitted and commissioned during the September 2017 dental visit. One of our local island dental nurses came to Dundee Dental Hospital to undertake bespoke training in 2018. A fantastic team effort and a lot of work made all these things possible.
“my first visit was really about delivering a ‘dental service’, offering simple but high quality dentistry – with examinations and x-rays”
“A lot of planning goes into a dental service that is an 11-day sail from Cape Town in a fishing boat; Amazon don’t do next day deliveries! The dental consumables are ordered in the UK, shipped to Cape Town from Bristol, and held in customs before boarding a ship bound for Tristan da Cunha, where they then make it to the hospital.
“With deadlines for two shipping dates to be met – planning and ordering needs to happen at least six or seven months prior to departure. We need to know exactly what we have on the island and what we need to order both for the dentist and the technician. It doesn’t always go to plan!
“During, COVID-19, the logistics were doubly challenging with many ships being cancelled. It took supplies from October 2020 until May 2021 to arrive on the island – fortunately before I got there.”
The island is considered the most remote permanent settlement on Earth
Edinburgh of the Seven Seas, the main settlement on the island
Penny added: “Currently we offer a year-round emergency dental service, provided by locally trained island staff. There is a year-round supervised toothbrushing programme in the school and nursery at lunchtimes, with free toothbrushes and toothpaste for children.
There is three-monthly chairside oral hygiene instruction, top-up of fissure sealants and duraphat application. In addition, there is regular PMPR for adults on the island from locally trained staff and treatment under prescription from the visiting dentist.
“An annual dental visit by a dentist and dental technician provides basic but high-quality dental treatments including exam, BPE, x-rays, periodontal treatment, extractions, surgical extractions, amalgam and composite restorations, RCT, GA’s and sedation when required, an overview of a preventive programme, and domiciliary visits as required.
“The support of excellent dental technicians coming to the island with me has been key, with Bob Carse visiting the 17 times and recently Sandy McLean joining our team
“A broader community approach is taken when reviewing the goods ordered in the supermarket to ensure affordable healthy options are available and sugar-friendly goods supplied.
“We work closely with the school with free school milk programmes and packed lunch suggestions. The aim is a broad community-based approach to dental health – looking at dental disease as sharing common risk factors with other NCD’s.
“The orthodontic service has traditionally been run remotely by taking study models of patients and photographs while on the island and returning with them to Professor Mossey in Dundee, where they are reviewed and treatment suggestions made. On return the following year the ‘timely extraction’ options are discussed with the patients and treatment carried out. The service has developed as staff training has increased.”
Tristan da Cunha trainee dental nurses Michelle, Conchita and Julie with H.O.P.E 3D printed training models
The 2021 Tristan da Cunha Dental Team – Michelle, Conchita, Teresa, Julie, Sandy and Penny
Is there a case that stands-out? “There have been many, but one in particular was when, during a routine dental check a suspicious indurated ulcer was noted on the lateral border of a patient’s tongue, with affected movement of the tongue on that side.
Back in Scotland, this would have been a fast-track referral to our local ‘MaxFac’ department who would have biopsied, diagnosed, treatment planned and arranged patient management as part of a multidisciplinary team.
“But with our closest tertiary care centre 1,734 miles away and no ship due for another six weeks, it became a very different case to manage, especially when you know that the treatment required may involve a protracted period away from the island.
“Photographs were sent via email and I had several phone-calls with Professor Ogden who walked me through the likely diagnosis, family background, how to discuss oral cancer with the patient, vocabulary to use and how to deal with the subject with sensitivity.
“The patient and their family were MedeVac’d to Cape Town where they undertook extensive surgery and radiotherapy.
“Two years later our challenge was to make some dentures with the help, skill, and expertise of dental technician Bob Carse. Later that visit, at an island social gathering, the patient came up to me to say thank-you – not only for the referral to Cape Town but also for allowing him to eat fried fish once more and, more importantly, have the confidence to smile again and be part of the local community’s social activities.”
Looking ahead, it is hoped that a digital scanner can be brought to the island so that orthodontic patients can be scanned and live data for 3D models sent back to Dundee. Live streaming with patients will also allow treatment plans to be devised in real time.
More training for island staff is planned along with more support for the children’s oral health education programme.
References
1www.sciencefocus.com/…the-most-remote-inhabited-place-on-earth
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