I would like to express my deepest gratitude to all ... - UBC Dentistry

I would like to express my deepest gratitude to all those involved in providing me thetremendous opportunity of participating in this externship; my appreciation to all thosewho made my time in Vietnam an experience that far surpassed my every expectation;and my admiration to all those who continue to devote their time and efforts to thepursuit of oral health, education and training.My welcome to Vietnam was so warm and it was my greatest privilege to be able towork along side such skilled and dedicated clinicians. I look forward to seeing howongoing and future projects progress as my commitment to continue to participate infuture endeavors overseas is reinforced.It is with a humble heart that I acknowledge the breadth of perspective, knowledge andexperience that I have gained, professionally, culturally, and personally.Renée Duprat, R1 GPR, UBC

Vietnam Externship:VIETNAM OUTCOMES ASSESSMENTNovember 2003Renée Duprat, BSc, DMDThis dental residency externship is a collaborative effort by the University of Ho ChiMinh City, Institute of Odonto-Stomatology of HCMC, Cancer Center of HCMC, and theUniversity of British-Columbia.Educational Objectives:1. To learn about different ways of health care provision, specifically oral health care, ina developing country.2. To expand on the scope of familiarity with various disease processes and traumaticinjuries involving the head and neck especially with respect to pathologies of highprevalence in Asian populations.3. To gain knowledge regarding different cultural beliefs and behaviors in general, andspecific to health care, and to be able to apply this heightened level of understandingto the large multicultural population of Canada.4. To offer educational reciprocity as well as possible aid to improve the provision oforal health care in the Vietnamese population.5. To foster educational and research development that can be mutually beneficial toVietnam and Canada.Resident Requirements:1. Residents will show a slide presentation during their rotation on a specific area ofHospital Dentistry at the University of Ho Chi Minh City.2. Residents will present THREE case studies with photographs to the UBC Faculty.3. Residents will complete an Outcomes Assessment for the rotation in Vietnamincluding a Needs Assessment of areas requiring aid at the various institutions.Rotation Parameters:The rotation is 3 weeks in duration and took place in Ho Chi Minh City, which is themajor center of southern Vietnam. In general, two different GPRs will participate duringthe months of November and March of the residency year.An additional one-week elective may be taken to perform charity pediatric dental servicesin Danang, in central Vietnam.

The core program consists of a standard working week Monday through Friday, withtime spent at the Cancer Center of HCMC and the Institute of Odonto-Stomatology.Some time will also be spent at the University of Ho Chi Minh City, Faculty of Odonto-Stomatology._____________________________________________________Institute of Odonto-Stomatology201A Nguyen Chi Tranh, Q5Ho Chi Minh City, VietnamTel: 855 6732 (Chi Ngan), 855 3698Fax: 848 – 855 1394Director Dr. Lam PhuongThis hospital is the national hospital of HCMC and includes both outpatient and inpatientcomponents. The outpatient building deals with all aspects of comprehensive dental careincluding oral diagnosis, oral medicine, restorative, oral surgery, periodontics andimplantology. The resident’s involvement is mainly with the inpatient component, whichserves as one of the major head and neck surgical hospitals in southern Vietnam. Thisfacility sees large numbers of head and neck traumas due in large part to the vast majorityof motorcyclists and their lack of protective headgear. Furthermore, all aspects of headand neck surgery are undertaken in the three operating rooms including tumor and cystresections, temporomandibular joint surgery, orthognathic surgery, correction ofcraniofacial deformities and cleft lip and palate repair. On average, 12 to 13 patients aretreated daily. The hours of operation are from 7am to 4pm. Most surgeons can speaksome English or French in addition to their native Vietnamese. At the Institute, residentswill have an opportunity to observe and provide assistance whenever possible.Procedures to be observed/assisted at the Institute of Odonto-Stomatology:1. Cleft lip and palate repair2. Temporomandibular joint surgery3. Repair of the following fractures:• Zygomatic arch• Subcondylar• Angle• Symphysis• Lefort 1, 2 and 34. Resection of cysts and tumors5. Wisdom teeth extractionActivities at the Institute of Odonto-Stomatology:1. Surgical assist of head and neck surgery with Dr. Lam Phuong, Director of OMFS. Ihad the pleasure of being present for the Institutes first mandibular advancement viasagittal split technique for correction of class II malocclusion. Other procedures

included a large majority of subcondylar, symphyseal and zygomatic fracturessecondary to motorcycle trauma in addition to parotid and other tumor resections.2. Participation in US Mission Operation Smile including screening of over 150 localand rural children and with varying degrees of complicated cleft lip and palate,craniofacial deformities, severe burns requiring scar revision, NOMA and othercommon and not so common lesions/infections. Over 100 patients were accepted andreceived surgical treatment over a period of 4 days. Many will require further phasesof surgical correction and will return to HCMC from great distances to attend the nextmission. Operation Smile coordinates approximately 8 local missions at the Instituteof Odonto-Stomatology per year in addition to 2-3 national missions, the last ofwhich was in Lao province.3. Morning grand rounds with OMFS residents III and IV. New admissions werediscussed with review of case history, films and surgical treatment plan. Patients onthe ward are separated into 1 of 5 bays by sex and treatment modality required with 2-3 patients commonly per bed.4. One day spent in the Oral Diagnosis department as the first point of entry for allpatients. Here, a variety of facial cellulitises, cysts, tumors, lesions, fractures andorofacial pain are screened and triaged for treatment. Drainage of large facialabscesses, needle biopsies and IMF removal are routinely performed in this setting.5. Meeting with Dr. Ngo Khanh, Vice Director of the Faculty of Odontostomatologyand Chairman of the Dental Public Health Department regarding information on oraldisease in Vietnam and dentistry demographics in Canada.6. Documentation of specific head and neck cancer, pathology and surgical cases fromboth the HCMC Cancer Center and the Institute of Odonto-Stomatology forpresentation purposes at UBC.Needs assessment of the Institute of Odonto-Stomatology:1. Additional OR space_____________________________________________________Ho Chi Minh City Cancer Center3 No Trang Long, Binh ThanhHo Chi Minh City, VietnamDirector Dr. Nguyen HongThis cancer center serves as the main cancer center for treatment of patients from thesouthern half of Vietnam. Head and neck cancers are diagnosed via CT, MRI, ultrasound,biopsy and radiography. This facility is capable of providing major treatment modalitiesof surgical resection, radiation and chemotherapy for the treatment of malignancies.Children from an overflowing pediatric ward are now also receiving chemotherapy for avariety of malignancies. The center continues to receive approximately 30 new head andneck cancer admissions per week. Patients travel from local and rural areas and stay incrowded wards, often 2 to 3 per bed, categorized by sex and location of their tumor, with

waits of up to 4 weeks for surgery and radiation therapy typical. Radiation is deliveredvia the center’s three cobalt radiation machines. Interstitial radiation of localized tumorsis also provided at this center via the placement of radium needles.Due to the high dose radiation protocols for treatment of a vast majority of advancedcancers (most receive a standard 6600cGy/33#), a relatively high incidence of ORNoccurs (15% for head and neck cancers and >50% for relapsed cases of patients havinginitial brachyradiation therapy and subsequent Cobalt radiation). The factors whichcontinue to result in a relatively high mortality and morbidity rate for head and neckcancer patients include:• Advanced stages of tumors due to lack of regular medical/dental visits madeby patients as a result of fear, restricted access to services, lack of funds, lackof public awareness and education.• Lack of standardized early detection measures (head and neck exam, toluidineblue staining).• Lack of post-treatment follow-up for potential oral complications uponcompletion of radiation therapy.• Lack of facilities and personnel to keep up with the number of head and neckcancer patients requiring treatment.• High levels of scatter radiation with limited immobilization and shieldingtechniques.There is one full time dentist on staff, however, his duties extend more to endoscopy andradiology than to clinical dentistry. Otherwise, the hospital dental clinic is, for the mostpart, staffed by volunteer new dentists who are committed to 3 years of mandatory parttime government service in order to be eligible to open their own practice. Pre, mid andpost cancer treatment protocols are in place however somewhat ill defined at this timewith a lack of standardization. On average 12 to 13 patients are seen per day with hoursof operation 8:30am to 3:30pm. Most dentists can speak some English or French inaddition to their native Vietnamese. At the cancer center, residents will have theopportunity to interact at all levels of the health care team and provide basic dentaltreatment, mostly pre, with some mid and post cancer treatment.Procedures to be observed/assisted at the Ho Chi Minh City Cancer Center:1. Weekly grand rounds of patient on the surgical ward.2. Endoscopy of patients for evaluation of oropharyngeal and nasopharyngeal cancers.3. Observation of CT examination and diagnosis.4. Observation of the radiation facilities.5. The placement of platinum coated radium needles in localized tumors.6. Surgical resection of benign and malignant tumors from the head and neck:• Skin, salivary glands, thyroid, parathyroid, nasopharyngeal, laryngeal,maxillary, mandibular, oral and neck dissections.

Activities at the Ho Chi Minh City Cancer Center:1. Setting up the dental clinic for the Head and Neck cancer ward. Panorex films arebeing supplied by neighboring facilities and have been incorporated as standard preradiationassessment protocol. Capacity exists for exposure and hand development ofsupplemental periapical views. Donations of a cavitron, scaling instruments andtoothbrushes have made provisions of oral hygiene and oral hygiene instructionpossible. The latter however is limited and has been identified as a major focus in thedevelopment of oral health promotion. Newly acquired autoclave remains unusedand outside of heat sterilization of instruments, issues of surface disinfection, crosscontaminationand cross-infection remain. Time was spent explainingrecommendations for and demonstrating infection control techniques.2. Continued with development of Needs Analysis and Pre-radiation Oral Assessmentsof new Head and Neck cancer admissions. Since November 2002, approximately 650assessments have been completed with the help and direction of Dr. Hong (Head ofPathology, University of HCMC). Data from 450 patients has been brought back toCanada and submitted for statistical analysis.3. Need identified and progress made towards development of a standardized treatmentprotocol for pre-radiation head and neck cancer patients. Discussions with Dr.Andrew Tsang and Dr. Michelle Williams will continue to this effect for developmentof a ‘draft’ protocol, customized for this particular population, by April 2004.4. Dental treatment of pre-radiation patients in the Head and Neck cancer ward isongoing with treatment limited to exodontia of compromised dentition in the field ofradiation and atraumatic restorative treatment of remaining dentition.5. Samples of Biotene gum, tooth paste and alcohol-free antibacterial mouthrinse,Oralbalance, Mouthkote and Moistir mouth lubricants, Neutragel and Oro-minremineralizing gels, Benzydamine and Oral-B fluoride rinses, Prevident 5000 andSensodyne tooth pastes provided with ingredient lists for duplication. Donations ofamalgam, composite, anaesthetic and sutures were provided by VGH.6. Grand rounds of patients waiting for head and neck surgery with review of casehistory, relevant pathology and imaging. This included a visit to the overflowingpediatric ward facilitated by the Pediatric Director Dr. Tran Khuong.7. Observed the radiation facilities whereby treatment is delivered in one of three Cobaltradiation rooms, with only lead blocks to assist in limiting scatter radiation and noimmobilization of the patient during the procedure.8. Meeting with Dr. Tran Anh Tuong who is currently conducting research on theincidence of Osteoradionecrosis and has collected data on 30 patients to date. Casesof mild, moderate and severe ORN were presented and reviewed with discussionstowards sharing of information regarding Canadian guidelines and protocols forHyperbaric Oxygen therapy. There are now three centers for HBO therapy inVietnam however treatment remains limited to those who can afford it(US$100.00/20 dives of 90 minutes) and tends to be delivered after surgicalintervention. Resident experts are limited.

9. Documentation of specific head and neck cancer, pathology and surgical cases fromboth the HCMC Cancer Center and the Institute of Odonto-Stomatology forpresentation purposes at UBC.Needs assessment of the Ho Chi Minh City Cancer Center:1. More consistent oral hard and soft tissue examination and charting.2. Patient education with respect to oral hygiene instructions, potential post-radiationcomplications and management. Visual aids such as posters, pamphlets, videos anddemonstrations to be incorporated as a standard.3. Continuing education for staff and volunteers with respect to oral health promotionand counseling of this particular patient population.4. Continuing education for the rural dental community with regards to early detectionof head and neck cancers.5. Incorporation of infection control principles in an effort to limit cross-contaminationand cross-infection.6. Standardization of protocols for provision of most effective dental care to a variety ofhead and neck cancer patients depending on their staging and the treatment to bereceived. Criteria to determine which teeth should be extracted prior to radiationtherapy in an effort to prevent potential complications of radiation treatment andfacilitate post-radiation management (fluoride application, diet modification,palliative adjuvants, etc.)7. Mid and post cancer treatment oral assessment follow-up and recall.8. Dental equipment/supplies (Surgical handpiece and improved suction capacity).9. Continue to establish the role of hospital dentistry as an important part of themanagement of Head and Neck cancer patients before, during and after radiationtherapy to reduce potential post-radiation treatment oral complications.10. Establish a presence in the pediatric ward at the level of prevention and OHI.11. Orofacial pain control and palliative care via pharmacotherapy protocol and provisionof affordable, homemade alternatives.12. Improve radiation shielding and immobilization technique and facilities.13. Facilitate sharing of resource material on ORN and development of HBO protocols.14. Further training and development of key Vietnamese caregivers in Hospital Dentistry.15. Research:• Epidemiological studies regarding incidence, morbidity and mortality ofORN.• Ongoing epidemiological studies regarding pre-radiation oral assessmentswith intentions of standardized protocol development and implementation.• Studies regarding feasibility and outcome of widespread fluoride varnishapplication for caries prevention post-radiation.16. Long-term:• Linear accelerator with shielding and immobilization.• Hyperbaric Oxygen therapy as a standard prior to surgery of irradiatedpatients.• Expansion of the facility.

• Hiring of full time dental personnel (dentist, hygienist, assistant) to aid inprovision of treatment to a large number of patients, supervision andconsistency.• Facial prosthetics training and facilities._____________________________________________________Faculty of Odonto-Stomatology, University of HCMC652 Nguyen Trai, Q5Ho Chi Minh City, VietnamVice Dean Dr. Huynh Anh LanThe Faculty of Odonto-Stomatology is the largest teaching institution of Vietnamesedental education and now provides training for all dental career options. Undergraduate,predoctorate and postgraduate programs are available with curriculum developmentunderway for dental hygiene and laboratory technology training. Approximately 80-100new students are accepted each year for the six-year undergraduate program. The facultyis active in the provision of clinical service to the public, community outreach and oralhealth promotion in addition to continuing education of dental practitioners.Furthermore, both regional and international research projects are ongoing with mostrecent efforts directed towards a survey of the oral health of drug addicted and HIVinfected population of HCMC.Activities at the Faculty of Odonto-Stomatology:1. Presented a PowerPoint presentation of “Oral Complications of Chemotherapy andtheir Management”. As this modality of treatment is now being implemented in thepediatric population at the HCMC Cancer Center, guidelines for management of thisparticular subset were provided in addition to BCCA guidelines for adult patients.2. Tour of faculty and student clinics facilitated by Vice Dean Dr. Anh Lan.3. Meeting with Dr. Anh Lan, Dr. Nguyen Hong, Dr. Andrew Tsang, Dr. Chris Zed,Sherry Priebe and many of the volunteer dentists from the HCMC Cancer Center todiscuss any concerns with regards to current hospital program and/or suggestions forimproved efficiency. Issues of oral health promotion, oral hygiene instruction, patientcounseling with regards to potential complications of treatment and theirmanagement, and standardization of treatment protocols specific to the Vietnamesepopulation, were brought up. Suggestions with regards to introducing a DentalHygiene rotation at the Center, developing patient education materials and practices,and implementing a draft treatment protocol were addressed favorably.