A cold place to start

Hygienist initiates and teaches the first class of dental hygiene students in Lithuania - finding a warm spot to do it was a little trickier!

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Hygienist initiates and teaches the first class of dental hygiene students in Lithuania - finding a warm spot to do it was a little trickier!

Judy Martin, RDH, BS

If someone told me four years ago that I would be seeing the first class of dental hygienists to ever graduate in Kaunas, Lithuania, I would not have believed it. How could I have become involved in such a thing? In retrospect, I guess it seems only natural now, because of my Lithuanian ancestry and having always been involved in Lithuanian causes. Lithuanian culture and traditions dominated over the Irish and Croatian links in my ancestral makeup. During a 1991 trip to Lithuania with a folk dance group, I was amazed at the poor conditions of the residents` teeth.

When I returned to Kansas City, I looked for an organization that might be involved in improving dental health in Lithuania, a newly independent republic of the former Soviet Union. I found one in Chicago - the Dental Assistance Foundation to Lithuania, better known as DAFL. I was the only hygienist this small group of Chicago dentists had. I soon became the most willing volunteer to go and deliver lectures and demonstrations at the Lithuanian dental school.

After my first "show and tell" trip in 1993, the Lithuanian dental school decided to start a dental hygiene program, asking me to help develop the program outline. After the program curriculum was developed, they asked me to train two hygiene instructors for seven months. Soon after that, 10 students were chosen and accepted into the first class of the four-year baccalaureate program. During the students` junior and senior years, I was there to teach for two years, alongside the two instructors I had trained in 1993. The three of us taught the clinical rotation, including tooth anatomy and morphology, periodontal disease diagnosis, treatment planning, instrumentation, disinfection, and sterilization, as well as the didactics.

The hygiene students were a joy to teach, eager to learn and please. But they were a little uncertain about how far this degree program would take them in their communities. Dental hygiene was new to the dental community, as well as to the Lithuanian community at large. They did not believe that they would have the same (if not more) opportunities in the working world as any dental student after graduation. Many of them had applied and did not get into the dental school. After graduation, they soon realized the many opportunities open to them. Some have teaching jobs in hygiene; some are studying now for their master`s degree in health administration; and some are in private practice.

It definitely was the toughest job I ever loved. Despite the difficulties, I would not give up the experience for anything. When people ask me about what it was like, I struggle with the words, since it`s hard to describe with any brevity. I have seen many changes and improvements during the four short years I`ve been involved with Lithuanian dentistry. Four years ago, no one had any idea what a dental hygienist was, and no one understood the importance of prophylaxis and prevention. Four years ago, the clinics in the dental school had 50-year-old dental chairs and units without water or suction. Now they have new chairs and units - DAFL and A-dec donated some, while others were bought through government grants and loans.

Teaching was a struggle because of the lack of books, instruments and teaching aids, language barriers, freezing cold and little heat - you name it, we had it or didn`t have it. I relied on a few donations of books from Esther Wilkins and my American hygiene friends, a healthy supply of donated instruments from Prudent Dental Instruments, and a generous batch of brushes and floss from Jim Ewbank at Butler.

During my last year there, I was presented with a laptop computer from Dr. Bob Nelson in Kansas City. Before that laptop, I wrote everything by hand - every lecture, every exam, every correspondence. Imagine teaching all that time without a computer or even a typewriter. It was primitive at times. The main struggle, though, that seemed to persist was addressing the desire to have everything at once. But, because of a nonexistent infrastructure, everyone was uncertain about how to plan and organize. This may be understandable, considering that the objective was to incorporate a new health field and educational program they knew nothing about.

But I noticed the poor problem-solving skills in much of the everyday life. Perhaps this lingered from 50 years under the iron fist of the former Soviet Union.

Lithuania is a small beautiful country that is about the size of West Virginia. It is bordered by the Baltic Sea (across the sea is Sweden), Russia to the east, and Poland to the south. The maritime climate means it`s wet and cold - cool, short summers and long cold winters. The rich farming country has many lakes and many forests. Potatoes and mushrooms are plentiful year round.

The most common religion is the Catholic faith, and the country has many centuries-old churches in Gothic, Baroque, and Renaissance architectures. Many church holidays are state holidays. One of the most beautiful is on November 1, All Soul`s Day. Lithuanians have a very high respect for their dead, and, on All Soul`s Day, they make large pilgrimages to the cemeteries to pay their respects, lay flowers, and light candles on all the graves. It is quite beautiful to go to the cemeteries at dusk and see it all aglow with candles.

The Lithuanian people are very unique. They are friendly and gracious. Even sharing a cup of coffee with someone - whether it is at home or in the office - is a sit-down event with table linens, fresh fruit, some pastry, or some chocolate.

Meals usually include fish or herring and some innovative potato dish. Most of the meat is salted or cured because it is slaughtered fresh from the farm and must last all winter. Potatoes that have been harvested in September are stored in a cold hole in the basement that helps them last all winter. The breads are delicious, heavy and dense. The whole loaves (unsliced) cost about 25 cents. The milk bought in stores is pasteurized, but I could never understand why it only lasts about four days before turning sour. Fresh milk straight from farm cows is the best, very delicious, but also only lasts about three or four days before spoiling. There are many great white cheeses, but almost no yellow cheeses. Canning and preserving fruits are very common, providing many fruit compotes, juices, and jams.

The diets, however, are high in sugar content, contributing to the high decay rates.

The first thing that comes to my mind about daily life in Lithuania is the cold. I was always cold, no matter what the season. The main reason is because the heating systems, which are regulated by the state, perform at a minimal level. In the winter, the heat is not turned on until the temperature reaches eight degrees and remains at that temperature for five days. When the heat is turned on, it is only at about 50 to 55 degrees. Most homes and buildings were built with the concrete-slab type of construction that has no insulation. I remember spending hours one cold winter`s day at the dental school with my nurse/assistant, cramming cotton wads and paper towels in the window cracks to keep out the cold wind and snow. Our efforts made little difference.

The water systems are also primitive. At least once a month, the hot water is turned off for several days. They say it is for "prophylaxis of the system." This makes it very hard to bathe. Lithuanians are used to this and simply sponge bathe with cold water. I always heated a few pans on the stove during these trying times.

Needless to say, they have no water fluoridation, which also contributes to the high decay rates.

As for entertainment, the performing arts are exceptional. The opera house is home to the national ballet, opera, and drama theater. A few movie theaters feature American films. The bars and restaurants have become quite trendy over the years, and there are many varieties, ranging from traditional Lithuanian folk to popular jazz clubs. A nice evening out could cost anywhere from $5 to $20.

The larger cities in Lithuania are Vilnius, the capital, and Kaunas, the second largest city. The two cities are very quaint with "old town" sections of centuries-old buildings and churches on small narrow streets. Many of the old castles dating back to the 13th century still remain and are treasured landmarks. Getting around town is easy on the trolley buses (for 30 cents) or by taxi ($1 to $2). But, for any distance less than 10 blocks, you walk.

Vilnius University is one of the oldest universities in Europe, dating back to the 15th century. Kaunas has eight technical colleges. One of the largest is the Kaunas Medical and Dental University.

The main language is Lithuanian, which is considered the oldest living language - older than Latin and Sanskrit. Most Lithuanians speak at least three languages, usually Lithuanian, Russian, and either English or German. I have studied the Lithuanian language for years, but I still find it hard to master. It is a very archaic language.

I taught in English, and another instructor would translate. This slowed things down, so I had to learn to be precise and to the point in all my communications. About half of my students understood English. The translations of my lectures were for the other half. When the students had an assignment from a hygiene journal or text, they had to study together, because half of them needed the text translated. All of our texts were in English.

The dental health of the patients in the clinics was among the poorest I`ve seen. Restorative work was very bad. Diagnosis was usually done without X-rays, and so much was missed. In both children and adults, the decay and periodontal disease was sky high. This can be attributed to many factors - unfluoridated water, high-sugar intake, high-alcohol intake, poor oral hygiene habits, and low dental IQ.

When I first visited Lithuania, it was difficult to find fluoridated toothpaste or dental floss. Now these things are plentiful in the shops, and the public is becoming more aware of dental health and prevention. The average cost of a filling is about $20, a crown about $100, a cleaning about $45, and periodontal surgery $250 to $500. Some archaic ways for treating periodontal diseases still exist in some clinics, such as irrigating sulci with vitamin C solutions. This is done instead of removing plaque or calculus.

On occasion, I would provide free consultations in the clinics. Because I was an American hygienist (often confused as a dentist), I had many requests to consult on everything from prosthetics to pathological lesions to orthodontia. I soon sought and found some of the better specialists to refer these patients to. They were confused at first as to why I couldn`t personally help them. All they knew and cared about was that I was a foreigner and a dental health care provider.

Lithuania has socialized health care, which is slowly being replaced by private medical and dental practices. As with many European countries, the state health care systems are used only by people who cannot afford otherwise. It is very difficult for Lithuanians to keep up with the costs of living. The average person earns about $100 to $200 per month. The family household includes many income workers, the parents, the children (married or unmarried), and the grandparent(s). I found it endearing that the elderly are held in high regard. For example, Lithuanians would never dream of sending an elderly parent or grandparent to a nursing home. The grandparent is the child care provider to the young. And the grandparent always stays in the home until death.

In searching the archives, I found some interesting trivia about my great-grandparents. They had immigrated to the United States from Lithuania in May 1891. Exactly 100 years later, in May 1991, I made my first trip to Lithuania. That is something I still marvel at. Unfortunately, I found no living relatives still in Lithuania. But that really doesn`t matter to me because I feel such a connection to the people I`ve met there; it`s almost as if I see familiar faces.

When you go to a different place to live, especially abroad, it is easy to notice the similarities and also the differences in the people and culture. I found many similarities, maybe because Lithuanians like to emulate American ways; anything American is interesting to them. But the differences are what were interesting to me. I hope I illustrated some of those interesting differences here.

The graduation ceremony on June 25, 1998, was a thrill for me. It was the culmination of four-plus years of hard work, little pay ($100 a month), long cold winters, frustration, joy, and, of course, the feeling of accomplishment. The ceremony was a big event for the dental school, since it was the first graduating class of dental hygienists. The deans of all the departments were in attendance, as well as the University Rector and even the Lithuanian Health Minister. For me, it was all a little bittersweet. I was so happy for those 10 hygiene students, happy for the dental school, and happy I was still there after four years to see it all. But I also was a little sad that it was all over for me.

I feel confident the program will continue to improve and progress, and I feel confident I will periodically return to see my many friends, and to lend a hand from this side of the Atlantic when I can. All 10 hygiene students graduated with high scores and clinical skills that I believe parallel the skills of any hygiene student in the west, and I couldn`t be prouder of them. As I told them on graduation day, "I don`t know who is happier, you or me."

So why did I get involved in dental hygiene in Lithuania? It seemed a must for me; I simply had to; if I didn`t do it, then who would? I felt I found my niche. I have a strong connection with the land of my ancestors, so it was a natural for me. And I have a strong connection to dental hygiene: I think the profession is important, and I think it`s essential.

Now I have relocated from Kansas City to St. Louis. I am working in private practice part time, and I also distribute for Prudent Dental Instruments. It has been an adjustment getting readjusted to American lifestyles and work styles. It all seems not quite the same. But I realize things haven`t changed here, but rather I have. I`ve grown in ways I never imagined. And now I`m looking for another challenge or alternative in dental hygiene.

Judy Martin, RDH, BS, who currently resides in Clayton, Missouri, can be reached at (314) 727-0934 (fax) or by e-mail at juditam@inlink.com.

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This winter view reveals the "old town" in Vilnius from atop Gediminas Castle. The cathedral is in the forefront.

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The author (holding the white flowers in the front row) poses with the first graduating class of dental hygienists in Kaunas, Lithuania. The ceremony was conducted in June 1998.

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The dental clinic in Kaunas dealt with such obstacles as overflowing spit sinks, primitive equipment, and poor lighting.

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