by Judith E. Sulik, RDH, MBA
A group of 18 dental hygienists from across the United States made history when they traveled to China on Nov. 8, 2001, as members of a People to People Ambassador Program delegation. People to People, formed in 1956 by President Dwight Eisenhower, was founded on the belief that private citizens reaching out in friendship to the people of other nations could make a significant contribution to world peace and understanding.
Dental hygienists had never been invited as a profession to participate in a People to People delegation until Catherine Draper was invited to form and lead a delegation. She was president of California Dental Hygienists' Association (CDHA) at the time.
Draper said the response from CDHA was immediately enthusiastic. All members of CDHA were invited to participate as well as American Dental Hygienists' Association members from outside of California. While the majority of hygienists who accepted the invitation were from that state, people traveled from Washington, Massachusetts, Florida, Virginia, Colorado and Ohio to make the trip. Four guests who are not dental hygienists shared the adventure, including Draper's husband Don.
Draper said, "Everyone who went on the 12-day trip was passionate about dental hygiene. Professional experience ranged from one year to 30 years and they represented public health, education, and private practice."
The Chinese Tourist Service and People to People developed the itinerary that "provided a very good cross-section of the Chinese experience," Draper said. They visited Beijing, Shanghai and Guiyang. In addition to making professional-oriented visits, the delegation had the opportunity to visit various Chinese cultural and tourist attractions, including the Great Wall, Tian'anmen Square and the Forbidden City.
Draper, Mary Kellerman of Massachusetts and Carole Noel of California began the trip with different expectations; the three agreed to share what they learned with RDH readers.
As the leader of the delegation, Catherine Draper found her experience as president of the 3,600-member California Dental Hygienists' Association helpful. She was told to bring four or five short presentations, with the emphasis on brief, because the focus was supposed to be on learning about Chinese practices rather than teaching American ways. Because of translation challenges, the presentations couldn't be very complex, and she was encouraged to limit the audiovisual requirements, although during the trip she was surprised to see that laptops and some LCD projectors were available.
Draper was particularly interested in looking at dental education training provided in China. She observed that the Chinese are redesigning and appraising how they educate dental professionals. "They are making major changes in the Beijing Medical University dental program," she said. "There are now several tracks, but the goal is to make the program more uniform."
Draper worked as a dental hygienist in Germany for six years, so she was familiar with education systems outside of the United States. She recalled how at the end of fourth grade in Germany, students were tested and their scores would determine the educational track they would pursue — onwards to universities or the average/middle school route. Students had a second chance to change directions in the seventh grade. However, if the students didn't pass the rigorous exam at that stage, they would never have the option to attend university. She noted that China's educational system is similar to Germany's. Student test scores determine their eligibility for university. Failure to pass the two-day, high-stakes exam given in July limits people to the lower level of the workforce during their adult lives. Those who are successful immediately may enter dental school.
She explained that currently Germany doesn't have a dental hygiene program. All hygienists are foreigners. Similarly, dental hygiene as we know it does not exist in China. Draper said that nurses, who sometimes begin their training at age 15, fill the dental hygienists' role. They focus on improving oral health and provide dental education. She noted that the quality of the health program varies. For example, the program in Beijing is superior to the one available in Guiyang.
"We saw a little bit of everything, from the finest in Shanghai to very poor, limited resources in Guiyang," Draper said. "It was an interesting cross-section of level of care. They are still catching up from the effects of Mao's Cultural Revolution, a very black period in their history. For 25 years, they've been trying to rebuild their infrastructures; they deserve credit for all they've done so far."
The group visited the Guang An Men Traditional Chinese Medicine Hospital. Draper explained that this is a "National Model Hospital for Traditional Chinese Medicine" (TCM), and many foreign health care providers visit each year. Physicians utilize a variety of diagnostic techniques, including CT scans and MRI, to develop treatment plans that could incorporate a combination of TCM and conventional western medicine. In general, acute conditions are treated with Western medicine while chronic conditions (arthritis, auto immune disease, back pain) are often treated with TCM.
The group learned that the School of Stomatology at the Beijing Medical University serves as the national research center for dentistry in China. Its mission is to train dental health care professionals in the treatment and prevention of dental disease, the promotion of dental health services, and to conduct research as directed by the Ministry of Health.
Most dental patients are treated in hospital out-patient clinics; an average of 1,600 patients visit the clinic at the School of Stomatology daily. The facility is divided into a general and a VIP clinic, with the latter offering a full range of services in a fairly modern setting. The delegates also visited the Oral Implant Center, opened in 1994, where they learned that more than 3,000 implants have been placed with a success rate of 98 percent. Draper noted that the definition of success was not given.
While at the Baiyun Lu Primary School in Beijing, the delegation divided into small groups and entered several classrooms where they gave a basic dental health education presentation. Each group had an interpreter as they explained the "universal truths of plaque, decay, brushing and flossing to the children," said Draper.
Three days were spent in Guiyang, the capital of Guizhou Province. Draper said Guiyang, a city of one million people, was described as a small city. It is one of China's least developed provinces, and few tourists visit. It is also home for a number of native Chinese minorities, most notably the Miao. She explained that in contrast with the unexpected modernity of Shanghai, Guiyang offered a picture of what they had expected to see on the trip: rice drying by the roadside, people carrying large loads on their backs and shoulders, and large open market places. She said, "It almost felt as if time had stood still in this part of the country with the exception of the satellite dishes that were visible on the slate rooftops!"
The delegation visited the Dental Clinic of Guiyang, described as the 'only first class dental clinic in Guizhou Province.' The nine-floor building is devoted exclusively to dental care. Specialty areas include: restorative, endodontics, orthodontics, pediatrics, and maxillofacial surgery. Operation Smile, a nonprofit U.S. organization, helps fund the cleft lip and palate surgeries performed by the maxillofacial surgeons. The clinic staff of 69 dentists and 20 nurses treats approximately 200 patients daily. Draper explained that this province is very poor, so the clinic has limited financial resources available to treat children with a high caries rate and adults with a similarly high incidence of periodontal disease.
Draper, who earned a master's degree from the University of Michigan, practices four days a week in a general cosmetic dentistry practice that performs many implants. One afternoon a week she volunteers at Stanford Hospital's Health Library researching dental health questions.
She said that being a part of the People to People's Ambassador Program was "great, a fantastic opportunity. Professionally, it was probably the most rewarding thing I've ever done." She added that the one-on-one face-to-face meeting lead to establishing on-going friendships. "Since I've returned, I've been contacted by the interpreter/guide, who recently led a group of oral surgeons, and asked for special vocabulary and advice about leading the delegation. Thanks to the Internet, communication is easier, especially using software that gives simultaneous translations."
Mary Kellerman of Billerica, Mass., brought the most experience as a dental hygienist. She began practicing 35 years ago and still enjoys her chosen profession. The recipient of the 1998 Fones Award, she was the president of the Massachusetts Dental Hygienists' Association from 1995-1996, and attends the national conventions now as a delegate.
When she received the letter about the People to People Ambassador Program trip to China, she was immediately interested, especially since this was the first time dental hygienists had been invited. She noted that Dr. Esther Wilkins had gone on one of the trips but as a dentist.
Back in 1982, she successively initiated a movement to fluoridate her town's public water supply. Along with her dental hygienist friend Janet Sharpe, she worked tirelessly to get the question on the ballot; it passed after one vote.
Sharpe had since moved to Florida. Kellerman thought it would be nice if they joined together once again as delegates to China. Sharpe agreed and the two roommates were the only two participants who knew someone prior to the trip.
The two-week trip was not inexpensive at $4,495. Kellerman set out to find sponsors. She sent letters to associations and contacted 20 to 30 companies asking for financial donations and dental supplies to distribute to the Chinese. She said the response was overwhelming. Dentsply and 3M gave her product samples and money. Her local Patterson supplier in Wilmington, Mass., among many other companies, gave her money toward her expenses.
"After months of discussion," she said, "I made a contact who authorized a $2,000 contribution, plus they shipped samples of the brushes with labels and packaging written in Chinese that they're currently selling in China."
She said the delegation received first class treatment saying, "Our names were up in lights, banners were hung welcoming us, and we received floral arrangements with streamers written in both English and Chinese."
Kellerman noted that there is only one dentist per 50,000 people. Most of the population lives in the country so they never see a medical doctor or dentist.
She said, "We couldn't help sharing dental hygiene advice concerning proper teeth cleaning techniques. We told them how good general health and good oral health are connected. They didn't understand the concept of deep scaling or root planing. The government is still trying to get people to brush their teeth daily. In fact, they literally have a "I Love My Teeth Day" in September. I'm not even sure if tooth brushes are available in the countryside."
Kellerman, who is active in the national smoking cessation program, was disturbed to see so many people smoking.
She explained that dental assistants are actually medical nurses and they don't assist chair-side as they do here. Cavitrons are only used and implants only performed on patients who can afford the service. Generally, that means international business people. Procedures that are traditional to the Chinese are untraditional to us, she said. For example, acupuncture is often used; also, heated cups "draw out aliment." She observed that often the ground floor of a building housed the medical offices and the dental clinic was on the upper floor.
Like Draper, Kellerman has kept in touch with people she met in China. She said, "Dr. Lee in Beijing e-mailed a request for Glide Floss, and a huge bag was sent." She also helped a clinic receive a delivery of fluoride varnish used to desensitize the tooth lining. In China, it will be used to help arrest decay, especially in cases of rampant caries prior to treatment. She obtained this product from Omnii Oral Pharmaceuticals in Florida. The people in Shanghai will use this for prevention.
The trip has piqued her interest in acupuncture and she has since taken a course at the Yankee Dental Conference. She said, "There are three pulses on the wrist; they spend 30 minutes looking at the person and focusing on the kidneys and liver. They study the tongue to determine treatment plans for periodontal disease: is the coating yellow or white? A yellow tongue is an indication of infection and requires a specific type of herbal toothpaste, available over the counter or in the pharmacy."
She noticed that many people are missing teeth. Kellerman was intrigued by the traditional treatments used, including moxibustion and cupping. Moxibustion is the application of a burning moxa plant to the skin while cupping is a process by which a glass bulb is placed over the area to be treated and heated to produce a vacuum to draw the blood from the affected area.
Kellerman said that People to People asked each participant to submit an article to its journal. Since her return, she has spoken to several MDHA components. In the spring, she will present a slide show to the Middlesex component; she will also give an acupuncture demonstration using the Meridian model she bought in China. Kellerman works in Cambridge at Windsor Dental Clinic where her clients come from many countries, including China.
Carole Noel of California left China in 1985 when the Chinese government briefly made it possible for people to leave the country. This trip was the first time she had been back to China, and she said she was eager to see how, and if, things had changed. She visited her home town, which was not part of the itinerary, after the official trip ended. While she was cautiously optimistic about the changes she saw, she noted, "When everything is changing, chaos results. A lot needs to be done."
Born in northern China, she had never been to the southern parts, but she had some expectations — most of which turned out to be wrong. For example, she said, "I had expected to see traditional homes made of mud bricks in Beijing. I'd been told the buildings, or 'quarters,' were built around a courtyard with many families living in the compound. I had also been told that while people in the north liked to take baths, those in the south didn't bathe daily and when they did they had to bring a bucket and wait in a long line at the central bathroom for hot water. Well, I didn't see any buckets, and the tour guide said that the high rise apartment buildings I saw had long replaced the homes I had expected. And, of course, those apartments all have their own bathroom."
She also expected to be able to speak Chinese while there. Although Cantonese is her native dialect, she did learn Mandarin in school, and she had been fluent when she arrived in the United States. But she discovered that while she could understand the speakers at meetings, she couldn't speak without stumbling. Ultimately, she decided to speak English and rely on the translator.
Noel could understand the difficulty Chinese practitioners have persuading the people about the importance of taking care of their teeth. She said, "In China, if you're not in pain, you don't go to a dentist. I'd never been to a dentist or had my teeth cleaned until I was preparing to leave the country. I was told that if I waited until I got to the United States, it would cost me an arm and a leg." She said, "I sat in an old barber shop-type chair, and using rusted tools, the woman started digging in my mouth. I was bleeding and everything hurt."
Given that experience, it's not surprising that she didn't go to an American dentist until she met her husband and he suggested her breath would improve if she had a cleaning. Noel can empathize easily with patients because she understands the ignorance and fears they may bring with them to an appointment, and why they might not take advice readily. She remembers the root planing she experienced and again, the blood; she remembers the hygienist, who was her neighbor, explaining that she should return for another appointment, but her English was still poor, she was afraid, and she never returned. The neighbor, she recalls, stopped talking to her.
Noel said she couldn't believe how prevalent the rate of periodontal disease is in China, even among the dentists. She noticed that even the dentists were wearing poorly fitting partials and dentures, and that it was apparent that flossing is virtually non-existent.
Noel has no regrets about immigrating almost two decades ago. She said she is one of what the Chinese call the Garbage Generation, adolescents during the dark days of the Cultural Revolution when children were educated in propaganda and not in academics. She considers herself fortunate that she was able to leave.
All three women enthusiastically describe the People to People Ambassador Program as an experience not to be missed if the opportunity presents itself again.
Judith E. Sulik, RDH, MBA, is president of Finely Finished Press of Bridgeport, Conn., and is the publisher of No Sinks? No Counters? No Problem! 50 One-Pot Meals To Get You Through Kitchen Remodeling and An Adventure for Your Palate, Coastal Connecticut Waterfront Dining With Chef's Recipes. She can be reached by email at [email protected].
Tough to be private
In Shanghai, the delegation visited one of the few private dental clinics, Shen Da, located in an old mansion in the French sector and opened in 1994. With six operatories, the clinic employs four general dentists, one oral surgeon and one orthodontist. They also employ four dental nurses trained in four-handed dentistry and one full-time sterilization assistant. Until recently, the government has not allowed any privatization of dental care and the laws surrounding private practices are complex.
The dental director explained some of the obstacles to establishing private practices in China:
• Practice loans are uncommon, so the dentist must provide the money
• A minimum of five years experience in one of the hospital-based clinics is required
• Most daunting, the mindset of the average Chinese consumer must change from traditional hospital-based care to care by the private dentists.
Because they are accustomed to being seen in a large hospital clinic without an appointment; they perceive small clinics/offices as inferior, and they are resistant to the concept of appointments.