Dental Charity: Dental Aid Network in Kashmir by Dr Imran Ashghar

Many months of planning and organising had been spent and we assumed as it was our third trip to Kashmir, it would be somewhat easier. It was, however, our most difficult yet! Nevertheless it was a most successful and rewarding trip.

Four dentists from Glasgow, one from Liverpool and I made up the Dental Aid Network (DAN) team travelling to Kashmir flying out on the 6th October.

We had taken two different flights and planned to meet up in Dubai before flying out together to Islamabad. However, the flight from Manchester to Dubai had been in the air for about three hours when a medical emergency occurred. A passenger had suffered a cardiac arrest and the pilot had to make an emergency landing in Greece. When we were ready to take off again and were on the runway, we could hear the roar of the engines fading away. To our shock we were told there a second passenger had suffered a cardiac arrest!

Zohaib and I therefore missed our connecting flight and arrived a whole day late. We finally got to the hotel in Mirpur, Kashmir, on 4.30am on Sunday 8th October. Fortunately, we had kept in touch with the team and had they managed to change our plans for the coming day accordingly.

Left to right: Dr Zohaib Khan, Dr Amer Mobarik, Dr Imran Shafi, Dr Abdulwahab Aslam-Pervez, Dr Imran Asghar and Dr Khuram Shafiq.

Sunday 8th October
We met up at breakfast at 8am. This was the first time some of us had met in person. Four of the team visited the Kashmir Orphans Relief Trust (KORT) to screen the children. We have been working with this orphanage for the past two years and they were our main facilitators. The two other dentists and helpers from KORT visited the dental wing of the local hospital. The hospital team cleaned all three surgeries, prepared our instruments and equipment, and set up the sharps boxes, local anaesthetic and restorative materials that we had bought from the UK. The team at KORT examined and screened all 260 children, listing those who needed treatment. Our main priority was pain ,but we did have many cases of hypoplastic anterior teeth, fractured upper incisors and periodontal issues. All were given oral hygiene, brushing and diet advice along with toothpaste. We also applied topical fluoride varnish on all children.

This was our third year visiting this orphanage, so we had records for children we had previously seen. This meant that we could review what treatment had been previously done and if anything was outstanding from the previous visits.

It was pleasing to see children who had previously been seen requiring no or minimal treatment because they had been following previous dental advice given to them. They were very keen to show us their teeth and how ‘white’ they were! Since our last visit, the orphanage had taken in many more children from remote areas and villages affected by natural disasters. KORT had initially started just over 10 years ago when the devastating earthquake hit Kashmir in 2005, resulting in hundreds of thousands losing their lives and countless children became orphans.

We were given a full tour of the orphanage, its facilities and talked to several staff members. It was amazing to see that such a place had been created for these children.

It was designed to give them a high standard of education so they had a chance for a successful future. After our evening dinner we discussed plans for the following day and packed our equipment.

Monday 9th October
After five hours sleep, we travelled for two hours to a remote area of Kashmir called Bhimber. We had visited this hospital in 2016 to assess if we could set up camp and had several meetings in the UK to plan this day.

A month or so before our arrival, banners and announcements were made to inform the local community and neighbouring villages that we were coming. (See photo at left.) It was good to see the hospital had furthered its progress in construction, and most of the ground floor had been completed—all from private charitable funds. We had no idea of how many patients would turn up, so it was astonishing to see that people from as far as the India–Pakistan border (which was a zone of conflict) had been arriving by public transport and by foot!

This area was more poverty-stricken than Mirpur. If anyone had any medical or dental problems, they would suffer in silence or pay high prices to go to the main city to receive treatment; the DAN team was the first dental camp of its kind in this area. As there was no formal dental setup, the only treatment we could offer were extractions, examinations and dental advice.

We spent just over an hour setting up our treatment rooms, delegating duties, arranging the waiting area, creating a workflow and creating a system that everyone could adhere to.

We trained three of the hospital staff in giving tooth brushing and diet advice with use of models and pictures. They did this with every patient who arrived, and this was then reinforced in the treatment rooms.

We examined and advised 82 patients and extracted 22 teeth. The portable autoclave stopped functioning early on in the day; this meant we could not sterilise the instruments once they were used, which made things a lot more difficult. Thankfully we had been donated many extraction forceps, luxators and elevators from dental colleagues in the UK and so these were used sparingly. Many of the patients who attended wanted a ‘special medicine’ to alleviate their dental problems rather than having their offending tooth removed. A lot of time was spent with our rudimentary Urdu and with the help of the local pharmacist to explain the dangers of just taking antibiotics.

Advice was given in regard to periodontal disease, orthodontic-related issues, cleaning fixed and removable prostheses, effects of diabetes on the dentition and smoking’s effects on the mouth, including oral cancer advice.

The DAN team were given a generous donation of safety plus syringes by Septodont. These were simple to use and helped protect our team and patients from the risk of cross-infection. They were also simple to discard and remove from the hospital.

The last extraction patient of the day, however, became a difficult case. A young lady’s lower right second molar became problematic in its removal. All six dentists had an attempt at removing these roots, with no success. The main reason for this was that we only had a few instruments left and they were not the ones we actually needed for the job.

We needed a small elevator or luxator, but all of them had been previously used and so were not sterile. The anaesthetic had started to wear off, so we reluctantly made the decision to abandon the treatment and dispense painkillers with antibiotics to the patient. We explained to the patient the exact problem we encountered and that we had made arrangements on the following day for her to be seen by a private dentist and have the roots removed without having to travel or pay for treatment.

We took this as an opportunity to learn from our experience and when we plan to visit this area again next year, we will be better prepared.

Later that evening we were invited to KORT’s annual remembrance event. The children put on a spectacular event with poems, songs and articulate speeches in both English and Urdu. They also performed emotional plays about how the catastrophic earthquake in 2005 had affected some of them in losing parents and loved ones, but also how the founder and staff of the orphanage had given them hope for a brighter future.

Tuesday 10th October
The morning was spent treating young boys from the orphanage. This involved nine direct restorations (composite, amalgam, glass ionomer), three scalings and 26 extractions.

We had invaluable help from the staff and older children who have been training with the DAN teams since 2015. This help involved suctioning, bringing the children in, calming the very anxious children, mixing materials and giving postextraction instructions.

Meanwhile that morning, two dentists visited Zobia school. This is a small school which caters for children with special needs and disabilities. The dentists were welcomed with flowers and cards from the children. Thirty-six children were screened with the help of the staff. The team also gave toothbrushes and toothpaste to all the children and carried out simple oral hygiene advice.

After lunch, we visited and screened the 120 children at the AKAAB school for the blind, which is based just outside the town of Mirpur. We were surprised to note that not as many of the children needed treatment as expected. This educational facility was headed by a blind professor of English and helped children and young adults ages 6–22. Again, this establishment was mainly run on private donations from across Pakistan and the UK.

We were given a tour of the whole facility from the deputy head teacher, who also was blind. He showed us the well-thought-out and designed building specifically catering for blind children. We saw how the children learned to read Braille in Urdu and English. It was astonishing to see how these children had achieved so much in academia but also entering sports, music and talent events throughout Kashmir and Pakistan.

The head of the institute discussed his passion to build such a place, which was the only one of its kind in the whole area.

We were told that before a school like this, most children who were born blind had no future and at best some would become shoe cleaners or bread mixers. The rest would mostly be forced into begging on the streets unless they were born into a wealthy family.

Some children who had attended this school had gone on to become teachers, work in banking and finance and government jobs. The effect the staff and school had on these children was amazing and humbling to see.

In the evening we held an event at the hotel, with the help of our local dentist, the orphanage and friends of the charity who had helped us for the past two years. Lecture topics included oral cancer, hepatitis, orthodontics, trauma and an introduction to the Hall crown technique.

The event was attended by 60 people including general dentists, professors/academics from university, general medical practitioners, those involved with healthcare commissioning from the local government, lay people, dental assistants and students.

The event was recorded live from a news team and broadcast around the local area and online. We explained the intentions of our charity and how we work together with people from Kashmir and Pakistan to help improve health and dental care.

We explained that we could improve together as a profession and ultimately reduce dental disease, raise awareness and also aim to reduce the transmission of blood-borne viruses. The event ended with presentation of attendance certificates for delegates and also certificates of appreciation for those who had helped us.

Wednesday 11th October
The morning involved screening 142?children from the Kashmir Institute of Special Education (KISE), which educated children who were deaf and who could not speak. A few of the children we had seen in the previous year remembered who we were, and as soon as we arrived they gave us big smiles showing us their teeth and indicated brushing their teeth with their fingers!

We also handed out toothbrushes, toothpaste and toys.

The afternoon was spent treating all the girls from the KORT orphanage (23?restorations, three scalings and 19 extractions).

As we had finished on time for once, we took this opportunity to visit Dr Tahir’s private dental clinic, which was within walking distance of the hospital. It was pleasing to see a clinic where the team was caring and patient-focused and how they took decontamination, single-use policy and prevention of disease very seriously. (In contrast, there are many establishments where nonqualified people undertake dental work and extractions at a very low cost, risking the spread of blood diseases.)

The evening was spent at the KORT orphanage handing out toys to the all the children.

Thursday 12th October
This was a very busy day undertaking treatment on children who were blind, deaf and those who were wheelchair-bound coupled with other disabilities. We had staff members from each school assisting us in treating “their” children. All rooms including our stock room were used to carry out treatment.

One colleague became a treatment coordinator and delegated treatments to each dentist, which made the workflow easier. He also made sure our used instruments were being collected and sterilised and ready for use when needed. The day started at 8.30am and finished approximately 5.30pm with a short lunch break.

The team was under pressure, because these children could come for treatment only on this day, so the aim was to get everyone disease free by the end of the day. Seventy-nine patients were treated, with 59 extractions and five restorations.

Later that evening we were invited to a boating club and experienced high-speed boating on the famous Mangla Dam. This was followed by tea and food with professionals from the community.

The evening ended with our team individually going through personal feedback and thoughts of the mission. We considered what improvements we could make for future trips and discussed our own personal learning experiences. This was the first time some of the team had ever done something like this and it was a life-changing experience.

Friday 13th October
The morning session was used to undertake treatment on all remaining boys from the orphanage. This involved 15 extractions, 23?restorations and three scalings. We completed all charted required treatments on all of the children we had seen from all four institutes. We noted that many of them, like the boy pictured here, had anterior incisor fractures because of falls, running and cricket.

An inventory was made of all our stock and equipment which was then stored in a secure location to be used for following aid trips.

I can truly say by the end of the week the whole team was extremely worn out and exhausted with little energy to even pack our bags for the return trip!

We would like to thank all those involved from the UK and Kashmir—especially to those who donated their time, money and efforts.

Thank you to Septodont for donating the safety plus syringes, KORT for always looking after us and making this possible each year, the children of KORT, local dentists and, of course, the wonderful people of Kashmir. We plan to go back again in November 2018.