Future Focus: Emily Blackburn

Inspiration

My decision to undertake an elective in dentistry was inspired by an incident during my clinical placement prior to lockdown in early 2021, which saw me extract an extensively decayed lower molar in a wheelchair bound patient, under the supervision of my tutor. This experience inspired me to pursue an elective that allowed me to develop a deeper understanding of the role of oral and maxillofacial surgeons and how they work collaboratively with general dentists to support patients.

I knew that arranging a clinical elective in oral maxillofacial surgery and acute care locally in Sydney would enable me to learn from the experienced clinicians looking after patients in the public system. Fortunately I was able to secure an elective placement in the Emergency Dental Department at Westmead Hospital. The pandemic really impacted clinical electives, with many being suspended, however, with restrictions easing towards the end of 2021, I was able to commence my elective.

Inequity in oral health

With a cessation in the provision of public dental treatment due to the pandemic, as well as the exacerbating oral health inequalities in Australia, communities in low income areas were most effected.  As the number of adult patients on the wait list for public dental treatment increases, many of the patients presenting to the Emergency Dental Department at Westmead had time-sensitive dental procedures delayed.

As such, many of the patients who presented had limited access to care as public dental services in Australia are unable to provide services in a timely manner to all individuals in need. Australia's dental healthcare system is complex and is operated via a mixed private-public provider model. Medicare does not cover dental examinations or treatment for most individuals. While some disadvantaged populations are eligible for public dental services, there are many that fall through the cracks and are unable to access regular private oral healthcare. Those eligible for public services are faced with numerous structural barriers in accessing treatment.  Within the Australian adult population, disparities in access to care is a pertinent issue that is widely acknowledged, however, public policy has been slow to provide greater access to services. My elective allowed me to witness firsthand, how the social determinants of health have such a profound impact on the early onset of oral morbidity via measures such as tooth loss, gum disease and lack of oral hygiene literacy in patients of lower socioeconomic status.

Managing dental pain via emergency treatment

Clinics ran from 08:30-17:00 daily. A typical acute care session would often commence with a triage of the patient to ascertain their source of pain.  My colleagues and I were able to see 2-3 patients per session. Triaging, diagnosing and management of patients who presented to Westmead in pain was a humbling reminder of why I chose to do dentistry in the first place. All appointments started with a thorough assessment of the patient's 'chief complaint' followed by additional tests and diagnoses before deciding on the course of treatment. Under the guidance of more experienced senior dental officers within the emergency department, I was able to carry out procedures to help remove pain, such as replacing broken fillings, removing severely inflamed nerves within teeth and extracting broken-down teeth that could not be saved due to gum disease and dental decay.

On my first day, I treated a patient with a broken back tooth. She complained of being unable to eat or sleep for the past 2 weeks and was clearly in a great deal of pain. After assessing the condition of her remaining teeth, it was decided that a large metal filling would replace the lost tooth structure. By the end of the appointment, she had tears of happiness as she was finally able to eat and speak again. Another patient presented with a facial swelling from a reinfected root as a result of a coronectomy - a procedure where the crown of a tooth is removed with the root left behind in order to avoid damage to the nerves and anatomical structures in close proximity.  I was shown how to adeptly deliver local anesthetic in order to successfully drain the infection out of the abscess around the patient's jaw, requiring a great deal of precision. This patient was extremely anxious and sleep deprived from being in immense pain the night before. It was my responsibility not only to assist with her pain and arrange her referral to the oral maxillofacial department, but to also console her and her worried father.

Outcomes, challenges and lessons

Through my elective, I was able to gain exposure to the management and role of a general dentist in facilitating the care of patients who were on palliative care for serious conditions such as oral cancer. There are such profound effects of oral health on a patient's systemic wellbeing, which are often overlooked. One patient that presented to the department had a rare cancer that affected his salivary glands that had spread to his tongue lymph nodes. As such, he had to undergo surgery to remove the cancer and had received high doses of post-operative radiotherapy. Dry mouth, a devastating side effect of the cancer treatment, resulted in gross decay in many of the his teeth, with sharp edges of tooth structure left behind that were constantly cutting into his gums. The maxillofacial surgery department at Westmead had referred him to the acute care clinics for an enameloplasty, a dental procedure where teeth are reshaped for functional or aesthetic reasons. With the help of our clinical educator, my colleague and I were able to reshape his teeth to provide him with a comfortable biting surface for his front four teeth. I found this procedure to be particularly rewarding as a young clinician. I was also able to put my skills to the test, rebuilding the front tooth of a patient who had lost her job due to the pandemic, and was unable to afford private dentistry. The wide range of clinical work that I undertook throughout my elective provided me with a great deal of satisfaction, as I was able to make a difference to the patients I helped treat.

Elective conclusion

This elective allowed me to witness first hand, many of the challenges that public health dentists face when treating the patients via the public health system. This experience would not have been possible without the unwavering support of BOQ Specialist via the FutureFocus grant.  This grant provided funds for me to continue my development through a professional course, identifying and screening oral cancers in high risk patients, as well as further courses in oral surgery. With restrictions on surgeries in hospitals easing, I endeavor to undertake my other elective in Oral and Maxillofacial Surgery in the latter half of this year. The resilience and strength of patients from different backgrounds has been awe-inspiring, and I remain steadfast and committed in my desire to improve the access to oral healthcare and specialist services to the less fortunate.

The COVID-19 pandemic has shed light on many lessons such as our interconnectedness and codependence as human beings and the importance of the healthcare system that looks after a shared humanity. I am thankful for the opportunity to learn a great deal from this elective. There is much to do with regards to 'filling the gap' and reducing oral health disparities in Australian society, and I look forward to working towards this post-graduation.