Ministry of environment, water and natural resources state department of natural resources report of the kenya implementation of the



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5.CAPACITY BUILDING WORKSHOP HELD IN UGANDA ON 6TH TO 7TH MARCH 2013


The training of trainors workshop was held on 6th and 7th March 2013 at the School of Public Health, Uganda. FDI met the travel and accommodation costs. The workshop was successful and the Ugandan team was very hospitable.

The following members attended and participated in the workshop. Training was done in the respective areas of the EADAP shown below;



  • Dr B.K Kisumbi – Phase-down of dental amalgam and alternative dental materials

  • Dr Patricia Mwere –Clinical Prevention of dental caries

  • Mr Godffrey Makhanu – Best waste management practice and installation of separators.

A report on status of the EADAP in Kenya was presented by Dr Kisumbi. This is herein attached.

The curriculum of the training entailed lectures and hands on training via practical demonstrations.

The main areas were; ?

The details of the curriculum were as stipulated below;


5.1 UNEP-WHO-IDM-FDI curriculum on dental amalgam Best Management Practices (BMP), prevention and alternative materials

This curriculum is aimed for dental educators, waste management personnel, local trainers in Eastern Africa (Kenya, Tanzania, Uganda) . Capacity building, training and education were provided on



  1. Mercury life cycle and global health and the UNEP mandate

  2. BMP on dental restorative materials usage and environmentally sound waste management

  3. Information on alternative dental filling materials

  4. Clinical preventive dentistry

The curriculum should be used by local trainers to train local oral health care professionals and waste management personnel at the 3x3 pilot sites.

The course should be based on hands-on skills development and organised at a dental school, involving also a few patients for practical training of the participants.


5.1.1Mercury life cycle and global health, and the Minamata Convention


    • Mercury life cycle and global health and the UNEP political mandate

    • What is mercury, mining, life cycle, physical and chemical properties

    • Current usage in industry, gold mining, healthcare and dentistry

    • Toxic forms of mercury and toxic effects

    • Mercury in products and wastes

    • Why and how reducing the global use of mercury

    • What are practical consequences of the Minamata Convention

Responsible: Jean-Luc Eiselé FDI, PhD ; Dr. Desiree Montecillo- Narvaez, UNEP

Supporting documents:



  • UNEP toolkit: Mercury a priority for action; modular approach.

  • Minamata Convention / UNEP treaty on mercury

5.1.2 BMP on dental amalgam usage and environmentally sound waste management


    • Protecting the patients, dentists, health care professionals

    • Set-up, chair, suction, filters

    • Preparation of dental amalgam

    • Protecting the patient during intervention, including polishing

    • Handling of unused amalgam

    • Handling of amalgam particles

    • Handling of the restored extracted tooth

    • Biosepsis measures

    • Use of separator, replacement of cartridge

    • Amalgam waste management- waste prevention and minimization, handling, separation, collection, packaging, labeling, transportation and storage, environmentally sound disposal including recycling and recovery

Responsible: Shunichi Honda (Ministry of Environment, Japan; Pam Clark (Australia); Morten Rykke (Norway)

Supporting documents:



  • WHO: Future use of materials for dental restoration, 2010 available at www.who.int/oral_health

  • Technical guidelines for the environmentally sound management of wastes consisting of elemental mercury and wastes containing or contaminated with mercury available at

http://www.basel.int/Portals/4/Basel%20Convention/docs/techmatters/mercury/guidelines/UNEP-CHW-10-6-Add_2_rev_1.pdf

  • Australian Dental Association, 2012, Policy statement 6.11 & Guidelines to amalgam waste management

  • American Dental Association, 2007, Best management practices for amalgam waste

  • FDI policy statements 2006, Waste management; 2007, Mercury hygiene guidance; 2007 Safety of Dental Amalgam

  • http://www.homesteadschools.com/dental/courses/dentalamalgamonlineslides/amalgam.ppt

  • Pam Clark’s presentation

  • UNEP Kenya guidelines

5.1.3Alternative materials for dental restoration


    1. Dental caries- type, severity of lesion, complexity of dental care

    2. Why do we need dental restoration

    3. Why do we need alternative materials

    4. Available alternative restorative materials

    5. Clinical conditions

    6. ART approach

    7. Safety: Pros and Cons

    8. Technical requirements: Pros and Cons

    9. Costs & insurance: Pros and Cons

    10. Time requirements: Pros and Cons

    11. Durability and wear resistance and fracture resistance: Pros and Cons

    12. Challenges in waste management

    13. Information to patients

    14. Patient oriented care: clinical decision making

    15. The quality needed of new materials


6. Annex 1 - Stakeholders Workshop On Amalgam Phasedown Held At Kenya Institute Of Education On 29th October 2013, From 8am To 4pm


Attendance:

A total of 56 participants attended the workshop from University of Nairobi, Ministry of Health, Ministry of Environment, Water and Natural Resources, NEMA and Dental Materials Suppliers. The full list of participants is in Annex 1. (Include said annex in body of minutes)



Prayers and Introduction and official Opening

Opening prayers were done by Dr. Matheka. Stakeholder’s representatives introduced themselves.


This session was chaired by Dr. Onyiego and was officially opened by Mr. Mwendandu after a brief speech on the scope of mercury and mercury waste threat to the environment and human health.
Objective/project brief, by Dr Stephen Irungu, Chief Dentist, MOMS

Dr Irungu welcomed the stakeholders and made a presentation on the objectives and the progress of the East Africa amalgam project.

He gave the following as the objectives of the project:


  • To brief the stakeholders on the project.

  • To create awareness of preventive dental care and encourage phase-down of amalgam use.

  • To discuss and explore the use of alternative dental materials

  • To develop future actions and sustainability of Amalgam phase-down.

Minamata convention/financial framework/waste management by Mr. Kihumba

The following were the highlights of his presentation:



  • Text of the Minamata Convention on mercury was explained.

  • The principle objective of this convention is to protect human health and the environment from anthropogenic emissions and releases of mercury and it compounds.

  • Dental amalgam is listed as a mercury added product and thus listed as one of the products to be phased down.

  • Article 6 on the exemptions available to a state party on written request was elaborated to the stake-holders.

  • An explanation of Article 8 on reduction of mercury emissions was made. There was concern raised on improper incineration and open burning of medical waste which could also include mercury waste in some public health facilities

  • Reduction of levels of mercury released to the environment and the use of best available techniques in this process was elaborated as proposed in article 9.

  • The role of Global Mercury Partnership was explained to the stakeholders.

  • It was also made known to the stakeholders that Global Environmental Facility Trust Fund (GEF) was available under article 13 of the Minamata convention on Financial Resources and mechanisms to help in capacity building and in technology transfer.

  • Suppliers were also informed of their role in funding research and capacity building.

Reactions:

  1. There emerged the question of budgetary implications on the central government due to the phase-down of dental amalgam and the use of the more expensive alternative dental materials.

  2. The lack of a national recycling facility for dental amalgam waste was discussed. NEMA representatives raised doubts on the feasibility of such an undertaking considering the low volumes of dental amalgam waste generated by the dental clinics in the country and the cost involved.

  3. It was also noted that the cost of the alternative dental materials may discourage the poor citizens from seeking dental treatment and thus leading to an increase in disease burden in the country.

Dental amalgam, alternative filling materials/ best waste management practice by Dr. Kisumbi

The following were the key points in the presentation:



  • A brief history on the use of dental amalgam was presented.

  • The composition of dental amalgam was also explained in detail.

  • Alternative filling materials were listed as follows: Resin Composites, Glass Ionomer Cements, Ceramics, Compomers, Gold, Noble metals, Non-noble metals. It was noted that according to a recent study conducted among dentists in East Africa, the use of these alternative materials was on the rise. This was attributed to increased demand for aesthetic fillings, increased mechanical properties and due to the controversy of dental amalgam.

  • Alternative materials to dental amalgam were said to have the following limitations: Reduced strength compared to dental amalgam, higher cost and increased technique sensitivity. These limitations leave the dentist with no better filling material than dental amalgam.

Reactions:

Stakeholders noted that a majority of clinicians do not segregate extracted teeth that have amalgam fillings but instead discard them with the general pathological waste.

The high failure rate of alternative filling materials was said to be a reason why most clinicians still prefer to use dental amalgam.

Prevention of dental caries in light of dental amalgam phase-down by Dr. Mwere

An eye-opening presentation was made by Dr. Mwere on prevention of dental caries.

These were the highlights:


  • Dental caries is a progressive irreversible microbial disease affecting the hard tissues of tooth resulting in demineralization of inorganic constituents and dissolution of organic constituent, thereby leading to cavity formation.

  • The following are responsible for prevention of dental caries

      • The individual

      • The oral health worker/dental personnel

      • Other health personnel

      • Parents and guardians of underage children, and adults with disabilities

      • The government

      • Other stake holders: faith based health facilities, manufacturers of dental care items, WHO, professional bodies.

    • The levels of prevention are primordial, primary, secondary and tertiary.

    • The individual is involved both actively and passively.

    • Ideally the individual should attend regular checkups for preventive dental care.

    • Due to the current shortage in the number of dentists, there is a high disease burden and the cost of treatment is high.

    • According to the Alliance for Cavity Free Future(ACFF), health promotion, health literacy, patient education and risk assessment should be the best way forward.

    • Good oral hygiene, fluorides, vaccination against caries, prophylaxis, pits and fissure sealants, a traumatic restorative treatment and diet counseling go a long way in prevention of caries.

    • Innovative ways of prevention of caries was emphasized.

Dental amalgam waste in the dental clinic by Mr. Makhanu

He elaborated the technical details and specifications for dental amalgam separators and the installation requirements were elaborated. (Mr. Makhanu asked to insert bullets on 3 key issues discussed)



Reactions: There was concern raised as pertains to the use of hypochlorite in disinfecting the units. This practice was said to lead to conversion of amalgam to soluble form.

(Possibility of alternatives was suggested as one bullet.)



Group discussion by Dr. Kisumbi

Stakeholders were divided into five (5) groups and each group assigned a number of questions as follows:



Group 1: Accidental exposure to mercury in a dental clinic and the systemic effects of such an exposure.

Group 2: Recycling of dental amalgam and environmentally sound management of mercury waste.

Group 3: Collection and storage on amalgam in the clinic.

Group 4: Behavioral change towards amalgam waste management.

Group 5: Steps towards sound mercury waste management.

(Dr. Kisumbi to add for each group suggestions raised)

The results from these groups were readout by the group leaders and later discussed by all the stakeholders.

Demonstration of clinical management of dental caries in light of dental amalgam phase-down by Dr. Kisumbi

The management of dental caries in light of amalgam phase-down was discussed and the following were agreed on as the determinants of the choice of a filling material.



  1. Size of the cavity

  2. The position of the tooth

  3. The tooth involved

  4. Patient habits

  5. The dentition involved

  6. Patient preference

As a general rule the smaller the cavity and the more anterior the tooth, the more one can use an alternative material. The bigger the cavity, the more posterior the tooth amalgam is recommended.

Patients should also be educated on filling materials.




Way forward

The following were the action points for the way forward as proposed by the stakeholders during the workshop:



Ministry of Environment, Water and Natural Resources

  • Awareness to the relevant stakeholders and the public on Minamata Convention on Mercury

  • Liaise with the ministry of trade(write in full) on quantifying the volumes of mercury imported

  • Cordinate the development of a proposal to GEF on funding of startup activities before ratification of the treaty.

  • Support and research on feasibility of a national recycling plant for dental amalgam

Ministry of Health

  • Domestication of the guidelines on dental amalgam

  • Enforcement of guidelines

  • Research on quantities of amalgam and mercury waste generated by hospitals

  • Create awareness on mercury waste management and phase down of amalgam

  • Involve Ministry of education in educating students on oral health

  • Incorporate oral health in all Maternal and Child Health projects

  • Procure early caries detection equipment for health facilities (Dr. Kisumbi to research)

  • Ensure only encapsulated amalgam is procured

  • develop a protocol and policy for use of dental amalgam

  • Revise the National Solid Medical Waste Management Policy to include dental amalgam waste

  • Develop policy and implement guidelines of school oral health

  • Support and Research on feasibility of a national recycling plant for dental amalgam

  • Policy on data collection from private facilities

Ministry of Education

  • Curriculum development on oral health

  • Encourage research on amalgam related issues

  • Create awareness on good oral hygiene

Universities

  • Research on amalgam related issues

  • Curriculum development to incorporate the Minamata Convention

  • Create awareness to the students ,staff and the public on effects of mercury waste

  • Community outreach programmes

  • Train and practice Best Waste Management Practice

Hospitals

  • Adoption of the Minamata convention guidelines on ?

  • Research on alternatives to dental amalgam

  • Awareness creation on amalgam phase-down

Kenya Medical Practitioners and Dentists Board and Kenya Dental Association

  • Create awareness on policy guidelines in private clinics

  • Create awareness on alternative materials to amalgam



East Africa Dental Amalgam Phase down (EADAP)

  • Lobby for extension of duration of the phase down of dental amalgam

  • Disseminate report and results of the project

  • Monitor and evaluate the EADAP project

  • Research on dental amalgam issues

Private clinics

  • Use of separators

  • Education of the patients

  • Embrace alternative materials to dental amalgam

Suppliers

  • Stop the importation of free Mercury

  • Encourage use of encapsulated amalgam



  • Create awareness to the dentist on availability of alternatives to amalgam

  • Conform to the policy guidelines



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