When Zero means All

From Club of Amsterdam Journal

"ma 27 ta 54116", says Gomathi, "is the treatment for this child" and performs it successfully. Success is measured by the width of the smile on the child's face that reaches the eyes and his/her willingness to come back happily in case some other problem arises.

Gomathi, a housewife, is one of the few health hygienists from rural India who have been trained for dental health care. An important element of the small dental care ripple that is revolutionizing life, she works in the villages neighbouring Auroville, Tamil Nadu, (south India). The focus of this programme is training women and primarily treating children: treat the children and train them wll in dental care while young and they will have fewer problems when they grow up.

The treatment "ma 27 ta 54116" meant filing a cavity of "the second left upper molar filling in occlusal surface with composite", indeed a unique way of communicating a diagnosis. The treatment and its delivery are unique too!

Smile is the measure of Success!

Knowledge owners and stakeholders

This human-centric dental care programme holds enormous potential to be replicated, scaled, sustained and co-opted along with other health care initiatives, globally.

What we have here is a perfect integration of:

• experiential knowledge
• open access for all individuals to this knowledge-practice
• a learning that can be implemented without any discrimination or cultural barriers
• creation of a sense of service to one's community
• a respectable remuneration with minimal investment

You own your teeth, so look after them well! (Children check their own teeth)

All one needs is a flat surface for the patient to lie upon, a stool for the dental health worker and minimal necessary instruments and materials to perform the basic treatments. In practice, basic treatments can be carried out on the field: in schools, village halls or in health centres with minimum equipment and resources.

The dental health worker is trained by dentists in Atraumatic Restoration Treatment (ART). ART for dental care developed in Tanzania in the mid-80s. The World Health Organisation (WHO) started to actively promote it in the early 90s as the first line of dental treatment in developing countries. ART is an approach for both prevention and treatment of dental caries in children and grown ups. ART equips dental health workers to spot caries early and treat them immediately with minimal tools and infrastructure.

For this particular dental health care programme, the "ART" technique is associated with Zero Concept and Proprioception.

Pedagogy-driven design and practice

Zero Concept and Proprioception

"Backaches and neck pains were the bane of my life" said Dr. Jacques Verré, the founder of the Auroville Dental Care Centre and this programme; "most dentists suffer from them; it is a like a professional hazard. But ever since I learned and started to use Concept Zero and PD during my practice, I have been a happy man. I also taught it to my colleagues. Now my patients, my assistants, fellow doctors and I are free from pains that occur during treatment" (Dr. Verré is a Frenchman settled in Auroville, India). Dr. Amar Raja his colleague at the main Centre, Ms Suryagandhi who heads the rural dental care programme and looks after the main Centre agree with him wholeheartedly.

Dr. Verré's clinic looks like a Zen temple equipped with some state-of-art gadgets for analysis.

Dental care can be provided anywhere

Zero, an ancient Indian concept, starts with 'nothing' (not a thing) --- absence of preconceptions or biases. The general idea of Zero Concept is that, for a given condition, there is an elemental or basic condition to which it can be compared to and from which other conditions can be inferred. When applied to health care, health or the absence of need for care is the goal, and is represented by the numeric 0.

Proprioception ('self-perception' from Latin) is the self-awareness of the position and movements within our own body. There is an instinctive logical response of our body to perform a precise task for its optimal use. Only a state of body balance (Ø condition) in free space allowing free movements can enhance our manual skills with more accuracy and less tension. This inborn physical perception called "Proprioceptive Derivation" (PD) is not a question of culture but is characteristic of all human beings, a common heritage.

Consciousness approach

Human-centered design

This form of dentistry is the result of a life-long pursuit of a better way to practice dentistry by American dentist, Dr. Daryl Beach, residing in Osaka, Japan. He redesigned the dentistry equipment through Proprioceptive Derivation (PD) to let the body of the performer move freely in open space - avoid stressful positions and useless waste of energy. The best position of the operator's head, body, and fingers is determined by masked-eye tests using the proprioceptive senses of the body. The proprioceptive senses of the body are used to derive the most ergonomic design of dental equipment and instruments. Typically, one needs about 20 forceps to address ailments of 32 different types of teeth. With this method the need is only for 2!

The result is a new way of performing dentistry!

The relationship of operator to patient is stabilized and consistently keeps the dentist in a full upright alert seated posture behind the head of the patient. The dentist's upright posture allows the best control of the fine stabilized finger movements required when operating in the mouth and on the teeth positioned at the "zero" point. The patient is offered a lying or full rest position for treatment on a stable horizontal support. The traditional tilting dental chair is of no use as it even jeopardizes the balance of the operator, the operator does not bend over the patient anymore in a stressful posture causing life-long back pain.

Zero Concept of Health is based on "Experience" or "a Sensing" -- Proprioception. The concept centers on "knowing" the positions, movements, contacts and discomfort that we sense within our bodies as both providers and receivers of care. The scope of concerns includes derivation of all acts, space and human interface with technology in clinics, hospitals or field care for achieving desired outcomes.

Learning to "know" - Image - Zero Point

Thus Zero Concept and Proprioceptive Derivation (PD) can be applied to the entire range of health care pursuit and Life in general. However, there is still a long way to go for this concept to reach out and be accepted in the conservative world of dentistry.

Knowledge-based sustainability approach for Health Care

• Positive health is in extending the knowing to doing
• Knowledge (expressed and latent) is an asset
• Shared knowledge and collaborative action foster "health equities"
• Equities "hold and carry" value - emotional and tangible
• Losses are to be seized as occasions for learning in real time
• Profits are to be measured in terms of larger, intense and long-term impacts measured over a generation of population

Language for Outreach:

Although innovative and universal, this concept disrupts the traditional habits and thoughts and perhaps the present business model and profit-seeking motivation of the equipment manufacturers. Resistance to Zero Concept and Proprioceptive Derivation (PD) also stems from a lack of knowledge about the technique and the acceptance of the concept of minimal intervention.

This way of doing dentistry is being practiced by very few dentists and these dentists are scattered throughout the world.

Dr. Beach developed a syllabo-numeric language for easy and precise communication. The global terms, which can be both written and spoken, use the most common syllables in the world (ma, me, mi, mu, mo, ta, te, to…) in combination with digits. The numeric 0 is the basic reference for easy codification and classification of information. Example: the lingo "ma li le", also written "ma 21", designates the upper left incisor. In this case, "ma" means the mouth in its xyz coordinates, li or 2 means the first quarter (upper left) and, le or 1 means the first teeth of the quarter. The jaws are indeed numbered clockwise into four intuitive quarters.

Learning Syllabo-numeric terms: mi300 ma43 mo33
Description: Tip of the third right finger on the lower right canine on the vestibular surface

More advanced example sited earlier is for a treatment: "ma 27 ta 54116" means "the second left upper molar filling in occlusal surface with composite". This means, all dentists (no matter which country they belong to or the dental courses they have studied) and even a hygienist who has no scientific background, can record her work and can communicate without misunderstanding. The Global Terms are learnt together with the PD exercises.

Gains without Pains: A win-win for all!

Gain from the care provider's perspective:

• The programme is based on the universal 'Zero(Ø) Concept', a reasoning applied to Proprioceptive Derivation (PD) and is easy to learn
• Recognised as para-medical training programme, the Atraumatic Restoration Treatment (ART) is promoted by the WHO for developing countries where local population is trained to deliver basic dental care
• The health workers are trained in the Zero Concept reasoning, which consists of a series of self-awareness exercises aimed at finding out one's preferred body conditions.
• A syllabo-numeric terminology to describe various dental conditions and their treatment help the dental health workers to overcome language barriers
• Thus equipped, the health workers can perform basic treatments in the most efficient way

Zero Concept on the Table (Child on the table)

Gain from the care receiver's perspective:

• Location for treatment can be a school verandah, temple hall or even under a tree. Simple natural settings drives away fears of visiting a dentist/dental worker
• Prevention is key: simple and early cares prevents tooth extraction, pain, painful treatment, expenses
• The care provider belongs to the same community and is easily accessible, this induces a willingness to get the treatment
• Timely treatment is almost pain free and encourages the young and old to seek it, besides it reduces further deterioration of dental problems
• Costs for basic treatment are minimal and therefore affordable.

Knowledge Practioners as Outreach Agents

Simplicity of technique arouses curiosity among children who then become potential care-providers, confirming the sustainability loop from the human resource point of view.

As of now about 20 women dental health workers across 10 sub-centres cater to a population of 25,000 individuals of varying ages and at various stages of tooth problems. Complex cases are attended to by dental surgeons at the main Centre. This is in stark contrast to the picture that one finds in India where some 700 million people have poor or no access to dental care and most of this population resides in the country's rural areas. Good dental care is expensive, besides a dentist can hardly make a living as a dentist in rural areas.

Health needs to be seen as Wealth. This can become possible when explicit knowledge is translated into strategy and action, creating value that leverages tacit knowledge especially when stakeholders consciously choose to be collaborative, as is the case with this programme.

Dr. Verré and his team of Dental Care Providers (Team photo)

Women, intrinsically, are holistic care-providers. By training them as dental health workers their intrinsic nature finds a happy expression making them dynamic, confident and innovative while delivering health care. Their status as professional heath care workers raises their self-esteem in the family, their community and among local governance bodies. They are accepted for what they are; sparkling toothy smiles are the new measure of success!

Smaller but conscious organizations like self-help groups and entrepreneurs need to base their sustainability by managing knowledge and knowledge resources (in this case-women) even more, because they lack the market leverage and resources of their larger counterparts. They have to be more nimble, responsive than reactive, take timely and more "right" decisions and use appropriate communication strategies- for, their survival depends on it.

"You are what you eat;" says Suriyagandhi, "if you cannot chew your food properly you will have poor digestion and therefore poor health. Poor health will affect your whole life and your family will suffer too!" The logic is quite simple.