Tackling hurdles … one leap at a time
A discussion on the merits of interdisciplinary collaboration and the potential of free online website development as tools to address barriers to oral health education
Synergistic collaborations are always worth exploring. This is especially true when the potential output can contribute to patient care or wellbeing. For a number of years, there has been a relationship between the University of Dundee Dental School and the Medical Art programme at Duncan and Jordanstone College of Art and Design, where resources are developed, benefitting both institutions.
Educators from the Dundee Dental School pitch potential projects to the art students, who can then choose to take on the project if it interests them. We first became acquainted through this initiative and collaborated to produce an interactive resource demonstrating fluoride and demineralisation principles. Rebekah’s insight and skill was very impressive and the use of free website development tools as a platform for evidence based oral health education held almost limitless potential. There is now a plethora of useful tools that allow creation of interactive websites with relative ease. Gone are the days of reliance on expensive website developers!
Throughout this process, Rebekah expressed a desire to focus her masters project on health interventions relating to Down’s syndrome. We were very happy to once more collaborate on this worthwhile endeavour. We decided that a tool to educate the general public on oral health considerations for children with Down’s syndrome would best fit with our goals. We had similar visions on how to best execute the project. In the next few sections, we will discuss this in more detail.
Down’s syndrome is a common genetic disorder caused by an additional chromosome 21 [Fig. 1].
There is a potential myriad of oral manifestations associated with the syndrome, along with broader medical considerations that can impact on dental treatment. Patients with Down’s syndrome can also potentially have developmental delay which can vary from mild to severe. Regarding oral health, there are significant inequalities in clinician and parent preparedness and limited online resources targeted at educating, parents and carers of children with Down’s syndrome.
In addition, dental resources available focused on Down’s syndrome do not take advantage of the medical illustration technological advancements that have boomed throughout the digital age. Illustrations and models focused on Down’s syndrome oral health found online were limited, and the majority of resources were targeted at the clinician. This is surprising given the prevalence of the syndrome and the need for education for all those affected, including the parents and carers.
The main proportion of oral care happens within the home. The dental health of children with disabilities is often reliant on their caregiver’s oral health knowledge and attitudes [Fig. 2]. These behaviours will therefore be the principal factor in shaping the oral health of these children, for better or worse. Having readily accessible, high-quality, and easily understood guidance is therefore of paramount importance.
The lack of high-quality information and illustrations found on Down’s syndrome oral health, presented an opportunity to develop an online resource to tackle the issue. Rebekah is a recent graduate at the University of Dundee, earning a master’s degree in Medical Art. Her brother, Jeremy, is an individual with Down syndrome who is the ultimately inspiration for this resource. He is someone Rebekah has seen experience inequality relating to dental health care first-hand.
Rebekah began drawing her brother in high school fine art classes in Oregon, USA [Fig. 3]. At this point she also held the position of vice-president of Best Buddies at her school – a club designed to create a one-to-one friendship with intellectual and developmental disabilities. This experience later emerged when Rebekah embarked on her Medical Art course at the University of Dundee, where she began drawing her brother again for the Life Art course. Rebekah has since explored and developed numerous art forms throughout her career from tangible models through to photorealistic digital renders [Fig 4]. Rebekah has always felt inspired to showcase this often-unrepresented cohort. Additionally, the influence of a team of dental professionals at the University of Dundee passionate about decreasing the social gradient of disability support within the field was also motivating.
Our primary objective was to raise awareness and improve the quality of resources targeted towards Down’s syndrome oral health education. Many dental diseases can be prevented through appropriately targeted home interventions. Interactive and visually striking resources are more likely to appeal to a broader audience and simultaneously be more inclusive than simple text based educational tools. By training families and caregivers on oral health, the overall quality of life of those with Down’s syndrome will be improved.
Our second objective was to increase clinician and trainee preparedness when caring for patients with Down’s syndrome. Dental students can learn more about their future Down syndrome patients by utilising this resource. It is intended that students will benefit from the high-quality 3D models, which clearly demonstrate a number of anatomical considerations associated with this patient group [Fig. 5]. The website may also allow students to gain a more empathic perspective, connecting with the personal inspiration.
Choosing the appropriate platform
An educational website was created because of its free and easy accessibility to anyone, especially primary caregivers of Down’s syndrome and early-year dental students. By designing a website, all 3D models and 2D animations, in addition to an interactive FAQ page and complementary information, were all able to be hosted in one place. The website was created using wix.com, where the domain downsydromeoralheallth.com was purchased for this project, making it easier for viewers to find. Another advantage of using Wix, is that all the elements on the site are highly customisable and it allows embedding of YouTube videos, Sketchfab 3D models, 2D images and other external components.
As the resource was aimed towards a broad audience, easy-to-understand language that avoided technical terms was used. The modifiable nature of the Wix.com platform allows us also to rapidly make changes to the content, in line with changing guidance and in response to feedback received.
Essential subjects related to oral health risks for individuals were found and listed. The animation goes through a series of expected delays, anatomical features, and possible complications. These topics include teeth eruption, predisposal to gum disease, tooth hypoplasia, tongue fissures, mouth breathing, temporomandibular joint dysfunction, sleep apnoea, and atlantoaxial instability, to name a few. A narrative was then composed, which was latterly reviewed and modified in accordance with expert feedback.
The 2D drawings seen in the animation were created by Adobe Illustrator 2021 [Fig. 6].
Vector lines created the illustrations that allowed for scaling without losing quality or sharpness in the image. The goal of the depictions was to be simplistic yet informative and accurate. Ultimately, all illustrations and voice recordings constructed were imported and edited within Adobe After Effects 2021. The video files were hosted on YouTube, where they were then embedded on to their designated page on the website. This is yet another example of the benefits of modern modular website development tools.
Accurate and reliable resources were essential when beginning to create the 3D models. Fortunately, a cranium from a person who had Down syndrome was located, and 3D scanned. However, the cranium available was incomplete, and the model was further manipulated to become the skull seen in the resource. The original cranium was missing the maxillary dentition along with parts of the palate.
The missing components, including teeth, mandible, palate, gums, C1-C2 vertebrae, ears, lips, eyes, and facial muscles were extracted from “BodyParts3D, © The Database Centre for Life Science licensed under CC Attribution-Share Alike 2.1 Japan”. The 3D modelling software ZBrush 2020 by Pixologic was utilized because these two separate anatomic models needed to be reshaped, added on, and sculpted into something brand new. This allowed for texturizing, painting, scaling, and creating new models. The newly created skull later served as the substructure for the models including the écorché, tongue and palate [Fig. 7].
The resource showcases anatomic features of the mouth, head, and neck commonly present in people with Down’s syndrome, explains everyday dental phenomena, and gives overall guidance and recommendations to users. We were given advice and feedback from the Dundee Dental School throughout the project, benefitting from the expertise of Professor Peter Mossey, Dr Abigail Heffernan, Dr Katharine Blain, and Professor Mark Hector, who all offered Rebekah unique perspectives. We worked closely with this dental team, who provided overall guidance, and quality assurance.
Overall, this project was intended to raise awareness of the oral health considerations of people with Down’s syndrome and inspire future changes within the field by improving the quality of resources available and showcasing the potentially readily available technologies at our disposal. If a dental trainee does not have an opportunity to provide care to an individual with Down’s syndrome during the duration of their clinics or in times where online learning is endorsed, then having high quality simulations become crucially important. This is particularly significant during our current predicament, where patient contact is still reduced in light of the global pandemic. In addition, the resource can efficiently be utilised by any dental practitioner wanting to offer additional support to their patients.
Overall, the website proved to be engaging, informative and visually striking. The resource is still evolving, developing and improving. We have clearly demonstrated the potential to rapidly develop websites addressing specific issues. This is a testament to the potential of developing non-profit websites for specific cohorts with particular oral health needs. Such websites could be “prescribed” by clinicians for families allowing them to have the relevant information on hand. There is, however, a need to consider the digital literacy required along with access to technology of the end user. We must be aware of the potential of making a digital barrier to oral health.
Future investigators can build upon this research by creating additional Down’s syndrome dental resources, conducting comparative case studies, or expanding into relevant fields within Down syndrome oral health.
Clement Seeballuck is a Clinical Lecturer in Paediatric Dentistry at the Dundee Dental School and Hospital.
Rebekah Sadok is a Medical Artist and recent Graduate of the University of Dundee. You can see examples of her work, along with details of how to contact her on her website www.atomstoart.com. You can also follow Rebekah on Instagram: @atomstoart