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| - Background |
| - Introduction |
| - The Nodal Agency |
| - The Project Team |
| - Overview of Activities |
| - Project Director's Message |
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National Oral Health Care Programme a project of DGHS and Ministry of Health & Family Welfare was initiated in 1998 and later on the Department of Dental Surgery, All India Institute of Medical Sciences was chosen as the nodal agency to implement it. The objectives of this programme are to improve the oral health of the masses and to prevent/ reduce the burden of oral disease in the country. Towards this objective, the Nodal Agency is working to develop an accessible, low-cost, sustainable, primary preventive programme using existing primary health care infrastructure and resources. The programme has 3 basic components:
The Ministry of Health & Family Welfare decided to implement Oral Health Programme right up to the Village level. The programme aims at designing and accessible a low cost, sustainable Oral Health Care Programme suitable for National dissemination targeting the focus on rural population. The Goals of National Oral Health Care Programme are: The Short Term Goals (for the pilot project):
The Long term Goals:
Oral Health Problems In India Before any preventive programme is designed for a particular oral disease or condition, the problem must be clearly recognised and understood. Unfortunately, in our country no National Survey has been conducted to understand the magnitude of Oral & Dental problems, however, isolated studies are available to indicate the prevalence of Oral and Dental diseases. These studies have clearly indicated that Dental Caries, Periodontal diseases, Malocclusion and Dento-facial deformities and Oral Cancer are highly prevalent in our country. 1. Dental Caries Dental Caries has been consistently increasing both in prevalence and severity for the last five decades. In the year 1941, its prevalence was reported between 40 - 50 % with an average DMFT of 1.5. In 1980's the point prevalence increased to about 80% in children with an average DMFT of 2-6 at the age of 16 years in different regions of the country. The point prevalence in 10 to 15 years old children of Delhi was found to be 39.2% and DMFT was 2.61 in the year 1992 (Prakash H et al, 1992), while according to Global Oral Data Bank (WHO website) in 1996 the point prevalence was 89% with DMFT ranging between 1.2 - 3.8. Dental caries is consistently increasing in its prevalence and severity especially in children and today according to a number of investigators 80 to 85 % of children suffer from this disease and the average number of decayed, missing and filled teeth per child at the age of 16 years is about 4 in rural areas and 5 in urban areas with almost no dental restorative help available particularly in the rural & deprived areas.
2. Gum or Periodontal diseases Almost 95 to 100 percent of our adult population is suffering from periodontal diseases which is initially painless, chronic, self destructive leading to gradual tooth loss and mostly people accept it as the disease of old age. 3. Oral Cancer Oral cancer presents a major health problem in India as 30-35% of all Cancers diagnosed are Oral Cancers with buccal mucosa contributing to about 15% of that. The prevalence of Oral Cancers in India ranges between 0.02 - 0.03 % in different Urban and Rural areas with southern states more prone to it, some part of the Uttar Pradesh also has special predilection. 4. Malocclusion About 30% of the children suffer from malaligned teeth and jaws effecting proper functioning of dentofacial apparatus and aesthetics.
Status of Oral Health Care System in India The Oral Health Care has not received due importance in India. During the past 50 years of independence the Medical Sciences have made tremendous progress in combating most of the communicable and non-communicable diseases, however the Oral Health Care has been neglected. This is evident from the increased prevalence of dental diseases in recent years and from the meagre funds being allotted for Oral Health Care. It is recently the Govt. of India accepted the Oral Health Policy in 1995 and has been made part of the National Health Policy. As per dental manpower committee report of Dental Council of India there are approximately 44,000 dentists for population of more than 100 million with dentist population ratio of 1:30,000 in urban areas and 1:1,50,000 in rural areas. In the past decade, the country has established 140 approved and recognised dental colleges but these colleges have been set up arbitrarily and haphazardly without considering the magnitude / need of the population in different states. It has been well established that Preventive programmes are very cost effective and advantageous method for fighting oral diseases. But restorative / rehabilitative approach has been practised in India in spite of being very expensive and with limited facilities. About 75% of the rural population has been totally neglected, it is therefore essential for a vast country like India Preventive approach including health education and promotion should be given due importance in implementing the Oral Health Care.
Economic burden of oral diseases (a) Treatment Cost It is a well know fact that the treatment of dental disease is very expensive and time consuming. For a rough estimate, If we consider only children below 16 years for restorative treatment of dental caries having average DMFT of 2, It would require about 66 years for all dental professionals of the country to restore caries teeth and about 520 crores rupees (statistics below). Population of India about - 10 billion In USA alone $ 43,83,000.00 were spent in 1970 for dental caries with major expenditure going for restoration of caries teeth. This sum was approximately 1% of total national income and 10% of nations health bill. Similarly in U.K. in 1977 approximately 250 million pounds were spent in England and Wales alone on dental treatment within the general dental services section of National Health Services. Whereas in India approximately 2% of budget is spent on health and there is no separate allocation for oral health.
(b) Loss of Man-days Though the dental diseases are not considered to be life threatening but they seriously affect day to day activities. When a person is suffering from dental pain due to any of the mentioned dental diseases, he is amenable to loss of concentration on his work or may not be able to work at all. Though the factor does not seem to be important but it has serious economic implications on the country. In India, we do not have statistical data but it can be estimated by the data of other countries for example in USA in the year 1988 on an average 8 working hours per person were lost due to either dental problems or appointment with dentist. So we can very well understand the social and economic implications due to ignorance of oral health. The loss of working hours is especially important in Indian context since about 25-30% of the population is below poverty line and depend on daily earnings. The families where a worker is the only earning member, the situation can be even worse if the earning member suffer from dental ailment stopping him from working for one full day. This could lead to serious situation for food and daily needs for the whole family of 4 or 5 persons.
(c) Public Health Expenditure This is very unfortunate that till date in India no serious effort been taken to improve oral health of the masses. Till today oral health does not have a separate budget allocation in national or state health budget. As compared to other countries, we are still lacking in paying sufficient attention to such an important part of our health. In India with increasing level of dental diseases, limited resources and manpower it seems practically impossible to provide curative services to each and every individual, which is primary duty of Government of India. To find out a viable mean to handle such situation the only alternative seems to be preventive approach. This is relatively simple and cost effective utilising oral health education, preventive strategies and mass media utilisation.
1. Oral Health Education It is recommended that to spread the message of oral health to the masses, all the three media of communication i.e. audio-visual, print and folk media should be utilized to the maximum. For children and people with low literacy level, these messages should be more pictorial than in writing. Central Health Education Bureau shall be involved to formulate IEC material. It is recommended that to spread oral health awareness, existing infra-structure should be strengthened. Multipurpose health workers (MPW) should be trained to impart oral health education, provide basic pain relief and be able to refer the cases for further investigation and treatment. It is proposed that one dental surgeon for a population of 30,000 should be appointed at PHC level and in tribal and remote areas, one health assistant/hygienist to cover a population of 20,000 should be available. Since school children constitute a major proportion of population and children learn easily and they have long years to go, oral health education of school children will have far reaching benefits. Therefore, it is recommended that one dentist should be appointed for a population of 50,000 school children. Regular oral health promotional activities in the form of health education, regular dental check-up, demonstration of brushing and rinsing technique and preventive and interceptive treatment can be undertaken at school level. In addition, chapters on oral health can be included in school textbooks of 3rd, 5th and 8th grade level, commensurating with the maturity level of the child.
2. Utilisation of the Mass Media Since there is a wide spread network of radio and television and press and cable network in our country, the proper utilisation of these medias will ensure not only spreading the right message but also would lend authentically to what the various types of workers would be propagating in the field. For this purpose, with the help of the Ministry of Mass Communication, some short 2-3 minutes films can be made to be projected on television at peak hours and also with clearly defined radio messages and flashes. NGOs, Electronic media, T.V. and Press should be involved in spreading the message of Oral Health Awareness. Oral Health Education materials like charts, posters, pamphlets, models and comics should be developed to be used in the community and schools. Special plays, skits, poems and songs on Oral Health should be developed as part of the folk media to spread Oral Health awareness in rural areas. 3. Oral Health Set up
In order to provide dental health curative and restorative services along with primary prevention of dental diseases, it is proposed that there should be well equipped mobile dental clinics so that the services can be rendered to the rural masses at their doorsteps, more so in various remote and inaccessible areas. There should be at least 3-4 mobile dental clinics at each district level catering to a population of 4,50,000 to 5,00,000. Each mobile dental clinic should have two dental chairs and units, each with air-turbine, micro-motor, ultra-sonic scalers and other equipment. There should be three dental surgeons posted with mobile dental clinic, with one dental technician and three chair-side assistants. Two dental surgeons sequently should look after restorative and curative work of the patients whereas one to devote time on the primary prevention of dental diseases through lectures, participating in discussion using audio-visual aids to educate and motivate the rural masses to follow the primary preventive measures. k. In-house training to dental doctors at Govt. Dental Colleges and other Institutions recommended by the Ministry of Health should be provided to impart oral health education, and to provide preventive, interceptive and curative treatment at the community level.
Continuing Dental Education Programme Each state under the Directorate of Health Services (dental) must identify one or two training centres in the state. The directorate must conduct at least one CDE programme every 6 months. This CDE programme must be compulsory for each dental surgeon serving in the state health services. Through these CDE programmes the dental surgeon's knowledge must be updated regarding the most recent concepts of dental procedures as well as on the various methods and approaches of preventive and curative aspects of the dental diseases. Directorate must ensure not only compulsory attendance of dental surgeons but also their active participation through group discussion/panel discussion /practical training, etc. so that they must participate with interest. Directorate should involve a system to objectively evaluate (some point system) the active participation of the dental surgeons in these CDE programmes. The directorate should also make arrangements to conduct such CDE programmes. The directorate should also make arrangements to conduct such CDE programmes for the private practitioners. ROLE OF DENTAL COLLEGES Each dental college should be given the responsibility to adopt one whole district so as to take care of the preventive oral (dental) health services to the rural and the urban communities of the district effectively using the internship programme. The interns working in the dental colleges should be posted compulsorily for 2 months in the community so as to get oriented to train the school teachers, para-health workers and Anganwadi workers in delivering the oral health preventive package to the masses Dental Colleges can explore and utilise the special provision of funds available with the Planning Commission for such like projects for adoption of one district by a dental college community.
STRATEGIES OF ORAL HEALTH CARE IN URBAN AREAS The dentist population ratio in urban areas is approximately 1 : 30,000 as compared to 1 : 1,50,000 in rural areas. However if the prevalence of dental disease in urban and rural areas is compared, the average number of decayed, missing and filled teeth per child by the age of 16 years in urban areas is approximately 5.0 as compared to 4.0 in rural areas, reported by a number of investigators. Almost 85-90 percent of the children and 100 percent adults in both urban and rural areas suffer from gingival and periodontal diseases, respectively. This clearly indicates that no doubt the services of dental specialists are available to the masses in the urban areas but in reality the oral diseases prevalence has not decreased and is rather high. This is probably due to lack of awareness and motivation of the public as well as the dentists in the primary prevention of the oral diseases. It has been seen in a number of developed countries, e.g. Sweden, USA, UK, etc. that only after institution of organised preventive measures in the community, the dental caries could be reduced by almost 50-70% over a period of 10-15 years. So, there is a need to change the attitude of the public as well as the dentists and also to make them aware that the oral diseases are preventable and reversible in the initial stages. To achieve this, the following needs to be done :
Involvement and Reorientation of the Dentists Working in Urban Areas: First of all there is need to involve the dentists, teaching staff posted in the dental colleges, hospitals as well as the private practitioners, two months refresher courses in the concept This can be started after the training of the dentists from various states for the implementation of the National Oral Health Policy in the rural areas is completed, i.e. over a period of 1-1/2 years. After that a group of 15 dentists from the various dental colleges and private practitioners from urban areas of the country can be trained at the centre identified for this purpose. This can be a continuous programme. The dentists so trained can further train the dentists in their own states. All the teaching aids and material can be made available to them.
Implementation of primary preventive package through the school health schemes in the different urban areas: Since very little organised health system is operative in urban areas, it is important to explore all the possible avenues to implement minimum oral health coverage to the urban population. The dentists of the school health schemes are operative in a large number of urban areas. The dentists of the school after proper training can form a good nucleus for the delivery of preventive package. Involvement, education and motivation of the teachers in the various schools / Colleges and other educational institutions in the urban areas for the delivery of primary preventive package to the school / college going children and young adults is essential. Education is one of the most organised systems prevalent in the urban areas, hence the utilisation of this system and involvement of the teachers at various levels starting from small school children to young adults in the colleges and universities would be ideal to create awareness and motivate the population in the formative years towards developing habits leading to prevention of oral diseases. The dentists employed in school health schemes and other hospitals in the preventive areas after proper training can be instrumental in the training of these important components, i.e. teachers in the delivery of the preventive package. Exploration and involvement of other voluntary (Rotary Club, Lion's Club, YMCA, YWCA etc.) and health organisations working in different urban areas in the achieving the oral health targets. The number of other health workers such as family planning workers, social health workers, Anganwadi workers and number of voluntary organisations such as Rotary Club, Lion's Club and other health organisations such as child welfare are operating and active in the various urban areas. These are very potential sources, which can be utilised for the delivery of the preventive package.
REORIENTATION OF DENTAL EDUCATION IN INDIA Community Dentistry component in each dental college should be made more dynamic, active and viable. From the Planning Commission, special funds can be allocated to each dental college for adopting one district to implement oral health care programmes, but these programmes would have to be standardised, monitored, evaluated and accommodated. Basic dental curriculum should be preventive and community need based. There would be a need to reorient some of the dental education programmes in the various dental colleges according to the national oral health policy. As already envisaged in the plan, two teachers (dentists) from each dental college would be given the training in the centre identified for this purpose, who in turn will be responsible for conducting the reorientation programmes in their own colleges. One of the important components should be that out of one-year internship, two months be spent in the rural areas. Involvement of other allied departments The Department of Education and Social Welfare should be involved to impart correct oral health promoting information to school children at an early age which would help to develop proper attitudes in them. It would be preferable to include chapters giving adequate knowledge about oral diseases and their prevention in the text books of class III, V and VIII.
National Institute of Dental Research (NIDR) To give a proper lead to the total health care systems in the country, it is important to set up apex bodies of national importance in post graduate dental education and research on the pattern of NIDR (National Institute of Dental Research) in USA and in India, the AIIMS (All India Institute of Medical Sciences) in New Delhi and P.G.I., Chandigarh. In the beginning at least one such institute of national importance be set up in oral health where meaningful research applicable to Indian conditions can be carried out systematically on a longitudinal basis. NATIONAL TRAINING CENTRE Training of the Trainer (TOT) It is important to calibrate the trainers, viz. dentists from the various states and union territories of India who would be assigned the duty of training the various health teams, posted at the PHC/CHC in their respective states. Union Government can identify a centre which would have the capacity of training the existing health infrastructure, i.e. Doctors, Multipurpose workers, health guides, school teachers etc. for this purpose and also would standardize the various education materials, courses, evaluation criteria for the training of different categories of health workers. The education materials for the education of the community by the health guides and multipurpose workers, school children in various age groups by the school teachers have also to be prepared and standardized.
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