Incorporating Oral Health Services in Basic Health Packages

INCORPORATING ORAL HEALTH SERVICES IN BASIC HEALTH PACKAGES IN POOR AND MIDDLE INCOME COUNTRIES

April 13, 2019 Audrey R. Chapman, Ph.D. Healey Professor of Medical Ethics & Humanities UConn School of Medicine [email protected]

FOCUS ON UNIVERSAL HEALTH COVERAGE (UHC)
Sustainable Development Goals (SDGs) – universal health coverage is central to Goal 3, omnibus health goal –ensure healthy lives and promote wellbeing for all at all ages:
Goal 3.8 of SDGs to achieve universal health coverage, including financial risk protection, access to quality essential health care services and access to safe, effective, quality and affordable essential medications and vaccines for all by 2030
WHO definition of universal health coverage: UHC “means that all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship.”

ORAL HEALTH CARE AS A COMPONENT OF ESSENTIAL HEALTH SERVICES
WHO recognizes the “intrinsic link between oral health, general health and quality of life” (resolution WHA 60.17)
Oral decay is linked to malnutrition, cardiac disease, diabetes, low birth weight, and depressed immune competency
WHO definition of oral health care: “A state of being free from chronic mouth and facial pain, oral and throat cancer, oral sores, birth defects such as cleft lip and palate, periodontal (gum) disease, tooth decay and tooth loss, and other diseases and disorders that affect the oral cavity.”
WHO has a Global Oral Health Programme
However lists of essential health services and indicators for UHC do not include oral health care

NEED FOR IMPROVED ORAL HEALTH CARE
Oral diseases are the most common noncommunicable diseases Global Burden of Disease Study 2016 estimated that oral diseases affected half of the world’s population (3.58 billion people) with dental caries (tooth decay) in permanent teeth being most prevalent condition assessed Oral health has not improved in past 25 years Severe periodontal (gum) disease, which may result in tooth loss, was estimated to be the 11th most prevalent disease globally Oral manifestations of HIV infection occur in 30% to 80% of people with HIV Oral infections can be life-threatening In some Asian-Pacific countries, the incidence of oral cancer ( cancer of the lip and oral cavity) is within the top 3 of all cancers

NEED FOR IMPROVED ORAL HEALTH CARE CONT
In many poor and middle income countries standard of oral hygiene is low
Coverage for oral health service in adults with expressed needs is estimated to be 35%
The majority of 12year old children have untreated dental carries (decay/cavities) with risk of pain, disfigurement, and spreading infections likely resulting in loss of teeth at young age
Currently oral health care in most rural and some urban areas in these countries is difficult to obtain and, if available, tooth extraction is predominant mode of treatment
Behavioral risk factors for oral diseases are shared with other major NCDs, such as an unhealthy diet high in free sugars, tobacco use and harmful use of alcohol

WHY INSUFFICIENT ORAL HEALTH SERVICES IN LMIC COUNTRIES
Access to oral health services is low in LMIC
A failure of policy makers to acknowledge that oral conditions pose a serious public health problem and that oral health goals must be included in the health agenda
Absence of preventive measures like fluoride in drinking water, availability of low cost fluoride tooth paste, teaching or oral care in school curriculums
Lack of availability of oral health professionals
 In Africa the ratio of dentists to population is 1:150,000 compared with 1:2,000 in industrialized countries
 Insufficient training facilities
Graduates of 4 to 6 year training courses disdain practicing in poor and rural areas and oppose use of dental auxiliary personnel there

BARRIERS TO INCORPORATING ORAL HEALTH CARE IN UNIVERSAL HEALTH COVERAGE
Currently oral care is inadequately integrated into the PHC system in most low and middle income countries
Historic separation of oral care from medical care
In many settings dentistry is treated more as a cosmetic initiative that basic health care
Dentistry’s traditional approach toward individual care rather than a community approach along with its inherently technical rather than social and behavioral character
Dentistry’s insistence that only fully trained professionals with full dental degrees should be allowed to practice dentistry

ORAL HEALTH PACKAGE FOR LOW RESOURCE SETTINGS
In low income countries traditional western oral health approaches should be replaced by a service that follows principles of PHC and offers care at a cost that the country and community can afford
“Task-shifting” basic primary oral care to community health workers and other auxiliary health officers with some training
Define fluoride toothpaste as an essential medicine and development of facilities to make fluoride toothpaste more affordable and accessible with proper packaging to distinguish it from counterfeit versions
Educational institutions should incorporate oral health promotion and oral disease prevention in their curriculum

ORAL URGENT TREATMENT FOR LOW RESOURCED AREAS
WHO recommends a package of Oral Urgent Treatment able to manage majority of cases requiring basic emergency oral care including
extraction of badly decayed and severely periodontally involved teeth under local anesthesia treatment of post-extraction complications such as dry sockets and bleeding referral of complicated cases to nearest hospital drainage of localized oral abscesses palliative drug therapy for acute oral infections
first aid for dento-alveolar trauma

ATRAUMATIC RESTORATIVE TREATMENT APPROACH
Conventional restorative treatment approaches rely heavily on electrically driven equipment that is expensive and difficult to maintain and complex to use – usually restricts treatment to a dental clinic so it is impractical in poor and middle income countries
Atraumatic Restorative Treatment uses hand instruments and involves no dental drill, plumbed water or electricity
Uses hand excavators for removing infected dentine
The cavities and adjacent fissures are filled with an adhesive fluoride releasing restorative material
Because all sound tooth tissue is retained during cleaning of the cavity, pain and discomfort are rare during treatment virtually eliminating need for an anesthetic
In studies three year survival percentages were between 77% and 92%