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WFPHA Newsletter - Special Edition on Oral Health

WFPHA Newsletter 12 - 2013

Published: December 2013

In this newsletter:

1.WFPHA - Oral Health Working Group - the first steps

2.Bring back the mouth into the body

3.Oral Health activities in the world

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1.WFPHA – Oral Health Working Group – the first steps

tl_files/images/executiveboard/raman-bedi-photo.jpgThe creation of the WFPHA oral health group was a significant step, both for the WFPHA as a whole as well as the global oral health community. It has created, first, an opportunity for the dental public health organizations, which have not embraced their national public health community, to embrace their activities with each other and also engage with the global community in public health. Second, the oral health group has also encouraged pan national organizations, e.g. the European Dental Public Health Association, to join the oral health group as well as WFPHA itself. Third, and most importantly, the group can advocate the importance of oral health to general health to the wider public health community and recruit dental health professionals to engage in more general public health initiat

The aim of the article is to provide a commentary on the initial activities of the oral health group during its first year.

The Oral Health Working Group (OHWG) was able to agree a constitution within a few weeks and subsequently established an executive group, which hold teleconferences every 2 months and a reference group which meets every six months. As a new group we decided to hold our first election and AGM at the 2015 WFPHA meeting in Kolkata, India. At present the chairman is Professor Raman Bedi and the two vice chairs are Drs Myron Allukain and Ken Eaton.

The members agreed to focus, during the first two years, on three activities; first to raise the profile of the group, primarily through participation at public health conferences, both within the WFPHA and the wider public health communities. Second, to undertake a survey, via a questionnaire, of global dental public health capacity. Third, to agree a Declaration on Child Oral Health and to pass this as a resolution at a WFPHA general assembly.

The group have attempted to give key note addresses at public health meetings and also to have sessions which focus upon oral health. In April 2013 at the 1st Arab World Congress on Public Health, Dubai, United Arab Emirates, the oral health group was able to organize presentations and panel discussion. The focus of the session was the high levels of childhood dental caries and local strategies aimed at oral health improvement. The Chief Dental Officers of Oman, Saudi Arabia and Qatar made presentations and the session was chaired by myself and Dr Bettina Borisch. One practical outcome of the session was the creation of a Gulf Oral Health network which is chaired by Dr Maryam Farhan, former head of the community programme at the National Guard, Saudi Arabia. Another oral health session was also held, under the chairmanship of Dr Myron Allukian, at the 2013 American Public Health Association conference.

In November 2013 the questionnaire on dental health capacity was sent to lead dental public health individuals in all the WHO regions. Considerable debate, among both the executive and reference groups, as to the information needed, took place throughout the summer. Finally, the questionnaire was finalised and piloted and the survey, which will be the first of its kind, will help map out the global dental health capacity and its geographical distribution. It is anticipated that the report will be finalised in the summer of 2014.

The declaration on Access to Oral Health for Children, aims to offer all children an equal opportunity to thrive and reach their full potential for a promising future, was proposed by the Oral Health Working Group and endorsed by the WFPHA policy committee. On May 19th 2013 the WFPHA General Assembly passed a resolution on “Oral Health for Children” and it has been well received by the health care community.

The Declaration on Child Oral Health

Every child has a right to good oral health. Oral health problems in children can impact on many aspects of their general health and development, causing substantial pain and disruption to their lives and often altering their behaviour. Oral health is an integral part of overall well-being and essential for eating, growth, speech, social development, learning capacity and quality of life.

To promote oral health every child should have access to:

• Oral health education including oral hygiene instructions and dietary advice, and access to affordable toothbrushes and toothpaste containing fluoride as soon as the first primary tooth erupts

• Preventive interventions, appropriate to the infrastructure and priorities of the country, which may include dental sealants, community fluoridation, and regular fluoride varnish applications

• Treatment of early stage decay to stop it from progressing to cavities, and treatment of dental cavities, acute pain and other oral diseases

• Environments that eliminate advertising of unhealthy foods to children.

Through good oral health all children will have an equal opportunity to thrive and reach their full potential for a promising future.

The first year of the oral health group has been a busy on and as Chair I am grateful to the support of all the members of the executive and reference group. In addition the help of the WFPHA central office has been invaluable. However, it is the on-going efficiency and work of Dr Marta Lomazzi, our Oral Health WG Executive Coordinator which has made much of our progress possible.

R. Bedi, Chair WFPHA Oral Health Working Group

2.Bring back the mouth into the body

The link between oral health and overall body health is well documented and backed by robust scientific evidence. Traditionally, Dental schools are separated from Medical schools in most places of the world. Another secession can be observed between oral health and public health; both communities live in separate circles. Despite this, better linking up of both the dental/medical and the public health worlds would bring substantial improvements for global population health.

The WFPHA as the only worldwide professional society representing and serving the broad field of public health is committed to facilitating and supporting the exchange of information, knowledge and the transfer of skills and resources for a healthy and productive world. Prof Borisch, Director of the WFPHA Headquarter, feeling that there is a need for a rapprochement of the expertise secluded in the respective groups of public and oral health, launched the idea of an Oral Health Working Group. She had the opportunity to find three experts willing to start this adventure: Raman Bedi, King’s College London; Ken Eaton, UK and Myron Allukian, US. The plan for a working group of global oral public health in the WFPHA was drafted so that in April 2012 the WFPHA general assembly and council of the WFPHA approved the establishment of the WFPHA Oral Health working group.

We hope that at the long run all people working with oral health from all horizons will come together and help to establish oral health as a pillar of global public health!

B. Borisch, founding member of the WFPHA Oral Health Working Group

3.Oral Health activities in the world

AFR - African Region

Kenya

Improving Oral Health: A community approach in Rural Western Kenya

Diseases associated with oral health lead to death for many children in sub-Saharan Africa. Debilitating flesh eating oral infections continue to exist due to poor sanitation, poor oral hygiene, malnutrition and immunosuppression among the poorest children in Africa. A large contributor to the adverse effect of oral diseases is lack of access to appropriate health services or preventative care. This poor health access rates have been linked to the low numbers of health workers and lack of available, affordable, and acceptable health services.

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The only available dental unit for patients at the local primary care facility (KCH)

An Oral Health Promotion strategy that engages the community has been developed for a rural community in Western Kenya. The inhabitants of this community are served by an occasional dentist using a make-shift dental chair at a faith based community hospital - Kiminini Cottege Hospital (KCH). The ratio of dentist to the population is estimated at 1;300,000 anecdotal evidence suggests that majority of the community resort to Traditional and Herbal remedies for their oral ailments; putting them at high risk of infections and complications of late presentations of oral disease.

The intervention plan ‘Smiling Healthy’ involves a training programme for members of the local community who will spread the message of healthy behaviours to reduce the burden of disease in the area. The plan also includes the scale- up of existing dental services at KCH. As support continues to be sought to implement this project, a local NGO – Link Africa Development Initiative, partnering with the Local Hospital (KCH) and volunteers from charities from abroad (Smiles in Kenya) have contributed to the development of this plan. This is a challenging undertaking, but is certainly a step in the right direction to improving quality of life and provision of sustainable healthy behaviour advice in this community.

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Images of the local market at Kiminini in Rural Western Kenya

Pictures Courtesy of Link Africa Development Initiative

K. Wanyonyi, AFR regional coordinator of the WFPHA Oral Health Working Group

Senegal

Oral diseases are not necessarily life threatening, but they represent a serious public health problem because of their high prevalence, their seriousness, and the public demand for services due to their impact on the individual and on society. According to the WHO, at least 80% of the global population suffers from oral disease, 80% of who live in developing countries such as Africa.

Objective: The objective of the study was to evaluate the oral health of the rural population and to analyze their attitude to oral health.

Methods: We carried out a descriptive, cross-sectional and analytical survey on 2,254 people living in rural areas. Senegal has 14 similar regions in terms of the size of the rural population. In each region, 160 people were surveyed, for a total of 2,254 people.

Results: The frequency of oral diseases is high, and fluoride toothpaste, which is inaccessible and unavailable, is often replaced by the chew stick. Dental services are located more than 50 kilometers from the homes of at least 52% of the population. Distance plays a negative role in access to care because people living less than 50 kilometers away are twice as likely to attend dental care facilities; this also applies to age with the age group 18-35 years 39% less likely to attend a dental clinic compared with other age groups. Care is expensive for more than 75% of the population who prefer to self-medicate or visit the traditional heale.

Conclusion: An oral health policy focused on rural areas is necessary with the integration of indicators such as the availability and accessibility of fluoride toothpaste, the creation of a minimum service package, and youth outreach.

To read the full article, click here.

D. Faye

Tanzania, Uganda & Kenya

Kenya, Tanzania and Uganda Piloting to Phase Down Dental Amalgam Use and Best Manage its Waste

On 5th - 6th November, 2013, Muhimbili University of Health and Allied Sciences in Dar es Salaam, Tanzania hosted a results workshop of the East Africa Dental Amalgam Phase-Down Project that is being successfully implemented in Kenya, Uganda and Tanzania.

Amalgam remains the most widely used means of repairing large cavities in molar teeth worldwide. Despite being in use for more than 150 years, scientists have expressed concerns about its contribution to mercury environmental pollution. Pollution occurs through mismanagement of amalgam wastes leading to possibilities of environmental release of mercury, which when methylated produces methylmercury, the most toxic form of mercury. Methylmercury can reach humans from contaminated water through the food chain such as fish and seafood. Amalgam contains up to 50 per cent mercury, a chemical that has been linked to various health effects on the immune system, altering genetic and enzyme systems, damaging the nervous system, including coordination and the senses of touch, taste, and sight as well as damage to the digestive tract. Methylmercury is particularly damaging to developing embryos, which are five to ten times more sensitive than adults.

The Minamata Convention whose aim is to protect the human health and the environment from anthropogenic emissions and releases of mercury and mercury compounds recommends that each country that signs and ratify the convention should take measures to phase down the use of dental amalgam taking into account the country’s domestic circumstances and shall include two or more of the following measures:

(i)Setting national objectives aiming at dental caries prevention and health promotion, thereby minimizing the need for dental restoration;

(ii)Setting national objectives aiming at minimizing its use;

(iii)Promoting the use of cost-effective and clinically effective mercury-free alternatives for dental restoration;

(iv)Promoting research and development of quality mercury-free materials for dental restoration;

(v)Encouraging representative professional organizations and dental schools to educate and train dental professionals and students on the use of mercury-free dental restoration alternatives and on promoting best management practices;

(vi)Discouraging insurance policies, and programmes that favour dental amalgam use over mercury-free dental restoration;

(vii)Encouraging insurance policies and programmes that favour the use of quality alternatives to dental amalgam for dental restoration;

(viii)Restricting the use of dental amalgam to its encapsulated form;

(ix)Promoting the use of best environmental practices in dental facilities to reduce releases of mercury and mercury compounds to water and land.

Under the co-ordination of UNEP Chemicals branch Division of Technology, Industry,and Economics (DTIE) and the World Health Organization’s Oral Health Programme, the ministries of Environment and Health in Kenya, Tanzania and Uganda are collaborating with the FDI World Dental Federation, International Dental Manufacturers (IDM) and their respective National Dental Associations to explore essential conditions for a phase-down in the use of dental amalgam.

The project has been investigating the status of supply and trade of dental amalgam and dental filling materials alternative to amalgam. It has also assessed the current waste management practices, created awareness of preventive dental care and encouraged a switch to appropriate alternatives to dental amalgam for small cavities among dental facilities’ supporting staff, students, practitioners, and patients. In addition, the project promoted environmentally sound management of dental amalgam waste in selected dental facilities in Kenya, Tanzania and Uganda through donation of 9 amalgam separators.

However, even with the success of the pilot project, the three East African Countries face inadequate funding to roll out to all dental facilities across the region. Stakeholders interested in this subject are encouraged to support the sustainability of this pilot project in Africa through the respective national Governments, national dental associations, UNEP Chemicals DTIE and WHO Oral Health Programme.

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Program Participants

E. A. Mugonzibwa-Mwanga

AMR - Region of the Americas

Canada

Canada – the debate over the benefits of the water fluoridation continues

Water fluoridation has consistently been acknowledged as a key contributor to the improvements of health in Canadians and been acknowledged for these achievements by the Centres for Disease Control (CDC) in the United States and by the Canadian Public Health Association (CPHA). In 2008, the recommended fluoride levels by Health Canada were lowered from 0.8–1.0 mg/L to 0.7 mg/L to minimize the risk of dental fluorosis. However, in recent years, the debate over the benefits of water fluoridation in Canada continued to be in the news. Several Canadian municipalities have voted to stop fluoridating water, including Calgary, Windsor and Waterloo. Fluoride's opponents primarily cite health and environmental concerns as risks of adding fluoride to the water supply. They also believe that fluoridating the public water supply is a fundamental violation of civil liberties. The decision whether to fluoridate lies with local governments, with guidelines set by provincial, territorial, and federal governments. In 2012, just under 40% of Canadians drank optimally fluoridated water, a reduction from 45% as measured in 2007. This slight reduction is indicative of the push back by public health and is not comparable to what was intended to be archived by the anti-fluoridation groups. Each time, city councils got pressured by relatively small and vocal anti-fluoridation groups and each time, dental professionals, researchers and advocacy groups would descend on the public hearings to bring the evidence that water fluoridation is a safe and efficient public health intervention. Such large cities as Toronto started to implement water fluoridation since 1963 and continue to fluoridate its water today. This is true of most of the large population centres where discussions have taken place and where communities opted to remain with water fluoridation. The Canadian public health community, including the Canadian Association of Public Health Dentistry, are encouraged that large cities continue to implement water fluoridation and dental professionals and public health leaders across the country continue to promote the effectiveness of community water fluoridation. The debate continues. It has much to teach us about how people evaluate potential health risks and how we can help them respond and understand the public health interventions.

G. Aslanyan

United States

Oral Health in the United States

Fluoridation

Over 204 million Americans live in fluoridated communities, about 74% of US population on public water supplies. The Healthy People 2020 (National Prevention Objectives) goal is that by the year 2020, 79.6 % of the US population will live in a fluoridated community.

Fluoridation has made an enormous impact in preventing tooth decay in the US.

National Health Program

In the year 2010 the Affordable Care Act (Obama Care) became law in the US with different phases being implemented each year. For the first time, most Americans will have some form of health insurance. Currently about 33 million low income US children are eligible for dental care under Medicaid a federal-state health insurance program for the low income. The Affordable Care Act will add another 7 million low income children to the Dental Medicaid program.

Workforce

Access to dental care is difficult for millions of Americans, so changes are occurring in state dental laws :

  1. Dental hygienists are allowed to provide more dental services. In the year 2000 only 8 states allowed dental hygienists to work under general supervision. By 2013 this had increased to 36 states.
  2. A number of states are considering the dental therapist model similar to the New Zealand’s to improve access. The first dental therapists in the US were in Alaska in 2005 serving Alaska Natives and American Indians. In 2009 Minnesota passed a law to allow dental therapists and about 10 other states are considering dental therapists.
  3. At least 45 states have changed their state practice acts to allow young patients in physician’s office to get dental preventive treatment such as fluoride varnish by a medical assistant or nurse.
  4. Many dental students are graduating with debts as high as $250,000 – $400,000. This is creating a great burden for newly graduated dentists and making care costly.
  5. Dental care is not included in Medicare (health care for those over age 65 years), therefore many seniors, and especially those who are homebound and in nursing home, have difficulty getting care.

Many changes are occurring in the United States to respond to the access to care crisis. The challenges are many, as we try to improve oral health for all.

For more information, click here.

M. Allukian, vice-Chair WFPHA Oral Health Working Group

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Oral health of oldest citizens

For more than a decade the oral health community in the United States – non-profit organizations, educational institutions, professional associations, as well as government entities has concentrated its efforts on improving access to dental care for infants, children and adolescents. Many states have expanded their public insurance to cover both preventive and restorative care for those citizens 21 years of age and younger. In addition, the country’s new universal health coverage mandates pediatric dental care. Only in the last few years has the dental community begun to assess the oral health needs of seniors– those 65 years of age and older.

While some individual states have implemented oral health assessments of their adult residents 65 years of age and older; as a country, 92% have experienced dental caries in their permanent teeth, and 23% have untreated tooth decay – more than the untreated caries among U.S. children.No longer are adults losing all or most of their teeth as they age. The use of life-long preventive strategies including community water fluoridation, fluoride toothpaste and professional preventive dental care has caused 73% to have some natural teeth.

The senior population currently represents 13% of the country’s citizens and is expected to grow to more than 20% by 2050. With more than 80% of seniors having at least one chronic disease and the evidence supporting a relationship between oral health and general health, more attention needs to be paid to increasing access to affordable dental care for all seniors, those living at home and in long-term care. This may be addressed through the acceptance of dental hygienists and dental therapists in settings that serve seniors, in addition to the universal training of physicians and nurses to perform oral and dental screenings. Currently, just 36 states allow dental hygienists to practice in settings outside of private practice and without the supervision of a dentist, very few states allow dental therapists, and the majority of medical and nursing schools don’t provide a meaningful number of hours in oral health education.

While the U.S. continues to concentrate its efforts on improving the oral health of its youngest citizens, in parallel it needs to continue the work that has been started by developing and supporting policies that will address the oral health of its oldest citizens.

L. A. Bethel

EMR - Eastern Mediterranean Region

Gulf Countries

Future of Dental Public Health in the GCC

Dental Public Health (DPH) is that part of dentistry providing leadership and expertise in population –based dentistry , oral health surveillance , policy development, community-based disease prevention and health promotion, and the maintenance of the dental safety net (1).

However there are obstacles facing the Dental Public Health Systems in the Gulf Countries (GC). The Public Health Systems in the GC fails to fully define the scope of Dental Public Health professionals and how they fit into the matrix of today's dental profession.

Public Health Systems in Gulf Cooperation Council (GCC) countries are not well established. Therefore, there is a need for an effective integrated and organized mechanism to shape this system based on acceptable guidelines and laws focusing on population health needs (2).

To improve this situtation, different activities should be carried out:

First, there is great need for effective legislative measures to support public dental health policies or measure.

There are effective interventions in improving dental public health like water fluoridation which need law or legislation to be implemented; there is strong scientific evidence that legislature measures can help improving health (3).

Second, it is the appropriate time and place to investment in management and leadership development for DPH professionals. Therefore dental schools in the Gulf Region should include leadership courses in the curriculum for dental students and as part of lifelong learning for practicing dentists, as well as for academics, to exhibit appropriate leadership skills in clinical education (4-5).

The last point is the oral health surveillance. An essential component of the oral health information systems is the analysis of trends in oral disease and the evaluation of oral health programs at the GCC region. Standard methodology for the collection of epidemiological data on oral health should be developed and by GCC oral health executive group and used for the surveillance of oral disease. The regional and national oral health databank should be developed to highlight the changing patterns of oral disease which primarily reflect changing risk profiles and the implementation of oral health strategies and programs oriented towards oral disease prevention and oral health promotion.

Article references available here.

M. Alfahran, Chair of the Oral Health Subgroup of the EMR region

Iran (Islamic Republic of)

Dental Public Health in Iran

Iran with 75,000,000 populations is a vast country with diverse oral health needs. The public as well as the private sectors are active in order to meet the population’s needs.

Population based preventive programs are now active to help the control of dental problems. These programs cover oral health and hygiene education, preventive and curative activities exclusively to be conducted by public sector for prevention and treatment of oral diseases.

Some of the current national level activities in oral health system of the country are:

1-Oral health care program for under 3 years old children.

2-Oral health care program for kindergartens children (3-6years).

3-Oral health promotion for elementary school children (6-12years).

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Oral healthcare activitis for children

4-Oral health care program for pregnant mothers.

5-Smoking cessation in dental office program.

6-Vital Pulp Therapy program using CEM-cement, a locally developed material.

7-Conducted extensive applied research in different areas such as policy, manpower, surveillance system, stewardship, etc.

8-National oral health survey was conducted over 2012-2013 using the latest version of WHO suggested pathfinder survey methodology, instructions and questionnaire.

9-In policy domain an extensive research has been carried out in order to develop evidence-based oral health policies for use at the national level in Iran.

The WHO Collaborating Center for Training and Research in Dental Public Health as well as the Preventive Dentistry Research Center at Shahid Beheshti University of Medical Sciences in Iran are helping with all aspects of the Oral health related activities. Over the past few years Iran has been very active in the field of Oral Health nationally and internationally. Two inter-country meetings of WHO-EMRO was held in Isfahan (2011) and Shiraz (2012). The final draft of Regional Oral Health Policy that was developed in the previous two meetings were finalized and sent to Geneva for final approval.

Iran is interested to exchange successful experiences in different areas of Dental Public Health and collaborate with other countries to further the Oral Health of the Communities worldwide.

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Oral healthcare activitis for children

M. Meschi

Lebanon & Middle East

On Line Public Health Networking in the Middle East: Lessons Learned

(from APHA meeting presentation)

EMRAIN, Eastern Mediterranean Regional Academic Institutional Network (EMRAIN), is a join initiative of the American University of Beirut (AUB) and the World Health Organization (WHO). The purpose of EMRAIN is to create a network of academic public health institutions across the Eastern Mediterranean Region for the sharing of best practices and research, and to improve health systems and influence policy. A comprehensive mapping of 266 institutions has been completed, and a survey will be distributed to these academic institutions to gather information about their academic programs, research initiatives, and administrative capacity. There will be opportunities for inclusion of oral public health institutions within this platform with the concurrent distribution of a dental public health survey by the World Federation Public Health Association’s Oral Health Working Group. The public health landscape has drastically changed in the Middle East over the past two years due to the Syrian Civil War, with six million Syrian refugees displaced both externally and internally. This has placed a lot of financial burden on government and international institutions such as UNRWA. Private individuals and organizations are addressing these needs with their own initiatives, whether it be Syrian refugee dental humanitarian aid mission trips, such as Zeitouna (Karam Foundation), or health social entrepreneurial start-ups, such as Donner Sang Compter. Due to long-standing Palestinian refugees in Lebanon, Syria, and Jordan, the Palestinian Dental Association is addressing the shortage of oral health needs in the camps by offering dentists bi-monthly scientific/research learning days, CE courses, vaccination programs, and OHI/fluoridation for children. On December 13th, the PDA will also be holding their 2nd International Scientific Conference.

L. Roumani

EUR - European region

The State of Oral Health in Europe

In September 2012, the Platform for Better Oral Health in Europe (PBOHE) published a report The State of Oral Health in Europe. The report assessed a number of key issues for Member States of the European Union (EU) including:

  • The prevalence of oral diseases.
  • An assessment of the economic impact of oral diseases.
  • Identification of best practice initiatives in oral health promotion.

A set of key recommendations for decision-makers to improve oral health was developed. Key findings were that:

  • Although the prevalence of dental caries has declined significantly in Western European children, other than those from socio-economically deprived groups, there has been little if any improvement in many Eastern European countries.
  • Because, epidemiological methods to assess periodontal diseases are so poor and there have been few national studies to assess them, it is impossible to report with any certainty on trends for this group of diseases.
  • The number of people dying annually from oral cancer has steadily increased over the last 15 years
  • In 2012, oral health services accounted for 5% of total health spending, which was estimated at 79€ billion.
  • Oral health services were delivered by a team of over 1 million people, including 400,00 dentists and 450,000 dental nurses.
  • There was good evidence from EU Member States such as Denmark and Sweden that the benefits of preventing dental caries exceeded the costs of treatment.

Three of the 15 key policy recommendations were to:

  • Recognise the common risk factors for oral and other chronic diseases and wotk towards linking oral health policies with EU healthcare policies.
  • Better integrate oral health into relevant national and EU health programmes.
  • Develop a coherent European strategy for the promotion of oral health and the prevention of oral diseases.

For more information, click here.

K. Eaton, vice-Chair WFPHA Oral Health Working Group

Spain

Regional plan for improving children’s oral health in Andalusia: dental sealant knowledge, opinion, values and practice of Spanish dentists

Dental caries is among the most common of preventable childhood infections [1], and methods are currently available to cost effectively reduce caries [2]. The most effective method to reduce occlusal caries are pit and fissure sealants, and over the last four years more than 11 guidelines and systematic reviews have recommended pit and fissure sealant use for at-risk populations [3-13]. However, studies from U.S. [14-16], Greece [17], Sweden [18], and Scotland [19,20] all indicate that sealants are underutilized.

In Spain, recent surveys indicate a 56% caries prevalence among 15–16 year olds, while only 17% have sealants [21,22]. Other Spanish studies demonstrate that occlusal sealants can reduce both occlusal and smooth surface decay by 87% and 68%, respectively, over a two year period [23]. Over a nine year period sealants can reduce occlusal decay by 65% [24].

Thus there are effective methods for caries prevention, but they are underutilized. The theoretical frame for behavior change is an assessment of knowledge and attitudes affecting practice. However, neither theories of behavior change nor knowledge nor attitudes predict clinical practice [25]. Instead, both indicate that values are better predictors [20,26]. Therefore, we examined knowledge combined with opinions and values, as a first step toward initiating comprehensive caries prevention program in Spain. More particularly we assessed dentists Andalusia regarding to the use of pit and fissure sealants.

The results suggest that, similar to other countries, Andalusian dentists know that sealants are effective, have neutral to positive attitudes toward sealants; though, based on epidemiological studies, underuse sealants. Therefore, methods other than classical behavior change (eg: financial or legal mechanisms) will be required to change practice patterns aimed at improving children's oral health.This is a prelude to the generation of a regional plan for improving children’s oral health in Andalusia.

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School dental examinations. Number of children with/without fissure sealants present.


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Continuing education for dentists

Article references available here.

L. San Martin

United Kingdom

Patients in the United Kingdom granted direct access to dental hygienists and therapists

tl_files/doc/about/OHWG/VW.jpgIn the United Kingdom, the General Dental Council has this year granted patients direct access to dental hygienists and therapists; this change has been met by a widespread mixed reaction. While hygienists and therapists have greeted such a change with positivity, citing clinical freedom as a main advantage, many dentists have expressed disappointment with the decision.

The general consensus is that such a ruling goes against best practice and negates the principle of teamwork in dentistry. A main concern is that while hygienists and therapists are valuable members of the dental team, their training is not as comprehensive as that of a dentist. Thus, there are worries that this may lead to oral health conditions remaining undiagnosed in patients who opt to visit the hygienist but not the dentist.

In essence, patients can now access hygienists and therapists directly without first seeing a dentist. However, the new guidelines have made it clear that dental professionals must not work beyond the scope of both their training and capability. One key idea behind this new development was to give the general public greater choice, however, this further complicates the division between dentistry as a healthcare profession and a consumer driven business. Nonetheless, it is hoped that such a move will actually promote skill mix within dental teams and ultimately pave the path for the future of dentistry. Whether this move will foster the foundations for better oral health within the general public remains to be seen.

V. Wordley, EUR regional coordinator of the WFPHA Oral Health Group

SEAR - South-East Asia Region

India

India: the oral health care manpower provider

India is the biggest country in the South East Asian Region with a population of over 1.2 billion. The start of the new millennium saw a mushrooming growth of dental education in the country. Dental Council of India governs the dental education and offers Bachelor and Masters of Dental Surgery degree along with courses for Dental Mechanist and Hygienist. BDS is a 4 year teaching program followed by 1 year of compulsory internship. MDS is a 3 year program which offers post graduation in 9 specialities.

Presently nearly 300 dental schools are approved by the government to offer BDS courses and about 25,000 dentists are created. About 2,500 post graduate students from different specialities complete their post graduation. Although India still lacks dental manpower as per World Health Organization guidelines, many Indian Dentists are willing to work on foreign soils. India may play a major role in supplying dental manpower to the rest of the world in times to come.

Key issues regarding the use of this potential dental manpower in other parts of the world are quality dental education and training which is being constantly monitored by the council. There is still scope to improve training and make it at par it international standards with latest tools and techniques. Further other countries need to recognize dentists who have studied in India. Student exchange programs are very limited at present time.

Dental Public Health is one of the recognised specialities in India and post graduation is obtained after 3 years of MDS. Presently more than 100 dentists seek further education in this speciality. The scope of this subject is wide and limited work has been carried out in this field. There are no function National Oral Health policies. Oral health care is provided in India mostly through private fee for service method. There are no dental insurance schemes by private or government sector.

There is an immense need for collaboration between Indian dentists and those of other parts. This will provide Indians technical expertise and help us train our students better who in turn may provide services in other parts of the world. The Oral Health Working Group of World Federation of Public Health Associations is good attempt to let us closer.

P. Gupta, SEAR regional coordinator of the WFPHA Oral Health Group 

Indonesia

Community Empowerment and Effective Prevention Programs in Indonesia

(from APHA meeting presentation)

In Indonesia there is a huge caries problem with 6 years old children already having 2 permanent teeth decayed in some provinces. With limited and exhausted dental manpower, and facts that each province has different caries severity and progression rate, it is needed an innovation in dealing with the situation. Innovative School Oral Health Approach, in short iUKGS (the word “I” means Innovative, but also represent ownership of every stakeholder in school oral health program) has been launched in 2006 and adopted by MOH as National policy in 2011. iUKGS believe in two things, (1) One for all treatment is no longer suitable, so risk-based approach is very important. (2) To have sustainable program, leadership and empowerment of stakeholders should be built and strengthened.
iUKGS focused on prevention approach before the caries disease ends up in decays. There are three pillars of preventions. (1) Caries risk assessment using Dr I. Adyatmaka ’s Donut software, (2) Remineralization therapy, to stop the progression of demineralized white spot lesions and to recover the pH plaque and saliva pH. (3) Surface protection to mature the erupting molars and to protect black fissured teeth from ongoing demineralization process. The difference between iUKGS and other programs is that the engines in iUKGS are local resources, such as the school communities (parents and teachers), local health district, local ministry of education.
So how iUKGS can move all the local resources? Because iUKGS starts with Dr I. Adyatmaka ’s Donut risk assessment which designed to give feedback of current condition, magnitude of the problem, motivate parents to take more responsibilities, gives advices and menu, bring empathy and build self efficacy. This software was built after a huge research involving 2,500 kindergarten pupils with their parents. This tool has becoming a strategic entry point to empowerment.
So what is empowerment? Empowerment is when we strive to give knowledge and skills to people so that they are motivated to take steps to improve their own lives.
Empowerment that has happened, was measured through 3 indicators, (1) technology transfer, (2) improvement in behavior and oral health condition, (3) community ownership. Presentation demonstrated the successful achievement on key performance indicators.

I. Adyatmaka

WPR - Western Pacific Region

Australia

Public Health Dentistry in Australia

In spite of having an extensive dental industry, Australians continue to suffer from the serious and costly impacts of oral diseases on their everyday lives. Caries rates remain unacceptably high across all strata of society, but, as with periodontal diseases, their effects are much more pronounced on population groups at risk. So Australia’s small public oral health workforce has much to do to address not only population oral health improvement but also the nation’s disparities in oral health care access and outcomes.

Although small in number our public oral health professional members have been highly active. We are committed to reducing oral health inequities across population subgroups and to improving overall oral health by regularly measuring, evaluating and reporting on:

  • oral health care access and equity
  • population wide and targeted oral health promotion strategies
  • oral health outcomes (epidemiology) of the whole population, of specific at risk populations and all age groups.

We also play key roles in population oral health research, oral health promotion, and policy advocacy in all political and stakeholder forums, including primary health care.

Australia is a wealthy country with a national health care system (Medicare) that provides universal access to care, ostensibly free of direct cost to patients. However, because the majority of health care professionals are self employed and able to set their own fee structures, many people find it difficult to afford the gap between private fees and Medicare reimbursements. Free public hospital and bulk billing medical services are available but access can be difficult and waiting times lengthy. So the Medicare system is far from equitable, especially as allied health and dental care have been largely excluded from it. Indeed, much has been made of the omission of dental care from Medicare and the implication that oral health is unrelated to general health and wellbeing.

Australia’s (first) National Oral Health Plan 2004-2013 “healthy mouths, healthy lives” contained four underpinning themes:

  • oral health is an integral part of general health
  • a population health approach
  • access to appropriate and affordable services
  • education of the workforce and communities

The Plan identified eight interrelated Action Areas:

  1. Promoting Oral Health across the Population
  2. Children & Adolescents
  3. Older People
  4. Low Income & Social Disadvantage
  5. People with Special Needs
  6. Aboriginal & Torres Strait Peoples
  7. Rural & Remote
  8. Workforce

Currently, various expert panels are working on producing short, medium and long timeframe actions for each Action Area in preparation for the release of the second National Oral Health Plan 2014-2023. It will be based on the framework of the first Plan which now has a proven track record of usefulness.

In 2013 a National Oral Health Promotion Plan was also prepared through wide consultation. It has gone to the Federal government but to date its recommendations and implementation plans have not been made public which is of considerable concern.

Across the 20th century, oral health in Australia improved dramatically through a combination of many factors including:

  • advances in scientific knowledge
  • increased population and individual oral health literacy encouraging oral hygiene and tooth retention
  • improvements in clinical techniques making dentistry more acceptable
  • growth in Australia’s wealth and middle class making dental care, including aesthetic and specialist care, more desirable and affordable
  • a growing oral health workforce to population ratio making dental care more accessible and available; and
  • widespread fluoridation (still a fight with anti-fluoridationists) and routine use of fluoride toothpaste and other fluoride supplements and treatments.

Consequently, over the past four or five generations, the expectations of both the public and the dental profession have shifted from extractions and dentures to prevention, dedicated tooth retention and aesthetic dentistry for those patients who have been able to afford such care. Historically, single-dentist private practices have dominated Australia’s oral health care provision.  Practices have generally been established in more affluent urban settings, and targeted at attracting regular patients and families who can afford the cost of comprehensive care. 

But as our National Plan indicates, there remain many for whom dentistry continues to be expensive, difficult to access and focused mainly on relief of pain. State and Territory governments provide public dental services targeted at children and financially disadvantaged adults but they are quite inadequate to meet the expressed demand for services let alone actual normative needs, based upon regular personalised and risk-based preventive care.

Today Australia is at an incredibly interesting and challenging cross road in oral health care. Over the past 10 years, the number of dental schools has doubled through the introduction of new dental courses in regional universities; and the number of new dental graduates, including oral health therapists and hygienists, has trebled. Added to this has been a rapid rise in overseas qualified dentists passing the Australian Dental Council’s assessment process.

Suddenly we have gone from having a long term dental workforce undersupply problem, compounded by a major maldistribution disadvantaging rural areas and public dental services to an apparent oversupply situation given the current funding models and constraints to universal demand for normative care. How will governments respond? Will they embrace the opportunity to create policies that address current disparities and inequities and expand the accessibility of personalised preventive dental care and flexibility of the workforce or will they simply seek to tighten the screws?

I hope readers have gained a picture of the Australian situation and some of the challenges public oral health professionals are addressing in seeking to improve the nation’s oral health.

B. Simmons &  J. Rogers

China

Oral Health Activities for Children in China

From 2008, the Chinese Central Government has set up a comprehensive oral health promotion project for children in the middle and western regions of China with a special governmental fund. The project covers 23 provinces and includes providing oral health education programs through training the trainers, providing oral health care training courses in community level, providing pits and fissure sealants for the first permanent molars in high caries risk children. During the 5 years, the governmental input of this project has been increased from 8.8 million Chinese Yuan ($1.5 million) in 2008 to 46.49 million Chinese Yuan ($7.8 million) in 2012, and the coverage of school children increased from 150 000 in 2008 to 540 000 in 2012, and the number of teeth sealed increased from 530 000 in 2008 to 2310 000 in 2012. The ability to providing oral health care in community level of health care workers improved through oral health care training, more than 20 000 health workers have received the oral health care training in this project. Based on this project, the provincial governments in the developed areas, such as provinces in the eastern region, started to provide provincial fund for oral health care for school children. Now a day, the comprehensive oral health promotion project is conducted in almost all provinces in China with the financial support from the central and provincial governments and the content of the project includes not only the content mentioned above, but also providing topical application of fluoride, such as fluoride varnish, for high-risk preschool children to prevent tooth decay in primary teeth, and providing simple fillings for permanent and primary tooth decays.

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Oral health education in kindergarten

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Providing sealants for school children in outreach clinic

W-S. Rong

Malaysia

Launching the Alliance for a Cavity Free Future (ACFF) - Malaysia Chapter

The Malaysian Association of Dental Public Health Specialists (MADPHS) takes pride in working alongside the Alliance for a Cavity-Free Future (ACFF) and Colgate-Palmolive Malaysia in providing the platform for the launching of Malaysia as the second Asian ACFF Chapter after China. The invited guest of honour Dr Khairiyah Abdul Mutalib, Principal Director of Oral Health Malaysia, officiated the launch of ACFF-Malaysia Chapter. Prof Nigel Pitts, Chairman of ACFF in announcing the appointment of Prof Rahimah Abdul Kadir, founder and Immediate Past President of MADPHS, as Chairman of the Malaysian Chapter believed Malaysia can contribute significantly to the aspirations and objectives of ACFF in meeting the goal of a cavity free population in the future. He is hopeful that Prof Rahimah with her vast network in the region will also inspire other regional countries to work towards the same goal. In her acceptance speech, Prof Rahimah pledged to work towards achieving the three goals formulated for Malaysia by working alongside all relevant stakeholders. The official launching of ACFF Malaysia Chapter culminated with the signing of the Alliance for A Cavity-Free Future Malaysia Chapter Declaration between the ACFF Chairman and Chairman of ACFF-Malaysia Chapter as well as supporting signatories; the Director of Oral Health representing the Oral Health Division MOH, Chairman of the Deans’ Council and President of MADPHS. In attendance was Mr John Hazlin, Managing Director of Colgate-Palmolive Malaysia. The occasion followed a 3-day, 23-25 October 2013, of activities, in Kuala Lumpur on the theme “Delivering a New Standard of Care in Cavity Protection” which included Early Caries Management Expert Workshop organized by MADPHS; ICDAS/ICCMS™ Train the Trainers Course organized by the Dental Deans’ Council and, Early Caries Management Symposium organized by MADPHS with Oral Health Division, MOH.

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The launch of the ACFF

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“Break Free from Smoke, a Healthier Mouth a Healthier You” Campaign in Malaysia

Smoking is still prevalent in Malaysia affecting mostly male adults but seeing an increase among the teens and women. Malaysia is a signatory to the WHO Framework Convention on Tobacco Control (FCTC) with the Ministry of Health leading Smoking Control efforts. Dentists involvement in tobacco control intervention efforts however was slow in coming. Few dental schools included smoking control in their curriculum and Tobacco Control was only recently included in the Oral Health Division MOH 2011-2020 National Oral Health Plan. In support of this move, the Malaysian Association of Dental Public Health Specialist (MADPHS) organized the first ever 5-day smoking cessation campaign in Malaysia, working alongside the academia (private and public institutions), government health agencies (Oral Health Division MOH, Malaysian Armed Forces Dental Unit) and non-governmental organization (MyWATCH). The big scale program officiated by the Deputy Minister of Health Malaysia was carried out from 9 – 13 October 2013 in a popular shopping mall in Lembah Klang, covering the Kuala Lumpur-Petaling Jaya residential areas, and was supported by our partner in dentistry, Johnson and Johnson-Listerine Malaysia. The campaign also officially launched the first Malaysian Tobacco Control Newsletter Bulletin for Health Professionals – a quarterly newsletter initiated by a multidiscipline expert panel from University Malaya Centre of Addiction Sciences and supported by Johnson & Johnson Malaysia. Activities included Oral Health screening by dentist volunteers, smoking level assessment, tobacco control counseling, public forums and talks by multidiscipline experts working in tobacco control, smoking posters and hands-on exhibition, schoolchildren school drawing competition among others. The effort was well received by the public from all walks of life. In addition, almost 700 adults consented to undertake oral screening, smoking assessment tests and counseling.

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Deputy Minister launching Campaign

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4th Year dental students showcase

R. AbdulKadir

Pacific Islands

Oral Health in the Pacific

Access to timely and appropriate dental care is challenging in Pacific island countries due to limited transportation between remote islands and shortage of formally trained dental workforce. Theses countries are also facing a transition in diet patterns, from locally produced products to imported foods and beverages that include high-sugar. Considering these special situations and pressing needs for oral health education and timely and accessible care, oral health experts from both public and private entities in the Pacific region have launched various oral health activities. Global Child Dental Fund started its Pacific Dental Network this year to design and implement Legacy projects in the Pacific region, starting from Fiji, Solomon Islands, and Vanuatu Islands. The aim of this network is to convene partners in dental public health to design, implement and expand impactful oral health projects to ultimately improve children’s oral health in this region.

The School of Oral Health of the Fiji National University, the dental school which provides dentistry and oral health professionals to over 14 Pacific island countries, recently hosted the Annual College of Oral Health Academics Meeting with support from Colgate Australia. Participants from 8 different institutions from the Pacific region discussed various dental workforce models and academic assessment methodologies for dental hygiene, dental therapy and oral health therapy programs in Australia, New Zealand and Fiji. The dental school also plans to launch a pilot project to provide interdisciplinary care to address the need for feeding assistance, counseling, speech therapy, caries management, orthodontic and oral surgery treatment among children with cleft lip and palate in Fiji. These children receive initial cleft closure care however there is no follow-up management provided to assist the child and family cope with the many challenges associated with clefts.

Solomon islands implemented its first National Oral Health Survey in May 2013 and data collection is currently underway. Honiara City, the capital of Solomon Islands, focuses on vigorous and effective community dental preventive programs, including a city-wide launch of a toothbrushing day that more than two thousand children and adults participated and demonstrated toothbrushing in public in 2013. The Honiara city oral health services also plans to provide oral health education for pregnant women and new mothers at antenatal clinics from 2014. This is a new initiative, however it needs to be strengthened and supported urgently be partners in public health due to the absence of such programs in Solomon Islands.

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Staff involved in the survey- Honiara City, Solomon Islands

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Oral health survey in Guadalcanal province, Solomon Islands

Vanuatu archipelago has a unique oral health workforce model, which formed a group called VOHA (Vanuatu Oral Health Awareness). Through VOHA, Vanuatu migrant farm workers in New Zealand, called Ni-Vanuatu, bring their newly gained knowledge of the importance of maintaining good oral hygiene back to their communities in Vanuatu. In partnership with Colgate and various charities, these Ni-Vanuatu oral health educators reached over 3,500 people by providing oral health awareness sessions at schools and churches this summer.

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Oral health education for children – Vanuatu Islands

H. Lee, WPR regional coordinator of the WFPHA Oral Health Group

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If you are interested in the OHWG and its activities please visit our webpage or contact us!

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We wish you all Happy Holiday and a New Year

filled of Prosperity and Health!