Dental dilemmas

Oral diseases such as dental caries (tooth decay), periodontitis (gum disease) and oral and pharyngeal cancers are a global health problem in both industrialised and increasingly in developing countries, especially amongst poorer communities, the World Health Organization (WHO) has stated.

Speaking on the findings of the ‘Sri Lankan Oral Health Report,’ which was last conducted in the year 2003, Dr. J.M.W. Jayasundara Bandara, Deputy Director General of Dental Health Service said that an estimated 27 million cavities among all age cohorts were threatening the oral health of the people nationwide.

“Worldwide, losing teeth is seen as a natural consequence of ageing, but it is in fact preventable,” said Dr. Bandara. “There is a perception that dental caries is no longer a problem in the developed world, but it affects 40- 60% of schoolchildren and a vast majority of adults. Dental caries is also one of the most prevalent oral diseases in several Asian and countries such as ours.”

The impact of oral diseases in terms of pain, suffering, impaired function and reduced quality of life is both extensive and expensive. Treatment is estimated to account for between 5-10% of health costs in the country and is beyond the resources of Sri Lanka. “In Sri Lanka, access to oral health care is limited and teeth are often left untreated or extracted,” he said.

“In Sri Lanka the population will have access to a dental surgeon every 10 kms throughout the country. However, our dentist-to-population ratio is approximately 1:10,000, against about 1:2,000 in most industrialised countries – despite the fact that we have about 400 dental therapists in addition to dentists – and while we have made limited progress in reducing tooth decay amongst younger people in the country, for many older people it remains a major source of pain and ill-health.”

According to the National Oral Health Survey (NOHS) which has been conducted in Sri Lanka three times during the past 20 years, the DMFT level (measurement of dental decay) is considered at an all time low in the case of children compared to adults.

“In 1984, if you take one key indicator age of 12-year-olds, they had 1.9 teeth (approximately two teeth) on average decayed and every six-year-old child had approximately six teeth decayed. However, by 1994 – 10 years later – a 12-year-old’s average number of decayed teeth reduced to 1.5 and a six-year-old’s to 4.9. 2003 saw a marked improvement when the average for a 12-year-old became 0.9 (lesser than one tooth) – so we see a change from two teeth to one within a period of 20 years.”

“As for the number of children who were affected by the disease, in 1984 it was approximately 80-85% but by 2003 it has reduced to 65%,” he further explained. This reduction, according to Dr. Bandara is both by percentage and severity. The severity of the disease has reduced by 50% over the past 20 years. “So it is a significant change for the better in 20 years,” he affirmed.

This improvement has however not been observed for adults. The DMFT of adults have gone beyond five currently. For a 35-44 year old the DMFT is 8.339 – from less than one tooth in children aged 12 years to more than eight in adults. Although adult caries levels are high, the low level of caries prevalence and severity in children has put Sri Lanka on par with developed world.

While it appears to be less severe in the case of children, the report also states that in terms of the prevalence as a percentage, 65% of five-year-olds alone have some sort of oral health issue. Therefore Sri Lanka can actually be at risk.

“It’s quite a problem,” said Dr. Bandara. “Even when you compare the active caries versus the treated caries, you have 65% of active caries but only 1.8% have been treated. Therefore we have concluded that treatment alone does not seem to be the answer to the problem.”

The major priorities and plans of the Health Ministry in terms of an Oral Health Programme were further discussed with the DDG. In addition to addressing modifiable risks such as oral hygiene practices, sugar consumption, which increases susceptibility of the tooth surface, key elements of the plan include addressing the major socio-cultural determinants. These include poor living conditions and low education level as well as lack of traditions supporting oral health.

“Our (the Government’s) strategy is now ‘prevention’. We have identified that the most crucial point – in other words the maximum increment of dental caries – takes place within the first three years of a newborn’s life. During the first year itself the dental caries start commencing in the child at risk. Some start soon after the teeth start irrupting. Therefore, our goal is to identify the children at risk before the dental caries develop in the teeth,” he stated.

“On the other hand, we also intend to reduce the risk factor in children by promoting oral health in the pre natal mothers. We have found that the mother’s oral health levels get promoted to the child before the delivery. So a child who is born to a mother whose oral health is of a high standard ensures that her attitude and habits, etc., get transferred to the child. Another scientifically proven fact is that the number of cariogenic bacteria which remains in the mouth is vital for the caries to develop in a child. These bacteria invariably come from the mother’s mouth to the child’s.

“Basically when the child is born even though its mouth is sterile, once the mother starts showing human affection, in terms of hugging, kissing, etc., the bacteria starts transferring. But if the level of bacteria in the mother’s mouth is reduced, the number that transfers to the child is also less. Therefore, our goal is to reduce the bacteria in the mother’s mouth and thereby reduce the risk of the bacteria being transferred to the child. Increasing emphasis has now been placed on targeting the pre-natal mothers as well as children under the age of three,” he explained.

Oral health systems need to be oriented to primary health care and prevention. The Health Ministry’s awareness initiatives, which seeks to mobilise health promotion and education levels at regional and national levels, has always been strengthened by a private sector partnership.

“We do a lot of health awareness, health camps, television shows, lectures, group discussions, etc. in order to ensure that even a six-year-old knows what causes dental caries. People don’t know that they have cavities – the disease awareness is low. If you are to ask anyone if they have tooth decay or gum disease, only a few (25-30%) will say ‘yes’. They are not aware of it, but 60% of them would have a cavity. They will only be aware of it when they are in pain. Limited treatment options are also a barrier – as by that time the tooth has to come out and it takes very expensive and time-consuming restorative treatments,” explained the DDG.

Commenting further on the role that the private sector plays in assisting the Government initiatives, Dr. Bandara added:  “We need to strengthen our routine structure – ensure that every five kms there is a dentist to attend to the patients. However, in inaccessible areas we promote mobile clinics, dental camps and outreach programmes specially targeted at school-going children. This is where the private sector companies such as Unilever’s Signal brand come in with their assistance – to assist the modern concept of public-private partnerships.

“We as the Government are responsible for the health services and for achieving good health of the people and we have a policy that every person should have access to the desired treatment, which is why these camps and programmes are considered as very important. Creating awareness in the public through such programmes is a laudable achievement. Such activities improve knowledge, change attitudes and strengthen and reinforce oral health promotion activities of the health system. That is why the Government and the private sector go hand-in-hand with these initiatives. Brands such as Signal play a larger role in raising awareness about the issue rather than increasing the number of teeth that may be filled, but that is our goal – awareness and thereby prevention.”

“Poor oral health can have a profound effect on general health and the quality of life,” stated Dr. Bandara in conclusion. “The experience of pain, endurance of dental abscesses, problems with eating, chewing and missing, discoloured or damaged teeth has a major impact on people’s daily lives and wellbeing.”

According to him, Sri Lanka should ensure appropriate use of fluorides for prevention of dental caries.  “The optimum fluoridisation of toothpaste – meaning if you optimally add the fluoride to the toothpaste – is the best option as brushing teeth is a grooming behaviour and everybody does it. So if the toothpaste contains fluoride, then it works best for prevention at early stages. Fluoride toothpaste was first introduced to the country in 1986 thanks to fluoridated toothpastes such as Signal and within these 20 years we have seen fluoride toothpaste playing the biggest role in the prevention of cavities.”

“We have no doubt that Unilever’s Signal fluoridated toothpaste has played a role in our efforts to uplift the oral health status of our country – both in terms of introducing fluoride into toothpaste for prevention of decay and also through raising awareness, which ultimately helps in prevention too. Therefore, in this public-private partnership towards uplifting the oral care of Sri Lanka, the share taken over by Unilever Signal is commendable,” he concluded.