||Oral Health Status in India
Dr Varun Kumar , Dr Ruchi Juneja
2Oral health is critical but underserved and overlooked component of the overall health and well-being of an individual. It has always received step motherly treatment by health policy- makers. Lack of information about the actual burden of oral diseases and inadequate understanding of the connection between oral diseases and systemic diseases are some of the reasons why oral health has not been on a priority list of the health policy makers. Worse, oral health is not a priority for the individuals either. Neglect on the part of individuals and attitude to defer the treatment until it becomes urgent, is also a reason that it has not received the attention it deserves. All these factors have led to an appalling oral health status in India.
Compromised oral health has psychological, nutritional and economic implications. A person with tooth loss resulting from trauma or dental infection, or with malodor resulting from infection in gums, tends to have a low self esteem, and tries not to mix with the people around. Inadequate oral care with the resultant loss in dentition results in elderly persons having to satisfy themselves with suboptimal nutrition due to inability to chew nutritious alternatives. Neglect of oral health leads to several episodes of severe localized discomfort with loss of productive hours. It is deeply lamenting that, till date, no study to find out the impact of oral diseases on national economy has been instituted.1
Oral health cannot be considered in isolation as a great deal of literature has suggested seeing the oral health and general health along a continuum. The correlation of oral health with many systemic diseases like cardiac problems, diabetes mellitus and hormonal imbalances etc. is being extensively studied. Till recently, it was difficult to believe that a minor tooth problem could negatively affect the blood sugar control, or could increase the incidence of heart attack, which has been proved to be otherwise by various researchers.2 Epidemiological studies largely support an association between gum disease, and atherosclerotic vascular diseases,3adverse pregnancy outcomes4 and severity of Alzheimer's disease.5,6 Oral diseases, as usually believed, are not always benign. A simple infection in a tooth can give way to infection in the jaw bones with resultant spread to neck spaces, which in some cases can become an acute emergency with life threatening implications. Tobacco abuse is causing menace for not only the poor and disadvantaged but also civilized population. India has the dubious distinction of harboring world's highest number (nearly 20%) of oral cancers.7 Early initiation of tobacco habits in children is causing havoc in terms of morbidity and mortality in our younger generations.
The burden of oral diseases is alarming. There is a high prevalence of dental caries i.e. cavities in teeth (50-60%), malocclusion i.e. misaligned teeth (30-35%), gums and periodontal diseases, i.e. infection of soft tissues and gums surrounding the teeth (90%) and oral cancer (19/100000 population) in India.8 These figures directly point towards glaring loopholes in existing oral health system, and sociological and behavioral aspects which are preventing the general public to realize the importance of the oral health.
The most vulnerable group of population in terms of oral diseases consists of elderly, children and pregnant ladies, but, there is no programme by either Union government or State governments aiming to provide universal and equitable access of oral health services to this vulnerable group, barring a few outreach programmes in the form of school dental camps by few State governments. A three phase survey was conducted in Delhi in 2003, by Maulana Azad Dental College and Hospital, and supported by Government of India WHO collaborative programme, with the professed objective to assess the patterns of utilization of oral healthcare services by the elderly.10 It showed that among the factors preventing the utilization of oral healthcare are the low priorities (attitude), and dependent status of the elderly. 'Geriatric medicine' is an emerging branch and 'geriatric dentistry' does not exist in India. Lack of in-depth understanding of the health care needs of elderly is also a factor preventing them from availing the services. Another group of patients, whose condition is pitiable, is the high risk patient group comprising the patients suffering from blood transmissible disease like HIV and hepatitis B and C. Due to fear of cross-infection, these patients have to face refusal for treatment, or repeated referrals, which adds to their agony.11
'Oral health policy in India, formulated way back 15 years ago, is still to see the light of the day. Government of India had accepted in principle National Oral Health Policy as a component of National Health Policy and moved 10 point resolution in its fourth conference in the year 1995.12 In pursuant to this, National Oral Health Care Program (NOHCP), a project of Directorate General of Health Services (DGHS) and Ministry of Health and Family Welfare, was launched on a pilot basis in 5 states (Delhi, Punjab, Maharashtra, Kerala, and North Eastern states). The strategies of this programme included oral health education with information, education and communication (IEC) by involving health workers, school children, teachers and mass media; formulation of basic package on rural healthcare; man power and infrastructure development; mobile dental clinic services for rural people; and public health as well as research monitoring.13 The project was reviewed by National Institute of Health and Family Welfare in 2004.
However, the resolutions by the Health and Family Welfare Department in its fourth Meeting in 1995, notwithstanding, the integration of oral health with general health is confined to text only, as evident from the recent National health policy 2015, which has treaded along the lines of National health policy 2002 in neglecting importance of Oral health.14 Apart from these, National Cancer Control Program, National Tobacco Control Program, National Rural Health Missions, and School Health Program are giving negligible importance to Oral health.15
The regulator of dental health education, Dental Council of India (DCI), has much in common with the other regulatory institutions of India. DCI, the statutory body to regulate the academic standards, dental practices and scientific advances in profession, should bear the responsibility for the morass the oral health profession is in today. Spree of approvals to the private dental institutions, to the utter neglect of their geographic location has produced the skewed variation in localization of oral health professionals in the country.16 Abysmal professional educational standards in these private institutions and laxity on the part of regulator to enforce strict standards due to widespread corruption, political interference, and professional incompetence, have deteriorated the quality of oral health education in India. This has produced the health professionals who are not very skilled to handle the intricacies of the oral procedures, which in turn has severely affected their employment potential. Not only is the employability, but the entire dignity of the profession is at a stake. The situation is so ignoble that dental graduates are forced to take up the jobs that are unbecoming of their qualification and credentials.
Of late, there has been recognition and acknowledgement of the miserable status of the oral health in India. National Oral Health Programme is a new initiative by the Government of India, and has been included in the 12th plan proposal. It is proposed to implement the programme in 200 districts (50 districts per year) across the country during the remaining period of 12th plan with a tentative budgetary provision of 100 crore rupees. Indian government has declared that medical and dental colleges will only be sanctioned if they were set in proximity to deprived areas to counter the barrier of distance to utilize the dental services especially by the rural elderly and deprived sections.
However, much needs to be done beyond this programme. There is a strong opinion that Oral health policy is an idea which can no longer be deferred. It is imperative to decrease the burden of oral diseases and promotion of oral health through preventive measures; to dispel the taboos, myths and misconceptions associated with treatment; to narrow down the rural-urban gap; and to promote quality dental education. There is urgent need for overhaul of Dental Council of India to bring transparency in its decisions that would help in enforcing quality education and research standards in institutions. There is an urgent need to bring behavioral and ethical sciences in dental curriculum, as very frequently the cause of reluctance to accept the treatment for oral diseases is anxiety over lack of sensitivity and financial impropriety.
Importance of Interdisciplinary approach involving medical professionals is yet to be realized to the full extent. It needs to be promoted as there are many diseases in the body whose first manifestations are always in oral cavity or whose treatment is affected or needs modification depending on oral health status. Some tertiary care institutes like PGIMER, Chandigarh have developed a healthy interdepartmental consultation mechanism which needs replication on a nationwide scale at all levels. Practice of maintaining a photographic record, of oral lesions which appear benign but may be indicative of serious systemic diseases, and training of rural health workers to educate the rural populace via this medium as has been initiated via a project by PGIMER, Chandigarh in collaboration with Department of Science & Technology, is proving to be of great benefits. It needs to be replicated on a nationwide scale.
Better infrastructure provisions in the primary health centre could lead to better health services delivery in rural areas as well as serve the purpose of reducing the burden of work upon the health professionals posted in tertiary care centers. Overburdened as the health professionals at tertiary care center are, with the patient overload and less numbers, the focus upon research work is all but non-existent. Policy of not posting the health professionals in their native districts needs to be reconsidered as this can reduce the resistance of theirs towards accepting the village postings. This is because it will not be located very far away from their places.
General complacency towards the oral health also highlights the need for better education on the link between oral health and general health .This awareness about the oral diseases and their possible impact upon general health can be enhanced by using the visual methods displayed by the health professional posted at primary health centre. Special emphasis of this education should be upon educating the importance of oral health care for pregnant ladies.
Dearth of the consumable materials used in the treatment procedures in almost all institutions ranging from primary health centre to tertiary care centre points to inadequate budgetary provisions for the treatment materials and needs serious attention as many a patients are turned away from the institutions due to lack of treatment materials.
Health insurance provided by public insurance companies does not address the dental treatment coverage. This idea also needs serious deliberations given the high cost associated with some of the curative procedures.